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Background:
Systematic Review

Apical Transportation of Apical Foramen by Different NiTi Alloy Systems: A Systematic Review

by
Francesco Puleio
1,*,
Ugo Bellezza
2,
Alessandra Torre
1,
Francesco Giordano
3 and
Giuseppe Lo Giudice
4
1
Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Messina University, 98100 Messina, Italy
2
Department of Dentistry, Sapienza University of Rome, Piazzale Aldo Moro 5, 00185 Rome, Italy
3
Department of Medicine, Surgery and Dentistry, University of Salerno, 84084 Salerno, Italy
4
Department of Clinical and Experimental Medicine, Messina University, 98100 Messina, Italy
*
Author to whom correspondence should be addressed.
Appl. Sci. 2023, 13(19), 10555; https://doi.org/10.3390/app131910555
Submission received: 29 July 2023 / Revised: 18 September 2023 / Accepted: 19 September 2023 / Published: 22 September 2023
(This article belongs to the Special Issue State-of-the-Art of Dental Materials)
Browse Figure
Versions Notes

Abstract

:

Featured Application

Apical transportation determined by the endodontic shaping phase can lead to failure of the therapy itself. The use of endodontic instruments with flexible alloys could reduce this problem. The objective of this systematic literature review is to evaluate whether the use of martensitic endodontic instruments can result in less apical transportation compared to austenitic instruments during endodontic therapy. Based on the analysis of the selected articles, it can be concluded that martensitic endodontic instruments result in less apical transportation compared to austenitic instruments during the shaping phase of endodontic treatment.

Abstract

Endodontic shaping can lead to canal and apical anatomical alterations, which may compromise the outcome of root canal treatment. The objective of this systematic literature review is to assess whether the use of martensitic endodontic instruments can result in less apical transportation compared to austenitic instruments during endodontic therapy. A search was conducted on PubMed, Ovid MEDLINE, and the Web of Science. The inclusion criteria were in vitro studies comparing apical transportation using endodontic instruments with austenitic or martensitic alloys. The search of the scientific databases yielded 592 results, of which only 10 were eligible for evaluation after screening. Based on the analysis of the selected articles, it can be concluded that martensitic endodontic instruments result in less apical transportation compared to austenitic instruments during the shaping phase of endodontic treatment. This behavior can be attributed to the increased flexibility of martensitic instruments. Further research is warranted to further explore this topic and provide additional evidence supporting the use of martensitic instruments in clinical practice.

