Basic Research—Technology
A Micro–computed Tomography Evaluation of
the Shaping Ability of Two Nickel-titanium
Instruments, HyFlex EDM and ProTaper Next
Pier Matteo Venino, DDS, Claudio Luigi Citterio, MD, DDS, Alberto Pellegatta, MD, DDS,
Marta Ciccarelli, DDS, and Marcello Maddalone, MD, DDS
Abstract
Introduction: The aim of this study was to evaluate and
compare, by means of micro–computed tomography im-
aging, the shaping ability of ProTaper Next (PTN) and
the novel HyFlex EDM (HFEDM) instruments. Methods:
Forty teeth were randomly divided into 2 groups and
prepared with PTN or HFEDM. Root canal transportation
and centering ratio were evaluated in mesiodistal and
buccolingual directions at 5 levels (at the midpoint of
the apical, middle, and coronal thirds and at the bound-
aries between them). Variations in volume, surface, and
cross-sectional shape were measured for the apical,
middle, and coronal thirds. The null hypotheses were
that no differences existed between the 2 groups. The
D’Agostino-Pearson test (a = .05) was conducted to
assess the normality of the data sets. The distributions
were compared by using the Mann-Whitney test
(a = .05). Results: Statistically significant differences
(P < .005) were recorded only for buccolingual canal
transportation and centering ratio at the section be-
tween the middle and coronal thirds, where HFEDM files
were superior. Conclusions: HFEDM and PTN files were
similarly effective, and both safely prepared the root
canals, respecting their original anatomies. HFEDM files
performed better in terms of buccolingual canal trans-
portation and centering ratio at the section between
the middle and coronal thirds. (J Endod 2017;43:628–
632)
Key Words
Centering ratio, controlled memory, HyFlex EDM,
M-wire, microcomputed tomography, ProTaper Next,
root canal preparation, transportation
From the School of Dental Medicine, University of Milano-Bicocca - San Gerardo Hospital, Monza, Monza and Brianza, Italy.
Address requests for reprints to Dr Pier Matteo Venino, School of Dental Medicine, University of Milano-Bicocca - San Gerardo Hospital, Via G. Pergolesi, 33, 20900
Monza (MB), Italy. E-mail address: piermatteovenino@icloud.com
0099-2399/$ - see front matter
Copyright ª 2016 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2016.11.022
628 Venino et al.
S haping is considered a
crucial phase in root
canal treatment because
Significance
ProTaper Next and HyFlex EDM showed a similar
shaping ability. Both systems could prepare the
it is not only aimed at
root canals while respecting the original anatomy.
removing remaining pulp
HyFlex EDM caused less transportation and
tissue, microorganisms,
stayed more centered in the buccolingual direction
and debris but should
between the middle and coronal thirds.
also create the precondi-
tions for effective irriga-
tion and obturation (1–3). These tasks should be accomplished without altering the
diameter and position of the apical foramen or excessively weakening the root in any
part. Root canal transportation and the consequent procedural errors (zipping,
ledging, stripping) should be avoided, because they imply a defective debridement
and can negatively influence the subsequent steps of the treatment (3). The degree
of transportation essentially depends on the severity of root canal curvature and on
the flexibility and geometry of the instruments (3). Nickel-titanium (NiTi) files allow
more centered preparations because of their higher flexibility, especially in severely
curved canals, even when increased apical preparation tapers and diameters are
required (4, 5).
During past years several innovations have been proposed to improve the perfor-
mance and safety of NiTi rotary files; as for shaping ability, the main advancements have
been achieved through metallurgical thermal processing and new instrument designs.
Both ProTaper Next (PTN) (Dentsply Maillefer, Ballaigues, Switzerland) and HyFlex
EDM (HFEDM) (Colt
ene/Whaledent, Altst€atten, Switzerland) are considered latest gen-
eration systems (6, 7).
