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ENDODONTOLOGY Original Research - 4

Influence of coronal preflaring using gates glidden and


protaper instruments on the first apical file size determination
- A comparative in vitro study.

B. V. SREENIVASA MURTHY *
JOHN V. GEORGE **
MUKESH KUMAR ***

ABSTRACT
The purpose of this study was to compare the first file that fits to the apex (FFFA) in each canal before and after
early flaring to analyze if the size of file to fit to the apex would increase after flaring. Eighty mesial canals of lower
first and second molars with complete apical formation and patent foramen were selected. The samples were
randomly divided into two groups of 40 canals each. A file was fit to the apex in each canal and that size
recorded. Coronal flaring was completed using Gates Glidden in group 1 and Pro Taper in group 2. After
flaring a file was again fit to the apex in the same manner as before it is recorded. The mean diameter of first file
fitting at apex before flaring (FFFAb) and first file fitting at apex after flaring (FFFAa) flaring was 12.30 (±4.31)×10 -
2
mm and 18.83 (±5.91) ×10-2 mm respectively for group 1 and was 10.58 (±2.56) ×10-2 mm and 18.25
(±5.94) ×10-2 mm respectively for group 2. A paired t test of intragroup values indicated a significance difference
(p<0.001) of file size before and after flaring. The increase in diameter was approximately two file sizes for both
groups. From this observation it can be concluded that early coronal flaring increases the file size that snug at the
apex and awareness of that difference gives the clinician a better sense of canal size. Early flaring of the canal
provides better apical size information and with this awareness, a better decision can be made concerning the
appropriate final diameter needed for complete apical shaping.
Key words: apical file size determination, coronal flaring, instrument type.

INTRODUCTION on the canal instrumentation in terms of filing,


A clinician’s primary concern is to thoroughly reaming or other instrument motions and usage and
clean the root canal system during root canal always stress the importance of enlarging the canal
treatment, mechanically and chemically remove size. Without solid scientific evidence, however it
microorganisms and their substrates from the canal. is still not clear how large is large enough 1. In the
Without proper chemo-mechanical absence of a study that defines what the original
instrumentation, the remaining irritants may reduce width and optimally prepared horizontal
the success rate and cause failure of the treatment. dimensions of canal are, Clinicians are making
In addition, canal surface irregularities require treatment decision without any support of scientific
proper instrumentation for adequate root canal evidence.
filling. Many text books and much literature focus
The horizontal dimension (working width) of
* Professor and Head, ** Professor, *** PG Student, Dept. of Conservative Dentistry and Endodontics, M. S. Ramaiah Dental College, Bangalore - 54.

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ENDODONTOLOGY INFLUENCE OF CORONAL PREFLARING USING GATES GLIDDEN AND PROTAPER INSTRUMENTS ON
THE FIRST APICAL FILE SIZE DETERMINATION - A COMPARATIVE IN- VITRO STUDTY.

root canal system is not only more complicated referred as initial working width.
than vertical dimension (working length) but also
There are so many factors like Irregularity of
more difficult to investigate because it varies greatly
walls /curvature of root which affect initial working
at each vertical level of canal. Routine clinical
width determination 6. To minimize the influence
radiographs may mislead clinicians to make a
of these affecting factors early coronal flaring is
different plan to clean the root canal system. The
recommended. One of the most commonly used
detection of apical constriction and the
rotary instruments for early coronal flaring is a
determination of the first file that binds at working
Gates-Glidden (GG) drill; however new nickel-
length are based on the tactile sense of the clinician.
titanium instruments like Pro Taper are also
This premise is based on the false belief that the
available for this use.
root canal is narrower in the apical portion and
that the file would pass without interference until This study aimed at to evaluate influence of
this narrow point. However it is demonstrated that coronal preflaring on determination of apical file
the sensation of the file fit does not necessarily size and to compare the efficacy of Gates Glidden
occur because of contact at apex as is assumed but drills and Pro Taper in preflaring.
may instead be the result of interference in the
MATERIALS AND METHODS
coronal and middle thirds of the canal.
Tooth Selection
Since the diameter of apical canals varies Forty mesial roots of mandibular first and
greatly in all tooth groups, no standard size is second molars having patent root canals and fully
available for the apical enlargement. One formed apices were selected. Teeth with
recommended approach is to enlarge apical root complicated anatomy, external resorption or
canal to three sizes larger than the first file bind 2-5. extreme root curvature were discarded. These
The concept behind this approach is that first file fourty roots yielded 80 canals for the use in this
to bind reflects the diameter of the apical canal; by evaluation. All the teeth were ultrasonically cleaned
using three successively larger files to the same to remove any surface debris. They were stored in
working length the layer of heavily infected dentin saline at room temperature.
should be removed from all regions of the apical
The distal root of each tooth was sectioned
canal wall. There has been minimal development
away at the furcation with a #169L fissure bur. A
of concepts, techniques and technology to measure
preoperative radiograph was taken for each sample
working width (first file that binds at working
from clinical and proximal view. Caries and
length).
restoration were removed and standard access
One common method of deciding on the size cavities were prepared. The pulp tissues were
of the apical preparation is first determine the removed with an extra fine (XF) barbed broach.
preoperative canal diameter by passing Care was taken to ensure that the barbed broach
consequently larger instrument to the working engaged only the pulp tissue without contacting
length until one binds. This initial file estimation is the apical third of the root canal. Canals were then

