Influence of autoclave sterilization procedures on the cyclic fatigue resistance of heat-treated nickel-titanium instruments: a systematic review

Effect of simulated clinical use and sterilization on the cyclic fatigue resistance of nickel titanium files

Aim

Assess the effect of simulated clinical use and sterilization on the cyclic fatigue resistance of Race Evo and Tia Tornado Blue nickel titanium (NiTi) files.

Materials and Methods

For this study, a total of sixty-four NiTi files were selected, with thirty-two files each from two different manufacturers. Files from each manufacturer were subdivided into four subgroups (n = 8) based on the test parameters. The control groups included files that were neither used nor sterilized. Files from the test groups were used to prepare the root canals of extracted mandibular premolars and then sterilized. This procedure was repeated once, twice, or thrice, depending on the test group. All files were then subjected to a cyclic fatigue test. Data was statistically analyzed using the Kruskal-Wallis and Mann-Whitney U tests.

Results

No significant difference was observed in the number of cycles to failure (NCF) among the subgroups for both types of files (P = 0.869 for Tia Tornado Blue, P = 0.626 for Race Evo). Tia Tornado Blue files displayed significantly higher NCF values in the control (P = 0.021), once (P = 0.027), and thrice (P = 0.031) usage groups when compared to Race Evo files.

Conclusions

Repeated clinical use and sterilization for up to three cycles did not affect the cyclic fatigue resistance of Race Evo and Tia Tornado Blue files.

Cyclic Fatigue of Different Ni-Ti Endodontic Rotary File Alloys: A Comprehensive Review

INTRODUCTION

Modern endodontics aims to decrease the bacterial load from the complex endodontic space. Over the years, improvements in the operative phases have led to a considerable increase in the success rate of endodontic treatments. The shaping phase has seen the development of new techniques supported by technological innovations that have led to higher treatment predictability. Endodontic instruments have experienced a series of changes that have led to modifications in their design, surface treatments, and heat treatments. The clinical use of rotating nickel-titanium instruments has become widespread and consolidated, a success due primarily to the alloy's mechanical characteristics, which are superior to steel ones, but also to innovations in instrument design. The advent of the Ni-Ti alloy has kept the concepts and requirements of shaping the same but has modified its implementation in endodontics.

AIM

The following review followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) protocol. The research question focused on Ni-Ti endodontic instruments whose cyclic fatigue was evaluated by analyzing cyclic fatigue strength and the incidence of fracture.

RESULTS

At the end of the research, 10 systematic reviews and 1 randomized controlled trial were included in this comprehensive review. The most frequently analysed alloys were M-wire, conventional Ni-Ti, and CM-wire. In seven articles, instruments made of M-wire alloy were used; in eight articles, instruments made of conventional Ni-Ti; and in seven articles, instruments made of CM-wire alloy.

CONCLUSIONS

The technological evolution of Ni-Ti alloys has led to the development of increasingly high-performance endodontic files that are resistant to cyclic fatigue during clinical practice and have greater resistance to sterilisation practices, making treatment easier and more predictable over time. In particular, heat-treated nickel-titanium root canal instruments present greater resistance to cyclic fatigue than untreated ones and those used with reciprocating kinematics concerning continuous rotation.

Cyclic Fatigue Resistance of Rotary versus Reciprocating Endodontic Files: A Systematic Review and Meta-Analysis

(1) Background: The failure of nickel-titanium (NiTi) rotary files is a complication related to endodontic instruments. The aim of this study was to compare the resistance to cyclic fatigue between rotary and reciprocating file systems. (2) Methods: Specific PICO: Population (P): artificial root canals; Interventions (I): instrumentation with NiTi rotary and reciprocating files; Comparison (C): rotary versus reciprocating files; Outcome (O): cyclic fatigue resistance. Studies were identified through bibliographic research using electronic databases (Medline, Embase, Scopus, SciELO, and WOS). The studies were combined using a random effects model by the inverse variance method. The effect size was the mean of the time to fracture (TTF) and number of cycles to fracture (NCF). Heterogeneity was assessed using the p value of the Q test for heterogeneity and the I2. (3) Results: TTF for rotary files was determined in 474.5 s and 839.1 for reciprocating without statistically significant differences. NCF for rotary systems was determined in 1444.2 and for reciprocating file systems in 4155.9 with statistically significant differences (p = 0.035), making reciprocating files more resistant. (4) Conclusions: Reciprocating files have better resistance to cyclic fatigue than rotary files. When tested in double curvature canals, reciprocating files also showed higher resistance.

Influence of sodium hypochlorite on cyclic fatigue resistance of nickel-titanium instruments: A systematic review and meta-analysis of in vitro studies

OBJECTIVE

This systematic review/meta-analysis investigated the influence of NaOCl on cyclic fatigue resistance of endodontic NiTi instruments.

