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Article in Endodonticpractice·February2016

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CLINICAL

The reciprocating movement in endodontics

Nicola Maria Grande, Gianluca Plotino, Hany Mohamed Aly Ahmed,

Stephen Cohen and Frédéric Bukiet provide a clinical perspective on the reciprocating movement in endodontics

perspective on the reciprocating movement in endodontics Nicola M Grande Shaping the root canal facilitates cleaning
perspective on the reciprocating movement in endodontics Nicola M Grande Shaping the root canal facilitates cleaning
Nicola M Grande
Nicola M Grande

Shaping the root canal facilitates cleaning the root canal system (RCS) and is probably the most important phase in endodontic treatment. It includes the removal of pulp tissue, microorganisms, infected dentine and

removal of pulp tissue, microorganisms, infected dentine and root canal filling materials (RCFMs) in non- surgical

root canal filling materials (RCFMs) in non- surgical retreatments (Hülsmann, Peter, Dummer, 2005). Shaping the canal enhances the efficiency of irrigants and medicaments, and optimises subsequent filling procedures (Hülsmann, Peter, Dummer, 2005; Frank,

1967).

In the last two decades, numerous advances in endodontic instrumentation have been developed to achieve proper enlargement of the main canal without procedural errors (Frank, 1967). Reciprocating motion (RM) had been extensively used with stainless steel (SS) files initially in the development of mechanical instrumentation in endodontics. RM applied to nickel titanium files has many differences from the one used with SS (Grande et al, 2015). RM has been a recent innovation employing nickel titanium instrumentation systems that claim to better resist instrument separation, thus permitting easier treatment thereby shortening the learning curve for nickel titanium file systems.

Evolution of RM in endodontics – historical perspective

The early era of mechanical instrumentation

Automated instrumentation of the root canal space was an

TURN TO PAGE 00

TURN TO PAGE 00 CPD AIMS AND OBJECTIVES This clinical article aims to provide a clinical
TURN TO PAGE 00 CPD AIMS AND OBJECTIVES This clinical article aims to provide a clinical
TURN TO PAGE 00 CPD AIMS AND OBJECTIVES This clinical article aims to provide a clinical
TURN TO PAGE 00 CPD AIMS AND OBJECTIVES This clinical article aims to provide a clinical

CPD AIMS AND OBJECTIVES

This clinical article aims to provide a clinical perspective on the reciprocating movement in endodontics.

EXPECTED OUTCOMES

Correctly answering the questions on page XX, worth one hour of verifiable CPD, will demonstrate that the reader understands the properties, effectiveness and clinical outcomes of the modern reciprocating files available in the market, as well as the favourable results of reciprocating files, which indicate their potential application as viable alternatives to rotary file systems.

28 FEBRUARY 2016 ENDODONTIC PRACTICE

file systems. 2 8 FEBRUARY 2016 ENDODONTIC PRACTICE Figure 1: The different types of reciprocating motion

Figure 1: The different types of reciprocating motion for endodontic instrumentation: Left: complete reciprocation with horizontal rotational oscillations. Right: partial reciprocation with rotational effect

early objective of clinical endodontics, beginning in the 20th century, when pioneers were trying to develop mechanical instruments (Hülsmann, Peter, Dummer, 2005). Rotary SS root canal instruments, such as Gates Glidden burs and Peeso Reamers, can be safely used in the coronal, and sometimes the middle third of relatively straight RCs, but their stiffness increases the risk of root perforation as the clinician approaches the middle third of the canal (Laws, 1968; Jungmann, Uchin, Bucher, 1975; Martin, 1976). For this reason, a RM that has equal angles in both directions was successfully introduced. This type of symmetric reciprocation can be defined as complete oscillating reciprocation (Figure 1), resembling the classic watch-winding movement used with manual SS files. In the 1960s, different handpieces were manufactured initially and designed to reciprocate at 90 o (Frank, 1967). The overall results regarding the shaping ability and its safety were generally similar (Frank, 1967; Luebke, Brantley, 1990; Lausten, Luebke, Brantley, 1993) or inferior (Dihn, 1972; Molven, 1970; O’Connell, Brayton, 1975; Klayman, Brilliant, 1974; Sargenti, 1974; Weine, Kelly, Lio, 1975; Weine, Kelly, Bray, 1976; Powell, Simon, Maze, 1986) to a classic approach using SS manual root canal preparation (RCP), with a higher frequency of iatrogenic errors, including a tendency for canal straightening (Abou-Rass, Ellis, 1996; Limongi et al, 2004). In general, reducing the amplitude of the movement toward a smaller oscillation with a higher frequency decreased the incidence of iatrogenic errors, but were still more of a problem than when using SS files manually to prepare canals

