Properties of endodontic hand instruments used in rotary motion. Part 1. Cutting efficiency

Advancing Nitinol: From heat treatment to surface functionalization for nickel–titanium (NiTi) instruments in endodontics

Nickel-titanium (NiTi) alloy has been extensively researched in endodontics, particularly in cleaning and shaping the root canal system. Research advances have primarily focused on the design, shape, and geometry of the NiTi files as well as metallurgy and mechanical properties. So far, extensive investigations have been made surrounding surface and thermomechanical treatments, however, limited work has been done in the realm of surface functionalization to augment its performance in endodontics. This review summarizes the unique characteristics, current use, and latest developments in thermomechanically treated NiTi endodontic files. It discusses recent improvements in nano-engineering and the possibility of customizing the NiTi file surface for added functionalization. Whilst clinical translation of this technology has yet to be fully realized, future research direction will lie in the use of nanotechnology.

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Nitinol (Nickel Titanium alloy) is widely used to clean/shape root canal system in endodontics.

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To enhance its performance, various thermo-mechanical and nano-engineering modifications have been performed.

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This comprehensive review summarizes the latest advances and future trends relating to functionalized NiTi endodontic files.

Cone-beam computed tomography analysis of primary root canals transportation and dentin loss after instrumentation with two-pediatric rotary files

Background

This in vitro study aims to compare rotary files (Fanta and Zuanba) with manual K files according to the amount of dentin removed and canal transportation in primary mandibular second molars by CBCT images.

Methods

This experimental study was conducted on 60 extracted human second primary molars. That were divided into three groups according to root canal preparation group "I" instrumented with manual K-files, group "II" instrumented with rotary Fanta files, and group "III" instrumented with rotary Zuanba files. After root canal preparation, teeth were scanned before and after mechanical preparation with CBCT scanner. Then the amount of dentin removed was determined at three levels, including the coronal, middle and apical levels. Data were statically analysed using the Kruskal–Wallis test.

Result

No statistically significant difference in the amount of dentin removed were noted between the manual and the rotary groups at the coronal and apical RC levels (P = 0.420) and (P = 0.819) respectively but significant difference was noted at the middle third (P = 0.043). Regarding RC transportation, no significant difference was noted among the three groups with the exception of the apical RC level (P = 0.043).

Conclusion

Although no significant differences were noted between rotary and manual files, the rotary files showed better performance.

Evaluation of rotary file system (Kedo-S-Square) in root canal preparation of primary anterior teeth using cone beam computed tomography (CBCT)-in vitro study

Background

In recent years, pediatric endodontics has witnessed various advances including use of rotary files in pulpectomy. This study aimed to comparatively evaluate taper, amount of dentin removal and instrumentation time of the pediatric rotary Kedo-S Square file, hand K-files and H-files in primary canines using cone beam computed tomography (CBCT).

Methods

60 primary canines were randomly assigned into three groups; A1 Kedo-S-Square rotary file (group I), hand stainless steel K file (group II) and hand stainless steel H file (group III). Teeth were mounted in vinyl poly siloxane impression material templates to be scanned before and after instrumentation by CBCT scans using Ondemand 3D software. Shaping ability of the files were evaluated in terms of taper of the canal and amount of dentin remaining of each group. Instrumentation time was recorded using a digital stopwatch.

Results

Kedo-S Square removed a significantly less amount of dentin in both apical (P < 0.002) and coronal thirds (P < 0.014). Taper of the preparations showed significant differences as Kedo-S Square file showed good taper in maximum number of root canals, while maual K- and H-files showed poor taper in maximum number of root canals (P < 0.0001). Rotary Kedo-S Square files required less instrumentation time (P < 0.0001).

Conclusion

The use of rotary Kedo-S Square files resulted in better conservation of tooth structure, superior tapering ability and least instrumentation time compared to hand K- and H-files.

