|Year : 2018 | Volume
| Issue : 2 | Page : 105-110
Apically extruded debris associated with different instrumentation systems and irrigation needles
Walaa M Ghoneim, Neveen A Shaheen
Department of Endodontics, Faculty of Dentistry, Tanta University, Tanta, Egypt
|Date of Submission||18-Feb-2018|
|Date of Acceptance||25-Apr-2018|
|Date of Web Publication||25-Jun-2018|
Walaa M Ghoneim
Department of Endodontics, Faculty of Dentistry, Tanta University, Tanta
Source of Support: None, Conflict of Interest: None
Of this study is to compare apically extruded debris associated with canal shaping using 2Shape, ProTaper Universal and Reciproc systems using two different irrigation needle tips, open-ended and side-vented.
Patients and methods
Sixty freshly extracted human mandibular premolars were randomly divided into six groups (n = 10) as follows; group 1 and 2, 2Shape system was used in root canal preparation, in groups 3 and 4, ProTaper Universal preparation system was used, but In groups 5 and 6, Reciproc preparation was performed. In groups 1, 3 and 5 irrigation was done with open-ended needle while in groups 2, 4 and 6 side-vented needle was used. One Eppendorf tube for each tooth was weighed with an electronic weighing machine before instrumentation procedures. During instrumentation, irrigation was performed after every instrument with 1 ml distilled water. On completion of the preparation, teeth were removed from the Eppendorf tubes. All of the tubes were incubated at 37°C for 15 days, to evaporate the irrigant. After the incubation period, the tubes were weighed again. The difference between initial and final tubes weights was calculated, and statistical evaluation was performed using two-way analysis of variance at 5% level of significance.
A statistically significant difference was observed between all groups (P≤0.05). The highest mean extruded debris value was recorded with group 3 while the lowest value was recorded with group 6. Open-ended needles were associated with significantly more extruded debris than side-vented needles regardless of the instrumentation system used (P≤0.05).
All the tested rotary instruments resulted in extrusion of debris beyond the apical foramen to an extent but Reciproc system is associated with less amount of apically extruded debris in comparison with 2Shape, ProTaper Universal systems. Side-vented needles extruded significantly less debris than open-ended needles.
Keywords: apical debris extrusion, needle, ProTaper, Reciproc, 2Shape
|How to cite this article:|
Ghoneim WM, Shaheen NA. Apically extruded debris associated with different instrumentation systems and irrigation needles. Tanta Dent J 2018;15:105-10
|How to cite this URL:|
Ghoneim WM, Shaheen NA. Apically extruded debris associated with different instrumentation systems and irrigation needles. Tanta Dent J [serial online] 2018 [cited 2018 Jul 18];15:105-10. Available from: http://www.tmj.eg.net/text.asp?2018/15/2/105/235138
| Introduction|| |
During root canal preparation, residual pulp tissue, bacteria, necrotic tissue, dentin chips from the root canal system and the irrigant may be extruded into the periapical tissues despite strict control of working length. This extrusion may cause an inflammatory reaction and postoperative pain . Vande Visse and Brilliant  were the first to quantify the amount of apical extruded debris during instrumentation.
The hypothesis is that engine-driven rotary instruments will produce less extrusion than hand instrumentation. This may be due to tendency of rotary instruments to pull the debris into their flutes, thus leading the debris out of the root canal in a coronal direction . Various types of rotary NiTi systems are available for root canal preparation, ProTaper Universal instruments are composed of conventional NiTi alloy and have a convex triangular cross-sectional design, a noncutting safety tip and a flute design that combines multiple tapers within the shaft . Instruments with such a cross-sectional design are claimed to cut dentine more effectively .
Reciproc is a single reciprocating file system that is claimed to completely prepare and clean root canals with only one instrument. These files are made of a special NiTi alloy called M-Wire that is created by an innovative thermal-treatment process. Instruments made of M-Wire have many advantages as increased flexibility and improved resistance to cyclic fatigue. Reciproc files are available in different sizes 25, taper 08; 40, taper 06; 50, taper 05 . It has a cross-sectional shape in the form of an S along the entire length of the working part, sharp cutting edges and no radial lands .
Recently, the new 2Shape NiTi rotary system which has been heat-treated using the T-Wire technology was introduced. It includes only two files for shaping and one optional file for apical finishing in continuous rotation with asymmetrical cross section. The instruments' flexibility provides users comfort and an outstanding negotiation of curvatures .
