ENDODONTOLOGY

Original Research - 3

Evaluation of fracture strength of tooth roots following

canal preparation by hand and rotary instrumentation
- An invitro study
MITHRA N. HEGDE *
SHISHIR SHETTY **
NAVNEET GODARA ***

ABSTRACT
Objectives: The present in-vitro study was undertaken to evaluate and compare fracture strength of tooth roots
following canal preparation by hand and rotary instrumentation and, further, to determine the effect of these
different canal preparation techniques on the direction and pattern of fracture lines.
Study design: 60 freshly extracted human mandibular premolars were randomly divided into four groups of 15
teeth each. In Group I, canals were prepared with step-back technique using standardized nickel-titanium K-files.
In Groups II, III and IV canals were prepared with crown-down technique using Quantec LX, ProTaper and VTaper rotary files respectively. After obturation, a vertical load was applied by means of a spreader inserted into
the canal until fracture occurred. The roots were subsequently examined under a dissecting microscope with 20X
magnification to determine the direction and pattern of fracture lines. The results were statistically analyzed using
Kruskal-Wallis and Mann-Whitney U-test.
Results: The Mean fracture load was 10.1 3.9 kg for K-files, 12.9 5.2 kg for Quantec LX files, 13.6 5.1 for
ProTaper files and 14.3 6.1 kg for V-Taper files, but the differences between four groups were not statistically
significant (p>0.05). Most of the fracture lines observed were in bucco-lingual direction, followed by proximal
and compound fractures.
Conclusion: Increased canal taper as advocated by Quantec LX, ProTaper and V-Taper files did not increase the
fracture susceptibility of mandibular premolars any more than conventional step-back K-file preparations and
may even increase the fracture resistance.

INTRODUCTION

fractures, with the greatest incidence occurring in

A vertical root fracture is a longitudinally

endodontically treated teeth and in patients older

oriented fracture of the root, extending throughout

than 40 years of age.2 Vertical root fracture is a

the entire thickness of dentin from the root canal

problem of particular clinical significance because

to the periodontium. It may be initiated in the crown

it indicates a dismal prognosis for the affected tooth.

or at the root apex, or, in some cases, along the

In some situations a fractured tooth may be salvaged

root between these two points. Vertical root

with root amputation or hemisection, but more

fractures represent between 2-5% of crown and root

often extraction is indicated.3

* Professor and Head, ** Reader, *** III year post- graduate student, Department of Conservative Dentistry and Endodontics, A. B. Shetty Memorial Institute of Dental
Sciences, Deralakatte, Mangalore- 575018.

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ENDODONTOLOGY

EVALUATION OF FRACTURE STRENGTH OF TOOTH ROOTS FOLLOWING CANAL PREPARATION

BY HAND AND ROTARY INSTRUMENTATION - AN IN-VITRO STUDY

The cause of vertical root fractures mainly is

greater taper rotary nickel-titanium instruments has

iatrogenic, resulting from dental treatment excesses,

allowed different canal shapes and sizes to be

for example, excessive canal shaping, excessive

achieved. Most of the new systems incorporate

pressure during compaction of gutta-percha,

instruments with a taper greater than the ISO

excessive width and length of a post space in

standard 0.02 taper design, indeed rotary nickel-

relation to the tooths anatomy and morphology,

titanium instruments are available with tapers

or excessive pressure during placement of the

ranging from 0.04 to 0.12.12 Up to now, little is

dowel. Trauma is the most likely cause of vertical

known about the influence of instrument taper on

root fractures in vital teeth, typically occurring from

the fracture strength of tooth roots.

physical trauma, clenching or bruxism, or occurring

Therefore the aim of this study was to evaluate

in teeth undergoing apexification. 4 Obturation

fracture strength of tooth roots, following canal

strains 5-7 and post placement 8 have been

preparation by hand using standardized K-files

investigated as major causes of vertical root fracture.

