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Original Article

The self-adjusting file instrumentation results


in less debris extrusion apically when compared
to WaveOne and ProTaper NEXT
Ajinkya M. Pawar, Mansing G. Pawar1, Zvi Metzger2, Sharad R. Kokate3
Departments of Conservative Dentistry and Endodontics, Dnyandeo Yashwantrao Patil Dental School and Hospital, Lohegaon, Pune,
1
Conservative Dentistry and Endodontics, Government Dental College and Hospital, Mumbai, 3Conservative Dentistry and Endodontics,
Yashwant Memorial Trust Dental College and Hospital, Kharghar, Navi-Mumbai, Maharashtra, India, 2Department of Endodontology,
The Goldschleger School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel

Abstract
Aim
Aim:The
present ex vivo study aimed to evaluate the debris extrusion after instrumenting the root canals by three different files
systems.
Materials and Methods: Sixty extracted human mandibular premolars with single canals were selected and randomly divided
into three groups (n = 20) for instrumentation with three different files. Group 1: WaveOne (primary) single reciprocating
file (WO; Dentsply Maillefer, Ballaigues, Switzerland) (25/08), Group 2: Self-adjusting file (SAF; ReDent-Nova, Raanana,
Israel) (1.5 mm), and Group 3: ProTaper NEXT X1 and X2 (PTN; Dentsply Tulsa Dental, Tulsa, OK) (25/06). Debris extruding
by instrumentation were collected into pre-weighed Eppendorf tubes. These tubes were then stored in an incubator at 70C
for 5 days. The tubes were then weighed to obtain the final weight, with the extruded debris. Statistical analysis for the debris
extruded apically was performed using one-way analysis of variance and post hoc Tukeys test.
Results: The statistical analysis showed a significant difference between all the three groups tested (P < 0.01). The following
post hoc Tukeys test confirmed that Group 2 (SAF) exhibited significantly least (P < 0.01) debris extrusion between the three
groups tested.
Conclusions: The SAF resulted in significantly less extrusion of debris when compared to reciprocating WO and rotary PTN.
Keywords: Apical extrusion, debris; instrumentation; ProTaper; SAF and NEXT; WaveOne

INTRODUCTION
Biologically, all irritants must be removed from the root canal
space (RCS), while at the same time mechanically create an
adequate space and shape for flushing and debridement.[1]
Complete debridement of the RCS using recently developed
rotary/reciprocating files and newer irrigation systems can
prove as an aide predicting endodontic success. However, the
instrumentation, irrigation solutions, and the formed debris
due to instrumentation containing necrotic tissue, microorganisms, pulpal fragments, and dentin particles may be
extruded from the RCS into the periapical region, resulting in
post-operative inflammation and treatment failure.[2]
The extrusion of debris using different protocols for
instrumentation and irrigation has been reported.[3-10]
The amount of debris extruded differs according to the

preparation techniques because of the various available


designs of the file systems and irrigation devices.[3] All
the instrumentation techniques used for biomechanical
preparation result in apical extrusion of debris, even after
the root canal preparation is maintained short of the apical
terminus.
Most nickel-titanium (NiTi) instrument systems work
in a crown-down manner with push-pull rotation filing
movements. Various advances in instrument design and
the use of different operational principles can successfully
influence the amount of debris extrusion.
An evolved generation in NiTi instrumentation files is
marked by the introduction of single files systems for
shaping and cleaning. The WaveOne (WO; Dentsply
Access this article online

Address for correspondence:

Quick Response Code:

Dr. Ajinkya M. Pawar, Y-10/155, Government Colony,


Bandra East, Mumbai - 400 051, Maharashtra, India.
E-mail: ajinkya@drpawars.com

Website:
www.jcd.org.in

Date of submission : 23.08.2014


Review completed : 30.11.2014
Date of acceptance : 09.12.2014

DOI:
10.4103/0972-0707.153057

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Pawar, et al.: Debris extrusion with WO, SAF, PTN