Figure 2a: Three-dimensional reconstruction of a micro-computed tomographic scan of a mesial root of a

Figure 2a: Three-dimensional reconstruction of a micro-computed tomographic scan of a mesial root of a mandibular first molar with three root canals before instrumentation (in yellow)

with three root canals before instrumentation (in yellow) Figure 2b: Superimposition of pre- and post-instrumentation
with three root canals before instrumentation (in yellow) Figure 2b: Superimposition of pre- and post-instrumentation

Figure 2b: Superimposition of pre- and post-instrumentation three-dimensional reconstructions (in pink postoperative) showing the centring ability of the reciprocating technique

showing the centring ability of the reciprocating technique Figures 3b and 3c: Superimposition of preoperative

Figures 3b and 3c: Superimposition of preoperative three-dimensional reconstruction and postoperative bi-dimensional sections at coronal middle and apical level

bi-dimensional sections at coronal middle and apical level Figure 3a: Three-dimensional reconstruction of a

Figure 3a: Three-dimensional reconstruction of a micro-computed tomographic scan of a mesial root of a mandibular first molar with three root canals before instrumentation (in yellow). Superimposition of preoperative three-dimensional reconstruction and postoperative bi-dimensional sections at coronal

and postoperative bi-dimensional sections at coronal Figure 3d: Showing the modification of root canal anatomy

Figure 3d: Showing the modification of root canal anatomy and geometry induced by reciprocating instrumentation

(Turek, Langeland, 1982; Harty, Stock, 1974; Hülsmann, Gambal, Bahr, 1999; Bolanos et al, 1988; Lehman, Gerstein, 1982; O’Conell, Brayton, 1975; Teodorovic, Ivanovic, 1998; Cheung, Chan, 1996; Nagy et al, 1997; Smith, Edmunds, 1997; Hülsmann, Rummelin, Schäfers, 1997; Petschelt et al,

1994).

The other common observation after RCP with mechanical SS files was that increasing the size of the preparation risked a higher incidence of procedural errors (Hülsmann, Gambal, Bahr, 1999; Bolanos et al, 1988; Lehman, Gerstein, 1982; O’Connell, Brayton, 1975; Teodorovic, Ivanovic, 1998; Cheung, Chan, 1996; Nagy et al, 1997; Smith, Edmunds, 1997; Hülsmann, Rummelin, Schäfers, 1997; Petschelt et al, 1994; Abou-Rass, Jastrab, 1982; Ianno, Weine, 1989). Other studies have also reported procedural errors linked to metal stiffness and restoring force of SS and worse results compared to nickel titanium instrumentation systems (Hilaly Eid, Wanees, Amin, 2011; Ceyhanli et al, 2014).

The modern use of SS files in reciprocation

Although there are many systems on the market, the tendency is to limit use to the scouting phase prior to shaping procedures, to obtain a glide path. This would minimise the adverse effects of SS files especially in larger more rigid sizes. Despite the widespread use of mechanical SS files, there is still a lack of scientific evidence on their efficacy (Limpngi et al, 2004). SS files used for glide path management should be used with equal 30° forwards and backwards movement in a reciprocating handpiece (M4 Safety Handpiece (Sybronendo/ Kerr). The primary observations regarding small SS files for glide path management seems to be promising, but studies are lacking on how they would fare in calcified, curved and

29 FEBRUARY 2016 ENDODONTIC PRACTICE

complex canals (Peters, Paque, 2010).

