Basic Research—Technology
Efficacy of Different Nickel-titanium Instruments in Removing
Gutta-percha during Root Canal Retreatment
€ urek, DDS, PhD, and Ebru Ozsezer
Taha Ozy€ € Demiry€
urek, DDS, PhD
Abstract
Introduction: The aim of this study was to compare the
cleanliness of root canal walls after retreatment using
ProTaper Next (PTN; Dentsply Maillefer, Ballaigues,
Switzerland), Twisted File Adaptive (TFA; Axis/
SybronEndo, Orange, CA), Reciproc (PRC; VDW, Munich,
Germany), and ProTaper Universal retreatment (PTR,
Dentsply Maillefer) nickel-titanium systems and the
time required for gutta-percha and sealer removal.
Methods: Eighty human maxillary central incisors
with single and straight root canals were instrumented
up to #40.02 with manual K-files (Dentsply Maillefer)
and obturated using the continuous wave of condensa-
tion technique. Removal of the gutta-percha and sealer
was performed using 1 of the following nickel-titanium
systems: PTN, TFA, RPC, or PTR. The teeth were
sectioned, and digital images were captured. The photo-
graphs were analyzed using AutoCAD software (Auto-
desk, San Rafael, CA). Also, the total time required for
gutta-percha removal was calculated by a chronometer.
Results: The total retreatment time was significantly
shorter in the PTR group compared with the other
groups (P < .05). There was a significant difference be-
tween the groups according to the total residual gutta-
percha and sealer (P < .05). The PTN and PTR groups left
significantly less gutta-percha and sealer remnant than
the TFA and RPC groups (P < .05). Conclusions: Within
the limitations of this study, the PTN and the PTR groups
showed less residual gutta-percha and sealer than the
TFA and RPC groups. The time required for gutta-
percha and sealer removal was similar for all the groups,
except for the PTR group. (J Endod 2016;-:1–4)
Key Words
ProTaper Next, reciprocation, retreatment, root canal
filling, Twisted File Adaptive
From the Department of Endodontics, Faculty of Dentistry, Ondokuz Mayis University, Samsun, Turkey.
€ €urek, Department of Endodontics, Faculty of Dentistry, Ondokuz Mayis University, Samsun 55139, Turkey. E-mail
Address requests for reprints to Dr Taha Ozy
address: tahaozyurek@hotmail.com
0099-2399/$ - see front matter
Copyright ª 2016 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2016.01.007
JOE — Volume -, Number -, - 2016
I n the case of root canal treatment failure, nonsurgical retreatment, periradicular sur-
gery, and extraction are the options for treating the tooth. Nonsurgical retreatment
should be the first choice because it is the most conservative method (1). Removal
of root canal filling material is the most important factor in nonsurgical retreatment
(2). Several techniques can be used to remove gutta-percha including the use of
heat, solvents, mechanical instruments, and various combinations of these methods
(3). Nickel-titanium (NiTi) rotary systems with different designs have been developed
to improve the efficiency of gutta-percha removal. One of these commonly used special
NiTi retreatment systems is the ProTaper Universal retreatment system (PTR; Dentsply
Maillefer, Ballaigues, Switzerland), which works in a continuous rotation motion (4).
A new concept has been introduced in which the canal shaping procedure is
managed using a specifically designed single-file NiTi system with an M-Wire alloy
that uses a reciprocating motion (5). The same technique is also indicated for retreat-
ment purposes (6). The Reciproc (RPC; VDW, Munich, Germany) endodontic instru-
ment is 1 type of NiTi file that is based on this reciprocating motion. A recently
introduced NiTi rotary instrument called the ProTaper Next (PTN; Dentsply Maillefer,
Ballaigues, Switzerland) features a rectangular cross-sectional design and an asym-
metric rotation that works on a continuous rotation motion and is manufactured
from M-Wire alloy. According to the manufacturer, the rotation combined with the
unique offset design generates an enlarged space for debris removal (7).
