J Clin Exp Dent. 2016;8(1):e60-3.

Importance of rotary systems in dental care by undergraduate students

Journal section: Operative Dentistry and Endodontics doi:10.4317/jced.52663

Publication Types: Research http://dx.doi.org/10.4317/jced.52663

Importance of rotary systems in dental care by undergraduate students

in patients of a public health service of Belo Horizonte

Fernanda-Alcaraz-Orta Bruno 1, Eduardo Nunes 2, Martinho-Campolina-Rebello Horta 2, Ana-Maria-Abras

da Fonseca 3, Frank-Ferreira Silveira 2

1
DDS, MS, Graduate student, Departament of Dentistry, Pontifícia Universidade Católica de Minas Gerais, Belo Horizonte, Brasil
2
DDS, MS, PhD, Professor, Departament of Dentistry, Pontifícia Universidade Católica de Minas Gerais, Belo Horizonte, Brasil
3
DDS, MS, Professor, Departament of Dentistry, Pontifícia Universidade Católica de Minas Gerais, Belo Horizonte, Brasil

Correspondence:
Rua Dom Padre Nóbrega 118 / 504
Belo Horizonte, MG, Brasil
Zip code: 30730230 Bruno FAO, Nunes E, Horta MCR, da Fonseca AMA, Silveira FF. ��� Im-
[email protected] portance of rotary systems in dental care by undergraduate students in
patients of a public health service of Belo Horizonte. J Clin Exp Dent.
2016;8(1):e60-3.
http://www.medicinaoral.com/odo/volumenes/v8i1/jcedv8i1p60.pdf
Received: 09/07/2015
Accepted: 04/11/2015
Article Number: 52663 http://www.medicinaoral.com/odo/indice.htm
© Medicina Oral S. L. C.I.F. B 96689336 - eISSN: 1989-5488
eMail: [email protected]
Indexed in:
Pubmed
Pubmed Central® (PMC)
Scopus
DOI® System

Abstract
Background: The aim of this study was to evaluate the fracture rates of ProTaper rotary files used in the endodon-
tics extension clinic of the Undergraduate Dentistry Course of the Pontifical Catholic University of Minas Gerais
during the prior eight years.
Material and Methods: Control record data regarding file usage by students were collected and analyzed by semes-
ter. For each period, the total number of patient consultations, the frequency of file use, the occurrence of fractures
and the file numbers for which fractures occurred were noted. Descriptive statistics, including frequency of file
fractures were calculated for all file types. The chi-square test was used to evaluate differences in the frequency of
file fractures between all file types.
Results: The study results revealed that during the examined period, there were 1006 consultations and 7993 uses
of files. A total of 30 file fractures were recorded throughout this period; thus, fractures occurred in 0.37% of total
file uses and 2.98% of all consultations. The most frequently used files were S1, S2 and F1, and these files also
accounted for the most fractures. However, no differences in the frequency of file fractures were observed between
the file types (p>0.05).
Conclusions: The low fracture rates observed in this study indicate that the examined instruments can be used to
safely provide dental care to patients.

Key words: Dental instruments, endodontics, public health.

Introduction res seek to remove organic and inorganic material from

The effective cleaning and shaping of the root canal sys- within the root canal to reduce the number of microorga-
tem is the most important factor affecting the success of nisms in the canal, neutralize endotoxins within the den-
endodontic therapy (1). Cleaning and shaping procedu- tin, and prepare the root canal for proper closure (2).

e60
J Clin Exp Dent. 2016;8(1):e60-3. Importance of rotary systems in dental care by undergraduate students