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ENDODONTOLOGY B. V. SREENIVASA MURTHY, JOHN V. GEORGE, MUKESH KUMAR

irrigated with copious amount of 2.5% sodium body of each canal. Flaring began with a GG#4.
hypochlorite solution. Apical patency was This drill was used to enlarge the orifice and
determined by inserting a size #6 k-file into the transported it toward the mesial-facial or mesial-
canal until the tip of file was visible at the apical lingual corner of the pulp chamber. The canal was
foramen. Working length was established by irrigated with 2 ml of a freshly prepared 2.5%
subtracting 1 mm from this full canal length. Cusp solution of sodium hypochlorite and flaring
tips were used as a reference points. Both the continued with a GG #3 extending the shaping 2
working length and the reference of each individual mm further apically and again transporting the
canal were recorded. shaping toward the mesial-facial and mesial-lingual
corners. The entry into the canals was always from
Sizing of Canals
the distal towards the mesial and removal applied
Files were inserted passively into the canal
pressure toward the mesial respective corner. This
with light watch-winding action and care was taken
methodology maintained transporting force away
to avoid any force during sizing. Measurement was
from the furcation and furcation concavity.
undertaken starting from ISO size 8. Apical fit was
Irrigation was repeated after each GG and patency
considered to have occurred when largest file
tested with a small file. GG #2 and GG #1 were
reached the apex and passage beyond that depth
used to complete flaring, each penetrating 2 mm
was not possible. In both groups the largest file
deeper than preceding drill. No transporting
that could fulfill the criteria and reach the working
motions were used with these three sizes, however
length was determined. In all instances a larger file
canal patency was checked and irrigation
was tried to ensure that it could not reach the same
continued.
depth (i.e. working length). Once satisfied that the
largest file has been chosen, radiographs were taken Group 2
from the proximal and clinical view. These In this group early flaring was conducted with
radiographs verified that the file had reached the rotary Pro Taper. Pro Taper instruments were used
working length and fit the canal correctly. The size in a crown-down manner according to the
of file was recorded as first file fitting at the apex manufacturer’s instructions using a gentle in-and-
(FFFA) before flaring (FFFAb). out motion. Instruments were withdrawn when
resistance was felt and changed for the next
Coronal and Middle Third Flaring
instrument. The instrumentation sequence is
Coronal flaring and middle third flaring were
described below:
done with Pro Taper rotary and Gates-Glidden
instruments using crown down approach to First make a glide path using 15 K-file. S1 was
eliminate all interferences. Flaring was terminated taken into the canal just short of the depth at which
4 mm short of the working length so that the apical the hand instrument was taken previously. Then,
third region remained unprepared. shaping the SX instrument was used to move the
coronal aspect of canal away from the furcal danger
Group 1
and to improve radicular access. This step was
In this group GG drills were used to flare the

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ENDODONTOLOGY INFLUENCE OF CORONAL PREFLARING USING GATES GLIDDEN AND PROTAPER INSTRUMENTS ON
THE FIRST APICAL FILE SIZE DETERMINATION - A COMPARATIVE IN- VITRO STUDTY.

