Iej 01 2009

doi:10.1111/j.1365-2591.2008.01460.
Effectiveness of ozone against endodontopathogenic microorganisms in a root canal biolm model
K. C. Huth1, M. Quirling1,2, S. Maier1, K. Kamereck3, M. AlKhayer1, E. Paschos4, U. Welsch5, T. Miethke3, K. Brand6 & R. Hickel1
1 Department of Restorative Dentistry & Periodontology, Ludwig-Maximilians University, Munich; 2Institute of Clinical Chemistry & Pathobiochemistry, Klinikum rechts der Isar, Technische Universita t Mu nchen, Munich; 3Institute of Medical Microbiology, Immunology and Hygiene, Technische Universita t Mu nchen, Munich; Departments of 4Orthodontics and 5Anatomy, LudwigMaximilians University, Munich; and 6Institute of Clinical Chemistry, Medizinische Hochschule Hannover, Hannover, Germany
Abstract
Huth KC, Quirling M, Maier S, Kamereck K, AlKhayer M, Paschos E, Welsch U, Miethke T, Brand K, Hickel R.
Effectiveness of ozone against endodontopathogenic microorganisms in a root canal biolm model. International Endodontic Journal, 42, 313, 2009.
Aim To assess the antimicrobial efcacy of aqueous (1.2520 lg mL)1) and gaseous ozone (153 g m)3) as an alternative antiseptic against endodontic pathogens in suspension and a biolm model. Methodology Enterococcus faecalis, Candida albicans, Peptostreptococcus micros and Pseudomonas aeruginosa were grown in planctonic culture or in mono-species biolms in root canals for 3 weeks. Cultures were exposed to ozone, sodium hypochlorite (NaOCl; 5.25%, 2.25%), chlorhexidine digluconate (CHX; 2%), hydrogen peroxide (H2O2; 3%) and phosphate buffered saline (control) for 1 min and the remaining colony forming units counted. Ozone gas was applied to the biolms in two experimental settings, resembling canal areas either difcult (setting 1) or easy (setting 2) to reach. Time-course experiments up to 10 min were included. To compare the tested samples, data were analysed by one-way anova.
Results Concentrations of gaseous ozone down to 1 g m)3 almost and aqueous ozone down to 5 lg mL)1 completely eliminated the suspended microorganisms as did NaOCl and CHX. Hydrogen peroxide and lower aqueous ozone concentrations were less effective. Aqueous and gaseous ozone were dose- and strain-dependently effective against the biolm microorganisms. Total elimination was achieved by high-concentrated ozone gas (setting 2) and by NaOCl after 1 min or a lower gas concentration (4 g m)3) after at least 2.5 min. High-concentrated aqueous ozone (20 lg mL)1) and CHX almost completely eliminated the biolm cells, whilst H2O2 was less effective. Conclusion High-concentrated gaseous and aqueous ozone was dose-, strain- and time-dependently effective against the tested microorganisms in suspension and the biolm test model. Keywords: antimicrobials, biolm, microbiology, ozone, root canal.
Received 18 April 2007; accepted 1 July 2008
endodontics,
Introduction
Correspondence: Dr Karin Christine Huth, Department of Restorative Dentistry, Periodontology & Pedodontics, Dental School, Ludwig-Maximilians University, Goethestr. 70, 80336 Munich, Germany (Tel.: +49 89 5160 9411; fax: +49 89 5160 9302; e-mail: khuth@dent.med.uni-muenchen.de).
The successful treatment of an infected root canal, especially those with persistent apical periodontitis remains a clinical challenge (Nair 2006). The main aim of endodontic treatment is to eradicate or substantially reduce the microbial load in the root canal
2008 International Endodontic Journal
International Endodontic Journal 42, 313, 2009
Ozone and endodontic biolms Huth et al.
