20.Vamsee Krishna N.cdr INTRODUCTION During biomechanical preparation, pulp tissue fragments, dentinal llings, necrotic tissue, microorganisms, and intracanal irrigants may extruded from the apical foramen into the periradicular region. The extruded material causes 1periapical inammation and post operative are–ups . All preparation techniques are associated with apical extrusion of some amount of debris, which depends on various factors, including anatomy of the apical area, instrument design and 2,3 4the instrumentation technique . Vandevisse and Brilliant found that instrumentation with irrigant produced extrusion, whereas instrumentation without irrigant produced no 5collectible debris. Martin & Cunningham reported that less debris was extruded when the intracanal preparation was performed with and ultrasonic instruments. Al-Omari & 6Dummer veried that involving a linear ling motion techniques, such as the step back techniques, create a greater portion of debris than those involving some sort of rotational motion. The rotary instruments use crown down or cervical aring type preparation that results in less apical extrusion of debris by creating a space large enough for 7 debris to be rinsed away in a coronal direction . Single le system have benets such as reduced canal shaping time allowing the clinician to consume more time on cleaning the canal with more advanced irrigation techniques. The aim of this invitro study was to compare the apically extruded debris during the root canal instrumentation using Hand Protaper, Protaper Next & Protaper Gold rotary systems with Wave one single le reciprocating system. METHODOLOGY: Sixty freshly extracted, single rooted mandibular incisors without caries or visible cracks were selected for the study. External surfaces of all the teeth were debrided with a hand scaler and were analyzed using the Vista Scan digital radiographic system in the labial and proximal directions to conrm the presence of single, straight root canals and non- complicated root canal anatomy. A standard access cavity was prepared for all the samples & canal patency was veried with a ISO size #15k le. The working length of each canal was determined by visible method i.e., size #15k le was placed at the major diameter of apical foramen and reduced by 1mm. Myers and Montgomery model was used in this study for the collection of apically extruded debris. An electronic balance with an accuracy of 10−5g was used to measure the pre- weight of the Eppendorf tubes that are going to be used in the study. A hole was created on each Eppendorf tube lid & each tooth was cemented upto the CEJ using cyanoacrylate gel. A 25-G needle was placed parallel to the tooth which helps as a drainage canula to maintain the air pressure inside and outside the Eppendorf tube. Then each lid with the tooth and the needle was attached to its Eppendorf tube, and the Eppendorf tubes were tted into stopper of the vials. These samples were then randomly divided into four groups (n=15) for instrumentation with different le systems. GROUP1: Protaper Handles (Dentsply Maillefer, Ballaigues, Switzerland) were used for instrumentation according to the COMPARATIVE EVALUATION OF APICAL EXTRUSION OF DEBRIS DURING ROOT CANAL PREPARATION USING FOUR DIFFERENT FILE SYSTEMS Original Research Paper Dr Dattaprasad S Professor & HOD, Department Of Conservative Dentistry & Endodontics, CKS Teja Institute of Dental Sciences & Research, Tirupati, Andhra Pradesh, India. X 1GJRA - GLOBAL JOURNAL FOR RESEARCH ANALYSIS Endodontic The success of root canal therapy is determined by proper access cavity preparation, biomechanical preparation and three dimensional obturation. Microorganisms that are apically extruded during chemo-mechanical preparation causes the host to be compromised by a more number of irritants than before. The aim of this invitro study is to quantitatively evaluate the apically extruded debris during the root canal instrumentation using Protaper Hand, Protaper Next, Protaper Gold, Wave one single le systems. 60 freshly extracted human mandibular incisors were selected and divided into four groups according to the le system used for biomechanical preparation. Apical extrusion of Debris was seen in all groups during the root canal preparation procedure regardless of the instrument or the preparation technique used. Protaper hand le extruded greatest amount of debris whereas Protaper next extrude less amount of debris when compared to that of other le systems (P< 0.05). ABSTRACT KEYWORDS : Protaper Next, Protaper Gold, Wave One Single File System VOLUME-9, ISSUE-3, MARCH-2020 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra Dr Kumari H Post Graduate Student, Department Of Conservative Dentistry & Endodontics, CKS Teja Institute of Dental Sciences & Research, Tirupati, Andhra Pradesh, India. Dr Sunil Kumar C Professor, Department Of Conservative Dentistry & Endodontics, CKS Teja Institute of Dental Sciences & Research, Tirupati, Andhra Pradesh, India. Dr. N.Vamsee Krishna * Associate Professor, Department Of Conservative Dentistry & Endodontics, CKS Teja Institute of Dental Sciences & Research, Tirupati, Andhra Pradesh, India. *Corresponding Author Dr Sunil Kumar S Reader, Department Of Conservative Dentistry & Endodontics, CKS Teja Institute of Dental Sciences & Research, Tirupati, Andhra Pradesh, India. Dr R Bharathi Suma Senior Lecturer, Department of Conservative Dentistry & Endodontics, CKS Teja Institute of Dental Sciences & Research, Tirupati, Andhra Pradesh, India. 