Irrigation of root canals aids in the removal of debris and is able to reach areas of the root canal untouched by endodontic instruments. Root canals should be irrigated with a small-diameter irrigation needle and its tip should be placed in the apical third of the canal to provide proper irrigation . Open-ended needles produce more apical pressure , which may increase risk of irrigant and debris extrusion towards the periapical tissues.
Although several studies have indicated that all instrumentation techniques and file systems are associated with the extrusion of debris, no data have been reported on apical debris extrusion using 2Shape system. So, the purpose of this study was to compare the amount of apically extruded debris with 2Shape system in comparison to ProTaper Universal and Reciproc systems using two different irrigation needle tips.
| Patients and Methods|| |
Teeth selection and preparation
Sixty freshly extracted nearly straight human mandibular premolars were selected. All patients were informed about the purpose and steps of this research and written consents were signed for using their extracted teeth in the research according to the Research Ethics Committee of Faculty of Dentistry, Tanta University. These teeth were extracted due to periodontal and orthodontic reasons. Teeth were analyzed using radiographs to confirm the presence of a single canal, absence of previous root canal treatment, resorptions, or calcifications.
The teeth were immersed in 5.25% sodium hypochlorite (Clorox Co., Ramadan, Egypt) (NaOCl) solution for 5 min to remove any organic components from the root surfaces and calculus was removed with a hand scaler. Teeth were then stored in distilled water until use. Coronal access cavities were made using a size 3 round bur (Dentsply Maillefer, Tulsa, Oklahoma, USA) and Endo Z bur (Dentsply Maillefer, Ballaigues, Switzerland) using high speed contra angle handpiece under water cooling. Then, working length was determined by advancing a size 10 K-file (Mani Inc., Tochigi, Japan) into the canal until it was just visible at the foramen and then subtracting 1 mm from this measurement. All selected teeth had initial apical file size 20 K-file.
Initial weighing of the Eppendorf tubes
The experimental model used to evaluate debris extrusion was similar to that described by Myers and Montgomery . An Eppendorf tube (Eppendorf AG, Hamburg, Germany) was numbered for each tooth, and a hole was created in the tube cap with a hot instrument. The Eppendorf tubes were individually weighted on an analytical balance (AUW220D; Shimadzu Analytical Balance, Tokyo, Japan). Five consecutive weighings were conducted for each tube, and the mean of weights obtained was regarded as the initial weight of the Eppendorf tube. Thereafter, each root was embedded into the tube cap and affixed on the lateral side with cyanoacrylate to prevent accidental leakage of irrigating solutions during the experiment. Each Eppendorf tube was placed in a bottle which was then covered with aluminum foil to render it opaque to prevent the operator from being able to see the root during instrumentation. A bent 27-G needle was also forced inside the tube cap to equalize the internal and external air pressure as shown in [Figure 1] and [Figure 2].
Root canal preparation
Sixty specimens were randomly divided into six groups (n = 10) according to instrumentation system and irrigation needle as follows:
- Group 1: According to the manufacturer's instructions, 2Shape NiTi instrument system (Micro-Mega, Besançon Cedex, France) was used which includes TS1 (25/0.04) and TS2 (25/0.06) for shaping. The previous two files were used in progressive movement in three waves (three up-and-down movements) with upward circumferential filing movement to reach the working length. First file was inserted into the root canal until a resistance can be felt then a circumferential brushing movement was performed when feeling resistance in order to eliminate the primary constraints. File was removed from the root canal, cleaned and the root canal was irrigated. Then continue the progressive downward movement until reaching working length. Then, F35 (35/0.06) for apical finishing was used to working length. 2Shape files were used with an endodontic motor (X-smart; Dentsply Maillefer, Ballaigues, Switzerland). Irrigation with distilled water was performed with an open-ended needle (27 gauge; Hayat, Istanbul, Turkey).
- Group 2: The instrumentation procedure was similar to that in group 1. However, the irrigation procedure was performed with a side-vented needle (NaviTip Sideport; Ultradent Products Inc., South Jordan, Utah, USA).
- Group 3: ProTaper Universal preparation system was used according to the manufacturer's instructions using a gentle in and out motion with an electric and torque-controlled endodontic motor. The instrumentation sequence was SX (19; tapers: 3.5–19%) at two-thirds of the WL, then S1 (17; tapers: 2–11%), S2 (20; tapers: 4–11.5%), F1 (20, 0.07–5.5%), F2 (25, 0.08–5.5%), F3 (30, 0.09–5%) and F4 (40/0.06) at the WL. Once the instrument had negotiated the full WL and rotated freely, it was removed. Each file was used with a brushing motion and irrigation was performed with an open-ended needle.
- Group 4: The instrumentation procedure was similar to that of group 3. However, the irrigation procedure was performed with a side-vented needle.
