|Year : 2022 | Volume
| Issue : 1 | Page : 9-16
The effectiveness of reciprocating instruments in the removal of root filling materials: A systematic review
Iman M Al-Zaka1, Jamal A Abu Al-Timan1, Mustafa Tariq Mutar2, Ahmed Sleibi1, Meelad Basil Findakly2, Aya Nashwan Naji2
1 Department of Conservative Dentistry, College of Dentistry, Mustansiriyah University, Baghdad, Iraq
2 Department of Conservative Dentistry, Ministry of Health, Baghdad, Iraq
|Date of Submission||13-Jul-2021|
|Date of Decision||28-Aug-2021|
|Date of Acceptance||29-Aug-2021|
|Date of Web Publication||8-Jan-2022|
Mustafa Tariq Mutar
Department of Conservative Dentistry, Ministry of Health, Baghdad
Source of Support: None, Conflict of Interest: None
Introduction: Re-establishing the health of the periapical tissues is considered to be the main objective of nonsurgical root canal retreatment in cases with posttreatment disease. Removal of filling material from the canal space is the most difficult and challenging step during retreatment, regardless of the technique/instrument used. The aim of this study was to determine the effectiveness of nickel–titanium reciprocating instruments in the removal of root canal filling material in comparison with continuous rotary shaping and retreatment instruments.
Materials and Methods: Four electronic databases were used (PubMed, Google Scholar, ScienceDirect, and Scopus) as information sources. Articles describing in vitro studies carried out on extracted human teeth were included in this systematic review, while narrative, systematic review, in vivo studies, animal studies, studies published in languages other than English, and studies that used methods other than micro-computed tomography to detect root filling material were excluded from this systematic review. The studies were assessed for eligibility according to inclusion criteria by two independent reviewers; the opinion of the third reviewer was requested when one of the reviewers did not accept the study to be included.
Results: Forty-one studies of 560 titles and abstracts screened were selected for full-text analysis; 26 studies were excluded, and 15 studies were included in this systematic review. Eleven studies (73%) showed a nonsignificant difference between reciprocating and rotary instruments.
Conclusions: The collected studies showed no effect of motion (either reciprocation or full rotary motion) on the remnant of root canal filling materials.
Keywords: Reciprocating, retreatment, root canal filling, rotary nickel–titanium
|How to cite this article:|
Al-Zaka IM, Abu Al-Timan JA, Mutar MT, Sleibi A, Findakly MB, Naji AN. The effectiveness of reciprocating instruments in the removal of root filling materials: A systematic review. Saudi Endod J 2022;12:9-16
|How to cite this URL:|
Al-Zaka IM, Abu Al-Timan JA, Mutar MT, Sleibi A, Findakly MB, Naji AN. The effectiveness of reciprocating instruments in the removal of root filling materials: A systematic review. Saudi Endod J [serial online] 2022 [cited 2022 Jan 17];12:9-16. Available from: https://www.saudiendodj.com/text.asp?2022/12/1/9/335238
| Introduction|| |
Endodontic treatment has good prognosis, provided that the treatment is done in aseptic conditions. Endodontic treatment may fail for several reasons, including poor coronal seal, inadequate root filling, and persistent infection. Re-establishing the health of the periapical tissues is considered as the main objective of nonsurgical root canal retreatment in cases with posttreatment disease.
However, removal of filling material from the canal space is the most difficult and challenging step during retreatment, regardless of the technique/instrument used.,,, It has been reported that the presence of root filling material may act as a source of hidden infection; therefore, several systems were applied to remove root filling material, including hand, rotary, and reciprocating instruments. Once the clinician is able to remove the old canal filling material, return apical patency, set an adequate working length, and revise the cleaning, shaping, and filling procedures, root canal retreatment will achieve a good outcome in most cases.
Specially designed nickel–titanium (NiTi) instruments were manufactured for root filling material removal. These include, for example, ProTaper retreatment, D-RaCe, and Mtwo retreatment, which rotate in continuous motion and are widely used in nonsurgical root canal retreatment.,, Other instruments, in spite of being originally developed for root canal preparation (shaping instruments), including systems with reciprocating motion (Reciproc, Reciproc Blue, and WaveOne Gold) or continuous motion, such as ProTaper Next and ProTaper Gold, are also suggested for secondary root canal treatment since these instruments are flexible with high resistance to cyclic fatigue and have high cutting efficiency which may enhance root filling removal., Nasir and Wrbas in a systematic review study highlighted the efficacy of retreatment instruments versus reciprocating instruments, but no available systematic review evaluated the ability of reciprocating instruments in the removal of root filling material in comparison with retreatment files and other newly emerged rotary shaping instruments which were undergone metallurgic and design enhancement. The outcome of this systematic review may enhance clinical guidelines and support the clinician to choose the appropriate instruments during endodontic retreatment.
The aim of this systematic review is to determine the effectiveness of NiTi reciprocating instruments in the removal of root canal filling material in comparison with continuous rotary shaping and retreatment instruments.
| Materials and Methods|| |
This systematic review followed a PRISMA statement checklist.