system, which is conventionally achieved by chemomechanical instrumentation followed by canal lling to prevent recolonization (Nair 2006). Endodontic irrigants must have effective antimicrobial activity but also exhibit relatively no cytotoxicity toward periapical and oral mucosal tissue. An anti-inammatory action especially in cases of persistent apical periodontitis might also be advantageous. Enterococcus faecalis and Candida albicans have been reported to be of particular interest in cases of persistent periodontitis (Molander et al. 1998, Sundqvist et al. c 1998, Siqueira & Ro as 2004, Fouad et al. 2005). Anaerobic bacteria, such as Peptostreptococcus micros or Gram-negative bacteria including P. species have also been associated with persistent infections (Siqueira 2002). These microorganisms grow in highly resistant biolms (Pinheiro et al. 2003), but also as planctonic cells suspended in the uid phase of the root canal or as remnants after mechanical canal preparation (Distel et al. 2002, Nair 2006). Sodium hypochlorite (up to 5.25%) is the most commonly used root canal irrigant and has been used alternately with H2O2 (3%) (Takeda et al. 1999). Chlorhexidine digluconate (2%) has also been recommended for root canal irrigation in combination with mechanical debridement (Siqueira et al. 1998, Gomes et al. 2001, Basrani & Lemonie 2005). However, the success rate for conventional treatment of persistent and refractory apical periodontitis is only in the order of between 50% and 70% (Weiger et al. 2001) and consequently NaOCl up to 3% has been reported to have limited efcacy against high-pathogenic endodontic microorganisms and CHX 2% has demonstrated inconsistent results (Siqueira et al. 1998, Gomes et al. 2001). In addition, side effects such as haemorrhage, oedema and skin ulceration have been reported when high concentrations of NaOCl and H2O2 come into nc contact with oral tissues (Pashley et al. 1985, O ag et al. 2003, Gernhardt et al. 2004). A signicant degree of cytotoxicity towards oral cells has been found in vitro as well (Hyslop et al. 1988, Nagayoshi et al. 2004, Huth et al. 2006). Chlorhexidine (2%) may cause mucosal desquamation, impaired wound healing and tooth staining (Bassetti & Kallenberger 1980, Cline & Layman 1992) and a high cytotoxic potential has been demonstrated on epithelial cells (Huth et al. 2006). Therefore, an alternative endodontic antiseptic with high antimicrobial potential and fewer side effects would be valuable. Ozone is currently being discussed as a possible alternative antiseptic agent in dentistry because of its
reported high antimicrobial power without the development of drug resistance (Restaino et al. 1995, Paraskeva & Graham 2002). Ozone gas in a concentration of 4 g m)3 (HealOzone; KaVo, Biberach, Germany) is already being used clinically for endodontic treatment. However, results of studies into its efcacy against endodontic pathogens has been inconsistent, and there is little information regarding the most appropriate application time and concentration to use (Nagayoshi et al. 2004, Arita et al. 2005, Bezrukova et al. 2005, Hems et al. 2005). Regarding the demand on relative non-toxicity toward periapical and oral mucosal tissue for the endodontic irrigants (Nair 2006), the ozone gas concentration currently used in endodontics (4 g m)3) has been shown to be slightly less cytotoxic than NaOCl (2.5%) and aqueous ozone (up to 20 lg mL)1) showed essentially no toxicity to oral cells in vitro (Filippi 2001, Ebensberger et al. 2002, Nagayoshi et al. 2004, Huth et al. 2006). The aim of this study was to investigate the antimicrobial efcacy of gaseous and aqueous ozone against specic endodontic pathogens in suspension and in biolms grown in human root canals.
Materials and methods Microorganisms

Freeze-dried microorganisms: E. faecalis (ATCC 14506; LGC Promochem, Wesel, Germany), C. albicans (ATCC MYA-273), P. micros (ATCC 33270) and P. aeruginosa (ATCC 15442) were suspended in brain heart infusion medium (BHI) and recultivated on Schaedler agar plates (vitamin K1 and 5% sheep blood; BD Diagnostic Systems, Heidelberg, Germany).