An Update on Nickel-Titanium Rotary Instruments in Endodontics: Mechanical Characteristics, Testing and Future Perspective-An Overview

Since the introduction of Nickel-Titanium alloy as the material of choice for the manufacturing of endodontic rotary instruments, the success rate of the root canal therapies has been significantly increased. This success mainly arises from the properties of the Nickel-Titanium alloy: the biocompatibility, the superelasticity and the shape memory effect. Those characteristics have led to a reduction in time of endodontic treatments, a simplification of instrumentation procedures and an increase of predictability and effectiveness of endodontic treatments. Nevertheless, the intracanal separation of Nickel-Titanium rotary instruments is still a major concern of endodontists, with a consequent possible reduction in the outcome rate. As thoroughly demonstrated, the two main causes of intracanal separation of endodontic instruments are the cyclic fatigue and the torsional loads. As results, in order to reduce the percentage of intracanal separation research and manufacturers have been focused on the parameters that directly or indirectly influence mechanical properties of endodontic rotary instruments. This review describes the current state of the art regarding the Nickel-Titanium alloy in endodontics, the mechanical behavior of endodontic rotary instruments and the relative stresses acting on them during intracanal instrumentation, highlighting the limitation of the current literature.

A critical analysis of research methods and experimental models to study the physical properties of NiTi instruments and their fracture characteristics

The aim of this review is to provide a critical overview of the physical properties (surface hardness, cutting efficiency, bending properties, flexibility and cyclic fatigue resistance) of NiTi instruments. Frequently used experimental models regarding these aspects will be presented and discussed with regard to their strengths and weaknesses. For all these aspects, a plethora of experimental models have been described. Based on a critical appraisal and especially taking the appropriate translation of experimental findings to clinical endodontics into account, suggestions for future research based on clearly defined and valid experimental methodologies will be provided. Up to now, very few attempts have been made to assess which particular physical properties of NiTi instruments exert an impact on the clinical outcome of root canal treatment. Departure from merely focusing on physical properties and fracture characteristics towards more biological aspects in terms of treatment outcome is essential.

Shaping ability of progressive versus constant taper instruments in simulated root canals

AIM

To compare the shaping ability of progressive versus constant taper shaft designed instruments in simulated root canals.

METHODOLOGY

Simulated L- and S-shaped resin canals were prepared by ProTaper (progressive taper) and high elasticity in rotation 642 (Hero 642) (constant taper) instruments (n = 10 canals in each case). The pre- and post-instrumentation images were recorded and assessment of the canal shape was completed with image pro plus 5.0. The width of resin removed was measured at 9 measuring points. Incidence of canal aberrations, instrument fracture, preparation time and change of working length were recorded. In addition, the change of curvature and centring ability were also assessed. The data were analysed statistically using Student's t-test or Fisher's exact-test.

RESULTS

In both canal types, Hero 642 instruments prepared canals more rapidly (P < 0.01) and maintained working length significantly more accurately than ProTaper instruments (P < 0.05). In canals prepared with Hero 642 instruments, there was less change in curvature. Instrumentation with ProTaper results in transportation towards the outer aspect of the L-shaped curved canals in the apical part and the inner aspect of the S-shaped canals at the curve. Hero 642 instruments had a better centring ability in the apical part of the canal, but resulted in shapes with a poor taper.

CONCLUSIONS

ProTaper and Hero 642 instruments prepared curved canals rapidly, maintained working length well and were relatively safe without creating perforations and danger zones. In both canal types, Hero 642 instruments maintained the original canal curvature better, and had a better centring ability in curved canals because of its constant taper design. The taper prepared by Hero 642 instruments in the coronal part of the canal was generally poor.