PTN are made of M-Wire NiTi (Sportswire LLC, Langley, OK), which yields a micro-
structure containing portions of martensite, thus enhancing the flexibility and cyclic
fatigue resistance of the alloy over conventional NiTi (8, 9). PTN instruments present
a unique off-centered rectangular cross section, except for the apical 3 mm of X1
file where the section is square. The tip sizes are 17/.04, 25/.06, 30/.07, 40/.06, and
50/.06, and the tapers are variable (increasing and then decreasing in the apico-
coronal direction for X1 and X2, fixed and then decreasing for X3, X4, and X5). These
design features have been studied to enhance flexibility and debris removal, avoid
unnecessary dentin removal, and limit taper lock, screw in, and torque (7, 10).
HFEDM are submitted to controlled memory (CM) treatment, which has been
proven to considerably increase flexibility and cyclic fatigue resistance (11, 12).
HFEDM are presently the only instruments produced by electrical discharge
machining. Their design is characterized by a variable cross section, with a transition
JOE — Volume 43, Number 4, April 2017
 Basic Research—Technology

Figure 1. Measurements performed on each cross section to evaluate root canal transportation and centering ratio (A) before and (B) after preparation.
(C) Heights of the cross sections. B, buccal; D, distal; L, lingual; M, mesial.

from roughly triangular near the shaft (conveying flexibility and fatigue Forty teeth were selected out of the 65 available for this study,
resistance) to rectangular at the tip (granting torsional resistance). preferring multirooted teeth to widen the samples. The teeth were
The HFEDM sequence is as follows: 25/.12 (Orifice Opener), 10/.05 randomly divided into groups HFEDM (20 teeth, 31 canals, 28 roots)
(Glidepath File), 25/.08 (OneFile), 40/.04, 50/.03, and 60/.02. The and PTN (20 teeth, 32 canals, 29 roots) and assigned to 1 of the 4 par-
OneFile has a .08 taper in its apical 4 mm, which decreases to .04 ticipants by using the RAND function of a spreadsheet (Numbers 3.2.2;
along the file. The other files present constant tapers. HFEDM have Apple Inc, Cupertino, CA). None of the researchers had previously used
been claimed to be exceptionally resistant to cyclic fatigue if compared HFEDM or PTN; 2 of them were experienced endodontists, and the other
with CM wire or M-Wire files of similar size and taper (6, 13, 14). 2 were students.
Although the shaping ability of PTN has already been investigated
(15–26), no studies about the ability of HFEDM have been published so TABLE 1. Median Values (Interquartile Range) of the Evaluated Parameters
far. The aim of this study was to fill this gap in knowledge by evaluating HFEDM PTN
and comparing, by means of micro–computed tomography (micro-CT)
imaging, the quality of preparation achieved by PTN and HFEDM. MDT S1 (mm) 0.065 (0.116) 0.077 (0.178)
MDT S2 (mm) 0.057 (0.134) 0.106 (0.111)
MDT S3 (mm) 0.059 (0.076) 0.085 (0.172)
MDT S4 (mm) 0.076 (0.132) 0.118 (0.201)
MDT S5 (mm) 0.077 (0.169) 0.144 (0.166)
Materials and Methods BLT S1 (mm) 0.059 (0.125) 0.098 (0.147)
The teeth had been collected following these inclusion criteria: BLT S2 (mm) 0.120 (0.129) 0.138 (0.150)
extraction because of periodontal, prosthetic, or orthodontic reasons; BLT S3 (mm) 0.081 (0.174) 0.149 (0.287)
intact tooth. Exclusion criteria were as follows: previous endodontic BLT S4 (mm)* 0.064 (0.129) 0.195 (0.342)
BLT S5 (mm) 0.129 (0.252) 0.181 (0.265)
treatment, calcified root canal system, open apex (apical periodontitis, MDC S1 0.368 (0.444) 0.442 (0.456)
apical resorption, age < 16 years), third molar, and extraction MDC S2 0.543 (0.551) 0.426 (0.373)
with burs. After the extraction each tooth was immersed in saline for MDC S3 0.604 (0.333) 0.594 (0.577)
30 minutes, wiped with gauze, and put in a labeled container filled MDC S4 0.458 (0.385) 0.383 (0.535)
MDC S5 0.579 (0.589) 0.403 (0.362)
with 10% formaldehyde.
