6 & 8 o t 9 7 2 2 a aNickel-Titanium Instruments Applications in Endodontics Thomas P. Serene, D.D.S., M.S.D. Professor and Director Division of Endodonti Department of General Dentistry College of Dental Medicine Medical University of South Carolina Charleston, South Carolina J. David Adams, D.M.D. College of Dental Medicine Medical University of South Carolina Charleston, South Carolina Ashok Saxena, Ph.D. Professor and Director School of Materials Science and Engineering Georgia Institute of Technology Auanta, Georgia Ishiyaku EuroAmerica, Inc. St. Louis * Tokyo2nd Printing, March 1 Copyright © 1995 by Ishiyaku EuroAmerica, Inc. All rights reserved. No part of this publication may be reproduced or transmitted by any means, electronic, mechanical, or otherwise, including photocopying and recording, or by any information storage or retrieval system, without prior written permission from the publisher. Nickel-Titanium Instruments: Applications in Endodontics Thomas P. Serene, D.D.S., M.S.D. J. David Adams, D.M.D. Ashok Saxena, Ph.D. ISBN: 1-56386-031-7 Library of Congress Catalogue Card Number: 94-76881 Copy Editor: Brian W. Cochran, M.RA. ‘Typesetter: Walter Livengood Printed in the United States of America Ishiyaku EuroAmerica, Inc. 716 Hanley Industrial Court, St. Louis, Missouri 63144, U.S.A.A Special Note to the Clinician eocccccce Tt should be noted that the findings reported in this book are based on limited studies using a new alloy. Continued research is essential, and the use of the new instruments should be carefully monitored. It is also of particular importance to monitor NiTi files for failure and fatigue (see Chapter 8). While the findings presented here represent the best informa- tion we currently have available, the authors and publisher cannot assume any responsibility for these relatively new instruments or techniques.Preface eoccccccccce eocccce This book is offered as a clinical aid for the dentist and to provide valuable and necessary information on the biological, physical and mechanical prop- erties of nickel-titanium (NiTi) instruments currently available for use in endodontic therap It is our sincere belief that these new instruments will improve canal instrumentation and accelerate the therapy. Additionally, we believe that the type of therapy afforded by NiTi instruments provides greater patient comfort than available before. Thomas P. Serene, D.D.S., M.S.D. J. David Adams, D.M.D. Ashok Saxena, Ph.D.Acknowledgments Ceccccccccccccccccccccccccccccccccccocccoeolele The authors would like to thank the students in the Classes of 1993 and 1994, at the College of Dental Medicine, Medical University of South Caro- lina, for their preclinical and clinical contributions. We wish to express our special appreciation to Dr. Robert A. Draughn, Biological and Physical Sci- ences, MUSG; Dr. Alan Gross and Qihao Jiang, Department of Biostatistics, Epidemiology and Systems Science, MUSC; Dr. Mark Chishom and Dr. Clark Dalton, Class of 1994, MUSC, and Thomson Rast, photographer, MUSG, for their contributions and encouragement during the preparation of this book. Additional thanks go to Dr. Mark Beard, Class of 1994, MUSG, for his proofreading skills in the preparation of this book. Special thanks must also go to Dr. John T. McSpadden, President, NT Company, Chattanooga, ‘Tennessee; Derek Heath, President, Quality Dental Products, Johnson City, Tennessee; and to Dr. Jerry Mooneyhan, Quality Dental Products, Johnson City, Tennessee for their expertise and material support, without which this book would not have been possible. Finally, a very special thanks goes to Ann Pinson, secretary, for her com- puter preparation of this book, and to Gloria Folk, dental assistant. Special thanks are also due to the Robert Bosch Corporation, Automotive Group, Charleston, South Carolina: Thomas Piness, Unit Manager, Materials and Chemical Laboratory; Richard Campbell, Senior Materials Technician; Wil- liam Matthews, Senior Material/Metallurgical Tech; Denise Russell, Metal- lurgical Technician; and Jerrold Almers, technician. viio Contents Introduction to Nickel-Titanium = 7 Stress-strain behavior; superelasticity; thermal deformations NiTi Hand Instrumentation 7 Clinical cases; NiTi spreaders; double-tapered files Mechanical Instrumentation 15 Advantages; single-tapered (.02) files; guidelines; laboratory cases; double- tapered (.04) to triple tapered (.06) files; laboratory cases; new multi-tapered techniques under evaluation The Instruments 35 Hand instrumentation: stainless steel K, NiTi K, NiTi Mac, NiTi Hedstrom, NiTi Flex R, NiTi U, NiTi X, and NiTi S; Mechanical: NiTi “Hedstrom style” H, NiTi U, NiTi Mac, and NiTi Canal Master; NiTi customers PhysicalTests 49 Comparative flexibility of hand files; rotation to deformation of blanks; rotation to breakage of files; torque to rotation; micro-hardness; trace element analysis; NiTi stress and micro-hardness Comparisons of NiTi and Conventional Instrumentation 67 Preclinical comparison study of stainless steel to NiTi instrumentation; comparison of conventional and NiTi over-instrumentation; comparison of conventional and NiTi instrumentation with a chelating agent Instrumentation — SectionedTeeth 79 Root canal anatomy before and after hand and mechanical instrumentation; U hand files; K and Mac hand files; H Mac mechanical files Failure and Lifetime of NiTi Hand Files 99 Fractures and deformations; preliminary experimental results Future Developments in NiTi Files 109 Ion implantation; life prediction models; file design optimization Index = 1111 Introduction to Nickel-Titanium Dentists are experiencing increased demand for endodontic services as more patients come to understand the benefits of preserving their natural dentition. With this increased demand, the manufacturers of dental products have taken a greater interest in endodontic instruments, which is a help to the dentist. Recent scientific and technologic advancements in metal alloys have significantly improved the flexibility and strength of a new generation of endodontic instruments. This enables the modern practitioner to provide a higher level of care than was previ- ously attainable. After years of relative inacti 'y with regard to improvements in metals and alloys used to make endodontic instruments, we now have instruments made from a remarkable alloy, nickel-titanium (NiTi). These instruments offer possibilities for improving the speed and efficiency of weatment, as well as achieving greater precision and accuracy. This alloy exhibits superelastic behavior, allowing it to return to its original shape upon unloading following substantial deformation. By contrast, other metals, such as stainless steel, sustain plastic deformation leading to permanent shape change when deformed similarly. The superelastic property of NiTi has been known for 30 years, and was discovered by chance by Buchler and Wang! while searching for nonmagnetic, salt-resisting, waterproof alloys for naval use. Alloys that show superelasticity undergo a stress-induced martensitic transformation from a parent structure which is austenite. Upon release of the stress, the structure reverts back to austenite, recovering its original shape in the process. Deformations involving as much as a 10 percent strain can be completely recovered in these materials, as compared to a maximum of one percent in conventional alloys.NICKEL-TITANIUM INSTRUMENTS: APPLICATIONS IN ENDODONTICS, Since the deformation is accommodated by martensitic transformation as opposed to the stretching of atomic bonds in conventional (or Hookean) clastic behavior, the increment of stress (or force) required to continue the deformation is very small in comparison to that required by conventional alloys. This is nicely illustrated by comparing the stress-strain diagram of wires made from conven- tional steel, such as_music wire, and that of the NiTi wire, as shown in Figure 1- 12. To stretch the music wire to 3 percent strain, a stress (force/cross-section area of the wire) of 2500 MPa (mega-pascals) is required, as compared to 500 MPa for the NiTi wire. At3 percent strain, the music wire breaks, and between 1 percent and 3 percent strain, it deforms plastically. On the other hand, the NiTi wire can be stretched to much beyond 3 percent without significant increase in applied stress level, and it can recover most of this deformation upon the release of stress. Music Wire 1000] Stress (MPa) Ti-$0.8 at.% Ni 500) i eanee Sun ios Ses tga? Strain (%) Fig. 1-1. Stress behavior of a conventional steel wire (music wire) and that of a NiTi alloy undergoing superelastic deformation. « Stoeckel and W. Yu, Wire Int J, March 1991) The superelastic behavior of NiTi occurs over a limited temperature win- dow. For example, Figure 1-2 shows the residual deformation in a NiTi wire after it was strained 8 percent, then had its load released at various temperatures. Minimum residual deformation occurs at approximately room temperature. How- ever, significant deformation is recovered between 10°C and 125°C. This tempera- ture window in which superelastic behavior is observed is dependent on the precise chemical composition of the alloy. Addition of iron to NiTi, for example, lowers the temperature window. We note that in endodontic applications, where it is desirable to have the greatest superelastic behavior in a temperature range of 23 to 36°C, a composition consisting of 50 atomic percent Ni and 50 atomic percent Ti is ideal. Note that the composition of the alloy used in the experiments from which Figures 1-1 and 1-2 are derived is approximately that amount.CHAPTER 1: INTRODUCTION TO NICKEL-TITANIUM NiTi alloys also exhibit a shape memory effect. That is, if an initially straight NiTi wire is bent at a temperature below that at which it is dominantly superelastic (in other words, at temperatures below the lower end of the superelastic tempera- ture window), it will regain its original configuration upon heating to a tempera- ture above the upper end of the superelastic temperature window. Thus, any deformation in an NiTi file occurring as a result of use can be removed by heating the file to a temperature above 125°C for the Ni-50 atomic percent Ti alloy. Thus, sterilization of endodontic files between uses, in autoclaves which utilize supersaturated dry steam, can further enhance the fatigue life of the files. Permanent Set (%) ‘ao eno ‘Temperature (°C) Fig. 1-2. Residual ( permanent) deformation as a function of tem- perature after straining to 8 percent and releasing the load with a NiTi alloy. (b. stroeckel and W. Yu, Wire ntl J, March 1991) There are many alloys which have superelastic properties? such as copper- zine, copper-aluminum, gold-cadmium, titanium-niobium and _nickel-titanium. Among these, however, nickel-titanium has the highest. biocompatibility and also has excellent corrosion resistance. Nickel-titanium, also known as “nitinol” in the United States, has been manu- factured in Shanghai, China since 1979 as “nitalloy” (56% nickel and 44% tita- nium).' As early as the 1970s, biomaterialists and clinicians were investigating its applications in medicine." In 1982, Hsieh and Yu’ reported the results of the implantation of nitalloy wires and cubes in the periosteum, muscles, and subcutaneous tissues of dogs. After 10 months, they found no obvious gross tissue reaction or resorption. Histol- ogy showed only mild proliferation of fibrous tissue with hyaline degeneration and few chronic inflammatory cells. In 1979, Schettler ® described the use of nickel-titanium in a new form of fixation in alveolar fractures. Since 1979, others"! have shown nickel-titanium’s unique applications in orthopaedics.NICKEL-TITANIUM INSTRUMENTS: APPLICATIONS IN ENDODONTICS. The first investigation of nickel-titanium in endodontics was reported in 1988 by Walia, Brantley, and