Studies were selected for inclusion in the present systematic review if they fulfilled all the following criteria:
- Articles describing in vitro studies carry out on extracted human teeth only
- Articles evaluating the ability of reciprocating instruments with continuous shaping files and/or retreatment files in the removal of filling materials in one study
- Articles that used micro-computed tomography (μCT) method in detection of the remnant of filling materials
- Only studies in English language were included; the search was from 2010 to 2020.
The “PICOS” questions for this systematic review were defined as follows:
- Population: Endodontically filled teeth
- Intervention/Comparison: Rotary versus (vs.) reciprocating instruments
- Outcome: Remnant of root filling material
- Study design: In vitro studies.
Narrative, systematic review, studies, studies done on animal teeth, studies published in languages other than English, and studies that used methods other than μCT to detect root filling material were excluded from this study, regarding the obturation the studies that used carrier-based obturation were excluded.
Four electronic databases were used (PubMed, Google Scholar, ScienceDirect, and Scopus). The search strategy was based on MeSH terms.
The keywords that were used (root filling material AND removal, root filling material OR remnant, filling materials AND rotary and reciprocating instruments AND retreatment, filling remnant AND retreatment file AND Reciproc) (“endodontic retreatment,” “retreatment file,” “reciprocating instruments, remnant gutta-percha,” “removal of filling material with reciprocating instruments”) (removal OR remnant, remnant of filling material OR remnant gutta-percha) were used in the search process in databases.
After completion of the search, the studies were collected and the duplicated studies were removed, and then, the studies were assessed for eligibility according to inclusion criteria by two independent reviewers. The studies were graded eligible, might be eligible, and not eligible. Initially, the titles and abstracts were screened and excluded when they did not meet the inclusion criteria; the full text was obtained when there was inadequate information from the abstract or when one reviewer refused to include the study. The opinion of the third reviewer was requested when one of the reviewers did not accept the study to be included.,
The extracted data included the following: author name and year, sample characteristics, techniques used for retreatment (intervention), methods of measuring of root filling remnant, sample size, outcomes, and conclusion.
Risk of bias
There is no standardized method to assess the quality of in vitro studies. The Cochrane only developed tools to assess the risk of bias of clinical studies (randomized and nonrandomized); therefore, a modified risk of bias assessment was developed similar to a previous study, as shown in [Table 1]. The following parameters were used to assess the quality of studies: randomization of samples, similarity of dimensions, blindness of assessment, materials used according to manufacturer instructions, sample size calculation, and treatment by a single operator. If the study had one to three parameters, the study was considered to have high risk of bias, four to five parameters as medium risk of bias, and six to seven parameters as low risk of bias. The publication bias was not statistically calculated.
| Results|| |
Forty-one studies of 560 titles and abstracts screened were selected for full-text analysis; 26 studies were excluded, and 15 studies,,,,,,,,,,,,,, were included in this review as they did meet the eligibility criteria. [Figure 1] shows the reasons for exclusion.
|Figure 1: Study design (flowchart). Overview of the search methodology and selection criteria used in the systematic review|
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[Table 2] and [Table 3] show the characteristics of included studies. Six studies,,,,, (40%) compared reciprocating versus shaping instruments. Nine studies,,,,,,,, (60%) compared reciprocating versus rotary shaping plus retreatment instruments. One study used solvent only, three studies,, used solvent plus Gates Glidden burs, three studies,, used Gates Glidden burs only, and eight studies,,,,,,,,, neither used solvent nor Gates Glidden burs.
|Table 2: Studies characteristics of reciprocating versus rotary shaping instruments regarding their efficacy in removal of root filling material|
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|Table 3: Studies characteristics of reciprocating versus shaping + retreatment instruments regarding their efficacy in the removal of root filling material|
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Eleven studies,,,,,,,,, (73%) showed a nonsignificant difference between rotary and reciprocating instruments, one study (7%) showed conflicting results in the same study, as there was no significant difference between Reciproc Blue and ProTaper Next, and the superiority of Reciproc was found. Two studies, (13%) showed the superiority of rotary instruments over reciprocating instruments, and one study (7%) showed the superiority of reciprocating instruments.
Reciprocating versus rotary shaping instruments
Six studies,,,,, compared reciprocating instruments versus shaping instruments without the use of retreatment instruments. Of these, five studies,,,, (83%) found a nonsignificant difference between shaping and reciprocating instruments, and one study (17%) found the superiority of rotary instruments over reciprocating instruments.
Reciprocating versus retreatment plus rotary shaping instruments
Nine studies,,,,,,,, compared reciprocating versus retreatment plus rotary shaping instruments. Of these, six studies,,,,, (67%) showed a nonsignificant difference, one study (11%) showed the superiority of reciprocating instruments, one study (11%) showed the superiority of rotary instruments (retreatment plus rotary shaping instruments) over the reciprocating instruments, and one study (11%) showed conflicting results.
Risk of bias
Of 15 studies, 7 studies showed moderate risk of bias and 8 studies showed high risk of bias. The results are presented in [Table 1] according to the parameters used in this study.
| Discussion|| |
The removal of root filling material during retreatment is essential to eradicate the hidden infection. Several studies compared the removal of root filling material by different techniques and instruments (hand, rotary, and reciprocating).
