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The reciprocating movement in endodontics

Article in Endodontic practice · February 2016

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CLINICAL

The reciprocating
movement in endodontics
Nicola Maria Grande, Gianluca Plotino, Hany Mohamed Aly Ahmed,
Stephen Cohen and Frédéric Bukiet provide a clinical perspective on the
reciprocating movement in endodontics

Shaping the root canal facilitates cleaning the


root canal system (RCS) and is probably the
most important phase in endodontic
treatment. It includes the removal of pulp
Nicola M Grande
tissue, microorganisms, infected dentine and
root canal filling materials (RCFMs) in non-
surgical retreatments (Hülsmann, Peter,
Dummer, 2005). Shaping the canal enhances
the efficiency of irrigants and medicaments,
and optimises subsequent filling procedures
(Hülsmann, Peter, Dummer, 2005; Frank,
1967). Figure 1: The different types of reciprocating motion for
In the last two decades, numerous advances endodontic instrumentation: Left: complete reciprocation with
in endodontic instrumentation have been developed to horizontal rotational oscillations. Right: partial reciprocation with
rotational effect
achieve proper enlargement of the main canal without
procedural errors (Frank, 1967). Reciprocating motion (RM)
had been extensively used with stainless steel (SS) files early objective of clinical endodontics, beginning in the 20th
initially in the development of mechanical instrumentation in century, when pioneers were trying to develop mechanical
endodontics. RM applied to nickel titanium files has many instruments (Hülsmann, Peter, Dummer, 2005).
differences from the one used with SS (Grande et al, 2015). Rotary SS root canal instruments, such as Gates Glidden
RM has been a recent innovation employing nickel titanium burs and Peeso Reamers, can be safely used in the coronal,
instrumentation systems that claim to better resist instrument and sometimes the middle third of relatively straight RCs, but
separation, thus permitting easier treatment thereby their stiffness increases the risk of root perforation as the
shortening the learning curve for nickel titanium file systems. clinician approaches the middle third of the canal (Laws,
1968; Jungmann, Uchin, Bucher, 1975; Martin, 1976). For
Evolution of RM in endodontics – historical this reason, a RM that has equal angles in both directions was
perspective successfully introduced. This type of symmetric reciprocation
The early era of mechanical instrumentation can be defined as complete oscillating reciprocation (Figure
Automated instrumentation of the root canal space was an 1), resembling the classic watch-winding movement used
with manual SS files.
In the 1960s, different handpieces were manufactured
TURN TO PAGE 00 initially and designed to reciprocate at 90o (Frank, 1967). The
overall results regarding the shaping ability and its safety were
generally similar (Frank, 1967; Luebke, Brantley, 1990;
Lausten, Luebke, Brantley, 1993) or inferior (Dihn, 1972;
CPD AIMS AND OBJECTIVES Molven, 1970; O’Connell, Brayton, 1975; Klayman, Brilliant,
This clinical article aims to provide a clinical perspective on the reciprocating 1974; Sargenti, 1974; Weine, Kelly, Lio, 1975; Weine, Kelly,
movement in endodontics. Bray, 1976; Powell, Simon, Maze, 1986) to a classic approach
using SS manual root canal preparation (RCP), with a higher
EXPECTED OUTCOMES frequency of iatrogenic errors, including a tendency for canal
straightening (Abou-Rass, Ellis, 1996; Limongi et al, 2004).
Correctly answering the questions on page XX, worth one hour of verifiable CPD, will
demonstrate that the reader understands the properties, effectiveness and clinical In general, reducing the amplitude of the movement
outcomes of the modern reciprocating files available in the market, as well as the toward a smaller oscillation with a higher frequency decreased
favourable results of reciprocating files, which indicate their potential application as the incidence of iatrogenic errors, but were still more of a
viable alternatives to rotary file systems. problem than when using SS files manually to prepare canals