Gerstein,” using #15 files fabricated from nickel- titanium orthodontic alloy. These files were shown to have two to three times the clastic flexibility in bending and torsion, as well as superior resistance to torsional fractures, compared with #15 stainless steel files manufactured by the same pro- cess. The results suggested that nitinol files might be promising for the instrumen- tation of curved canals. In early 1992, NiTi K files were introduced to students in the College of Dental Med e at the Medical University of South Carolina. NiTi Mac files be- came available to the general public during the University’s Endodontic Labora- tory course in May, 1992. NiTi instruments are currently available in a variety of forms (files, pluggers, spreaders, burs, etc.). Numerous research projects have been initiated, and a tremendous interest is being shown by the dental profession. In Summary Nickel-titanium is a superelastic (shape memoried) alloy ideally suited for endodontic instruments. Files made from this alloy are biologically acceptable, highly flexible and considerably stronger in fatigue resistance than conventional stainless steel files. Due to their higher flexibility, nickel-titanium files have the advantage that there is less chance of transportation of the canal during instru mentation, and they are at least 20% faster than conventional files. These files are now being introduced and used in the United States and throughout the world. Nickel-titanium is unique in that its structure can be transformed from austenite to martensite upon stressing, and vice-versa upon release of load. This stress-induced transformation can accommodate large deformations without a per- manent strain. These exciting characteristics of this material make it ideally suited for endodontic applications. However, continued research is essential, and the use of the new files should be carefully monitored.CHAPTER 1: INTRODUCTION TO NICKEL-TITANIUM References 1. Buchler, WJ., and Wang, E.: Effect of low temperature phase on the mechanical properties of alloy near composition NiTi. Journal of Apply Physics, 34:1475, 1963. 2. Stoeckel, D., and Yu, W.: Superelastic Ni-Ti wire. Wire Journal International, pp 45-50, March 1991. 3. Buchler, W.J., and Wang, E.: A summary of recent research as nitinol alloys and their application in ocean engineering. Ocean Engineering, 1:105-120, 1968. 4. Yang, H.B., Hong, W.O., and Dao, C.S.: The study and application of NiTi shape- memory alloy. Journal of Shanghae Steel Research, 25(4):1-8, 1982. 5. Baumgart, ‘I, Bensmann, G., and Haasters, J: Memory alloys new materials for implantation in orthopaedic surgery: Part 1, in Uhthoff HK(ed). Current Concepts of Internal Fixation of Fractures, Berlin, Springer-Verlag, pp. 122-127, 1980. 6. Haasters, J., Bensmann, G., and Baumgart, T:: Memory alloys new material for im: plantation in orthopaedic surgery - Part II, in Uhthoff HK(ed): Current Concepts of Internal Fixation of Fractures, Berlin, Springer-Verlag, pp. 128-135, 1980. Hsich, M., and Yu, YF: The basic research on NiTi shape-memory alloy-anti-corro- sive test and histological observation. Chinese Medical Journal, 1:105-120, 1982. 8. Schettler, D.: Method of alveolar bracing in mandibular fractures using a new form of fixation made from memory alloy. Journal of Maxillofacial Surgery, 7:51-54, 1979. 9. Dai, KR: The use of compressive staples on NiTi shape-memory alloy in orthopaedic surgery. Chinese Journal of Orthopaedics, 21:343-348, 1983. 10. Kuo, RPE: Clinical use of nickel-titanium shape-memory alloy in orthopaedics sur- gery, in: Progress in Artificial Organs, Cleveland, ISAO Press, pp. 1105-1107, 1986. 11. Yang, PJ., Zhang, Y.E, Tao, J-C., and et al.: Internal fixation with NiTi shape-memory alloy compressive staples in orthopaedic surgery: A review of 51 cases. Chinese Medical Journal, 100(9):712-714, 1987. 12. Walia, H., Brantley, W.A., and Gerstein, H.: An initial investigation of the bending and torsional properties of nitinol root canal files. Journal of Endodontics, 14:346-351, 1988.2 NiTi Hand Instrumentation Introduction ‘Traditionally, cleansing and shaping of root canal space has been accom- plished with conventional (stainless steel) hand files, reamers and broaches, but conventional files, because of their hardness and inflexibility, often deviate from the original canal path; a problem which is especially noticeable when small curved canals are enlarged beyond size #25. A multitude of techniques for stainless steel instrumentation have been advocated in attempts to maintain the original direction and shape of canals. Still, however, canal preparation with conventional instrumen- tation is time consuming, tedious and unpredictable. Recently, a revolutionary development in endodontics-the incorporation of nickel-titanium (NiTi) into fileshas transformed canal instrumentation. Canals are now less susceptible to transportation, ledge formation and perforation. The ex- treme flexibility of the new files enable them to follow even the most tortuous canals. An additional advantage is that NiTi files can be used with basically the same manual technique as their conventional counterparts, the primary caveat being that they should not be used with excessive force. Our students started using non-conventional NiTi files in 1992 and found the K file to be particularly technique-friendly and excellent for canal debridement. Becoming more familiar with the new alloy, the students found that the other NiTi hand files were more aggressive in their cutting ability. One of the early techniques from our 1992 laboratory course was to alternate using K and Mac files. This took into account the advantages of each file type: the Mac for its more aggressive cutting ability and the K for its debriding ability. Because the Mac file was found to be slightly smaller than the K file in each size group, the students used an alternat- ing technique (Mac #20 then K #20, Mac #25 then K #25, etc.). This proved to be an excellent approach. As students continued using NiTi hand files, their prefer- ence gradually moved toward the more aggressive cutting files (the Mac, Hedstrom, Flex R, X and S files)NICKEL-TITANIUM INSTRUMENTS: APPLICATIONS IN ENDODONTIC Recently, a #20 double-taper Mac .04 file has become available. This file is used for crown-down preparation and, while it does not eliminate the need for other flaring instruments, it does integrate their use into a continuous tapered al. There are many types of NiTi hand files, most of them excellent. Canal instrumentation can be initiated with a working length that is at least 1.5 to 2 mm short of the radiographic apex. This helps to prevent over-instrumen- tation beyond the apex. Should additional length be necessary at the end of the cleansing and shaping procedure, it is usually not difficult to increase working length. Preventing over-instrumentation can help decrease posttreatment pain and make it easier to dry out canals. Practitioners using NiTi hand files can enlarge most small curved canals with the working length to a minimum size of #40, and the procedure can be completed in less time than with stainless steel files. In addition, canals can be flared with larger NiTi files, or they can be flared later with conventional instru- ments, such as Gates Glidden Burs, when the canal orifices are larger and in the center of the roots. This helps to make the flaring procedure easier and safer. Large canals make cleansing and filling comparatively easy. Files are consistently effective up to 10 times use (10 cases); however, they have been used successfully up to 30 times (30 cases). Files should be examined (with magnification) after each use and should be discarded if the elastic limit has been exceeded or if severely bent. cai Clinical Cases Mandibular First Molar — Case 1 The final radiograph from a student case, showing a mandibular first molar with #45 NiTi files in the mesial canals and a #50 NiTi file in the distal canal. Note: The mesial canals join at about 3 mm short of the working length. Fig. 2-1. Mandibular first molar with NiTi files. (Case 1)CHAPTER 2: NT: HAND INSTRUMENTATION Mandibular Canine — Case 2 A mandibular canine case shows the fact that most teeth, even single rooted anteriors, display some canal curvature. The final file radiograph shows a #55 NiTi file inserted to the working length. The condensation radiograph shows flaring and retention of the original canal curvature. A B Fig. 2-2 (A, B). Mandibular canine. (Case 2) Mandibular Molars — Case 3 ‘A mandibular first molar was treated by a student prior to the availability of NiTi files. Note the straight canal preparations and unfilled canals in the apical third (arrow, Fig. 2-3). This was probably due to ledge formation during stainless steel preparation of the mesial canals. The mandibular second molar case was treated with NiTi files and shows more acceptable canal filling and extension. Fig, 2-3. Mandibular first molar prepared with conventional files, and a mandibular second molar prepared with NiTi files. (Case 3)NICKEL-TITANIUM INSTRUMENTS: APPLICATIONS IN ENDODONTICS Maxillary Molar — Case 4 Figure 2-4 shows a maxillary molar with an extremely curved mesial-buccal canal. These canals can usually be instrumented to a size #35 or #40 NiTi file to the working length. In cases like this, it is important to use NiTi spreaders for conden- sation, B Fig. 2-4 (A, B). Maxillary first molar prepared with NiTi files. (Case 4) 10CHAPTER 2: NiTr HAND INSTRUMENTATION Mandibular Second Molar — Case 5 A mandibular second molar with extremely curved mesial canals. These are usually instrumented with #40 NiTi files to the working length. Again, NiTi spreaders are important for lateral condensation. G Fig. 2-5 (A, B, C). Mandibular second molar instrumented with. NiTi files. (Case 5) 1.NICKEL-TITANIUM INSTRUMENTS: APPLICATIONS IN ENDODONTICS, NiTi Spreaders NiTi spreaders come in two types, parallel and tapered. They are flexible and ideal for use following NiTi instrumentation Fig. 2-6. NiTi spreaders, parallel and tapered types. Doubled-Tapered Hand Files New ‘double-tapered” hand files are used for tapering and flaring canals. These files are very effective when used in conjunction with single-taper files. Only one size is available at the time of this writing, with additional multi-tapered files to follow A. B. Fig. 2-7 (A, B). #20 Mac hand files. The double-tapered Mac is on the right in each image. 12CHAPTER 2: NT HAND INSTRUMENTATION In Summary Canal instrumentation can be initiated with a working length that is at least 1.5 to 2 mm short of the radiographic apex. This helps to prevent over-instrumen- tation beyond the apex. Should additional length be necessary at the end of the cleansing and shaping procedure, it is usually not difficult to increase working length, Preventing over-instrumentation could help to decrease posttreatment pain and make it easier to dry out canals. The canal can be flared later in the cleansing and shaping procedure, when the canal orifices are larger and in the center of the canal. This helps to make the flaring procedure easy and safe, Small curved canals can be enlarged to a mini- mum size of #40 to the working length, with virtually little transportation of the canal. The cleansing and shaping procedure can be completed in less time than with stainless steel files. Large canal size makes cleansing and filing comparatively easy. Files are effective up to ten times use, They should be discarded if the clastic limit has been exceeded or if they are severely bent. Recent preference in files has been toward the more aggressive cutting designs such as the Mac file, S file, etc, Future multi-tapered techniques using crown-down preparation may be promising. 