2 X GJRA - GLOBAL JOURNAL FOR RESEARCH ANALYSIS manufacturers instructions. Shaping les (Sx, S1 & S2) were used for crown down preparation and nishing les (F1 &F2) were used for apical-third preparation of the root canals. Group2: Protaper Next (Dentsply Maillefer, Ballaigues, Switzerland) rotary les were used for instrumentation according to the manufacturers instructions. X1(17/0.04) & X2(25/0.06) rotary les were used in an Endodontic motor sequentially at 300 rpm speed and torque of 4-5.2N/cm. A brushing out stroke motion was used until working length was reached. GROUP 3: Protaper Gold (Dentsply Maillefer, Ballaigues, Switzerland) rotary les were used for instrumentation according to the manufacturers instructions. Shaping les (Sx, S1 & S2) and nishing les (F1 &F2) were sequentially used with a slightly in-and-out movement at the speed of 300 rpm & torque of 3-5N/cm until working length was reached. Group 4: Wave One (Dentsply Maillefer, Ballaigues, Switzerland) reciprocating le at a speed of 300 rpm and torque of 2N/cm was used for instrumentation according to the manufacturers instructions. Canal preparation was done with Wave one primary le of tip size ISO 25 in a reciprocating slow in and out pecking motion to the full working length. During instrumentation each sample was irrigated with 9ml of distilled water using side vent endodontic needle. Immediately after instrumentation, the Eppendorf tubes were removed from the vial and then stored in an incubator at 70°C for 2 days to evaporate the distilled water. After that the Eppendorf tubes were post weighed using the same electronic balance. Three consecutive measurements were taken and the average values was recorded for each sample in each group to obtain the nal weight of tubes including the extruded debris. The dry weight of the extruded debris was calculated by subtracting the weight of the empty tube from that of the tube containing debris. RESULTS: The mean dry weights of extruded debris were analysed statistically using SPSS version 20.0 soft ware. Multiple group comparisons were analysed by using One-way ANOVA followed by Student's t-test for pair wise comparisons at a signicant level of P<0.05. The Protaper hand showed maximum amount of apical extrusion of debris among all the groups & the least amount of debris was observed in Protaper next system. Table 1: The mean values of amount of apically extruded debris (in mcg) SD, for all groups Table2: Paired Samples Statistics Table3: Paired Samples Correlations Table 4: ANOVA values of within group and between groups VOLUME-9, ISSUE-3, MARCH-2020 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra Protaper Hand 15 0.011 0.006 0.0016 4.887 0.004 Protaper Next 15 0.005 0.002 0.0006 Protaper Gold 15 0.006 0.002 0.0006 Wave one 15 0.008 0.006 0.002 Mean n Std. deviation Std. Error mean Pair 1 Protaper hand preweight 1.0871647 15 0.00496893 0.00128297 Protaper hand post weight 1.09803500 15 0.005635932 0.001455191 Pair 2 Protaper next pre weight 1.0840640 15 0.00350247 0.00090433 Protaper next postweight 1.0891793 15 0.00383242 0.00098953 Pair 3 Protaper goldpreweight 1.0875993 15 0.00327918 0.00084668 Protaper gold postweight 1.0933847 15 0.00477626 0.00123322 Pair 4 Wave one preweight 1.0865360 15 0.00381726 0.00098561 Wave one postweight 1.0944673 15 0.00420370 0.00108539 n Correlation Sig. Pair 1 Protaper hand preweight & Protaper hand post weight 15 0.336 0.220 Pair 2 Protaper next pre weight & Protaper next post weight 15 0.813 0.000 Pair 3 Protaper gold preweight & Protaper gold post weight 15 0.921 0.000 Pair 4 Wave one preweight & Wave one post weight 15 -0.085 0.764 Sum of Squares Df Mean Square F P Value Between Group 0.000 3 0.000 4.888 0.004 Within Groups 0.001 56 0.000 Total 0.001 59 Groups n Mean Std. deviation Std. error F value P value Table 5: Post Hoc tests Multiple group Comparisons Dependent Variable: Values - Tukey HSD *. The mean difference is signicant at 0.05 level. (I) GRP (J) GRP Mean Differenc e (I-J) Std. Error P Value 95% Condence Interval Lower Bound Upper Bound Protaper hand Protaper next 0.0057667* 0.0016571 0.005 0.001379 0.010155 Protaper gold 0.0050600* 0.0016571 0.018 0.00672 0.009448 Wave one 0.0029267 0.0016571 0.300 -0.001461 0.007315 Protaper next Protaper hand -0.0057667* 0.0016571 0.005 -0.010155 -0.001379 Protaper gold -0.0007067 0.0016571 0974 -0.005095 0.003681 Wave one -0.0028400 0.0016571 0.326 -0.007228 0.001548 Protaper gold Protaper hand -0.0050600* 0.0016571 0.018 -0.009448 -0.000672 Protaper next 0.0007067 0.0016571 0.974 -0.003681 0.005095 Wave one -0.0021333 0.0016571 0.575 -0.006521 0.002255 Wave one Protaper hand -0.0029267 0.0016571 0.300 -0.007315 0.001461 Protaper next 0.0028400 0.0016571 0.326 -0.001548 0.007228 Protaper gold 0.0021333 0.0016571 0.575 -0.002255 0.006521 DISCUSSION: The Endodontic Triad consisting of biochemical preparation, microbial control and complete obturation of the root canal space. An acute inammatory response may develop in the periradicular tissues as a result of insults from the root canal system, which can be mechanical, chemical, or microbial in 5 origin . Mechanical