Maillefer, Ballaigues, Switzerland) single reciprocating


file system simulates a reversed balanced force and a
linear motion. The Self-Adjusting File (SAF; ReDent-Nova,
Raanana, Israel) is also a single file system, which is a
hollow compressible design. The SAF is used with vibrating
movement accompanied by continuous irrigation with any
desired solution.[4]
The most recent generation of shaping files ProTaper NEXT
(PTN; Dentsply Tulsa Dental, Tulsa, OK) presents uniqueness
with the center of mass and the center of rotation offset
design. These files produce a mechanical wave of motion
that travels along the active length of the file. This unique
design is advantageous in minimizing the engagement
between the file and dentin, may also enhance removal of
debris out of a canal and improves flexibility of the files.[4]
Less apical extrusion associated with SAF and higher
extrusion with WO have been reported in previous
studies.[5,6] To the best of our knowledge, no report has
compared apical debris extrusion of debris by WO, SAF,
and PTN files; hence, the present study was designed to
compare the apically extruded debris when the root canals
were instrumented with these files. The null hypothesis
was that the three different files (WO, SAF, and PTN) that
used different kinematic motions (reciprocating, vibratory,
and rotary) would have no effect on the apically extruding
debris during instrumentation.

MATERIALS AND METHODS


Sixty extracted human mandibular premolars with single
canals confirmed radiographically (buccal and proximal)
were collected from random collection. The soft-tissue
remnants and calculi on the external root surface were
removed using ultrasonics. The buccal cusp edge of each
tooth was flattened aiding as a reference point, and coronal
access was prepared using an access cavity kit (Endo Z Access
Kit, Dentsply Tulsa). The canal patency was achieved and
controlled with a size 15 K-file. The working length (WL) of
each canal was determined as 1 mm short of the length of
a size 15 K-file that was visible at the major diameter of the
apical foramen. The teeth were then randomly divided into
three experimental groups for different instrumentation
techniques. The present study used the experimental
model described by Myers and Montgomery[7] for assessing
the debris extruded periapically.
An analytical balance (Single Pan K-15, K Roy Instruments
Pvt. Ltd., Varanasi, India) with an accuracy of 10-4 g was
used to measure the initial weights of the tubes. Three
consecutive weights were obtained for each tube, and the
mean was calculated. Each tooth was inserted up to the
cemento-enamel junction, and a 27-G needle was placed
alongside the stopper for use as a drainage cannula and
to balance the air pressure inside and outside the tubes.

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Then, each stopper with the tooth and the needle was
attached to its Eppendorf tube, and the tubes were fitted
into vials. The same operator trained to use all the file
systems efficiently carried out the instrumentation. The
Eppendorf tube was covered with a silver foil to blind the
operator from seeing the apex during instrumentation.

Instrumentation
The glide path for all the 60 samples was created till a # 20
K-file for all the groups and a new instrument/file (WO, SAF,
and PTN) was used for every sample.

Group 1 WaveOne (WO)


Twenty teeth were instrumented by single reciprocating
file WO (primary) instrument, used in a pecking motion.
The root canal orifice was flared using Sx file from the
universal ProTaper (Dentsply Tulsa Dental, Tulsa, OK). A
pre-programmed reciprocating endomotor (X-Smart Plus,
DentsplyMaillefer) possessing the program for WO (small,
primary, and large) files instrumentation was used. The
flutes of the instrument were cleaned after three pecks. On
meeting obstruction, the file was removed, the canal was
irrigated, recapitulated, and the file was re-introduced into
the canal again. The instrumentation was done till the WO
(primary) file reached the apex.

Group 2 The Self-Adjusting File (SAF)


Twenty teeth were prepared with the SAF system. A prior
glide path established accommodated the 1.5 mm SAF.
The SAF file was operated by using in-and-out manual
motion for 4 minutes in the canal, with continuous
irrigation by using bi-distilled (0.4-mm amplitude and
5,000 vibrations per minute), using VATEA peristaltic
pump (ReDent-Nova) at a rate of 4 mL/min. A total of
3 mL bi-distilled water was then used for 3 minutes as a
final rinse.

Group 3 ProTaper NEXT (PTN)


Twenty teeth were instrumented by PTN instruments, used
according to the manufacturers instructions using a gentle
in-and-out motion with a torque-controlled endodontic
motor (X-Smart Plus, Dentsply Maillefer) at 300 rpm and a
torque of 2.6 Ncm. The root canal orifice was flared using
Sx file from the universal ProTaper (Dentsply Tulsa Dental,
Tulsa, OK). This was followed by the use of X1 and X2 files.
On meeting obstruction the file was removed, the canal
was irrigated, recapitulated, and the file was re-introduced
into the canal again. The instrumentation was continued
till the X1 and X2 both reached the working length.