In this systematic review, only studies that used μCT for measuring the remnant of root filling were included, as μCT provides a three-dimensional picture; therefore, this method is considered the most accurate one. Other studies that used radiographic method, cone-beam computed tomography (CBCT), scanning electron microscopy (SEM), stereomicroscope, and dental operating microscope as a method of measuring were excluded, because these methods provide two-dimensional pictures (stereomicroscope, SEM, and dental operating microscope) or may depend on operator bias and provide qualitative results (SEM), while some of them may cause the destruction of the specimen during splitting (SEM and stereomicroscope). Cone-beam computed tomography was not included because of low resolution of this method compared to μCT.,
The Reciproc, which is the most frequently used reciprocating instrument for retreatment, was introduced by VDW company in 2008. This instrument was initially introduced for shaping, as it can complete the shaping process in one step; later, this instrument was used for retreatment; therefore, only studies that were done from 2010 to 2020 were included in this systematic review.
Meta-analysis was not done due to heterogeneity of different instrument designs, different metallurgy, and speed. The presence of more than one reciprocating or rotary instrument in the same study makes the comparison of reciprocating and rotary instruments by meta-analysis a challenging mission; therefore, qualitative analysis was used to assess the outcome by using the number of studies that showed significant and nonsignificant differences.
The collected studies showed no effect of motion (either rotary or reciprocating) on the remnant of root filling material, as eleven studies,,,,,,,,,, showed a nonsignificant difference between rotary and reciprocating instruments. The use of either shaping instruments alone or shaping instruments plus retreatment instruments does not make a difference, as both treatment strategies showed the same results, five studies,,,, showed a nonsignificant difference between reciprocating and shaping instruments, and six studies,,,,, showed a nonsignificant difference when shaping plus retreatment instruments were used.
The retreatment instruments have unique design features such as special cross-section which has high cutting efficiency, active tips to enhance filling penetration, and high-speed working instruments to enhance root filling removal., All of these features did not enhance the removal of root filling material, as shown in this systematic review; therefore, the retreatment instruments had no extra benefits in relation to the remnant of root filling material.
The comparison between rotary and reciprocating instruments in several studies was done at different protocols (various apical enlargement): some increased one instrument's size, other studies increased two instruments' sizes,,, some of them even increased three or four instruments' sizes, and others increased different numbers of instruments in the same study., Despite this variation in the number of instruments in the apical enlargement, the comparison between two motions was not affected, which ensures the relation of instruments motion and their efficacy in the removal of root filling material.
The reciprocating instruments in most of the studies showed no superiority over rotary instruments regarding the remnant of root filling material. Other aspects of the instruments should be studied, including the incidence of instrument separation and the time required to complete the retreatment procedure.
The use of solvents and Gates Glidden in several studies did not change the equation of efficacy of both rotary and reciprocating instruments (nonsignificant difference was found between rotary and reciprocating instruments), as their use was at the initial stage of retreatment and some studies found a negative impact of solvents on cleanliness of the root canal system.
The superiority of XP-endo Shaper rotary instruments was reported by De-Deus et al. in 2019. The efficacy of this instrument may be related to the expandable feature of the instrument which allows the instrument to reach inaccessible areas, and another feature which may give superiority to this rotary instrument is using the instruments at high speed, reaching about 1000 RPM.
In a previous study that compared Mtwo versus Reciproc instruments, a significant difference of Mtwo (rotary) over Reciproc was found. However, the opposite result was found by Silva et al. in 2018, as they found the superiority of the Reciproc instrument. This controversy may be related to the number of instruments used for retreatment, as Alves et al. in 2016 used a greater number of instruments (Mtwo), giving the superiority of the rotary instruments in the removal of root filling material.
Bago et al. in 2019 reported conflicting results; although they found the superiority of the Reciproc instrument in the removal of root filling material, they found no difference between other rotary and reciprocating instruments (Reciproc Blue vs. ProTaper Next). This may be related to the metallurgy of instruments, as both Reciproc and Reciproc Blue have a similar cross-section, and the Reciproc instrument has stiffer wire (M-wire technology), which may enhance the cutting efficiency.
The presence of studies with moderate and high risk of bias may explain the conflicting results, as some studies showed the superiority of either rotary or reciprocating instruments. The presence of confounding factors (lack of instrument design standardization) may affect the results of comparing the rotary versus reciprocating instruments; therefore, more standardized methods should be developed to compare rotary and reciprocating instruments.
The limitation of this systematic review is that it includes only in vitro studies which may not mimic the clinical situation; therefore, future in vivo studies with high standardized methods should be done to assess the efficacy of both rotary and reciprocating instruments.
| Conclusions|| |
From this systematic review, it can be concluded that there is no effect of motion type (reciprocating or full rotary) of the instruments on the removal of root canal filling material. Other factors, including the number of instruments, instrument design, speed of instruments, and apical enlargement, should be highlighted in further studies.
The authors would like to thank Mustansiriyah University (www.uomustansiriyah.edu.iq), Baghdad, Iraq, for its support in the present work.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]