More recently, a new NiTi system has been introduced called the Twisted File Adap-
tive (TFA; Axis/SybronEndo, Orange, CA), a system developed with its own endodontic
motor (Elements Motor, SybronEndo) that uses a unique motion. The movement de-
pends on the stress rate in the canal that the file faces. When there is no stress on
the file, the file rotates 600 clockwise and stops and then restarts again in the clockwise
direction. In cases in which the stress rate on the file increases, the microprocessors in
the Elements Motor calculate the rate of the stress and change the movement kinematic
rotation to reciprocation. This reciprocation movement may be changed up to 370
clockwise and 50 counterclockwise according to the stress rate on the file (8).
A literature review revealed that there are no previous studies comparing the
cleanliness of root canal walls after retreatment using the PTN and TFA NiTi systems.
Therefore, the aim of this study was to compare the cleanliness of root canal walls after
retreatment using PTN, TFA, RPC, and PTR NiTi systems with various movement kine-
matics and the time required for gutta-percha and sealer removal. The null hypothesis
was that there would be no significant difference between the cleanliness of root canal
walls after retreatment using different NiTi systems.
Materials and Methods
Specimen Selection
After Ondokuz Mayıs University Clinical Research Ethics Committee (no.
B.30.2.ODM.0.20.08/1561) approval, 80 straight, single-rooted human maxillary
NiTi Instruments and Removal of Gutta-percha 1
Basic Research—Technology
central incisors that were extracted for periodontal reasons were
selected. The inclusion criteria were a fully developed apex, no intra-
canal calcification or resorption, and no evidence of previous root ca-
nal treatment. All teeth used in this study had 1 canal in each root with a
curvature of less than 5 as evaluated by Schneider’s method (9). To
standardize the study, all the crowns were trimmed using a high-speed
bur under water cooling to leave a 20-mm tooth length. The teeth were
then stored in 4 C distilled water before the experimental procedures.
Root Canal Preparation
After endodontic access, to standardize the apical diameter, ca-
nals larger than ISO size 20 were discarded. The working length (WL)
was established by the direct method by subtracting 1 mm from the
real root length determined by introducing a number 10 K-file (Dents-
ply Maillefer) until it was visible through the apical foramen. Root ca-
nal instrumentation was performed by a crown-down technique using
K-files, starting with #60 up to #40.02 master apical file. The root ca-
nals were irrigated with 2 mL 5.25% sodium hypochlorite (NaOCl)
preceding the use of each instrument. Additionally, 2 mL 17% EDTA
for 2 minutes followed by 2 mL 5.25% NaOCl and 5 mL distilled water
were used for the final irrigation. The root canals were then dried with
sterile paper points.
Root Canal Obturation
The root canals were obturated with gutta-percha and AH Plus root
canal sealer (Dentsply DeTrey, Konstanz, Germany); 40.02 taper master
cones (Diadent Group International, Chongchong BukDo, Korea) were
then coated with sealer and placed into the canal to the WL. The root
canals were obturated using the continuous wave of the condensation
technique via a Calamus 3D Obturation System (Dentsply International,
Johnson City, TN). Temporary filling material was used to seal the cor-
onal orifice (Cavit-G; 3M ESPE, Seefeld, Germany). After obturation, the
teeth were stored at 37 C in 100% humidity for 14 days for sealer setting.
Retreatment Technique
No solvent was used in order to prevent any interference with the
removability of the sealers and its evaluation (4). The roots were
randomly divided into 4 groups (n = 20). A single experienced oper-
ator performed all of the retreatment procedures as described later.
Group 1: PTN. PTN X3 (30/.07) and X2 (25/.06) instruments were
used in the crown-down technique. The PTN X3 file was used to remove
the gutta-percha and sealer from the one third of the WL, and the X2 file
was used in the full WL. The instruments were activated according to the
manufacturer’s instructions by the torque control endodontic motor
(X-Smart, Dentsply Maillefer) at 300 rpm and 200 g/cm-1 torque.
