Basic ResearchTechnology

Incidence of Apical Root Cracks and Apical Dentinal Detachments after Canal Preparation with Hand and Rotary Files at Different Instrumentation Lengths
Rui Liu, DDS,* Anjali Kaiwar, MDS, Hagay Shemesh, DDS, PhD, Paul R. Wesselink, DDS, PhD, Benxiang Hou, DDS, PhD,* and Min-Kai Wu, MSD, PhD
Abstract
Introduction: The aim of this study was to compare the incidence of apical root cracks and dentinal detachments after canal preparation with hand and rotary les at different instrumentation lengths. Methods: Two hundred forty mandibular incisors were mounted in resin blocks with simulated periodontal ligaments, and the apex was exposed. The root canals were instrumented with rotary and hand les, namely K3, ProTaper, and nickel-titanium Flex K les to the major apical foramen (AF), short AF, or beyond AF. Digital images of the apical surface of every tooth were taken during the apical enlargement at each le change. Development of dentinal defects was determined by comparing these images with the baseline image. Multinomial logistic regression test was performed to identify inuencing factors. Results: Apical crack developed in 1 of 80 teeth (1.3%) with hand les and 31 of 160 teeth (19.4%) with rotary les. Apical dentinal detachment developed in 2 of 80 teeth (2.5%) with hand les and 35 of 160 teeth (21.9%) with rotary les. Instrumentation with rotary les terminated 2 mm short of AF and did not cause any cracks. Signicantly less cracks and detachments occurred when instrumentation with rotary les was terminated short of AF, as compared with that terminated at or beyond AF (P < .05). The AF deviated from the anatomic apex in 128 of 240 teeth (53%). Signicantly more apical dentinal detachments appeared in teeth with a deviated AF (P = .033). Conclusions: Rotary instruments caused more dentinal defects than hand instruments; instrumentation short of AF reduced the risk of dentinal defects. (J Endod 2013;39:129132)

otary instrumentation requires less time to prepare canals as compared with hand instrumentation (1). However, rotary les with large tapers may cause signicantly more complete and incomplete dentinal cracks than S-Apex rotary les with an inverted taper and exible hand les with .02 taper (2). These localized defects (35) may have the potential to develop into fractures (6). For minimizing the burden of root canal infection, infected canals should be cleaned to a level as close to the major apical foramen (AF) as possible (7, 8). The downside is the risk of overinstrumentation (9), which may cause postoperative pain (10) and hinder apical healing signicantly (1113). Furthermore, instrumentation to AF could cause more apical root cracks than instrumentation short of AF (5). The purpose of this study was to compare the incidence of apical root cracks after canal preparation with hand and rotary les at different instrumentation lengths.

Materials and Methods

Extracted mandibular incisors with straight roots were selected. Before and during the experiment, teeth were always stored in puried ltered water. Teeth presented with fracture lines, open apices, or anatomic irregularities were discarded. Radiographs were taken to verify the presence of a single canal.

Groups
Two hundred forty teeth were instrumented by using rotary and hand les, namely K3 (Dentsply Maillefer, Ballaigues, Switzerland), ProTaper (Dentsply Maillefer), and nickel-titanium Flex K les (Dentsply Maillefer). Instrumentation was terminated at different levels: AF, instrumentation terminated at AF; AF+1 mm, instrumentation 1 mm beyond the AF; AF1 mm, instrumentation 1 mm short of the AF; and AF2 mm, instrumentation 2 mm short of the AF. Twelve groups (n = 20) were formed according to the le type and instrumentation length. The root width was measured buccolingually and mesiodistally 5 mm from the apex. The 12 groups were comparable in root width.

Key Words
Apical root crack, apical dentinal detachment, instrumentation length, rotary instrument

Experimental Setup The crowns were removed 2 mm above the proximal cementoenamel junction. The distance between the coronal end and AF of each root was determined by inserting a size #10 le into the canal until the tip of the le was just visible at the AF. Each root was wrapped with a single layer of aluminum foil and embedded in acrylic resin (Duralay Dental MFg Co, Worth, IL) set in an acrylic tube. The root was then removed from the

From the *Department of Endodontics, Capital Medical University School of Stomatology, Beijing, China; V. S. Dental College, Bangalore, India; and Department of Endodontology, Academic Centre of Dentistry Amsterdam (ACTA), University of Amsterdam and VU University, Amsterdam, The Netherlands. Address requests for reprints to Dr Hagay Shemesh, Department of Endodontology, Academic Centre of Dentistry Amsterdam (ACTA), University of Amsterdam and VU University, Amsterdam, The Netherlands. E-mail address: hshemesh@acta.nl 0099-2399/$ - see front matter Copyright 2013 American Association of Endodontists. http://dx.doi.org/10.1016/j.joen.2012.09.019

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tube, and the aluminum foil was peeled off. A hydrophilic vinyl polysiloxane impression material (Provil Novo; Heraeus Kulzer GmbH, Hanau, Germany) that replaced the space created by the foil represented a simulated periodontal ligament (6), and the root was immediately repositioned. The apical 3 mm of the root was exposed and immersed in water during instrumentation, as shown in Figure 1. The size of the rst instrument that initiated the crack or detachment was recorded for each root with a defect.