continued with SX until about two-thirds of the 18.25 (±5.94) ×10-2 mm respectively for group
overall lengths of the cutting blades were below 2. A paired t test of intragroup values indicated a
the orifice. This was followed by S1 and S2 files. significance difference (p<0.001) of file size before
After early flaring was completed, a new evaluation and after flaring. It was observed that there was no
for the FFFA was done. This was accomplished in difference in FFFAa between group 1 and group 2.
the same manner as previously described. No lateral perforations, ledges or instruments
Radiographs were made using the clinical and failures were experienced during this study.
proximal view as before. This file was recorded as
FFFA after flaring (FFFAa).
Table 4
Distribution of the FFFA before and after flaring
RESULTS Group 2 - Pro Taper Group
From the FFFAb, only three canals (7.5%) in
group 1 and five canals (10%) in group 2 kept the File Size FFFAb FFAAa
same size after flaring. Group distribution of the Fr Rf Fr Rf
file diameters is summarized in table 1 and 2 and 8 11 0.27 - -
diameter increments of files are shown in table 3. 10 20 0.50 5 0.12
The file diameters were expressed in mm ×10-2. 15 9 0.22 16 0.40
The mean diameter of first file fitting at apex before 20 - - 10 0.25
flaring (FFFAb) and first file fitting at apex after 25 - - 8 0.20
flaring (FFFAa) flaring was 12.30 (±4.31)×10-2 mm 30 - - - -
and 18.83 (±5.91) ×10 mm respectively for
-2
35 - - - -
group 1 and was 10.58 (±2.56) ×10 mm and -2
40 - - 1 0.01
45 - - - -
Table 3
Distribution of the FFFA before and after flaring Total 40 1.0 40 1.0
Group 1- Gates Glidden Group

File Size FFFAb FFAAa


Fr Rf Fr Rf Table 5 - increment frequency of increase in file
size per group
8 9 0.22 1 0.02
10 14 0.35 3 0.07 Increment Frequency
Group -1 Group -2
15 11 0.27 16 0.40
None 3 5
20 4 0.10 8 0.20
1 22 13
25 2 0.05 10 0.25
2 11 14
30 - - 1 0.02
3 3 6
35 - - 1 0.02
4 1 1
40 - - - - 5 - -
45 - - - - 6 - 1
Total 40 1.0 40 1.0 Note – each increment = one file size.

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ENDODONTOLOGY B. V. SREENIVASA MURTHY, JOHN V. GEORGE, MUKESH KUMAR

Table 6 - statistical analysis

Group N Mean Std. Deviation Median Min Max ‘t’ value ‘p’ value
FFFAb Gates Glidden 40 12.30 4.31 10.00 8 25
2.176 .033
Protaper 40 10.58 2.56 10.00 8 15

Group N Mean Std. Deviation Median Min Max ‘t’ value ‘p’ value
FFFAAa Gates Glidden 40 18.83 5.91 17.50 8 35
2.176 .033
Protaper 40 18.25 5.94 15.00 10 40

Group N Mean Std. Deviation Median Min Max ‘t’ value ‘p’ value
FFFAAa Gates Glidden 40 18.83 5.91 17.50 8 35
2.176 .033
Protaper 40 18.25 5.94 15.00 10 40

Group Paired Differences Mean Std. Deviation t value ‘p’ value


Gates Glidden FFFAB - FFAAA -6.52 4.06 -5.411 <0.001
Protaper p FFFAB - FFAAA -7.68 5.91 -5.188 <0.001

