Influence of torque control motors and the operator's proficiency on ProTaper failures

Influence of endodontic motors on the behaviour of root canal shaping instruments: an in vitro comparative study

AIMS

The endodontic literature reports a lot of comparative study on endodontic instruments, concerning as well their geometry, instrumental dynamics, material, mechanical behavior or heat treatment. However, to our knowledge, no study has focused on the influence of endodontic motors on the shaping abilities of endodontic instruments. Thus, the aim of this study was to analyze the influence of the endodontic motors on root canal shaping instruments.

METHOD

Dual Move (MICRO-MEGA, Besançon, France), Canal Pro CL2i (COLTENE, Alstätten, Suisse), Canal Pro Jeni Motor (COLTENE, Alstätten, Suisse), Ai Motor (WOODPECKER, Guilin, China), Wave One motor (VDW, Postfach, Munich) and Smart A (WOODPECKER, Guilin, China) were pre-clinically compared in continuous rotation and reciprocating motion on a traction/compression bench using resin blocks. Canal shaping in continuous rotation and reciprocating motion were performed with One Curve and One RECI instruments (MICRO-MEGA, Besançon, France), respectively. The penetration/removal forces, making it possible to objectify the cutting effect and screwing effect of the instruments during root canal shaping, were analyzed.

RESULTS

The results showed (i) that endodontic motors influence the mechanical behavior of endodontic instruments, (ii) that the influence of the motors is essentially felt during reciprocating motion and (iii) that the reciprocating angles influence the mechanical behavior of endodontic instruments.

CONCLUSION

Only endodontic instruments are widely studied in literature while endodontic motors have a direct influence on root canal treatment. This study analyzes the influence of the endodontic motors on root canal shaping instruments. This study tends to demonstrate that Jeni Motor could optimize the mechanical behavior of endodontic instruments.

Effect of flushing temperature on preparation ability of rotary nickel-titanium files

PURPOSE

The effect of flushing at different temperatures on the preparation ability of rotary nickel-titanium files was investigated to provide guideline for clinical application.

METHODS

Sixty ProTaper Universal F1 rotary nickel-titanium files were randomly divided into three groups treated by flushing at 6°C, 23°C, and 40°C. Root canal preparation was conducted by step-by-step method on standardized nickel-titanium instrument fracture models. During preparation, the thrust force was set as 10 N, and water was continuously flushed. The motor speed was 350 rpm (rounds per minute), and the torque was 3.0 N cm. When the set torque was reached, the motor automatically rotated in the reverse direction and was pulled out.

RESULTS

Root canal preparation was performed using ProTaper Universal F1 rotary nickel-titanium files treated by flushing. The numbers of rotations before the device was fracture were 429.33 ± 214.68, 821.92 ± 410.43, and 1304.92 ± 297.81, respectively. When each root canal was completed, the numbers of instrument rotations were 272.15 ± 88.30, 188.85 ± 34.36, and 163.41 ± 16.18, respectively. Rank sum test and analysis of variance were performed by IBM SPSS Statistics v21.0 software, and both of them were p < 0.01, indicating that the number of cycles to failure (NCF) and the number of instrument rotations for each root tube were statistically different at the three temperatures.

CONCLUSIONS

The self-made resin-simulated curved root canal can replace the real root canal to complete the root canal preparation experiment. The group of nickel-titanium files treated by flushing at 23°C can prepare more root canals and prolong the life of nickel-titanium files than at 6°C. When flushing was done at 40°C, the number of root canals prepared by nickel-titanium files was the highest, and it was not easy to damage the instrument, but lateral perforation occurred easily during root canal preparation.

In Vivo Evaluation of Operative Torque Generated by Two Nickel-Titanium Rotary Instruments during Root Canal Preparation

Objectives  This in vivo study evaluated the operative torque and preparation time of ProTaper NEXT (Dentsply Maillefer; Ballaigues, Switzerland) and EdgeFile X7 (EdgeEndo; Albuquerque, New Mexico, United States) rotary systems during root canal preparation of maxillary premolars.

