Basic ResearchTechnology

Comparison of Two Techniques for Assessing the Shaping Efcacy of Repeatedly Used Nickel-Titanium Rotary Instruments
Hani F. Ounsi, DCD, DESE, MSc,* Giovanni Franciosi,* Raffaele Paragliola,* Khalid Al Huzaimi, BDS, MSc, Ziad Salameh, DDS, MSc, PhD, Franklin R. Tay, BDS (Hons), PhD, Marco Ferrari, DDS, MD, PhD,* and Simone Grandini, DDS, PhD*
Abstract
Introduction: The shaping capacity of nickel-titanium (NiTi) rotary instruments is often assessed by photographic or microcomputed tomography (micro-CT) measurements, and these instruments are often used more than once clinically. This study was conducted to compare photographic and micro-CT measurements and to assess if the repeated use of NiTi instruments affected the shape of canal preparation. Methods: Ten new sets of ProTaper Universal instruments (Dentsply-Maillefer, Ballaigues, Switzerland) were used in 60 resin blocks simulating curved root canals. Groups 1 to 6 (n = 10) represented the rst to sixth use of the instrument, respectively. Digitized images of the prepared blocks were taken in both mesiodistal (MD) and buccolingual (BL) directions and area measurements (mm2) were calculated using AutoCAD (Autodesk Inc, San Rafael, CA). The volumes of the same prepared canals were measured using micro-CT (mm3). Statistical analysis was performed to detect differences between photographic and volumetric measurements and differences between uses. Results: Two-way repeatedmeasures analysis of variance revealed signicant differences between groups (P < .001). Regarding measurement type, there were no signicant differences between BL and MD measurements, but there were signicant differences between micro-CT and BL measurements (P < .001) and micro-CT and MD measurements (P = .001). Signicant differences were also noted between uses. Conclusions: Within the limitations of the present study, micro-CT scanning is more discriminative of the changes in canal space associated with repeated instrument use than photographic measurements. Canal preparations are signicantly smaller after the third use of the same instrument. (J Endod 2011;37:847850)

Key Words
Nickel-titanium, repeated use, root canal, shaping

ickel-titanium (NiTi) rotary instruments are frequently used in endodontics because of their superelastic properties that permit efcient canal preparation (1, 2). They differ in taper, tip size, cross-section, helix angle, and blade pitch (3, 4). The major disadvantage associated with their use has always been the tendency to separate during function without warning in inexperienced hands (5). Although the repeated clinical use of NiTi rotary instruments resulted in the reduction of their cyclic fatigue resistance (69), clinicians often reuse these instruments because of nancial reasons (10). The number of times in which a NiTi rotary instrument can be reused remains uncertain (11). The shaping efciency of these instruments is usually assessed by two-dimensional (2D) photographic techniques and three-dimensional (3D) techniques such as micro computed tomography (micro-CT) scanning. 2D photographic techniques involve taking digitized images/radiographs in two perpendicular directions and using a software program (eg, AutoCAD; Autodesk Inc, San Rafael, CA) to perform calculations with or without superimposition. These techniques have been used to assess the shape of the preparation, canal transportation, residual dentin after shaping or post space preparation, and the cutting efciency of different instruments (1214). They are easy-to-use, inexpensive, and potentially informative depending on the question to be investigated (15) but lack the capacity to disclose volumetric information. Improvements in micro-CT techniques enable noninvasive 3D sampling at relatively high resolution (16). Data generated using micro-CT scanning may be represented as 2D- or 3D-rendered images that can be analyzed qualitatively and quantitatively (17). Previous studies that evaluated the shaping ability of rotary les (1823) investigated changes in various parameters after canal preparation. These parameters include surface area and volume of the root canal, the amount of dentin volume removed, canal diameter, prepared surface, canal curvature, canal transportation, transportation of the center of mass, canal straightening, proportion of unchanged canal surface, and canal centering ratio. To date, no study has compared results obtained by 2D versus 3D measurement techniques or the effect of repeated use of NiTi rotary instruments on the nal shape of the canal preparation. Thus, the objective aim of the present study was to compare photographic (2D) and micro-CT (3D) measurements and to assess if the repeated use of NiTi instruments adversely affects the shape of the preparation. The null