(Dentsply Maillefer, Baillaigues, Switzerland), and

The lateral condensation technique, in particular,

three different rotary instrumentation techniques

has been blamed as a major cause of vertical root

using Quantec LX files (Sybron Dental Specialties,

fracture.9, 10 However Lertchirakarn et al5 studied

Orange, CA, USA), ProTaper files (Dentsply

forces encountered during lateral condensation and

Maillefer, Baillaigues, Switzerland), and recently

concluded that lateral condensation alone should

available V-Taper files (Guidance Endodontics, LLC,

not be a direct cause of vertical root fracture, as

USA), and, further, to determine whether these

loads generated during lateral condensation were

different canal preparation techniques would alter

significantly lower than the load required to fracture

the direction and pattern of fracture lines.

the root. This indicates the need for further

investigation into factors that predispose to root

MATERIALS AND METHODS

fracture. One possibility is the weakening effect of

Selection of Teeth

excessively large canal preparations.

60 straight, single- rooted mandibular

premolars with mature root apices and single canal

Advancements in rotary nickel- titanium (Ni-

extracted on periodontal or orthodontic grounds

Ti) instruments over the last decade have led to

were used. Teeth with gross caries involving the

new design concepts and techniques of canal

root, cracks on the root surface and for

preparation. In order to improve working safety,

exceptionally short and thin roots were excluded.

shorten preparation time and create a continuously

All teeth were stored in 10% neutral buffered

tapered, conical flare of preparations advanced

formalin for at least 2 weeks and then in distilled

instrument designs with noncutting tips, radial

water until they were tested. The teeth were

lands, different cross-sections, superior resistance

thoroughly cleaned with an ultrasonic scaler.

to torsional fracture and varying tapers have been

developed.11

Teeth were randomly divided into four groups

of 15 teeth in each group.

Increase canal taper advocated by various

23

ENDODONTOLOGY

MITHRA N. HEGDE, SHISHIR SHETTY, NAVNEET GODARA

Group I: Step-back technique using

Group II: Crown-down technique using Quantec

standardized Ni-Ti K- files

LX rotary Ni-Ti files

The canals were prepared with Quantec LX

Group II: Crown-down technique using

nickel titanium instruments using a 1:128 reduction

Quantec LX rotary Ni-Ti files

handpiece (NiTi Control, Dentsply) at a speed of

Group III: Crown-down technique using

350 rpm. Coronal flaring was done by taking

ProTaper rotary Ni-Ti files

Quantec #25, 0.06 taper, 17 mm length, to a depth

just short of the apical one third using light pecking

Group IV: Crown-down technique using V-

motion. Shaping sequence was proceeded through

Taper rotary Ni-Ti files

the 0.12, 0.10 and the 0.08 tapered instruments.

Instrumentation

Each file was passively carried into the canal. The

Each tooth was decoronated 2mm coronal to

sequence was repeated from the 0.10 tapered

the cemento- enamel junction (CEJ) with a diamond

instruments until Quantec 0.06 taper, 21 mm length

disc to facilitate straight line access for

readies working length.

instrumentation and obturation. Proper access was

Group III: Crown-down technique using ProTaper

established and the apical patency was determined

rotary Ni-Ti files

by inserting an ISO # 08 K-file until it appeared at

The canals were prepared with ProTaper nickel

the apical foramen. Working length was determined

titanium instruments using a 1:128 reduction

by placing a size 10 K-file into the canal until it

handpiece (NiTi Control, Dentsply) at a speed of

appeared at the apical foramen; this length was

300 rpm. Shaping was started with the shaper S1

measured and the working length was set 0.5mm

using multiple, passive-pressure passes to the

short of this distance. The flat surface 2mm above

anticipated working length.

the CEJ was used as the reference point. The four

Using S1 and later

S2, the preparation was extended to the working

groups were then prepared according to the

length. Apical third of the canal was finished using

following techniques:13, 14, 15, 16

Finishing file F1 and later F2 to the working length.

