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Year : 2014  |  Volume : 17  |  Issue : 2  |  Page : 129-132
Comparative evaluation of apically extruded debris during root canal preparation using ProTaper™, Hyflex™ and Waveone™ rotary systems

Department of Conservative Dentistry & Endodontics, Kamineni Institute of Dental Sciences, Sreepuram, Narketpally, Nalgonda, Andhra Pradesh, India

Click here for correspondence address and email

Date of Submission05-Jul-2013
Date of Decision10-Dec-2013
Date of Acceptance03-Jan-2014
Date of Web Publication1-Mar-2014


Background and Aims: Extrusion of any debris during endodontic treatment may potentially cause post-operative complications such as flare-ups. The purpose of this in vitro study was to assess the amount of apically extruded debris during the root canal preparation using rotary and reciprocating nickel-titanium instrumentation systems.
Materials and Methods: In this study, 60 human mandibular first premolars were randomly assigned to 3 groups (n = 20 teeth/group). The root canals were instrumented according to the manufacturers' instructions using the Reciprocating single-file system WaveOne (Dentsply Maillefer, Ballaigues, Switzerland) and full-sequence rotary Hyflex CM (Coltene Whaledent, Allstetten, Switzerland) and ProTaper (Dentsply Maillefer, Ballaigues, Switzerland) instruments. The canals were then irrigated using bidistilled water. The debris that was extruded apically was collected in preweighed eppendorf tubes and assessed with an electronic balance and compared.
Statistical Analysis Used: The debris extrusion was compared and statistically analyzed using analysis of variance and the post hoc Student-Newman-Keuls test.
Results: The WaveOne and ProTaper rotary instruments produced significantly more debris compared with Hyflex CM rotary instruments (P < 0.05).
Conclusions: Under the conditions of this study, all systems that were used resulted in extrusion of apical debris. Full-sequence rotary instrumentation was associated with less debris extrusion compared with the use of reciprocating single-file systems.

Keywords: Apical extrusion; Hyflex; reciprocating motion; WaveOne

How to cite this article:
Surakanti JR, Venkata RP, Vemisetty HK, Dandolu RK, Jaya NM, Thota S. Comparative evaluation of apically extruded debris during root canal preparation using ProTaper™, Hyflex™ and Waveone™ rotary systems. J Conserv Dent 2014;17:129-32

How to cite this URL:
Surakanti JR, Venkata RP, Vemisetty HK, Dandolu RK, Jaya NM, Thota S. Comparative evaluation of apically extruded debris during root canal preparation using ProTaper™, Hyflex™ and Waveone™ rotary systems. J Conserv Dent [serial online] 2014 [cited 2023 Oct 1];17:129-32. Available from:

   Introduction Top

During the root canal preparation procedures, dentin chips, pulp tissue, microorganisms and/or irrigants may get extruded into the periradicular tissues. Though a thorough control of the working length (WL) may decrease the risk, but nevertheless extrusion of any debris may potentially cause post-operative complications such as flare-ups, [1] which are characterized by pain, swelling causing unscheduled visits of the patients resulting in interappointment emergency. [2],[3],[4]

At present, all preparation techniques and instruments are associated with extrusion of debris, even when the preparation is maintained short of the apical terminus and manual instrumentation happens to produce greater extrusion when compared to engine driven rotary preparation. [5],[6],[7] The studies so far have proven that none of the various techniques and instruments can clean and shape the root canal system without producing some apically extruded debris (AED). [8] However, it has been proved that various instrumentation techniques have been associated with different amounts of AED. [9]

ProTaper (Dentsply Maillefer, Ballaigues, Switzerland) system exhibits progressively variable tapers of each instrument that develop a "progressive preparation" in both the vertical and horizontal directions. The ProTaper cross-sectional design mimics that of a reamer, with three machined cutting edges and convex core. [10]

Hyflex CM nickel-titanium (NiTi) Files (Coltene-Whaledent, Allstetten, Switzerland) is produced by an innovative methodology (patent pending) which uses a unique process that controls the material's memory (a complex heating and cooling treatment). The cross-sectional design of Hyflex files is very much similar to EndoSequence. [11]

WaveOne (Dentsply Maillefer, Ballaigues, Switzerland), the recently introduced single-file NiTi system is claimed to complete root canal preparation with only one instrument in reciprocating motion with adequate size and taper. These files are made of a special NiTi alloy called M-Wire that is created by an innovative thermal treatment process. [12] It is available in sizes of 21.06, 25.08 and 40.08 and these are used in a reciprocal motion that requires a special automated devices.

