Basic ResearchTechnology

The Effect of Cervical Prearing Using Different Rotary Nickel-Titanium Systems on the Accuracy of Apical File Size Determination
Christian Tennert, DDS,* Josef Herbert, DDS, MS, PhD, Markus Jorg Altenburger, DDS,* and Karl-Thomas Wrbas, DDS, Priv. Doz.*
Abstract
Introduction: An exact determination of the apical root canal diameter is crucial for correct cleaning and shaping of a root canal. The aim of this study was to investigate the discrepancies of the initial apical root canal diameter and the diameter that is measured by the initial apical le (IAF) after cervical aring using current rotary nickel-titanium systems. Methods: Mesiobuccal canals of 40 extracted mandibular molars were randomly assigned to four groups. In the rst group, root canals were not ared. Root canals of the other groups were preared using FlexMaster (VDW, Munich, Germany), ProTaper (Dentsply, Konstanz, Germany), or RaCe (FKG Dentaire, Genf, Switzerland) instruments. The tooth length was determined by inserting an ISO 06 Kle to the apical foramen. The working length (WL) was set 1 mm short of the apical foramen. File sizes were increased after binding sensation was felt at the WL. Transversal sections of the WL regions were examined under stereomicroscope, and the diameter of the root canal and the IAF at WL were assessed. Results: Canals preared with RaCe instruments had the lowest discrepancy between the apical root canal diameter and the IAF diameter (15.7 9.7 mm) followed by ProTaper (22.2 11.0 mm) and FlexMaster (35.0 17.2 mm). Conclusions: Prearing of root canals prevents underestimation of the actual apical root canal diameter. The type of instruments used for prearing show differences on the accuracy of IAF determination. Prearing with larger tapered instruments leads to a more accurate apical sizing, and this information is crucial concerning the appropriate nal diameter for complete apical shaping. (J Endod 2010;36:16691672)

urrent standards in endodontic treatment are cleaning and shaping of the root canal before lling (1). Endodontic success relies on the accurate determination of the working length (WL) and adequate enlargement of the root canal (2). The use of electronic apex locaters increases the determination of the WL and precisely localizes the apical foramen (3). The amount of apical enlargement is typically based on the estimation of the diameter at the apical constriction. The initial apical size of a root canal is determined by inserting K-les with increasing ISO size to the apex. The initial apical size of a root canal is assumed as the size of the rst le that binds at the WL and is dened as the initial apical le (IAF) (1). Continued and progressive dentin formation leads to progressive constrictions, mainly at the cervical third. Any morphologic discrepancy between the gauging instrument and the root canal leads to an early instrument engagement of the root canal wall, causing a prior apical binding. Traditional methods used for the determination of the anatomic diameter solely based on the clinicians tactile sense are inaccurate and have underestimated the real diameter of the apical portion (4, 5). As a result, apical enlargement of the root canal with three instruments with increasing le diameter does not guarantee the total removal of infected dentine from root canal walls (6). Previous studies investigated the inuence of different rotary instruments for cervical aring on the determination of the IAF (79). In these studies, hand les, Gates-Glidden drills, and different types of rotary instruments were used for prearing (5, 810). The objective of the present study was to investigate the inuence of prearing using current and widely used rotary nickel-titanium instruments (FlexMaster [FM; VDW, Munich, Germany], ProTaper [PT; Dentsply, Konstanz, Germany], and RaCe [RC; FKG Dentaire, Genf, Switzerland]) for cervical aring on the determination of the IAF. These systems include les with a large taper for cervical aring of the root canal and les for apical enlargement.

Materials and Methods

Tooth Selection and Preparation For this study, only mesiobuccal root canals of 40 intact extracted permanent mandibular molars displaying normal pulp chambers, patent root canals, and fully formed apices without any sign of resorption were used. No tooth has had a previous root canal treatment or root lling. The roots had a slight or severe curve with an angle from 10 to 70 . The angle of the curve was dened as described previously (11). The cusps of the teeth were cut horizontally to get a plane occlusal zone to determine the working length precisely. Standard access cavities were performed, and the apical region of the mesial root was covered with wax. Teeth were embedded in methacrylate

Key Words
Apical diameter, apical shaping, cervical aring, aring, IAF, initial apical le, prearing, root canal