The birth of modern reciprocation for nickel titanium files of greater taper

Studies have demonstrated the potential in using greater taper nickel titanium files in shaping the root canal even in the most challenging of anatomical complexities (Hulsmann, Peters, Dummer, 2005; Parashos, Messer, 2006). However, fracture of nickel titanium rotary instruments continues to be of concern (Best et al, 2004) and appears to be a manifestation of continuous rotation. In 2004, one study investigated the endurance limit of nickel titanium files (Best et al, 2004); this is the level of stress or strain at which the file can be subjected to before separating (Lindeburg, 1999). This value is a specific deflection angle (DA), characteristic of each instrument; it depends on the size and design features of the instrument. Every time a rotating file cuts dentine in a constricted canal, torsional deformation develops on its axis. If the deformation is within the plastic limit of the metal, there are no structural changes. However, if repeated cyclic axial deformation accrues, the instrument will fracture due to torsional fatigue and this is in addition to the flexural fatigue that develops within a curved canal (Pedulla et al, 2015). Limiting the angle of rotation in the cutting direction under the endurance limit of the instrument led to the development of a movement that could be defined as partial or asymmetrical reciprocation (Figure 1), in which the angle of rotation in the cutting direction is higher than the angle of rotation in the opposite non-cutting direction. After a certain number of cutting cycles the instrument would complete a full rotation. When first introduced (Yared, 2008), an ATR Teknica motor (ATR, Pistoia, Italy) was programmed for this

Teknica motor (ATR, Pistoia, Italy) was programmed for this Figure 4a: Three-dimensional reconstruction of the

Figure 4a: Three-dimensional reconstruction of the cross-section at 1mm from the apex of micro-CT scan of a root canal before instrumentation (in yellow)

scan of a root canal before instrumentation (in yellow) Figure 5: Left: previous Waveone Primary file

Figure 5: Left: previous Waveone Primary file made in M-wire alloy and features of the coronal, middle and apical part of the instrument. Right: the new Waveone Gold Primary file and features of the coronal, middle and apical part of the instrument. The heat treatment of the files has been changed from M-wire to gold alloy treatment. Note the ability to prebend the file

gold alloy treatment. Note the ability to prebend the file Figure 4b: Three-dimensional reconstruction of micro-CT

Figure 4b: Three-dimensional reconstruction of micro-CT scan images of the same canal at the same cross-section after instrumentation with a reciprocating file to an apical size of 40 (in pink)

with a reciprocating file to an apical size of 40 (in pink) Figure 6a: Preoperative radiograph

Figure 6a: Preoperative radiograph of a lower left second molar tooth

Preoperative radiograph of a lower left second molar tooth CLINICAL Figure 4c: Superimposition of pre- and

CLINICAL

radiograph of a lower left second molar tooth CLINICAL Figure 4c: Superimposition of pre- and post-instrumentation

Figure 4c: Superimposition of pre- and post-instrumentation images showing the centring ability of this type of instrumentation technique

centring ability of this type of instrumentation technique Figure 6b: Working length. Note the sharp apical

Figure 6b: Working length. Note the sharp apical curvature of the distal root

Figure 6c: One-year control radiograph. Note conservative access only removed the old filling. Maximum maintenance of the dental structure of the distal area makes it compatible to proper cleaning, shaping and filling procedures

asymmetrical motion and the file used was a Protaper F2 (Dentsply Maillefer). The angles used were described as four- tenth of a circle (144°) in clockwise (CW) cutting direction and two-tenth of a circle (72°) in counter-clockwise (CCW) non-cutting direction with a speed of 400rpm. The technique showed promising results (Malentacca, Lalli, 2002). The overall speed of this kind of rotational reciprocation is much lower than the speed used for symmetric oscillating reciprocation. Consequently, the rotating effect given by the net difference between CW and CCW movements maintains an adequate cutting efficiency and an apical progression of the instrument while reducing torsional stress. It has been speculated that this kind of reciprocation is similar to the manual balanced force technique as described by Roane and colleagues in 1985. The dynamics enables the instrument to remain centred in the canal, as the cutting force is equal on the concave and convex side of the canal curvature (Figures 2, 3 and 4). Torsional stresses, which are developed on the shank of the file during the cutting action, are reduced as the rotation is under the ideal limit of the DA specific for the file. This novel asymmetrical movement led to the development of dedicated reciprocating single file (RSF) systems and a new technique where only one file is needed to fully shape a canal to length. Initial canal negotiation with small (0.08, 0.10mm tip