MATERIALS AND METHODS

A systematic search until July 2022 in PubMed/MEDLINE, Embase, Scopus, Web of Science, SciELO, Cochrane Library, and grey literature was conducted. According to the PECOS strategy, only in vitro studies evaluating the effects of NaOCl on the cyclic fatigue resistance of NiTi instruments were eligible. Cyclic fatigue resistance was the primary outcome. A modified Joanna Briggs Institute's Checklist was used for risk of bias assessment.

RESULTS

Of the 2,445 records screened, 37 studies were included. Most studies used simulated canals made of stainless-steel block with severe to moderate curvatures. NaOCl concentration varied from 1-6%, mainly at 37 °C. Regarding fatigue resistance, 23 studies using 1.2% to 6% NaOCl showed a reduction in the resistance compared to the control groups, especially when pre-heated. Four meta-analyses were performed according to the tested NiTi systems. The meta-analyses indicated that the PTU F2 files had higher reduction of fatigue resistance after exposure to 5.25% NaOCl; no differences between NaOCl and no immersion were observed for Reciproc R25, WaveOne 25.08, and WaveOne Gold Primary files. Included studies had low risk of bias.

CONCLUSION

NaOCl appears to reduce cyclic fatigue resistance of certain NiTi files, especially when they are pre-heated, particularly in conventional NiTi files compared to some heat-treated instruments. It is possible that the temperature of the solution may have a greater influence on resistance than NaOCl itself. Important to note that an overall tendency toward no significant influence was observed among various systems.

CLINICAL RELEVANCE

Precautions are necessary when a pre-heated high-concentration NaOCl is used to enhance its properties during root canal preparation, mainly using conventional wire.

Cyclic fatigue resistance of EdgeTaper Platinum, Protaper Gold, and TruNatomy Prime rotary files before and after autoclave sterilization

Background

This in vitro investigation aimed to determine the influence of multiple autoclave cycles on the cyclic fatigue resistance of three heat-treated nickel-titanium (NiTi) files: EdgeTaper Platinum (ETP), ProTaper Gold (PTG), and TruNatomy Prime (TN).

Materials

Sixty NiTi files, twenty of each NiTi file type: ETP 25/.06, PTG 25/.08, and TN 26/.04 were randomly divided into four equal subgroups (n = 5). The files for the control group were left un-autoclaved. Different autoclave sterilization cycles (one, five, and ten) were used for the other three groups. The files were then placed in a metal canal block and rotated according to the manufacturer's instructions until fracture. The length of the broken segment and the time taken for fracture were measured. The fractured surfaces were subsequently subjected to SEM imaging. The Kruskal-Wallis test was used to analyze the data, followed by Dunn-Bonferroni pairwise comparisons. Statistical significance was set at p < 0.05.

Results

ETP showed significantly greater resistance to cyclic fatigue than TN in all autoclave groups and PTG after five autoclave cycles (p = 0.014). Fatigue resistance was not affected by the number of autoclaving cycles, except for ETP. After the first and tenth autoclaving cycles, they required significantly more rotations to failure than the non-sterilized files (p = 0.039 and p = 0.021, respectively). The fractured segments of the ETP files in these two groups were also longer than those in the control group (p = 0.010).

Conclusion

The cyclic fatigue resistance of ETP was greater than that of TN in all tested conditions. Repeated autoclave cycles of sterilization improved the cyclic fatigue resistance of the ETP files only and did not affect the cyclic fatigue resistance of TN and PTG. However, the ETP files separated at a longer distance from the tip with increased autoclaving cycles.

Fracture Resistance of Heat-Treated Nickel-Titanium Rotary Files After Usage and Autoclave Sterilization: an in vitro study

INTRODUCTION

This study aimed to evaluate the dynamic cyclic fatigue resistance of heat-treated nickel-titanium (NiTi) files after usage and autoclaving.

METHODS

Two heat-treated NiTi file systems with the tip sizes of #25 of ProTaper Gold F2 (PG) and TruNatomy Prime (TN) were selected. Files in each system was divided into three experimental subgroups (n=10). For subgroup-1, new files were tested to establish baseline number of cycles to failure (NCF). For subgroup-2, files underwent canal instrumentation in a simulated J-shaped canal block with the 35-degree of curvature with 16.5-mm of length. The simulated canals were pre-enlarged using stainless-steel files, #10K and #15K. After instrumentation, the files were tested. For subgroup-3, files underwent canal instrumentation as in subgroup-2 and followed by autoclave sterilization then were tested for cyclic failure. Cyclic fatigue test was performed in dynamic pecking motion under body temperature. The time to fracture was recorded and calculated into NCF. Fracture fragments lengths were measured using digital microcaliper. Statistical analysis was conducted using independent t-test and multi-factorial analysis of variance with 95% significance. Scanning electron microscopy was used to examine the topographic characteristics after cyclic fatigue tests.

RESULTS

There were no significant differences between file systems in subgroup-1 using new files (P<.05). While PG reduced the NCF after use, TN showed significantly increased NCF (P<.05). However, after sterilization, TN showed reduced NCF than the used one (P<.05).