1. Introduction

Shaping the root canal system is essential for achieving clinical success in endodontic treatment [1]. Canal shaping should aim to preserve the canal and apical anatomy as much as possible [2]. Numerous NiTi instruments have been introduced to reduce alterations to and deformations of the canal during endodontic shaping [3,4,5]. However, due to various factors, such as the geometry, alloy, and movement of the instruments, as well as the characteristics of the canal (dentin hardness, canal curvature radius and angle, and complex anatomies) and operator experience, it is still possible to alter this anatomy, leading to consequences such as stripping, canal transportation, or apical transportation [6,7]. Apical transportation refers to the deviation of the physiological apical position from the iatrogenic position, generally located on the outer surface of the curvature, which can compromise the outcome of root canal treatment, and once transportation has occurred, it is impossible to return the canal to its original shape, particularly in curved canals [8,9]. Apical transportation occurs due to the leaning of the rotary instrument in order to return to the original position when subjected to deformation. Consequently, rotary instruments tend to remove more of the dentin on the outermost side of the canal curve. Apical transportation can be classified into three types, depending on the degree [10]:
Type I: minor movement of the position of the foramen, leading to its iatrogenic relocation.
Type II: moderate movement of the physiological position of the foramen, with consequent iatrogenic displacement on the external root surface. In this type of apical transport, a wider communication with the periapical space is achieved. As a result, type II apical transportation can lead to a weak or perforated root.
Type III: severe movement of the physiologic position of the canal, resulting in a significant iatrogenic relocation of the physiologic foramen.
Regarding the treatment of different types of apical transportation, type I transportation is the only type manageable by nonsurgical endodontics. Type II and III require surgical endodontics in order to properly complete the endodontic therapy [11].
Apical transportation may result in inadequately cleaned root canals, root weakening, and improper debridement of the canal in the apical region, and can also lead to the zipping or perforation of the apical foramen [12]. Moreover, it may result in the extrusion of irrigation solution, debris, and filling materials [13,14]. Furthermore, although type I does not require surgical endodontic treatment, it can still make orthograde endodontic therapy more difficult, sometimes making it necessary to use mineral trioxide aggregate (M.T.A.) or new bioceramic materials in order to obtain a correct apical seal [15,16].
In recent decades, there has been a revolution in the production of endodontic instruments with different mechanical characteristics. Technological advancements in the production and treatment of NiTi alloys for use in endodontic files have allowed the development of alloys with different phase transformation behaviors, improving their flexibility, centering ability, fatigue, and torsional resistance [17,18,19,20,21]. Companies have devised various methods for altering the manufacturing process or modifying the physical properties of NiTi instruments, including the use of complex heating–cooling phases to vary the temperature of NiTi alloy’s transition between austenitic and martensitic phases. While austenitic NiTi is strong and hard, the material becomes soft, ductile, and flexible in its martensitic form [22,23,24,25,26]. This has led to the creation of alloys such as M-Wire™ (Dentsply-Tulsa & WDV), R-Phase™ (Kerr), CM-Wire™ (Coltène Whaledent), Blue™ (Dentsply-Tulsa), Gold™ (Dentsply-Tulsa), and Max-Wire™ (FKG), characterized by their ability to transition from the martensitic to austenitic phase at different temperatures. This allows the instruments to operate in the martensitic phase at room temperature and return to the austenitic phase when heated to their phase transition point. The transition temperatures from martensitic to austenitic phases are as follows: 17 °C for R-Phase; 35 °C for Max-Wire; 38 °C for Blue; 50 °C for M-Wire; and 55 °C for CM and Gold [27,28]. This increased flexibility enables instruments with martensitic heat treatments to rotate more centrally within the endodontic canal, following the canal’s anatomy and reducing issues such as canal and apical transportation.
The objective of this systematic literature review is to evaluate whether the use of martensitic endodontic instruments results in less apical transportation compared to the use of austenitic instruments during endodontic therapy.

2. Materials and Methods

2.1. Protocol and Registration

The preferred reporting items of systematic reviews and metanalyses (PRISMA) guidelines were followed for the writing of this systematic review [29]. Before writing this paper, a point-to-point protocol describing the methodology was developed. The review was registered in the CRD York website, PROSPERO (International Prospective Register of Systematic Reviews), organized by the Centre for Reviews and Dissemination (the University of York, National Institute for Health Research, York, UK), with the protocol number CRD42023405277 and the title “Apical Transportation of Different NiTi Alloy Systems: a Systematic Review”.

2.2. Search Strategy

The systematic review was carried out on electronic databases, including Ovid MEDLINE, PubMed, and the Web of Science. No search by hand was performed on other databases. The date parameter for the paper collection was set from January 2013 until April 2023. The following terms and their combinations were searched: (Apical transportation) AND (Instrument alloy), to which Boolean operators were applied. The keywords were selected with the aim of gathering and registering as much relevant data as possible.
The following focus question was developed, according to the population, intervention, comparison, and outcome (PICO) study design:
“Do files with martensitic alloys (I) cause less transportation of the apical foramen (O) than files with austenitic alloys (C) in endodontically treated teeth (P)?”
The review included in vitro studies in which a comparison was performed on the apical transportation of teeth endodontically treated with different endodontic instruments made of different alloys.