28 FEBRUARY 2016 ENDODONTIC PRACTICE


CLINICAL

Figure 3a: Three-dimensional


Figure 2a: Three-dimensional Figure 2b: Superimposition of pre- and reconstruction of a micro-computed Figure 4a: Three-dimensional Figure 4b: Three-dimensional Figure 4c: Superimposition of pre- and
reconstruction of a micro-computed post-instrumentation three-dimensional tomographic scan of a mesial root of a reconstruction of the cross-section at 1mm reconstruction of micro-CT scan images of post-instrumentation images showing the
tomographic scan of a mesial root of a reconstructions (in pink postoperative) mandibular first molar with three root from the apex of micro-CT scan of a root the same canal at the same cross-section centring ability of this type of
mandibular first molar with three root showing the centring ability of the canals before instrumentation (in yellow). canal before instrumentation (in yellow) after instrumentation with a reciprocating instrumentation technique
canals before instrumentation (in yellow) reciprocating technique Superimposition of preoperative file to an apical size of 40 (in pink)
three-dimensional reconstruction and
postoperative bi-dimensional sections at
coronal

Figure 5: Left: previous Waveone Primary Figure 6a: Preoperative radiograph of a Figure 6b: Working length. Note the sharp
file made in M-wire alloy and features of lower left second molar tooth apical curvature of the distal root
Figures 3b and 3c: Superimposition of preoperative three-dimensional reconstruction Figure 3d: Showing the modification of
the coronal, middle and apical part of the
and postoperative bi-dimensional sections at coronal middle and apical level root canal anatomy and geometry induced
instrument. Right: the new Waveone Gold
by reciprocating instrumentation Figure 6c: One-year control radiograph.
Primary file and features of the coronal,
Note conservative access only removed
middle and apical part of the instrument.
the old filling. Maximum maintenance of
The heat treatment of the files has been
the dental structure of the distal area
(Turek, Langeland, 1982; Harty, Stock, 1974; Hülsmann, complex canals (Peters, Paque, 2010). changed from M-wire to gold alloy
makes it compatible to proper cleaning,
Gambal, Bahr, 1999; Bolanos et al, 1988; Lehman, Gerstein, treatment. Note the ability to prebend the
shaping and filling procedures
1982; O’Conell, Brayton, 1975; Teodorovic, Ivanovic, 1998; The birth of modern reciprocation for nickel titanium file
Cheung, Chan, 1996; Nagy et al, 1997; Smith, Edmunds, files of greater taper
1997; Hülsmann, Rummelin, Schäfers, 1997; Petschelt et al, Studies have demonstrated the potential in using greater
1994). taper nickel titanium files in shaping the root canal even in
The other common observation after RCP with mechanical the most challenging of anatomical complexities (Hulsmann,
SS files was that increasing the size of the preparation risked Peters, Dummer, 2005; Parashos, Messer, 2006). asymmetrical motion and the file used was a Protaper F2 diameter) SS scouting files allows the clinician to determine
a higher incidence of procedural errors (Hülsmann, Gambal, However, fracture of nickel titanium rotary instruments (Dentsply Maillefer). The angles used were described as four- the size of the RSF, which will shape the canal (De-Deus et al,
Bahr, 1999; Bolanos et al, 1988; Lehman, Gerstein, 1982; continues to be of concern (Best et al, 2004) and appears to tenth of a circle (144°) in clockwise (CW) cutting direction 2010a; De-Deus et al, 2010b). This approach can be risky for
O’Connell, Brayton, 1975; Teodorovic, Ivanovic, 1998; be a manifestation of continuous rotation. In 2004, one study and two-tenth of a circle (72°) in counter-clockwise (CCW) files used in complete rotation because if the file exhibits
Cheung, Chan, 1996; Nagy et al, 1997; Smith, Edmunds, investigated the endurance limit of nickel titanium files (Best non-cutting direction with a speed of 400rpm. The technique ‘taper lock’ in the canal, immediate fracture could occur
1997; Hülsmann, Rummelin, Schäfers, 1997; Petschelt et al, et al, 2004); this is the level of stress or strain at which the file showed promising results (Malentacca, Lalli, 2002). (Yared, 2008). This modified CW/CCW movement led to