Materials and Methods  Ten double-rooted maxillary premolars with independent canals were selected. Each canal in each tooth was prepared with one of the rotary systems ( n = 10), ProTaper NEXT or EdgeFile X7. The instruments were rotated at 300 rpm with maximum torque set at 2 N.cm using an electric motor (KaVo; Biberach, Germany) that automatically recorded torque values at every 1/10th of a second (ds).

Statistical Analysis  Operative torque (N.cm) and preparation time (s) of the first shaping instrument (size 17/.04) of both rotary systems were recorded and statistically compared using the Mann–Whiney U test with a significance level set at 5%.

Results  No instrument exhibited flute deformation or underwent intracanal failure. No differences were found between the instruments regarding the maximum (peak) torque values ( p > 0.05). EdgeFile X7 17/.04 required significantly less preparation time (3.75 seconds interquartile range [IQR]: 3.2–9.0) than ProTaper NEXT X1 (15.45 seconds IQR: 8.35–21.1) ( p < 0.05). The median operative torque values of ProTaper NEXT X1 (0.26 N.cm; IQR: 0.18–0.49) were significantly higher compared with EdgeFile X7 17/.04 (0.09 N.cm; IQR: 0.05–0.17) ( p < 0.05).

Conclusions  Although no difference was found between the median peak torque values of ProTaper NEXT X1 and EdgeFile X7 17/.04 instruments, the operative torque and instrumentation time results were impacted by their different designs and alloys during clinical preparation of root canals.

A web-based endodontic case difficulty assessment tool

OBJECTIVE

To develop a web-based tool to facilitate identification, evaluation and management of teeth requiring endodontic treatment.

MATERIALS AND METHODS

Following a literature search and thorough analysis of existing case difficulty assessment forms, the web-based tool was developed using an online survey builder (Qualtrics, Qualtrics Lab, UT, USA). Following feedback from a pilot study, it was refined and improved. A study was performed, using the updated version (EndoApp) on a cohort (n = 53) of dental professionals and dental students. The participants were e-mailed instructions detailing the assessment of five test cases using EndoApp, followed by completion of a structured feedback form. Analysis of the EndoApp responses was used to evaluate usage times, whereas the results of the feedback forms were used to assess user experience and relevance, other potential applications and comments on further improvement/s.

RESULTS

The average usage time was 2 min 7 s; the average times needed for the last three (Cases 3-5) were significantly less than the preceding two (Cases 1 & 2) test cases. An overwhelming majority of participants expressed favourable views on user experience and relevance of the web-based case difficulty assessment tool. Only two participants (4%) were unlikely or very unlikely to use EndoApp again. The potential application of EndoApp as an 'educational tool' and for 'primary care triage' was deemed the most popular features and of greater importance than the secondary options of 'fee setting' and as a 'dento-legal justification tool'.

CONCLUSIONS

Within the study limitations, owing to its ability to quantify the level of difficulty and provide guidance, EndoApp was considered user-friendly and helped facilitate endodontic case difficulty assessment. From the feedback, further improvements and the development of a Smartphone App version are in progress.

CLINICAL RELEVANCE

EndoApp may facilitate treatment planning, improve treatment cost-effectiveness and reduce frequency of procedural errors by providing appropriate guidance on endodontic case management.

Obturation over an S1 ProTaper instrument fragment in a mandibular molar with three years of follow-up

This case report describes root canal filling performed over a large S1 ProTaper file fragment in a second mandibular molar with irreversible pulpitis. An S1 ProTaper file was fractured during the instrumentation of the mesiobuccal canal. Approximately 10 mm of file fragment remained in the apical and middle thirds of the canal. The obturation was performed over this fragment using thermomechanically compacted gutta-percha and sealer. Radiographic findings and the absence of clinical signs and symptoms at 3-year follow up indicated successful treatment. Cone-beam computed tomography images revealed absence of periapical lesion and details of intracanal file fragment related to root fillings and apex morphology. In this case, the presence of a large intracanal fractured instrument did not have a negative impact on the endodontic prognosis during the follow up evaluation period.

Comparison of air-driven vs electric torque control motors on canal centering ability by ProTaper NiTi rotary instruments

AIM

Cleaning and shaping is one of the most important phases in root canal therapy. Various rotary NiTi systems minimize accidents and facilitate the shaping process. Todays NiTi files are used with air-driven and electric handpieces. This study compared the canal centering after instrumentation using the ProTaper system using Endo IT, electric torque-control motor, and NSK air-driven handpiece.

