ENDODONTOLOGY INTRODUCTION. Original Research ABSTRACT

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1 Original Research SEM evaluation of smear layer formation after using three different nickel titanium rotary instruments-endowave, K3 and protaper - An invitro study DHANYAKUMAR N. M. * VASUNDHARA SHIVANNA ** SAURABH GARG *** ABSTRACT Background and Objectives: The purpose of this invitro study was to evaluate the smear layer formation after using three different nickel titanium rotary instruments-endowave, K3 and Protaper using Scanning Electron Microscope. Materials and method: A total of 30 freshly extracted human mandibular premolars were subjected for the study. They were divided into 3 groups, each group consisting of 10 teeth. Group 1: Endowave rotary; Group 2: ProTaper rotary; Group 3: K3 rotary. Crowns of each tooth were removed with carborundum disks at the level of cementoenamel junction in order to obtain root segments of approximately 12mm. Canal length was determined by placing a size 15 K-file. The working length was 0.5 mm short of canal length. Two longitudinal grooves were prepared on the lingual and buccal surfaces of each root to facilitate vertical splitting with a chisel after canal instrumentation. The sections were then observed under SEM for presence or absence of smear layer and photographs were taken at coronal, middle and apical 1/3 with a magnification of 4000 X. Results: There was no significant difference between three groups. All three groups resulted in significantly more smear layer in the apical 1/3 of the canal, compared to coronal and middle 1/3. Interpretation and Conclusion: The study demonstrated that, Endowave, Protaper and K3 resulted in significantly more smear layer in the apical 1/3 of the canal, compared to coronal and middle 1/3. Cleaning was significantly more effective in the coronal and middle 1/3 of the canals Keywords: Smear layer, Rotary instruments, NiTi files, SEM analysis INTRODUCTION A fundamental aim of endodontic treatment is to prevent or cure apical periodontitis. In teeth with apical periodontitis, bacteria invade and colonize the entire root canal system and treatment is directed towards the elimination of microorganisms from the root canal system and prevention of reinfection. 1 Biomechanical preparation, disinfection and obturation all together constitute equally important phases of endodontic treatment. 2 However common to all types of cutting instruments during endodontic therapy it has been shown by SEM studies that a layer of material composed of organic and inorganic substances covers the instrumented walls. This layer has an amorphous irregular and granular appearance under the SEM. This layer has been called as Smear layer. 3 * Professor and Guide, ** Professor and HOD, *** Post Graduate Student, Dept. of Conservative and Endodontics, College of Dental Sciences, Davangere Karnataka 28

2 DHANYAKUMAR N. M., VASUNDHARA SHIVANNA, SAURABH GARG Whether smear layer needs to be removed or retained before obturation is a controversial topic. Smear layer contributes to leakage and is a source of nutrients for microorganisms. Smear layer removal affords, a better adaptation of obturation material. Dentin permeation by diffusion is increased by 5 to 6 times, this allows an improved penetration of disinfecting agents, medicaments.4 Insufficient removal of debris and smear layer material can induce stresses on the cutting segment of endodontic instruments. Their removal depends not only on the irrigation method but also on the endodontic instrument, the way the instrument is used and the method of preparation. 2 During the last decade, advanced instrument design including non cutting tips, radical lands and varying tapers have been developed to improve the safety of preparation, to shorten working time, produce less debris and smear layer and to create a greater flare of preparations. 5 Recently, new rotary Ni-Ti instruments have been marketed as Endowave (J. Morita Co., Japan), K3 (Sybron Endo, CA, USA) and ProTaper (Dentsply, Maillefer, Switzerland). Introduction of these nickel titanium instruments have minimized the incidence of procedural errors such as zipping, ledging. Preparations are better centred, working length is rarely lost and larger size apical stops can be achieved. 6 The comparative evaluation of the new instruments to remove smear layer material produced during endodontic preparation is unknown. Since the ability of rotary instruments to form smear layer during shaping is connected to the flute and cross sectional design, the amount of smear layer produced by these three Ni-Ti rotary instruments must be assessed. Aim of present study was to assess smear layer formation following canal preparation using Endowave, K3 and ProTaper using Scanning Electron Microscope. OBJECTIVE The objective of the present study was to: The aim of this study was - SEM evaluation of smear layer formation in coronal, middle and apical one third of the root canal after using three different nickel titanium rotary instruments: Endowave, K3 and Protaper. METHODOLOGY METHOD Selection of teeth The study samples comprised of 30 intact freshly extracted single rooted human mandibular premolars. The criteria for selection was that The teeth were :-Free of caries, free of restoration, with straight roots, complete root formation Preparation of specimens A conventional access cavity was prepared in each tooth with a round diamond point with high speed to allow direct access to all root canals. Pulp extirpation was done with barbed broaches. Patency of each canal was determined with size 15 K-file. Straight line access was achieved using the Gates Glidden drills through no Crowns of each tooth were removed with carborundum disks at the level of cementoenamel junction in order to obtain root segments of approximately 12mm in length to standardize the preparations. The working length was 0.5 mm short of canal length. Two longitudinal grooves were prepared on 29

