|Year : 2012 | Volume
| Issue : 3 | Page : 136-141
Comparative evaluation of debris extruded apically by using, Protaper retreatment file, K3 file and H-file with solvent in endodontic retreatment
Chetna Arora1, Rohit Bahri2, Neelam Mittal3
1 Department of Conservative Dentistry and Endodontics, Swami Devi Dayal Dental College, Barwala, Panchkula, Haryana, India
2 Department of Orthodontics, Post Graduate Institute of Medical Sciences and Research, Chandigarh, India
3 Faculty of Dental Sciences, Department of Conservative Dentistry and Endodontics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
|Date of Web Publication||30-May-2013|
Swami Devi Dayal Dental College, Barwala, Panchkula, Haryana
Source of Support: None, Conflict of Interest: None
Aim: The aim of this study was to evaluate the apical extrusion of debris comparing 2 engine driven systems and hand instrumentation technique during root canal retreatment. Materials and Methods: Forty five human permanent mandibular premolars were prepared using the step-back technique, obturated with gutta-percha/zinc oxide eugenol sealer and cold lateral condensation technique. The teeth were divided into three groups: Group A: Protaper retreatment file, Group B: K3, file Group C: H-file with tetrachloroethylene. All the canals were irrigated with 20ml distilled water during instrumentation. Debris extruded along with the irrigating solution during retreatment procedure was carefully collected in preweighed Eppendorf tubes. The tubes were stored in an incubator for 5 days, placed in a desiccator and then re-weighed. Weight of dry debris was calculated by subtracting the weight of the tube before instrumentation and from the weight of the tube after instrumentation. Data was analyzed using Two Way ANOVA and Post Hoc test. Results : There was statistically significant difference in the apical extrusion of debris between hand instrumentation and protaper retreatment file and K3 file. The amount of extruded debris caused by protaper retreatment file and K3 file instrumentation technique was not statistically significant. All the three instrumentation techniques produced apically extruded debris and irrigant. Conclusion: The best way to minimize the extrusion of debris is by adapting crown down technique therefore the use of rotary technique (Protaper retreatment file, K3 file) is recommended.
Keywords: Apical extrusion, endodontic retreatment, H-file K3 file, protaper retreatment files
|How to cite this article:|
Arora C, Bahri R, Mittal N. Comparative evaluation of debris extruded apically by using, Protaper retreatment file, K3 file and H-file with solvent in endodontic retreatment. Saudi Endod J 2012;2:136-41
|How to cite this URL:|
Arora C, Bahri R, Mittal N. Comparative evaluation of debris extruded apically by using, Protaper retreatment file, K3 file and H-file with solvent in endodontic retreatment. Saudi Endod J [serial online] 2012 [cited 2020 Mar 31];2:136-41. Available from: http://www.saudiendodj.com/text.asp?2012/2/3/136/112706
| Introduction|| |
The main causes of endodontic failure which leads to retreatment are thought to be insufficient cleaning and inadequate obturation. , Additionally teeth with inadequate obturation, unfilled or untreated root canals or under extended root filling may require retreatment before coronal restorations are placed as failure may occur in the future.  Treatment alternative of failure includes nonsurgical and surgical endodontic treatment. There are numerous materials which have been described in the literature for the obturation but gutta-percha in combination with a sealer is the most frequently used material.
There are various techniques for removal of gutta-percha such as the use of hand instrument, heat carrying instruments, ultrasonic devices and solvents. ,,,,
There are various studies which indicated that almost all instrumentation techniques may lead to some amount of apical extrusion of debris. ,, The technique of gutta-percha removal which requires a push pull motion usually creates a greater mass of debris than the techniques which requires a rotational motion. ,,
The aim of this in vitro study was to evaluate the amount of debris extruded apically during endodontic retreatment when comparing the protaper retreatment files and K3 system with H-file and solvent.
| Materials and Methods|| |
Recently extracted human mandibular premolars were collected from the Outpatient Department of Oral and Maxillofacial Surgery, Banaras Hindu University, Varanasi.
