0099-2399/95/2104-0173503_00/0
JOURNALOFENDODONTICS
Copyright © 1995 by The American Association of Endodontists
A Comparison of Canal Preparation with Nickel-
Titanium and Stainless Steel Instruments
Peter T. Esposito, DMD, MS and Charles J. Cunningham, DDS
Maintaining the original canal path during instru-
mentation is a challenge in narrow curved canals.
This study compared the maintenance of the orig-
inal canal path of curved root canals during instru-
mentation with nickel-titanium (Mac) hand files,
nickel-titanium engine-driven files, and stainless
steel (K-Flex) files. Canal path maintenance was
determined by superimposing instrumentation ra-
diographs over an initial file radiograph and exam-
ining for discrepancies. Nickel-titanium hand and
engine-driven instruments maintained the original
canal path in all cases. The incidence of deviation
from the original canal path during instrumentation
with stainless steel files increased with file size.
The difference between nickel-titanium groups and
stainless steel became statistically significant with
instruments larger than size 30. In this study, nick-
el-titanium files were more effective in maintaining
the original canal path of curved root canals when
the apical preparation was enlarged beyond size
30.
Cleaning and shaping of the root canal space is a primary objective
of root canal therapy (1, 2). This has been traditionally accom-
plished with hand files, reamers, and broaches. Schilder (1) has
stated that the objective of making the final root canal preparation
conform to the general shape and direction of the original canal
may be the most neglected phase of endodontic treatment and that
the greatest problems lie in attempting to maintain the canal
curvatures in the apical regions. Weine (3) demonstrated that every
file, whether precurved or not, tended to straighten a curved canal.
Weine (3) concluded that despite instrument selection or technique
used, prepared canals showed undesirable characteristics that re-
flected the inability to maintain the original direction and shape of
the canal. A multitude of techniques for hand instrumentation of
curved canals have been advocated in an attempt to address these
problems (3-6).
The canal preparation procedure can be quite time consuming
and tedious. Factors that can make instrumentation more difficult
include tooth length, degree of canal curvature, and canal diameter.
In an attempt to decrease time required, simplify canal preparation,
173
Printed in U.S.A.
VOL. 21, No. 4, APRIL1995
and reduce operator fatigue, engine-driven and automated devices
have been developed (7). An early flat plane reciprocating hand-
piece was the Giromatic. This device delivered a quarter turn
motion 3000 times/min. A fundamental problem with powered
instruments was that the cutting blades were not specifically de-
signed for this purpose (8). Frank (9) evaluated the Giromatic and
found marly claims of the manufacturer and distributor to be
exaggerated.
The Dynatrak file developed by McSpadden was the first in-
strument designed for use in the reciprocating handpiece. This
variation of the Unifile had a noncutting pilot tip and an altered
helical pitch angle to prevent the instrument from binding in use
(8). Hill and del Rio (10) found no significant difference between
canal wall planing ability of K files, K-Flex files, and Dynatrak
files.
An engine-driven rotary instrumentation system capable of pre-
dictably negotiating curved canals to their apex has not been
described in the literature previously. The problems encountered
when using rotary instruments in curved canals are identical to
those associated with the use of hand, sonic, and ultrasonic instru-
ments in curved canals. These include ledging into the canal wall
dentin, stripping of the lateral canal wall, perforation of the root
into periodontal ligament, zipping of the apical foramen, and
instrument separation (4). These complications have been shown to
be more common when using engine-driven devices than with
hand instruments (11, 12). For these reasons, the use of rotary
instruments to the apical foramen of curved canals has been con-
traindicated.
Recent advances in technology have permitted the manufacture
of endodontic files from Nitinol, a nickel-titanium alloy with a
very low modulus of elasticity. The #15 Nitinol files have been
shown to have two to three times more elastic flexibility in bending
and torsion, as well as superior resistance to torsional fracture,
when compared with size #15 stainless steel files manufactured by
the same process (13). The flexibility of endodontic files is an
important characteristic as the more flexible files tend to negotiate
curved canals better and reduce the tendency of straightening,
zipping, ledging, or perforation of curved canals (2, 14).
NT nitinol files (NT Co., Chattanooga, TN) have a unique
design that differs from conventional files. According to the man-
ufacturer, the design and flexibility of these files result in balanced
cutting forces along the full working surface of the instruments.
Hand and engine-driven instruments are available. The purpose of
this study was to compare the ability of K-Flex stainless stee/files,
174 Esposito and Cunningham Journal of Endodontics