3 SEM EVALUATION OF SMEAR LAYER FORMATION AFTER USING THREE DIFFERENT NICKEL TITANIUM ROTARY INSTRUMENTS-ENDOWAVE, K3 AND PROTAPER - AN INVITRO STUDY the lingual and buccal surfaces of each root with a diamond disk used with a high speed water cooled handpiece to facilitate vertical splitting with a chisel after canal instrumentation. The grooves were not deep enough to enter the canals. The teeth were then randomly divided into 3 groups each containing 10 teeth each namely:- 1) GROUP-I: Using Endowave NiTi instruments (J.Morita, Japan) 2) GROUP-II: Using ProTaper NiTi instruments (Dentsply-Maillefer, Switzerland) 3) GROUP-III: Using K3 NiTi instruments (Sybron Endo, CA, USA) GROUP-I: (n = 10) Root canals were prepared using Endowave NiTi instruments (J.Morita, Japan) using following steps:- 1) Canal length was determined by placing a size 15 K-file until it was visible at the apical foramen. 2) After patency verification with a size 15 K- file, the instruments were used in a crown down fashion as per manufacturer s instructions. a) Size 35; 0.08 taper orifice shaper b) Size 30; 0.06 taper 7mm c) Size 25; 0.06 taper 9mm d) Size 20; 0.06 taper 10mm e) Size 15; 0.02 taper 12mm f) Size 20; 0.02 taper 12mm g) Size 25; 0.02 taper 12mm h) Size 25; 0.04 taper 12mm i) Size 30; 0.04 taper 12mm j) Size 30; 0.06 taper 12mm k) Size 35; 0.06 taper 12mm GROUP-II: (n = 10) Root canals were prepared using ProTaper NiTi instruments (Dentsply-Maillefer, Switzerland) using following steps:- a) S1 ( shaping file no.1) at WL 8mm b) SX ProTaper ( auxillary shaping file) at WL 10mm c) S1 ( shaping file no.1) at WL 11mm d) S2 ( shaping file no.2) at WL 12mm e) F1 ( finishing file no.1) at WL 12mm f) F2 ( finishing file no.2) at WL 12mm g) F3 ( finishing file no.3) at WL 12mm (Corresponding Size 30) GROUP-III: (n = 10) Root canals were prepared using K3 NiTi instruments (Sybron Endo, CA, USA) using following steps:- a) Size 25; 0.10 taper orifice shaper b) Size 25; 0.08 taper orifice shaper c) Size 30; 0.06 taper 7mm d) Size 30; 0.04 taper 8mm e) Size 25; 0.06 taper 9mm f) Size 25; 0.04 taper 10mm g) Size 20; 0.02 taper 12mm h) Size 20; 0.04 taper 12mm 30