diameter) SS scouting files allows the clinician to determine the size of the RSF, which will shape the canal (De-Deus et al, 2010a; De-Deus et al, 2010b). This approach can be risky for files used in complete rotation because if the file exhibits ‘taper lock’ in the canal, immediate fracture could occur (Yared, 2008). This modified CW/CCW movement led to nickel titanium files specifically designed for the use in partial reciprocation, such as Waveone (Dentsply Maillefer) and Reciproc (Dentsply VDW). The files are used with different angles in the cutting and non-cutting direction of 150°/30° (Reciproc with an average speed of 300rpm and Waveone with an average speed of 350rpm) and that are within their characteristic endurance limit (Webber, 2015). Actual and set values of the asymmetrical reciprocating movement of different motors was assessed because variables, such as the delay between the two directions of movement and the acceleration to reach the desired speed, could play an important role in the efficacy of the different instruments (Fidler, 2014). Additional studies are needed to explore this variable. For commercial reasons, the flutes of reciprocating files are manufactured in a backwards direction so that the CCW movement is greater than the CW movement and after three cutting cycles the instrument completes a full reverse rotation. All commercially available nickel titanium files rotate in a CW direction (Fidler, 2014). Both commercially

ENDODONTIC PRACTICE FEBRUARY 2016

30

Figure 7a: Preoperative periodical radiograph of the upper left second molar with apical periodontitis Figures

Figure 7a: Preoperative periodical radiograph of the upper left second molar with apical periodontitis

Figures 7d and 7e: Periapical radiographs at different horizontal angulation of the final obturation. The scouting and negotiation of the MB2 was made possible with the mechanical reciprocation scouting approach using R25

the mechanical reciprocation scouting approach using R25 Figures 7b and 7c: Periapical radiograph of working length
the mechanical reciprocation scouting approach using R25 Figures 7b and 7c: Periapical radiograph of working length

Figures 7b and 7c: Periapical radiograph of working length with manual stainless steel files. In MB2 it was impossible to negotiate the root canal with manual files

was impossible to negotiate the root canal with manual files available RFs are marketed as single
was impossible to negotiate the root canal with manual files available RFs are marketed as single

available RFs are marketed as single file techniques, after initial scouting of the canal to determine the correct file size to use to obtain the final shape. A single RSF produces a shape that traditionally would be obtained after a series of three or more rotary nickel titanium files. The favourable results of reciprocating files indicate their potential as viable alternatives to rotary file systems. Occasionally it might be necessary to use additional instruments to initially establish glide path or clean the apical third and the fins of the RCS (Baugh, Wallace, 2005). A RSF is subjected to a certain amount of mechanical

stress during use that otherwise would be distributed amongst a series of different rotary files. For this reason, manufacturers urge single-use for RSF techniques to prevent the increased risk of file separation in case of multiple usages (Yared, 2008). Recently, Waveone has been upgraded to Waveone Gold. The kinematic of this system is unchanged but the cross section, size and geometry of the files have been modified to make the file more flexible and efficient. Gold heat treatment is a proprietary Dentsply post manufacturing heat treatment process unlike M-Wire, which is a pre-manufactured heat treatment process. The Gold heat treatment process improves flexibility (Shen et al, 2013) and allows the instrument to be precurved, an advantage when placing the file into canals in more

difficult to reach posterior regions (Figure 5). Reciproc (Dentsply VDW) is marketed as a file that can prepare the coronal and middle thirds of the root canal without the establishment of an

initial glide path (Yared, Ramil, 2013). This procedure has been shown to be clinically successful and safe even in complex canals (De-Deus et al, 2013), when the clinician follows the manufacturers directions for use (Plotino, Grande, Porciani, 2015). TF Adaptive files and the dedicated Elements motor (Sybronendo) have recently been launched. The motor changes its kinematics from a rotating movement (600° CW hor-izontal rotational motion and 0° CCW) to partial reciprocation (370° in a CW cutting direction and 50° in the

‘The favourable results

of reciprocating

files

indicate their potential as viable alternatives to rotary file systems’