13,3 Mechanical Instrumentation Introduction ‘The properties of nickel-titanium, used under controlled conditions and with an appropriate file design, make it possible to use mechanical (rotary handpiece) instrumentation. This mode of canal preparation is fast and uniform. The action of the file continuously removes debris from the canal. To prevent files from “screwing in” and engaging the canal walls, file blades must have flat (radial land) areas with a tolerance of + .003 mm as opposed to the usual tolerance of + .02 mm. New files, designed along these parameters, perform a planing action, resulting in a smooth canal finish. Files sizes #15 through #35 use either Hedstrom (H) or U design with ‘radial land” areas and half sizes. File sizes #40 through #60 can be either Mac (patented eccentric tip), or U design, depend- ing on the anatomy of the root canal system and personal preference. ‘The speed of rotation is a critical consideration when using mechanical instrumentation and should be about 300 RPM (approximately the speed of hand rotation). It is important that the handpiece be designed to avoid excessive stress and maintain a constant speed while compensating for load. The NT-Matic handpiece and electric motor unit are engineered with precision load-torque compensation to provide constant RPM even at very slow speeds (Fig. 3-1 A, B, C).NICKEL-TITANIUM INSTRUMENTS: APPLICATIONS IN ENDODONTICS B. Control Panel (detail) ©. Handpiece Fig. 3-1 (A, B, C). The NT-Matic motor unit and handpiece. (Courtesy NT Company, 7011 Shallowford Road, Suite 202, Chattanooga, TN. $7424.) Advantages of Mechanical Instrumentation 1 Instrumentation is physically effortless Ease of instrumentation is important today considering the necessity of using rubber gloves and the fact that»some dentists may have developed manual dexterity problems. Canals are enlarged quickly Canals are not only enlarged quickly but also appear larger and flared to a greater extent than with hand instrumentation of the same size Debris is removed easily Canals are easier to fill, probably because they are cleaner. Canals are more uniform and smoother Canal drying and filling is easier and more predictable, probably because walls are smoother and more uniform. 16CHAPTER 3: MECHANICAL INSTRUMENTATION Technique: Single Taper (.02) Files Irrigate often with distilled water or ultrasonic irrigation if available (Some practitioners prefer to use sodium hypochlorite, glyoxide, etc.). 1. Establish the working length Use stainless steel hand file sizes #8 & #10 or NiTi file sizes #8, 10, 15 and larger (NiTi K, Mac, H or U). 2. Initial instrumentation Use NiTi hand files up to at least size #15, and even sizes #20 to #25 if desired (NiTi K, Mac, H or U). 3. Initiate mechanical instrumentation Use NiTi files size #15 through #35, including half sizes if available (NiTi H or U with radial planes). Advance the file apically approximately 0.5 mm per second into the canal. When the working length is reached, change to the next larger size. Apply no more pressure than would be necessary to break a sharp lead pencil. After instrumentation to a size #30, the canal orifice can be opened to a #2 Gates Glidden drill. When working with students, however, we have even found it acceptable to defer our flaring until later because mechanical insirumentation also flares the canal. 4. Recheck working length When dealing with students, this step is important to prevent over- instrumentation. o Complete mechanical instrumentation Continue rotary preparation to the largest desired file, usually a minimum size #40 in small curved canals (#35 in dilacerated canals) and a minimum of size #50 in large, straighter canals. Use files size #40 and #45 for circumferential filing, integrating the flare taper with that of the filed portion of the canal, and incorporating any unprepared ramifications of the canal. 6. Complete preparation Check for adequate flaring and debris removal when instrumenta- tion is completed. Although flaring and “stepping back” can be ac- complished using the rotary files, the orifice can also be flared with Gates Glidden drills (#1 and #2 in small canals, #3 and possibly #4 in larger canals). 7. Final file radiograph A final file radiograph can now be taken, using the individual rotary files, in preparation for drying and filling the canals (Fig. 3-2).NICKEL-TITANIUM INSTRUMENTS: APPLICATIONS IN ENDODONTICS Mechanical Instrumentation Guidelines A mandibular first molar was instrumented by an undergraduate student using H Mac mechanical files. The mesial-buccal and mesial-lingual canals were instrumented to a size #45 and the distal canal was instrumented to a size #55. Flaring was accomplished using the large mechanical Mac files prior to filling. A. #45 files, #55 file. B. Filling. Fig. 3-2 (A, B). Mandibular first molar. Tip #1 — Effective Mechanical Instrumentation Mechanical instrumentation is most effective when the working length of the canal is reached as quickly as possible while applying minimal pressure with each file. Tip #2 — If Excessive Resistance is Encountered If excessive resistance is encountered before reaching the working length, use the following steps: 1. Withdraw the file approximately 3 mm and ty again, staying no longer than three seconds using the usual pressure. If the file begins to advance into the canal, check the integrity of the file after pro- gressing each additional 2 mm into the canal. 18CHAPTER 3: MECHANICAL INSTRUMENTATION 2. If the file fails to advance to the working length: A. The operator may decide to change to the next larger file size until size #40 (Mac) is reached. The Mac files have dissimilar helical angles with a cutting tip and have a tendency to “pull into” the canal. As they advance into the canal space not instrumented by the smaller instrument, check the integrity of the file after each 2 mm advancement. B. It may also be possible to return to the working length with the use of NiTi Mac hand-files. It is also possible to use a liquid or paste chelating agent with hand instruments if abso- lutely necessary. 3. File sizes #40 or larger are aggressive in cutting, have a flexible tip and have enough torsional strength to enlarge the canal to the work- ing length or to at least provide the step-back enlargement necessary for most situations. General Guidelines 1. Be sure to have the correct working length and use markings or stops. 2. Use each file size, without skipping sizes, until the largest desired file has been used. 3. Examine each instrument for distortion before each use. Discard if the file is severely bent or the regularity of the flute design has been distorted. 4. Should a larger file bind or stop in the canal, unlatch the file from the handpiece and lift it out of the canal. 5. Resist the “pulling in” of larger files as they are more aggressive and have a tendency to screw into the canal. 6. Use the instruments for approximately eight cases and discard. 7. If the operator feels uncomfortable in instrumenting a particular problem case, prepare that portion of the canal with hand instru- mentation. The handpiece does not have to be used in an “all or nothing” fashion to enhance the quality and efficiency of canal prepa- ration. 8. NiTi files can be used to open previously sealed canals. ‘To remove gutta percha, the H files (sizes #15 through #35) are used with the condenser handpiece on the NT-Matic (4500 RPM). 9. Practice canal preparation on extracted teeth. 19NICKEL-TITANIUM INSTRUMENTS: APPLICATIONS IN ENDODONTICS Laboratory Cases: Mandibular Molar — Case 1* The mesial root of a mandibular molar was instrumented with H-Mac me- chanical files (up to a size #60) to the working length. This was an experimental attempt to examine the extent of transportation of the canals and see if the maxi- mum size NiTi Mac files could stay within the root surface. The mesial root was sectioned at two critical areas (corresponding to the arrows) and showed no lateral root perforation. Usually in a mesial root of this size a final file size of #40 or #45 would be sufficient for adequate canal preparation A. Before instrumentation. B. #60 file, . Mesial root section. D. Mesial root section. Fig. 3-3 (A, B, C, D). H Mac_ mechanical instrumentation. (Case 1) *Case courtesy of Dr. Donald Gardner 20CHAPTER 3: MECHANICAL INSTRUMENTATION Maxillary Molar — Case 2* A maxillary molar was instrumented with mechanical U files. The severely curved mesial-buccal root was instrumented to a #35 file to the working length, the distal-buccal root to a size #40 file and the palatal root to a size #50 file. The mesial-buccal root was sectioned in three critical areas (corresponding to the arrows) and showed only slight transportation of the canal. y " f A B. Fig. 3-4 (A, B). U file mechanical instrumentation. (Case 2) Fig. 3-5 (A, B, C). Mesial-buc root sections. (Case 2) "Case courtesy of Dr. Toney Dillard 21NICKEL-TITANIUM INSTRUMENTS: APPLICATIONS IN ENDODONTICS Maxillary Molar — Case 3* A maxillary molar was instrumented with mechanical U files. The mesial- buccal and distal-buccal roots were instrumented to a #42.5 file and the palatal root was instrumented to a #50 file. Following instrumentation, the mesial-buccal and distal-buccal roots were sectioned in three critical areas. An attempt was made to cut the preparations at right angles to the root. All sections showed circular canal preparations, even at the apex. A. #42.5 file, —_B. #50 file. Fig. 3-6 (A, B). U file mechanical instrumentation. (Case 3) Fig. 3-7. Mesial-buc al root tip. (Case 3) Fig. 3-8 (A, B, C). Mesial-buccal root sections. Apical section is a SEM at high magnification. (Case 3) “Case courtesy of Dr. Kenneth King 22CHAPTER 3: MECHANICAL INSTRUMENTATION Fig. 3-9. Distal-buccal root tip. (Case 3) Fig. 3-10 (A, B, C, D). Distal-buccal root sections. Apical section is a SEM at high magnification. (Case 3) 23NICKEL-TITANIUM INSTRUMENTS: APPLICATIONS IN ENDODONTICS. Maxillary Molar — Case 4 A maxillary molar mesial-buccal canal was over-instrumented with mechanical The apical opening, as shown on electron micrographs, U files up to a size #40. was circular c D, Fig. 3-11 (A, B, C, D). Maxillary molar over-instrumentation. The mesial-buccal canal was over-instrumented with a #40 mechanical U file. Foramen is shown using a SEM at high magnification. (Case 4) 24CHAPTER 3: MECHANICAL INSTRUMENTATION Basic Technique: Double-Taper (.04) to Triple-Taper (.06) Files Recently, mechanical instrumentation has been advanced and improved with the use of the double to triple-taper files. Instruments in cither the H (radial land) style or the U style are now becoming available (Fig. 3-12). The case in Figures 3-12 through 3-15 shows the typical continuously ta- pered canal characteristic of double-taper instrumentation with the crown-down technique. Fig. 3-12. Mandibular first molar (Pro Series 29 double-taper U files, sizes #2 through #6), case courtesy of Dr. Ben Johnson. Fig. 3-13. The usual continuous instrument contact when using regular taper files. 25NICKEL-TITANIUM INSTRUMENTS: APPLICATIONS IN ENDODONTICS Fig. 3-14. The initial coronal contact with increased taper files allow- ing crown-down instrumentation. Fig. 3-15. Only a small portion of the file engages the canal surface during final apical enlargement. 26CHAPTER 3; MECHANICAL INSTRUMENTATION Advantages: Double to Triple Taper Files 1. The files flexibility. appear to be larger, stronger and uniform while retaining 2. They have a taper greater than the taper of the canal and therefore their initial contact is coronal, allowing crown-down instrumentation (Figs. 3-13 and 3-14). 3. As cutting efficiency is greatest when only a small portion of the file surface engages the wall of the canal, different tapers are used to maximize efficiency. 4. The files produce a continuously tapered canal that reduces the effort needed for final apical enlargement (Fig. 3-15). 