BASIC RESEARCH – TECHNOLOGY

, DDS, MS,
Eugenio Pedulla
Cyclic Fatigue Resistance of PhD,* Giusy Rita Maria La Rosa,
DDS,* Chiara Virgillito, DDS,*
Nickel-titanium Rotary Ernesto Rapisarda, DDS,*
Hyeon-Cheol Kim, DDS, MS,
Instruments according to the PhD,† and Luigi Generali, DDS‡

Angle of File Access and

Radius of Root Canal

ABSTRACT
SIGNIFICANCE
Introduction: The aim of this study was to compare the influences from different access
angles and curvature radii on cyclic fatigue resistance of nickel-titanium rotary files. The angulated file access and/
Methods: Two file systems (2Shape [TS; MicroMega, Besançon, France] and HyFlex CM or severe curved canal
[HCM; Colte
ne/Whaledent, Allst€atten, Switzerland]) were used. A total of 192 instruments of curvature with a small radius
TS #25/.04 (TS1), TS #25/.06 (TS2), HCM #25/.04, and HCM #25/.06 were evaluated at 3 could influence (reduce) cyclic
insertion angles (0 , 10 , and 20 ) and 2 radii (5 mm and 3 mm) in 16-mm stainless steel fatigue resistance of heat-
artificial canals with a 60 curvature. Cyclic fatigue resistance was determined by the number treated nickel-titanium
of cycles to failure (NCF) using a customized testing device. Data were analyzed statistically instruments.
with the significance level established at 95%. Results: In the 3-mm radius canal, the in-
struments showed lower cyclic fatigue resistance than in the 5-mm radius canal (P , .05).
HCM #25/.06 and all .04 taper instruments had a significant NCF reduction at 20 and 10 in
the 3-mm radius canal (P , .05), whereas TS2 showed no significant differences. In the 5-mm
radius of curvature, although .06 taper instruments had no significant NCF reduction for each
angle tested, .04 taper files exhibited significant NCF reduction when tested at 20 (P , .05).
Comparing the same size instruments, HCM had higher NCF than TS (P , .05). Instruments
with a .04 taper exhibited higher NCF than the .06 ones with the same heat treatment (P ,
.05). Conclusions: An inclined insertion into the canals decreased cyclic fatigue resistance of
thermal-treated instruments with a .04 taper at all radii of curvature tested. The synergistic
effect of a small radius of curvature and access angulation of heat-treated instruments de-
creases their fatigue resistance. (J Endod 2019;-:1–6.) From the *Department of General Surgery
and Surgical-Medical Specialties,
University of Catania, Catania, Italy;
KEY WORDS †
Department of Conservative Dentistry,
School of Dentistry, Dental and Life
2Shape; angle of file access; canal curvature; canal radius; cyclic fatigue resistance; HyFlex Science Institute, Dental Research
CM Institute, Pusan National University,
Yangsan, Korea; and ‡Department of
Surgery, Medicine, Dentistry and
Morphological Sciences with Transplant
Nickel-titanium (NiTi) rotary instruments may exhibit a higher risk of intraoperative fracture within the root Surgery, Oncology and Regenerative
canal1. Fracture may occur due to torsional failure or cyclic fatigue2,3. Cyclic fatigue appears to be the Medicine Relevance (CHIMOMO),
University of Modena and Reggio Emilia,
more prevalent cause of ‘‘unexpected’’ breakages4. Cyclic fatigue fracture occurs from an incremental
Modena, Italy
crack propagation caused by repeated tensile-compressive stress when the file is placed in a curved
Address requests for reprints to Dr
canal5,6.
Hyeon-Cheol Kim, Department of
Several factors influence the fracture of rotary files, such as size, cross-sectional area, design, heat Conservative Dentistry, Pusan National
treatment, and metallurgic properties of instruments7. One of the most important variables involved in University, School of Dentistry, Geumo-ro
instrument fracture is the radius of curvature8. This anatomic variable plays a crucial role, especially in S- 20, Mulgeum, Yangsan, Gyeongnam
shaped curvatures9,10. Another parameter is inclined insertion of the file into the canal; it depends on the 50612, Korea.
E-mail address: golddent@pusan.ac.kr
anatomic access configuration and operator skills11,12. In particular, for noninvasive dentistry and 0099-2399/$ - see front matter
endodontics, the recent contracted endodontic cavities could be associated with excessive inclination of
Copyright © 2019 American Association
NiTi instruments12. of Endodontists.
Heat treatments have been attempted in order to develop a superelastic alloy that improves the https://doi.org/10.1016/
characteristics of traditional NiTi instruments13. HyFlex CM (HCM; Colt
ene/Whaledent, Allst€atten, j.joen.2019.11.015