From the *Department of Endodontics and Restorative Dentistry, University of Siena, Policlinico Le Scotte, Viale Bracci, Siena, Italy; Eng AB Chair for Growth Factors and Bone Regeneration, King Saud University, Riyadh, Saudi Arabia; and Department of Endodontics, School of Dentistry, Medical College of Georgia, Augusta, Georgia. Address requests for reprints to Dr Hani F. Ounsi, Department of Endodontics and Restorative Dentistry, University of Siena, Policlinico Le Scotte, Viale Bracci, Siena, Italy. E-mail address: ounsih@gmail.com 0099-2399/$ - see front matter Copyright 2011 American Association of Endodontists. doi:10.1016/j.joen.2011.02.030

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hypotheses tested were as follows: (1) there is no difference between 2D and 3D measurements in assessing canal dimensions after repeated uses of NiTi rotary instruments, and (2) the repeated use of NiTi rotary instruments has no effect on the nal shape of a canal preparation. image. Three randomly chosen blocks were used as controls. Their lengths and widths were taken in both directions using a pair of digital calipers, and the respective areas were calculated and compared with the values obtained by AutoCAD surface measurements of the same blocks.

Materials and Methods

Specimen Preparation Ten new sets of ProTaper Universal instruments were used. Sixty resin blocks simulating curved root canals (Dentsply-Maillefer) were randomly divided into six groups: specimens from group 1 (designated as 1-1, 2-1,., 10-1) were prepared with new ProTaper instruments, group 2 (1-2, 2-2,., 10-2) was prepared with instruments used in group 1 (second use), group 3 (1-3, 2-3,., 10-3) was prepared using the instruments used in group 2 (third use), group 4 (1-4, 2-4,., 10-4) was prepared using the instruments used in group 3 (fourth use), group 5 (1-5, 2-5,., 10-5) was prepared using the instruments used in group 4 (fth use), and group 6 (1-6, 2-6,., 10-6) was prepared using the instruments used in group 5 (sixth use). Shaping was performed by the same experienced operator, and canal negotiation was performed to full length using size 10 K-les (Dentsply-Maillefer) with Glyde (Dentsply-Maillefer) as lubricant. The NiTi rotary instruments were then used in a crown-down technique with a pure pricking motion (no lateral pressure) using an endodontic electric motor at the manufacturer recommended speed and torque values for each instrument. The instrument sequence was SX, S1, S2, F1, and F2. Irrigation was performed in between instrumentation using 2.5% sodium hypochlorite delivered via a 30-G endodontic needle inserted to 1 mm short of the working length (2 mL each time). Patency was conrmed between instruments using a size 10 K-le. Canal shaping was performed according to manufacturers instructions with each instrument reaching working length only once and held in that position for no longer than 2 seconds. The les were not autoclaved but simply wiped with a moist gauze. They were regularly inspected between and during uses and showed no sign of deformation, and there was no le separation. 2D Photographic Measurements Black ink (Pelikan, Schindellegi, Germany) was injected into the simulated root canal space after sequence completion to serve as the contrasting medium. Standardized photographic images of the resin blocks were taken in both mesiodistal (MD) and buccolingual (BL) directions using a copy stand and a digital camera. Precise positioning of the blocks was ensured using a silicone mold. The 120 digitized images were imported into AutoCAD and analyzed by an operator who was unaware of the purpose of the study. Area measurement (in mm2) of each prepared canal was performed for each