BLC S1 0.396 (0.579) 0.247 (0.462)
Subsequently, amalgam restorations were removed, and the teeth BLC S2 0.268 (0.502) 0.305 (0.445)
were rinsed with water. An adequate number of transparent, cylindrical, BLC S3 0.429 (0.609) 0.214 (0.455)
plastic containers with a diameter of 3.5 cm were cut to a height of BLC S4* 0.520 (0.443) 0.300 (0.322)
2.5 cm. Each tooth was placed inside a container and embedded in BLC S5 0.462 (0.583) 0.364 (0.413)
DV A (%) 73.74 (152.96) 92.92 (120.81)
epoxy resin (Cristallo Liquido MAKE Design, Torbole Casaglia, BS, Italy) DV M (%) 172.7 (266.87) 84.42 (91.51)
up to the cementoenamel junction. This resin is extremely hard, trans- DV C (%) 76.46 (271.69) 78.59 (109.97)
parent, and considerably less radiopaque than dentin and cementum; DS A (%) 28.29 (33.14) 36.17 (44.60)
therefore, it is an ideal material because it can protect the teeth but still DS M (%) 40.68 (82.56) 28.40 (36.98)
DS C (%) 23.06 (80.29) 27.61 (40.23)
permit both direct and radiographic observation. A small amount of DSMI A 0.242 (0.359) 0.295 (0.297)
boxing wax (Perypheral Wax; Henry Schein Krugg, Buccinasco, MI, DSMI M 0.245 (0.445) 0.226 (0.471)
Italy) was used to keep the teeth in the desired position and to DSMI C 0.278 (0.383) 0.329 (0.340)
protect the apical foramina from resin. This resin inclusion method
A, apical third; BLC, buccolingual centering ratio; BLT, buccolingual transportation; C, coronal third;
made positioning of the teeth inside the micro-CT easier and more DS, surface variation; DSMI, Structure Model Index variation; DV, volume variation; M, middle third;
reproducible; it also facilitated the handling of specimens during end- MDC, mesiodistal centering ratio; MDT, mesiodistal transportation; S1, section at midpoint of apical
odontic procedures. third; S2, section at boundary between apical and middle thirds; S3, section at midpoint of
The teeth were scanned by using a SkyScan 1176 micro-CT middle third; S4, section at boundary between middle and coronal thirds; S5, section at midpoint
(Bruker, Billerica, MA), with a resolution of 8.92 mm. The cross- of coronal third.
section images were reconstructed by using NRecon (Bruker). *Statistically significant difference.

JOE — Volume 43, Number 4, April 2017 Shaping Ability of HyFlex EDM and ProTaper Next 629
Basic Research—Technology

Figure 2. Representative images of roots of mandibular second molar (A–D) before and (E–H) after preparation with PTN and of maxillary second molar (I–L)
before and (M–P) after preparation with HFEDM. The cross sections correspond to level S4. In the three-dimensional models the original root canal anatomy is
depicted in white, and the shape produced by instrumentation is shown in red for PTN and in green for HFEDM.

Periapical radiographs were taken to allow preoperative evaluation
of pulp chamber morphology and working length (DBSWIN; D€urr Dental
AG, Horn, Switzerland). Access cavities were prepared, and the working
lengths were checked by taking radiographs with K-files inserted in the
canals. The root canals were instrumented according to the manufac-
turers’ instructions (6, 7). The files were visually inspected to check
for damage. Two orifices could not be located, and 5 canals were
obstructed by resin infiltrations, which occurred through the furcation
canals of some molars; indeed, only the apical foramina were
protected with wax, whereas it was considered unnecessary to take
the same precaution for furcations. Consequently, 4 canals were
excluded from HFEDM group and 3 canals from PTN group.