Test agents
Doseresponse experiments were performed for gaseous and aqueous ozone covering a concentration range as wide as possible to evaluate if there was a concentration that could possibly compete with the established endodontic irrigants in antimicrobial effectiveness. Basically following a log2 scale, the concentration ranges were limited because of the experimental setting and equipment. Ozone gas (Ozonosan photonic, Dr Ha nsler, Iffezheim, Germany) in concentrations between 1 g m)3 (the minimum concentration to measure by the available ozone gas measuring device) and 53 g m)3 (the highest achievable concentration because of the experimental set-up and the limitation
International Endodontic Journal, 42, 313, 2009
Huth et al. Ozone and endodontic biolms
of the ozone generator) was applied to the test microorganisms in a self-constructed glass chamber with simultaneous concentration measurement (GM-6000-NZL; Anseros, Tu bingen, Germany). The analytical method of the concentration measuring device is based on UV light absorption at a wavelength of 253.7 nm where gaseous ozone has its maximum absorbance (Bocci 2002). For aqueous ozone, bidistilled water was treated with ozone gas (75 lg mL)1, 15 min) using the ozone generator, which resulted in a nal photometrically conrmed (Palintest 1000 Ozone Meter, Palintest Ltd, Gateshead, UK) ozone concentration in water of 20 lg mL)1 (saturation point), which was diluted to 1.25 lg mL)1. The ozone concentration measurement in water involves the oxidation of a colourless indicator (diethyl-p-phenylene diamine) to a pink compound by ozone in comparison with a reference sample without ozone (manufacturers information, operating wavelength of the photometer is 505 nm). Ozone was compared with freshly prepared solutions of NaOCl (5.25%, 2.25%), CHX (2%), H2O2 (3%) and phosphate buffered saline (PBS) as a control. As ozone is an endothermic, highly instable oxygen compound (Sehested et al. 1991, Hoigne 1998, Stu binger et al. 2006), both the gas and the ozonated bi-distilled water were freshly prepared before each experiment. During production and processing of the ozone experiments only ozone-resistant materials were used (e.g. ozone demand-free glass, ozone-resistant piping material).
Testing ozone against microorganisms in biolms grown in human root canals

Crowns of freshly extracted single rooted permanent teeth (root length 1819 mm), were removed at the level of the cemento-enamel junction. The use of the teeth for these experiments had been agreed upon by informed consent of the patients. The root canals were instrumented to the size ISO 40 (K-les; Dentsply Maillefer, Ballaigues, Switzerland), the apical regions to size 30 (ProFile.04; Dentsply Maillefer) with intermittent canal irrigation following each le size (3 mL of NaOCl 5.25%) (Takeda et al. 1999, Zehnder et al. 2003). Finally, the canals were irrigated with EDTA 10% (5 min, 1030 mL) followed by normal saline (Zehnder et al. 2003), dried with paper points and the roots sterilized (121 C, 2 bars, 5 min). The biolm growth assembly (Fig. 1) contained a programmable peristaltic pump (IPC-8; Ismatec, Wertheim-Mondfeld, Germany), freshly prepared autoclaved articial complete saliva (Pratten et al. 1998), 10% aqueous sucrose solution (Sigma-Aldrich, Schnelldorf, Germany), exible silicone tubes (diameter 1 or 2.06 mm; Hartlmaier, Munich, Germany), several asks and the prepared dental roots. The ingredients for the saliva were from Oxoid (Wesel, Germany), Sigma-Aldrich and BD Diagnostic Systems. All the equipment was sterilized before use. Overnight cultures of E. faecalis, C. albicans or P. aeruginosa were used. The latter species substituted the anaerobic P. micros which could not be evaluated since the growth assembly was too large to be incorporated into the anaerobic work bench. The experiments with P. aeruginosa were conned to the biolm trials because of the greater relevance than the suspension experiments already undertaken for the other three strains. The articial saliva was constantly pumped through a exible tube into a 50-mL reservoir, supplemented with the sucrose solution three times a day (30 min, 3 33 mL) (Wilson et al. 1998). For the rst week, an overnight culture (37 C in 10 mL of BHI) of the respective strain was added daily to the saliva. The nutrient broth from the reservoir was pumped (720 mL day)1) (Wilson et al. 1998) through the canals of four parallel-mounted dental roots each hanging in a ask, the coronal canal orice connected to the exible tube by a 10-lL micropipette tip (Eppendorf, Hamburg, Germany). To avoid a contamination of the root surface, the used saliva, which dropped from the roots apical region to the bottom of the ask, was constantly pumped off into a waste ask
Testing ozone against microorganisms in suspension

Microorganisms were grown overnight (37 C, 10 mL of BHI), centrifuged, resuspended in PBS to a turbidity of McFarland 1 [3 108 colony forming units (CFU) mL)1] and diluted 1 : 3. Ten microlitres were suspended in 1 mL of agent for 1 min followed by immediate, appropriate dilution with PBS as evaluated by preceding experiments. Thereof, 10 lL were plated out on agar plates and incubated aerobically (48 h, 37 C). For the obligate anaerobic P. micros, all experimental steps were completed in an anaerobic work bench (Bactron, Sheldon Manufacturing Inc., Cornelius, OR, USA; 85% N2, 5% H2, 10% CO2; 37 C). Again, 10 lL of an equal dilution of the specic microorganism suspension were plated out on agar plates and exposed to ozone gas whilst the control plates were exposed to ambient air (1 min). After incubation of the agar plates (48 h, 37 C), the number of CFU mL)1 was determined.