Root Canal Instrumentation Image Recordings Two calibrated operators performed all root canal instrumentations, and the specimens were evenly distributed. The cervical and middle thirds of each canal were ared with #2 and #1 Gates-Glidden drills (Dentsply Maillefer). The root apex was stained with 1% methylene blue solution, and images were recorded before and after coronal aring by using a stereomicroscope (Zeiss Stemi SV6; Carl Zeiss, Jena, Germany) under 20 magnication. Instrumentation with K3 and ProTaper les was done with a lowtorque motor (VDW, Munich, Germany) at a constant speed of 300 rpm. Composite resin was used to x rubber stoppers to control instrumentation length. When instrumentation length was AF1 mm or AF2 mm, apical patency was maintained after each le by inserting #10 K-le (Dentsply Maillefer) until it appeared at the AF. Each canal was irrigated by using a syringe and a 27-gauge needle with 2 mL of a freshly prepared 2% NaOCl solution between the use of each instrument. K3 les were used in a crown-down sequence by using #35 .04 taper, #30 .06 taper, #30 .04 taper, and #25 .06 taper le until 1.5 mm short of the full instrumentation length. Thereafter, each root canal was enlarged to the full instrumentation length according to the following sequence: #25 .04 taper, #25 .06 taper, #30.04 taper, #30 .06 taper, and #35 .04 taper. A total of 8 images were recorded of each root before and after the crown-down preparation and at each le change during the apical enlargement. ProTaper les were used in the following sequence; Sx prepared the coronal half of the canal, and thereafter, S1, S2, F1, F2, and F3 were used to the full instrumentation length. A total of 8 images were recorded of each root during the apical enlargement at each le change. Nickel-titanium Flex hand les were used with the balanced force technique as described by Roane et al (14). Hand le sizes 2035 were used to the full instrumentation length. Step-back was performed by using size 4050 les. A total of 10 images were recorded of each root during instrumentation at each le change. Presence of cracks and dentinal detachments was determined by comparing the baseline image of each root with the later images of the same root. Any visible crack line that was not present in the preceding image was recorded as a crack. Dentinal detachment was dened as a missing portion of the apex that was present in the preceding image or zipping of the AF that was diagnosed when the ratio of long to short AF diameter was obviously higher than the ratio in the preceding image.

Sectioning and Microscopic Observation Twelve roots with apical cracks were horizontally sectioned 2 mm from the AF with a low-speed saw (Leica SP1600, Wetzlar, Germany) under water cooling (4). Slices were then viewed through a stereomicroscope (Zeiss Stemi SV6) by using a cold light source (KL 2500 LCD; Carl Zeiss) at a magnication of 20. Statistical Analysis Multinomial logistic regression test was used to explore the inuence of the le used and instrumentation length on the appearance of apical crack and dentinal detachment by using the SPSS/PC version 20 software (SPSS Inc, Chicago, IL). Covariates analyzed included operator, the size of the rst instrument that initiated root defect, and the position of AF (either in the center of the root or deviated from the apex). The level of signicance was set at a = 0.05.

Results
No cracks were observed after coronal aring with Gates-Glidden drills. Results are shown in Table 1 and Figure 2. Logistic regression analysis revealed that operator (P = .668 for crack, P = .292 for detachment) was not an inuencing factor for the initiation of defects. Type of le, instrumentation length, and instrument size signicantly inuenced the incidence of cracks (P < .05) and apical dentinal detachment (P < .05). K3 (P = .021) and ProTaper (P = .015) caused more cracks than hand les. Instrumentation short of AF caused signicantly less cracks than instrumentation to or beyond AF (P < .001). Instrumentation to AF (P = .019) or beyond AF (P = .012) caused signicantly more detachments than instrumentation 2 mm short of AF. No cracks were observed after crown-down preparation with K3 instruments or after preparation with ProTaper instruments Sx and S1. Interestingly, the rst instruments that initiated cracks were more often the smaller les rather than large les (P < .001). A crack was already observed in 27 of 32 teeth (84.4%) after #30.04 taper or F1 (Table 1). The AF deviated from the anatomic apex in 128 of 240 teeth (53%). The percentage of roots with cracks was 37% in teeth with a deviated AF, 10% higher than that in teeth with AF in the center of the root (P = .919). Deviation of AF signicantly inuenced development of dentinal detachment (P = .033). The incidence of dentinal detachments was 62% in teeth with a deviated AF but 18% in teeth with AF in the center of the root when instrumentation was terminated at AF and AF+1 mm.
TABLE 1. Cracks and Dentinal Detachments Generated According to Instrumentation Length and File Type Instrumentation length Defects
Crack Detachment