MATERIALS AND METHODS

This ex vivo randomized controlled trial study involved 26 mesial mandibular root canals with 10 to 35° curvature. The roots were randomly divided into 2 groups of 13 canals each. The roots were mounted in an endodontic cube with acrylic resin, sectioned horizontally at 2, 6 and 10 mm from the apex and then reassembled. The canals were instrumented according to the manufacturer's instructions using ProTaper rotary files and electric torque-control motors (group 1) or air-driven handpieces (group 2). Photographs of the cross-sections included shots before and after instrumentation, and image analysis was performed using Photoshop software. The centering ability and canal transportation was also evaluated. Repeated measurement and independent t-test provided statistical analysis of canal transportation.

RESULTS

The comparison of the rate of transportation toward internal or external walls between the two groups was not statistically significant (p = 0.62). Comparison of the rate of transportation of sections within one group was not significant (p = 0.28).

CONCLUSION

Use of rotary NiTi file with either electric torquecontrol motor or air-driven handpiece had no effect on canal centering.

CLINICAL SIGNIFICANCE

NiTi rotary instruments can be used with air-driven motors without any considerable changes in root canal anatomy, however it needs the clinician to be expert.

Cyclic fatigue resistance of Mtwo NiTi rotary instruments used by experienced and novice operators--an in vivo and in vitro study

Background

The aim of the present study was to evaluate the cyclic fatigue resistance of Mtwo NiTi rotary instruments after clinical use by 1 experienced and 1 novice operator.

Material/Methods

Cyclic fatigue testing of instruments was performed on tapered artificial canals with a 5 mm radius of curvature and 60° angle of curvature. Twenty Mtwo instruments for each size were selected and divided into 2 groups: group A consisted of 10 instruments of each size used for shaping 10 root canals in molar teeth of patients by an experienced operator; group B consisted of 10 instruments of each size used for shaping 10 root canals in molar teeth of patients by a novice operator. Instruments were rotated until fracture occurred and the numbers of cycles to failure (NCF) were recorded. Data obtained were subjected to an independent sample t-test to determine statistical differences. The significance was determined at a 95% confidence level.

Results

No statistically significant difference (P<0.05) was noted between the instruments of groups A and B for all sizes. More instruments with visible signs of plastic deformation were identified for the novice operator.

Conclusions

The clinical use of Mtwo NiTi rotary instruments by a novice operator did not significantly affect the cyclic fatigue resistance when compared with the control group of the same instrument sizes used by an experienced operator. It can be concluded that novice operators can use these instruments safely under the recommended technical guidelines.

Influence of multiple clinical use on fatigue resistance of ProTaper rotary nickel-titanium instruments

AIM

To examine the influence of clinical use on the occurrence of deformation and fracture and on the fatigue resistance of ProTaper rotary instruments.

METHODOLOGY

Root canal treatments were performed on patients using the ProTaper rotary system. Ten sets of instruments were used by an experienced endodontist, each set in five molars. Another 10 sets of instruments were used by the same operator, each set in eight molars. In addition, 10 sets of instruments were used, each set in five molars, by undergraduate students with no clinical experience with the system. After clinical use, S1, S2, F1 and F2 instruments were analysed for damage by optical and scanning electron microscopy. The used sets, along with a control group of 12 sets of new instruments, were then tested in a bench device for fatigue resistance.

RESULTS

The use of the ProTaper rotary instruments by an experienced endodontist allowed for the cleaning and shaping of the root canal system of up to eight molars without fracture. During the students work, six instruments fractured. Fatigue resistance decreased upon clinical use for all instruments analysed.

CONCLUSIONS

Fatigue resistance of used instruments was reduced, but no significant change was observed amongst the instruments used for shaping the canals of five and eight molars. Operator experience affected the occurrence of fracture and plastic deformation during shaping.