and chemical injuries are usually associated with iatrogenic factors, such as over- instrumentation, apical extrusion of debris or irrigant, perforations, etc.,Apical extrusion of contaminated debris into the periradicular tissues is one of the principal cause of mid treatment are-up and postoperative pain. Passive insertion of the needle & passive irrigation with side vent needles have been shown to provide safer treatment procedure, decreasing the likelihood of considerable amounts of liquid being pushed 8periapically . Furthermore, the proximity of the irrigating needle to the apex plays an important role in removing the 9,10canal debris . Instrument design plays a role in apical 11extrusion of debris. Tınaz et al., concluded that more debris 12was extruded with an increase in apical diameter. Elmsallati showed that the short pitch design extruded less debris than 13the medium and long ones.Diemer et al., compared the effect of pitch length and stated that the increasing variable pitch decreases the tendency to screw in and also reduces the helical angle which in turn reduces the apical extrusion. Apart from instrument design, instrumentation technique also play a role in the apical extrusion of debris. Full-sequence rotary instrumentation was associated with less debris 14extrusion compared to reciprocating single-le systems . A common nding is that push-pull instrumentation produces more apical debris than instrumentation techniques that incorporate a rotational force. This leads to the hypothesis that engine driven rotary instruments will produce less debris 12than hand ling techniques . Canal preparation in a step back manner led to increased debris extrusion, in comparison to a canal instrumentation with balanced force or rotary technique. It seems that push-pull motions of les during root canal preparation cause more debris extrusion than 7,15techniques that are based on a reaming or rotational action . 6Al Omari and Dummer instrumented 208 canals using eight different hand instrumentation techniques and found that balanced and crown down pressure less technique extruded 16the least amount of debris. Ferraz and Gomes observed that engine driven nickel-titanium systems were associated with less apical extrusion. Apical extrusion of debris tends to be greater with hand instruments than with techniques that use rotary forces because the les may act as pistons that push irrigating solutions and debris towards the apex conversely rotary instruments may move debris along the les, which 7results in debris being expelled cervically . In the present study, extrusion of debris apically occurred independent of the type of instrument used. First protaper hand shows signicantly more debris compared to that of the reciprocating single-le followed by the full sequence rotary NiTi instruments (P < 0.05). Protaper hand extrude more debris compared to that of rotary le. Protaper hand and Protaper gold rotary systems has same convex triangular 17cross-section and a variable progressive taper . Engine driven rotary les contacts the apical area for lesser period of time and also rotational speed and torque is xed for rotary les. Protaper hand le prepares the apical area for an extended period of time and rotational movement of the le is an operator controlled variable factor. Longer pitch design and extended period of working time at the apex, extrude greater amount of debris by Protaper hand system in comparison to the Engine driven le systems. This long pitch design of Protaper hand has been changed to variable pitch in 18case of Protaper rotary les . ProTaper next System, which uses an offset mass of rotation are made from M-wire technology and have an off-centered rectangular cross-section. This off-centered rectangular design gives the les a snake like swaggering movement and reduces the screw effect by minimizing the contact between 19the le and dentin . WaveOne is the single-le NiTi system that work on the reciprocating action and simulate the Balanced Force Technique, as theorized by Roane and 20Sabala . These les are made of M-Wire under specic tensions and heat treatments at various temperatures. The WaveOne primary le used in this study has tip size 25 & continuously decreasing taper from its tip to its shaft (0.8, 0.65, 0.6, 0.55). In the tip region, the cross-section presents radial lands, while the middle part of the working length and near the shaft, the cross sectional design changes from a modied triangular convex cross-section with radial lands to a neutral rake angle triangular convex cross-section. This design may enhance debris transportation towards apex when used in combination with a reciprocal motion. The variable pitch utes along the length of the instrument considerably improve safety. The counterclockwise (CCW) movement of WaveOne le is greater than the clockwise (CW) movement. CCW movement advances the instrument, engaging and cutting the dentine. CW movement disengages the instrument from the dentine before it can lock into the canal. Three reciprocating cycles complete one complete reverse rotation and the instrument gradually advances into the canal with little apical pressure required. The reciprocation movement is formed by a wider cutting edge angle and smaller release angle. 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