JOE  Volume -, Number -, - 2019 Fatigue Resistance of NiTi Rotary Instruments 1

Switzerland) is made with an exclusive process
in which austenitic and martensitic transition
phases are developed at room temperature,
which is different from traditional NiTi files. The
resulting controlled memory alloy (CM wire)
shows a higher flexibility and cyclic fatigue
resistance14. HCM instruments have 2 kinds of
cross sections: a triangular cross section for file
sizes #20/.06 and #25/.06 and a quadrangular
cross section for file sizes #20/.04 and #25/.04.
Another thermal treatment is used to
manufacture 2Shape files (TS; MicroMega,
Besançon, France). TS is made of a T-Wire
alloy that exhibits higher flexibility and fracture
resistance compared with traditional NiTi
instruments10. TS is available in 2 sizes, TS1
(size #25/.04) and TS2 (size #25/.06) with a
triple helix cross-sectional design10.
One study compared cyclic fatigue
resistance of NiTi instruments according to
different access angles. This study was
performed using Reciproc (VDW, Munich,
Germany) and heat-treated Reciproc Blue
(VDW) instrument systems. It was reported that
Reciproc Blue files exhibited higher cyclic fatigue
FIGURE 1 – The artificial canals used in this study. The files were placed in the artificial canal with (A ) 0 , (B ) 10 , and (C ) 20 angles of access in either (D ) 5-mm radius or (E ) 3-mm
radius canals.
2
et al.
Pedulla
resistance than Reciproc when the access to the
canal was straight or with a limited inclination15.
However, no other studies investigated
the influence of different angles of access in
different radii canals on cyclic fatigue for the
conventional rotary NiTi instruments.
Therefore, the purpose of this study was to
evaluate the cyclic fatigue resistance of TS and
HCM rotary files when they rotate in canals
with a different radius of curvature and different
angles of file access.
MATERIALS AND METHODS
The study protocol for the present study
received approval from the institutional review
board although neither human nor animal
subjects were used in the study. One
hundred ninety-two new files of a 25-mm
length were used. Forty-eight instruments of
each group (TS1, TS2, HCM #25/.04, and
HCM #25/.06) were tested within 2 curved
artificial stainless steel canals with a 5- and
3-mm radius of curvature, respectively, with a
60 curvature angle. Instruments (n 5 8 in
each test) were tested in each canal in 3
different conditions of insertion angle (0
corresponded to an ideal straight access and
10 and 20 corresponded to the artificial
canal axis) (Fig. 1A–E). Sample size
estimation was calculated a priori with
G*Power 3.1.9.2 software (Heinrich-Heine-
€sseldorf, Du
Universit€at Du €sseldorf, Germany)
in order to have 80% power and an alpha
error probability of 0.0515. All instruments
were inspected by an optical
stereomicroscope with !20 magnification.
No instrument reported signs of deformation,
and none was discarded.
Cyclic Fatigue Resistance Test
Device
Cyclic fatigue resistance tests were
performed using a customized device with a
fixed block that maintained a 6:1 reduction
electric handpiece (Sirona Dental Systems
GmbH, Bensheim, Germany) in a fixed 3-
dimensional position and a mobile support on
rails allowing insertion/withdrawal of the file15.
JOE  Volume -, Number -, - 2019
Each instrument was placed inside the TABLE 1 - The Number of Cycles to Failure (Mean 6 Standard Deviation [SD]) of Different Groups of Files with Different
artificial canal in a precise and reproducible Insertion Angles (0 , 10 , and 20 ) Tested in Canals with Different Radii of Curvature (5 mm and 3 mm)
way using the electric handpiece. The artificial
canal was specifically designed for the Artificial canal Group Insertion angle Mean ± SD
instruments used in this study in terms of size 5-mm radius TS2 #25/.06 0 254 6 311a
and taper, giving it a sufficient lumen with 60 angle 10 296 6 961a
proper trajectory16. A stopping mechanism 20 245 6 421a
blocked the mobile support at the same HyFlex CM #25/.06 0 1390 6 1542b
point. The different inclination of file access 10 1327 6 1452b
was produced by the platform containing the 20 1286 6 662b
artificial canal, which maintained the entrance
TS1 #25/.04 0 697 6 993a
of the instrument perpendicular to the canal.
10 647 6 933a
Therefore, cyclic fatigue resistance was 20 564 6 714a
tested with different inclinations (10 or 20 ) HyFlex CM #25/.04 0 3760 6 5795b
of files with respect to the standard 10 3487 6 6765b
position (0 ). 20 2604 6 1466b
Moreover, in this study, 2 radii of