1994; Abou-Rass, Jastrab, 1982; Ianno, Weine, 1989). can be subjected to before separating (Lindeburg, 1999). This The overall speed of this kind of rotational reciprocation is nickel titanium files specifically designed for the use in partial
Other studies have also reported procedural errors linked value is a specific deflection angle (DA), characteristic of each much lower than the speed used for symmetric oscillating reciprocation, such as Waveone (Dentsply Maillefer) and
to metal stiffness and restoring force of SS and worse results instrument; it depends on the size and design features of the reciprocation. Consequently, the rotating effect given by the Reciproc (Dentsply VDW).
compared to nickel titanium instrumentation systems (Hilaly instrument. net difference between CW and CCW movements maintains The files are used with different angles in the cutting and
Eid, Wanees, Amin, 2011; Ceyhanli et al, 2014). Every time a rotating file cuts dentine in a constricted an adequate cutting efficiency and an apical progression of non-cutting direction of 150°/30° (Reciproc with an average
canal, torsional deformation develops on its axis. If the the instrument while reducing torsional stress. speed of 300rpm and Waveone with an average speed of
The modern use of SS files in reciprocation deformation is within the plastic limit of the metal, there are It has been speculated that this kind of reciprocation is 350rpm) and that are within their characteristic endurance
Although there are many systems on the market, the tendency no structural changes. However, if repeated cyclic axial similar to the manual balanced force technique as described limit (Webber, 2015).
is to limit use to the scouting phase prior to shaping deformation accrues, the instrument will fracture due to by Roane and colleagues in 1985. The dynamics enables the Actual and set values of the asymmetrical reciprocating
procedures, to obtain a glide path. This would minimise the torsional fatigue and this is in addition to the flexural fatigue instrument to remain centred in the canal, as the cutting force movement of different motors was assessed because variables,
adverse effects of SS files especially in larger more rigid sizes. that develops within a curved canal (Pedulla et al, 2015). is equal on the concave and convex side of the canal curvature such as the delay between the two directions of movement
Despite the widespread use of mechanical SS files, there is Limiting the angle of rotation in the cutting direction (Figures 2, 3 and 4). Torsional stresses, which are developed and the acceleration to reach the desired speed, could play an
still a lack of scientific evidence on their efficacy (Limpngi et under the endurance limit of the instrument led to the on the shank of the file during the cutting action, are reduced important role in the efficacy of the different instruments
al, 2004). development of a movement that could be defined as partial as the rotation is under the ideal limit of the DA specific for (Fidler, 2014). Additional studies are needed to explore this
SS files used for glide path management should be used or asymmetrical reciprocation (Figure 1), in which the angle the file. variable. For commercial reasons, the flutes of reciprocating
with equal 30° forwards and backwards movement in a of rotation in the cutting direction is higher than the angle of This novel asymmetrical movement led to the development files are manufactured in a backwards direction so that the
reciprocating handpiece (M4 Safety Handpiece (Sybronendo/ rotation in the opposite non-cutting direction. After a certain of dedicated reciprocating single file (RSF) systems and a new CCW movement is greater than the CW movement and after
Kerr). The primary observations regarding small SS files for number of cutting cycles the instrument would complete a technique where only one file is needed to fully shape a canal three cutting cycles the instrument completes a full reverse
glide path management seems to be promising, but studies full rotation. When first introduced (Yared, 2008), an ATR to length. rotation. All commercially available nickel titanium files
are lacking on how they would fare in calcified, curved and Teknica motor (ATR, Pistoia, Italy) was programmed for this Initial canal negotiation with small (0.08, 0.10mm tip rotate in a CW direction (Fidler, 2014). Both commercially