2.3. Eligibility Criteria

The full texts of all potentially relevant research papers were obtained, in consideration of the following inclusion criteria:
  • In vitro studies comparing apical transportation using endodontic instruments with austenitic or martensitic alloys.
The exclusion criteria that were considered were:
  • Research involving teeth with disease.
  • Research evaluating canal transportation and not apical transportation.
  • Research comparing apical transportation using only one file type.
  • Research comparing apical transportation using only one type of alloy.
  • Case reports, case series, reviews, and meta-analyses.
  • Papers with no full text available.
  • Papers written in languages other than English.

2.4. Study Selection and Data Extraction

To reduce bias, two researchers from Messina University (F.P. and A.T.) independently conducted the literature search, and in cases where there were discrepancies in the results, a third senior researcher (G.L.G.) was consulted at each phase (i.e., initial screening, eligibility for final inclusion, data extraction and analysis, and quality assessment). The following variables were defined in this investigation: first author’s last name and year of publication; instrument used; evaluation methods; object of research; conclusions.

2.5. Risk of Bias Assessment

The evaluation of in vitro studies was performed on the basis of a methodological index in which a checklist is used for in vitro studies on dental materials (CONSORT). This checklist of items has the purpose of evaluating how the study was designed, analyzed, and interpreted, and uses 14 domains [30].

2.6. Study Selection

The initial search of the scientific databases yielded 592 results. Duplicate studies and studies published before 1 January 2013 were excluded, resulting in a total of 288 studies. Of these, 8 articles were excluded as they were reviews, meta-analyses, or case reports. After the initial selection, 280 studies underwent a full-text examination. Of these, 34 articles were discarded because they evaluated endodontic instruments made of the same alloy, while 79 were not included as they focused on canal transportation rather than apical transportation. Seven studies were excluded as they evaluated apical transportation using only one endodontic instrument, and 149 studies were discarded because they were not relevant to the objectives of the review. One article was not included in the review because the endodontic instruments analyzed were used with different parameters than those specified by the manufacturer [14]. In total, 10 studies were included in this review [22,31,32,33,34,35,36,37,38,39] (Figure 1). The included papers are listed in Table 1 and Table 2.

2.7. Risk of Bias

Table 3 presents the risk of bias in the in vitro studies.