5. The files eliminate the need for Gates Glidden drills, and therefore, cause little threat to plug or form ledges. 6. The armamentarium is limited, since only a few sizes are necessary. Double- to Triple Taper Files Now Available Several mechanical files are now available inthe H (radial land) design, one #25 double-taper (.04) and one #25 2.5 taper (.05). These files are .25 mm at D, and then increase to .89 mm and 1.05 mm respectively at D, (Fig. 3-16) A. #25 2x taper on right B. 5x taper on right Fig. 3-16 (A, B). H (radial land) mechanical files, (.02), one #25 double-taper (.04) and one #25 2.5 taper (.05). 27NICKEL-TITANIUM INSTRUMENTS: APPLICATIONS IN ENDODONTICS, Other mechanical files are available in the U design. They are in sizes #2 double-taper (129 D, - .769 D,) through #6 double-taper .) Pro Series 29 (Fig. 3-17), and in sizes #15 double-taper (.15 D, - .79 D,) through #40 double-taper (.40 D, - 1.04 D,) regular series (Fig. 3-18). In addition, a #40 triple- taper file (40 D, - 1.36 D,) has also been manufactured (Fig. 3-19), with other 2.5 and triple-taper sizes to follow. Fig. 3-17. Pro Series 29 double-taper (.04) files, sizes #2 through #6. et Fig. 3-18. Regular series double-taper (.04) files, sizes #15 through #40, 28CHAPTER 3: MECHANICAL INSTRUMENTATION Fig. 3-19. U mechanical files, one #40 regular taper (.02), one #40 double-taper (,04) and one #40 triple-taper (.06). Laboratory Cases: Maxillary Premolar — Case 1 This premolar laboratory case shows crown-down instrumentation. After the working length has been determined and hand instrumentation (single-taper files) has been completed up to about #20 or #25 , crown-down mechanical instru- mentation is initiated with double-taper files. The files can be alternated (from large to small and from small to large) until the apex is reached and the entire canal has been flared. At this time, a check of the apical preparation can be made ge single-taper hand files. with la A B. c D. Fig. 3-20 (A, B, C, D). Maxillary premolar. A. Initial crown-down instrumentation. B, Continue crown-down instrumentation C. Initiate flaring. D. Complete flaring of entire canal. 29NICKEL-TITANIUM INSTRUMENTS: APPLICATIONS IN ENDODONTICS Mandibular Molar — Case 2 This mandibular molar was instrumented and flared with double-taper me- chanical files. The instruments used were Pro Series 29 double-taper U files, sizes #2 through #6. Fig. 3-21 (A, B). Mandibular molar. Instrumented and flared with double-taper mechanical U files (Pro Series 29, #2 through #6). (Case 2) 30CHAPTER 3: MECHANICAL INSTRUMENTATION New Multi-Tapered Techniques Under Evaluation McXIM Series ‘The McXIM files utilize changing tapers which maximize cutting efficiency. The series consists of six tapers, the conventional .02 taper, .03 taper, .04 taper, .045 taper, .05 taper, and .055 taper. Each time a larger taper is used, preparation occurs by crown-down instrumentation. The file tip is one size, #25, and the canal is then enlarged progressively toward the apex with the same sized tip remaining loose in the canal, acting as a guide. The McXIM series includes four file designs: the U file, the H file .04 and .05 tapers with radial planes (wide at the tip, preventing side cutting but with narrow radial planes toward the handle for more aggressive cutting coronally, and for flaring and incorporating coronal ramifications), the H file .02 taper with radial planes that are the same width from tip to handle, and the Mac files .02 taper with dissimilar helical angles. The four file designs are said to perform complimentary functions necessary for the broad spectrum of anatomical canal variations Recommended Sequence 1. Instrument to working length with at least #15 NiTi hand file. #20 H file .02 taper - mechanical. H file .02 taper - mechanical. a ew oe s & #25 U file .03 taper - mechanical. . #25 H file .04 taper - mechanical. oo * 8 U file .045 taper - mechanical. a * 25 H file .05 taper - mechanical. 8. #25 U file .055 taper - mechanical. & 9. #37.5 Mac file .02 taper - mechanical. 10.#40 Mac file .02 taper - mechanical, ete. In the McXIM series, mechanical files can always be used in conjunction with hand files. Mechanical files should be carried just to but not beyond the working length. 31NICKEL-TITANIUM INSTRUMENTS: APPLICATIONS IN ENDODONTICS Advantages: McXIM Series 1. Little or no canal transportation. 2. Graduating tapers maximize cutting efficiency. 3. Four file designs overcome anatomical variations. 4, Canals are clean, smooth and uniformly tapered. 5. Comfortable for patient 6. Canals are easily obturated. Pro Series The size sequence of the Pro series files allows for a diameter increase of twenty-nine percent as each file size is increased. The mechanical Pro series con- sists of the following sizes and tip diameters: #2 - 13mm, 17mm, #4 - 22mm, #5 - 28mm, #6 - 36mm, #7 - 47mm, #8 - .GOmm, #9 - .77mm, and #10 - 100mm. Each rotary file has the U design and a .04 taper. When the .04 taper follows the 02 taper, or with the correct .04 file size sequence, maximum cutting efficiency occurs and the preparation is crown-down. The file sequence is important since a 04 taper file is followed by a .04 taper file. Recommended Sequence 1. #4 U file .04 taper-mechanical, 1/2 to 2/3 distance down canal. 2. #5 U file .04 taper-mechanical to same depth. 3. #3 U file .04 taper-mechanical, 2/3 to 3/4 distance down canal. 4. Instrument to working length with appropriate hand files (#15 NiTi). 5. #2 U file .04 taper-mechanical to working length. 6. #3, #4, #5, etc. .04 taper-mechanical to working length. x . Additional flaring with Gates Gidden drills, sonics or circumferential filing. Advantages: Pro Series 1. Lite or no canal transportation. 2, Graduating taper and file sequence maximize cutting efficiency. U file design produces round preparation. 4, Canals are clean, smooth and uniformly tapered. 5. Comfortable for patient. 6. Canals are easily obturated. 32CHAPTER 3: MECHANICAL INSTRUMENTATION MUSC Series This series consists of sizes #15 through #40 with a .04 taper, #15 through #40 with a .05 taper, and #35 through #60 with a .06 taper. Each file has the U file design and, by changing size and taper, maximum cutting efficiency and crown- down preparation can be achieved. Recommended Sequence 1. Instrument to working length with at least a #20 NiTi hand file. . #25 H file .04 taper-mechanical, 3/4 distance down canal. . #25 U file .05 taper-mechanical, 3/4 distance down canal a ew #35 H file .06 taper-mechanical, 1/2 distance down canal. #20 U file .04 taper-mechanical, just short of working length. #20 H file .05 taper-mechanical, just short of working length. #15 U file .04 taper-mechanical, to working length. #15 U file .05 taper-mechanical, to working length. #25 U file .04 taper-mechanical, to working length. seen se 0. #30 H file .04 taper-mechanical, to working length (minimum size in small curved canals). 11. #30 U file .05 taper-mechanical, to working length. 12. #35 U file .04 taper-mechanical, to working length (minimum size in larger curved canals). 13.#35 U file .06 taper-mechanical, 3/4 distance down canal. 14. #40 H file .06 taper-mechanical, 1/2 distance down canal (flare com- pleted with desired .06 taper file). 15. For final instrumentation to working length, use at least a #35 NiTi hand file, 33,4 The Instruments Introduction Nickel-titanium, NiTi, has elastic memory, so all files are manufactured by grinding the groove for their design. There are different types of hand files and many of these have a design similar to conventional files. Included in this group are the K file, Hedstrom file, Flex R file, $ file, and X file. The Mac file, however, has a unique design that differs from conventional files because it incorporates dissimilar helical angles. This new design has nonparallel blades which intersect along the shaft of the file, thus providing for balanced forces on each side of the canal wall. NiTi mechanical files incorporate one of two designs to prevent the instru- ment from screwing in and binding in the canal. One design is the Mac file with dissimilar helical angles. The other design has a space between each groove that provides a flat or land area, a so-called “radial plane.” These files cannot become locked into the canal wall and the cutting occurs through a planing action. Such rotary files are subdivided into two categories: Utshaped and L-shaped, according to the shape of the grooves. The U file is constructed by grinding three equally spaced grooves around the shaft. The portion of the shaft that has not been ground, the radial plane area, allows for extremely accurate diameters. The “Hedstrom style” H file is manufactured by grinding a single L-shaped groove which spirals around the shaft. Leaving a space between each spiraled groove creates the radial plane area. The NiTi Canal Master file “light speed” has basically the same appearance as a Gates Gidden drill, except the grooves have the U file design and there are radial plane areas.NICKEL-TITANIUM INSTRUMENTS: APPLICATIONS IN ENDODONTICS, Hand Instrumentation Stainless Steel K Hand Files A stainless steel K type file (#30), made by grinding a circular tapered blank into a wiangular shape and then twisting. The file has a tolerance of + 0.02 mm, and is used with traditional filing and reaming action (watch-winding, quarter-turn- pull, etc.). These are available in all lengths in sizes #08 through #140. B. (50x) C. (120x) Fig. 4-1 (A, B, C). #30 stainless steel K file. 36CHAPTER 4: THE INSTRUMENTS NiTi K Hand Files A NiTi K hand file (#45), made by grinding a circular tapered blank into a K design, is used with the traditional filing and reaming action. However, this file can be rotated more than a traditional stainless steel file. These files are available in 21 mm and 25 mm lengths in sizes #08 through #60 A. (50x) B. (180x) Fig. 4-2 (A, B). #45 NiTi K hand file. 37NICKEL-TITANIUM INSTRUMENTS: APPLICATIONS IN ENDODONTICS NiTi Mac Hand Files A NiTi Mac hand file (#45), made by grinding a circular tapered blank into a combination K and Hedstrom alternating design with a diagonal cutting tip, is used with the traditional filing and reaming action. However, this file can be rotated more than a traditional stainless steel file. This file is important when using larger sized hand and mechanical instrumentation. These files are available in 21 mm and 25 mm lengths in sizes #20 through #60. A #20, .04 (double-taper) file is also available, with other tapers to follow A. (50x) B. (180x) Fig. 4-3 (A, B). #45 NiTi Mac hand file. 38CHAPTER 4; THE INSTRUMENTS NiTi Hedstrom Files A NiTi Hedstrom file (#30), made by grinding a circular tapered blank into a Hedstrom design, is used with the traditional push-pull action. Files sizes #15 through #90 are available in 21 mm and 25 mm lengths. B. (180x) Fig. 4-4 (A, B). #30 NiTi Hedstrom file. ! 39NICKEL-TITANIUM INSTRUMENTS: APPLICATIONS IN ENDODONTICS NiTi Flex R Hand Files A NiTi Flex R hand file (#30), made by grinding a circular (near parallel) blank into a K design. It is used with the traditional filing and reaming action and with a balanced force technique. However, this file can be rotated more than a traditional stainless steel file. File sizes #15 through #80 are available. A. (50x) B. (25x) Fig. 4-5 (A, B). #30 NiTi Flex R hand file. (Courtesy of Union Broach MOYCO, Emigsville, PA 17318.) 