NSK reciprocating handpiece: in vitro comparative analysis of dentinal removal during root canal preparation by different operators

The purpose of this study was to assess dentin removal during root canal preparation by different operators using a NSK reciprocating handpiece. Eighty-four human single-rooted mandibular premolars were hand instrumented using Triple-Flex stainless-steel files (Kerr) up to #30, weighed in analytical balance and randomly assigned to 4 groups (n=21). All specimens were mechanically prepared at the working length with #35 to #45 Triple-Flex files (Kerr) coupled to a NSK (TEP-E10R, Nakanishi Inc.) reciprocating handpiece powered by an electric motor (Endo Plus; VK Driller). Groups 1 to 4 were prepared by a professor of Endodontics, an endodontist, a third-year dental student and a general dentist, respectively. Teeth were reweighed after root canal preparation. The difference between weights was calculated and the means of dentin removal in each group were analyzed statistically by ANOVA and Tukey's test at 5 % significance level. The greatest amount of dentin removal was found in group 4, followed by groups 2, 3 and 1. Group 4 differed statistically from the other groups regarding dentin removal means [p<0.001 (group 1); p=0.005 (group 2); and p=0.001 (group3)]. No statistically significant difference was found between groups 1 and 2 (p=0.608), 1 and 3 (p=0.914) and 2 and 3 (p=0.938). In conclusion, although the group prepared by a general dentist differed statistically from the other groups in terms of amount of dentin removal, this difference was clinically irrelevant. The NSK reciprocating handpiece powered by an electric engine was proved an effective auxiliary tool in root canal preparation, regardless of the operator's skills.

Effect of cryogenic treatment on nickel-titanium endodontic instruments

AIM

To investigate the effects of cryogenic treatment on nickel-titanium endodontic instruments. The null hypothesis was that cryogenic treatment would result in no changes in composition, microhardness or cutting efficiency of nickel-titanium instruments.

METHODOLOGY

Microhardness was measured on 30 nickel-titanium K-files (ISO size 25) using a Vicker's indenter. Elemental composition was measured on two instruments using X-ray spectroscopy. A nickel-titanium bulk specimen was analysed for crystalline phase composition using X-ray diffraction. Half of the specimens to be used for each analysis were subjected to a cryogenic treatment in liquid nitrogen (-196 degrees C) for either 3 s (microhardness specimens) or 10 min (other specimens). Cutting efficiency was assessed by recording operator choice using 80 nickel-titanium rotary instruments (ProFile 20, .06) half of which had been cryogenically treated and had been distributed amongst 14 clinicians. After conditioning by preparing four corresponding canals, each pair of instruments were evaluated for cutting efficiency by a clinician during preparation of one canal system in vitro. A Student's t-test was used to analyse the microhardness data, and a binomial test was used to analyse the observer choice data. Composition data were analysed qualitatively.

RESULTS

Cryogenically treated specimens had a significantly higher microhardness than the controls (P < 0.001; beta > 0.999). Observers showed a preference for cryogenically treated instruments (61%), but this was not significant (P = 0.21). Both treated and control specimens were composed of 56% Ni, 44% Ti, 0% N (by weight) with a majority in the austenite phase.

CONCLUSIONS

Cryogenic treatment resulted in increased microhardness, but this increase was not detected clinically. There was no measurable change in elemental or crystalline phase composition.

Efficiency of rotary nickel-titanium K3 instruments compared with stainless steel hand K-Flexofile. Part 1. Shaping ability in simulated curved canals

AIM

To compare the shaping ability of K3 rotary nickel-titanium instruments with stainless steel K-Flexofiles manipulated by hand. Part 1 of this two-part report describes the efficiency of these two instruments in simulated curved root canals.

METHODOLOGY

Simulated canals with 28 degrees and 35 degrees curves in resin blocks were prepared by K3 instruments with a rotational speed of 250 r.p.m. using a crown-down preparation technique, or by K-Flexofiles using a reaming motion -i = 24 canals in each case). All canals were prepared up to size 35 at the end-point of preparation. Pre- and postinstrumentation images were recorded, and assessment of canal shape was completed with a computer image analysis program. Material removal was measured at 20 measuring points, beginning 1 mm from the apex. Incidence of canal aberrations, preparation time, changes of working length and instrument failures were also recorded.

RESULTS

In comparison with stainless steel K-Flexofiles, rotary K3 instruments achieved better canal geometry and showed significantly less canal transportation (P < 0.05) Eleven K3 instruments and none of the K-Flexofiles fractured during preparation (P < 0.05). Between both the canal types, K3 was significantly faster (P < 0.001) than K-Flexofiles. Both instruments maintained a good working distance.

