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Journal of Indian Society of Pedodontics and Preventive Dentistry Official publication of Indian Society of Pedodontics and Preventive Dentistry
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Year : 2019  |  Volume : 37  |  Issue : 1  |  Page : 75-79

Comparison of instrumentation time and obturation quality between hand K-file, H-files, and rotary Kedo-S in root canal treatment of primary teeth: A randomized controlled trial

Department of Pediatric and Preventive Dentistry, Saveetha Dental College, Saveetha Institute of Medical and Technical Sciences, Chennai, Tamil Nadu, India

Date of Web Publication25-Feb-2019

Correspondence Address:
Dr. Veerale Panchal
Department of Pediatric and Preventive Dentistry, Saveetha Dental College, Saveetha Institute of Medical and Technical Sciences, Poonamalee High Road, Chennai - 600 077, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JISPPD.JISPPD_72_18

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Introduction: Pulpectomy has been a treatment of choice in all necrotic primary teeth. Advancing technology has brought the rotary system to reduce the manual dexterity and improve the quality of treatment for pulpectomy. Advancing technology in pediatric dentistry should be used for the better treatment protocol. Aim: The aim of this study is to compare the obturation quality and instrumentation time after root canal instrumentation with rotary Kedo-S files, hand K-files, and H-files in primary molars. Materials and Methods: A randomized control trial where pulpectomy was performed on 75 primary molars equally distributed for instrumentation with K-file, H-files rotary Kedo-S files, respectively. The instrumentation time and obturation quality were noted. Results: Kedo-S files showed the least instrumentation time with better obturation quality as compared to other two groups (P < 0.001). Conclusion: Pediatric rotary files Kedo-S has better obturation quality in minimum instrumentation time.

Keywords: H-file, instrumentation time, Kedo-S files, K-file, obturation quality

How to cite this article:
Panchal V, Jeevanandan G, Subramanian E. Comparison of instrumentation time and obturation quality between hand K-file, H-files, and rotary Kedo-S in root canal treatment of primary teeth: A randomized controlled trial. J Indian Soc Pedod Prev Dent 2019;37:75-9

How to cite this URL:
Panchal V, Jeevanandan G, Subramanian E. Comparison of instrumentation time and obturation quality between hand K-file, H-files, and rotary Kedo-S in root canal treatment of primary teeth: A randomized controlled trial. J Indian Soc Pedod Prev Dent [serial online] 2019 [cited 2022 Oct 7];37:75-9. Available from: http://www.jisppd.com/text.asp?2019/37/1/75/252862

   Introduction Top

Primary teeth act as a natural space maintainer and guide the eruption of permanent teeth to their optimal position in the dental arch. The retention and preservation of the primary tooth in the dental arch in its normal function and free of pathology is of utmost importance. Literature suggests that preserving the integrity of primary dentition will aid in mastication, prevent aberrant tongue movement, prevent speech problems, maintains esthetics, prevents psychological effects associated with tooth loss, and maintains the normal eruption of the succedaneous teeth.[1] For ideal management of the necrotic pulp in deciduous teeth, endodontic treatment (pulpectomy) remains the treatment of choice.[2] The primary aim of pulpectomy in deciduous teeth is to debride the root canal and maintain the nonpathologic state until the exfoliation of the tooth.[2] This can be achieved by the careful manipulation of the root canal with the instruments and adherence to the biologic principles essential for cleaning and promote healing.[3] The biologic aim involves removal of necrotic pulp, bacteria and bacterial toxins with instrumentation and irrigation and filling the sterile canal with a resorbable material.[4] Apart from the meticulous cleaning and debridement of the root canal, the time taken for the treatment holds significance in pediatric dentistry. With the aim of achieving a quality treatment within a short period, use of rotary instrumentation has been introduced in dentistry.[5]

