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Original Article

Fracture resistance exhibited by endodontically


treated and retreated teeth shaped by ProTaper
NEXT versus WaveOne: An in vitro study
Neha Deepak Khalap, Vibha Hegde, Sharad Kokate
Department of Conservative Dentistry and Endodontics, YMT Dental College and Hospital, Kharghar, Navi Mumbai, Maharashtra, India

Abstract
Aim: To compare the fracture resistance exhibited by teeth after primary endodontic treatment and retreatment.
Materials and Methods: One hundred freshly extracted human teeth were selected. 20 samples served as control
(untreated). Eighty experimental samples were divided into two groups (n = 40) for instrumentation using rotary Protaper
NEXT (PTN) or reciprocating WaveOne (WO) files and obturated using warm lateral compaction. Half of the samples (n =
20) from each group were subjected to a load. The remaining half were subjected to retreatment using Protaper universal
retreatment files (RFs) followed by a file larger than the master apical file used in groups 1 and 2 and reobturated. Group
A: Control, Group B: PTN + obturation, Group C: WO + obturation, Group D: RF + PTN + obturation and Group
E: RF + WO + obturation. The retreatment specimens were also subjected to load and the readings acquired were
statistically analyzed.
Result: When compared between the groups, control group exhibited the highest fracture resistance (P < 0.01). When multiple
tests were performed, Group E exhibited significantly less fracture resistance (P < 0.01).
Conclusion: Endodontic treatment and retreatment both results in lowering the fracture resistance of a tooth.
Keywords: Fracture resistance; Protaper NEXT; retreatment; WaveOne

INTRODUCTION apex, or any point in between.[3,4] The reasons attributed


for increased susceptibility to fracture are dehydration,
The role of endodontic instrumentation is to remove excessive loss of dentin, removal of caries, access cavity
tissue debris and an infected inner layer of dentine, preparations, canal shaping techniques, effects of irrigating
along with allowing a hermatic fluid-air tight seal.[1,2] solutions, prolonged placement of calcium hydroxide,
Vertical root fracture’s (VRF) are the most challenging pressure during obturation, postplacement, tooth/crown
complication associated with endodontically treated preparation, and retreatment procedures.[5-9]
teeth.[3] It is a longitudinally oriented fracture extending
to the periodontium that may begin in the crown, root
Various design features of the file systems such as the
nickel-titanium (NiTi) core diameter, cross-sectional
Address for correspondence:
Dr. Neha Deepak Khalap, Department of Conservative Dentistry shape, rake angle, and flute depth affect the behavior of
and Endodontics, YMT Dental College and Hospital, Kharghar, the file and, which in turn influences the generation of
Navi Mumbai, Maharashtra, India.
E-mail: neha.khalap@gmail.com This is an open access article distributed under the terms of the Creative
Commons Attribution-NonCommercial-ShareAlike 3.0 License, which
Date of submission: 11.05.2015
Review completed: 08.07.2015 allows others to remix, tweak, and build upon the work non-commercially,
Date of acceptance: 08.09.2015 as long as the author is credited and the new creations are licensed under
the identical terms.
Access this article online For reprints contact: reprints@medknow.com
Quick Response Code:
Website:
www.jcd.org.in
How to cite this article: Khalap ND, Hegde V, Kokate S. Fracture
resistance exhibited by endodontically treated and retreated teeth
DOI: shaped by ProTaper NEXT versus WaveOne: An in vitro study. J
10.4103/0972-0707.168808
Conserv Dent 2015;18:453-6.

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Khalap, et al.: Fracture resistance of endodontically treated and retreated teeth

cracks, apical stress, and strain concentrations resulting Initial endodontic treatment
in VRF.[10,11] Group B: Instrumentation with Protaper NEXT
A total of 40 specimens were instrumented by PTN files
Recently, newer generation NiTi instruments have been till full sequence X2. These files were used in outward
designed that is the Protaper NEXT (PTN) and WaveOne brushing manner at 300 rpm/2.6 nm. Three percent sodium
(WO) (PTN; Dentsply Tulsa Dental, Tulsa, OK). PTN files are hypochlorite and ethylenediaminetetraacetic acid (EDTA)
uniquely designed such that the center of mass and the was used as an irrigant and lubricant alternatively between
center of rotation are offset.[11,12] each file and recapitulation.