The preparation of straight root canals is relatively un- The increasingly frequent use of rotary systems in en-
complicated; however, even for seasoned professionals, dodontic treatment underscores the need to provide stu-
atresic root canals or root canals with severe curvatures dents with adequate clinical training with these systems.
present difficulties related to the potential for iatrogenic The present study sought to evaluate the fracture rates of
defects. The characteristic stiffness of stainless steel files the ProTaper rotary files used by undergraduate dental
hinders the use of these files in the cleaning and prepa- students over an eight-year period.
ration of root canals with severe curvatures (3). Despite
the introduction of flexible nickel-titanium (NiTi) ins- Material and Methods
truments, the preparation of severely curved root canals This study was approved by the Pontifical Catho-
remains challenging (4). lic University of Minas Gerais (PUC Minas) Re-
The development and utilization of NiTi files has led to search Ethics Committee (protocol number CAAE –
great advances in endodontic treatment; relative to stain- 10732812.1.0000.5137). The present study was based on
less steel instruments, NiTi instruments can produce data regarding treatments performed using the ProTaper
not only higher treatment quality and greater treatment system (Maillefer, Baillaguess, Switzerland) during the
speed but also fewer failures (5). NiTi instruments are prior eight years in the endodontics extension clinic of
sturdy, have good biocompatibility, and exhibit the no- the Undergraduate Dentistry Course PUC Minas. In par-
table characteristic of superelasticity, which refers to the ticular, data collected in the file usage control records,
ability to recover to an initial shape simply through the organized by student and semester, were utilized in this
removal of stress, with no heating required (6,7). investigation. The endodontics clinical extension is an
In clinical practice, the main disadvantage of NiTi ins- optional component of the dentistry undergraduate pro-
truments is the possibility of unexpected instrument gram at PUC Minas; during this extension, students are
fracture within the root canal, an event that compromi- supervised by teachers who have experience with auto-
ses treatment success. These fractures can occur due to mated endodontics. The protocol adopted for this study
either torsion or flexural fatigue (8). When an instrument advocates the disposal of instruments after five uses.
is held within the root canal, static torsion occurs if one For each semester of the examined period, data relating
end of the instrument twists while the other end conti- to total consultations, the number of times each ProTa-
nues the rotary movement of the motor. Dynamic tor- per file was used, the occurrence of fractures, and which
sional fracture results from the friction produced by the files in the recommended sequence fractured were co-
shear strength of dentin in response to a file. llected and assessed.
In the context of endodontic treatment, during automated A total fracture index relative to total consultations and
instrumentation in curved canals, rotation causes files to the number of uses of files was established. In addition,
be subjected to tension and compression forces concentra- this fracture index was stratified by file type in the file
ted on the point of maximum curvature of the instrument sequence advocated in the protocol adopted in the exa-
within the root canal (1,9). These forces can lead to instru- mined clinical extension.
ment fracture due to flexural fatigue; in particular, the ins- Descriptive statistics, including frequency of file fractu-
trument may be subjected to cyclic deformation that pla- res were calculated for all file types. The chi-square test
ces stress on the alloy, leading to the nucleation of cracks was used to evaluate differences in the frequency of file
that ultimately expand to produce fractures. It is therefore fractures between all file types. The level of significance
important to assess the internal geometry of curved root was set at 5%. The analyses were performed using Gra-
canals prior to treatment. Relevant measurements that are phPad Prism Software (GraphPad Software, San Diego,
generally obtained include a canal’s angle and radius of California, USA).
curvature. These parameters are extremely important for
evaluating root canal instrumentation (10,11). Results
The possibility of intracanal instrument fracture is the No differences in the frequency of file fractures were
underlying motivation for studies that attempt to identi- observed between the file types (p>0.05). The data ob-
fy factors that may increase the risk of instrument failure tained in this study are presented in table 1. These data
and establish parameters for the safe and efficient use indicate that during the examined period, there were
of NiTi files in automated systems. These approaches 1006 consultations and 7993 uses of files. A total of 30
reflect the fact that the best treatment for intracanal file file fractures were recorded throughout this period; thus,
fracture is to prevent such fractures from occurring. fractures occurred in 0.37% of total file uses and 2.98%
During endodontic treatment using automated NiTi file of all consultations.
systems, the risk of intracanal file fracture is affected by
multiple factors, such as the anatomy of the root canal (12),
the angle of curvature of the canal, rotation speeds and tor- Discussion
que (10,12), and how frequently files are reused (13). The appropriate cleaning and preparation of the root ca-
nal system is an essential step in successful endodontic

e61
J Clin Exp Dent. 2016;8(1):e60-3. Importance of rotary systems in dental care by undergraduate students

Table 1. Comparison of file fractures between all file types.