Figure 1 Growth assembly for the mono-species biolms in root canals. Mono-species biolms of endodontic pathogens were grown for 3 weeks in prepared dental root canals of extracted single-rooted permanent teeth. For this purpose, a peristaltic pump carried pre-warmed articial saliva supplemented with sucrose and microorganism broth from a reservoir through the roots to a waste ask at a rate of 720 mL day)1 under aerobic conditions at 37 C. The right part of the drawing is a magnied view of an exemplary root hanging in a ask.
via a wider exible tube (diameter 2.06 mm). After 3 weeks, the roots were removed and cut into 5-mmthick horizontal slices, and the apical root portions were disposed of. For each test condition, one slice was carefully transferred to a ask and 1 mL of the test agent added (four independent trials). For the ozone gas exposure, two experimental settings were used: setting 1, the slices were laid at on glass beads into the gas box, that the gas streamed over the canal space (resembling canal areas that are difcult to reach); setting 2, the slices were positioned upright so as to allow the gas to stream through the root canal (resembling canal parts that are easy to reach). After 1 min, the agent was removed or the slice was removed from the gas box, 1 mL of PBS was immediately added and the slice vortexed for 1 min (Wilson et al. 1998). Restrained reactions beyond the 1 min contact time could have occurred as no chemicals were used to stop the action. Rather, the vast majority of the test agents were
removed immediately after 1 min and PBS added for appropriate dilution. Thereafter, 100 lL were plated out on agar plates and incubated (48 h, 37 C), and the CFU per plate were counted. Additionally within setting 2, ozone gas (4 g m)3) was applied for longer time intervals, i.e. 2.5, 5 and 10 min. The counted number of CFU were calculated as a percentage of the respective control (mean SD; n = 34). For each of the independent trials, one slice was checked for the presence of a biolm inside the root canal and for possible microbial contamination of the outer root surface by scanning electron microscopy (JSM-35 CF; Jeol, Eching, Germany and SmartSEM; Zeiss, Oberkochen, Germany).
Statistical methods
As a result of the large number of test agents, the experiments were conducted in several stages each with its own control. To compare the antimicrobial
activity of the agents, the counted CFU were calculated in percentage of the respective controls (mean SD; n = 34). For all experiments, the absolute numbers of CFU, the percentage values and the means with standard deviation of the independent trials are given in the accompanying Supporting Information. Data were analysed by one-way anova with Tamhane post hoc tests to compare independent samples (two-tailed tests, a-level 0.05) (spss software 12; SPSS Inc., Chicago, IL, USA).
bacterial contamination or biolm formation (pictures not shown). P. aeruginosa was substituted for the anaerobic P. micros because the growth assembly was too large for the anaerobic chamber.