DISCUSSION enlargement is commonly carried out at #25 or #30


Clinicians typically begin shaping by placing file sizes. In our study, out of 80 canals the diameter
a file to the apex and determine the apical diameter, of canal at working length (working width) before
FFFA. From this procedure they make judgments flaring was in range of #8 to #15 k-file size, in 74
that determine the extent of apical shaping and how canals i.e. 92.5% cases. Where as after flaring it
much the canal space must be enlarged. This study was in the range of #15 to #25 K-file size. Data
indicates that their judgment can be in error. The from this study suggest that mesial canals of
FFFA can be significantly larger after flaring the mandibular molars should be enlarged more than
canal than it is before . This information suggests
7
previously accepted. The increase in file size after
that canal interference and curvature are a factor flaring can be explained by realizing that within
in the clinician’s ability to sense apical diameter canal irregularities and curvature produced contacts
with a file. The results clearly indicate that the FFFA with the file and interferes with its progression
size is significantly different after flaring (i.e. almost toward apex 12, 13. Early flaring, regardless of the
two file sizes greater in each canal studied) 8-10. method used removes these contacts opens the
space and reduces file contact; thus a file progresses
This study was conducted in the mesial roots
more easily towards the apex after flaring. This was
of mandibular molars where the canals are
previously suggested by Leeb 6. After flaring a file
considered very small in diameter and complicated
comes to a stop only when the diameter of canal
anatomy 11 . Small enough that the apical

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ENDODONTOLOGY INFLUENCE OF CORONAL PREFLARING USING GATES GLIDDEN AND PROTAPER INSTRUMENTS ON
THE FIRST APICAL FILE SIZE DETERMINATION - A COMPARATIVE IN- VITRO STUDTY.

begins to apply pressure against the instrument. thereby increasing cutting efficiency. Originally Pro
Early flaring allows the operator to sense the canal Taper sets included five instruments, shaping file 1
size near the apex, not curvature and irregularities. &2 and finishing file 1 to 3. However additional
This better sense of apical diameter provides instrument (shaper X and finishing file 4) were
information that should result in better control of subsequently introduced whose task is to relocate
biomechanical preparation. Early flaring offers canal orifices and shape the coronal part of canal
several clinical advantages and it can be and for F4 apical preparation in a wide canal
accomplished either by manual or by mechanical respectively. This is commonly used NiTi rotary
means. Mechanical (i.e. rotary flaring) reduces system these days having the advantage over
treatment time, but is accompanied by a risk of conventional stainless steel GG drills due to its
complications. Over enthusiastic use, inappropriate super elasticity and chances of strip perforation and
size and excessive depth can result in lateral canal transportation is less. In the present study
perforations, ledges and instrument breakage . 14
coronal flaring was completed with Sx, S1 & S2
files 15.
It is important to note that the technique used
with the GG flaring was crown-down in this study Data reveal no relationship between the FFFA
and progressed from large to small through the size and the use of either GG drills or the Pro Taper
canal, sequence#4,#3,#2 & #1. This nuance altered system to provide early coronal flaring. This
the insertion axis for the small drills (#4, #3 and observation is explained by the fact that both
#2) and allowed the smaller drills to shape 2 mm systems shape the coronal two-third of the canal
increments of the canal each. This method provides and remove contacts that when present provide
deeper access with the smaller drills and limits the resistance and change the operator’s ability to pass
possibility of instrument failure. As stated earlier a file to the apex. Both systems removed canal
when used adequately GG instruments are interference and allowed the file to contact mostly
inexpensive, safe and clinically beneficial tools. in the apex and give the clinician a different sense
of resistance plus an ability to place a larger file to
Pro Taper instruments were used in second
the apex.
group for coronal flaring which is a NiTi rotary
system. Two properties of the NiTi alloy are of CONCLUSION
particular interest in endodontics: super elasticity Within the limitation of this in-vitro study, it
and high resistance to cyclic fatigue. Pro Taper can be concluded that
instruments were recently introduced and embody
1. Traditional method of apical size
the two new concepts. Firstly in cross section
determination may lead to a substantial
instruments do not have a U-file design and
underestimation of actual canal size. Early coronal
secondly the instrument shaft has variable taper
preflaring offers substantial advantages for more
along its cutting surface. This concept minimizes
accurate apical sizing, with clinical implications
the number of instruments per set and is claimed
regarding the adequacy of apical enlargement and
to decrease tortional loads by reducing the frictional
debridement.

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ENDODONTOLOGY B. V. SREENIVASA MURTHY, JOHN V. GEORGE, MUKESH KUMAR

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determination. Internal Endodontic Journal 2005; 38:430-435.
are equally effective in coronal preflaring.
9. Tan BT, Messer HH. The effect of instrument type and
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