Irrigation for the rotary/reciprocating files


After each instrument (rotary) or after three pecks
(reciprocating) 2 mL of bi-distilled water was used as
irrigant. The irrigation needle (NaviTip 31ga; Ultradent,
South Jordan, UT) was placed as deep as possible into the

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Pawar, et al.: Debris extrusion with WO, SAF, PTN

canal but not deeper as the predetermined WL minus 1


mm. Ethylenediaminetetraacetic acid (EDTA) gel was used
as a lubricant throughout the instrumentation procedures
for all the groups.

Debris collection
Following instrumentation, the teeth were removed from
the tube and the debris adhering to the root surface was
collected by washing off the apical area of the tooth with 1
ml of distilled water into the centrifuge tube. The centrifuge
tube was stored in an incubator at 70oC for 5 days, to allow
the moisture to evaporate, before weighing the dry debris,
using an electronic balance.

Statistical analysis
Theraw pooled data of the weights were statistically
analyzed using DAgostino-Pearson test for normal
distribution and test for homogeneity. This was followed
by application of one-way analysis of variance (ANOVA) and
post hoc test to determine the significant group (statistical
package of social sciences (SPSS) 16, SPSS Inc, Chicago, IL).
The alpha-type error was set at 0.05.

RESULTS
The weights obtained were analyzed using DAgostinoPearson test for normal distribution, which was not
significant (P > 0.05). Also, the test for homogeneity was
satisfied (P > 0.05) aiding in successful application of
parametric test one-way ANOVA to find out the significant
difference.
Statistical analysis exhibited a significant difference
between all the three groups (P < 0.001) (one-way ANOVA;
SPSS software v16). Post hoc tukeys test revealed Group 1
(WO) resulted in higher debris extrusion (P < 0.001) and
Group 2 (SAF) resulted in least debris extrusion (P < 0.001)
in the three groups tested (SPSS software v16). Whereas,
PTN group presented with an intermediate debris
extrusion when compared to SAF it was higher (P < 0.01)
and with WO it was lesser (P < 0.01). The mean, minimum,
maximum, and standard deviation of the three experimental
groups are shown in Table 1. The mean extrusion of debris
extruded apically is plotted in Figure 1.

DISCUSSION
According to the results obtained from the current study,
the resultant debris from instrumentation of root canals
was extruded periapically regardless of the file design
(convex triangular WO, hollow SAF, and rectangular PTN)
and different kinematic motions (reciprocating, vibratory,
and rotary) used. The reciprocating file WO resulted
in maximum debris extrusion (P < 0.01), whereas the
vibratory file SAF resulted in least debris extrusion in the

Figure 1: Meanwise distribution of the apical extrusion of


debris for all the three groups. (A Highest and B Least debris
extrusion among the groups)
Table 1: Mean, minimum, maximum, and standard
deviation of the debris extruded for all the three
groups. (*Statistically significant differences between
the three groups)
Debris extrusion
Mean
Minimum
Maximum
Standard Deviation

WO

SAF

PTN

0.000488* 0.00031* 0.000328* P < 0.01


0.00048
0.000301 0.00032
0.000494 0.000315 0.000334
0.0000041 0.0000043 0.000004

three groups tested (P < 0.01). Thus, the null hypothesis


was rejected. Previous studies have reported less debris
extrusion associated with SAF and more with rotary
(Protaper) and reciprocating files;[5,6] however to the best of
authors knowledge the apical extrusion of debris resulting
from the recently evolved ProTaper NEXT rotary file is
rarely reported.[8]
The present study used method of Myers and Montgomery;[7]
to simulate clinical conditions, only the buccal cusp edge of
each tooth was flattened aiding as a reference point and the
shaping procedures were conducted without de-coronation.
Distilled water was used as an irrigation solution to avoid
any possible crystallization of sodium hypochlorite. The
amount of periapically extruded debris being extremely low,
the contact of moist or greasy fingertips alters the weight of
the extruded debris. Another important issue is the absence
of a physical backpressure provided by periapical tissues,
an imminent shortcoming of in vitro studies.[7,9] Also, the
residual pulp tissue, condition of the pulp, and normal
or pathological periapical tissues may act as barriers and
inhibit the apical extrusion in vivo conditions.[9-11] Some
suggestions to simulate the periodontal ligament have
been made, by the use of floral foam,[11] but they lead to
absorption of the irrigant as well as the debris.[12]
The present study compared three different instrumentation
protocols, a reciprocating file (WO), a vibratory file (SAF),