Rotary instrumentation has been introduced in primary teeth by Barr et al. in 2000.[6] Rotary instrumentation pose its own advantages and disadvantages in both primary as well as permanent teeth. The use of rotary system aids in uniform preparation and adequate debridement of root canals. Silva et al. reported decreased duration of time for root canal preparation with a rotary in primary teeth.[7] Studies have also shown that nickel-titanium (NiTi) rotary instruments provide a good taper to the preparation, thus aiding in better obturation quality with minimal risk of transportation.[8],[9] Drukteinis and Balciuniene proposed incomplete cleaning of the isthmus and fins of primary teeth by rotary instruments due to the centering of rotary instruments in the root canal. Therefore, they proposed additional use of H-file to remove the infected tissue from the ribbon-shaped canals and overcome this disadvantage.[10] Increased cost and breakage are other disadvantages of the usage of rotary instrumentation.[11] Exclusive rotary file systems for primary teeth have been developed over the time to overcome the disadvantage of the existing rotary files. Kedo-S pediatric rotary instrumentation (Reeganz dental care Pvt. Ltd. India) is developed for cleaning and shaping in primary teeth. The Kedo-S pediatric rotary file system consists of three NiTi rotary files with a total length of 16 mm. The working length of the file is 12 mm with a gradual taper.[12] This proves as an advantage for biomechanical preparation of primary teeth having shorter, thinner, curved roots, and ribbon-shaped morphology as compared to permanent teeth.[13] This benefit efficient root canal instrumentation without over instrumentation of thin root canal wall. All the previous studies comparing rotary instrumentation with hand files use the root canal system for permanent teeth. No study has compared the NiTi root canal system for primary teeth. Furthermore, no comparison has been done on the two most common root canal hand instrumentation used.

Hence, this study was performed with the aim of comparing instrumentation time and obturation quality of Kedo-S files pediatric rotary system with the hand files system: K-files and H-files.

   Materials and Methods Top

The present study is a randomized controlled double-blinded clinical trial. The ethical approval for the study was obtained from the Institutional Review Board of Saveetha Dental College, Chennai, with ethical committee number STP-SDMDS17PED3-B. The sample size was calculated using the results of the previous pilot study done using 20 participants in each group. Since the pilot study showed parametric results, the sample size for the study was increased to 25 for each group.

All the patients requiring pulpectomy procedure between the age group of 4–7 years visiting Saveetha Dental College, Chennai, were included in the study. An informed consent was obtained from individual parent regarding the participation of the study. All necrotic posterior teeth with minimum of 2/3rd root structure remaining, sufficient crown structure for rubber dam, and crown placement were included in the study. Patients who did not provide informed consent, patient with systemic illness, nonrestorable tooth with furcal perforation, and pathological mobility were excluded from the study.

Randomization of the treatment protocol used was done according to the computer-generated sequence of random number. The patient and the parents were blinded regarding the treatment protocol. The evaluator of the treatment procedure was blinded about the treatment protocol for each group. Since the type of treatment provided was known to the operator, the operator could not be blinded.

Single visit pulpectomy was performed for all primary teeth. Local anesthesia was administered using Lignocaine Hydrochloride (LOX*2% ADRENALINE, Neon Laboratories Limited, India) injected with a 2-ml syringe containing 20-mm 25G needle (UNOLOCK single-use syringe, Hindustan Ltd., Chennai, India). The subjective and objective signs of the local anesthesia were verified before the continuation of the further treatment procedure. Rubber dam (GDC Marketing, Hoshiarpur, Punjab, India) isolation was done for all the pulpectomy procedures. Access cavity was made using no 4 round carbide bur (Dentsply Maillefer, OK, USA) after initial caries removal was completed which was accompanied by pulpal involvement. The roof of the access cavity was removed using safe ended diamond tapered fissure with outward brushing motion. The initial orifice was located using DG-16 explorer (Hu-Friedy, IL, USA) which was followed by working length determination using no 15 hand K-file (Dentsply Maillefer, OK, USA). The working length was determined using the radiographic method and was kept 1-mm short of radiographic apex. Based on the randomization protocol, the type of instrumentation is chosen for a particular tooth. In Group 1, hand instrumentation was carried out using hand K-file (Dentsply Maillefer, OK, USA) up to no 35 K-file using quarter turn and pull motion. In group 2 hand instrumentation was carried out using hand H-file (Dentsply Maillefer, OK, USA) up to no 35 H-file using retraction motion. In Group 3, rotary instrumentation was preceded by initial hand instrumentation up to no 20 K-file. The rotary instrumentation was done using the Kedo-S rotary files (Reeganz dental care Pvt. Ltd, India) for primary teeth with D1 and E1. In between subsequent filling, saline irrigation was done for all the groups. The total instrumentation time was measured using a digital stopwatch. The timer was started with the introduction of the first file and stopped at the final saline irrigation. The corresponding instrumentation time was noted for each group by the operator.