The criteria for specimen selection were teeth with single root canals, completely formed apices and root curvature not exceeding 10°. The selected teeth should not have cracks, open apices, root caries or root resorption. The teeth were observed under a surgical microscope (Carl Zeiss) to confirm that they had a single apical foramen. After excluding teeth that have failed to meet the above criteria, 45 sample teeth were collected. The external root surfaces of experimental teeth were cleaned off adherent tissue tags and debris using a periodontal curette. Teeth were stored in normal saline solution and kept in 2.5% sodium hypochlorite for 24 h before experimentation. Following this procedure, the teeth were opened for endodontic access with a round bur size 1/4 and pulp tissues were removed with barbed broaches. Number 10K file was passed 1 mm beyond the apical foramen to ensure the canal patency. The file which tightly fits at the apical foramen was selected for individual tooth and working length was established by subtracting 1 mm from this length. All teeth were prepared 1 mm short of the apical foramen with hybrid instrumentation technique. Coronal and middle third were prepared with Gates Glidden drill (size 1-3). Canals were then prepared with K file to a master apical file size 30 and step-back in 1 mm increments to a size 50. After each instrument the canals were irrigated with 5.25% sodium hypochlorite. Canal patency was maintained by inserting number 10 file slightly beyond the apical foramina during recapitulation. All teeth were obturated with cold lateral condensation with gutta-perch points and zinc oxide eugenol sealer. The access cavity of all the teeth were restored with Cavit and radiographs were taken both in mesiodistal and buccolingual plane to assure the quality of obturation. All teeth were stored in the incubator at 37°C temperature and 100% humidity for 30 days.
The hole was created in the rubber stoppers with the help of heated instrument and the teeth were inserted into the hole and fixed with self-curing acrylic in order to create hermetic seal. Since self-curing acrylic resin underwent polymerization shrinkage during setting, a second sealing of self curing acrylic resin was accomplished to confirm that the setup would not permit any leakage. A 0.5 ml of polyethylene tube was used as collecting container for any debris and irrigant extruded apically during instrumentation. The identification numbers were carved on the polyethylene tubes. The excess particles as a result of carving were completely removed by methyl alcohol. These tubes were pre-weighed to 10 -5 gms precision using microbalance prior to the retreatment. The rubber stopper with the tooth was fitted into open end of the tubes with the apical part of the root suspended within the tubes and this assembly was then placed into the 5 ml glass vial. The glass vial is filled with auto polymerizing acrylic resin to place the polyethylene tube firmly into the vial during the instrumentation procedure. A 23 gauge needle was inserted in the rubber stopper next to the fixed root to equalize the external and internal pressures. The operator was shielded from seeing the root apex during the instrumentation by placing the rubber dam over the vial. The vial was hand held vertically during the instrumentation. All the instrumentation was done by the same person. Forty five teeth were randomly assigned to 3 groups, 15 teeth in each.
Group 1 - Protaper retreatment files.
Group 2 - K3 files.
Group 3 - H files with solvent.
Gutta-percha in all the three groups was removed with protaper retreatment fails, K3 rotary instruments and H files with tetrachloroethylene.
All canals, regardless of the system used, were irrigated with 2ml of distilled water after each instrument using 30 - gauge needles. The total volume of irrigant was 20 ml/tooth. Distilled water is used instead of sodium hypochloride to avoid any possible weight increased caused by NaOCl crystal formation. Only 1 set of instruments was used for five samples. Retreatment was considered to be complete when no debris of gutta-percha/sealer was visible on the instrument surfaces and the canals were smooth.
Debris extruded, along with the irrigating solutions during the retreatment procedures was carefully collected in the Eppendorf tubes. The tubes were removed from the glass vial. The debris adhering to the root surface was collected by washing off the apex with 0.5ml of distilled water into the tube. The aluminium foil was wrapped over the tubes and secured with rubber bands. Holes were made with 18 gauge needle into the foil for the evaporation of liquid. The tubes were stored in the incubator at 68°C for 5 days to evaporate the moisture. The tubes were then allowed to cool in the desiccator containing silica gel for 30 min. Weighing of the tubes was then carried out on the same electronic balance. The weight of the extruded debris was determined by subtracting the weight of the pre-weighed empty tubes from the weight of the tubes plus the dried debris. The mean weight of extruded debris was calculated for each group and statistical analysis performed.
| Results|| |
The weight of the extruded debris was determined by subtracting the weight of the pre-weighed empty tubes from the weight of the tubes plus the dried debris. The data were checked for the normalcy by Kolmogorov-Smirnov Test for normality and was found normally distributed. The test for homogeneity was done by Levene Statistics which showed data was homogenous. The datawere analyzedd by one way ANOVA for the comparison of three groups (pre-weighed value). No statistical significant difference was found [Table 1].