29 FEBRUARY 2016 ENDODONTIC PRACTICE ENDODONTIC PRACTICE FEBRUARY 2016 30


CLINICAL

• The cleaning effectiveness of reciprocating files is Hybrid reciprocation can be fixed or


comparable to full rotary file sequence systems. Further flexible, ie, it can shift from one type of
studies should be conducted to understand the respective reciprocation to the other in the canal based on
influence of the kinematics, the file design and the number mechanical resistance and torque.
Figure 7a: Preoperative periodical Figures 7b and 7c: Periapical radiograph of working length with manual stainless steel Gianluca Plotino
radiograph of the upper left second molar files. In MB2 it was impossible to negotiate the root canal with manual files
of instruments needed to fully shape canals It must be borne in mind, however, that no
with apical periodontitis • Reciprocating single file usage reduces the shaping time file system is able to completely clean the
compared to a full sequence rotary system canal, totally eliminate sessile and planktonic
• Dentine microcracks occur independently of the type of microorganisms or remove the filling material
Figures 7d and 7e: Periapical radiographs file and its kinematics completely from the root canal system.
at different horizontal angulation of the
• The results of published studies show that the use of However, the favourable results of RFs,
final obturation. The scouting and
negotiation of the MB2 was made possible reciprocating files would lead to fewer or an equivalent especially their safety and low rate of fracture,
with the mechanical reciprocation scouting amount of dentine microcracks compared with full sequence indicate their potential as viable alternatives to
approach using R25 rotary systems rotary file systems (Figures 6 and 7). ¡
• RFs can promote significant bacterial reduction, but, like
rotary full sequence systems, they are not able to completely
AUTHORS
disinfect the RCS
available RFs are marketed as single file techniques, after non-cutting direction). The change to reciprocation is • The ability of RFs to extrude less debris than rotary files NICOLA MARIA GRANDE DDS PHD is assistant professor of endodontics at the
initial scouting of the canal to determine the correct file size dependent on the torque to which the file is subjected. The remains a matter of debate Catholic University of Sacred Heart. He works in private practice limited to
to use to obtain the final shape. A single RSF produces a average speed of the RM is not declared by the manufacturer. • Reciprocating files are effective in removing root canal endodontic and microsurgery in Rome, Italy.
shape that traditionally would be obtained after a series of This type of movement could be defined as a hybrid filling material in less time as compared to rotary files, yet
GIANLUCA PLOTINO DDS PHD maintains a private practice in Rome, Italy
three or more rotary nickel titanium files. The favourable reciprocation. no system is able to remove the filling material completely
limited to endodontics and restorative and aesthetic dentistry.
results of reciprocating files indicate their potential as viable Recently, Morita (Japan) has introduced the Root ZX II from the RCS.
alternatives to rotary file systems. Occasionally it might be OTR Module, a low-speed handpiece where the torque is HANY MOHAMED ALY AHMED BDS HDD (ENDO) PHD is a senior lecturer and
endodontist at the School of Dental Sciences, Universiti Sains Malaysia, Kubang
necessary to use additional instruments to initially establish automatically measured during file rotation. The manufacturer Conclusion
glide path or clean the apical third and the fins of the RCS claims that if the torque is less than the set value, the file Kerian, Kelantan, Malaysia.
RM is defined as a repeated backward and forward
(Baugh, Wallace, 2005). rotation continues, but if the torque has reached the set value, (clockwise/counter-clockwise) movement, has been STEPHEN COHEN MA DDS FICD FACD is an adjunct clinical professor of
A RSF is subjected to a certain amount of mechanical the file reverses rotation by 90° and then continues in the extensively used in endodontics for many years and can be endodontics at the Arthur A Dugoni School of Dentistry, University of the Pacific,
stress during use that otherwise would be distributed amongst cutting direction once again. This type of movement could be applied to many endodontic files. San Francisco, California, USA.
a series of different rotary files. For this reason, manufacturers also defined as a hybrid reciprocation. The clinician has the There are many variations of RM, including: FRÉDÉRIC BUKIET DDS MSC PHD is a senior lecturer, hospital practitioner, and