curvature (5 mm and 3 mm) were used for the 3-mm radius TS2 #25/.06 0 156 6 351a
simulated stainless steel artificial canals with a 60 angle 10 180 6 641a
60 angle curvature (Fig. 1). All instruments 20 169 6 471a
HyFlex CM #25/.06 0 730 6172b
were activated using the handpiece powered
10 681 6 642b
by a torque-controlled motor (Silver Reciproc,
20 564 6 563b
VDW) in continuous rotation at a constant
speed of 300 rpm (revolutions per minute) TS1 #25/.04 0 563 6 1183a
following the manufacturer’s instructions. The 10 437 6 594a
instrument was placed in the contra-angle 20 422 6 624a
handpiece and then sited into each canal at the HyFlex CM #25/.04 0 2788 6 3265b
same position. The friction of the file on the 10 2071 6 1856b
artificial canal walls was reduced by a special 20 1777 6 986b
high-flow synthetic oil (Super Oil; Singer Co
TS, 2Shape.
Ltd, Elizabeth, NJ) designed for lubrication of Different superscript numbers indicate a statistically significant difference among angles of insertion of the same instrument
mechanical parts. (P , .05). Different superscript letters indicate a statistically significant difference between the 2 brands of instruments with
Each file was rotated until fracture the same dimensions tested in artificial canals with a specific radius (P , .05).
occurred. The length of the fractured tip of the
instruments was measured using a digital resistance than in the 5-mm radius canal (P , in the fracture surface of all instruments
caliper (Digimatic; Mitutoyo Co, Kawasaki, .05). HCM #25/.06 and all .04-taper (Fig. 2A–L).
Japan). The number of cycles to failure (NCF) instruments had a significant NCF reduction at
was calculated by multiplying the time to failure 20 and 10 in the 3-mm radius canal (P ,
and the rpm. The broken fragments were .05), whereas TS2 showed no significant
DISCUSSION
analyzed using a field-emission scanning differences. In the 5-mm radius of curvature, Instrument dimensions18, cross-sectional
electron microscope (Nova NanoSEM 450; although .06 taper instruments had no design19, and manufacturing techniques
FEI, Eindhoven, Netherlands) under various significant NCF reduction for each angle influence resistance to fracture of endodontic
magnifications to investigate the main features tested, .04 taper files exhibited significant NCF files. Furthermore, many variables potentially
of the fracture surface17. reduction when tested at 20 (P , .05). affect cyclic fatigue resistance, including
Comparing the same (tip size and taper) anatomic variations like the extent of curvature,
Statistical Analysis size instruments, HCM had higher NCF than double curvatures9, and inclination of the files15.
Data were subjected to the Shapiro-Wilk test TS (P , .05). Instruments with a .04 taper Even if some authors have investigated the
to characterize their normality and statistically exhibited higher NCF than the .06 ones with effects of a double curvature on cyclic fatigue
analyzed using 2-way analysis of variance and the same heat treatment (P , .05). resistance of NiTi files9,10,20,21, only a recent
the Bonferroni multiple comparison post hoc The mean length of the fractured study investigated the influence of different
test (Prism 8.0; GraphPad Software, Inc, La fragments was not significantly different for all angles of file access on NiTi instruments’ cyclic
Jolla, CA) with the significance level TS and HCM files tested (P . .05). It was 5 6 fatigue15. The results indicated that an
established at 95% (P , .05). 0.2 mm for files tested in the 5-mm radius excessive inclined insertion of files into the canal
canal and 3 6 0.1 mm for instruments tested in reduced the cyclic fatigue resistance of
the 3-mm radius canal. Reciproc and Reciproc Blue, especially when
RESULTS Field-emission scanning electron the access to the canal was 20 or 30 .
Table 1 shows the cyclic fatigue resistance in microscopic images of the fracture surfaces Nevertheless, there was no study
NCF (mean and standard deviation values) for showed similar and typical features of dimples regarding the effects of the radius of curvature
each angle of file access tested and for each on the entire fracture surfaces of the in association with the inclination of file access
canal used. instruments tested for cyclic fatigue. The crack on cyclic fatigue of continuous rotary NiTi
In the 3-mm radius canal, the initiation areas and the overload fast fracture instruments. Consequently, this study was the
instruments showed lower cyclic fatigue zone caused by cyclic fatigue are identifiable first attempt to compare the influence of