3. Results and Discussion

Clinically speaking, flexibility is considered to be one of the most important characteristics in choosing one type of endodontic instrument over another instrument [21]. In fact, it is possible to use instruments with different mechanical properties based on the specific characteristics of the root canal anatomy [21]. NiTi instruments have undergone continuous evolution in terms of the different cutting blade designs, flute numbers, variations in helical angles, cross-sectional configurations, and thermomechanical treatments employed.
All of the studies examined in this review were in vitro studies. To evaluate whether endodontic files with martensitic alloy caused less apical transportation compared to those with austenitic alloy, the authors of the included studies utilized various devices and methods, such as Micro CT, photographs and periapical radiographs [22,40]. Micro CT is recognized as the gold standard for the morphological evaluation of the effects of canal shaping. This method is important, as it can be used in in vitro studies to improve the distribution in the study sample, using established morphological parameters to provide a consistent baseline [41]. For example, it is possible to select radicular systems with similar morphologies to eliminate potential anatomical bias that would alter the research results, using established morphological parameters to provide a consistent baseline [42].
The authors of the studies included in this review agree on the results, stating that the use of instruments with martensitic alloys results in less apical transportation during endodontic treatment [22,31,32,34,35,36,37,38].
The NiTi alloys used in endodontic instruments contain approximately 56% by weight of nickel and 44% of titanium, in an equiatomic ratio of 1:1 [41]. In some nickel–titanium alloys, 2% of the nickel is converted to cobalt [43]. Due to the possibility of changing the type of atomic bonds by means of the nickel and titanium included in the alloy, the mechanical properties of NiTi alloy and its crystal structure can change. The alloy can exist in two different microstructural phases—austenite and martensite—with distinct mechanical properties [8]. In the austenitic phase, the alloy is rigid and exhibits shape memory, meaning that when the instrument is bent, it tends to return to its original shape. On the other hand, the martensitic phase is more flexible, and does not have shape memory [21]. The phase transition can occur either through the application of force or through temperature variation.
  • Application of force: This results in the transition from the austenitic phase to the martensitic phase. Force is applied when the canal walls compress the rotating instrument, particularly in curved canals [21,44,45].
  • Variation in temperature: High temperatures induce the austenitic phase, while low temperatures induce the martensitic phase [21,44,45].
The heat treatments applied to NiTi alloys by companies are aimed at modifying the alloy’s transition temperature, which is the temperature at which the alloy transitions from one phase to another. This allows the creation of instruments with varying percentages of martensite and austenite, resulting in instruments with different levels of flexibility [21,44,45]. The flexibility of the instrument enables it to rotate centrally within the canal, reducing alterations to the endodontic anatomy. When an endodontic instrument passes through a curved canal, it tends to work more on the outer portion of the curve, particularly if the instrument is rigid [45,46,47]. Since it is rare to find a perfectly straight canal in nature, with most canals having varying degrees of curvature, especially in the apical portion, a rigid instrument is more likely to cause apical transportation [22,31,32,34,35,36,37,48,49,50,51,52].
Two the studies included in this systematic review focused on endodontically treated teeth [32,35]. Both studies concluded that the use of martensitic alloys resulted in less apical transportation, even in cases of retreatment.
Two of the articles included in this review did not find any differences in apical transportation when comparing austenitic and martensitic instruments [33,39].
  • Saber et al. suggested that the absence of differences in apical transportation could be attributed to the specific characteristics of the iRaCe instruments analyzed, such as their small cross-sectional areas, which increase flexibility and allow for better debris removal, as well as the design of their working parts, which feature alternating cutting edges. This design enables the preparation of curved root canals with larger apical diameters to be achieved with minimal apical transportation compared to when using other rotary NiTi instruments [39,53,54].
  • Yilmaz et al. stated that there were no differences in apical transportation among the tested instruments, but attributed this result to the similar behavior of the ProTaper Next and EdgeFile alloys [33]. The results of this study may also be influenced by procedural errors, as the authors prepared the teeth using instruments with different apical diameters (EdgeFile with #40, ProTaper Next with #30, and One Shape with #25). Finally, the authors concluded that the absence of differences in apical transportation could be due to the limited sample size of the study.