40CHAPTER 4: THE INSTRUMENTS NiTi U Hand Files A NiTi U hand file (#30), made by grinding a circular tapered blank into a design with “radial planes” ( 6 B, arrows), allows for a tolerance of + 0.003 mm. This tolerance is important in the manufacturing of half sizes and necessary for mechanical instrumentation in small sizes. The U file is used primarily with a rotating technique. Files sizes #15 through #50, and half sizes #17.5, #22.5, #27.5 #32.5, #37.5, #42.5, #47.5, have been made in 21 mm and 25 mm lengths. The U hand file is not, however, available for sale at this time. A. (50x) B. Cross section (120x), with arrows indicating radial land area. Fig. 4-6 (A, B). #30 NiTi U hand file. 41NICKEL-TITANIUM INSTRUMENTS: APPLICATIONS IN ENDODONTICS, NiTi X Hand Files A NiTi X hand file (#30), made by grinding a circular tapered blank into a Hedstrom double fluted pattern, is used with a traditional filing and ream action. Howey File ng this file can be rotated more than a traditional stainless steel zes #15 through #80 are available in 21 mm and 25 mm lengths. le. A. (50x) B. (180x) Fig. 4-7 (A, B). #30 NiTi X hand file. 42CHAPTER 4; THE INSTRUMENTS NiTi S Hand Files A NiTiS hand file, the Mity Turbo (#30). Such a file is made by grinding a circular tapered blank into a double helix fluted pattern. The file is used with a traditional filing and reaming action, and is avery aggressive cutting file. Files sizes #8 through #80 are available in 21 mm and 25 mm lengths A. (50x) B. (180x) Fig. 4-8 (A, B). #30 NiTi S hand file. 43NICKEL-TITANIUM INSTRUMENTS: APPLICATIONS IN ENDODONTICS, Mechanical Instrumentation NiTi “Hedstrom Style” H Mechanical Files A NiTi “Hedstrom style” H hand file (#30), made by grinding a circular tapered blank into a Hedstrom style file with “radial planes,” allows for a tolerance of + 0.003 mm. This tolerance is important in the manufacturing of half sizes and ary for mechanical instrumentation in small sizes. The H file is used with a rotating technique. les sizes #15 through #35, and certain half sizes, #22.5, #27.5 and #32.5 are available in 21 mm and 25 mm lengths. A #25, .04 (double-taper) and .05 (taper) file are also available in a 21 mm length. nece: A. (50x) B. Cross section (130x) Fig. 4-9 (A, B). #30 NiTi “Hedstrom style” H mechanical file. 44CHAPTER 4: THE INSTRUMENTS NiTi U Mechanical Files A mechanical file, the NiTi U file (#30), made by grinding a circular ta- pered blank into a design with “radial planes,” allows for a tolerance of + 0.003 mm. This tolerance is important in the manufacturing of half sizes and necessary for mechanical instrumentation. Files sizes #15 through #80, and half sizes #17.5, #22.5, #27.5, #32.5, #37.5, #42.5 and #47.5 are available in 21 mm and 25 mm lengths. The U file, .04 (double-taper), is also available in sizes #15 through #45, 21 mm and mm lengths and in Pro Series 29 sizes #2 through #10, 21 mm and 25 mm lengths. Fig. 4-10. NiTi U mechanical file, .04 double-taper file (50x). NiTi Mac Mechanical Files Another mechanical file, the NiTi Mac file (#40), is identical to the hand Mac file. The file is used in sizes #40 through #60, and is available in 21 mm and 5 mm lengths. A. #40 NiTi Mac mechanical (50x). 45ICKEL-TITANIUM INSTRUMENTS: APPLICATIONS IN ENDODONTICS B. Cross section (130x). Fig. 4-11 (A, B). #40 NiTi Mac mechanical file. NiTi Canal Master Files The NiTi Canal Master file (#40) is made by grinding a circular parallel blank into a U file design at the tip. Files sizes #20 through #140, and half sizes #22.5, 27.5, #32.5, #37.5, #42.5 and #47.5, are available in 21 mm and 25 mm lengths. Fig. 4-12. NiTi Canal Master file (50x). 46CHAPTER 4: THE INSTRUMENTS Note: NiTi hand and mechanical files are subject to changes in design and size the future. In addition, the Pro Series 29 also has a hand reamer with its K and H files. The Pro Series 29 K files and reamers in sizes #00 through #11 are available in 21 mm, 25 mm and 30 mm lengths, while the H files in sizes #2 through #9 are available in 21 mm, 25 mm and 30 mm lengths. Manufacturers of Endodontic Instruments 3111 Hanover Road, Johnson City, TN 37604 Phone: (615) 282-1453 + Fax: (615) 282-1995 NiTi CUSTOMERS: Brassler USA, Inc. N.T. Company 800 King George Biva. 7003 Shallowford Rd. Savannah, GA 31419-9598 Chattanooga, TN 37421 Phone: 1-800-841-4522 Phone: 1-800-288-6484 R. Chige, Inc. Pearson Dental Supply 4531 N. Dixie Hwy. 18847 Del Sur St Boca Raton, FL 33431 San Fernando, CA 91340 Phone: 1-800-645-2628 Phone: 1-800-535-4535 Endo Technic Corporation Roydent Dental Products 981 Calle Amanacer 1010 W. Hamlin San Clemente, CA 92672 Rochester Hill, Ml 48309 Phone: 1-800-323-3913, Phone: 1-800-992-7767 ‘The Hygenic Corporation Charles B. Schwed Company, Inc. 1245 Home Ave. 138 Audley St. ‘Akron, OH 44310 Richmond Hill, NY 11418-1005 Phone: 1-800-321-2135 Phone: 1-800-847-4073 Texceed Corporation lisa Dental Products Dental Produels Division 3168 S. 108th Ave. E 3001 Redhill Ave. #4-104 Tulsa, OK 74146 Costa Mesa, CA 92626, Phone: 1-800-662-1202 Phone: 1-800-344-1321 J.S. Dental Mfg., Inc. P.O. Box 904 Ridgefield, CT 06877 Phone: 1-800-284-3368 Fig. 4-13. NiTi customers. 475 Physical Tests Introduction A variety of physical tests of NiTi and conventional files were conducted at the Medical University of South Carolina, Comparative flexibility, rotation to de- formation, rotation to breakage, micro-hardness, and recovery of trace clements were all studied and analyzed. The results of this research, with accompanying tables and photographs, are presented in this chapter. The Tests Comparative Flexibility of Hand Files* A flexibility test measuring the force in grams required to bend a file tip 45° was used to compare conventional stainless steel files with NiTi K and Mac files (Fig. 5-1). Six files in each size, #25 through #45, were studied. The average results for each size are shown in Figure 5-2. . a rect Fig. 5-1. Flexibility-testing apparatus. *This research was conducted by Dr. David Adams and Dr. Mark Chishom, MUSC. Glass of 1994, The statistical analysis was compiled by Qihao Jiang and Dr. Alan Gross.S: APPLICATIONS IN ENDODONTICS. NICKEL-TITANIUM INSTRUMEN Flexibility Comparisons Force in Grane File Size Fig. 5-2. Average force in grams needed to bend files 45°. The results demonstrate a huge difference between conventional and NiTi files, the NiTi files being significantly more flexible (p».01). The force needed to bend a NiTi #45 file was comparable to that needed to bend a conventional #25 file. Rotation to Deformation of Blanks * Conventional stainless steel tapered blanks and NiTi tapered blanks in sizes #30 through #45 were deflected at their tips (Fig. 5-3), and the resultant deforma- tion angle was compared to the twist angle (Figs. . The #45 stainless steel blank deformed 27° when twisted only 90°, while the #45 NiTi blank de- formed only 31° when twisted 360°. This resulted in a twist-angle ratio of about 1 to 4, although the smaller sizes had about a 1 to 3 ratio. 5-4 and 5. nan os Fig. 5-3. Deformation apparatus. *This research was conducted by Dr. Glen Willis and Dr. Chad Golden, MUSC, Class of 1993. 50Deformation Degrees 40 30 20 10 y CHAPTER 5: PHYSICAL TESTS Z) oO 45 60 7 90 Twist Angle Fig. 5-4. Deformation of stainless steel blanks. Oo 90 180 270 360 Twist Angle Fig. 5-5. Deformation of NiTi blanks. 51NICKEL-TITANIUM INSTRUMENTS: APPLICATIONS IN ENDODONTICS Rotation to Breakage of Files * A rotation-to-breakage study was used to compare conventional stainless steel files with NiTi files. Six files in each size group were rotated in a 90° metal tube (about .75 mm in diameter) until they broke at about 3 to 4 mm from the tip (Fig. 5-6). The results demonstrate a statistically significant difference between con- ventional stainless steel files and all NiTi files ata p « .01 (with the exception of the NiTi K files, p « .05). In addition, within the NiTi file groups, the H-Mac and U files had a statistically significantly difference from the K files (p « .05). It must be noted that in rotation-to-breakage studies with NiTi files, the range of results within each same-size group can be large and unpredictable. The average number of complete revolutions to breakage is recorded for the following files in Figures 5-7 through 5-17: conventional stainless steel, NiTi K, NiTi Flex R, NiTi H-Mac, and NiTi U. A picture of each broken file type is included with each figure. Rotational Machine Endodontic File Shaft: Metal Tube Crucial Point of Fracture 34mm From Tp Fig. 5-6. Rotation-to-breakage apparatus. “This research was conducted by Dr. Clark Dalton, MUSC Class of 1994. The statistical analysis was compiled by graduate student Qihao Jiang, Department of Biostatistics, Epidemiology and Systems Science, 52CHAPTER 5: PHYSICAL TESTS Stainless Steel as #40 |—— #35 #30 #25 0 | 10a iz0heee cement Peersor a? © 60 Revolutions to Breakage Fig. 5-7. Rotation to breakage of stainless ste K files. A. (50x) B. (150x) Fig. 5-8. Stainless steel K_ file after rotation to breakage. Note the permanent plastic deformation prior to fracturing. 53NICKEL-TITANIUM INSTRUMENTS: APPLICATIONS IN ENDODONTICS NiTiK 0 50 100 «150-200 250-00 Revolutions to Breakage Fig. 5-9. Rotation to breakage of NiTi K files. A. (50x) B. (150x) Fig. 5-10. NiTi K file after rotation to breakage. 54CHAPTER 5: PHYSICAL TESTS. NiTi Flex R #45 #40 #35 | File Size #30 425 © 100 200 300 400 500 G00 700 Revolutions to Breakage Fig. 5-11. Rotation to breakage of NiTi Flex R files. A. (50x) B. (150x) Fig. 5-12. NiTi Flex R file after rotation to breakage. 55NICKEL-TITANIUM INSTRUMENTS: APPLICATIONS IN ENDODONTICS. NiTi H Mac #45 #40 #35 File Size #30 #25 ————— 0 100 200 300 400 500 600 700 Revolutions to Breakage Rotation to breakage of NiTi H Mz ; Mac files: #40 and #45). Fig. 5-13, #30, and files (H files: #25, A. (50x) B. (150x) 5-14. NiTi H mechanical file after rotation to breakage. 56CHAPTER 5; PHYSICAL TESTS A. (50x) B. (150x) Fig. 5-15. NiTi Mac mechanical file after rotation to breakage. 57NICKEL-TITANIUM INSTRUMENTS: APPLICATIONS IN ENDODONTICS NiTiU File size 0 100 200 300 400 500 600 700 800 Revolutions to Breakage Fig. 5-16. Rota ion to breakage of NiTi U files. Fig. 5-17. NiTi U Fil Note that the fi tion. je after rotation to breakage (50x and 150x). acture site appears to show some plastic deforma- 58CHAPTER 5: PHYSICAL TESTS Original Research Conducted Outside MUSC These studies were conducted by Quality Dental Products, Inc., prior to the distribution in 1992 of NiTi K hand files. Torque to Rotation Study* ‘Twenty stainless steel (SS) twisted K hand files in sizes #15, #25 and #35 were compared with twenty NiTi K files of the same sizes. Torque necessary to rotate each file one complete revolution in metal tubes with curvatures of 45°, 90°, and 180° was measured in inch-ounces and recorded. Files were then rotated to breakage in the curved metal tubes and fractured at about 8 mm from the file tips. The average torque (T) and number of revolutions to breakage are shown in Figures 5-18 through 5-20. ‘Torque - The results show that it took more torque (4 to 12 times more) to rotate the SS K files. In addition, there was a substantial increase in torque as the curvature increased. Number of Revolutions - The results show that the NiTi K files revolved (3 to 500 times more) before breaking. In addition, there was a substantial increase in rotational differences (SS verses NiTi) as the curvature increased. 1000 900 200 700 600 500 400 200 100 | of Revolutions 46) Spor ais0he 3 4 90 180 Matai Tube Curvature (Degcees) Fig. 5-18. Torque and rotation to breakage: stainless steel and NiTi K files, size #15. “This research was conducted by Dr. Jerry Mooneyhan, Quality Dental Products, Inc., Johnson City, TN. 37604. 59NICKEL-TITANIUM INSTRUME! VTS: APPLICATIONS IN ENDODONTICS, 4590 50h 4 tan anal 180 a metal tube Curvature (negrSSs) Fig. 5-19. Torque and rotation to breakage: stainless steel and NiTi K files, size #25. 