As AED generates an acute inflammatory reaction in the periapical tissues, it is considered as an important parameter to assess the efficacy of an instrumentation technique or instrument design during root canal preparation. [9] The aim of this study was to compare the amount of AED during preparation of straight root canals in extracted human teeth using WaveOne compared with the rotary full-sequence HyFlex CM and ProTaper .

   Materials and Methods Top

In this study, 60 freshly extracted human mandibular premolar teeth that were sacrificed for orthodontic and periodontal purpose were used. The inclusion criteria was the single rooted mandibular premolar teeth with single root canal and apical foramen with root curvature between 0° and 10°. Radiographs were taken both mesiodistally and buccolingually to assess internal resorption, root canal calcification and curvature of the root canals. The degree of root curvature was calculated from the buccolingual radiographs by using the method of Schneider. [13] Teeth with signs of crack, internal and external resorption, root caries, canal calcifications and open apices were excluded from the study. The selected teeth were randomly assigned into 3 experimental groups (Groups 1-3) with 20 teeth in each group.

The debris and soft-tissue remnants were cleaned from external root surface and then stored in phosphate-buffered saline solution. To maintain similar tooth lengths, all teeth were measured and the crowns were sectioned with a high-speed bur under copious water spray until equal lengths were obtained. Access cavity preparation was done in each tooth and all external tooth surfaces were covered with 2 layers of nail polish except for 1 mm around the apical foramen. [14] A 15 K-file (Mani, Tochigi, Japan) was used to determine the WL until it was visible at apical foramen. The WL was re-established by subtracting 1 mm from this measurement.

The debris collection apparatus was made according to the design described by Myers and Montgomery. [15] Eppendrof tubes were taken and weighed by electronic microbalance (Single Pan K-Roy analytical balance, K Roy and Co, Kolkata, India). Each individual tooth was held in a preweighed eppendorf tube which was fixed inside a glass vial through rubber plug. It was seen that no possible contact was made between the tube and the glass vial. The tube was vented with a 25 gauge needle to equalize the pressure inside and outside.

All instruments were set into permanent rotation with a 6:1 reduction using X-SMART Plus endo motor (Dentsply, Maillefer). For each file, the individual torque limit and rotational speed programmed in the file library of the motor were used, whereas Wave-One was used in a reciprocating working motion generated by the motor. All the preparations were made by a single operator. The preparation sequences is as follows:

1. Group 1: ProTaper instruments were used according to the manufacturer's instructions by a gentle in-and-out motion in the recommended sequence up to F4 (40.06) till the WL. The instrumentation was done till the file rotated freely

2. Group 2: Hyflex CM instruments were used according to manufacturer's recommendations i.e., 06/20, 06/25, 06/30, 06/35, 06/40

3. Group 3: A large reciprocating WaveOne file (40/08) was used in a reciprocating motion according to the manufacturer's instructions.