4 DHANYAKUMAR N. M., VASUNDHARA SHIVANNA, SAURABH GARG i) Size 25; 0.04 taper 12mm j) Size 30; 0.04 taper 12mm k) Size 30; 0.06 taper 12mm l) Size 35; 0.06 taper 12mm In all three groups, canals of each group were irrigated with 1ml of 5.25% NaOCl followed by 1ml of 3% H2O2 solution and followed by 0.5ml of 10% EDTA after each change of instrument. Canals were flooded with irrigating agent throughout the procedure using passive irrigation. After canal preparation a final 1ml of 17% EDTA solution was left in situ for 2 min and replaced by 1ml of 5.25% NaOCl for 3 min. All irrigation procedures were delivered with a 27 gauge needle. Immediately after canal preparation each sample was split into two halves with a stainless steel chisel. The section with the most visible part of the apex was conserved and fixed. Each root specimen was air dried, mounted on a metal stub and coated with gold in a sputtering unit (JEOL- JFC-1100E, JAPAN) under vacuum. The sections were then observed under Scanning Electron Microscope (JEOL-JSM-840A, JAPAN) for presence or absence of smear layer and photographs were taken at coronal, middle and apical 1/3 with a magnification of 4000 X. The photographs were saved and analyzed for the absence or presence of smear layer. The cleanliness of each root was evaluated at three areas (coronal, middle and apical) by means of a numerical evaluation scale scoring system consisting of following 5 criteria. 5,6,8,16 NUMERICAL EVALUATION (SCORING SYSTEM) 23 Smear layer: - Dentin particles, remnants of vital or necrotic pulp tissue, bacterial components and retained irrigant. 1. SCORE 1 No smear layer, dentinal tubules open 2. SCORE 2 Small amount of smear layer, some dentinal tubules open 3. SCORE 3 Homogenous smear layer covering the root canal wall, only few dentinal tubules open. 4. SCORE 4 Complete root canal wall covered by a homogenous smear layer, no open dentinal tubules 5. SCORE 5 Heavy, inhomogeneous smear layer covering the complete root canal wall The final result for each section of the canals was obtained by calculating the mean of the scores of each of the photographs. Statistical analysis: Differences in the scores in different instruments were analyzed by Kruskall Wallis ANOVA, when F was significant, significance of the difference in level of smear layer between groups was tested by Mann Whitney U Test. In between the groups for different regions scores were analyzed by Friedman s test and Wilcoxon Signed rank test. RESULTS The present in vitro study was conducted for comparative analysis of smear layer in coronal, middle and apical third of the root canal by using Endowave (group 1), Protaper (group 2) and K3 31

5 SEM EVALUATION OF SMEAR LAYER FORMATION AFTER USING THREE DIFFERENT NICKEL TITANIUM ROTARY INSTRUMENTS-ENDOWAVE, K3 AND PROTAPER - AN INVITRO STUDY (group 3) NiTi rotary instruments. Comparison between the groups (GRAPH 1) The mean scores for smear layer were least for Endowave (group 1) followed by K3 (group 3) and Protaper (group 2). There was no statistically significant difference found in smear layer formation at coronal, middle and apical 1/3 between three groups. Therefore, in the present study completely cleaned root canals were never found and scores for smear layer formation were highest for Protaper instrumentation in coronal, middle and apical third amongst the three groups. The scores for smear layer formation were least for Endowave instrumentation in coronal, middle and apical third amongst the three groups. Comparison between the regions (GRAPH-2) The mean scores for smear layer at coronal1/ 3, middle 1/3 and apical 1/3 regions of the root canal for Endowave showed that the scores for smear layer at apical 1/3 are significantly higher than the mean scores at coronal 1/3 and middle 1/3 The mean scores for smear layer at coronal1/ 3, middle 1/3 and apical 1/3 regions of the root canal for Protaper showed that the scores for smear layer at apical 1/3 are significantly higher than the mean scores at coronal 1/3 and middle 1/3 The mean scores for smear layer at coronal1/ 3, middle 1/3 and apical 1/3 regions of the root canal for K3 showed that the scores for smear layer at apical 1/3 are significantly higher than the mean scores at coronal 1/3 and middle 1/3 Therefore, in the present study on evaluating the three sections(coronal, middle and apical) of the canal walls, all three NiTi instrumentation groups namely Endowave, Protaper and K3 resulted in significantly more smear layer (p<0.05) in the apical third of the canal, compared to coronal and middle third. On an average, cleaning was significantly more effective in the coronal 1/3 followed by middle 1/3 and apical 1/3 of the canals (p<0.05). Region TABLE 1 COMPARISON BETWEEN GROUPS Group 1 Group 2 Group 3 Mean SD Mean SD Mean SD P* Value Coronal 1/3rd Middle 1/3rd Apical 1/3rd TABLE 2 COMPARISON BETWEEN REGIONS Mean Values Region Coronal 1/3rd Middle 1/3rd Apical 1/3rd P* Value Significance Significant pairs** Group P<0.05 Significance I&III, II&III Group P<0.05 Significance I&III, II&III Group P<0.05 Significance I&III, II&III 32