File type*
K3 ProTaper Hand le K3 ProTaper Hand le

AF+1 mm
6 8 0 7 8 2

AF
7 5 1 7 9 0

AF1 mm
2 3 0 1 2 0

AF2 mm
0 0 0 1 0 0

Total
15 16 1 16 19 2

Figure 1. Schematic representation of the experimental setup.

*Eighty teeth were instrumented with each le type, 20 of 80 teeth for each instrumentation length.

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Figure 2. (AC) Images taken during instrumentation with K3 working to AF+1 mm. (A) Baseline: 2 apical foramina and a major apical foramen that deviates from the apex. (B) After instrumentation with K3 size 25/.04, a crack (arrow) was initiated. (C) After instrumentation with K3 size 30/.04, loss of tooth structure occurred between 2 foramina (arrow). (D and E) Images taken during instrumentation with K3 working to AF. (D) Baseline: the major apical foramen deviates from the apex. (E) After instrumentation with K3 size 30/.06, a crack line was visible (arrow). (F and G) Images taken during instrumentation with ProTaper working to AF+1 mm. (F) Baseline. (G) After instrumentation with ProTaper F2, cracks (arrow) were initiated. (H) Cross-section cut 2 mm short of AF, a complete crack extended from the root canal to the outer root surface (arrow).

In teeth instrumented with hand les, a crack was observed in 1 of 80 teeth (1.3%); detachment was observed in 2 of 80 teeth (2.5%). The AF deviated from the apex in 2 of the 3 teeth with dentinal defects. Crack lines were observed on 9 of 12 horizontal sections (75%). Three of them were complete, extending from the root canal to the outer surface (Fig. 2H), 5 were incomplete, extending from the root canal into the dentin, and 1 was incomplete, extending from the outer root surface into the dentin.

Discussion
In a study by Bier et al (2), exible K-les with a .02 taper caused signicantly less cracks than rotary les with large taper. Similarly, in this study, the consequences of taking a ProTaper le with a .09 taper in the apical portion past the AF were drastically different than taking a #35 hand le with an .02 taper 1 mm past the AF (Table 1). Furthermore, the torque increases with the penetration depth of the instrument (15) and counterclockwise movement of les in the balanced force technique reduced the penetration depth and the torque generated (16). Adorno et al (17) found no statistical difference in crack propagation between hand and rotary instruments, probably because rigid stainless steel hand les were used. Canal preparation with rotary les should be terminated 2 mm short of AF that did not cause cracks, whereas the apical 2 mm should be prepared with exible hand les only.
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Although instrumentation procedures should be limited within the AF, unintentional overinstrumentation may not be avoided (9). When instrumentation with K3 and ProTaper les was terminated at AF and AF+1 mm, cracks developed in 26 of 80 teeth (32%), and missing portion of the apex or zipping of AF took place in 31 of 80 teeth (38%) (Table 1) (Fig. 2). Therefore, instrumentation to AF or beyond AF may clean the most apical portion of the main canal (7, 18) but increases the risk of apical dentinal defects (Table 1). Martos et al (19) reported deviation of AF from the apex in 34% 92% of examined teeth. Deviation of AF was observed in 53% teeth in this study, which might be, among others, a contributing factor in the initiation of dentinal defects. In teeth with a deviated AF, a curvature must have been present in the very apical region, and the radius of the curvature could be small. It has been recognized that canal curvature with a small radius results in increased fracture susceptibility (20, 21). No cracks were generated when instrumentation was terminated at AF2 mm, possibly because the sharp apical curvature was located within the apical 2 mm. However, cracks were also observed in teeth with AF in the center of the root. Complete and incomplete cracks were observed in 9 of 12 sectioned teeth (75%). Clinically, bacteria may proliferate in crack lines and later establish biolms on the root surface (22). Furthermore, the localized dentinal defects may develop into root fractures (6). 131