The extruded debris and irrigant during preparation were collected in eppendrof tube. A total volume of 7 mL of distilled water was used in each root canal for irrigation. The irrigation needle (NaviTip 31ga; Ultradent, South Jordan, UT) was placed short of WL or slightly coronal to the point where resistance was encountered. [14]

After canal preparation, the eppendorf tube was removed from the glass vial. Then the tooth was separated from the tube and the root apex was washed off with 1 ml of distilled water that was collected in the same tube. All the eppendorf tubes were then incubated at 37°C for 15 days to allow the evaporation of moisture before weighing the dry debris. For each eppendorf tube three consecutive measurements were taken on an electronic microbalance and the mean measurement for each tube was considered to be its weight. The weight of extruded debris in each tube was calculated by subtracting pre experiment weight of the tube from the weight of tube with dried debris. The mean weight of extruded debris was calculated for each group. The data were statistically analyzed using Statistical Package for Social Science; 16 (SPSS, version 16; SPSS Inc., Chicago, IL, USA). Analysis was performed using Kruskal-Wallis one-way analysis of variance and post hoc Student-Newman-Keuls test at a significance level of P < 0.05.

   Results Top

The mean AED weight and standard deviation of the three experimental groups is shown in [Table 1]. The results showed that all instrumentation techniques produced a significant amount of extruded debris.
Table 1: Amount of apically extruded debris after the use of the different instruments

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The mean extruded debris weight of the three groups. The mean apically extruded weight of debris in WaveOne (0.0076 g) was more when compared with the Hyflex (0.0019 g). On post hoc student-Newman-keuls test it was found that AED produced by reciprocating single file WaveOne and ProTaper (0.0071 g) was significantly more when compared to Hyflex (P < 0.05). However, no statistical significant difference was obtained between WaveOne and ProTaper (P > 0.05).

   Discussion Top

A major objective of root canal therapy is to obtain a clean root canal system. Debris such as dentine chips, necrotic pulp tissue, microorganisms and irrigants may be extruded into the periradicular tissue during canal instrumentation which leads to endodontic flare-up. Apical extrusion of infected debris to the periradicular tissues is possibly one of the principle cause of this post-operative pain. [1] Many factors affect the amount of extruded debris such as the instrumentation technique, instrument type and size, preparation endpoint and irrigation solution. [6],[7]

The main objective of the present investigation was to determine the apical extrusion of dentine debris as a result of canal shaping by different rotary systems.

As per the results obtained, extrusion of debris apically occurred independent of the type of instrument used. The reciprocating single-file system showed significantly more debris extrusion compared with both the full-sequence rotary NiTi instruments (P < 0.05). The obtained differences may be caused by the preparation technique and/or the cross-sectional designs of the instruments. [12] Hyflex CM files have a cross-sectional design very similar to EndoSequence. [11] The cutting profile of each Hyflex CM file facilitates penetration in the canal and presents a root canal shape corresponding with the original anatomy. A study by Bürklein et al. found that there was more debris in the apical part of the canals after canal preparation with WaveOne and ProTaper instruments as they are characterized by three cutting edges with radial lands to support the blades and a relatively small chip space. [10] ProTaper and WaveOne are characterized by a triangular or modified triangular cross-section resulting in a lower cutting efficiency and smaller chip space. [10] This design may enhance debris transportation toward the apex when used in combination with a reciprocal motion. Contrarily, in continuous rotation may improve coronal transportation of dentin chips and debris by acting like a screw conveyor. [12]

In this present study, the canal WL was 1 mm short of the apical foramen. Myers and Montgomery [15] clearly showed that a WL 1 mm short of canal length contributed to significantly less debris extrusion. A certain degree of caution must be taken when these results are transferred to the clinical situation because of the zero back pressure used in this study design, gravity may have carried the irrigant out of the canal. This is a known drawback of in vitro designs with no periapical resistance. It has been suggested that using floral foam may simulate resistance of periapical tissues. [16] However, foam may absorb some irrigant and debris when used as a barrier and therefore, no attempt has been made in this present study to simulate periapical resistance. Bidistilled water was used as an irrigant in this study to avoid any possible weight increase due to NaOCl crystal formation. The tubes were stored in an incubator in order to evaporate the moisture and weigh the dry debris.