45 90 180 45 90 180 Metal Tube Curvature (Degres 5-20. Torque and rotation to breakage: stainless steel and NiTi K files, size #35, Micro-Hardness Study* A study was initiated to compare the hardness of stainless steel to the hardness of NiTi. In addition, the clinically important comparison of hardness as it relates to autoclave and dry heat sterilization was made. Stainless steel and NiTi blanks of .040 gauge (used to make file sizes #50, 55, 60) were used for the micro- hardness test. *This research was conducted, in part, by Eric Scheufler, MUSC 60 ss of 1995.CHAPTER 5: PHYSICAL TESTS The blanks were cut into three sections for mounting. They were in equal amounts of Extec Edge Retention Molding Compou Extec XW44 Red Phenolic Powder. Each specimen was placed in a Pneumet M g Press 300° and then cooled for 15 minutes. The specimens were then g Euromet 1 Power Head (water cooled) using rough 240 grit for 2 minutes 2 grit for 2 minutes. Polishing was accomplished with nylon paper and polish followed by .05 micron polish. Each specimen was then rinsed with wate 95 and dried with alcohol. Hardness was measured in the center and 25jm from the edge of each blank with a Leitz Micro-Hardness tester with diamond impression 1). Three hardness readings were made at each site. The averages in Vickers and Rockwell-C units are recorded in Tables 5-1 and 5-2 (Fig. Fig. 5-21. Leitz micro-hardness impressions: center and 25 jum from edge 61NICKEL-TITANIUM INSTRUMENTS: APPLICATIONS IN ENDODONTI Stainless Steel Micro-Hardness Specimen Vickers Rockwell-C enter 525 3 25 um from Edge 533 52 “Tx DH Center 542, 52 25 um from Edge 541 31 '5xDH Center 323 50 25 um from Edge 534 St 1xA Center 330 St 25 um from Edge 535; 3 5x ACenter 522 50 25 um from Edge 535 31 Telnitial DH=DryHest Vickers # = Ave. 3 Readings ‘A= Autoclave Rockwell # = Ave. 3 Readings Table 5-1. Stainless steel micro-hardness. Niti Micro-Hardness Specimen Vickers Rockwell-C Genter 325; 32 25 um trom Edge 308; 30 11x DH Center 310) 31 25 um from Edge 347 35. 5x DH Center 346; 35 25 um from Edge 342 34 1x A Center 359) 36 25 um from Edge 357 36 ‘Sx A Centr 362, 7 25 um from Edge | 341 35 T= initial "DH = Dry Heat ve. 3 Readings ‘Az Autoclave Readings Table 5-2. NiTi mit The stainless steel blanks showed a hardness ranging from 522 to 542 Vickers units, and the hardness remained constant with dry heat and autoclave sterilization. The NiTi blanks, however, showed a much lower hardness, ranging from 303 to 362 Vickers units. In addition, the NiTi blanks showed an increase in hardness when subjected to dry heat and autoclave sterilization. The NiTi hard- ness results suggest an improvement in the alloy following heat treatment, and this has been verified by increased rotation-to-breakage times (Fig. 5-22). It is therefore possible that dry heat and autoclave sterilization may rejuvenate the NiTi files after each use. An element analysis on each initial blank was completed and is shown in Tables 5-3 and 5-4. 62CHAPTER 5: PHYSICAL TESTS Effects of Heat Treatment Revolutions to Breakage 90°Curve #25 #35, #30 File Size Fig. 5-22. Rotation to breakage: average of six same-size files before and after extensive dry heat sterilization (10x). Quantex>T WEIGHT ATOMIC & LINE PERCENT | PERCENT cr kA 18.40 19.68 Fe kA 71.06 70.46 Ni ka 10.54 9.34 TOTAL 108.90 Table 5-3. Stainless steel analysis. Quantex>T WEIGHT ATOMIC & LINE PERCENT — PERCENT# Ti KA 41.93 Hat Ni KA 58.01 52.99 ToTAL = 19.88 Table 5-4. NiTi analysis. 63NICKEL-TITANIUM INSTRUMENTS: APPLICATIONS IN ENDODONTICS Trace Element Analysis* A study was initiated to detect the recovery of trace elements (chromium, iron, nickel and titanium) from stainless steel files and NiTi files. Elements were detected using a Plasma 2 ICP Perkin Elmer Apparatus (atomic emission tech- nique). Stainless steel files and NiTi files, size #30 (Quality Dental Products, Inc.) were cut into equal lengths, and 3 specimens (one, two and three files each) were placed in 20 ml 0.9 NaCl injectable saline at 38°C. A standard was set for the four elements at | ppm (part per million) concentration. The specimens were analyzed and percent recovery (% Recovery = Theoretical conc./measured conc. x 100) was verified for the elements (.1 ppm spike sol.). The percent recovery for nickel was above 90%. The results after 48 hours showed that the stainless steel specimens on average contained trace nickel in concentrations ranging from only .001 ppm to .016 ppm, depending on the number of files in each specimen. The NiTi speci- mens showed no trace nickel. The other elements (chromium, iron and titanium) were not detected from any specimens. A seven-day result was also studied; however, only slightly higher concen- trations of trace nickel (2x) were found in the stainless steel specimens when com- pared to the forty-eight hour specimens. Because of the extremely low concentra- tions of trace nickel recovered and the sensitivity of the testing procedure, it was concluded that there was very little difference between the stainless steel and NiTi specimens at these time intervals. The trace nickel was well below the recommended target concentration of Ippm for consumer products.! In addition, these findings compare favorably with cell culture studies? which show that while nickel inhibits mitosis of human fibro- blasts, NiTi (Nitinol) does not and therefore, NiTi is biocompatible and acceptable as a surgical implant. NiTi Stress and Micro-Hardness Study A study was initiated to demonstrate the effect of deformation on the hard- ness of NiTi. Five NiTi blanks of .040 gauge (used to make file sizes #50, #55, and #60) were heat treated (autoclaved five times) and then deformed 50 times back and forth at an angle of 90°. Following the cyclic deformation, one specimen (#1) was immediately tested for hardness while others were autoclaved or dry heat sterilized (one cycle of stress and heat #2 and #3, up to five cycles of stress and heat #4 and #5). ‘The #1 specimen showed a center hardness of 383 Vickers units, while edge hardness was considerably lower, at 339 Vickers units (a drop of 44 Vickers units) The four autoclaved and dry heat sterilized blanks (#2 through #5) were more consistent and had Vickers hardness ranging from 355 to 381. Study courtesy of Charles A. Nunnally, Senior Analytical Chemist, Robert Bosch Corp. and Dr. Clark Dalton, MUSC. 64CHAPTER 5: PHYSICAL TESTS 50 X 90° Center 25 um from Edge 50 X90" 1KA Center 25 um from edge #3 50X90" 1x DH Canter 25 um from Edge #4 50X90" stress 5X BXA Center 25 um from Edge '50 X 90" stress 5X A= Autoclave Vickers #,= Avg. 3 Readings OH = “Dry Heat Rockwell # = Avg. 3 Readings Table 5-5. NiTi stress and micro-hardness. It appears that the low edge hardness of the #1 blank is consistent with the fact that during bending, considerable stress is concentrated on the surface. In this study, none of the remaining autoclaved or dry heat sterilized blanks showed substantially low hardness readings. Therefore, it is possible that stress may actu- ally decrease hardness while heat restores hardness. 65 aNICKEL-TITANIUM INSTRUMENTS: APPLICATIONS IN ENDODONTICS. References 1. Basketter, D.A., Briatico-Vangosa G., Kaestner, W., Lally, C., and Bontinck, W.J.: Nickel, cobalt and chromium in consumers products: A role in allergic contact dermatitis? Contact Dermatitis, (Denmark), 28 (1), pp. 15-25, Jan. 1993. 2. Putters, J.L., Kaulesar SuKul, D.M., de Zeeuw, G.R., Bijma, A., and Besselink, P.A.: Comparative cell culture effects of shape memory metal (Nitinol), nickel and titanium: A biocompatibility estimation. Eur Surg Res, (Switzerland), 24(6), pp. 378-82, 1992. 666 Comparisons of NiTi and Conventional Instrumentation Preclinical Comparison Study Junior dental students, in a preclinical laboratory course, conducted a com- parison study with conventional stainless steel and NiTi Mac files. The students were randomly selected and placed into two groups (ten students in Group 1 and ten students in Group 2). A crossover design was then used: Group I students completed their first molar with conventional files and their second molar with NiTi Mac files, while Group 2 students completed their two molars in reverse order. Students in Group I enlarged the mesial-buccal canals with NiTi Mac files, and the difference in size between the NiTi and conventional files was highly significant statistically. This group took 20% less time for NiTi instrumentation, and the NiTi files offered a significant improvement in molar canal instrumenta- tion. A basic rotation or reaming motion was used. After therapy, the roots of all teeth were sectioned at 1 mm intervals using an Isomet diamond saw. In Group 1, 30% of first molars prepated with conventional files showed ledge formation and/or perforation. There were no ledge formations or perfora- tions with NiTi Mac files on the second tooth. In Group 2, there were no ledge formations or perforations on the first tooth with NiTi files. Ledge formations and/or perforations were present in 40% of the second tooth cases using conventional files. Conventional instrumentation in a maxillary first molar can result in ledge formation and perforation of the mesial-buccal root (Fig. 6-1), In Figure 6-1, arrows show the critical areas, i.e., the furcation and apical areas in conventional instru- mentation.NICKEL-TITANIUM INSTRUMENTS: APPLICATIONS IN ENDODONTICS Fig. 6-1. Maxillary first molar, stainless steel instrumentation; arrows show critical areas on mesial-buceal root. (Case 1) Stainless Steel Instrumentation — Case 1 In Figure 6-2, a section taken just above the furcation area shows the me- sial-lingual canal (arrow) transported and located close to the distal side of the mesial-buccal root. A section taken in the apical third of the root shows both ledge formation and eventual perforation of the mesial-buccal root, specifically (arrow) on the me- sial side (Fig. 6-2) Fig. 6-2. Maxillary first molar, sections of mesial-buccal roo show critical areas. (Case 1) 5 arrows 68CHAPTER 6; COMPARISONS OF NiT: AND CONVENTIONAL INSTRUMENTATION An electron micrograph of the same apical area shows the inability to fill the canal following transportation, ledge formation and perforation (Fig. 6-3). The arrow shows a gutta percha cone used in an attempt to fill the canals. Fig. 6-3. Maxillary first molar, electron micrograph of apical sec- tion; arrow shows gutta percha in one part of canal system. (Case 1) NiTi Instrumentation — Case 2 NiTi instrumentation in a mandibular first molar shows no ledge formation or perforation of the mesial root (Fig. 6-4). Note that these results were uniform throughout the study (no ledge formation or perforation in 100% of cases using NiTi instrumentation). The arrow in Figure 6-4 shows the approximate level at apex where the two mesial canals come together. Sections of the mesial root show the canals are circular and in the center of the root with no ledge formation or perforation (Fig. 6-5). An electron micrograph of the same apical area shows the canals filled with gutta percha (Fig. 6-6). Fig. 6-4. Mandibular first molar, both views following NiTi instru- mentation and filling. (Case 2) 69NICKEL-TITANIUM INSTRUMENTS: APPLICATIONS IN ENDODONTICS, Fig. 6-5. Mandibular first molar, sections of mesial root. (Case 2) Fig. 6-6. Mandibular first molar, electron micrograph of apical sec- tion, gutta percha filling canals. (Case 2)» 70CHAPTER 6: COMPARISONS OF NiT: AND CONVENTIONAL INSTRUMENTATION NiTi Instrumentation — Case 3 NiTi instrumentation of another mandibular first molar shows no ledge formation or perforation of mesial root (Fig. 6-7). The arrow shows the approxi- mate level at mid-root where the canals meet to form one apical canal. Sections of the mesial root show that the canals are circular and in the center of the root (Fig. 6-8). Fig. 6-7. Mandibular first molar, both views following NiTi instru- mentation and filling. (Case 3) Fig. 6-8. Mandibular first molar, sections of mesial root. (Case 3) 1NICKEL-TITANIUM INSTRUMENTS: APPLICATIONS IN ENDODONTICS Comparison of Conventional and NiTi Over-instrumentation Students over-instrumented the mesial roots of mandibular molars with size #40 files and instrumented 1-2 mm beyond the apex. Roots were selected with curved canals and canals which exited as either one canal or two canals. Conventional Over-instrumentation — Case 4 Radiographs taken from both directions show over-instrumentation with a #40 stainless steel file in a single canal root at the apex (Fig. 6-9). In Figure 6-10, electron micrographs of the same case show an accessory canal (arrows) and blun- derbuss canal preparation (transportation of canal) at the apex (Fig. 6-10). Mesial Buceal Fig. 6-9. Mandibular first molar, mesial rodt canals over-instrumented with #40 stainless steel files. (Case 4) 72CHAPTER 6; COMPARISONS OF NiTi AND CONVENTIONAL INSTRUMENTATION Fig. 6-10. Mandibular first molar, electron micrograph of mesial root apex, before and after sectioning. (Case 4) 3NICKEL-TITANIUM INSTRUMENTS: APPLICATIONS IN ENDODONTICS Conventional Over-instrumentation — Case 5 Radiographs from both directions show over-instrumentation with a #40 stainless steel file in a root with two canals at the apex (Fig. 6-11). An electron micrograph of the same case shows a transported apex (Fig. 6-12) Fig. 6-11. Mandibular first molar, mesial root canals over-instru- mented with #40 stainless steel files; mesial and buccal views, two canals at apex. (Case 5) Fig. 6-12. Mandibular first molar, electron micrograph of mesial root apex. (Case 5) 74CHAPTER 6: COMPARISONS OF NiT! AND CONVENTIONAL INSTRUMENTATION NiTi Over-instrumentation — Case 6 Radiographs taken from both directions show over-instrumentation with a #40 NiTi Mac file in a root with a single canal at the apex (Fig. 6-13). Electron micrographs of the same case show a more acceptable apical canal preparation and the circular foramen (Fig. 6-14). Note: During specimen preparation, a small piece of cementum chipped off. Fig. 6-13. Mandibular first molar, mesial root canals over-instru- mented with #40 NiTi files; mesial and buccal views. (Case 6) Figure 6-14, Mandibular First Molar, electron micrographs of me- sial root apex, before and after sectioning. (Case 6)NICKEL-TITANIUM INSTRUMENTS: APPLICATIONS IN ENDODONTICS NiTi Over-instrumentation — Case 7 Radiographs taken from both directions show over-instrumentation with a #40 NiTi Mac file in a root with two canals at the apex (Fig. 6-15). An electron micrograph of the same case shows typical circular apical preparations (Fig. 6-16). Note: This apex would be difficult to fill due to the septum between the canal openings. Mesial Buceal Fig. 6-15. Mandibular first molar, mesial root canals over-instru- mented with #40 NiTi files; mesial and buccal views, two canals at apex. (Case 7) Fig. 6-16. Mandibular first molar, electron micrograph of mesial root apex. (Case 7) 76CHAPTER 6: COMPARISONS OF NiT1 AND CONVENTIONAL INSTRUMENTATION Comparison of Conventional and NiTi Instrumentation with a Chelating Agent Students instrumented mesi chelating agents (ENDO Cleanse G al roots of mandibular molars up to size #40 using 17% buffered EDTA Neutral pH, by Roydent Dental Products). A technique using serial filing with recapitulation was used. Conventional Instrumentation with Chelating Agent — Case 8 Radiographs show working length and final instrumentation (see Fig. 6-17). Note: Transportation and straightening of both root canals. An electron micrograph of the same case shows transportation of canal leading to ledge formation and perforation of the root (Fig. 6-18). Fig. 6-17. Mandibular first molar, mesial root canals instrumented with #40 stainless steel files and chelating agent. (Case 8) Fig. 6-18. Mandibular first molar, electron micrograph of mesial root apex with stainless steel file in canal. (Case 8) 17NICKEL-TITANIUM INSTRUMENTS: APPLICATIONS IN ENDODONTICS NiTi Instrumentation with Chelating Agent — Case 9 Radiographs show working length and final instrumentation (Fig. 6-19). Note: Very little evidence of transportation of canals, An electron micrograph of the same case shows little transportation of the canal with no ledge formation or perforation of the root (Fig. 6-20) Fig. 6-19. Mandibular first molar, mesial root canals instrumented with #40 NiTi files and chelating agent. (Case 9) Fig. 6-20. Mandibular First Molar, electron micrograph of mesial root apex with NiTi file in canal. (Case 9) 78if Instrumentation - Sectioned Teeth Root Canal Anatomy Before and After Instrumentation Introduction to the Study* In this chapter, we present the results of a study conducted at the Medical University of South Carolina Dental School in 1993. During an endodontic labora- tory course, ten teeth (five mandibular molars and five maxillary molars) were selected to show root canal anatomy before and after instrumentation. Selected teeth with visible canals were mounted in acrylic-stone blocks. Two screws were placed in each block to hold each tooth together after sectioning. The roots were sectioned in two critical areas (level 1 is 2 mm apical to the furcation and level 2 is 3 mm short of the apex) with an Isomet diamond circular saw, removing about 0.3 mm of tooth structure with each cut. Approximately 0.6 mm of root was removed from each tooth. Electron micrographs were taken of the canals at both levels prior to instrumentation. Teeth were then accessed and instrumented by undergraduate students using a variety of hand and mechanical NiTi files. After instrumentation (without flaring), electron micrographs of each section were taken again. The identical electron micrograph negatives, before and after instrumentation, were then super- imposed to determine the extent of canal enlargement and transportation. Al- though some transportation of canals was evident, it was not extensive enough to cause ledging and perforation. Several important hand and mechanical cases are included in this chapter. “Study conducted by Dr. David Adams and Dr. Clark Dalton, MUSC Class of 1994.NICKEL-TITANIUM INSTRUMENTS: APPLICATIONS IN ENDODONTICS, Hand Instrumentation — Case 1 A mandibular molar mounted in an acrylic-stone block was used to test the effectiveness of canal instrumentation performed with NiTi files. Electron micro- graphs were taken at two levels before therapy, and then again at the same two levels after therapy. The before and after micrographs were then superimposed. Although some transportation of the canals occurred, it was not extensive enough to cause ledging or perforation. Fig. 7-1. Mandibular molar mounted in acrylic-stone block. D indi- cates distal, and M indicates mesial. (Case 1) Fig. 7-2. The cut levels (2 mm apical to the furcation and 3 mm from the apex) are indicated by arrows. Screws were placed in the block to hold the tooth together. (Case 1) 80CHAPTER 7: INSTRUMENTATIO N-SECTIO NED TEETH A. Distal root 1 B. Mesial root 1 C. Distal root 2 D. Mesial root 2 Fig. 7-3 (A, B, C, D). Electron micrographs were taken at each cut level prior to therapy. Level 1 (see A and B) was 2 mm apical to the furcation, and level 2 (see C and D) was 3 mm from the apex. (Case 1) 81NICKEL-TITANIUM INSTRUMENTS: APPLICATIONS IN ENDODONTICS, Fig. 7-4. NiTi K files. The students performed an access opening and then determined tooth length. (Case 1) Fig. 7-5. NiTi Mac hand files. Enlargement of the canals was com- pleted using NiTi Mac hand files. The final sizes to the apex were #45s in the mesial canals and #50 in the distal canal. (Case 1) 82CHAPTER 7: INSTRUMENTATIO N-SECTIO NED TEETH A. Distal root 1 B. Mesial root 1 aS = C, Distal root 2 D. Mesial root 2 Fig. 7-6 (A, B, C, D). Afier instrumentation. Electron micrographs were taken again at each cut level after therapy. (Case 1) 83NICKEL-TITANIUM INSTRUMENTS: APPLICATIONS IN ENDODONTICS. Bu A. Distal root 1 B. Mesial root 1 C. Distal root 2 D. Mesial root 2 Fig. 7-7 (A, B, C, D). Superimposed electron micrographs, before and after instrumentation. The original canal anatomy is depicted by a broken white line, and the completed canal is represented by a solid white line. (Case 1) 84CHAPTER 7: INSTRUMENTATIO N-SECTIO NED TEETH Case 1 Results At level | the distal canal shows very little transportation and the mesial canals were transported toward the furcation area At level 2 the distal canal curves naturally to the mesial, and the transpor- tation of the canal during instrumentation was to the distal. The mesial canals curve naturally to the distal, and the wansportation of the canals during instru- mentation was to the mesial. Mechanical Instrumentation — Case 2 A mandibular molar mounted in an acrylic-stone block. Electron micro- graphs were then taken at two levels before therapy, and again at the same two levels after therapy. The before and after micrographs were superimposed. Fig. 7-8. Mandibular molar mounted in acrylic-stone block. M indi- cates mesial and D indicates distal. (Case 2) 85NICKEL-TITANIUM INSTRUMENTS: APPLICATIONS IN ENDODONTIC! Bu A. Mesial root 1 B. Distal root 1 2, Mesial root 2 D. Distal root 2 Fig. 7-9 (A, B, C, D). Before instrumentation. Electron micrographs were taken at each cut level prior to therapy. Level | (see A and B) is 2 mm apical to the furcation, and level 2 (see C and D) is 3 mm from the apex. (Case 2) 86CHAPTER 7: INSTRUMENTATIO N-SECTIO NED TEETH Fig. 7-10. NiTi H Mac (mechanical) files. Enlargement of the canals was completed using NiTi H-Mac files with mechanical instrumenta- tion. The final sizes to the apex were #45s in the mesial canals and #50 in the distal canal. The cut levels are shown by the arrows. (Case 2) 87NICKEL-TITANIUM INSTRUMENTS: APPLICATIONS IN ENDODONTICS. Bu A. Mesial_ root_L B_Distal root 1 C. Mesial root D. Distal root Fig. 7-11-(A, B, C, D). After instrumentation. (Case 2) 88CHAPTER 7: INSTRUMENTATIO N-SECTIONED TEETH B. Distal root 1 G. Mesial root 2 D. Distal root 2 Fig. 7-12 (A, B, C, D). depicted by a broken I line. (Case 2) superimposed SEMs. Original canal anatomy e, and completed canal represented by solid 89NICKEL-TITANIUM INSTRUMENTS: APPLICATIONS IN ENDODONTICS. Case 2 Results At level 1 the mesial canals show some transportation toward the furcation, but the distal canal shows very little transportation. At level 2 the mesial canals come together to form one canal that curves naturally to the distal. There is transportation of the canal on the mesial surface as the canals come together. The distal canal basically shows enlargement with some transportation on the distal and buccal surfaces. U Hand Files — Case 3 A mandibular molar was mounted in an acrylic-stone block. Electron micro- graphs were then taken at two levels before therapy, and again at the same two levels after therapy. Fig. 7-13. Mandibular molar mounted in acrylic-stone block. M indi- cates mesial and D indicates distal. (Case 3) 90CHAPTER 7: INSTRUMENTATIO N-SECTIONED TEETH Bu B. Distal root 1 . Mesial root 2 D. Distal root 2 Fig. 7-14 (A, B, C, D). Before instrumentation. Electron micrographs taken at each cut level prior to therapy. Level | (see A and B) was 2 mm apical to the furcation and level 2 (see G and D) was 3 mm from the apex. (Case 3) 91NICKEL-TITANIUM INSTRUMENTS: APPLICATIONS IN ENDODONTICS A. Mesial B. Distal Fig. 7-15 (A, B). NiTi U (hand) files. The final sizes to the apex were #40s in the mesial canals and #45 in the distal canal. Cut levels are shown by the arrows. (Case 3) 92CHAPTER 7: INSTRUMENTATIO N-SECTIO NED TEETH Bu A. Mesial root 1 B. Distal root 1 ©. Mesial root 2 D. Distal root 2 Fig. 7-16 (A, B, C, D). After instrumentation. (Case 3) 93NICKEL-TITANIUM INSTRUMENTS: APPLICATIONS IN ENDODONTIC Case 3 Results At level 1 the prepared mesial canals show almost no transportation, and the canal openings are circular in shape. The distal canal also shows little to no transportation, but the prepared canal is on the palatal side of the original long narrow canal opening. At level 2 the mesial canal shows minimal transportation, and the canal opening is circular in shape. The distal canal also shows minimal transportation and is circular. K and Mac Hand Files — Case 4 A maxillary molar was mounted in an acrylic-stone block. Electron micro- graphs were then taken at two levels before therapy, and again at the same two levels after therapy. tone block. D indi- Fig. 7-17. Maxillary molar mounted in acryli cates distal, and M indicates mesial. (Case 4) 94CHAPTER 7: INS >NED TEETH: A. Mesial-buceal root 1 B, Distal-buccal root 1 C. Palatal root 1 D. Mesial-buccal root 2 E E. Distal-buceal root 2 F. Palatal root 2 Fig. 7-18 (A, B, CG, D, E, F). Roots | and 2 before instrumentation Electron micrographs were taken at each cut level prior to therapy. Level 1 (see A, B, and C) was 2 mm apical to the furcation, and level 2 (see D, E, and F) was 3 mm from the apex. (Case 4) 95NICKEL-TITANIUM INSTRUMENTS: APPLICATIONS IN ENDODONTICS Fig. 7-19. NiTi K (hand) files. Final sizes to the apex were #40s in the buccal canals and #50 in the distal canal. The largest NiTi K file available was a #45; therefore, a #50 NiTi Mac file was placed in the palatal canal. The cut levels are shown by the arrows. (Case 4) 96CHAPTER 7: INSTRUMENTATIO N-SECTIO NED TEETH Bu Pal A. Mesial-buceal root 1 B. Distal-buceal root 1 ©. Palatal root 1 D. Mesial-buceal root 2 E. Distal-buce&l root 2 F. Palatal root 2 Fig. 7-20 (A, B, C, D, E, F). After instrumentation. (Case 4) Case 4 Results At level 1 the mesial-buccal canal shows slight transportation to the distal while the distal-buccal and palatal canals show very little transportation. At level 2 the mesial-buccal canal shows transportation to the mesial, and the distal-buccal canal shows transportation to the distal and palatal. The palatal canal shows no transportation. 