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Key Words
Endodontic instrument, fractured, removal, tube technique
From the *Department of Operative Dentistry, Universitatsklinikum Munster; Institute of Biostatistics and Clinical
Research; and Central Interdisciplinary Ambulance in the
School of Dentistry, Universitatsklinikum Munster, Munster,
Germany.
Address requests for reprints to Dr Michael Wefelmeier,
Department of Operative Dentistry, Albert-Schweitzer-Campus
1, Building W30, Universitatsklinikum Munster, 48149,
Munster, Germany. E-mail address: mwefel@uni-muenster.de
0099-2399/$ - see front matter
Copyright 2015 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2015.01.018
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Basic ResearchTechnology
Materials and Methods
In pull-out tests, the disconnecting force between 3 different
fixation materials and 2 different stainless steel endodontic instruments was determined. Twenty specimens were investigated in each
group.
Two different endodontic instruments (ISO 20: Hedstrom files,
Kerr files; VDW Dental, Munich, Germany) were cut exactly at the
same diameter of 0.4 mm. These fragments were fixed in a vise with
an overlap of either 1 or 2 mm. Microtubes (NDurance syringe tips;
Septodont, Saint-Maur, France) with an outer diameter of 0.85 mm
and an inner diameter of 0.64 mm (22-G) were shifted over these instruments and fixed as shown (Fig. 1).
In group 1, cyanoacrylate-based adhesive (Instant Fix; Henry
Schein Dental, Melville, NY) was aspirated into the tubes before putting
them over the endodontic instrument. For faster setting of the cyanoacrylate, the tubes were stored in water for 30 minutes to guarantee a homogenous setting and maximal adhesion.
In group 2, a dual-curing composite resin (Rebilda DC; VOCO,
Cuxhaven, Germany) was used to fix the endodontic instrument in
the microtube. The setting time was 30 minutes to guarantee complete
polymerization.
In group 3, a light-curing composite resin (Surefil SDR; Dentsply,
York, PA) was used to fix the endodontic instruments inside of the
tube. An optical fiber (Conrad Electronic SE, Hirschau, Germany)
with a diameter of 0.5 mm was inserted into the microtube and pushed
forward until the fiber got in contact with the endodontic instrument
(Fig. 1). Then, the SDR was light polymerized by Smartlite PS (Dentsply) through the optical fiber for 1.5 minutes. The light source was
applied in contact to the fiber (Fig. 2).
After polymerization, the compound between the tubes and the
endodontic instruments was used for pull-out tests. A total of 240 samples were prepared as follows:
Statistics
To compare the different instruments, instrument lengths, and
fixation materials in regard to the force necessary to break the
Figure 1. A schematic drawing showing the fixed instrument, metallic tube, and 2 different methods of adhesion (lower right: cyanoacrylate; Rebilda DC, dualcuring composite; upper right: SDR, smart dentin replacement, light-curing composite).
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Wefelmeier et al.
Basic ResearchTechnology
Results
Regardless of the type of instrument or instrument length, the use
of light-curing SDR reached the highest median amount of force, which
was necessary to break the connection between the microtube and the
instrument (Table 1). For all instruments and instrument lengths, significant differences between SDR and Rebilda as well as cyanoacrylate
were achieved (P < .0001).
In all pull-out tests with SDR and 2-mm Hedstrom files, the
connection between composite resin and the instrument did not fail.
However, this was primarily because of previous fracturing of the endodontic instrument itself.
Two different mechanisms of failure of the adhesive joint were
observed when using Rebilda in 2-mm Hedstrom files or
2-mm K-files. The connection between composite and the inner surface of the tube failed and led to total disconnection, which was
observed in 20% (K-files) or 40% (Hedstrom) of the samples. The
increased variance resulting from this phenomenon can clearly be
seen in Table 1.
The glue or composite resin reacts differently with the 2 types of
instruments. The adhesive joint seems to be more durable in Hedstrom
files for Rebilda and SDR (eg, the median force when using SDR was
79.7 N [IQR = 66.086.8 N] in Hedstrom files and 53.3 N [IQR =
47.158.5 N] in K-files). The connection is more durable in any combination of fixation materials and instruments with instrument lengths of
2 mm compared with 1 mm (Table 1).
Discussion
Figure 2. Microtube and optical fiber to show the way of the light, which is
necessary for polymerization after shifting both over the tip of the endodontic
instrument.
adhesive joint, descriptive statistics were calculated. Values are presented as median and interquartile range (IQR) throughout the text.