CONCLUSIONS

K3 instruments prepared curved canals rapidly and with minimal transportation towards the outer aspect of the curve. Fractures occurred significantly more often with K3.

Effect of physical vapor deposition on cutting efficiency of nickel-titanium files

The purpose of this study was to investigate possible changes in cutting efficiency of nickel-titanium K-files that had undergone physical vapor deposition coating. Titanium nitride coatings were deposited using different process parameters. A total of 84 nickel-titanium K-files (size 35) were randomly divided into 7 groups of 12 instruments each. Groups A to F (experimental): instruments were coated with titanium nitride using different process parameters regarding substrate temperature, applied voltage, coating thickness, and ion bombardment. Group K (control): samples were not coated with titanium nitride. The cutting efficiency of all instruments was determined in a rotary working motion by means of a computer-driven testing device. Special plastic samples with a cylindrical canal were used, and the maximum penetration depth of the instruments into the lumen was the criterion for cutting efficiency. Instruments of groups A, F, and C achieved significantly greater penetration depths than the uncoated instruments of the control group (p < 0.05). Cutting efficiency of physical vapor deposition-coated nickel-titanium files was increased by up to 26.2% in comparison with uncoated instruments.

Effect of sterilization on the cutting efficiency of PVD-coated nickel-titanium endodontic instruments

AIM

To investigate alterations in cutting efficiency when conventional and titanium nitride (TiN) coated nickel-titanium (NiTi) K-files were exposed to repeated sterilization using an autoclave.

METHODOLOGY

A total of 96 NiTi K-files (size 35) were randomly divided into two groups (A and B) of 48 instruments each. Whilst the instruments of group B were exposed to physical vapour deposition (PVD) creating a coating of a TiN layer, the files of group A were not coated. The instruments of groups A and B were randomly divided into four subgroups of 12 instruments each. A.1/B.1: Instruments were exposed to five cycles of sterilization. A.2/B.2: Instruments were exposed to 10 cycles of sterilization. A.3/B.3: Instruments were immersed in NaOCl for 30 min, rinsed in water, and exposed to five cycles of sterilization. A.C/B.C: Instruments were not sterilized (controls). The cutting efficiency of all files was determined by means of a computer-driven testing device. Special plastic samples with cylindrical canals were used and the maximum penetration depth of the files into the lumen was assessed.

RESULTS

The TiN-coated instruments of groups B.1, B.2 and B.3 showed no significant difference in comparison with the penetration depths of the controls (P> 0.05). The uncoated files of groups A.1, A.2 and A.3 displayed significantly lower maximum penetration depths (P< 0.05) when compared to the control files.

CONCLUSIONS

Repeated sterilization under autoclave or exposure to sodium hypochlorite (NaOCl) prior to sterilization did not alter the cutting efficiency of PVD-coated NiTi K-files.

Efficiency of rotary nickel-titanium FlexMaster instruments compared with stainless steel hand K-Flexofile--Part 1. Shaping ability in simulated curved canals

AIM

The purpose of this study was to compare the shaping ability of FlexMaster rotary nickel-titanium instruments with stainless steel hand K-Flexofiles. This part of the two-part report describes the efficiency of these two instruments in simulated curved root canals.

METHODOLOGY

Simulated 28 degree- and 35 degree-curved canals were prepared by the FlexMaster instruments with a rotational speed of 250 rpm using a crown-down preparation technique. and by the K-Flexofiles using a reaming motion (n = 24 canals in each case). All canals were prepared up to size 35. The pre- and post-instrumentation images were recorded and assessment of the canal shape was completed with a computer image analysis program. The material removal was measured at 20 measuring points, beginning 1 mm away from the apex. Incidence of canal aberrations, preparation time,changes of working length and instrument failures were also recorded.