A dozen ways to prevent nickel-titanium rotary instrument fracture

BACKGROUND

and Overview. With the increased use of nickel-titanium (NiTi) rotary instruments for root canal preparation in endodontics, instrument fracture has become more prevalent. Extensive research has been conducted on the physical properties and mechanical characteristics of NiTi rotary instruments, as well as the factors that can contribute to instrument failure. NiTi rotary instruments are subjected to torque and are susceptible to cyclic fatigue, which are the main causes of instrument fracture. However, with an understanding of how these instruments function in preparing root canals and by applying ways to reduce torque-generated metal fatigue, clinicians can use the instruments safely in clinical practice.

RESULTS

The author presents 12 measures that clinicians can take to prevent NiTi rotary instrument fracture and discusses them in detail.

CLINICAL IMPLICATIONS

NiTi rotary instrument fracture complicates the progress, and compromises the prognosis of endodontic treatment. However, when clinicians take appropriate measures, rotary instrument fractures can be prevented.

The influence of various automated devices on the shaping ability of Mtwo rotary nickel-titanium instruments

AIM

To compare the shaping ability of Mtwo rotary nickel-titanium instruments in simulated curved canals and in curved canals of extracted teeth when set into permanent rotation with two different torque-limited automated devices.

METHODOLOGY

Root canal instrumentation was performed with two different torque-limited automated devices (Mtwo direct handpiece and Endo IT motor) using Mtwo rotary nickel-titanium instruments up to size 35. Simulated canals: 28 degrees and 35 degrees curved canals in resin blocks (n = 20 canals in each group) were prepared. Pre- and post-instrumentation images were recorded and assessment of canal shape was completed with a computer image analysis program. Extracted teeth: a total of 40 curved root canals were divided into two groups, which were balanced with respect to the angle and the radius of canal curvature. Straightening of the canal curvatures was determined with a computer image analysis program. Incidence of canal aberrations, preparation time, changes of working length and instrument failures were recorded both in simulated and real canals and were analysed using the t-test and a chi-square test.

RESULTS

In simulated canals, instrumentation with Endo IT was significantly faster than with Mtwo direct (P < 0.05). No significant differences between the two devices were noted when all other parameters were assessed (P > 0.05). Only one instrument separated (Mtwo direct) during the enlargement of 28 degrees curved simulated canals. All systems maintained working distance well.

CONCLUSIONS

Both systems respected original root canal curvature well and were safe, indicating that the Mtwo direct handpiece is suitable for preparing curved root canals with the Mtwo instruments.

Nickel-titanium rotary instrument fracture: a clinical practice assessment

AIM

To prospectively determine the incidence of nickel-titanium rotary instrument fracture in an endodontic clinical practice setting.

METHODOLOGY

Eleven second year endodontic residents, using four nickel-titanium rotary instrument systems (ProFile, ProTaper, GTRotary and K3Endo) according to the recommendations of the manufacturers, instrumented 3181 canals in 1403 teeth of 1235 patients, in a dental school post-graduate endodontic clinic, in 1 year. The incidence of instrument fracture was determined based on the number of instruments used. When fracture occurred, data were collected concerning the type, size, taper and prior use of the fractured instruments, the length and location of the fragment within the root canal and the curvature of the canal.

RESULTS

The overall incidence of instrument fracture was 0.39%. The incidence of fracture for ProFile, ProTaper, GTRotary and K3Endo files was 0.28%, 0.41%, 0.39% and 0.52%, respectively. There was no statistically significant difference between instrument systems. The percentage of teeth in which instruments fractured was 1.9% (0.28% for anterior teeth, 1.56% for pre-molars and 2.74% for molars). A total of 26 instruments fractured, of which 23 had tapers of 0.06 or greater. Most of the fragments were located in the apical third of the root canal, and both the median and mode amongst the fragment lengths were 2 mm.

CONCLUSIONS

The low incidence of nickel-titanium rotary instrument fracture supports the continued use of these instruments in root canal treatment.

Fracture of ProFile nickel-titanium rotary instruments: a laboratory simulation assessment

AIM

To determine the incidence of ProFile nickel-titanium rotary instrument fracture in an endodontic laboratory simulation.