Because normal distribution could not be assumed, the 3 groups
were compared using the Kruskal-Wallis (26) test followed by the
Dunn test (27) for pairwise comparison applying the closed testing
principle (28). These comparisons were performed for the 2 instruments and 2 instruments lengths separately, and all P values were
therefore adjusted by the Bonferroni method to account for multiple
testing. The multiple significance level was set to a = 0.05. Statistical
analyses were conducted using IBM SPSS Statistics 22 (IBM Corp,
Somers, NY) and R Version 3.1.0 (SAS Institute Inc, Cary, NC).
TABLE 1. Mean Force, Standard Deviation, and Range of All Pull-out Tests
Endodontic instrument
Fixation length
Fixation material
Mean
Standard deviation
Range (minimummaximum)
1 mm
cyanoacrylate
Rebilda DC
SDR
cyanoacrylate
Rebilda DC
SDR
cyanoacrylate
Rebilda DC
SDR
cyanoacrylate
Rebilda DC
SDR
11.24 N
32.42 N
64.66 N
17.69 N
55.82 N
86.15 N
11.56 N
29.83 N
47.67 N
27.59 N
43.20 N
59.79 N
3.83 N
11.30 N
9.13 N
7.42 N
25.51 N
4.33 N
4.44 N
7.35 N
7.07 N
5.55 N
17.28 N
9.45 N
4.9318.50 N
11.6951.67 N
49.1381.47 N
6.1630.88 N
14.1796.59 N
78.9193.60 N
2.8518.86 N
18.2042.12 N
33.4258.83 N
18.5436.31 N
10.3464.36 N
45.6276.15 N
Hedstrom
2 mm
K-file
1 mm
2 mm
Rebilda DC, dual-curing composite; SDR, smart dentin replacement light-curing composite.
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Basic ResearchTechnology
(K-files), the resistance of the connection between composite resin and
fractured instrument seems to be lower.
The application of chemically polymerized Rebilda DC showed
significantly lower values and greater standard deviations than lightcured SDR. This could be explained by different shrinkage of the tested
composites (30) and the content of filler but not a lack of polymerization or other physical properties. In their studies, axial shrinkage of SDR
was 2.26% and Rebilda DC reached 2.96%. The shrinkage force
amounted to 20 N for SDR in average and about 37 N for Rebilda
DC (30).
During polymerization, the composite seems to shrink toward
the structured surface of the endodontic instrument. As a result of
this, the connection between the composite and the inner surface
of the tube failed using Rebilda DC for fixation and led to total
disconnection. These observations may elucidate the standard deviations in Table 1.
Using this modified microtube technique may offer some advantages compared with other tube techniques. Within the limitations of
the results of this experiment, the following aspects about the clinical
relevancy might be considered:
1. The microtubes can be bent in any desirable direction or a Cancellier instrument (SybronEndo, Orange, CA) might be used for placing
the tubes over the instrument so that nothing will interfere with the
straight line of sight a microscope requires.
2. Both microtubes and optical fibers are available in a wide range of
diameters down to 0.25 mm. Because of this fact, the size of the tube
can be adapted individually, and additional reduction of radicular
dentine is minimized.
3. A circumferential staging platform facilitates the removal of fractured endodontic instruments with ultrasonic devices or microtubes
(13). The more radicular dentin can be saved; the lower is at risk of
perforation (23). For this modified tube technique, high forces can
be transferred to the fractured instrument with an exposure of
12 mm.
4. Furthermore, there are huge differences in application time.
Although the polymerization of SDR can be controlled by the clinician and is induced by light for 1.5 minutes, longer setting times for
the other materials were necessary. Preliminary tests showed a constant level of maximal fixation after 20 minutes for cyanoacrylate and
Rebilda.
5. In addition, the polymerization of SDR only depends on the intensity of light, which is inside and in front of the tube. Material
outside of the tube will not polymerize and can be removed
easily.
The investigation of additional rotational forces and different types
of endodontic instruments will have to show whether this technique is a
meaningful rewarding addition to the standard techniques frequently
used by clinicians. Further studies concerning rotary nickel-titanium instruments are necessary to elucidate if the results can be extrapolated to
instruments with other metallurgical properties and cross-sectional designs.
Conclusion
Within the limitations of this in vitro pilot study, the use of lightcuring composite resin inside of the microtube was superior compared
with the use of cyanoacrylate or chemically cured composite resin.
The applicable forces differed significantly (SDR > Rebilda
DC > cyanoacrylate, Hedstrom file > K-file).
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Wefelmeier et al.
Acknowledgments
The authors deny any conflicts of interest related to this study.
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