The files were used with a brushing motion against the lateral walls.
Final apical preparation was then achieved with a PTN X5 (50/.06)
file at the same speed and torque values.
Group 2: TFA. In this group, TFA ML2 (35/.06) and ML1 (25/.08)
instruments were used in the crown-down technique as described in
the PTN group. The gutta-percha and sealer in the coronal third of
the canal were removed using the TFA ML2 file. Then, the TFA ML1
file was used to reach the WL. The instruments were activated with
the Elements Motor in the ‘‘TF Adaptive’’ program. The final apical
enlargement was performed with a TFA ML3 (50/.04) file using the
same program.
Group 3: RPC. The RPC R25 (25/.08) instrument was used with the
VDW Silver Reciproc (VDW) endodontic motor in-and-out pecking
motion in the ‘‘RECIPROC ALL’’ program until reaching the WL. The
instrument was used with an in-and-out pecking motion. According
2 €zy€urek and Demiry€urek
O JOE — Volume -, Number -, - 2016
to the manufacturer’s instructions, gentle apical pressure was applied
to the file, and the file was used with a brushing motion. The final api-
cal preparation was achieved with the RPC R50 (50/.05) file using the
same program.
Group 4: PTR. In the PTR group, the retreatment procedure was per-
formed by the crown-down technique with the PTR D1 (30/.09), D2
(25/.08), and D3 (20/.07) retreatment files. The files were activated
with the X-Smart endodontic motor. The gutta-percha and sealer in
the coronal and middle thirds of the canal were removed by the D1
and D2 files at 550 rpm and 200 g/cm-1 torque. Then, at the apical third,
the removal process was performed with the D3 file at 250 rpm and
150 g/cm-1 torque. The files were used with a brushing motion against
the lateral walls. The final apical preparation was achieved with the Pro-
Taper Universal (Dentsply Maillefer) F5 (50/.05) file at 250 rpm and
200 g/cm-1 torque.
The canals were irrigated in each group with 2 mL 5.25% NaOCl
solution during each instrument change. Two milliliters of 17% EDTA
for 2 minutes followed by 2 mL 5.25% NaOCl and 5 mL distilled water
were used for final irrigation to remove the smear layer in each tooth.
Three root canals were prepared with a new set, and then the set was
discarded (10).
The retreatment procedure in each group was considered com-
plete when both the final apical preparation file fit loosely in the canal
at the full WL and no residual gutta-percha or sealer was visible to the
naked eye on the file surface after removal from the canal (11).
Evaluation of Gutta-percha Removal
The teeth were grooved buccolingually with a stainless steel disc
and then split into halves using a chisel and mallet. Digital images at
8 magnification were obtained from both halves under a stereomicro-
scope (Olympus BX43; Olympus Co, Tokyo, Japan) attached to a digital
camera. The photographs were analyzed using AutoCAD software (Au-
todesk, San Rafael, CA) software to measure the areas of residual gutta-
percha and sealer (Fig. 1).
Time Required for Gutta-percha Removal
To calculate the total time, a chronometer was used. The total time
required to remove the gutta-percha and sealer was considered to be
the time elapsed from the moment the instruments were first applied
in the canal until the instruments reached the original WL. When the in-
strument was removed from the canal, the chronometer was stopped
and restarted, and then the instrument was placed into the canal.
Figure 1. Photograph showing the area of the gutta-percha and sealer
remaining in each canal third.

Statistical Analysis
The time data were normally distributed. Therefore, 1-way analysis
of variance was used to analyze the differences between the groups. Sta-
tistical analysis for the area of the residual gutta-percha and sealer was
performed using 2-way analysis of variance and the Duncan test with a
significance level of <.05.
Results
The results for the total retreatment time and the mean area of re-
sidual gutta-percha and sealer are shown in Table 1. The total retreat-
ment time was significantly shorter in the PTR group compared with the
other groups (P < .05).