From the *Department of Operative Dentistry and Periodontology, University School and Dental Hospital, Albert-Ludwigs-University Freiburg, Freiburg i. Br, Germany; and Department of Interdisciplinary Dentistry and Technology, Danube University Krems, Krems, Austria. Address requests for reprints to Christian Tennert, DDS, University Medical Center, Dental School and Hospital, Department of Operative Dentistry and Periodontology, Hugstetter Strae 55, 79106 Freiburg, Germany. E-mail address: christian.tennert@uniklinik-freiburg.de. 0099-2399/$0 - see front matter Copyright 2010 American Association of Endodontists. doi:10.1016/j.joen.2010.06.017

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Figure 1. Stereomicoscope pictures of transverse sections of root canals at the WL with the IAF xed in the root canal to show the discrepancies of root canal diameter and diameter of the IAF of (A) nonared root canals and root canals preared using (B) FM, (C) PT, and (D) RC instruments. (This gure is available in color online at www.aae.org/joe/.)

(Techovit 4070; Haereus Kulzer, Wernheim, Germany). The apical foramen was not covered by methacrylate.

Sizing of Canals The precise tooth length was specied by inserting an ISO 06 K-le (VDW) into the canal until the le was visible at the apex. Then, the le was placed exactly at the apex of the tooth to determine tooth length using 5 magnication. The WL was set 1 mm short of the tooth length. Flaring the Coronal and Middle Section of the Root Canals Coronal and middle aring were performed using FM, PT, or RC instruments in combination with Endo IT Professional (VDW) at 250 rpm. The 40 molars were randomly divided into four groups (n = 10). Teeth of the rst group were not ared (NF). Coronal aring of the teeth of the other groups was performed using FM, PT, or RC instruments. Flaring was perfomed system specic according to the manufacturers recommendation for each system. Flaring of the FM group was performed using the intro le (0.11/22) of the FlexMaster instruments. Then, les 0.06/25 and 0.04/25 were used for aring terminating 3 mm short of the WL. Teeth of the PT group were ared coronal to two thirds of the WL using ProTaper SX (ISO 19, taper 3.5%-19%), S1 (ISO 17, taper 2%-11%), and S2 (ISO 20, taper 4%-11.5%) instruments. Coronal aring of teeth of the RC group was performed using RC instruments. Files of size 0.10/40 and 0.08/35 were used for aring 10 mm of the WL. Then, the IAF was determined. Each le was used for aring 5 root canals. Determination of IAF Files were inserted into the mesiobuccal root canal starting with K-le ISO 08/02 at the WL. At ISO 10, the le size was typically increased in increments of 5 ISO units or 5 102. The rst le that had apical
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friction at the WL was xed with methacrylate in the root canal. One millimeter of the apex of the root was cut horizontally with a microcutter (Exact, Norderstedt, Germany) so that the remaining tooth was at the WL. The apical cross-section was visualized using a Leica M3Z System (Leica, Bensheim, Germany), and images were taken from the sectioned apical region using a Zeiss AxioCam MRc 5 system (Carl Zeiss Imaging Solutions, Hallbergmoos, Germany). Axio Vs 40 V 4.5.0.0 software (Carl Zeiss Imaging Solutions) was used to determine the diameter of the root canal and the diameter of the IAF. The largest and the smallest diameter of the root canal and the largest diameter of the instrument were recorded. Data were submitted to a nonparametric Mann-Whitney U test and one-way analysis of variance (Kruskal-Wallis) to assess the effect of prearing techniques on the discrepancies found between the diameter of the binding instrument and the anatomic diameter of root canals.

Results
Flaring of the coronal and middle section and the type of instruments had a signicant effect on apical size estimate. Prearing with RaCe instruments leads to the most accurate determination of the IAF. In the RC group, the maximal apical root canal diameter and the diameter of the IAF had the lowest discrepancy (15.7 9.7 mm), whereas ProTaper (22.2 11.0 mm) and FlexMaster (35.0 17.2 mm) showed greater discrepancies between the IAF diameter and apical root canal diameter (Fig. 1). By aring the coronal and middle section of the root canal, le size reading was increased. The IAF was determined one (FM group and RC group) to two (PT group) ISO sizes larger after cervical aring compared with root canals without prearing (NF group). The discrepancies of maximal root canal diameter and the IAF are shown in Table 1.