- Group 5: instrumentation was done using Reciproc system (VDW, Munich, Germany), R40 (40/0.06) file was coupled to an endodontic motor in the Reciproc program. The file was used in smooth back and forth movements, and after three passes, it was cleaned with gauze, and the canal was irrigated. These procedures were repeated until the file reached the WL and irrigation was performed with an open-ended needle.
- Group 6: Instrumentation was performed in the same way as for group 5. Irrigation was performed with side-vented needle.
A single operator performed all canal preparations. Rotary instruments were discarded after preparing three teeth, whilst reciprocating instruments were used only once for each tooth according to the manufacturer's recommendation. Irrigation during each root canal preparation was performed using a total of 8 ml distilled water. The irrigation needle was maintained at 3 mm from working length.
Final weighing of the Eppendorf tubes
On completion of the preparation, the canals were irrigated with 2 ml of distilled water as a final irrigation, dried with paper points (Diadent, Chongju City, Korea), and the teeth were removed from the Eppendorf tubes. The apical part of the tooth was washed with 2 ml of distilled water in order to collect the apically extruded debris that had adhered to the root. All of the tubes were incubated at 37°C for 15 days before being weighed again, to evaporate the irrigant in the Eppendorf tubes. After the incubation period, the tubes were checked for complete evaporation of irrigant by naked eye and weighed again five times. The mean of these measurements was considered to be the weight of the tube plus the debris. The amount of apically extruded debris was calculated by subtracting the initial weight of tube from the final weight.
Mean and SD values for extruded debris for different tested groups were calculated and statistically analyzed using two-way ANOVA to evaluate the significant effect of instrumentation system and type of irrigation needle on the amount of apically extruded debris. Then least significant difference (LSD) test was performed for multiple comparisons using SPSS statistical software (version 20; SPSS Inc., Chicago, Illinois, USA). The significance level was set at P value up to 0.05.
| Results|| |
The amount of apically extruded debris (mean±SD) of all groups was presented in [Table 1]. When comparing extruded debris of all groups, the highest mean value was recorded with group 3 while the lowest value was recorded with group 6 with statistical significant differences among groups (P < 0.0001). LSD test was performed for multiple comparisons between groups and it showed that there were statistically significant differences between all groups (P≤0.05) except between group 1 versus group 2, group 3 versus 4 and between group 2 versus 4 (P≥0.05).
|Table 1: Mean and SD values of apically extruded debris (g) for different tested groups and their statistical analysis|
Click here to view
When comparing between the types of irrigation needle regardless of the instrumentation system used, it was recorded that open-ended irrigation needle resulted in significantly higher amount of extruded debris (0.00080467 ± 0.00034065) than side-vented needle (0.00024333 ± 0.00009439) recording P value of up to 0.05 as shown in [Figure 3].
|Figure 3: Bar chart showing comparison between two types of irrigation needles regardless of the instrumentation systems.|
Click here to view
Results revealed that a significant difference existed between the instrumentation systems regardless of the type of irrigation needle (P < 0.0001). ProTaper system recorded the highest amount of extruded debris (0.000701 ± 0.000454) followed by 2Shape system while Reciproc system recorded the least amount (0.000274 ± 0.000174) as shown in [Figure 4]. Multiple pairwise comparisons revealed statistical significant differences among three instrumentation systems.
|Figure 4: Bar chart showing comparison between three instrumentation systems regardless of the type of irrigation needle.|
Click here to view
| Discussion|| |
The main objective of the current study was to evaluate the amount of apically extruded debris during root canal preparation using 2Shape, ProTaper Universal and Reciproc systems using two needle types as during root canal instrumentation pulp tissue remnants, dentine debris, microorganisms and intracanal irrigants may be extruded from the apical foramen and induce flare-ups .
Standardization of methodology could provide information to compare the tested groups in terms of apical extrusion. So, in this study, mature human mandibular premolars with a nearly straight root and one canal were used, teeth with similar initial apical file were selected and the size of the master apical instrument was fixed at the same apical diameter of size 40 for all groups except for 2Shape system to assure standardization. In 2Shape system, size 35 is selected according to the manufacturer's instructions who recommends F35 (35/0.06) for apical finishing in straight root canals.
A previously described method was modified for debris collection . Although the technique allows a comparison of the file systems under identical conditions, it has limitations as no attempt was made to simulate the presence of vital pulp or periapical tissues which is considered a weak point in most extrusion studies ,,. In this study, distilled water was used as irrigant solution during preparation to prevent misleading weight measurements as a result of possible crystallization of other irrigants . Weighing procedures were repeated five times and the mean was recorded in an attempt to gain accurate measurement.