The data were then analyzed by Two Way ANOVA for the comparison of post weighed extruded debris which shows there was a significant change from pre-weighed to post-weighed values and there was a significant difference between three groups [Table 2].
|Table 2: Univariate analysis of variance ANOVA shows comparison of pos-tweighed values|
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In group-A, instrumentation was done with Protaper Retreatment files showed the mean extrusion value of 346.8907 ± 12.73873.
In group-B, instrumentation was done with K3 files showed the mean extrusion value of 350.7400 ± 17.04284.
In group-C, instrumentation was done with an H-file with solvent showed the mean extrusion value of 350.549 ± 13.56570.
For comparison between three groups for extruded debris gain post hoc test was done [Table 3].
The P values obtained showed statistically significant difference in comparison of group 3 with group 1 and 2, though comparis ons between group 1 and 2 was statistically insignificant.
The result of post hoc test shows:
Data were also analyzed by Non parametric test i.e., Mann-Whitney Test which showed statistically significant difference in comparison of group 3 with group 1 and 2 [Table 4].
- There was a significant difference in the apical extrusion of debris between Hand instrumentation and protaper retreatment file and K3 file.
- The amount of extruded debris caused by protaper retreatment file and K3 file instrumentation technique was not significant.
| Discussion|| |
The failure of an endodontic treatment may lead to root canal retreatment. Treatment alternative to root canal failure are non surgical and surgical root canal retreatment. According to the literature the success of retreatment ranges from 40-100%. This variable outcome in retreatment is due to different factors such as age of the patient, type of teeth,  the presence of alteration in the natural course of root canal,  the technique used to remove the existing filling material and possibility to repair pathologic or iatrogenic defect  and the possibility of removing the coronal restoration to assess the pulp chamber.  Gutta-percha in conjunction with the sealer is the most frequently used root canal filling material. In endodontic retreatment it is necessary to completely remove gutta-percha and sealer to uncover the remnants of necrotic tissue or bacteria that might be responsible for endodontic failure. ,
There are various techniques for gutta-percha removal in endodontic retreatment and all the techniques may lead to apical extrusion of debris.  Debris express into the periradicular tissue may lead to acute exacerbation of chronic inflammatory condition. The immunological aspect of apical extrusion has been discussed in a number of studies. Seltzer and Naidorf reported that new irritants in the form of chemically altered pulp tissue protein may be introduced into the granulomatous lesion which is followed by severe reaction.  Naidorf demonstrated the presence of immunologlobin in the periapical area. He proposed that the canal can contain antigen and granuloma may have antibodies. Therefore, when intracanal content is pushed through it will result in an antigen antibody complex. This reaction will trigger the complement cascade causing damage to cell membrane resulting in prostaglandin release, edema, bone resorption, amplification of the kinin system and ultimately pain to the patient.  The presence of mast cell has also been shown in human periapical lesion. ,,, Based on this information Torabinejad et al., concluded that physical/chemical injury of the periradicular tissue during root canal preparation can cause degranulation of mast cells in periapical tissues. Mast cells discharging vasoactive amine into the periapical tissue initiate an inflammatory response or aggravate an existing inflammatory process.  The histological consequences of apical extrusion have also been analyzed by a number of researches. Seltzer et al., reported that even sterile dentin debris in the periapical area was associated with persistent inflammation.  They observed that apical collagen fibers of the periodontal ligament were distended by oedema. Torneck et al., reported similar finding in the incisor of young primates.  Aside from these local effects, extrusion of microbes into periradicular tissue during endodontic treatment has the potential to bring about serious systemic diseases such as endocarditis, brain abscesses and septicemia particularly in compromised patients. , Protaper retreatment files are one set of 3 files i.e., D1, D2, D3 which have a convex cross section with taper/tip diameter 0.09/0.30, 0.08/0.25 and 0.07/0.20 mm respectively. These files were used with endomotor at 3 N/cm torque and 500 RPM speed. These files are used with brushing motion in the crown-down manner at the cervical, middle and apical 3 rd respectively. The D1 file has an active tip which facilitate the penetration of the subsequent files i.e. D2 and D3. The non-cutting tips of D2 and D3 reduces the incidence of ledging, perforation and stripping during the removal of filling material. K3 file is a triple fluted file with asymmetrical cross section in combination with radial land, relief negative rake angle and constant taper. The peripheral blade relief area has two functions first to increase the peripheral mass in order to increase the fracture resistance and secondly to reduce the amount of area of the radial lands that come in contact with the canal wall in order to reduce the frictional resistance.