JOE  Volume -, Number -, - 2019 Fatigue Resistance of NiTi Rotary Instruments 3

FIGURE 2 – Representative field-emission scanning electron microscopic appearances of the instruments after fatigue tests (A–F: HCM and G–L: TS). Typical features of cyclic fatigue
fracture of the ductile fatigue area (encircled with dotted line ) with microdimples and cones are observed at the fractured cross sections regardless of the fracture. Crack initiation
origins (black or white arrows; major and prominent are pointed) are visible, and (C–E and G ) some of the specimens show an overloaded fast fracture zone (rolled-over area marked
with **** zone); the fast fracture zone is located at the opposite side of the major crack initiation area, and these indicate the direction of fracture.

different file access angles on cyclic fatigue of
continuous rotary NiTi instruments in
combination with different canal radii of
curvature. A customized cyclic fatigue test
device was used to allow the reproducibility of
testing conditions15. Inclined insertion angles
of 10 and 20 were selected for a valid
simulation of clinical conditions in which a file
can be inclined as in contracted endodontic
cavities12,22. In particular, the mean angle of file
access in a mesial canal of a first mandibular
molar was approximately 20 with a traditional
endodontic cavity12.
Radii of curvature of 3 mm and 5 mm
were chosen because they are the most
common values observed on apical curvature
as previously reported8,9,19,21. HCM and TS
files were selected for their flexibility based on
the manufacturers’ heat treatments (ie, CM
wire and T-Wire for HCM and TS files,
respectively). Moreover, HCM and TS files
were chosen because they are multifile
systems available in #25/.04 and #25/.06
sizes, which are generally the most used in
endodontic treatment, with the aim to change
only the taper23.
The results of the present study showed
that TS1 had higher cyclic fatigue resistance
than TS2; HCM #25/.04 also obtained higher
NCF compared with HCM #25/.06, which is in
agreement with previous studies that reported
higher flexibility and fatigue resistance of
instruments with a lower taper20,24. In
particular, HCM #25/.04 showed the highest
values of NCF. These results were probably
caused by the benefits of thermal
treatment6,13,14 associated with the file’s
reduced dimensions20,24. Independent of
dimensions, all files reported lower cyclic
fatigue resistance when tested in canals with
an angle of curvature of 60 and a 3-mm radius
compared with canals with the same angle of
curvature but a 5-mm radius9,21,24,25.
Although it was inappropriate to directly
compare HCM and TS files because of their
differences in design and cross section, when
comparing instruments with the same
dimensions, HCM presented significantly
higher cyclic fatigue resistance than TS. These
results are probably because of the different
design and manufacturing processes. Higher
cyclic fatigue resistance was reported for the
files made with the CM wire process compared
with traditional NiTi files or instruments made
with different thermal treatments6,25.
Meanwhile, there were not many published
studies regarding the metallurgic
characteristics of T-Wire treatment; there was
€ u
1 recent study by Ozy €rek et al26 that showed
that TS files had lower resistance and flexibility
than HyFlex EDM (Colt
ene/Whaledent) made in
CM wire as well as HCM files.
In addition, according to the present
results, the different access angles did not
influence cyclic fatigue of TS2 in both radii of
curvature. The same result was found when
HCM #25/.06 was rotated into canals with a
5-mm radius curvature. These results
indicated that angles of access did not
influence cyclic fatigue resistance of
instruments because thermal treatments
conferred good flexibility properties25,26. It
was recently reported that cyclic fatigue
resistance of TS2 was reduced in double
curvature canals compared with single
curvature ones10. The different results from
the present study were probably caused by
the different methodological conditions, the