RESULTS

In comparison with stainless steel K-Flexofiles, the rotary FlexMaster instruments achieved bet-ter canal geometry, showed less canal transportation and created fewer canal aberrations in both the canal types. Two FlexMaster instruments were separated, and 15 FlexMaster instruments and 11 K-Flexofiles were permanently deformed during preparation. However, these differences were not significant (P > 0.05). Between both the canal types, FlexMaster was significantly faster (P < 0.001) than K-Flexofiles. Both instruments maintained a good working distance.

CONCLUSIONS

FlexMaster instruments prepared curved canals rapidly, and with minimal transportation towards the outer aspect of the curve.

Shaping ability of Hero 642 rotary nickel-titanium instruments and stainless steel hand K-Flexofiles in simulated curved root canals

OBJECTIVE

The purpose of this study was to compare the shaping ability of Hero 642 rotary nickel-titanium instruments with that of stainless steel hand K-Flexofiles.

STUDY DESIGN

Simulated 28 degrees and 35 degrees curved canals were prepared with Hero 642 instruments by using a crown-down preparation and with K-Flexofiles by using a reaming working motion (n = 24 canals in each case). All canals were sequentially prepared up to size 35. Preinstrumental and postinstrumental images were taken, and assessment of the canal shapes was completed with a computer image analysis program. Material removal was measured at 20 measuring points, beginning 1 mm away from the apex. In addition, preparation time, changes of working length, and instrument failures were recorded.

RESULTS

In comparison with stainless steel K-Flexofiles, rotary Hero 642 instruments achieved better canal geometry and showed less canal transportation, both in canals with 28 degrees curves and in canals with 35 degrees curves. Three Hero instruments separated, whereas none of the K-Flexofiles separated. In 28 degrees curved canals, Hero instruments were significantly faster (P <.01) and maintained working distance significantly better (P <.05) than K-Flexofiles. These differences were insignificant in 35 degrees curved canals.

CONCLUSION

Hero 642 instruments prepared curved canals rapidly, without change in working length and with only minimal transportation toward the outer aspect of the curve.

A comparative scanning electron microscopic investigation of the efficacy of manual and automated instrumentation of root canals

The cleaning effectiveness of automated and manual root canal instrumentation was investigated with the aid of a scanning electron microscope. Hand instrumentation was performed with K-Flexofiles used in a reaming working motion and according to the step-back technique and with Hedstrom files used in a filing motion. Automated preparation was performed with the KaVo-Endo Flash device featuring torque-limited rotation using K-Flexofiles, as well as with the mechanical ProFile system using rotary nickel-titanium instruments. Twelve teeth each with either straight or curved root canals were instrumented to size 40. After cracking the roots longitudinally (n = 120), the amount of debris and smear layer were quantified on the basis of a numerical evaluation scale (1 through 5). Comparison of manual instrumentation with the automated KaVo-Endo Flash resulted in an equivalent degree of canal cleaning. Complete cleanliness was not achieved by any of the techniques and devices investigated. Best instrumentation results, especially in curved canals, were obtained with rotary ProFile instruments.

Comparison of cutting efficiency and instrumentation of curved canals with nickel-titanium and stainless-steel instruments

The cutting efficiency and the effects of instrumentation on curved canal shape of both stainless-steel and nickel-titanium nonstandardized ProFile Series 29 hand instruments and stainless-steel Flexoreamer were investigated under standardized conditions. Concerning cutting efficiency in rotary motion, the Flexoreamer had significantly (p < 0.01) greater cutting efficiency than stainless-steel ProFiles and nickel-titanium ProFiles. Changes in the canal shape differed significantly between the different instruments at all measuring points (p < 0.001). After instrumentation with Flexoreamers with inclusion of two half-sizes (#17 and #22), there were fewer undesirable changes in canal shape compared with both stainless-steel and nickel-titanium ProFile Series 29 instruments. In this study, it seemed that flexible stainless-steel instruments with noncutting tips were superior to the nonstandardized ProFile Series 29 instruments with regard to cutting efficiency and instrumentation of curved canals.