The discrepancy in the results obtained from these two studies is likely attributable to various factors, and is not necessarily related to the alloy of the file used. Instead, the differences may be attributed to variations in the design and kinematics of the instruments, as well as the asymmetric or centralized motion and rotation axis of the instruments. Other factors, such as sample size, methodology, and procedural errors, may also contribute to the discrepant findings [55].
Only three of the studies included in this systematic review evaluated the apical transportation occurring during the root canal shaping phases in curved canals [35,36,39]. The apical curvature of the canal is one of the factors with the greatest effect on the occurrence of apical transport. In fact, the risk of transportation is linked to the degree and radius of canal curvature: the more severe the curvature and the smaller the radius of curvature, the more distinct the risk of straightening. Furthermore, it has also been shown that both the radius and the degree of canal curvature have an impact on the stress of the instruments used to prepare these canals [56,57]. For these reasons, future scientific literature should carry out such evaluations on canals with apical curves.
Only one of the studies included in this systematic review of the literature investigated apical transportation using resin blocks and no teeth [36]. In these resin blocks, the canals had precisely defined parameters, including length, taper, curvature, and degree of curvature. All resin blocks were the same, thus representing a sample with repeatable characteristics. This is essential to be able to exclude the bias that can affect the results of studies performed on non-homogeneous samples. In fact, it is possible that the characteristics of root canal anatomy, such as length, curvature and taper, can alter the results of the research. Furthermore, the resin blocks are transparent, making measurements easier for the researcher [36]. The authors concluded that martensitic endodontic instruments determined a lower apical transportation than austenitic instruments during the endodontic shaping phases [36]. However, it must be considered that the dentin and the resin used have different physical characteristics; the compressive resistance and elasticity of resin are lower than dentin [56]. Furthermore, during the shaping phase, the rotation of the tools in the resin blocks generates heat, which may contribute to the softening of the resin material, thus leading to inefficient shaping [58,59].
However, it must be considered that most of the studies included in this systematic review of the literature compare different instruments not only in terms of the type of heat treatment undergone, but also with regard to characteristics such as taper, cross-sectional profile and blade design. Differences in mechanical properties such as flexibility are not only determined by heat treatment, but also by geometric factors such as pitch length, taper or conicity, and cross-sectional shape [60]. All of these characteristics affect clinical performance. For example, non-cutting tips are characterized by a reduction in the tip or the transition angle [61,62]. The literature shows that passive (and therefore non-cutting) tips result in more uniform material removal on the outside and inside of the curve than instruments with active tips [63].
Some of the studies included in this review compared the apical transportation occurring during the shaping phase using instruments with the same design but using different heat treatments [32,34,35]. Two studies analyzed the results obtained after performing shaping using geometrically identical One Shape and One Curve files [32,34]. Both systems use instruments with a clockwise rotation at a constant taper of 0.06. The apical part of the One Curve and One Shape files has a triple-helix cross-sectional design and the middle and coronal parts of the file are designed with an S shape with two blades [64]. One Shape files are made of electropolished austenite 55-NiTi alloy; files in the One Curve system are made with C-wire alloy, which provides shape memory [32,64]. In both studies, the use of the martensitic instrument determined the smallest apical transportation. Kırıcı also evaluated the apical transportation occurring when using two identical reciprocating instruments, but made from different alloys, i.e., Reciproc, made with M-Wire alloy, and Reciproc Blue, made using an innovative heat treatment that gives the instrument a characteristic blue color [35]. This new alloy increased the flexibility and resistance of cyclic fatigue compared to M-Wire [65]. Reciproc Blue was 42.31% more flexible than the Reciproc file [66]. Both instruments have an S-shaped cross-section with two cutting edges and a 0.08 taper, and use reciprocating motion in which the direction of rotation alternates between the counterclockwise and clockwise directions [67,68]. All of the studies included in this systematic review of the literature that analyze the effect of instruments with the same geometric design but with different alloys conclude that instruments with martensitic alloys determine lower apical transportation compared to instruments with austenitic alloys [32,34,35].