6 GRAPH 1- COMPARISON OF MEAN SCORES OF SMEAR LAYER AT CORONAL, MIDDLE AND APICAL 1/3 rd BETWEEN THREE GROUPS DHANYAKUMAR N. M., VASUNDHARA SHIVANNA, SAURABH GARG B) C) FIG- 6 SEM VIEW AFTER PREPARATION WITH PROTAPER FIG- 4 STUDY SAMPLE AFTER GOLD SPUTTERING A) FIG- 5 SEM VIEW AFTER PREPARATION WITH ENDOWAVE A) B) 33

7 SEM EVALUATION OF SMEAR LAYER FORMATION AFTER USING THREE DIFFERENT NICKEL TITANIUM ROTARY INSTRUMENTS-ENDOWAVE, K3 AND PROTAPER - AN INVITRO STUDY C) B) FIG- 7 SEM VIEW AFTER PREPARATION WITH K3 A) C) DISCUSSION It is axiomatic that well shaped canals produce well packed canals. Consistently producing shape is one of the strategic cornerstones in the foundation of endodontic success. 21 Biomechanical preparation is one of the most important steps in the success of root canal treatment. Over the years a variety of instruments and techniques have been proposed to reach this goal namely carbon steel, stainless steel and nickel titanium. 11 Traditional stainless steel instruments that lose their flexibility may cause significant alterations of canal morphology, these include ledging, stripping of the lateral canal walls, perforation of the root into periodontal ligament, zipping of apical foramen, elbow formation and instrument separation. 29 Moreover several studies have shown the inability of K type file to completely remove debris and smear because of complex internal anatomy, deficiencies in instrument design and inherent stiffness of metal. 2 Common to all types of cutting instruments during endodontic therapy it has been shown by scanning electron microscope studies that a layer of material composed of organic and inorganic substances covers the instrumented walls. The smear layer is a surface film of a thickness of approximately 1-2 microns. Smear layer, which is mainly inorganic, is produced every time a canal is instrumented, no smear layer is found on areas that are not instrumented. 12 Insufficient removal of debris and smear layer material can induce stresses on the cutting segment of endodontic instruments. 34

8 DHANYAKUMAR N. M., VASUNDHARA SHIVANNA, SAURABH GARG Their removal depends not only on the irrigation method but also on the endodontic instrument, the way the instrument is used and the method of preparation. 4 However, there is still a lack of scientific data regarding the debridement/ cleaning ability of this new rotary system to remove smear layer that is produced during instrumentation. 21,19,15 Scanning electron microscope has been used to evaluate cleanliness of canal walls. The cleanliness of an entire section of canal (coronal, middle and apical) was thus presumed to resemble that of a very small part of its total area. The same magnification was used in coronal, middle and apical thirds of specimen. The results of the present study conducted showed that the coronal 1/3 and middle 1/3 of the canal prepared using Endowave, ProTaper and K3 by crown down technique method were significantly cleaner when compared with the apical 1/3. However there was no significant difference found in smear layer formation at coronal 1/3, middle 1/3 and apical 1/3 between the three groups. The scores for smear layer formation at coronal 1/3 and middle 1/3 were lower for Endowave as compared to Protaper and K3. The scores for smear layer formation at apical third were highest for Protaper followed by K3 and Endowave. The present study showed that there was no significant difference between smear layer removal scores between Endowave, ProTaper, and K3 NiTi files at the coronal 1/3 and middle 1/3 of the root canal preparations. The reasons for this could bea) Unique design of Endowave and ProTaper instruments, the presence of generous radial lands in K3 and convex triangular cross section of ProTaper instrument causing efficient cutting in the coronal and middle third. b) The Endowave, K3 and Protaper instruments has large taper (4-11%) which will allow effective shaping and cleaning due to good cutting contact and will create a continuous smooth funnel shape, that may allow penetration of needle and irrigating solution and sufficient wide flow channel that might have allowed more removal of smear layer during bio mechanical preparations procedure. 18 c) The efficient irrigant flow exerting a mechanical flushing effect in these parts of the canal. 22 d) These NiTi instruments have variable helical angles and variable pitch which are an important aid to moving debris and smear up and out of the canal. 14 The results are comparable to those of the previous studies. 24,20,16 The present results indicate that on average the apical third of the canals was significantly less clean than the middle and coronal thirds regardless of the instrument used. The reasons for this could be- 1. ProTaper instruments exhibit a unique variable taper design with a triangular cross section they have reduced radial lands that might allow the file more freedom within the canal and contribute to more aggressive and unconstrained cutting which means more smear The Endowave, K3 and Protaper instruments has large taper (4-11%) which will allow effective 35