This in vitro study was conducted using mandibular first premolar because they are extracted commonly for orthodontic treatment. Moreover, although their canals are often straight, they are often flattened mesiodistally, an important anatomic variation during treatment. The factor that was not taken into the consideration was the apical diameter of the roots. The reason for not calculating this area was based on the results obtained by Al Omari and Dummer, McKendry and Fairebourn et al., who determined no significant correlation between the apical size and amount of debris extruded. ,, Fairbourn et al., further determined that the inclusion of parameter such as canal angle canal size, foramen area and morphology may not have been necessary since these covariates had no significant influence on the quantity of debris extruded. 
The results of the present in vitro study indicated that weight of debris extruded were lesser in Protaper retreatment and K3 file technique as compared to H-file with solvent. The extrusion produced by all the three techniques was expected because it is considered a problem of all canal instrumentation techniques. 
The finding of this study partially coincides with the work done by Uezu MK et al.  In their study they compared the efficacy of ProTaper retreatment files and ProTaper Universal in the retreatment of mandibular premolars. They conclude that ProTaper Universal files were faster than the ProTaper retreatment files to perform the gutta-percha removal, but no significant difference was found between the files regarding the amount of apical extrusion.
The finding of this study is in accordance with the study performed by Xiangya Huang et al., who conclude that the Protaper retreatment files extruded less amount of debris as compared to H-files and K-flex file. 
| Conclusion|| |
Within the parameters of this in vitro study it was concluded that:
- All the three instrumentation techniques for gutta-percha removal produced apically extruded debris and irritant.
- A greater amount of debris was forced periapically when H-file was used as compared to protaper retreatment files, or K3 file with the quantity of debris extrusion being statistically significant. There was no significant difference among two rotary instruments.
- The best way to minimize the extension of debris is by adapting crowns down technique consequently use of rotary technique (Protaper retreatment file, K3 file) to minimize the extrusion of debris is recommended.
| References|| |
|1.||Abou Rass M. Evaluation and clinical management of previous endodontic therapy. J Prosth Dent 1982;47:528-34. |
|2.||Siqueira J Jr. Etiology of root canal treatment failure: why well treated teeth can fail. Int Endo J 2001;34:1-11. |
|3.||Friedman S, Stabholz A. Endodontic retreatment - case selection and technique, Part 1 Criterion for case selection. J Endod 1986;12:28-33. |
|4.||Stabholz A, Friedman S. Endodontic retreatment - case selection and technique Part 2 treatment planning for retreatment. J Endod 1988;14:565-9. |
|5.||Mandel E, Friedman S. Endodontic retreatment: A rational approach to root canal reinstrumentation. J Endod 1992;18:565-9. |
|6.||Teplitsky P, Rayner D, Chin I, Markoesky R. Gutta-percha removal utilizing GPX Instrumentation. J Can Dent Asso 1992;58:53-8. |
|7.||Imura N, Zuolo M, Ferreira M, Novo N. Effectiveness of the canal finder and hand instrumentation in removal of gutta-percha root fillings during endodontic retreatment. Int Endo J 1996;29:382-6. |
|8.||Hulsmann H, Stotz S. Efficacy, cleaning ability and safety of different devices for gutta-percha removal in root canal retreatment. Int Endo J 1997;30:227-33. |
|9.||Alomari MA, Dummer PM, Canal blockage and debris extrusion with eight preparation technique. J Endod 1995;21:154-8. |
|10.||Tanalp J, Kaptan F, Sert S, Kayahan B, Baving G. Qualitative evaluation of the amount of apically extruded debris using different rotary instrumentation system. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:252-9. |
|11.||Hinrichs RE, Walker WA, Schindler WG. Comparison of amount of apically extruded debris using handpiece driven nickel titanium instrument system. J Endod 1998;24:102-6. |