Limitations

The main limitation of this article is its reliance on in vitro studies. Although in vitro studies provide valuable insights into the effects of different endodontic instruments, they may not fully reflect the complexities and variations found in clinical settings. Factors such as the presence of surrounding tissues, biological responses, and patient-specific variables cannot be accurately replicated in an in vitro environment. Therefore, the findings of this review should be extrapolated to clinical practice with caution, and further research involving clinical trials is needed to validate the results.
The main limitation of the in vitro studies considered in this review is the high risk of bias. The absence of a blinded investigator and the lack of a methodology involving random sequence generation introduce potential selection bias. Blinding is important in order to minimize the influence of bias in the assessment of outcomes, and random sequence generation is crucial for ensuring the unbiased allocation of interventions. The absence of these key elements in the included studies raises concerns regarding the internal validity of their findings.
Another limitation is the lack of standardization across the studies. Each study evaluated different root canals with varying diameters and curvatures, leading to diverse results. The impossibility of testing both instrument systems in the same root canal hampers direct comparisons and makes it challenging to draw definitive conclusions. The variations in the anatomy of the root canals and the lack of standardization in the experimental conditions introduced potential confounding factors that may have influenced the observed outcomes.
Furthermore, a significant proportion of the literature is focused primarily on evaluating canal transportation rather than apical transportation. Only a few studies have been performed in which apical transportation was specifically investigated, and different types of NiTi alloy compared. This limited availability of studies directly examining apical transportation with the use of different NiTi alloys restricts the depth and breadth of evidence on this specific aspect. Therefore, further research is needed to address these limitations and to provide more comprehensive insights into the effects of different NiTi alloys on apical transportation.
One strong point of this article is its rigorous adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. By following a well-defined protocol and conducting a comprehensive literature search, the authors have ensured transparency and reproducibility in their review process. The inclusion of a registered protocol number further enhances the credibility of the study. Additionally, the involvement of two independent researchers and consultation with a senior researcher for discrepancies adds to the robustness of the study. These methodological aspects increase the reliability of the findings and strengthen the overall quality of this systematic review.