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TABLE 1. Discrepancies of Maximal Root Canal Diameter and IAF Diameter at the WL Instrument type
No aringa FlexMasterb ProTaperbc RaCebc

Mean SD mm
66.4 11.7 35.0 17.2 22.2 11.0 15.7 9.7

Min mm
51.0 19.0 4.0 2.0

Max mm
90.0 67.0 41.0 38.0

N
10 10 10 10

IAF, initial apical le; WL, working length. Means with different superscript letters (a, b, c) are signicantly different (p < 0.05); means with the same superscript letters indicate no signicant difference according to Mann-Whitney U and KruskalWallis tests.

Discussion
The apical zone has been recognized to be critical for instrumentation (1). Moreover, the use of stainless steel instruments in this area can cause apical transportation (12). Clinicians typically start root canal treatment by inserting a le to the apex to determine the apical diameter of the root canal. To date, there is no other method to determine the apical root canal diameter or the amount of apical preparation during instrumentation (13). The amount of apical enlargement during canal shaping is based on the determination of the initial apical diameter by the IAF and is suggested to be performed three le sizes greater than the IAF (1, 10). Determination of the IAF without cervical aring leads to a great discrepancy between the diameter of the IAF and the actual diameter of the root canal. Studies have shown that the IAF is underestimated without cervical aring of the root canal. Regardless to the type of instruments used for cervical aring, prearing will decrease the discrepancy of the diameter of the IAF and the initial apical diameter of the root canal compared with nonared root canals (68, 1416), Nair et al (17) showed that regions of the mesiobuccal canal of mandibular molars are hardly accessible because of their peculiar anatomy. To make the apical portion of a root canal more accessible, prearing is performed to eliminate any irrigularities at the coronal protion. Kuttler (18) and Mizutani et al. (19) have described irregularities in the shape of apical root canals. There are untouched surface areas at the apical region after root canal preparation regardless of the preparation technique (20, 21). Underestimation of the initial apical root canal diameter will leave a greater portion of untouched surface areas at the apical region. Using les of larger size for instrumentation will lead to an adequate cleaning of the apical region (5, 22, 23). A correct determination of the apical diameter would be an ideal precondition to clean and shape the apical region of a root canal system completely. Previous studies investigated that different instrument types used for prearing inuence the accuracy of IAF determination (6, 7, 9, 24). The aim of the present study was to determine the discrepancies of the apical root canal diameter measured by the IAF and the actual apical diameter of the root canal using current mechanical nickel-titanium aring systems (FM, PT, and RC) for prearing. In contrast to other studies, the roots of the teeth in the present study were embedded in methacrylate to preserve the apical region and to avoid any destruction during root canal preparation and cutting the root. The apical foramen was not covered by methacrylate to be able to precisely measure tooth length and exactly cut 1 mm of the apex with the IAF xed in the root canal (4, 6, 7, 9). In the present study, aring of the coronal and middle third of a root canal using FM, PT, or RC instruments signicantly increases the accuracy of determining the initial apical diameter by the IAF compared with nonared root canals. Rotary instruments of each system used for prearing vary in terms of ISO and taper. Because of

the different characteristics of the instruments, each system has its own preparation technique. The les were used according to the manufacturers recommendation for each system. Flaring was performed until the point of root canal treatment when determination of the working length and the initial apical diameter of the root canal were recommended. This leads to different results in the shape of the root canal after prearing for each rotary system. Analyzing the data, the accuracy of IAF determination is obviously depending on the taper of instruments used for cervical aring. Using larger tapered instruments (RaCe) for prearing will led to the most accurate determination of the actual root canal diameter by the IAF. In previous studies, prearing using La Axxess burs led to the lowest discrepancy of IAF diameter and diameter of the root canal (68). Compared to LA Axxess burs, RaCe, ProTaper and FlexMaster increase the accuracy of apical le size reading. The present study has conrmed previous ndings, that prearing increases IAF size by one to two ISO sizes compared to non-ared root canals (19).

Conclusions
Cervical aring increases the accuracy of apical size determination. There are differences between prearing techniques on the accuracy of measuring the initial apical diameter by the IAF. Prearing using RaCe instruments leads to the best results in apical size determination followed by ProTaper and FlexMaster.

References
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