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Coordena??o de Aperfei?oamento de Pessoal de N?vel Superior - CAPES
Introduction: The fracture of nickel titanium endodontic instruments may have a negative impact on the prognosis of the treatment, mainly because it blocks or prevents access to the root canal system in all its extension, compromising its modeling and sanification. Results from in vitro studies suggest that reciprocating motion can reduce the risks of torsion fracture and cyclic fatigue of NiTi instruments, compared to the continuous rotation movement. However, most of the studies that evaluate fracture resistance of instruments in reciprocating and rotational motion are in vitro studies, the generation of evidence of which is limited in comparison to the level of evidence generated by clinical studies in humans. Therefore, the present systematic review investigated whether the available evidence supports the hypothesis that reciprocating motion results in a lower clinical incidence of NiTi limb fracture as compared to rotational kinematics. Methodology: The PubMed, Embase, Isi Web of Science and Cochrane Library databases were searched until August 2017, without language restriction. In addition to the electronic searches, manual searches were made for additional references in specific chapters of relevant books in the area and also search in the gray literature. Based on the inclusion and exclusion criteria, two reviewers independently assessed the quality of each study based on the NewCastle Ottawa scale. The main exposure variable was the type of kinematics used to prepare the root canal (continuous or reciprocating) and the primary outcome variable was determined by the incidence of fracture of NiTi instruments in endodontic treatments. The incidence of fracture was recorded, having as unit of analysis: patients, teeth, instruments or channels. Other confounding variables collected included: country, year of publication, study design, type of system, group of teeth, number of sessions, operator and number of uses of NiTi instruments. The sources of heterogeneity were explored and the bi and multivariate meta logistic regression were performed to calculate the pooled estimates - odds ratios (OR) and 95% CI - for the incidence of instrument fracture, assessing the role of primary exposure and co- as moderators of the outcome. Results: Among the 737 articles initially identified, after the duplicates were removed, 39 comprised the final quantitative analysis, of which 32 reported the use of continuous rotation and 7 the use of reciprocating kinematics. Thirty-seven studies were included in the meta regression (N = 48,405 instruments). The aggregate clinical incidence of fracture of NiTi files was 2.43%, being 2.62% for continuous rotational movement and 0.4% for reciprocating kinematics. In the bivariate analysis, continuous rotational motion showed a greater incidence of fracture in relation to the reciprocating kinematics (OR = 6.39, 95% CI = 1.10-36.9), and the other associated covariates (p 1 tooth (OR = 6.46, 95% CI = 1.42-29.3) and that general clinical operators (OR = 11.8, 95% CI = 1.49-93.5) were independently associated with a higher incidence of fracture of NiTi files, whereas kinematics was non-significant (OR = 1.56, 95% CI= 0.24-10, 0) after the settings. Conclusions: Available evidence from observational studies is limited but consistent, suggesting that reciprocating kinematics is associated with a lower incidence of fracture of NiTi files when compared to continuous rotation. In addition, the results revealed that other related clinical factors to the abilities of the operator,to the number of uses of the NiTi instruments, and to the advances in alloy composition as well as in the design of the files, have proved to be more relevant factors for fracture prevention than the type of kinematics employed.
Introdu??o: A fratura de instrumentos endod?nticos de n?quel tit?nio pode ter um impacto negativo no progn?stico do tratamento, sobretudo por bloquear ou impedir o acesso ao sistema de canais radiculares em toda sua extens?o, comprometendo a sua modelagem e sanifica??o. Resultados de estudos in vitro sugerem que o movimento reciprocante pode reduzir os riscos de fratura por tors?o e fadiga c?clica dos instrumentos de NiTi, comparado ao movimento de rota??o cont?nua. Ainda assim, a maioria dos estudos que avaliam a resist?ncia ? fratura de instrumentos no movimento reciprocante e rotat?rio s?o estudos in vitro, cuja gera??o de evid?ncias ? limitada em compara??o ao n?vel de evid?ncia gerada por estudos cl?nicos em humanos. Portanto, a presente revis?o sistem?tica investigou se a evid?ncia dispon?vel suporta a hip?tese de que o movimento reciprocante resulta em uma menor incid?ncia cl?nica de fratura de limas de NiTi, em compara??o com a cinem?tica rotat?ria. Metodologia: Foram pesquisadas as bases de dados PubMed, Embase, Isi Web of Science e Cochrane Library at? agosto de 2017, sem restri??o de idiomas. Al?m das buscas eletr?nicas foram realizadas buscas manuais por refer?ncias adicionais em cap?tulos espec?ficos de livros relevantes na ?rea e tamb?m busca na literatura cinza. Com base nos crit?rios de inclus?o e exclus?o, dois revisores avaliaram independentemente a qualidade de cada estudo com base na escala de NewCastle Ottawa. A principal vari?vel de exposi??o foi o tipo de cinem?tica empregada para o preparo do canal radicular (rotat?ria cont?nua ou reciprocante) e a vari?vel de desfecho prim?rio foi determinada pela incid?ncia de fratura de instrumentos de NiTi em tratamentos endod?nticos. A incid?ncia de fratura foi registrada, tendo como unidade de an?lise: pacientes, dentes, instrumentos ou canais. Outras vari?veis de confundimento coletadas incluiram: pa?s, ano de publica??o, desenho do estudo, tipo de sistema, grupo de dentes, n?mero de sess?es, operador e n?mero de usos dos instrumentos de NiTi. As fontes de heterogeneidade foram exploradas e a meta regress?o log?stica bi e multivariada foram realizadas para calcular as estimativas agrupadas ? odds ratios (OR) e 95%IC ? para a incid?ncia de fratura de instrumentos, avaliando o papel da exposi??o principal e das co-vari?veis, como moderadores do desfecho. Resultados: Entre os 737 artigos inicialmente identificados, ap?s remo??o das duplicatas, 39 compuseram a an?lise quantitativa final, dos quais 32 reportavam o uso de rota??o cont?nua e 7 o uso de cinem?tica reciprocante. Trinta e sete estudos foram inclu?dos na meta regress?o (N=48.405 instrumentos). A incid?ncia cl?nica agregada de fratura de limas de NiTi foi de 2,43%, sendo de 2,62% para o movimento rotat?rio cont?nuo e de 0,4% para a cinem?tica reciprocante. Na an?lise bivariada, o movimento rotat?rio cont?nuo demonstrou uma incid?ncia maior de fratura em rela??o ? cinem?tica reciprocante (OR=6,39, IC95%=1,10- 36,9), e as outras covari?veis associadas (p1 dente (OR=6,46, IC95%=1,42-29,3) e que operadores cl?nicos gerais (OR=11,8, IC95%=1,49-93,5) foram associados de modo independente com uma maior incid?ncia de fratura de limas de NiTi, enquanto que a cinem?tica demonstrou-se n?o-significante (OR=1,56, IC95%=0,24-10,0) ap?s os ajustes. Conclus?es: A evid?ncia dispon?vel, oriunda de estudos observacionais, ? limitada por?m consistente, sugerindo que a cinem?tica reciprocante est? associada com uma menor incid?ncia de fratura de limas de NiTi, quando comparada ao movimento de rota??o cont?nua. Al?m disso, os resultados revelaram que outros fatores cl?nicos relacionados ?s habilidades do operador, ao n?mero de usos dos instrumentos de NiTi, e aos avan?os na composi??o das ligas bem como no desenho das limas, demonstraram ser fatores mais relevantes para a preven??o da fratura do que o tipo de cinem?tica empregada.
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