Group I: Step-back technique using standardized

Group IV: Crown-down technique using V-Taper

Ni-Ti K- files

rotary Ni-Ti files

The canals were prepared by ISO 0.02 taper

The canals were prepared with V-Taper nickel

hand instrumentation with size 25 as the master

titanium instruments using a 1:128 reduction

apical file (MAF). Gates-Glidden drills (size 2 and

handpiece (NiTi Control, Dentsply) at a speed of

3) were used initially to preflare the canal. This

350 rpm. Coronal half of the canal was shaped with

was followed by hand filing to the master apical

#30(V10) and #25(V08) V-Taper rotary files using

file and then step-back in 1mm increments for three

multiple, passive-pressure passes. Then the final

additional file sizes. Recapitulation with the master

Glide-Path was established by taking #10(V04) and

apical file at the working length was carried out

#10(V06) V-Taper hand file to the working length.

after each step back size file.

Apical half of the canal was shaped using #30(V10)

24

ENDODONTOLOGY

EVALUATION OF FRACTURE STRENGTH OF TOOTH ROOTS FOLLOWING CANAL PREPARATION

BY HAND AND ROTARY INSTRUMENTATION - AN IN-VITRO STUDY

and #25(V08) V-Taper rotary files passively to the

applied a force within the canal through the gutta-

working length.

percha and stopped immediately after fracture was

detected. The load at fracture was recorded in

The master apical file size was kept constant

kilogram force.

for all the four groups as 25. Throughout the

instrumentation procedure, all canals were irrigated

The roots were subsequently examined under

using a long 27 gauge needle with 2.5% sodium

a dissecting microscope with 20 X magnification

hypochlorite and recapitulation with an ISO # 10K

to determine the location and direction of fracture

file was done after every instrument use. Teeth were

lines.

stored in water after the instrumentation to prevent

Statistical analysis

dehydration.

To compare the statistical significance among

Obturation

the scores of the four groups, Kruskal-Wallis test

After the root canals had been dried with

was used. Once a significant difference in average

absorbent points, all the specimens were obturated

score was found among these four groups, the

using cold flowable gutta-percha (GuttaFlow,

Mann-Whitney U-test was carried out to find out

Coltene Whaledent, West Sussex, UK) according

significant difference in average score between any

to manufacturers guidelines.

two pairs. All statistical analysis was performed at

17

95% level of confidence.

Mounting of roots

RESULTS

All the specimens were then mounted

individually in Additional silicone putty (Aquasil,

Load at fracture

Dentsply DeTrey, Konstanz, Germany). Each root

The comparison of Mean fracture load among

was mounted vertically, such that the apex of the

four groups using Kruskal-Wallis test showed that

root will retain on a hard surface. The putty was

the canals prepared with rotary instrumentation

allowed to set for at least 30 min before teeth were

were stronger than the canals prepared with hand

tested. The roots were kept wet using damp towels

instrumentation. On comparison among different

to prevent dehydration.

rotary instrumentation, V-Taper showed the highest

Measurement of fracture load

fracture load (14.3 6.1), followed by ProTaper

(13.6 5.1) and then Quantec LX (12.9 5.2).

All the specimens were placed individually

The load required to fracture the roots prepared

on the testing platform of an Instron testing machine

with K-files was lowest (10.1 3.9). Fracture loads

(Model 4206, Instron Corp., Canton, MA) which is

ranged from as low as 5 kg to a high of 24.3 kg

running at a cross head speed of 1mm/min. A, D11

across the four instrumentation groups. However

hand spreader tip (Hu-Friedy) was attached to the

the differences between four groups were not

machine and was inserted into the root canal to

statistically significant at the 95% confidence level

contact gutta-percha as a means of distributing the

(p=0.181). (Table I)

load to the canal walls for fracture testing. Once

the test started, the hand spreader tip gradually
25

ENDODONTOLOGY

MITHRA N. HEGDE, SHISHIR SHETTY, NAVNEET GODARA

Direction of fracture lines

an indication of fracture susceptibility of the root

Most of the fracture lines observed in the four

when subjected to forces encountered during

groups were in bucco-lingual direction (48/60),

obturation, post place-ment, or subsequent clinical

followed by roots fracturing in the proximal

function. The mean fracture load obtained by

direction (8/60) and then compound fractures (4/

Lertchirakarn et al5 for mandibular premolars was

60). (Table II)