Myers and Montgomery suggested a reassessment of the apical dentinal plug because of the potential benefits of reducing the amount of AED and irrigants and the prevention of over instrumentation in combination with extrusion of filling materials. [15] A study has shown that establishing apical patency in mesiobuccal roots of maxillary molars resulted in apical extrusion of sodium hypochlorite in 100% of the specimens. [17] A similar study has shown that maintaining apical patency was associated with less AED when compared with teeth in which the constriction remained intact. [18]

Ruiz-Hubard et al. [19] found that extrusion of debris apically was less using a crown-down pressure less technique in curved and straight canals when compared with the step-back technique. Zarrabi et al. [20] compared ProFile, RaCe and Flex Master rotary instruments with the step-back technique using manual files and reported that the step-back technique extruded greater amounts of debris than the rotary instruments. Ghivari et al. found that step-back technique extruded a greater quantity of debris and irrigant in comparison to the other hand and rotary Ni-Ti systems.­ [21],[22] Garlapati et al. showed that K3 rotary instruments using crown down technique extruded less number of bacteria. [23]

Earlier studies have shown that manual instrumentation produced significantly more debris than the rotary NiTi techniques and the balanced-force technique. [4] It was observed that rotation during instrumentation, with both the rotary and balanced-force techniques, tend to pull dentinal debris into the flutes of the file and direct it toward the coronal aspect of the canal. In case of engine-driven instruments early flaring of the coronal part of the preparation may improve instrument control during preparation of the apical third of the canal. The rotary motion tends to direct debris toward the orifice, avoiding its compaction in the root canal. [24]

De-Deus et al. in their study have reported no difference in debris extrusion between conventional ProTaper Universal technique and single-file ProTaper F2 used in reciprocating movement. [25] However, the results of this present study are in agreement with previous studies by Bürklein and Schafer [12] which showed reciprocating single-file systems extruded more debris compared with the full-sequence rotary NiTi instruments.

In the present study, the Group 3 (WaveOne ) has shown more extrusion of debris compared with Group 1 (ProTaper ) followed by Group 2 (Hyflex CM ) suggesting that reciprocation motion might cause more apical extrusion compared with continuous motion during root canal preparation.

   Conclusion Top

Under the conditions of this study, Waveone was associated with more debris extrusion compared with ProTaper and Hyflex suggesting that reciprocating single-file system extruded more debris than continuous full sequence rotary NiTi instruments.