4
et al.
Pedulla JOE  Volume -, Number -, - 2019
apical radius tested in double curvature (2
mm) canals, and the fact that anatomic
double curvature was a different condition
from that induced by file inclination.
Only HCM #25/.06 tested in canals with
a 3-mm radius curvature revealed a negative
impact of the access angle that, increasing
from 0 to 20 , causes a reduction of NCF with
no difference between 0 and 10 . It meant
that the 5 times higher NCF associated with
HCM #25/.06 in comparison with TS2 raises
the significance level of the fatigue resistance,
testifying that an excessive inclined coronal
access (20 ) associated with a severe curve
(3-mm radius) in the apical third of the canal
negatively affects fatigue resistance of thermal-
treated files only when they perform a high
NCF12,21. Tests conducted on TS1 and HCM
#25/.04 led to similar conclusions. In
particular, for .04 taper instruments, the
difference was observed both at 5 mm and 3
mm, probably because in both conditions the
instruments performed a higher number of
NCF compared with the same instruments
with a .06 taper24. Nevertheless, at 5 mm, it
was necessary to use a higher file inclination
(such as 20 ) to induce a significant decrease
of NCF, whereas at 3 mm it was sufficient to
use a file inclination of 10 . Thus, it is possible
to hypothesize that these results are because
of the major stress caused by an abrupt apical
curvature8.
The field-emission scanning electron
microscopic analysis revealed that, regardless
of the test conditions, typical fractographic
appearances of cyclic fatigue fractures were
similar between the 2 brands tested and test
conditions. Cyclic fatigue fracture is
characterized by fatigue crack initiation at 1 or
more cutting edges and fatigue dimples on all
fracture surfaces of the cross sections (Fig. 2).
These results must be extrapolated in
clinical conditions with caution. Indeed, in vitro
conditions differ from intracanal
instrumentation in which the fracture occurs
because of several factors that act together at
the same time, including torsional stress16.
Moreover, several factors such as anatomic
variations and the type of instrument could
influence the results obtained in vivo27. Despite
the advantages of an artificial canal milled on a
stainless steel block for standardization and
reproducibility, it is reasonable to think that in
clinical conditions instruments may encounter
various ranges of friction according to the
lengths and points of its blades, which might
be more stressful than in the artificial
canal16,28. During clinical use, an inclined file
could induce canal transportation in a curved
canal. Nevertheless, the use of more flexible
NiTi rotary instruments such as HCM and TS
might be a less invasive and safer method to
maintain the original canal anatomy, reducing
canal transportation and flexural stress29.
Further investigations are desirable regarding
this aspect.
Under the conditions of this study, an
inclined insertion into the canals as well as a
small radius of canal curvature decreased
cyclic fatigue resistance of NiTi rotary
instruments. Specially heat-treated
instruments with a small taper may increase
the fatigue resistance under the angulated
access and/or severe curved canal conditions.
Although in vivo investigations are necessary to
validate the outcomes of the present study and
more relevant clinically, clinicians may consider
the reduced fatigue resistance of heat-treated
NiTi files because of the synergistic effect of
access angulation and severe curvature of the
root canal.
ACKNOWLEDGMENTS
The authors deny any conflicts of interest
related to this study.

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