9.7 kg. This value is closest to the hand preparation

group in this study (10.1 kg), but considerably lower

DISCUSSION

than the fracture loads in the Quantec LX (12.9

In this study, canals prepared with step-back

kg), ProTaper (13.6) and V-Taper (14.3 kg) groups.

technique using standardized K-files created a taper

The fracture loads ranged from as low as 5 kg to a

of 0.05 in the apical 4mm of the canal, whereas

high of 24.3 kg across the four instrumentation

Quantec LX rotary files created a canal where the

groups. The minimum load required to fracture a

apical 4mm has a taper of 0.06. The ProTaper and

mandibular premolar was 5.6 kg, 5.0 kg, 5.9 kg

V-Taper rotary files have variable taper within the

and 5.1 kg for K-files, Quantec LX, ProTaper and

same file. The ProTaper created a taper of 0.08 in

V-Taper, respectively. These values are similar to

the apical 3mm of the canal whereas V-Taper

that found by Lertchirakarn et al. (minimum load

created a taper of 0.08 in the apical 4mm of the

4.8 kg).5 Pitts et al6 measured the fracture strength

canal.

of maxillary central incisors, the mean fracture load

This study utilized GuttaFlow to passively

was found to be 15.2 kg. Holocomb et al.18 found

obturate the canals. The method of obturation was

that the minimum force required to fracture a

not intended to simulate recommended obturation

mandibular incisor was 1.5 kg. As in previous

techniques, but to fulfill the need of having gutta-

studies, there was wide variability in the fracture

percha as the medium within which the forces

load of the roots, with a four to five-fold range,

could be transmitted throughout the canal by means

compared to a three-fold range in the Lertchirakarn

of a spreader inserted into the canal.

et al. study5 and a four -fold range in the work of

Pitts et al.6 This is presumably because of the

The technique used in this study for producing

variation in root morphology, dentin thickness,

root fracture involved the generation of forces

calcification, and canal preparation techniques.

within the canal space by means of a spreader

inserted into the obturated canal which is in

Despite larger preparations by Quantec LX,

accordance with several studies.5, 6, 18, 19, 20, 21 This

ProTaper and V-Taper files compared to K-files, no

method was chosen because it produces force

statistically significant differences were observed

distribution from inside the root canal wall and

among all the groups with regard to fracture load.

fracture occurs as a result of forces transmitted

In fact, there appeared to be some tendency for

through the obturating material. This resembles root

higher frac-ture loads for roots prepared with rotary

fracture of endodontic origin or from a post.5

Ni-Ti instruments (30-50% higher). This finding is

contrary to the study by Wilcox et al. 20 and

The load required to frac-ture the root provides

Zandbiglari et al.22 which concluded that the more

26

ENDODONTOLOGY

EVALUATION OF FRACTURE STRENGTH OF TOOTH ROOTS FOLLOWING CANAL PREPARATION

BY HAND AND ROTARY INSTRUMENTATION - AN IN-VITRO STUDY

root dentin was removed, the more likely a root

is more susceptible to high stress than a more

was to fracture. This may be a result of the effect of

circular one and fracture occurs when the tensile

the rounder canal shapes prepared by Quantec LX,

stress in the canal wall exceeds the ultimate tensile

ProTaper and V-Taper files, leading to reduced areas

strength of dentin.

of stress concentration which may offset the effect

In the present study, the mechanism of

of increased dentin removed.

resultant bucco-lingual fracture could be explained

This study also observed that most fracture

due to the following reason:

lines were in a bucco-lingual direction, and the

When an apical pressure is applied with a

second most common direction was proximal

round instrument (D11 Hand spreader) inserted into

fracture. This is in agreement with that reported in

an elliptical canal, it will bind at its narrowest width,

other studies. 5, 7, 18, 21 No major differences in

which is typically from mesial to distal. The initial

fracture patterns were noted among the four groups.