CONCLUSIONS

Cyclic loading by usage and heat treatment during sterilization may result in different cyclic fatigue resistance according to the geometry and alloy characteristics.

Effect of body temperature on the cyclic fatigue resistance of the nickel”titanium endodontic instruments: A systematic review and meta-analysis of in vitro studies

Aim:

The aim of this systematic review was to compare the effect of body temperature (I) on the cyclic fatigue resistance (O) of nickel–titanium (NiTi) endodontic instruments (P) to that of room temperature (C).

Methods:

The study was registered in the PROSPERO database (CRD42020204286). A systematic search in PubMed, Scopus, Web of Science, Google Scholar, and OpenGrey was conducted in English until December 31, 2021. In vitro studies comparing the cyclic fatigue resistance of NiTi instruments at the body (35°C ± 2°C) and room temperature (20°C–25°C) were included. Eligible studies were evaluated for risk of bias and meta-analyzed to estimate the effects.

Results:

Twenty-one studies out of 347 met the criteria for inclusion. The meta-analysis included six studies (n = 215) with comparative study parameters. The overall effect sizes (5.49; 95% confidence interval [CI]: 4.04–6.93) were significantly different (P < 0.001), indicating that the mean values at room temperature were significantly (P < 0.001) higher. The effect sizes for full rotary motion (standardized mean difference [SMD]: 4.80; 95% CI: 3.04–6.56) and reciprocating motion (SMD: 6.37; 95% CI: 3.63–9.11) were not significantly different (P = 0.346). Heterogeneity was high (I² = 94%). Sensitivity analysis revealed that the SMD values were not significantly different (P > 0.05) from the overall effect size, indicating that none of the studies had an effect on the overall effect size.

Conclusions:

Within the limitation of the study, the cyclic fatigue resistance of heat-treated NiTi endodontic files is significantly reduced at body temperature when compared to room temperature. Cyclic fatigue testing should be conducted at simulated body temperature.

Effect of Autoclaving Cycles on the Cyclic Fatigue Resistance of Race and Race Evo Nickel-Titanium Endodontic Rotary Files: An In Vitro Study

Objective: The aim of this study was to evaluate the influence of autoclave sterilization on the resistance to cyclic fatigue of two nickel-titanium (NiTi) endodontic files of identical design and taper, but with different NiTi alloy treatments: the newly introduced heat-treated Race Evo and the electropolished Race files. Materials and methods: Fifteen Race (25/0.06) files and fifteen Race Evo (25/0.06) files (n = 30 in total) were randomly assigned to five sub-groups each consisting of three files of the same NiTi alloy treatment. One group served as a control with files unautoclaved. The four remaining groups were sterilized in a steam sterilizer for 1, 3, 5, and 10 autoclave cycles, respectively. Files then underwent cyclic fatigue testing in a simulated metal canal block. A scanning electron microscope was used to inspect the surface of the fractured instruments. Statistical analysis was conducted using independent t-test and multi-factorial analysis of variance with significance set at a p value of ≤0.05. Results: Both Race Evo and Race files showed no significant difference between the different autoclaving cycles in terms of the number of cycles to fracture (p = 0.232 and p = 0.359). Despite rotating at a higher speed, the number of cycles to fracture of heat-treated Race Evo files was significantly higher than that of Race files (p ≤ 0.0001). Conclusion: Autoclave sterilization has no significant effect on the resistance to cyclic fatigue of heat-treated Race Evo or electropolished Race files. However, Race Evo files showed superior resistance to cyclic fatigue irrespective of autoclaving cycles.

Effect of number of uses and sterilization on the instrumented area and resistance of reciprocating instruments

Objectives

This study evaluated the effect of repeated uses and autoclaving in the instrumented area, fracture resistance, and time of instrumentation of thermally treated nickel-titanium reciprocating systems.

Materials and Methods

Two hundred simulated canals were instrumented using Reciproc Blue and WaveOne Gold. Each file was used up to 10 times or until fracture. The instrumented area was measured in pre- and post-operative images, using ImageJ software. Kaplan-Meier survival analysis evaluated the number of uses of instruments before fracture. Instrumented area and time of instrumentation were analyzed by Mann-Whitney U test and Kruskal-Wallis. Correlations among the number of uses and instrumented area were measured. The level of statistical significance was set at p < 0.05.

Results

Reciproc Blue presented a higher estimated number of uses in comparison with WaveOne Gold (p = 0.026), but autoclaving did not affect the resistance to fracture of instruments (p > 0.05). The instrumented area was different among the evaluated groups (p = 0.039), and the instrumented area along the uses of both tested instruments was reduced. With the time of instrumentation, there was also a significant difference among the evaluated groups; the groups without sterilization cycles were faster, in comparison to those submitted to autoclaving (p = 0.010).

Conclusions

Reciproc Blue was more resistant than WaveOne Gold, suffering later fracture. Additionally, the sterilization cycles did not influence the estimated number of uses of thermally treated reciprocating instruments, but the instrumented area of root canals was reduced along with the repeated uses of both instruments.