Micro-CT Measurements The same blocks were placed vertically on the staging platform of a Skyscan 1172 scanner (Skyscan, Kontich, Belgium) and analyzed volumetrically at 100 kV. The operator was blinded to the purpose of the study. Datasets were acquired with a 0.04 step rotation and a voxel size of 11.75 mm3. Each block was divided into three sections (coronal third, middle third, and apical third) to facilitate scanning of the entire root canal space. Scanning of each section generated 899 virtual slices (ie, 2697 slices per block); 3D reconstruction was performed using NRecon software Version 1.6.1.3 (Skyscan) with the following parameters: beam hardening reduction 43%, ring artifact correction 4%, and Gaussian low-pass for noise reduction 50%. The CTAn Version 1.9.3 software (Skyscan) was used to calculate the volume of the prepared canal in each block. The volume of interest was determined using a standardized rectangular area selection on the binary images. Similar thresholding levels were applied to separate resin blocks from empty canals. This resulted in binary images of the canals that permitted precise and comparable measurements. Three randomly chosen blocks served as control and had their length, width, and thickness measured using a pair of digital calipers. Their respective volumes were calculated and compared with the values obtained by micro-CT measurements of the same blocks. Statistical Analysis Because surface and volume values could not be compared directly, the value obtained after the rst instrument use was used as reference, and the values obtained after the subsequent uses of that instrument were calculated as a symmetrized percent change (SPC) of that value (24). Two-way repeated-measures analysis of variance with Bonferroni correction was used to analyze the data with number of uses as within-subject factor and type of measurement as betweensubject factor followed by the Tukey Honestly Signicant Difference test for pairwise comparisons, also called the Tukey range test. The signicance level was preset at a = 0.05.

Results
Values obtained by the two measurement techniques for the controls were consistent with direct physical measurements. The means and standard deviations for groups 1 through 6 were calculated and SPC performed (Table 1). The normality of distribution of the data and homogeneity of variance were conrmed, and repeated-measures

TABLE 1. Symmetrized Percent Changes (SPC) between Groups 2 and 6 and Group 1 Group 1 (1st use)
Measurements BL (mm2) MD (mm2) Micro-CT (mm3) SPC Bucco-lingual (mm2) MD (mm2) Micro-CT (mm3) 16.36 (0.56) 15.76 (0.59) 22.75 (1.04) 0 (0) 0 (0) 0 (0)

Group 2 (2nd use)

16.15 (0.64) 15.45 (0.46) 21.79 (1.02) 0.66 (2.03) 0.98 (2.47) 2.17 (1.59)

Group 3 (3rd use)

15.88 (0.76) 15.30 (0.43) 21.08 (0.90) 1.51 (2.50) 1.49 (2.25) 3.82 (2.71)

Group 4 (4th use)

15.73 (0.34) 15.42 (0.53) 19.97 (1.05) 1.96 (1.49) 1.08 (1.85) 6.09 (3.23)

Group 5 (5th use)

15.62 (0.32) 15.31 (0.40) 18.85 (1.15) 2.31 (1.70) 1.46 (1.96) 9.41 (2.77)

Group 6 (6th use)

15.32 (0.70) 15.30 (0.35) 20.98 (1.59) 3.3 (2.80) 1.46 (1.99) 4.14 (5.01)

BL, buccolingual; CT, computed tomography; MD, mesiodistal. Values are means (standard deviations). Group 1 is not represented after symmetrized percent change because it served as control.

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TABLE 2. Tukey HSD Test for Pair-wise Comparisons Values between Uses and Signicance Values (I) Use
2

(J) Use
3 4 5 6 2 4 5 6 2 3 5 6 2 3 4 6 2 3 4 5

Mean difference (I-J)

1.001* 1.769* 3.121* 1.696* 1.001* 0.768 2.120* 0.694 1.769* 0.768 1.352* 0.074 3.121* 2.120* 1.352* 1.425 1.696* 0.694 0.074 1.425

P value
.009 <.001 <.001 .009 .009 .089 <.001 .202 <.001 .089 .002 .897 <.001 <.001 .002 .062 .009 .202 .897 .062

HSD, Honestly Signicant Difference. *Signicant values.

analysis of variance testing on SPC values revealed signicant differences between groups (P < .001). Regarding measurement type, there were no statistically signicant differences between BL and MD measurements, but there were signicant differences between micro-CT and BL (P < .001) and between micro-CT and MD (P = .001). Signicant differences were also noted between uses (Table 2).