9 SEM EVALUATION OF SMEAR LAYER FORMATION AFTER USING THREE DIFFERENT NICKEL TITANIUM ROTARY INSTRUMENTS-ENDOWAVE, K3 AND PROTAPER - AN INVITRO STUDY shaping and cleaning due to good cutting contact and will create a continuous smooth funnel shape in coronal and middle 1/3, that may allow penetration of needle and irrigating solution and sufficient wide flow channel that might have allowed more removal of smear layer in coronal and middle 1/3 during biomechanical preparations procedure It is possible that the greater number of wall irregularities of this portion of canal such as depressions, and grooves may be responsible for the presence of uninstrumented areas. The use of larger masterfiles would be more liable to remove a greater portion of debris and smear from the apical 1/3 with the removal of inner dentin. The results are comparable to those of the previous studies. 8,13,16,18,23 However the smear layer removal scores between Endowave and K3 NiTi files at the coronal 1/3, middle 1/3 and apical 1/3 of the root canal preparations were better than Protaper NiTi files. The reasons for this could bea) Positive rake angle of K3 provides more effective cutting surface and instruments work like a curette and may help eliminate dentinal shavings during instrumentation. 10 b) By design, K3 body shapers channel debris and smear away from their tips, which can mean somewhat less debris and smear in coronal 1/3. 15 c) Endowave NiTi files employ modified triangular blade design with sharper edge along with the process of electropolishing. Electropolishing will greatly enhance the cutting efficiency of an edge. 14 Although the file is very efficient at cutting it has excellent debris and smear removal as a result of its variable helical angles 14 d) Endowave possess no radial lands therefore does not attack the canal walls. Because it is less aggressive this system generates only minimal smear layer. e) The presence of intermediate taper files of 4% taper in Endowave and K3 system allows gradual increase in taper and thus more efficient cleaning. f) The final apical size was corresponding to no.30 (finishing file no.3) in Protaper system and the final apical diameter in the K3 and Endowave group was of size 35. Canals prepared to a larger final apical size would show a superior cleanliness to those with a smaller apical preparation because a larger volume of irrigant may reach the apical region 22. g) More chelator (EDTA) and irrigant were used in the K3 and Endowave group due to the larger number of instruments used for preparation. 18 The results are comparable to those of the previous studies. 18 The results of our study demonstrate that the coronal and middle 1/3 of the canal prepared using Endowave, ProTaper and K3 by crown down technique method were cleaner when compared with the apical 1/3. The use of the Endowave system allowed cleaner canal walls but not statistically significant when compared with K3 and Protaper. A particularly large improvement was observed in the middle and apical thirds. However, additional in-vivo and in-vitro studies are desirable to further substantiate the 36