forces will be directed towards the mesio-distal

Most vertical root fractures occur in the bucco-

direction leading to a strain on the bucco-lingual

lingual direction, even in mandibular incisors18 and

surface. Hence the resulting fracture lines will orient

molars

5, 21

where the dentin thickness in the bucco-

in the bucco-lingual direction. (Figure 3)

lingual direction is almost twice that in the mesio-

CONCLUSION

distal direction. The mechanism of bucco-lingual

Within the parameters of this in-vitro study the

fracture was proposed by Lertch-irakarn et al.23, who

following conclusions may be drawn:

stated that when pressure is applied in a thickwalled vessel stresses are of two types: tensile stress

1) Increased taper as advocated by Quantec

in a circumferential direction and compressive

LX, ProTaper and V-Taper rotary files do not weaken

stress in the radial direction. The thin (proximal)

roots any more than the conventional step-back K-

part of the wall will be forced to expand more

file preparations and may even increase the fracture

readily than the thick (bucco-lingual) part of the

resistance of mandibular premolars.

wall in a radial direction. The asymmetrical

2) Most of the fracture lines observed in

expan-sion creates additional circumferential

mandibular premolars were in bucco-lingual

tensile stresses on the inner surface of the thicker

direction, followed by roots fracturing in the

areas, resulting from the outward bending of the

proximal direction and then compound fractures.

thinner part of the dentin wall. The single most

important factor which potentially influences the

Further investigations into other types of Ni-

location and direction of fracture lines is the root

Ti instruments and in other groups of teeth may

canal shape with a reduced radius of curvature.

give further insights as to the effects of different

The other factors include external root morphology

rotary Ni-Ti instruments on fracture strength of teeth

and dentin thickness. A markedly oval root canal

and susceptibility to vertical root fracture.

27

ENDODONTOLOGY

MITHRA N. HEGDE, SHISHIR SHETTY, NAVNEET GODARA

Table I- Comparison of Mean fracture load among four groups using Kruskal - Wallis test
Group

Mean

Standard

Minimum

Maximum

Deviation

Load

Load

Group I

15

10.1533

3.93190

5.60

18.10

Group II

15

12.9200

5.24516

5.00

20.40

Group III

15

13.6067

5.10343

5.90

21.10

Group IV

15

14.3200

6.17451

5.10

24.30

4.882

0.181 ns

N Number of specimens, H Kruskal-Wallis test, p Probability, ns not significant (p > 0.05)

Table II- Direction and pattern of fracture lines
among four groups

Figure 1- Specimen mounted on Instron machine

for testing the fracture strength

Group

Direction

Frequency

Group I

Buccco-lingual
Proximal
Compound

12
1
2

Group II

Buccco-lingual
Proximal
Compound

11
3
1

Group III

Buccco-lingual
Proximal
Compound

12
2
1

Group IV

Buccco-lingual
Proximal
Compound

13
2
0

Figure 3- Schematic drawing of a root cross-section

illustrating resultant bucco-lingual fractures in
mandibular premolars. (a) canal preparation, (b)
pulp space, (c) fracture lines oriented buccolingually, (d) dentin. Arrows show the direction of
forces resulting from instrument contact with
proximal canal walls.

Figure 2- Specimen examined under dissecting

microscope with 20 X magnification to determine
the direction of fracture lines
28

ENDODONTOLOGY

EVALUATION OF FRACTURE STRENGTH OF TOOTH ROOTS FOLLOWING CANAL PREPARATION

BY HAND AND ROTARY INSTRUMENTATION - AN IN-VITRO STUDY

Graph I- Bar graph showing the comparison of

Mean fracture load among four groups

Graph II- Bar graph showing the distribution of

fracture patterns within each group of canal
preparation techniques

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