After complete instrumentation and irrigation, the canals were dried using no. 30 paper points (Dentsply Maillefer, OK, USA) and canals were obturated using calcium hydroxide iodoform paste (Metapex, META Biomed Co, PA, USA). The excess of coronal filling is removed, and initial entrance filling was given using glass ionomer cement (Shofu, Shofuinc. Japan). The final restoration was completed using stainless steel crown (3M ESPE, St Paul, MN, USA) placed on the same visit. To evaluate the quality of obturation, the radiograph was taken using a size 0 phospho plate sensor and portable X-ray unit (Vista Scan Mini plus, Durr Dental AG, Bietigheim-Bissingen). Paralleling technique was used for all the X-rays. A separate observer was assigned who was blinded regarding the type of instrumentation protocol used. The observer graded each radiograph as optimal, over and underfilling based on the criteria given by Coll and Sadrian.[14] The obturation was considered as over in case of beyond the apex. Obturation 2-mm short of radiographic apex was considered as under obturation. Obturation at or within 1 mm of radiographic apex was considered as optimal obturation.

The data were entered over a spreadsheet, and statistical analysis was performed using SPSS software version 22 (IBM, Armonk, New York, United States). One-way ANOVA was used to compare the mean instrumentation time between the three groups. Chi-square test was used to compare the quality of obturation between three groups.

   Results Top

Out of 69 children included in the study, 64 children were treated once, 4 children were treated for 2 pulpectomies in two different appointments and one child was treated for three pulpectomies in three different appointments. Thus, the total sample size was 75 teeth undergoing pulpectomy, equally divided into three groups based on randomization. The demographic data for the division in each group are given in [Table 1]. Out of the 69 children being treated, 38 were girls and 31 were boys in the age group of 4–6 years with the mean age of 5.25 years [Table 1].
Table 1: Demographic variables describing age and distribution of girl and boy participants in each group

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The normality tests Kolmogorov–Smirnov and Shapiro–Wilks tests results show that the variable follows normal distribution. Therefore, for analysis, the data parametric methods were applied.

The mean instrumentation time observed for instrumentation with rotary Kedo-S files is 9.3804 min with a standard deviation of 0.774. The mean instrumentation time observed for instrumentation with K-file is 12.8096 min with a standard deviation of 0.853. The mean instrumentation time observed for H-file instrumentation is 13.3604 with a standard deviation of 0.536. Results of one-way ANOVA comparing the mean instrumentation time between the three groups reveal a statistically significant result of rotary Kedo-S files showing less instrumentation time as compared to K-file and H-file (P < 0.001) [Table 2] and [Figure 1].
Table 2: Comparison of instrumentation time between three groups

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Figure 1: Comparison of mean instrumentation time between three groups

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Sixty-four percent of teeth instrumented with rotary Kedo-S files showed optimal obturation, 28% of teeth showed over and only 8% showing under obturation. In the case of instrumentation with K-file, 48% of teeth showed optimal obturation, 8% showed over obturation and 44% showed under obturation. In the case of H-file instrumentation, 46.7% of teeth showed optimal obturation, 12% of teeth showed over obturation, and 41.3% of teeth showing under obturation [Table 3] and [Figure 2].
Table 3: Comparison of obturation quality between the three groups

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Figure 2: Comparison of obturation quality between three groups

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Chi-square test between the three groups reveals rotary Kedo-S files showing statistically significant optimal obturation as compared to K-file and H-file (P < 0.001). Rotary Kedo-S files thus showed better obturation quality as compared to K-file and H-file.

   Discussion Top

Pulpectomy is a treatment of choice for necrotic primary teeth. Success for pulpectomy in primary teeth is being attributed to the cleaning and debridement of root canal,[1] apical and coronal seal.[14] Advancement is being achieved in the field of endodontics for primary teeth from the use of hand Headstrom files and Kerr-files to the current rotary systems being used.[1],[15] Since biomechanical preparation with hand instrumentation has been time-consuming, focus has shifted to rotary instruments for biomechanical preparation with the aim of decreased treatment time.[16] Previous studies[6],[7],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26] have compared hand and rotary instrumentation in primary teeth. However, these studies have used the instruments for permanent teeth in primary teeth. The present randomized controlled trial holds its uniqueness in using specialized rotary files for primary teeth.