Endodontic hand instruments: cutting efficiency, instrumentation of curved canals, bending and torsional properties

In an assessment of the usefulness of different root canal instruments, two aspects are of particular interest for the endodontist: the cutting efficiency of the instruments and their ability to enlarge curved canals without undesirable changes of the canal shape such as the formation of zips and elbows. This review paper is based on own investigations on the cutting efficiency and instrumentation of curved canals. Additionally, two parameters which are described in ISO 3630-1, resistance to bending and resistance to fracture, are discussed. With regard to cutting efficiency in rotary motion, flexible stainless steel reamers and K-files clearly display the best results and are superior to conventional stainless steel as well as titanium-based reamers and K-files. Regarding cutting efficiency in linear motion, stainless steel Hedström files made by certain manufacturers are significantly superior to stainless steel and titanium-based Hedström files of other brands. Flexible stainless steel instruments with modified noncutting tips clearly produce the best canal shape in curved canals. With only rare exceptions, all the instruments tested fulfilled the requirements of the ISO standard concerning resistance to fracture and resistance to bending.

Preparation of simulated root canals using the Macfile, Canal Master U and K-Flexofile

The efficacy of three different root canal instruments in maintaining the original shape of curved canals was evaluated. Acrylic blocks were prepared to simulate canals with 40 degrees and 60 degrees curvature. K-Flexofiles and Macfiles were used with a step-back technique utilizing an 'in/out' filing motion. The balanced-force technique was used with Canal Master 'U' instruments. Ten 40 degrees and 10 60 degrees canals were prepared with each instrument. The results were evaluated using superimposed photographic slides at x20 magnification to show the canals before and after the instrumentation. The width of the prepared canals was measured at their convex/concave point to determine the divergence of the instrumented canal shape from the original canal shape. The measurements were taken at the level of the apical foramen and 3 and 6 mm coronal to it. In this way it was possible to recognize all the defects created during the preparation of a canal. Among the tested instruments, the Macfile provoked minimal canal deviation (P = 0.05). The Canal Master 'U' was similarly effective (P = 0.05), but had the highest incidence of instrument fracture. The K-Flexofile demonstrated the most defects in canal preparation and canal deviation, particularly at the level of the apical foramen (P < 0.01).

Properties of endodontic hand instruments used in rotary motion. Part 3. Resistance to bending and fracture

Bending and torsional properties of 24 different types of nickel-titanium K-files, titanium-aluminium K-files and reamers, conventional stainless steel K-files and reamers, and flexible stainless steel instruments were investigated corresponding to ISO 3630-1 by determination of the bending moment on the one hand and the torque and angular deflection on the other. Numbers 15, 25, and 35 instruments were tested with a sample size of 10 instruments for each type and size. In ascending order of bending moment the instruments ranked: nickel-titanium K-files, titanium-aluminium K-files and reamers, flexible stainless steel instruments, conventional stainless steel K-files, and reamers. Nickel-titanium, titanium aluminium, and flexible stainless steel instruments displayed lower torque values than conventional stainless steel K-files and reamers. The average angular deflection ranged from 380 degrees (#15 reamer) to 2370 degrees (#35 K-file). Overall, the fracture risk of the instruments tested in this study was comparably low.

Properties of endodontic hand instruments used in rotary motion. Part 2. Instrumentation of curved canals

The shaping abilities of nickel-titanium K-files, stainless steel reamers, K-files, and flexible stainless steel instruments with conventional cutting tips and with modified noncutting tips were investigated under standardized conditions using a computer-driven testing device simulating the clinical use of the instruments. Simulated root canals with a 42-degree curvature were sequentially enlarged from #15 to #35. Undesirable changes in the canal shape as a result of instrumentation occurred in all cases. None of the instruments were able to remove material on the whole length of the inner side of the curvature, whereas all instruments removed material on the whole length of the outer side of the curvature, resulting in slight to severe bulging. The extent of undesirable changes in the canal shape depended typically of the type of instrument used. Best instrumentation results were obtained with flexible instruments with noncutting tips.