urge single-use for RSF techniques to prevent the increased advantage of continuous rotation when needed, and • Complete reciprocation (oscillation) associate researcher (Giboc, ISM, UMR CNRS 7287) at the University of Aix
risk of file separation in case of multiple usages (Yared, 2008). reciprocating movement in a reverse direction activated by • Partial reciprocation (rotational effect) Marseille, Assistance Publique des Hôpitaux de Marseille. He maintains a clinical
Recently, Waveone has been upgraded to Waveone Gold. the torque measurement. If too much force is applied the • Hybrid reciprocation (combined movements). practice limited to endodontics.
The kinematic of this system is unchanged but the cross handpiece will continue reading a torque limit over the set
section, size and geometry of the files have been modified to value and the reciprocating movement will continue.
make the file more flexible and efficient. Gold heat treatment More recently, several motors have come to market with References versus WaveOne. J Endod 2012;38:54De-Deus G, Arruda TE, Souza EM, Neves
Abou-Rass M, Ellis MA (1996) A comparison of three methods of hand and A, Magalhães K, Thuanne E, Fidel RA (2013) The ability of the Reciproc R25
is a proprietary Dentsply post manufacturing heat treatment the functionality to adjust both forward and backwards angle
automated instrumentation using the CFS and M4 for preparations of curved instrument to reach the full root canal working length without a glide path.
process unlike M-Wire, which is a pre-manufactured heat of reciprocation, as well as the speed of movement. Int Endod J 46: 993-8
and narrow simulated root canals. Braz Endod J 1: 25-33
treatment process. The Gold heat treatment process improves Theoretically, any instrument on the market could be used in Dihn Q (1972) An in-vitro evaluation of the Giromatic instrument in the
Abou-Rass M, Jastrab RJ (1982) The use of rotary instruments as auxiliary aids
flexibility (Shen et al, 2013) and allows the instrument to be an asymmetrical reciprocation with these motors but studies to root canal preparation of molars. J Endod 8: 78-82 mechanical preparation of root canals. Thesis. Univ. of Minnesota; Minn.
precurved, an advantage when are still lacking on how they would perform in terms of safety Fidler A (2014) Kinematics of 2 reciprocating endodontic motors: the
Baugh D, Wallace J (2005) The role of apical instrumentation in root canal
placing the file into canals in more and quality of the preparation. treatment: a review of the literature. J Endod 31: 333-40 difference between actual and set values. J Endod 40: 990-4
Due to the increased popularity of RM and reciprocating
‘The favourable results difficult to reach posterior regions
(Figure 5). Reciproc (Dentsply files usage, numerous studies have been conducted mainly
Best S, Watson P, Pilliar R, Kulkarni GG, Yared G (2004) Torsional fatigue and Frank AL (1967) An evaluation of the Giromatic endodontic handpiece. Oral
endurance limit of a size 30.06 ProFile rotary instrument. Int Endod J 37: Surg Oral Med Oral Pathol Oral Radiol Endod 24: 419-21
of reciprocating files VDW) is marketed as a file that investigating the mechanical properties, shaping ability, 370-3 Grande NM, Ahmed HM, Cohen S, Bukiet F, Plotino G (2015) Current
indicate their potential can prepare the coronal and preservation of the root canal anatomy, shaping time, cleaning Ceyhanli KT, Erdilek N, Tatar I, Cetintav B (2014) Comparative micro-computed Assessment of Reciprocation in Endodontic Preparation: A Comprehensive

as viable alternatives middle thirds of the root canal effectiveness, microcrack formation, bacterial reduction, tomography evaluation of apical root canal transportation with the use of
ProTaper, RaCe and Safesider systems in human teeth. Aust Endod J 40: 12-6
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De-Deus G, Moreira EJ, Lopes HP, Elias CN (2010a) Extended cyclic fatigue life area, and extent of canal-wall touching on using 3 instrumentation
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TF Adaptive files and the dedicated Elements motor files tested Assessment of apically extruded debris produced by the single-file ProTaper with the automated Excalibur endodontic handpiece. Clin Oral Invest 3: 70-8
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hor-izontal rotational motion and 0° CCW) to partial
two new nickel-titanium instruments used in reciprocation motion: Reciproc
reciprocation (370° in a CW cutting direction and 50° in the original canal anatomy

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