NT hand (Mac) files, and NT rotary (nickel-titanium (NiTi)) files TABLE 1. Response counts
to maintain the original root canal pathway during instrumentation.
Cases Mac Ni-Ti SS X2 p
15/25 + 15 15 14 2.24 0.325
- 0 0 1
MATERIALS AND METHODS 15/30 + 15 15 13 4.58 0.101
- 0 0 2
Forty-five extracted human teeth with mature apicies were se- 15/35 + 15 15 11 9,59 0,008*
lected for this study. Each tooth had a moderate to severe curvature - 0 0 4
between 20 and 45 degrees using the Schneider (15) method. One 15/40 + 15 15 10 12.29 0.002*
root was used from each tooth. Multirooted teeth had additional - 0 0 5
roots resected. Teeth were accessed and patency of the canal 15/45 + 15 15 8 18.17 0.001"
- 0 0 7
verified with a #10 pathfinder file. Working length 0.5 mm short
of the apical foramen was established. Teeth were mounted so * Statistically significant.

repeated radiographs could be exposed in a reproducible angula-

tion with the root canal curvature perpendicular to the X-ray beam
(16). The teeth were subdivided based on curvature. Fifteen teeth
were randomly assigned to each of three experimental groups.
Group 1 was instrumented using K-Flex files. Group 2 was
instrumented using NT (Mac) hand files. Group 3 was instru-
mented with NT (Ni-Ti) rotary files using the Ni-Ti-matic engine-
driven handpiece. All groups were instrumented to an apical prep-
aration of size 45 without additional coronal flaring. Radiographs
were exposed with a size 15 instrument inserted to working length
and subsequent radiographs were exposed with size 25, 30, 35, 40,
and 45 files in place. The initial radiograph for each specimen was
superimposed over each sequential radiograph.
These images were digitized for viewing on a computer moni-
tor. NIH image, a public domain image processing and analysis
program for the Macintosh computer, is capable of magnifying and
enhancing these images. Blind evaluation of these superimposed
radiographs by two examiners was used to note deviation from the
original canal path. Complete superimposition of the larger file
such that the #15 was not clearly identifiable was graded (+),
indicating the original canal path was maintained.
The presence of two files in the apical or middle third of the root
indicated stripping of the lateral root surface or apical zipping and
was graded ( - ) . When intermediate sized files (#25, 30, 35) could
not be advanced to the full working length without exceeding the
recommended apical pressure for the Ni-Ti-matic rotary system,
but maintained the original canal path to the depth of penetration,
the grade (+) was used. The data generated were tabulated and
chi-square analysis was used to evaluate significance.
RESULTS
In comparing the ability of stainless steel, nickel-titanium hand
(Mac) files, and nickel-titaniumrotary (Ni-Ti) files to maintain the
original path of a root canal during instrumentation, the following
was observed:
1. Stainless steel instruments maintained the original canal path
in 14 of 15 cases at size 25 file and in 13 of 15 at size 30 files.
Nickel-titanium hand (Mac) files and rotary (Ni-Ti) files
maintained the original path in 15 of 15 cases for these sizes.
The differences between the stainless steel files and the Mac
and Ni-Ti groups were not statistically significant (Table 1).
2. Stainless steel instruments maintained the original canal path
in 11 of 15 cases at size 35 files, in 10 of 15 cases at size 40
files, and in 8 of 15 cases at size 45 files. Nickel-titanium
hand (Mac) files and rotary (Ni-Ti) files maintained the
original path in 15 of 15 cases for these sizes. The differences
TABLE 2. Angle by group*
Mean SD
Mac 27.86 7.14
Ni-Ti 28.20 6.86
SS 28,20 6.21
*F = 0.01; p = 0.99.
between the stainless steel files and the Mac and Ni-Ti
groups were statistically significant (Table 1).
3. There was no statistically significant difference among the
three experimental groups with regard to root curvature when
the mean degree of curvature and standard deviation were
examined (Table 2).
4. One nickel-titanium rotary (Ni-Ti) instrument separated dur-
ing this study. The apical 1.5 mm of a size 25 Ni-Ti file
separated upon activation of the handpiece following radio-
graphing this file at working length. This single incident of
instrument separation was not statistically significant when
compared with the other experimental groups.
DISCUSSION
Current endodontic instrumentation techniques recognize the
inherent problems associated with cleaning and shaping curved
root canals. In an effort to minimize procedural complications, the
apical preparation of these canals is frequently restricted to file
sizes in the 25 to 30 range. E1 Deeb et al. (17) demonstrated that
regardless of the type of stainless steel file tested, the incidence of
canal zipping increased significantly as file size increased. Data
from this study confirm those observations.
The advent of strong yet flexible nickel-titanium endodontic
instruments may remove some of the traditional constraints im-
posed by the more rigid stainless steel instruments. This study
demonstrates that both hand and rotary nickel-titaniuminstruments
can predictably enlarge curved canals, while maintaining the orig-
inal path, to sizes not routinely attainable with stainless steel
instruments (Figs. 1 and 2).
The current design of the Ni-Ti rotary instruments may require
that apical preparations be enlarged to a minimum of size 40. In
this study, instruments smaller than size 40 frequently could not be
inserted to working length at the recommended apical pressures
(Figs. 3 and 4). Exceeding the recommended apical pressures with
the Ni-Ti-matic handpiece may increase the risk of instrument
separation. The inability to reach working length may be attribut-
able to the less aggressive flute design found in the Ni-Ti rotary
instruments up to size 35. In all cases, the more aggressive size 40
Vol. 21, No. 4, April 1995
FIG 1. Size 45 M a c file at working length.
FIG 2. Size 45 rotary Ni-Ti file at working length.
F~G 3. Size 30 rotary Ni-Ti file falling t o reach working length.
instruments were successful in reaching the full working length
while maintaining the original canal path (Fig. 5). This progression
of inserting a larger instrument to working length immediately
following a smaller instruments failure to reach working length is
not advocated by any traditional instrumentation technique.
It appears that nickel-titanium instruments flex to follow the
path of least resistance as they progress apically down the root
canal. The original canal direction may act as a pilot pathway for
larger instruments. This flexibility greatly reduces the degree of
anticurvature filing and flaring that can be accomplished with these
instruments. However, if nickel-titanium instruments are shown to
Ni-Ti Canal Preparation 175
FIG 4. Size 35 rotary Ni-Ti file falling to reach w o r k i n g length.
FIG 5. Size 40 rotary Ni-Ti file reaching w o r k i n g length.
enlarge circumferentially along the central axis of the canal, the
need for anticurvature filing may be reduced. The prebending
required for stainless steel files is contraindicated with nickel-
titanium instruments.
CONCLUSIONS
Under the conditions of this study, nickel-titanium hand (Mac)
and rotary (Ni-Ti) files were:
1. Significantly more effective than stainless steel (K-Flex)
files in maintaining the original path of curved root canals
when the apical preparation was enlarged to size 35, 40, or
45.
2. Nickel-titanium instruments allow larger apical preparations
of curved root canals while maintaining the original canal
path compared with stainless steel (K-Flex) files.
This research was supported in part by an Endodontic Graduate Student
Award from the Research and Education Foundation of the American Asso-
ciation of Endodontists. The opinions, assertions, materials and methodolo-
gies herein are private ones of the authors and are not to be construed as
official or reflecting the views of the American Association of Endodontists or
the Research and Education Foundation of the American Association of
Endodontists.
Dr. Esposito is an endodontic postgraduate student and Dr. Cunningham
is professor and director, Postgraduate Endodontic Program, University of
Florida College of Dentistry, Gainesville, FL Address requests for reprints to
Dr. Charles J. Cunningham, Department of Endodontics, P.O. Box 100436,
University of Florida, Gainesville, FL 32610-0436.
176 Esposito and Cunningham Journal of Endodontics