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Pawar, et al.: Debris extrusion with WO, SAF, PTN

and a rotary file (PTN), a comparison yet to be reported


in literature. The results obtained from the current study
may be explained by differences in the instrument design
and movement kinematics between the WO, SAF, and PTN
systems.
The WO file was associated with the maximum debris
extrusion apically in the present study, which is accordance
with other studies.[6,13,14] The WO files are characterized
by a modified triangular cross-section, which results in
decreased cutting efficacy and smaller chip space resulting
in auguring the formed debris after instrumentation,
periapically.[6,13] The WO files also exhibit a larger taper
of 0.08 at the apical 3 mm, which can be attributed
for excessive debris formation apically, and extrusion
periapically.[8]
SAF a single-file system, devoid of a central metal core
and any cutting edge or flutes, instead has an abrasive
surface.[15] The SAF is operated with a transline in-and-out
vibratory motion and associated continuous simultaneous
irrigation. This continuous flow of irrigant does not build
up any pressure in the canal as the metal meshwork allows
the free escape of irrigant. In the narrowest apical part of
a canal prepared up to a # 20 K-file, the SAF is effective,
leaving more than 38% of the canal cross-section free for
backflow of fluid and dentinal debris.[15] deMeloRibeiro
et al.,[16] stated that in the apical third, the SAF system
created cleaner inner canal walls when compared to rotary
system.
The PTN is a novel rotary file system and very rare
reports on apical extrusion of debris resulting from its
instrumentation. Capar et al., reported less debris extrusion
associated with PTN files when it was compared to the
universal ProTaper file systems.[8] The PTN possess a unique
design, an offset center of mass and rotation. This design
provides more cross-sectional space for enhanced cutting,
loading and successfully allowing the debris to travel out of
a canal (coronally), compared to a file with a centered mass
and axis of rotation. It may also decrease the chances for
the file packing the debris laterally, aiding in reducing the
chances of blockage of the root canal system.[4] This can be
the main advantage of the file and may lead to least debris
extrusion; hence, it was used as one of the instrumentation
techniques for the present study. The samples in the group
instrumented by PTN resulted in less extrusion of the
debris when compared to the WO group.
With rotary and reciprocal systems a predictable and
circularly standardized apical preparation can be expected
but incase of the SAF group, the apical enlargement
depends upon the apical anatomy of the samples. In the
present study, SAF group resulted in less extrusion of debris
when compared to the other two groups tested. In a study
by Dietrich et al.,[17] comparing reciprocal movement to the

92

SAF, reciprocal instrumentation resulted in more debris in


the apical part of the root canal than the SAF or a rotary
system. The amount of debris formed in the apical third
may also cause its extrusion periapically.

CONCLUSION
In the present ex vivo study, the extrusion of debris
associated with three different files possessing different
designs that used different kinematic motions was assessed.
Within its limitations, it can be concluded that the three file
systems used for instrumentation resulted in extrusion of
debris even though the working length was maintained 1mm
short of the apex. The SAF that used a vibratory motion with
continuous irrigation resulted in significantly less debris
extrusion when compared to PTN and WO files systems. The
results of the current study are favorable to the SAF system,
but further studies clinically evaluating the incidence of postinstrumentation pain with these instrumentation systems
can provide a better understanding of these file systems.

ACKNOWLEDGEMENT
Dr Zvi Metzger serves as Scientific Consultant to ReDent-Nova
Co., manufacturer of the SAF System. All other authors deny any
conflict of interest to the present study

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How to cite this article: Pawar AM, Pawar MG, Metzger Z,


Kokate SR. The self-adjusting file instrumentation results in
less debris extrusion apically when compared to WaveOne and
ProTaper NEXT. J Conserv Dent 2015;18:89-93.
Source of Support: Nil, Conflict of Interest: None declared.

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