There was a significant difference between the groups in the
removal of the gutta-percha and sealer according to the total residual
gutta-percha and sealer (P < .05). The PTN (1.58  0.12) and PTR
(1.47  0.06) groups left significantly less gutta-percha and sealer
remnant than the TFA (2.35  0.13) and RPC (2.39  0.12) groups
(P < .05). However, there was no significant difference between the
TFA and RPC groups (P > .05).
With respect to groups, the middle third for all groups had a signif-
icantly less residual gutta-percha and sealer when compared with the
coronal and apical thirds (P < .05). There was no significant difference
between the apical and coronal thirds (P > .05).
When comparing the regions, there was no significant difference
between groups regarding the middle third (P > .05). However, there
were significant differences between groups in the apical and coronal
thirds; the PTN and PTR groups left less gutta-percha and sealer
remnant than the TFA and RPC groups (P < .05).
There were no procedural errors in the PTN, PTR, and RPC
groups. However, 1 TFA ML1 file fracture occurred during retreat-
ment procedures in the TFA group; this sample was replaced with a
new one.
Discussion
It is essential to remove as much root canal filling material as
possible during retreatment to expose the residual necrotic tissue
or bacteria that might be responsible for root canal treatment fail-
ure (12). Previous studies have assessed the remaining filling ma-
terial through different techniques and methods (13–16). The use
of longitudinal sectioning to obtain images to inspect the root canal
walls has also been established (17) along with the use of stereo-
microscopes to evaluate the presence of filling material remnants
(18). Longitudinal sectioning has been shown to be more useful
for detecting the remaining filling material compared with radio-
graphic techniques (19). Radiographic images provide only 2-
dimensional information on a 3-dimensional structure and may
be subject to magnification and distortion (20). The cleaving
method must be performed carefully so as not to dislodge the
gutta-percha. Eight specimens in the current study were damaged
(3 in the PTR, 3 in the PTN, and 2 in the TFA groups) in the
sectioning procedure and replaced with 8 other specimens. In
TABLE 1. Mean and Standard Deviations of Residual Gutta-percha and Sealer on Canal Walls (mm2) and Total Time (s) Required for Retreatment
Group Apical Middle
ProTaper Next 1.79  0.12 ay
1.28  0.31
TF Adaptive 2.84  0.23az 1.49  0.1by
Reciproc 2.98  0.18az 1.56  0.12by
ProTaper Universal 1.66  0.13ay 1.19  0.06by
P value <.001 .132
Different superscript letters indicate a significant difference between groups (ab for rows and yz for columns).
JOE — Volume -, Number -, - 2016
Basic Research—Technology
this study, AutoCAD software was used for the quantitative evalua-
tion of residual filling material (21).
In the present study, central maxillary incisors were used; in fact,
in most of the experimental studies about retreatment techniques,
straight root canals have been used (22) to simplify the standardization
of the specimens. Some previous retreatment studies have obturated
teeth with lateral condensation. A hybrid technique was chosen in the
present study because it produces a better root canal filling adaptation
to the root canal walls than lateral condensation (23).
Hassanloo et al (24) reported that in nonsurgical retreatment
when the apical preparation size was larger than the initial apical
size, the residual root canal filling material was minimized. Therefore,
in the present study, apical enlargement was performed bigger than the
initial apical size (ISO size #50). In the present study, no solvent was
used with NiTi instruments because they generally plasticize gutta-
percha through the heat generated by friction, easily allowing them to
reach the WL but chemically softened gutta-percha can settle into the
complex canal anatomies (15). NiTi files show alterations such as
wear, distortion, and microcracks in their surface after repeated usage.
Thus, their cutting ability decreases, and they become more suitable for
separation (25, 26). Therefore, in the present study, the 3 root canals
were prepared with a new set, and then the set was discarded according
to the previous studies (10, 13).