SX S1 S2 F1 F2 F3 p value*
Fracture - 974 1886 1888 1893 969 353 >0.05
(99.90%) (99.37%) (99.48%) (99.74%) (99.79%) (100%)
Fracture + 1 12 (0.63%) 10 5 2 0
(0.10%) (0.52%) (0.26%) (0.21%) (0%)
Total 975 1898 1898 1898 971 353
(100%) (100%) (100%) (100%) (100%) (100%)
* p value obtained by the chi-square test.

treatment. Rotary NiTi files are currently being utilized large diameter; this finding corroborated concerns that
in endodontic practice; relative to stainless steel files, F3 files are relatively susceptible to cyclic fatigue fractu-
NiTi files provide quality, efficiency, comfort, and safety re (18). In contrast, consultations in the extension clinic
advantages for both dentists and patients. However, the of the current study prioritized the treatment of molars;
occurrence of unexpected instrument fracture within the thus, the F3 file was not the most frequently used type
root canal is a commonly reported problem. This issue of file. This phenomenon may explain why a higher in-
underscores the importance of not only studies addres- cidence of F3 fractures was not observed.
sing the use of rotary systems but also the training of Given the number of consultations considered in this
professionals and undergraduate students. investigation and the low observed incidence of instru-
Prior research has indicated that the technique and skill ment fracture, the results of this study should encourage
of the operator of an automated system are correlated the academic community to review extremely well-esta-
with the incidence of unexpected intracanal instrument blished paradigms in endodontic practice.
fracture (7). However, a study has revealed that inexpe- The Department of Dentistry of PUC Minas seeks to
rienced dental students can use rotary systems to ade- provide undergraduate students with appropriate cli-
quately prepare curved canals while preserving tooth nical training in rotary NiTi systems that use ProTaper
structure; in fact, these students committed few procedu- files. In accordance with this objective, undergraduate
ral errors and completed procedures more quickly when students admitted to the endodontics extension clinic re-
using rotary systems than when using hand instruments ceive specific instructions and basic theoretical preclini-
(14). These findings have been corroborated by resear- cal training; this preparation has proven to be adequate
chers who observed the occurrences of fractures and to allow these students to begin using rotary systems in
instrumentation times during the preparation of curved endodontic treatment.
molar canals by students without clinical endodontic ex- All treatments performed in the extension clinic are con-
perience and concluded that the ProTaper rotary system trolled by the completion of worksheets that indicate the
can be utilized appropriately by students without clinical identities of the student and the responsible teacher, the
experience if these students have received basic training treatment period, the date of consultation, the patient’s
with the equipment (15). record, the treated tooth, the number of uses of the Pro-
A study that evaluated students’ perceptions regarding Taper files, and the occurrence of instrument fracture.
endodontic dental treatment with rotary NiTi instruments Due to the significant number of patient consultations
and with manual stainless steel instruments indicated that during the period examined in this study and the low
training in the use of automated systems should be inclu- number of file fractures during this period, a low overall
ded in the undergraduate dentistry curriculum to improve incidence of instrument fractures (2.98%) was observed.
students’ levels of clinical experience (3). Another inves- An extremely important consideration is that each file
tigation has described cases in which training with NiTi was used five times (for five teeth); as a result, the small
rotary instruments was successfully introduced into an number of fractures was a relevant finding.
undergraduate program in endodontics (16). Regarding the root canal treatment performed in a con-
A recent study that sought to identify factors affecting ventional manner, the rotary system has a gain in pro-
the fracture of ProTaper files reused in clinical treatment ductivity and quality, especially with teeth anatomical
with a rotary system indicated that fractures occurred in complexity. Therefore, professionals working in the
2.6% of treated teeth, which corresponded to 1.1% of public health service should be encouraged to use this
the number of treated canals (17). Although these resear- technology, with significant reduction in the time taken
chers concluded that instrument fracture is a multifacto- for completion of the treatment, which can reverse in a
rial process, they found that the type of file that is most greater number of people served.
frequently fractured is F3 because of this file’s relatively

e62
J Clin Exp Dent. 2016;8(1):e60-3. Importance of rotary systems in dental care by undergraduate students

Conclusions Acknowledgements
Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (Ca-
The results of this study demonstrate that ProTaper files
pes), Brazil; Conselho Nacional de Desenvolvimento Científico e Tec-
exhibited a low fracture rate and indicate that the mate- nológico (CNPq), Brazil; Fundação de Amparo à Pesquisa do Estado
rials and practices used in the endodontics extension cli- de Minas Gerais (FAPEMIG), Brazil.
nic of the Undergraduate Dentistry Course of PUC Mi-
nas are efficient for providing safe and effective care. Conflict of Interest
The authors deny any conflicts of interest.