References
1. Schilder H. Cleaning and shaping the root canal. Dent Clin North Am
1974; 18:269 -96.
2. Weine F. Endodontic therapy. St. Louis: CV Mosby, 1989:277.
3. Weine F, Kelly R, Lio P. The effect of preparation procedures on the
original canal shape and on apical foramen shape. J Endodon 1975;1:255-62.
4. Abou-Rass M, Frank A, Glick D. The anticurvature filing method to
prepare the curved root canal. J Am Dent Assoc 1980;101:792-4.
5. Goreig A, Michelich R, Schultz H. Instrumentation of root canals in
molar using the step-down technique. J Endodon 1982;8:550-4.
6. Roane J, Sabala C, Duncanson M. The "balanced force" concept for
instrumentation of curved canals. J Endodon 1985;11:203-11.
7. Tronstad L, Barnett F, Schwartzben L, Frasca P. Effectiveness and
safety of a sonic vibratory endodontic instrument. Endod Dent Traumatol
1985;1:69-76.
8. Ingle J. Endodontics. Philadelphia: Lea & Febiger, 1985:176-8.
9. Frank A. An evaluation of the Giromatic endodontic handpiece. Oral
Surg Oral Meal Oral Pathol 1967;24:419-21.
10. Hill R, del Rio C. A histological comparison of the canal wall planing
ability of two new endodontic files. J Endodon 1976;2:298-303.
11. Weine F, Kelly R, Bray K. Effect of preparation with endodontic hand-
pieces on original canal shape. J Endodon 1976;2:298-303.
12. O'Connell D, Brayton S. Evaluation of root canal preparations with two
automatic endodontic handpieces. Oral Surg Oral Med Oral Pathol 1975;39:
298-303.
13. Walia H, Brentley W, Gerstein H. An initial investigation of the bending
and torsional properties of Nitinol root canal files. J Endodon 1988;14:346-50.
14. Mullaney TP. Instrumentation of finely curved canals. Dent Clin North
Am 1979;23:575-92.
15. Schneider SW. A comparison of canal preparations in straight and
curved root canals. Oral Surg 1971 ;32:271-5.
16. Blitzkow SG, Batista A, Loureiro de Melo L. The radiographic platform:
a new method to evaluate root canal preparation in vitro. J Endodon 1991;
17:570-2.
17. EIDeeb M, Boraas J. The effect of different files on the preparation
shape of severely curved canals, lnt Endod J 1985;18:1-7.

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