978 Failure and Lifetime of NiTi Hand Files Introduction Nickel-titanium is unique in that it transforms from one phase into another (austenite to martensite) and then returns to its original phase. When this stress- induced phase transformation takes place, however, the external shape change cannot be detected visually. It is therefore important that these files be carefully monitored for failure and fatigue. The scanning electron microscope (SEM) has been used to study the initiation of fatigue failures in the laboratory One hypothesis regarding the fracture of these instruments is that file fractures are caused by a combination of torsional and bending fatigue. The source of bending stress is the back and forth flexing of the file during use, and the cyclic torsional stress is generated during back and forth twisting of the file from the handle. File failure occurs when the cutting edge is no longer effective or when files fracture due to torsional and bending fatigue. Failure criteria are: exceeding the elastic limit, having a 45° to 90° bend (stvere bend), or actual instrument fracture.NICKEL-TITANIUM INSTRUMENTS: APPLICATIONS IN ENDODONTICS Examples of File Failures (Figs. 8-1 through 8-4) A. 100x Fig. 8-1. File fracture, Ni (over 100 times or cases). Cutting edge shows smeared surface with small central area of dimpling. Fracture occurred about 3 mm from the file tip 100CHAPTER 8: FAILURE AND LIFETIME OF NiTi HAND FILES A. 10x. B. 300%, Fig. 8-2. File fracture, NiTi K #25. Fracture due to severe usage (over 100 times or cases). Cutting edge shows numerous fatigue cracks. Fracture occurred at about 3 mm from the file tip. 101NICKEL-TITANIUM INSTRUMENTS: APPLICATIONS IN ENDODONTICS A. 35x B. 200% Fig. 8-3. NiTi Mac #30 file. File deformed, exceeding the elastic limit when used in a calcified canal. The file was used in 11 cases before being discarded. B. 30x Fig. 8-4. NiTi Mac #25 file. File was severely bent at tip and then fractured in the canal (where two canals came together). The was used in 14 cases before being discarded. 102CHAPTER 8: FAILURE AND LIFETIME OF NiTt HAND FILES. Study of Failure and Lifetime* NiTi K and NiTi Mac 21 mm files in sizes #20, 25, 30, 35, 40 and 45, used on patients by undergraduate students in the endodontic clinic, were examined for wear on the cutting edges in the first 3 mm of the instrument. Observations were based on the number of times the instruments were used and sterilized. The nickel-titanium files were examined at three intervals, up to 30 times or cases use (0-15-30). Any discarded instruments were also studied and characterized. The SEM was used to study the progressive wear of the cutting edges within the first 3 mm of the instruments (Figs. 8-5 through 8-8). Note that we had previously ob- served that the majority of file defects or fractures are in the 3 mm range of the file near the tip. The files were packaged into twelve stainless steel boxes, six K and six Mac, for a total of 72 files. The study instruments were used for first-appointment instrumentation in posterior cases only. Two micrographs were taken at the 2-3 mm distance mark, one at 50x magnification and the second at 180x magnifica- tion. A research grant for Failures and Life Times of Nickel-Titanium Hand Files was funded by the Research and Education Foundation of the American Association of Endodontists, 211 East Chicago, Chicago, Ill. 60611-2691. While the project was not yet finished at the time of this publication, the following observations are important for consideration. Preliminary Results 1. All NiTi K and NiTi Mac hand files (in all groups) were used up to 10 times or cases without any instru- ment failures. 2, One group (A) of NiTi K and one group (A) of NiTi Mac hand files were used up to 30 times or cases without any instrument failures. 3. Instrument failures occurred after 10 times or cases use ‘and seemed to be more a matter of how the instru ments were used, rather than how long they were used. 4. The failure rate for NiTi Mac files was higher than for NiTi K files. This was probably due, in part, to the fact that the Mac files are more aggressive. *This research was supported in part by an Endodontic Faculty Award from the Research and Education Foundation of the American Association of Endodontists. The opinions, assertions, materials and methodologies herein are private ones of the author and are not to be construed as official or reflecting the views of the AAE or the Foundation. 103NICKEL-TITANIUM INSTRUMENTS: APPLICATIONS IN ENDODONTICS D. After 15 times use (300x), ig- 8-5 (A, B, C, D). NiTi K #25 file. Metal flash in A and B is due to manufacturing (grinding) process. Many practitioners have sug- gested that NiTi files seem to get sharper as they are used. This may be due, in part, to the loss of metallic flash. 104CHAPTER 8: FAILURE AND LIFETIME OF NiTi HAND FILES A. 180x, B. 300x, Fig. 8-6 (A, B). NiTi K #40 File. The file shows the results of “fretting.” As oxides are worn off, exposing fresh metal, a reaction occurs with elements that come in contact with the surface. The file was used in 15 cases A. Before use. B. After 15 times use (180x). C, After 15 times use (750x). Fig. 8-7 (A, B, C). NiTi Mac #45 file. Fatigue cracks due to bending and unbending of larger, less flexible file appeared after 15 times use. 105NIGKEL-TITANIUM INSTRUMENTS: APPLICATIONS IN ENDODONTICS. K 620 90 useces Fig. 8-8 (A, B, C, D). NiTi K #20 File. Pitting corrosion as it appears after 30 times use. This is probably due, in part, to lack of cleanliness, irrigants, sterilization and repeated use. (A) and (B) show pitting after 30 times use, (C) and (D) show an analysis of clean and dark areas. The dark pitted areas are apparently filled with calcified debris. 106CHAPTER 8: FAILURE AND LIFETIME OF NiTi HAND FILES Results of 15 times (cases) use (Tables 8-1 and 8-2) Folland Lite Times (0205 685; 2hrm ATS CTO El F Discarded Files = #15 Fractured handle afo'Fradred & tin shaker Table 8-1 ge Fe Ea ceo erect et, b jent and exceeded elastic limit Table 8-2 1079 Future Developments in NiTi Files Introduction The results of the clinical trial described in the previous chapters have generated considerable excitement in the field of endodontics. Several areas offer exciting research possibilities to further enhance the performance of these files. These research possibilities include: A. Use of ion implantation to provide harder and wear resistant cutting edges in the file. B. Investigation of failure modes in NiTi files to develop mathematical models to accurately predict the life ex- pectancy of these files during use. C. Optimization of flexibility, bending and torsional strength of files without sacrificing cutting ability, by using modern mechanics analysis methods; for ex- ample, finite element analysis. Additional details for each of these areas are provided under the following headings. Z lon Implantation Ton implantation is a process by which ions of elements such as boron and nitrogen are accelerated in a vacuum to such an extent that they can penetrate through the substrate (in this case the NiTi) to a depth of a few um. The surface properties of the substrate material are modified without changing its bulk prop- erties. Ion implantation increases surface hardness and improves friction, wear fatigue and corrosion resistance. All these properties are important in endodontic file applications.NICKEL-T11 ANIUM INSTRUMENTS: APPLICATIONS IN ENDODONTICS Implanting nitrogen ions in NiTi can lead to formation of small TiN pre- cipitates which can significantly enhance surface hardness. Increased hardness leads to higher wear resistance, which will promote cutting edge retention in endodontic file applications. Life Prediction Models Endodontic file failure occurs by the fatigue mechanism. Fatigue failures occur due to repeated cyclic loading, such as the bending and unbending of the files. Fatigue failures originate at the surface by crack formation near regions of stress concentration, such as at roots of notches. These cracks subsequently propa gate during continued load cycling, leading to fractures. The understanding of fatigue failure mechanisms in metals and alloys has progressed considerably in the last three decades. Thus, on the basis of laboratory testing of the material, it is possible to develop mathematical models to predict the failure lifetimes of files. Establishment of lifetime prediction models and development of meaningful fa- tigue test methods will also considerably aid in quantitatively characterizing the influence of variables such as file size, geometry, and surface treatment on the fatigue lifetime of the files. File Design Optimization Using modern analytical tools such as_ finite element analysis, it is possible to optimize the design of files to improve flexibility without sacrificing bending and torsional fatigue strength. Finite element analysis (FEA) allows one to predict stress, strain and displacement behavior at all locations of a file in response to an externally applied force or displacement. Optimum file designs can be obtained by comparing the stress and strain response to a fixed bending displacement of sev- eral file geometries in which the depth and shape of flutes are varied. The flute designs to analyze can be chosen on the basis of manufacturability and cutting efficiency. The finite element analysis of NiTi files can be quite involved, due to the pseudo-elastic characteristics of the material derived from the stress-induced trans- formations. These deformation mechanisms lead nbt only to a nonlinear stress- strain response but also to one that is different during loading and unloading. Also, the application requires inclusion of large deformation effects in the analysis. Thus, a detailed experimental characterization of the stress-strain response of the NiTi material at various temperatures will be necessary prior to attempting finite element analysis. However, these studies are well within the realm of the capabili- ties of modern experimental and computing facilities and will result in a high payoff, 110