10 DHANYAKUMAR N. M., VASUNDHARA SHIVANNA, SAURABH GARG findings of our study. CONCLUSION Within the limitations of this in-vitro study the following conclusions can be drawn from the results of this study: 1. The coronal and middle 1/3 of the canal prepared using Endowave, ProTaper and K3 by crown down technique method were cleaner when compared with the apical 1/3. 2. The mean scores in the coronal, middle and apical third of the canals prepared using Protaper were higher than those prepared with Endowave and K3. 3. The use of the Endowave system allowed cleaner canal walls but not statistically significant when compared with K3 and Protaper. A particularly large improvement was observed in the middle and apical thirds. Potential stress, which could be applied to the cutting segment of the endodontic file by accumulation and compression of the smear layer, was thus minimized. Clinically this finding may be more important because the microorganisms which remain in the apical portion of the root canal have been considered the main cause of failure of endodontic treatment. REFERENCES 1. Young GR, Parashos P, Messer HH. The principles of techniques for cleaning root canals. Aust Dent J 2007; 52(1S): S52-S63 2. Bertrand MF, Pizzardini P, Muller M, Medioni E, Rocca JP. The removal of the smear layer using the Quantec system: A study using the scanning electron microscope. Int Endod J 1999; 32 : Sen BH, Wesselink PR,Turkun M. The smear layer: A phenomenon in root canal therapy. Int Endod J 1995; 28: Mario C, Wilson et al. The smear layer in endodontics: controversies in Endodontics. Dent Clin North Am 1990; 34 : Versumer J, Hulsmann M, Schafers F. A comparative study of root canal preparation using Profile.04 and Lightspeed rotary Ni-Ti instruments. Int Endod J 2002; 35: Mayer BE, Peters OA, Barbakow F. Effects of rotary instruments and ultrasonic irrigation on debris and smear layer scores: a scanning electron microscopic study. Int Endod J 2002; 35: Ruddle C. ProTaper technique: Shaping the future of endodontic, the ProTaper geometries, features and guidelines for use : news letter Dentsply Maillefer 2002; Foschi F, Nucci C, Montebugnoli L, Marchionni S, Breschi L, Malagnino VA, Prati C. SEM evaluation of canal wall dentine following use of Mtwo and ProTaper NiTi rotary instruments. Int Endod J. 2004; 37(12): McComb D. and Smith D. C. A preliminary scanning electron microscope study of root canals after endodontic procedures. J Endod 1975;1: Sharma H, Shivanna V. Smear layer removal using manual instrumentation of K file versus Lightspeed, Profile and Hero 642 instrumentation: a SEM study. Endodontology 2002;14: Cohen S Bums RC. Pathways of the pulp, 8 th Edition St. Louis CV Mosby Co., 2003: Schafer E, Schlingemann R. Efficiency of rotary nickeltitanium K3 instruments compared with stainless steel hand K-Flexofile Part 2: Cleaning effectiveness and shaping ability in severely curved root canals of extracted teeth. Int Endod J 2003; 36(3): Hulsmann M, Herbst U, Schafers F. Comparative study of root-canal preparation using Lightspeed and Quantec SC rotary NiTi instruments. Int Endod J 2003; 36(11): Koch K, Brave DG. Real world EndoSequence file. Dent Clin North Am 2004; 48 : Mounce RE. The K3 rotary nickel-titanium file system. Dent Clin North Am 2004; 48 : Schafer E, Vlassis M. Comparative investigation of two rotary nickel-titanium instruments: ProTaper versus RaCe. Part 2: Cleaning effectiveness and shaping ability in severely curved root canals of extracted teeth. Int Endod J 2004; 37(4): Kaptan F, Sert S, Kayahan B, Haznedaroðlu F, Tanalp J, Bayirli G. Comparative evaluation of the preparation efficacies of HERO Shaper and Nitiflex root canal instruments in curved root canals. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 37

11 SEM EVALUATION OF SMEAR LAYER FORMATION AFTER USING THREE DIFFERENT NICKEL TITANIUM ROTARY INSTRUMENTS-ENDOWAVE, K3 AND PROTAPER - AN INVITRO STUDY 2005 ;100(5): Paqué F, Musch U, Hulsmann M. Comparison of root canal preparation using RaCe and ProTaper rotary Ni-Ti instruments. Int Endod J 2005; 38(1): Elmsallati EA, Wadachi R, Ebrahim AK, Suda H. Debris and wear in three different nickel titanium rotary instruments. Aust Endod J 2006; 32(3): Jodway B, Hulsmann M. A comparative study of root canal preparation with NiTi-TEE and K3 rotary Ni-Ti instruments. Int Endod J 2006; 39(1): Kum KY, Kazemi RB, Cha BY, Zhu Q. Smear layer production of K3 and ProFile Ni-Ti rotary instruments in curved root canals: a comparative SEM study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006 ;101(4): Liu SB, Fan B, Cheung GS, Peng B, Fan MW, Gutmann JL, Song YL, Fu Q, Bian Z. Cleaning effectiveness and shaping ability of rotary ProTaper compared with rotary GT and manual K-Flexofile Am J Dent. 2006; 19(6): Rodig T, Hulsmann M, Kahlmeier C. Comparison of root canal preparation with two rotary NiTi instruments: Profile.04 and GT rotary. Int Endod J 2007; 40: Yang G, Wu H, Zheng Y, Zhang H, Li H, Zhou X. Scanning electron microscopic evaluation of debris and smear layer remaining following use of ProTaper and Hero Shaper instruments in combination with NaOCl and EDTA irrigation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008;106(4):e

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