The results of this study revealed that PTN and PTR groups left
similar gutta-percha and sealer remnant on the canal walls. In contrast,
the TFA group and the RPC group left significantly more gutta-percha
and sealer remnant on the canal walls than the other 2 groups (PTN
and PTR). Therefore, the null hypothesis was rejected. These results
may be because of the groups’ movement kinematics similarity. In
the evaluation of the gutta-percha and sealer removal duration, the
PTR NiTi rotary system was significantly faster than the other groups.
In a previous study that compared the total time required for removal,
root canal filling material using RCP and Mtwo R (VDW) found that RCP
was significantly faster than Mtwo R (10). In another study, RCP and
PTR had similar results in the total time required for retreatment
(18). These contrary findings may be explained by operator-related var-
iables and methods for calculating the total retreatment time.
In the present study, none of the NiTi rotary systems were able
to remove all of the gutta-percha and sealer. This finding agrees with
several previous studies that used different systems and instruments
(10, 12, 22). In this study, the PTR NiTi rotary system left
significantly less gutta-percha and sealer remnant than the other
groups. Previous studies compared the efficacy of the RPC and
PTR NiTi rotary systems, and the authors reported there was no dif-
ference between the 2 NiTi systems (13, 22). In another study, Zuolo
et al (10) found that the hand instruments and the RPC system were
significantly more effective than the Mtwo R system. Because the PTR
group had the biggest final apical taper (.06) in the present study,
the PTR group might leave significantly less gutta-percha and sealer.
Also, operator-related variables such as the intensity of the brushing
motion and determination of the end point of the retreatment might
play a role in these findings. According to the present study, the PTN
Coronal P value Total Time
by
1.68  0.12 ay
.015 1.58  0.12 y
30.89  2.86y
2.73  0.22az <.001 2.35  0.13z 39.2  2.79y
2.62  0.2az <.001 2.39  0.12z 37.28  3.65y
1.56  0.11ay .019 1.47  0.06y 28.63  2.61z
<.001 <.001 .044
NiTi Instruments and Removal of Gutta-percha 3
Basic Research—Technology
system left less gutta-percha and sealer remnant than the RPC and
TFA groups. The literature review revealed there were no previous
studies that had evaluated the retreatment efficacy of the PTN and
TFA systems. Thus, the PTN and TFA results from this study cannot
be compared with previous reports. However, PTN might be more
effective than TFA and RPC because of its novel offset design. This
design serves to further minimize the engagement between the file
and the dentin or gutta-percha. Additionally, an offset design facili-
tates debris removal from the canal and improves flexibility along
the active portion of the PTN instruments (27). The decreased effi-
cacy of the TFA system on the removal of gutta-percha and sealer
might be because of its R-phase metallurgy. This is supported by a
previous study by Park et al (28), who reported the lowest torsional
resistance was observed in Twisted File instruments. Especially NiTi
files face torsional stress during retreatment (29). In our study,
just 1 TFA ML1 file fracture occurred. This fracture might have
occurred because of the Twisted File instrument’s low torsional resis-
tance. In the other study, Capar et al (18) reported that the PTR NiTi
rotary system significantly removed more root canal filling material
when used in the adaptive motion compared with the continuous
rotation motion. The authors concluded that the combination of a
continuous rotation and a reciprocation motion might explain the
increased removal of root canal filling material. However, in the pre-
sent study, the TFA and RPC groups showed significantly more resid-
ual gutta-percha and sealer than the other groups.
Conclusion
Within the limitations of this study, the PTN and the PTR groups
showed less residual gutta-percha and sealer than the TFA and RPC
groups. The PTR group was significantly faster than the other groups
in the time required for gutta-percha and sealer removal.
Acknowledgments
The authors would like to thank Samet Hasan ABACI, Research
Assistant, Faculty of Agriculture, Department of Animal Science
Biometry–Genetic Unit, Ondokuz Mayis University for his help
with statistical analyses.
The authors deny any conflicts of interest related to this study.
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