Endodontic Topics 2015, 33, 43–49 © 2015 John Wiley & Sons A/S.

All rights reserved Published by John Wiley & Sons Ltd

ENDODONTIC TOPICS
1601-1538

Endodontic instrumentation and

root filling procedures: effect on
mechanical integrity of dentin
HAGAY SHEMESH

Vertical root fractures are a major reason for extraction of endodontically treated teeth and teeth after root
canal treatment are more prone to fracture compared to untreated teeth. One suggested reason for this
difference is the destructive effects of some files and filling methods used during root canal treatment.
However, most studies that investigated the effects of specific instrumentation and filling methodologies on
the root canal walls are in vitro destructive experiments and a concern has lately been raised on the clinical
relevancy of the results of these studies. Novel non-destructive methodologies and a cadaver study recently
tried to challenge the concept of dentinal defects caused by instrumentation alone. This article presents an
overview of the various studies conducted on the effect of endodontic procedures on the appearance of dental
defects and will critically examine the evidence in light of the relevant literature.

Received 5 April 2015; accepted 9 September 2015.

craze lines or incomplete cracks in root dentin (4,5).

Introduction
During root canal treatment, various instruments
and materials are used. Those developed in the past
decade include an elaborate array of files, filling
methods, and advanced materials aimed at making
the procedure quicker and more reliable and to
allow the clinician to successfully treat difficult cases
and complex anatomies. However, these methods
and materials usually come with higher costs (1).
Above all, the impact of these instruments and
materials on the outcome of the treatment is
unclear (2). Moreover, claims were made that some
of these new methodologies, and especially
machined file systems, are destructive and might
cause microcracks in dentin, which could later
propagate to clinically significant fractures with
devastating effects (3).
Clinical procedures during root canal treatment
were previously shown to contribute to the
development of various localized defects such as
Several factors may be responsible for the formation
of these dentinal microcracks: instrumentation and
root filling (3,4), high concentrations of
hypochlorite (6), tooth anatomy (7), and post
placement (8).
After initial reports on the potential damage of
instrumentation and root canal filling to the root
canal walls (3,9), numerous studies checked the
effect of different steps of the root canal treatment
on the integrity of dentin. This recent surge in
reports raised a debate on the damaging potential of
certain procedures but also on the clinical relevance
of these studies (10).
The clinical effect of operative procedures on the
formation of microcracks in dentin is multifactorial:
occlusal forces, remaining tooth structure, patient
habits, and environmental factors may all play a role.
However, the in vitro and ex vivo experiments that
check the influence of specific files and filling
methods on the appearance of microcracks are

43
Shemesh

performed on extracted teeth that lack bone and A

periodontal ligament support. The influence of the
generated forces could thus be altered and affect the
results and their clinical relevancy (11).
The aim of this review is to present the evidence
regarding the appearance of dentinal microcracks
during endodontic procedures and to critically assess
their relevance to clinical practice.
The studies will be discussed based on the
following classification:
(i) microscopic studies on root sections;
(ii) studies using external microscopic observations;
(iii) micro-computed tomography (lCT) studies;
and
B
(iv) other studies.

Microscopic studies on root sections

Research on the effect of endodontic procedures on
the root canal wall concentrate on the findings that
vertical root fractures are probably caused by the
propagation of smaller, less pronounced defects and
not directly by the force practiced during
preparation or obturation (12).
The methodology of most of these microscopic
studies includes inspection of extracted teeth (often
from an unknown source or time interval after
extraction), sectioning of the teeth at 2–3 levels
(mostly 3, 6, and 9 mm from the apex), and
inspecting the sections under a light microscope
(Fig. 1). A control group is almost always present
and includes teeth that were not instrumented.
Cracks are observed according to their position,
either originating in the external root surface or the
canal lumen. The number and types of cracks in
each section are reported.
Using sectional microscopic observations, many
file systems were investigated with respect to their
damaging potential and their ability to create
microcracks. These include hand files (9,14–17),
Greater Taper (GT) files (3,9), ProTaper Universal
(9,13–15,17–23), Self-Adjusting File (SAF) (13,20,
21), Reciproc (14,15,21,24), WaveOne (17,22–24),
and others, namely ProTaper Next, S-Apex, Revo-S,
Twisted Files, Mtwo, and One Shape. It seems that the
available file systems are checked for their damaging
ability immediately after their release almost routinely.
As the above-mentioned studies use different
files, sizes, tapers, and teeth, a comparison of the
Fig. 1. Dentinal microcrack on a histological section
after (A) root canal instrumentation and (B) root canal
filling with lateral compaction.
results is impossible. However, a few general
conclusions can be drawn by studying the data
from histology studies looking at microcracks after
instrumentation:
• In almost all cases, the control groups
(unprepared teeth) showed no crack formation in
sectional observations (13,15–17,19,20).
• Studies that included a hand file group reported
less dentin damage by hand instrumentation
compared to machined files (9,15,17).
• Studies that included a SAF group concluded
that the SAF is significantly less damaging than
other file systems (13,20,21).
• Various machined nickel–titanium systems show
different degrees of damage to the root canal
wall even without further intervention (13–17).
Although evaluation methods were similar, the
protocols used in these studies are not always