4. Conclusions

The analysis of the obtained results indicates that the use of martensitic endodontic instruments determines lower apical transportation compared to austenitic instruments during the endodontic shaping phases. This behavior is attributable to the greater flexibility of martensitic instruments. The authors therefore recommend the use of martensitic instruments, especially for the shaping phase of complex root canal anatomies.

Author Contributions

Conceptualization, F.P.; methodology, G.L.G.; software, A.T.; formal analysis, F.G.; writing—original draft preparation, F.P.; writing—review and editing, U.B.; supervision, G.L.G. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Conflicts of Interest

The authors declare no conflict of interest.

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Applsci 13 10555 g001
Figure 1. PRISMA flowchart.
Figure 1. PRISMA flowchart.
Applsci 13 10555 g001
Table 1. Data extraction from selected studies.
Table 1. Data extraction from selected studies.
AuthorInstrument UsedEvaluation
Methods		Object of the ResearchConclusion
I.L.L. Gomes
2021 [31]		Mani GPR;
HyFlex NT		Micro CT38 rootsThe canals retreated with Mani GPR showed significantly higher horizontal apical transportation.
L. Alsofi
2021 [32]		One Curve
One Shape		Micro CT10 premolars with two separate roots endodontically treatedOne Shape produced more apical transportation than One Curve.
F.Yilmaz
2020 [33]		ProTaper Next; One Shape; EdgeFileMicro CT27 mesiobuccal canals of maxillary molarsNo apical transportation was observed with any of the instrumentation systems.
A. Alghamdi
2020 [34]		One Curve
One Shape		Micro CT40 separate mesial canals of 20 mandibular molarsOne Curve treatment produced significantly less apical transportation than One Shape.
D Kırıc
2020 [35]		Reciproc;
Reciproc Blue		Micro CT26 mandibular first and second molars with mesial roots that had 2 separate canals with angles between 20 and 40, endodontically treatedThe apical canal transportation values were significantly higher in the Reciproc group than in the Reciproc Blue group.
M. Radwański
2018 [36]		ProTaper Universal; ProTaper Next; Hyflex CM; Hyflex EDM; WaveOne GoldPhoto50 L-shaped resin canalsIn the nickel–titanium alloy subjected to a thermal treatment process, lower values of apical transportation were observed.
G.S. Sympsi,
scaricare,
2016 [37]		ProTaper Universal;WaveOne;
Hyflex CM		CS3D software and Adobe Photoshop45 mandibular teethHyFlex produced less apical transportation than the other groups.
Gagliardi J.
2015 [38]		ProTaper Next;
ProTaper Universal; ProTaper Gold		Micro CT24 mandibular first molars with 2
separate mesial canals		ProTaper Gold and ProTaper Next produced less apical transportation than ProTaper Universal
S.E.D.M. Saber
2014 [39]		ProTaper Next;
iRaCe;
Hyflex CM		Pre- and post-instrumentation radiographs60 mandibular molars with mesio-buccal canals having angles of curvature ranging from 25° to 35°There were no significant differences between the three groups with respect to apical transportation
D. Zhao
2013 [22]		Hyflex CM; Twisted Files;
K3 		Micro CT36 mesiobuccal root canals of maxillary first molarsTwisted Files and Hyflex CM produced less apical transportation than the K3
Table 2. Identification of the included studies.
Table 2. Identification of the included studies.
AuthorPMIDDOISample Size per Group
I.L.L. Gomes
2021 [31]		3324788010.1111/aej.12470n (19)
L. Alsofi
2021 [32]		3459045910.52586/4959n (10)
F.Yilmaz
2020 [33]		3215148210.1016/j.joen.2020.01.022n (9)
A. Alghamdi
2020 [34]		3329176610.3390/ma13235546n (20)
D Kırıc
2020 [35]		3188362110.1016/j.joen.2019.11.003n (13)
M. Radwański
2018 [36]		3044432410.17219/dmp/95201n (10)
G.S. Sympsi,
scaricare,
2016 [37]		2799432310.4103/0972-0707.194028n (15)
Gagliardi J.
2015 [38]		2632106210.1016/j.joen.2015.07.009n (7)
S.E.D.M. Saber
2014 [39]		2469759010.1111/iej.12291n (20)
D. Zhao
2013 [22]		2340251210.1016/j.joen.2012.11.030n (12)
Table 3. Bias in the in vitro studies.
Table 3. Bias in the in vitro studies.
ItemI.L.L. Gomes
2021 [31]		L. Alsofi
2021 [32]		F.Yilmaz
2020 [33]		A.
Alghamdi
2020 [34]		D Kırıc
2020 [35]		M. Radwański
2018 [36]		G.S. Sympsi
2016 [37]		Gagliardi J.
2015 [38]		S.E.D.M. Saber
2014 [39]		D. Zhao
2013 [22]
1 Abstract YesYesYesYesYesYesYesYesYesYes
2a Background
and objectives 		YesYesYesYesYesYesYesYesYesYes
2b Background
and objectives 		YesYesYesYesYesYesYesYesYesYes
3 Intervention YesYesYesYesYesYesYesYesYesYes
4 Outcomes YesYesYesYesYesYesYesYesYesYes
5 Sample size YesNoNoNoNoNoNoYesNoNo
6 Randomization: Sequence generation NoYesYesYesYesYesYesYesNoYes
7 Allocation concealment mechanism NoNoNoYesYesNoNoNoNoNo
8 ImplementationNoNoNoYesNoNoNoNoNoNo
9 BlinginNoNoNoYesNoNoNoNoNoNo
10 Statistical methodsYesYesYesYesYesYesYesYesYesYes
11 Results, outcomes, and estimation YesYesYesYesYesYesYesYesYesYes
12 Discussion LimitationsNoYesNoYesNoNoNoNoNoNo
13 Other information FundingYesYesNoYesNoNoNoYesNoNo
14 ProtocolYesYesYesYesYesYesYesYesYesYes
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Puleio, F.; Bellezza, U.; Torre, A.; Giordano, F.; Lo Giudice, G. Apical Transportation of Apical Foramen by Different NiTi Alloy Systems: A Systematic Review. Appl. Sci. 2023, 13, 10555. https://doi.org/10.3390/app131910555

AMA Style

Puleio F, Bellezza U, Torre A, Giordano F, Lo Giudice G. Apical Transportation of Apical Foramen by Different NiTi Alloy Systems: A Systematic Review. Applied Sciences. 2023; 13(19):10555. https://doi.org/10.3390/app131910555

Chicago/Turabian Style

Puleio, Francesco, Ugo Bellezza, Alessandra Torre, Francesco Giordano, and Giuseppe Lo Giudice. 2023. "Apical Transportation of Apical Foramen by Different NiTi Alloy Systems: A Systematic Review" Applied Sciences 13, no. 19: 10555. https://doi.org/10.3390/app131910555

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