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In both the study by Adorno et al (5) and the present study, mandibular incisors were instrumented to #35 le, which facilitated apical irrigation with 27-gauge needle. The experimental setup used in this study allowed recordings of the effects of each le size on the generation of dentinal defects during instrumentation. Because cracks already occurred after the use of #30 le in 84.4% of cracked teeth, reducing the apical size of the nal preparation to #30 le may not help in reducing the incidence of cracks. This is in agreement with Adorno et al (17), who also found that cracks were mostly initiated with small instruments rather than larger ones. In this study, the root tip was immersed in water during instrumentation to prevent dehydration of the root. Composite resin was used to x the rubber stop, which otherwise could move during instrumentation. Under the conditions in this study, rotary instruments caused more dentinal defects than exible hand instruments; instrumentation short of AF reduced the risk of dentinal defects.
5. Adorno CG, Yoshioka T, Suda H. Crack initiation on the apical root surface caused by three different nickel-titanium rotary les at different working lengths. J Endod 2011;37:5225. 6. Wilcox LR, Roskelley C, Sutton T. The relationship of root canal enlargement to nger-spreader induced vertical root fracture. J Endod 1997;23:5334. 7. West JD, Roane JB. Cleaning and shaping the root canal system. In: Cohen S, Burns RC, eds. Pathways of the Pulp, 7th ed. St Louis, MO: Mosby; 1998:20357. 8. Wu MK, Wesselink PR, Walton RE. Apical terminus location of root canal treatment procedures. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:99103. 9. EIAyouti A, Weiger R, Lst C. Frequency of overinstrumentation with an acceptable o radiographic working length. J Endod 2001;27:4952. 10. Nehammer CF. Treatment of the emergency patient. Br Dent J 1985;158:24554. 11. Bergenholtz G, Lekholm U, Milthon R, Engstrm B. Inuence of apical overinstruo mentation and overlling on re-treated root canals. J Endod 1979;5:3104. 12. Yusuf H. The signicance of the presence of foreign material periapically as a cause of failure of root treatment. Oral Surg Oral Med Oral Pathol 1982;54:56674. 13. Ricucci D, Langeland K. Apical limit of root canal instrumentation and obturation, part 2: a histological study. Int Endod J 1998;31:394409. 14. Roane J, Sabala C, Ducanson M. The balanced force concept for instrumentation of curved canals. J Endod 1985;11:20311. 15. Blum JY, Machtou P, Ruddle C, Micallef JP. Analysis of mechanical preparations in extracted teeth using ProTaper rotary instruments: value of the safety quotient. J Endod 2003;29:56775. 16. Blum JY, Machtou P, Esber S, Micallef JP. Analysis of forces developed during root canal preparation with the balanced force technique. Int Endod J 1997;30:38696. 17. Adorno CG, Yoshioka T, Suda H. The effect of root preparation technique and instrumentation length on the development of apical root cracks. J Endod 2009;35: 38992. 18. Buchanan LS. The standardized-taper root canal preparation, part2: GT le selection and safe handpiece-driven le use. Int Endod J 2001;34:6371. 19. Martos J, Lubian C, Silveira LFM, et al. Morphologic analysis of the root apex in human teeth. J Endod 2010;36:6647. 20. Lertchirakarn V, Palamara JE, Messer HH. Patterns of vertical root fracture: factors affecting stress distribution in the root canal. J Endod 2003;29:5238. 21. Sathorn C, Palamara JE, Palamara D, Messer HH. Effect of root canal size and external root surface morphology on fracture susceptibility and pattern: a nite element analysis. J Endod 2005;31:28892. 22. Shen Y, Stojicic S, Haapasalo M. Antimicrobial efcacy of chlorhexidine against bacteria in biolms at different stages of development. J Endod 2011;37:65761.

Acknowledgments
The authors deny any conicts of interest related to this study.

References
1. Pasqualini D, Scotti N, Tamagnone L, et al. Hand-operated and rotary ProTaper instruments: a comparison of working time and number of rotations in simulated root canals. J Endod 2008;34:3147. 2. Bier CA, Shemesh H, Tanomaru-Filho M, et al. The ability of different nickel-titanium rotary instruments to induce dentinal damage during canal preparation. J Endod 2009;35:2368. 3. Sathorn C, Palamara, Messer HH. A comparison of the effects of two canal preparation techniques on root fracture susceptibility and fracture pattern. J Endod 2005; 31:2837. 4. Shemesh H, Bier CA, Wu MK, et al. The effects of canal preparation and lling on the incidence of dentinal defects. Int Endod J 2009;42:20813.

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