METHODOLOGY

Three hundred and sixty dental students used 2880 ProFile nickel-titanium rotary instruments to prepare 1440 simulated root canals in 720 plastic teeth, and another 2880 ProFile nickel-titanium rotary instruments to prepare 1440 natural root canals in 720 extracted teeth. A standardized crown-down rotary instrumentation technique was used, which included measures to prevent fracture. Rotary instrument fracture was monitored during and after completion of the laboratory simulation exercises to determine the incidence of fracture. When fracture occurred, data were collected concerning the size of the instrument, the length of the instrument fragment, the location of the fragment in the canal and the curvature of the canal in which the instrument fractured.

RESULTS

The incidence of instrument fracture was 0.41% in plastic simulated canals and 0.31% in natural root canals. The overall incidence of instrument fracture was 0.36%. Of the instruments that fractured 67% were size 25, 0.04 taper; and 81% of the fragments were located in the apical third of the canal. The mean, median and mode of the fragment lengths were all 3 mm.

CONCLUSIONS

The low overall incidence of fracture in this study suggests that ProFile rotary instruments are safe for use by dental students in laboratory simulations and that if preventive measures are taken the incidence of instrument fracture can be minimized.

Failure mechanism of ProTaper Ni-Ti rotary instruments during clinical use: fractographic analysis

AIM

To evaluate the failure mechanism of ProTaper Ni-Ti rotary instruments fractured under clinical conditions.

METHODOLOGY

A total of 46 ProTaper instruments that failed (fractured and/or plastically deformed) during the clinical use were collected from various dental clinics, whereas a new set of ProTaper instruments served as control. After inspection under stereomicroscopy the instruments were classified into three categories: (i) plastically deformed but not fractured, (ii) fractured with plastic deformation and (iii) fractured without plastic deformation. Three instruments from each group were analysed with computerized X-ray microtomography (micro-XCT) to detect surface and internal defects, whilst all the fracture surfaces were investigated under SEM.

RESULTS

Stereomicroscopic inspection showed that 17.4% of the discarded instruments were only plastically deformed, 8.7% were fractured with plastic deformation and 73.9% were fractured without plastic deformation. Micro-XCT revealed instruments without any surface or bulk defects along with a few files with crack development below the fracture surface. No defects were identified in the unused instruments. SEM examination of fractured surfaces demonstrated the presence of dimples and cones, a typical pattern of dimple rupture developed because of ductile failure.

CONCLUSIONS

The results suggest that a single overloading event causing ductile fracture of ProTaper instruments is the most common fracture mechanism encountered under the clinical conditions.

Influence of different types of automated devices on the shaping ability of rotary nickel-titanium FlexMaster instruments

AIM

To compare the shaping ability of rotary FlexMaster nickel-titanium instruments in simulated curved canals and in curved canals of extracted teeth when set into permanent rotation with three different torque-limited automated devices.

METHODOLOGY

Root canal instrumentation was performed with three different torque-limited automated devices (ENDOadvance, SIRONiTi and Endo IT motor) by FlexMaster nickel-titanium instruments up to size 35. Simulated canals: 28 degree and 35 degree curved canals in resin blocks (n = 20 canals in each group) were prepared. Pre- and post-instrumentation images were recorded and assessment of canal shape was completed with a computer image analysis program. Extracted teeth: A total of 60 curved root canals were divided into three groups, which were balanced with respect to the angle and the radius of canal curvature. Straightening of the canal curvatures was determined with a computer image analysis program. Incidence of canal aberrations, preparation time, changes of working length and instrument failures were recorded both in simulated and real canals.

RESULTS

In simulated and real canals, instrumentation with Endo IT was significantly faster than with SIRONiTi (P < 0.05). With respect to canal aberrations in simulated canals, there were no significant differences between the devices (P > 0.05), even though more aberrations were created with ENDOadvance and SIRONiTi. In real canals, the Endo IT motor resulted in significantly less straightening during instrumentation (P < 0.05) than SIRONiTi. A total of three instruments separated (one file in each group) during the enlargement of 35 degree curved simulated canals. All systems maintained working distance well.

CONCLUSIONS

All systems respected original root canal curvature well and were safe, indicating that torque-limited rotation handpieces are suitable for preparing curved root canals.