The irrigation procedure was carried out using two needle types: open-ended and side-vented. The side-vented needles extruded significantly less debris than the open-ended needles. This is in agreement with Altundasar et al.  and Yeter et al. . This result was also supported by Boutsioukis et al. , who recorded more apical pressure with open-ended needles which may increase amount of apically extruded debris and Boutsioukis et al. who reported that side-vented needles were superior amongst the manual irrigation techniques.
ProTaper Universal instruments were associated with significantly highest amounts of apically extruded debris when used with open-ended needle (group 3) while the lowest amount was associated with Reciproc system/side-vented needle (group 6). These results may be due to interplay amongst several variables: movement kinematics, number of files, instrument design  preparation technique and differences in instrument taper ,.
As ProTaper Universal files have a convex triangular cross-sectional design and a flute design that combines multiple tapers within the shaft, they are claimed to cut dentine more effectively , with increased risk of debris extrusion. In addition to the high number of files used for preparation which may be another contributing factor . This was in agreement with Tanalp et al. , Kocak et al. , Capar et al. , Ozsu et al. , De-Deus et al. , Kocak et al.  and Silva et al. .
2Shape system with open-ended needle (group 1) extruded debris less than ProTaper Universal/open-ended needle (group 3) which may be due to the asymmetrical cross section which is tripe helix containing two main cutting edges for cutting and one secondary cutting edge for debris removal . This asymmetrical cross section provides the nonuniform and reduced contact points between the instrument and the root canal wall , in addition to, the smaller tip size may create better space for coronal displacement of debris and less apical debris extrusion.
The Reciproc system/side-vented needle (group 6) was associated with the least amount of apically extruded debris which may be explained by movement kinematics as reciprocating motion is a type of automatized balanced-force pressureless technique  which is regarded to have the better control of apically extruded debris . Additionally, Reciproc R40 file has S cross-sectional shape along the entire length of the working part and a constant taper in the first 3 mm of the working part that decreases to D16 which may favour better removal of debris in coronal direction .
This was supported by Ustun et al.  and Arslan et al.  who reported that reciprocating motions were associated with less debris extrusion than continuous rotation. However, the reduced amount of apically extruded debris associated with reciprocating systems is not a consistent finding. Burklein and Schafer  concluded that reciprocal motion appeared to increase transportation of debris towards the apex and that continuous rotation seemed to improve coronal transportation of dentine chips and debris by acting like a screw conveyor. In addition, Topcuoglu et al.  found that Reciproc produce more debris extrusion than continuous rotation files as OneShape single rotary file. This controversy may be explained by differences in the experimental set-up, design, type of teeth used and different instruments with various designs and number of files .
| Conclusion|| |
- All the tested instruments resulted in extrusion of debris beyond the apical foramen to an extent.
- Reciprocating motion kinematics is associated with less amount of apically extruded debris in comparison with full rotary motion.
- The type of irrigation needle has a great effect on apically extruded debris as open-ended needles extruded significantly more debris than side-vented needles.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Seltzer S, Naidorf IJ. Flare-ups in endodontics: I. Etiological factors. J Endodont 1985; 11:472–478.
Vande Visse JE, Brilliant JD. Effect of irrigation on the production of extruded material at the root apex during instrumentation. J Endodont 1975; 1:243–246.
Tanalp J, Kaptan F, Sert S, Kayahan B, Bayirli G. Quantitative evaluation of the amount of apically extruded debris using 3 different rotary instrumentation systems. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006; 101:250–257.
Schafer E, Vlassis M. Comparative investigation of two rotary nickel-titanium instruments: ProTaper versus RaCe. Part 1. Shaping ability in simulated curved canals. Int Endod J; 37:229–238.
Bergmans L, van Cleynenbreugel J, Beullens M, Wevers M, van Meerbeek B, Lambrechts P. Progressive versus constant tapered shaft design using NiTi rotary instruments. Int Endod J 2003; 36:288–295.
Burklein S, Hinschitza K, Dammaschke T, Schafer E. Shaping ability and cleaning effectiveness of two single-file systems in severely curved root canals of extracted teeth: Reciproc and WaveOne versus Mtwo and ProTaper. Int Endod J 2012; 45:449–461.
Xavier F, Nevares G, Romeiro MK, Goncalves K, Gominho L, Albuquerque D. Apical extrusion of debris from root canals using reciprocating files associated with two irrigation systems. Int Endod J 2015; 48:661–665.
Zehnder M. Root canal irrigants. J Endod 2006; 32:389–398.