The WO (Dentsply Maillefer) NiTi single-file system Group C: Instrumentation with WaveOne
functions in reciprocating motion. The counterclockwise A total of 40 specimens were instrumented by WO Primary
engaging angle is 5 times the clockwise disengaging file (25/.08) (Dentsply Maillefer, Ballaigues, Switzerland) in
angle and is designed to be less than the elastic limit of pecking motion, using X Smart Plus endomotor (Dentsply-
the file. These instruments are manufactured with M-Wire Maillefer). These files were used in outward brushing manner
technology which may increase flexibility and resistant to at 300 rpm/2.6 nm. Three percent sodium hypochlorite and
cyclic fatigue.[10,11,13] EDTA was used as an irrigant and lubricant alternatively
between each file and recapitulation.
Retreatment procedure aims to remove the entire
obturating material.[12,14] Various techniques have been
Obturation for Group B and C
advocated to remove obturating materials which may
After complete instrumentation, final irrigation was
require more mechanical manipulation leading to more
performed with 10 mL of 17% aqueous EDTA (Prime Dental
radicular dentine removal and subsequent dentinal
Products, India) followed by 10 mL of sodium hypochlorite
defects.[13-15]
to remove the organic and inorganic smear layer. The canals
Studies show that the Protaper universal retreatment files were dried with sterile absorbent paper points. Following
(RFs) are ineffective for removing the entire obturating the manufacturer’s instructions, the AH plus sealer
material and have suggested the use of supplementary files (DentsplyDeTrey GmbH, Konstanz, Germany) was mixed
for better removal of root canal filling residues.[15,16] and applied with master cone Gutta-percha within the root
canal and obturated using lateral condensation technique.
Hence, the current study was designed to compare Excess Gutta-percha was sheared off and condensed with a
the fracture resistance exhibited by teeth after initial heated plugger 1 mm below the canal opening. The orifice
endodontic treatment and retreatment using rotary PTN was sealed with Coltosol (Coltene-Whaledent, Cuyahoga
and reciprocating WO file systems. Falls, OH, USA) and the teeth were stored at 37°C in 100%
humidity for 2 weeks.
MATERIALS AND METHOD
Retreatment technique
Specimen selection Twenty samples from group 1 and 2 underwent retreatment
Freshly extracted human mandibular premolars (for (Group D and E) after 30 days. Protaper Universal RFs
orthodontic treatment) with single straight canal were (D1-D3; Dentsply Maillefer), were used at 300 rpm and
selected. Confirmation of single canal was done by bucco- 3 N/cm torque to remove the bulk of root canal filling.
lingual and mesio-distal angulated radiographs. The Endosolv R (Septodent, Cedex, France) was used as the
samples were decoronated to length of 15 mm with a solvent subsequently after each RFs.
diamond disk under water. The teeth were examined with
a stereomicroscope under ×10 magnification to detect Group D
craze lines or cracks which were excluded from the study. After removal of bulk Gutta-percha, the residual root filling
The bucco-lingual and mesio-distal diameter of the roots was removed using PTN X3 and X4 files.
were measured with Vernier calliper and standardization
was done. Performing the above procedure resulted in 100 Group E
samples. After removal of bulk Gutta-percha, the residual root filling
was removed using WO large file.
Group A
A total of 20 teeth were uninstrumented. Reobturation of Group D and E
The canals are irrigated and obturated as described earlier
In the remaining 80 samples, hand instrumentation was with standardized master cone (40/.06). The teeth were
done till #20 k-file. stored at 37°C in 100% humidity for 2 weeks.