In pediatric dentistry, the duration of the treatment is very essential in decreasing the anxiety among children. Shorter treatment duration decreases the anxiety, thus rendering optimal treatment protocol.[24] Hence, the present study evaluates the instrumentation time and obturation quality to measure treatment outcome with the three different methods of biomechanical preparation.

The previous study by Makarem et al. has reported decreased chair side time with rotary instrumentation than with hand instrumentation.[21] The present study shows a similar result with statistically significant decreased instrumentation time as compared to hand instrumentation. Similar findings have also been reported by other studies both in vitro and in vivo.[17],[20],[22],[24],[25] The present study shows a higher number of optimal obturation with rotary instrumentation, as compared to more under obturation with K-file and H-file groups. The under obturation was higher in K-file group than that of the H-file group. Similar findings have been reported by Tania Ochoa-Romero et al. and L. Govindaraju et al. Tania Ochoa-Romero et al. reported 80% of teeth showing optimal obturation as compared to only 50% in primary teeth. Govindaraju et al. reported higher number of optimal filling with rotary files as compared to hand filing group.

Rotary instrumentation reduces manual dexterity, thereby increasing the efficiency of the operator.[15] This can be the possible reason for reduced instrumentation time. The present rotary system uses a progressively increasing taper.[12] The previous study has reported higher cervical enlargement and restricted apical preparation with progressive taper than constantly fixed taper.[26] This can be the reason of better obturation quality with the progressive taper rotary Kedo-S files as compared to fixed taper Hand files. Another reason for better obturation quality with rotary Kedo-S files as compared to hand files can be due to the use of NiTi material used, which increases the flexibility of files.[12] This aids in the adaptation of files to the primary canal curvature, rather than increased zipping and transportation as in hand instrumentation.[27] One more factor which can provide better preparation with the present rotary Kedo-S instrumentation is the wider cervical enlargement and more conical preparation[12] which aids in ease of obturation as compared to less conical preparation with hand files. In comparison of the two hand files, H-files have shown better obturation quality as compared to K-files. This can be attributed to the higher cutting efficiency of H-file due to the triangular cross-section as compared to K-files.[5]

The present study measures success based on the clinical outcome. However, a more microscopic and volumetric analysis would provide better scope for improvement in the present study to achieve evidence. Further studies for comparison of Kedo-S rotary files for primary teeth with adult files used in primary teeth, will aid in understanding the efficiency of the de novo rotary Kedo-S file system.

   Conclusion Top

Rotary Kedo-S files clearly show better obturation quality with a higher number of optimal obturation as compared to K-file and H-file instrumentation techniques. The instrumentation time with Rotary Kedo-S files was significantly less as compared to K-file and H-file instrumentation.

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Conflicts of interest

There are no conflicts of interest.

   References Top

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Barr ES, Kleirer DJ, Barr NV. Use of nickel-titanium rotary files for root canal preparation in primary teeth. Pediatr Dent 2000;22:77-8.  Back to cited text no. 6
Silva LA, Leonardo MR, Nelson-Filho P, Tanomaru JM. Comparison of rotary and manual instrumentation techniques on cleaning capacity and instrumentation time in deciduous molars. J Dent Child (Chic) 2004;71:45-7.  Back to cited text no. 7
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Drukteinis S, Balciuniene I. A scanning electron microscopic study of debris and smear layer remaining following use of AET instruments and K-flexofiles. Stomatologija 2006;8:70-5.  Back to cited text no. 10
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Finn SB. Morphology of primary teeth. In: Finn SB, editor. Clinical Pedodontics. 4th ed. Philadelphia: Saunders Co.; 1973. p. 59-70.  Back to cited text no. 13
Coll JA, Sadrian R. Predicting pulpectomy success and its relationship to exfoliation and succedaneous dentition. Pediatr Dent 1996;18:57-63.  Back to cited text no. 14
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  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3]

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