Boutsioukis C, Lambrianidis T, Verhaagen B, Versluis M, Kastrinakis E, Wesselink PR, van der Sluis LWM. The effect of needle-insertion depth on the irrigant flow in the root canal: evaluation using an unsteady computational fluid dynamics model. J Endod 2010; 36:1664–1668.
Boutsioukis C, Verhaagen B, Versluis M, Kastrinakis E, Wesselink PR, van der Sluis LW. Evaluation of irrigant flow in the root canal using different needle types by an unsteady computational fluid dynamics model. J Endod 2010; 36:875–879.
Myers GL, Montgomery S. A comparison of weights of debris extruded apically by conventional filing and Canal Master techniques. J Endod 1991; 17:275–279.
Siqueira JF Jr. Microbial causes of endodontic flare ups. Int Endod J 2003; 36:453–463.
Burklein S, Schafer E. Apically extruded debris with reciprocating single-file and full-sequence rotary instrumentation systems. J Endod 2012; 38:850–852.
Tanalp J, Gungor T. Apical extrusion of debris: a literature review of an inherent occurrence during root canal treatment. Int Endod J 2013; 47:211–221.
De-Deus GA, Nogueira Leal Silva EJ, Moreira EJ, de Almeida Neves A, Belladonna FG, Tameirao M. Assessment of apically extruded debris produced by the self-adjusting file system. J Endod 2014; 40:526–529.
Kocak MM, Cicek E, Kocak S, Saglam BC, Yılmaz N. Apical extrusion of debris using ProTaper Universal and ProTaper Next rotary systems. Int Endod J 2015; 48:283–286.
Altundasar E, Nagas E, Uyanik O, Serper A. Debris and irrigant extrusion potential of 2 rotary systems and irrigation needles. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011; 112:e31–e35.
Yeter KY, Evcil MS, Ayranci LB, Ersoy I. Weight of apically extruded debris following use of two canal instrumentation techniques and two designs of irrigation needles. Int Endod J 2013; 46:795–799.
Boutsioukis C, Psimma Z, Kastrinakis E. The effect of flow rate and agitation technique on irrigant extrusion ex vivo
. J Endod 2014; 47:487–496.
Silva EJ, Carapia MF, Lopes RM, Belladonna FG, Senna PM, Souza EM, De-Deus G. Comparison of apically extruded debris after large apical preparations by full sequence rotary and single-file reciprocating systems. Int Endod J 2016; 49:700–705.
Burklein S, Benten S, Schafer E. Quantitative evaluation of apically extruded debris with different single-file systems: Reciproc, F360 and OneShape versus Mtwo. Int Endod J 2014; 47:405–409.
Kocak S, Kocak MM, Saglam BC, Turker SA, Sagsen B, Er O. Apical extrusion of debris using self-adjusting file, reciprocating single-file, and 2 rotary instrumentation systems. J Endod 2013; 39:1278–1280.
Capar ID, Arslan H, Akcay M, Ertas H. An in vitro
comparison of apically extruded debris and instrumentation times with ProTaper Universal, ProTaper Next, Twisted File Adaptive, and HyFlex instruments. J Endod 2014; 40:1638–1641.
Ozsu D, Karatas E, Arslan H, Topcu MC. Quantitative evaluation of apically extruded debris during root canal instrumentation with ProTaper Universal, ProTaper Next, WaveOne and self-adjusting file systems. Eur J Dent 2014; 8:504–508.
De-Deus G, Neves A, Silva E, Mendonca T, Lourenco C, Calixto C, et al
. Apically extruded dentin debris by reciprocating single-file and multi-file rotary systems. Clin Oral Investig 2015; 19: 357–361.
Elnaghy AM. Cyclic fatigue resistance of ProTaper Next nickel-titanium rotary files. Int Endod J 2014; 47:1034–1039.
McKendry DJ. Comparison of balanced forces, endosonic, and step-back filing instrumentation techniques: quantification of extruded apical debris. J Endod 1990; 16:24–27.
Ustun Y, Canakci BC, Dincer AN, Er O, Duzgun S. Evaluation of apically extruded debris associated with several Ni-Ti systems. Int Endod J 2015; 48:701–704.
Arslan H, Doganay E, Alsancak M, Capar ID, Karatas E, Gunduz HA. Comparison of apically extruded debris after root canal instrumentation using Reciproc instruments with various kinematics. Int Endod J 2016; 49:307–310.
Topcuoglu HS, Ustun Y, Akpek F, Aktı A, Topcuoglu G. Effect of coronal flaring on apical extrusion of debris during root canal instrumentation using single-file systems. Int Endod J 2016; 49: 884–889.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]