Discussion
The results justied rejection of both null hypotheses. Although the use of simulated root canals has the advantage of providing a standardized baseline canal form and reproducible conditions, several studies have described differences between the hardness and abrasion behavior of dentin and plastic (25, 26). The use of an operator-driven instrument instead of a standardized computer-driven instrument has the disadvantage of introducing operator bias but the advantage of simulating clinical conditions wherein an operator can compensate for the shortcomings of the instrument by modifying digital pressure. It has to be stressed that the present study investigated only a particular type of NiTi rotary instrument with a convex triangular section and variable taper. Thus, the results obtained cannot be directly extrapolated to other instruments with different designs. It is important to point out that the present study assessed solely volumetric changes without analyzing the possible geometric changes that may be associated with repeated use of the same instrument. Furthermore, it should be noted that the standard deviations are often rather close to the mean values themselves. This variation is an important observation indicating that even with an identical simulated canal for all preparations and the same experienced operator, the outcome is subject to considerable differences. It is also noteworthy that the operator was not blinded to the number of uses of the instruments. Radiography is the major tool for studying intrabony structures. These 2D projections of 3D structures do not provide an adequate representation of an object, which results in reduced accuracy in quantitative studies. Taking another angulated radiograph (generally perpendicular to the rst one) provides insight on the third dimension but still falls short of generating 3D data for quantitative analysis. Moreover, interpretation of radiographs is highly subjective (27). A 3D image may be obtained by destructive processes such as those involving object
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sectioning, making surface measurements on those sections, and then integrating the results to generate volumetric information. Micro-CT scanning has the advantage of acquiring volumetric information nondestructively. Balto et al (28) showed that micro-CT scanning produced results that are comparable to those obtained by histologic sectioning. In the present study, the differences observed in the measurement methods indicate that volumetric measurements are more discriminative to variations than data derived from 2D area measurements, conrming the conclusion derived from 2D and 3D examination of intrabony voids (29). The most signicant nding of the present study is that there is indeed a reduction in the volume of the prepared canal space of the plastic blocks after the repeated use of ProTaper rotary instruments. This may be explained by topographic changes of the instruments. Svec and Powers (30) reported the evidence of aking, pitting, and crack formation on the surface of Prole rotary instruments after their repeated use in extracted molars. Wei et al (8) examined ProTaper rotary instruments after repeated clinical use and reported similar signs of surface wear in addition to roll over of the cutting edges of the instruments. Such modications of the cutting edges adversely affect the cutting efciency of the instrument that would, in turn, increase working time inside the canal (or force the dentist to increase apical pressure on the instrument). Other studies indicated that the repeated use of dull instruments increases the risk of instrument separation (7, 31). For clinical application, the operator should take into consideration all the factors that may inuence instrument fatigue, such as root canal anatomy (9, 21), operator experience (31), and instrument design (32). The creation of a manual glide path with stainless steel hand les before introducing rotary les is an effective way to reduce stresses on NiTi rotary instruments and reduce the frequency of le separation (33). During the cleaning phase of root canal treatment, attempts are made to clean the root canal system of microorganisms and inorganic and organic debris. Shaping is performed to facilitate the placement of a permanent 3D lling. These two procedures are closely related; when the rst one is performed well, the other will be easy to perform. This is also true for the relationship between cleaning and shaping and 3D obturation of the canal space (34). From a biological standpoint, a reduced cutting efciency of NiTi rotary instruments may adversely affect dentin removal, possibly compromising the mechanical reduction of bacteria load (35). Because the repeated use of NiTi rotary instruments is well accepted in clinical practice, the need to manually gauge the apical third of the canal preparation before lling the root canal system cannot be overemphasized to ensure proper shaping and cleaning of the canal space.

Conclusion
Within the limitations of the present study, it appears that the repeated use of ProTaper nickel titanium rotary instruments affects the root canal shape in simulated canals. Further in vitro studies on extracted teeth and in vivo studies are required to quantify the relative loss of efciency in the coronal, middle, and apical thirds of the canal space; the possible change in geometry of the preparation; and to what extent different instrument designs would be subjected to similar wear effects.

Acknowledgments
The authors thank M. Raju Kunchapu for his help with micro computed tomography scanning. The authors deny any conicts of interest related to this study.
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