The teeth were scanned again, and changes produced by shaping
were assessed by using CTan software (Bruker). Transportation and
centering ratio were evaluated as originally described by Gambill et al
(27), in both mesiodistal and buccolingual direction (Fig. 1A
and B), for every root canal that had been prepared to its working
length. Measurements and calculations were performed on 5 cross sec-
tions corresponding to the midpoint of the apical (S1), middle (S3),
and coronal (S5) thirds and to the boundaries between them
(S2, S4). These heights were determined by dividing by 6 the distance
between the anatomic apex (A) and the pulp chamber floor (F); in
single-rooted teeth, the latter was identified as the most apical slice
where cervical enamel appears (Fig. 1C).

630 Venino et al. JOE — Volume 43, Number 4, April 2017


Figure 3. (A) Radiopaque fragment in apical third of maxillary canine prepared with PTN. (B and C) Apical third section of mandibular premolar before and after
instrumentation showing dentinal crack caused by instrumentation with HFEDM.
Variations in volume, surface, and cross-sectional shape were
evaluated for the root canal systems of every root in which at least 1
of the canals had been instrumented to its working length. The measure-
ments were performed separately for the apical, middle, and coronal
thirds. The resolution was resized to 17.8 mm for these computations.
Because the canal systems were non-uniform in terms of length, diam-
eter, and morphology, increases in volumes and surfaces were calcu-
lated as a proportion relative to the initial value. Geometry variations
were investigated by using the Structure Model Index (SMI) as pro-
posed by Peters et al (28); a subtraction between the final and the initial
value was sufficient in this case.
Statistical analysis was performed with Prism 6.0 (GraphPad Soft-
ware Inc, La Jolla, CA). The D’Agostino-Pearson normality test
(a = 0.05) was conducted on each data set. The null hypotheses
(ie, no differences between the 2 groups) were tested by using the
Mann-Whitney test (a = 0.05).
For the calculation of transportation and centering ratio the statis-
tical units were represented by single-root canals. When 2 or more ca-
nals merged into 1, only those that could be instrumented to the apical
foramen were considered valid. Taking into account the aforemen-
tioned dropouts, the sample size was n = 27 for HFEDM group and
n = 29 for PTN group.
As for variations in volume, surface, and SMI, the statistical units
were the roots, and the sample size after the dropouts was n = 24 for
HFEDM group and n = 26 for PTN group.
Results
The results are reported in Table 1.
In mesiodistal direction, HFEDM caused less transportation in
every section and stayed more centered in S2, S3, S4, and S5; a better
centering ratio was achieved with PTN in S1. However, these differences
were slight, and none of them were statistically significant (P > .05).
In buccolingual direction, HFEDM produced less transportation at
every level and a more centered preparation in S1, S3, S4, and S5; PTN
were more centered in S2. Statistically significant differences (P < .005)
were found for both transportation and centering ratio in S4. The other
differences were modest and non-significant (P > .05).
Variations in root canal (or canal system) volume, surface, and
SMI were a little less pronounced in HFEDM group for the apical and
coronal thirds, whereas the opposite was observed for the middle third.
None of these differences were found to be statistically significant
(P > .05).
Figure 2 shows representative images of molars prepared with PTN
(Fig. 2A-H) and HFEDM (Fig. 2I-P).
JOE — Volume 43, Number 4, April 2017
Basic Research—Technology
Discussion
To date, no article has been published on the shaping ability of
HFEDM, whereas several studies have reported generally good results
for PTN (15–26).
Canal transportation is commonly found to be in the range of 100–
200 mm (5). Median values ranged from 57 to 129 mm for HFEDM and
from 77 to 195 mm for PTN; therefore, as regards transportation, both
systems achieved good results, especially in the apical third.
Statistically significant differences were observed only for bucco-
lingual canal transportation and centering ratio at section S4 (ie, be-
tween the middle and the coronal thirds). Transportation at this level
may potentially cause excessive weakening of the dentinal walls and
stripping perforations. There is no evidence on what should be the min-
imal remaining dentin thickness because several thresholds have been
proposed (29–31); however, a thickness of 0.3 mm is generally
considered critical (29). In our sample transportation was substantial
only in a few cases, and dentin thickness never exceeded this limit.