44
Shemesh
A appearance of microcracks (31). In a different study,
B teeth in aluminum foil, embedding them in acrylic
C De-Deus et al. concluded that root canal
Fig. 2. Spontaneous cracking of dentin after drying
(A) immediately after cutting, (B) after 1 hour, and
(C) after 5 hours, with Methylene blue dye. Courtesy
of C. Aznar-Portoles.
microcracks on the apical surface as compared to
working at full length or beyond the apex. They also
saw a correlation between the larger file sizes and the
46
the same group found that root canal procedures
such as instrumentation and obturation could initiate
and propagate cracks in the apical region (32).
A second research group adapted a similar
methodology and concluded that rotary nickel–
titanium instruments K3 and ProTaper Universal
caused more microcracks than hand instruments, and
that shorter preparations reduced the risk of
microcracks (33). In a second study by the same
group, it was concluded that SAF and Reciproc
caused fewer cracks than ProTaper Universal and
One Shape files (21). The last group tried to imitate
the effects of the periodontal ligament by placing the
resin, and placing the exposed apex in water to
prevent dehydration.
Studies inspecting the external surface of the apex
rather than (or in addition to) cutting the teeth are
less destructive and every tooth can serve as its own
control because the apex is first visualized before the
treatment as a “baseline.”
Micro-computed tomography (lCT)
studies
So far, only a few studies have explored the influence
of files on the root canal walls with lCT (34–36).
instrumentation with WaveOne, BioRace, Reciproc
(34), ProTaper Next, and Twisted Files Adaptive
(35) did not result in more microcracks than before
the instrumentation. They argued that destructive
microscopic evaluation is unreliable in assessing the
damage after root canal instrumentation. However,
the resolution of conventional lCT scans could be
insufficient to detect microcracks and fractures (37).
Pop et al. (36) used synchrotron radiation to
produce highly detailed scans. With phase-enhanced
technology, resolutions of a few microns or less
could be achieved (38) (Fig. 4). Pop et al. (36)
concluded that although some unprepared teeth
from the control group presented dentinal
microcracks even before instrumentation, their
number and length increased after instrumentation
with ProTaper and WaveOne files.
Unfortunately, it is unclear if teeth were scanned
wet or under dry conditions in these lCT and
synchrotron-based lCT studies. While the scanning
Shemesh
A appearance of microcracks (31). In a different study,
B teeth in aluminum foil, embedding them in acrylic
C De-Deus et al. concluded that root canal
Fig. 2. Spontaneous cracking of dentin after drying
(A) immediately after cutting, (B) after 1 hour, and
(C) after 5 hours, with Methylene blue dye. Courtesy
of C. Aznar-Portoles.
microcracks on the apical surface as compared to
working at full length or beyond the apex. They also
saw a correlation between the larger file sizes and the
46
the same group found that root canal procedures
such as instrumentation and obturation could initiate
and propagate cracks in the apical region (32).
A second research group adapted a similar
methodology and concluded that rotary nickel–
titanium instruments K3 and ProTaper Universal
caused more microcracks than hand instruments, and
that shorter preparations reduced the risk of
microcracks (33). In a second study by the same
group, it was concluded that SAF and Reciproc
caused fewer cracks than ProTaper Universal and
One Shape files (21). The last group tried to imitate
the effects of the periodontal ligament by placing the
resin, and placing the exposed apex in water to
prevent dehydration.
Studies inspecting the external surface of the apex
rather than (or in addition to) cutting the teeth are
less destructive and every tooth can serve as its own
control because the apex is first visualized before the
treatment as a “baseline.”
Micro-computed tomography (lCT)
studies
So far, only a few studies have explored the influence
of files on the root canal walls with lCT (34–36).
instrumentation with WaveOne, BioRace, Reciproc
(34), ProTaper Next, and Twisted Files Adaptive
(35) did not result in more microcracks than before
the instrumentation. They argued that destructive
microscopic evaluation is unreliable in assessing the
damage after root canal instrumentation. However,
the resolution of conventional lCT scans could be
insufficient to detect microcracks and fractures (37).
Pop et al. (36) used synchrotron radiation to
produce highly detailed scans. With phase-enhanced
technology, resolutions of a few microns or less
could be achieved (38) (Fig. 4). Pop et al. (36)
concluded that although some unprepared teeth
from the control group presented dentinal