|12.||Walia H, Willium A, Brantley, Gerstein H. An initial investigation of the bending and torsional properties of Nitinol root canal files. J Endod 1998;14:346-51. |
|13.||Bramante C, Betti L. Efficacy of Quantec rotary instrument for gutta-percha removal. Int Endo J 2000;33:463-7. |
|14.||Imura N, Kato A, Hata G, Uemura M, Toda T, Weine F. A comparison of the relative efficacy of four hand and rotary instrumentation techniques during endodontic retreatment. Int Endo J 2000;33:361-6. |
|15.||Imura N, Pinheiro EI, Gomes BP, Zaia AA, Ferraz CC, Souza-Filhof J. The outcome of endodontic treatment: retrospective study of 2000 cases performed by a specialist. J Endod 2007;33:1278-82. |
|16.||Gorni FG, Galliani MM. The outcome of endodontic retreatment 2 years follow up. J Endod 2004;30:1-4. |
|17.||Forzanch M, Abitol S, Friedman S. Treatment outcome in endodontics the Toronto study Phase I and II orthograde retreatment. J Endod 2004;30:627-33. |
|18.||Ruddle C. Non-surgical retreatment. J Endod 2004;30:827-45. |
|19.||Bergenholtz G, Lekholm U, Milthon R, Heden G, Engstrom B. Retreatment of endodontic fillings. Scand J Dent Res 1979;87:217-24. |
|20.||Sjogren U, Hagglund B, Sundqvist G, Wing K. Factors affecting the long term result of endodontic treatment. J Endod 1990;16:498-504. |
|21.||Ladley RW, Campbell AD, Hicks ML, Shou Hual. Effectiveness of Halothane used with ultrasonic or hand instrumentation to remove gutta-percha from the root canal. J Endod 1991;17:221-4. |
|22.||Seltzer S, Naidorf I. Flare up in endodontics etiological factors. J Endod 1985;11:472-7. |
|23.||Naidorf IJ. Endodontic flare ups - bacteriological and immunological mechanism. J Endod 1985;11:462-4. |
|24.||Matniesen A. Preservation and demonstration of mast cell in human apical granulomas and radicular cysts. Scan J Dent Res 1973;81:218-29. |
|25.||Perruni N, Fonzi L. Mast cell in human periapical lesion ultrastructural aspect and possible physiopathological implication. J Endod 1985;11:197-202. |
|26.||Ledesma Montes C, Garces Ortiz M, Rosales Garcia G, Hermandez Guerrero JC. Importance of mast cell in human periapical inflammatory lesion. J Endod 2004;30:855-9. |
|27.||De Oliveira Rodini C, Batista AC, Cara US. Comparative immunohistochemical study of the presence of mast cells in apical granuloma and periapical cyst possible role of mast cell in the course of human periapical lesion. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;97:59-63. |
|28.||Torabineiad M, Eby WC, Naidorf IJ. Inflammatory and immunological aspect of the pathogenesis of human periapical lesions. J Endod 1985;11:479-88. |
|29.||Seltzer S, Sollanoff W, Sinai I, Goldenserg A, Bender IB. Biological aspects of endodontics part III-Periapical tissue reaction to root canal instrumentation. Oral Surg 1968;26:534-46,694,705. |
|30.||Torneck CD, Smith JS, Grindall P. Biologic effect of endodontic procedures on developing incisor teeth III effect of debridement and disinfection procedures in the treatment of experimentally induced pulp and periapical diseases. Oral Surg Oral Med Oral Pathol 1973;35:532-40. |
|31.||Debelian GJ, Olsen I, Tronstad L. Bacteraemia in conjunction with endodontic therapy. Endod Dent Traumatol 1994;11:142-9. |
|32.||Savarrio L, Mackenzie D, Riggio M, Saunders WP, Bagg J. Detection of bacteremias during non surgical root canal treatment. J Dent 2005;33:293-302. |
|33.||McKendry DJ. Comparison of balanced forces, endosonic and step-back filling instrumentation techniques: Quantification of extruded apical debris. J Endod 1990;16:24-7. |
|34.||Fairbourn OR, McWalter GM, Montgomery S. The effect of four preparation techniques on the amount of apically extruded debris. J Endod 1987;13:102-8. |
|35.||Vende Visse JE, Brilliant JD. The effect of irrigation on the production of extruded materiel at the root apex during instrumentation. J Endod 1975;1:243-6. |
|36.||Uezu MK, Britto ML, Nabeshima CK, Pallotta RC. Comparison of debris extruded apically and working time used by protaper universal rotary and protaper retreatment system during gutta-percha removal. J Appl Oral Sci 2010;18:542-5. |
|37.||Huang X, Ling J, Wei X and Gu L. Quantitative evaluation of debris extruded apically by using protaper universal Tulsa rotary system in endodontic retreatment. J Endod 2007;33:1102-5. |
[Table 1], [Table 2], [Table 3], [Table 4]