References
1. Kim HC, Kwak SW, Cheung GS, Ko DH, Chung SM, Lee W. Cy-
clic fatigue and torsional resistance of two new nickel-titanium ins-
truments used in reciprocation motion: reciproc versus WaveOne. J
Endod. 2012;38:541-4.
2. Averbach RE, Kleier DJ. Clinical update on root canal disinfection.
Compend Contin Educ Dent. 2006;27:286-9.
3. Martins RC, Seijo MO, Ferreira EF, Paiva SM, Ribeiro Sobrinho
AP. Dental students’ perceptions about the endodontic treatments per-
formed using NiTi rotary instruments and hand stainless steel files.
Braz Dent J. 2012;23:729-36.
4. Bürklein S, Schäfer E. Critical evaluation of root canal transporta-
tion by instrumentation. Endod Topics. 2013;29:110-24.
5. Alencar AH, Dummer PM, Oliveira HC, Pécora JD, Estrela C. Pro-
cedural errors during root canal preparation using rotary NiTi instru-
ments detected by periapical radiography and cone beam computed
tomography. Braz Dent J. 2010;21:543-9.
6. Thompson SA. An overview of nickel–titanium alloys used in den-
tistry. Int Endod J. 2000;33:297-310.
7. Vieira EP, França EC, Martins RC, Buono VT, Bahia MG. Influence
of multiple clinical use on fatigue resistance of ProTaper rotary nickel-
titanium instruments. Int Endod J. 2008;41:163-72.
8. Sattapan B, Palamara JEA, Messer HH. Torque During Canal Instru-
mentation Using Rotary Nickel-Titanium Files. J Endod. 2000;26:156-
60.
9. Li UM, Lee BS, Shih CT, Lan WH, Lin CP. Cyclic fadigue of endo-
dontic nickel titanium rotatory instruments: static and dynamic tests. J
Endod. 2002;28:448-51.
10. Pruett J, Clement D, Carnes DJ. Cyclic fatigue testing of nickeltita-
nium endodontic instruments. J Endod. 1997;23:77-85.
11. Bahia MG, Buono VT. Decrease in fatigue resistance of nickel-ti-
tanium rotary instruments after clinical use in curved root canals. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod. 2005;100:249-55.
12. Gao MJ, Zhou J, Jiang XZ, Liang L. Evaluation of the fracture of
nickel-titanium rotary Protaper during root canal preparation. Shanghai
Kou Qiang Yi Xue. 2012; 21:294-7.
13. Pessoa OF, Silva JM, Gavini G. Cyclic fatigue resistance of rotary
NiTi instruments after simulated clinical use in curved root canals.
Braz Dent J. 2013;24:117-20.
14. Peru M, Peru C, Mannocci F, Sherriff M, Buchanan LS, Pitt Ford
TR. Hand and nickel-titanium root canal instrumentation performed
by dental students: a micro-computed tomographic study. Eur J Dent
Educ. 2006;10:52-9.
15. Ünal GÇ, Maden M, Orhan EO, Sarıtekin E, Teke A. Root canal
shaping using rotary nickel-titanium files in preclinical dental educa-
tion in Turkey. J Dent Educat. 2012;76:509-13.
16. Shen Y, Coil JM, Haapasalo M. Defects in Nickel-Titanium Instru-
ments after Clinical Use. Part 3: A 4-Year Retrospective Study from an
Undergraduate Clinic. J Endod. 2009;35:193-6.
17. Wu J, Lei G, Yan M, Yu Y, Yu J, Zhang G. Instrument separation
analysis of multi-used ProTaper Universal rotary system during root
canal therapy. J Endod. 2011;37:758-63.
18. Ounsi HF, Salameh Z, Al-Shalan T, Ferrari M, Grandini S, Pashley
DH, et al. Effect of clinical use on the cyclic fatigue resistance of Pro-
Taper nickeltitanium rotary instruments. J Endod. 2007;33:737-41.

e63