microcracks even before instrumentation, their
number and length increased after instrumentation
with ProTaper and WaveOne files.
Unfortunately, it is unclear if teeth were scanned
wet or under dry conditions in these lCT and
synchrotron-based lCT studies. While the scanning
 Endodontic instrumentation and root filling procedures
A B
Fig. 3. External apical cracks (A) before instrumentation and (B) immediately after instrumentation.
Fig. 4. Dentinal cracks after root canal filling as seen
from a synchrotron scan. Courtesy of P. Zaslansky.
procedure can last for an hour or more, the tooth is
placed in the scanner to dry. Under dry conditions,
spontaneous cracks in dentin could occur (10,39)
(Fig. 2). This could explain the appearance of cracks
in untreated teeth in those studies but also put to
question the reliability of the results. Fortunately,
scanning of teeth in lCT and synchrotron radiation
could be performed in wet conditions and hopefully
more studies will be able to shed light on the
appearance of microcracks by repeating these studies
under wet conditions.
Other studies
Arias et al. (10) performed a study on cadavers. In
their study, the lower incisors in 6 adult human
cadaver skulls were inspected. There were three
groups of 6 teeth each: a control group without any
treatment, root canal instrumentation with Profile
Greater Taper files, and WaveOne files. After peeling
the bone around the teeth away, roots were
sectioned and observed under a microscope. There
were no significant differences in the incidence of
microcracks among the three groups. The authors
question the ability of files to cause damage to root
canal walls and highlight the fact that the control
group had as many microcracks as the instrumented
teeth. Their conclusions are in line with those of
De-Deus et al. (34,35). The advantage of a cadaver
study is that teeth were not extracted; they are in
their socket surrounded by periodontal ligament and
they mimic the clinical situation better than
microscopic studies on extracted teeth. However,
the preservation condition of the cadaver could have
an influence on dentin quality and tissue
characteristics and the disadvantages of sectioned
studies as mentioned before still exist.
Discussion
It seems that root canal procedures can influence the
root canal walls but it is unclear in what way or
under which conditions. Studies of dentinal
microcracks report conflicting data, resulting in
confusing recommendations and conclusions. Most
47
Shemesh
studies showing the influence of specific files and
filling methods used extracted teeth and destructive
procedures to cut the roots in order to inspect the
root canal walls. Additionally, some of these studies
do not specify how teeth were kept during the
procedures and if they were fully moist at all times.
Dried root sections could spontaneously crack under
certain conditions and demonstrate both separation
of the cementum layer and craze lines. The influence
of instrumentation on the formation of microcracks
is especially controversial as new data suggests that
the influence of instrumentation is limited
(10,34,35). However, new challenges are being
raised because it seems that most unprepared teeth
demonstrate cracks inside the root canals. The
reason for this is unclear but speculations that the
age of the patient or mastication functions could
contribute to the appearance of such defects have
been raised (10). These observations deserve special
attention because they suggest that physiological
aging and wear could result in microcracks in root
canals.
Perhaps one of the most striking trends in the
development of new techniques, instruments, and
materials in the past years is the minimally invasive
concept (40). The concern about the potential
damaging effects of endodontic procedures could
have contributed to this new direction. New file
systems typically have smaller tapers (ProTaper Next
as compared to ProTaper Universal) and a design
that results in less aggressive action (SAF) while new
filling materials concentrate on conservative methods
with less applied pressure (C-point).
Conclusions
More research should be done on the effect of
drying and spontaneous dentin cracks before
conclusive recommendations can be provided on the
use of root canal treatment procedures on root canal
walls. Non-destructive techniques such as lCT and
synchrotron phase-enhanced scans offer insight into
the microstructure of dentin and the action of files
on dentin but should be interpreted with caution
due to the structural alterations of dentin when a
scan is performed under dry conditions. According
to the available in vitro data, no clinical
recommendations can be made on the destructive
influence of endodontic procedures on dentin.
48
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