   References Top

1.Seltzer S, Naidorf IJ. Flare-ups in endodontics: I. Etiological factors. J Endod 1985;11:472-8.  Back to cited text no. 1
2.Harrington GW, Natkin E. Midtreatment flare-ups. Dent Clin North Am 1992;36:409-23.  Back to cited text no. 2
3.Walton R, Fouad A. Endodontic interappointment flare-ups: A prospective study of incidence and related factors. J Endod 1992;18:172-7.  Back to cited text no. 3
4.Reddy SA, Hicks ML. Apical extrusion of debris using two hand and two rotary instrumentation techniques. J Endod 1998;24:180-3.  Back to cited text no. 4
5.Ferraz CC, Gomes NV, Gomes BP, Zaia AA, Teixeira FB, Souza-Filho FJ. Apical extrusion of debris and irrigants using two hand and three engine-driven instrumentation techniques. Int Endod J 2001;34:354-8.  Back to cited text no. 5
6.Azar NG, Ebrahimi G. Apically-extruded debris using the ProTaper system. Aust Endod J 2005;31:21-3.  Back to cited text no. 6
7.Tinaz AC, Alacam T, Uzun O, Maden M, Kayaoglu G. The effect of disruption of apical constriction on periapical extrusion. J Endod 2005;31:533-5.  Back to cited text no. 7
8.Gutmann JL, Gao Y. Alteration in the inherent metallic and surface properties of nickel-titanium root canal instruments to enhance performance, durability and safety: A focused review. Int Endod J 2012;45:113-28.  Back to cited text no. 8
9.Siqueira JF Jr, Rôças IN, Favieri A, Machado AG, Gahyva SM, Oliveira JC, et al. Incidence of postoperative pain after intracanal procedures based on an antimicrobial strategy. J Endod 2002;28:457-60.  Back to cited text no. 9
10.Bürklein S, Hinschitza K, Dammaschke T, Schäfer E. Shaping ability and cleaning effectiveness of two single-file systems in severely curved root canals of extracted teeth: Reciproc and WaveOne versus Mtwo and ProTaper. Int Endod J 2012;45:449-61.  Back to cited text no. 10
11.Testarelli L, Plotino G, Al-Sudani D, Vincenzi V, Giansiracusa A, Grande NM, et al. Bending properties of a new nickel-titanium alloy with a lower percent by weight of nickel. J Endod 2011;37:1293-5.  Back to cited text no. 11
12.Bürklein S, Schäfer E. Apically extruded debris with reciprocating single-file and full-sequence rotary instrumentation systems. J Endod 2012;38:850-2.  Back to cited text no. 12
13.Schneider SW. A comparison of canal preparations in straight and curved root canals. Oral Surg Oral Med Oral Pathol 1971;32:271-5.  Back to cited text no. 13
14.Parirokh M, Jalali S, Haghdoost AA, Abbott PV. Comparison of the effect of various irrigants on apically extruded debris after root canal preparation. J Endod 2012;38:196-9.  Back to cited text no. 14
15.Myers GL, Montgomery S. A comparison of weights of debris extruded apically by conventional filing and Canal Master techniques. J Endod 1991;17:275-9.  Back to cited text no. 15
16.Altundasar E, Nagas E, Uyanik O, Serper A. Debris and irrigant extrusion potential of 2 rotary systems and irrigation needles. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;112:e31-5.  Back to cited text no. 16
17.Camoes IC, Salles MR, Fernando MV, Freitas LF, Gomes CC. Relationship between the size of patency file and apical extrusion of sodium hypochlorite. Indian J Dent Res 2009;20:426-30.  Back to cited text no. 17
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18.Lambrianidis T, Tosounidou E, Tzoanopoulou M. The effect of maintaining apical patency on periapical extrusion. J Endod 2001;27:696-8.  Back to cited text no. 18
19.Ruiz-Hubard EE, Gutmann JL, Wagner MJ. A quantitative assessment of canal debris forced periapically during root canal instrumentation using two different techniques. J Endod 1987;13:554-8.  Back to cited text no. 19
20.Zarrabi MH, Bidar M, Jafarzadeh H. An in vitro comparative study of apically extruded debris resulting from conventional and three rotary (Profile, Race, FlexMaster) instrumentation techniques. J Oral Sci 2006;48:85-8.  Back to cited text no. 20
21.Ghivari SB, Kubasad GC, Chandak MG, Akarte N. Apical extrusion of debris and irrigant using hand and rotary systems: A comparative study. J Conserv Dent 2011;14:187-90.  Back to cited text no. 21
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22.Ghivari SB, Kubasad GC, Deshpande P. Comparative evaluation of apical extrusion of bacteria using hand and rotary systems: An in vitro study. J Conserv Dent 2012;15:32-5.  Back to cited text no. 22
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23.Garlapati R, Venigalla BS, Patil JD, Raju R, Rammohan C. Quantitative evaluation of apical extrusion of intracanal bacteria using K3, Mtwo, RaCe and protaper rotary systems: An in vitro study. J Conserv Dent 2013;16:300-3.  Back to cited text no. 23
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24.Goerig AC, Michelich RJ, Schultz HH. Instrumentation of root canals in molar using the step-down technique. J Endod 1982;8:550-4.  Back to cited text no. 24
25.De-Deus G, Brandão MC, Barino B, Di Giorgi K, Fidel RA, Luna AS. Assessment of apically extruded debris produced by the single-file ProTaper F2 technique under reciprocating movement. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;110:390-4.  Back to cited text no. 25

Correspondence Address:
Jayaprada Reddy Surakanti
Department of Conservative Dentistry & Endodontics, Kamineni Institute of Dental Sciences, Sreepuram, Narketpally, Nalgonda - 508 254, Andhra Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0972-0707.128045

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