31 FEBRUARY 2016 ENDODONTIC PRACTICE

non-cutting direction). The change to reciprocation is dependent on the torque to which the file is subjected. The average speed of the RM is not declared by the manufacturer. This type of movement could be defined as a hybrid reciprocation. Recently, Morita (Japan) has introduced the Root ZX II OTR Module, a low-speed handpiece where the torque is automatically measured during file rotation. The manufacturer claims that if the torque is less than the set value, the file

rotation continues, but if the torque has reached the set value, the file reverses rotation by 90° and then continues in the cutting direction once again. This type of movement could be also defined as a hybrid reciprocation. The clinician has the advantage of continuous rotation when needed, and reciprocating movement in a reverse direction activated by the torque measurement. If too much force is applied the handpiece will continue reading a torque limit over the set value and the reciprocating movement will continue. More recently, several motors have come to market with the functionality to adjust both forward and backwards angle of reciprocation, as well as the speed of movement. Theoretically, any instrument on the market could be used in an asymmetrical reciprocation with these motors but studies are still lacking on how they would perform in terms of safety and quality of the preparation. Due to the increased popularity of RM and reciprocating files usage, numerous studies have been conducted mainly investigating the mechanical properties, shaping ability, preservation of the root canal anatomy, shaping time, cleaning effectiveness, microcrack formation, bacterial reduction, extrusion of debris and removal of root canal filling materials. The conclusions from the literature can be summarised as follows (Plotino et al, 2015):

• Reciprocation extends the lifespan of all types of files tested

• The amplitude of reciprocation has a significant influence on the cyclic fatigue life of the files tested

• Reciprocation does not reduce the cutting efficiency of the files tested

• Reciprocating and rotary motion have similar cutting

efficiency

• Reciprocating files shape canals well and preserve the original canal anatomy

• The cleaning effectiveness of reciprocating files is comparable to full rotary file sequence systems. Further studies should be conducted to understand the respective

influence of the kinematics, the file design and the number of instruments needed to fully shape canals

• Reciprocating single file usage reduces the shaping time compared to a full sequence rotary system

• Dentine microcracks occur independently of the type of file and its kinematics

• The results of published studies show that the use of

reciprocating files would lead to fewer or an equivalent amount of dentine microcracks compared with full sequence rotary systems

• RFs can promote significant bacterial reduction, but, like

rotary full sequence systems, they are not able to completely disinfect the RCS

• The ability of RFs to extrude less debris than rotary files remains a matter of debate

• Reciprocating files are effective in removing root canal

filling material in less time as compared to rotary files, yet

no system is able to remove the filling material completely from the RCS.

Conclusion

RM is defined as a repeated backward and forward

(clockwise/counter-clockwise) movement, has been extensively used in endodontics for many years and can be applied to many endodontic files. There are many variations of RM, including:

• Complete reciprocation (oscillation)

• Partial reciprocation (rotational effect)

• Hybrid reciprocation (combined movements).

CLINICAL

Hybrid reciprocation can be fixed or flexible, ie, it can shift from one type of reciprocation to the other in the canal based on mechanical resistance and torque. It must be borne in mind, however, that no file system is able to completely clean the canal, totally eliminate sessile and planktonic microorganisms or remove the filling material completely from the root canal system. However, the favourable results of RFs, especially their safety and low rate of fracture, indicate their potential as viable alternatives to rotary file systems (Figures 6 and 7). ¡

Gianluca Plotino
Gianluca Plotino
AUTHORS
AUTHORS

NICOLA MARIA GRANDE DDS PHD is assistant professor of endodontics at the Catholic University of Sacred Heart. He works in private practice limited to endodontic and microsurgery in Rome, Italy.

GIANLUCA PLOTINO DDS PHD maintains a private practice in Rome, Italy limited to endodontics and restorative and aesthetic dentistry.

HANY MOHAMED ALY AHMED BDS HDD (ENDO) PHD is a senior lecturer and endodontist at the School of Dental Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia.

STEPHEN COHEN MA DDS FICD FACD is an adjunct clinical professor of endodontics at the Arthur A Dugoni School of Dentistry, University of the Pacific, San Francisco, California, USA.

FRÉDÉRIC BUKIET DDS MSC PHD is a senior lecturer, hospital practitioner, and associate researcher (Giboc, ISM, UMR CNRS 7287) at the University of Aix Marseille, Assistance Publique des Hôpitaux de Marseille. He maintains a clinical practice limited to endodontics.

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(1974) Engine powered canal preparation. Addendum 3 3 FEBRUARY 2016 ENDODONTIC PRACTICE ViewView

33 FEBRUARY 2016 ENDODONTIC PRACTICE