It is reasonable to ascribe the results to a higher flexibility of
HFEDM files. The differences in cross-sectional shapes and tapers
may have contributed to these outcomes. PTN X1 and X2 files present
a progressive taper in their apical part and a decreasing taper in the cor-
onal section; consequently, the greatest tapers coincide approximately
with section S4. On the other hand, the HFEDM OneFile (#25/.08) has a
decreasing taper starting at 4 mm from the tip. Therefore, there seems to
be a correlation between tapers and transportation that may explain the
significant difference in S4.
These observations are consistent with a recent study by Wu et al
(23), who compared the shaping ability of ProTaper Next, ProTaper
Universal, and WaveOne instruments. In L-shaped simulated root ca-
nals, PTN maintained the canal curvature best and caused the least api-
cal transportation but produced the highest transportation coronal to
the curvature.
HFEDM determined slightly less transportation at every level and in
most cases stayed a little more centered. Because the apical taper of the
HFEDM OneFile is greater or similar to those of the corresponding PTN
files, these data are interesting (although non-significant). However,
this is not surprising because CM treatment has been proven to make
HyFlex CM files more flexible than conventional NiTi and M-Wire instru-
ments of the same size and taper (11, 12).
Variations in volume, surface, and SMI were in favor of HFEDM in
the apical and coronal thirds, whereas PTN achieved better results in the
middle third; once again, the results can be interpreted as a consequence
of tapers. However, these differences were minor and non-significant;
hence, PTN and HFEDM were similarly conservative in terms of removed
dentin and in respect of the original cross-sectional shape of the canals.
Shaping Ability of HyFlex EDM and ProTaper Next 631
Basic Research—Technology
This study’s protocol did not contemplate other evaluations;
nevertheless, radiopaque fragments (Fig. 3A) and dentinal cracks
(Fig. 3B and C) were rather frequently observed in both groups, so a
brief report seemed opportune.
Ten canals in HFEDM group (37%) and 3 canals in PTN group
(10.3%) presented 1 or more radiopaque objects in their apical
part. The clinical meaning of these fragments seems of little relevance
because they did not impede thorough instrumentation, irrigation,
and obturation. Further investigations are in progress to ascertain the
origin of the fragments, which is not clear at the present time. Judging
from their aspect, they could be hand file tips or portions of the cutting
surfaces of rotary files, separated because of taper lock; no major dam-
age was noticed when the files were inspected after being used, probably
because of the small size of the fragments. In the first hypothesis, which
is more likely because the fragments were observed in both groups, the
different incidences may be explained with PTN files’ design, which is
expected to allow a more efficient debris removal. In the second hypoth-
esis, possible interpretations include an improper torque setting and/or
inadequate management of the auto-reverse function by the endodontic
motor used with HFEDM files (CanalPro CL 2; Colt
ene/Whaledent) and
the fact that the HFEDM instruments were prototypes, which may have
not been subjected to some of the steps of the commercial production
line. The sample preparation method may have contributed somehow to
these inconveniences.
Nine cracked roots in HFEDM group (37.5%) and 4 in PTN group
(15.4%) were observed. Only the cracks created or extended by instru-
mentation were counted. Because this study was not designed to eval-
uate this parameter, the sample had not been treated consequently.
Resin inclusion may have prevented crack propagation to some extent;
on the other hand, teeth were not kept moist after inclusion, possibly
promoting crack formation. However, these data are consistent with
the results of studies focused on this topic; the incidence in PTN group
was slightly lower than what is commonly reported (32–35).
Conclusions
At the section located between the middle and coronal thirds,
HFEDM files performed better in terms of buccolingual canal transpor-
tation and centering ratio. Overall, HFEDM and PTN systems were simi-
larly effective, and both safely prepared the root canals, respecting their
original anatomies.
Acknowledgments
Colt
ene/Whaledent supported this research, providing mate-
rials and funds for micro-CT scanning.
The authors deny any conflicts of interest related to this study.
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JOE — Volume 43, Number 4, April 2017