Comparison of root canal preparation using RaCe and ProTaper rotary Ni-Ti instruments

AIM

To compare various parameters of root canal preparation using RaCe (FKG Dentaire, La-Chaux-de-Fonds, Switzerland) and ProTaper (Dentsply Maillefer, Ballaigues, Switzerland) nickel-titanium (Ni-Ti) instruments.

METHODOLOGY

Fifty extracted mandibular molars with mesial root canal curvatures between 20 degrees and 40 degrees were embedded in a muffle system. All root canals were prepared to size 30 using RaCe or ProTaper rotary instruments in low-torque motors with torque control and constant speed of 300 r.p.m. (ProTaper with ATR Tecnika, Advanced Technology Research, Pistoia, Italy; RaCe with EndoStepper, S.E.T., Olching, Germany). In both groups irrigation was performed with 2 mL NaOCl (3%) after each instrument size. Calcinase-Slide (lege artis, Dettenhausen, Germany) was used as a chelating agent with each instrument. The following parameters were evaluated: straightening of curved root canals, postoperative root canal cross-sections, safety issues and working time. Cleanliness of the root canal walls was investigated under the SEM using 5-score indices for debris and smear layer. Statistical analysis was performed using the following tests: Wilcoxon's test for straightening and working time was used (P < 0.05); Fisher's exact test for comparison of cross-sections and root canal cleanliness (P < 0.05).

RESULTS

Both Ni-Ti systems maintained curvature well; the mean degree of straightening was less than 1 degrees for both systems. Following preparation with RaCe, 49% of the root canals had a round or oval diameter and 50% an irregular diameter, ProTaper preparations resulted in a round or oval diameter in 50% of the cases. For debris, RaCe and ProTaper achieved 47 and 49% scores of 1 and 2, respectively; there was no significant difference. For smear layer, RaCe and ProTaper achieved 51 and 33% scores 1 and 2, respectively; no statistically significant differences were apparent for the coronal and middle sections of the root canals, but RaCe performed significantly better in the apical region (Fisher's exact test, P = 0.0392). Two roots lost working length with RaCe instruments, whilst ProTaper preparation resulted in two roots loosing working length and one fractured instrument. Mean working time was shorter for ProTaper (90.9 s) than for RaCe (137.6 s); the difference was significant (Wilcoxon's test, P = 0.011).

CONCLUSIONS

Both systems respected original root canal curvature well and were safe to use. Cleanliness was not satisfactory for both systems.

Analysis of torque and force with differently tapered rotary endodontic instruments in vitro

The aim of this study was to compare torques and forces developed by two sequences of nickel-titanium rotary instruments, using only .04 taper instruments or a combination of .04 and .06 tapers, respectively. Curved canals in plastic blocks were shaped in a torque-testing device; torque, force, contact areas and numbers of working rotations were determined. Analysis of variance and Pearson correlation coefficients were used to compare the two sequences. Mean torque ranged from 0.2 +/- 0.03 to 3.19 +/- 0.28 Ncm and was higher for instrument sizes 25 to 45 in group A. Mean vertical forces ranged from 1.49 +/- 0.54 to 12.0 +/- 3.5 N; there were significant correlations between torque and force as well as between torque and contact areas. Numbers of rotations were lower in the combined .04 and .06 sequence. An instrumentation sequence encompassing various tapers seems to be safer regarding torsional and fatigue failure compared to a sequence that used one single taper. However, the former sequence requires the use of more instruments.

Current Challenges and Concepts in the Preparation of Root Canal Systems: A Review

Nickel-titanium rotary instruments are important adjuncts in endodontic therapy. This review attempts to identify factors that influence shaping outcomes with these files, such as preoperative root-canal anatomy and instrument tip design. Other, less significant factors include operator experience, rotational speed, and specific instrument sequence. Implications of various working length definitions and desired apical widths are correlated with clinical results. Despite the existence of one ever-present risk factor, dental anatomy, shaping outcomes with nickel-titanium rotary instruments are mostly predictable. Current evidence indicates that wider apical preparations are feasible. Nickel-titanium rotary instruments require a preclinical training period to minimize separation risks and should be used to case-related working lengths and apical widths. However, and despite superior in vitro results, randomized, clinical trials are required to evaluate outcomes when using nickel-titanium instruments.