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Khalap, et al.: Fracture resistance of endodontically treated and retreated teeth

Mechanical testing DISCUSSION


All samples were mounted on a custom made acrylic
blocks to accept the loading fixture. The acrylic blocks VRF is a sequel of gradual propagation of microcracks in
were mounted with the roots aligned vertically on the tooth structure.[10,17] After shaping and cleaning, there is
universal testing machine one at a time. The specimens almost 30% reduction in vertical fracture resistance.[4,18]
were subjected to a constant load at a crosshead speed During canal instrumentation with NiTi rotary/reciprocating
of 1.0 mm/min until the roots fractured. In this study, files, momentary stresses are concentrated in dentine due
“fracture” was defined as the point at which a sharp and to contact and friction between the instrument and canal
instantaneous drop was observed. This point was verified walls. This causes cracks which have been observed and
by a computer attached to the universal testing machine. reported at various levels.[19,20]
For most specimens, an audible crack was also heard. The
test was terminated at this point and the force applied was The new PTN files have an uncommon design with the center
recorded and measured in Newtons. of mass and the center of rotation being offset when in the
rotation. This unique design aids in more cross-sectional
Statistical analysis space for enhanced cutting, loading and auguring debris
Mean (± standard deviation) were calculated for each coronally. PTN (X1, X2, X3, X4) used in the present study
group, the groups compared using one-way analysis of have an increasing and decreasing alternating percentage
variance (ANOVA) and a multiple comparison test was tapered designs on these files.[12]
performed using Tukey post-hoc test (SPSS software
version 20, SPSS Inc, Chicago, IL). The WO reciprocating files are characterized by a triangular
or modified triangular cross-section resulting in a low
RESULTS cutting efficiency and less chip space. The reciprocal motion
seems to enhance debris transportation toward the apex
All the teeth exhibited fracture. The fracture resistance and may result in increased torsional forces.[21] WO caused
of teeth after endodontic treatment and retreatment significantly more microcracks than a full sequence of rotary
decreased [Table 1]. The mean fracture load required for files, also these cracks are seen more at the apical level,
Group A - 306.46 ± 80.25 N, Group B - 272.58 ± 66.08 N, which may result in less fracture resistance exhibited by the
Group C - 212.79 ± 68.67 N and Group D - 161.25 ± 63.45 teeth in the group instrumented by WO files in the present
N, Group E - 143.66 ± 70.78 [Table 1]. study.[22]
The fracture resistances exhibited significant differences
This rationale claims that using only a single large-tapered
between the groups (ANOVA, P < 0.01). Multiple Tukey’s
reciprocating instrument tends to create or aggravate more
post-hoc tests revealed; Group A (control) exhibiting no
dentinal defects than conventional preparation, which cuts
statistical significant difference when compared with
substantial amounts of dentin in a short time.[23]
Group B (P > 0.05), but a significant difference with
Groups C, D and E (P < 0.01). Furthermore, Group B
The results of our present study revealed statistic
and C presented a significant difference when compared
significant difference in samples instrumented with
with Group D and E. Group E exhibited the least fracture
decreased fracture resistance in samples instrumented
resistance among groups. The mean-wise presentation of
the data has been plotted in Graph 1.

Table 1: Mean and SD values of the fracture resistance


(N) exhibited by the specimens
Groups Number Minimum Maximum Mean ± SD
of load (N) load (N)
samples
Group A (control) 10 190.74 418.36 306.64±80.25a
Group B (PTN) 10 150.69 358.23 272.58±66.08a
Group C (WO) 10 105.64 301.56 212.79±68.67b
Group D 10 90.78 280.18 161.25±63.45c
(retreatment + PTN)
Group E 10 68.01 212.73 143.55±70.78d
(retreatment + WO)
Graph 1: Mean-wise comparison of the fracture loads
Minimum, maximum, mean and SD of the fracture loads required by the
required by the samples in all groups in Newton (N).
samples in all groups in Newton (N). Similar superscript letters denote no
statistical significant difference (P > 0.05) and dissimilar superscript letters
Similar superscript letters denote no statistical significant
exhibit a statistically significant difference (P < 0.01). PTN: ProTaper Next, difference (P > 0.05) and dissimilar superscript letters exhibit
WO: WaveOne, SD: Standard deviation a statistically significant difference (P < 0.01)

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Khalap, et al.: Fracture resistance of endodontically treated and retreated teeth

by WO having mean value of 212.79 N than PTN with Financial support and sponsorship
mean value of 272.58 N. This is in agreement with a Nil.
study conducted by Pawar et al.[4] which showed that WO
significantly decreased the fracture resistance of teeth Conflicts of interest
when compared to PTN. There are no conflicts of interest.

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