Effect of ozone on microorganisms in biolms

The antimicrobial action of ozone against E. faecalis, C. albicans and P. aeruginosa mono-species biolms was tested (see Supporting Information, Tables DF). Application of aqueous ozone for 1 min was dose-dependently effective against the microorganisms, its highest concentration of 20 lg mL)1 revealing mean CFU reductions of over 96%, similar to CHX 2% (Fig. 3a c, Supporting Information, Tables DF). Sodium hypochlorite (5.25%) completely eliminated the microorganisms, whilst H2O2 was less effective. In this series of experiments, ozone gas was applied to the root slices laying at in the gas box (setting 1), which revealed a dose-dependent effectiveness of ozone gas against the different species (Fig. 3ac). E. faecalis and C. albicans was almost eliminated by the highest gas concentration achievable within the experimental setting (53 g m)3) (Fig. 3a,b) and P. aeruginosa by the highest and the second highest concentration (Fig. 3c). Statistically, no signicant differences in effectiveness could be found between the antiseptics for E. faecalis and C. albicans (anova, P > 0.05). Against P. aeruginosa, ozone gas 4 g m)3 was signicantly less effective than NaOCl, CHX and ozonated water down to 10 lg mL)1 and ozonated water 10 lg mL)1 less effective than CHX 2% (anova, P < 0.05). This was mainly because of a very small standard deviation in comparison with lower gas and ozone water concentrations, which showed no signicant differences.
Results Effect of ozone on microorganisms in suspension

Firstly, the effect of aqueous and gaseous ozone on the specic endodontic pathogens in planctonic culture was evaluated (see Supporting Information, Tables AC). Aqueous ozone completely eliminated E. faecalis and C. albicans when used in concentrations down to 5 lg mL)1, whereas lower concentrations (2.5 and 1.25 lg mL)1) reduced substantially but did not eliminate them totally (Fig. 2a,b). In the case of P. micros, aqueous ozone down to 2.5 lg mL)1 led to complete eradication whilst 1.25 lg mL)1 was less effective (Fig. 2c). In comparison, NaOCl and CHX led to a total elimination of the tested microorganisms, whereas H2O2 reduced but did not eliminate them. Ozone gas in concentrations down to the tested minimum of 1 g m)3 for 1 min almost completely eliminated the tested strains with a mean reduction of more than 99% (Fig. 2ac, Supporting Information, Tables AC). Statistically, no differences in effectiveness of the different agents were seen for E. faecalis (anova, P > 0.05). Regarding C. albicans, H2O2 and low concentrations of ozonated water (2.5 and 1.25 lg mL)1) were signicantly less effective than all other agents (P < 0.05). Against P. micros, low dose ozonated water (1.25 lg mL)1) was less effective than the other antiseptics (P < 0.05).
Exposure of the biolm to ozone gas in a different setting and with longer contact times
In the following, the experimental conditions were changed by positioning the slices with E. faecalis biolms upright with their cut surfaces in front of the inlet of the gas box as to allow the gas to stream through the root canal (setting 2) rather than over the canal space as in the setting before. Two concentrations were selected, i.e. one high gas concentration (32 g m)3) as well as a lower concentration, which is currently used in dentistry (4 g m)3; HealOzone). Comparing the outcome of the two settings, the high gas concentration led to complete eradication of viable cells after 1 min in the new setting whilst in the old
Establishment of the anatomical biolm model

The experimental set-up (Fig. 1) allowed the growth of mono-species biolms of E. faecalis, C. albicans and P. aeruginosa over 3 weeks in an anatomically correct form inside the canal of tooth roots. The roots were sectioned into horizontal slices before exposure to the gas/agents. The formation of biolms was checked for the different species by SEM of one slice for each independent trial as well as the outer root surfaces, which showed no
(a)
(b)
(c)
Figure 2 Antimicrobial efcacy of ozone against endodontic pathogens in suspension. The suspended microorganisms were exposed to aqueous or gaseous ozone in different concentrations or established endodontic irrigants (NaOCl, CHX and H2O2) for 1 min. The numbers of CFU after contact with PBS for 1 min were dened as 100% control (dotted line). The remaining CFU after agent/gas exposure were counted and calculated as a percentage of the control (n = 34, mean SD) (see Supporting Information, Tables 13). (a) shows the antimicrobial activity against E. faecalis. (b) shows the antimicrobial activity against C. albicans. (c) Shows the antimicrobial activity against P. micros.
setting only a reduction was observed (Fig. 4a). Ozone gas in the lower concentration (1 min) reduced the cell count more than before, but not to zero. Therefore, as a last step, the effect of longer exposure times (2.5, 5 and 10 min) of this concentration was tested on the bacterial biolms. Contact times of 2.5 min and more with 4 g m)3 ozone gas led to complete elimination of the microorganisms (Fig. 4b), but without being sig-
nicantly different to the cell count after 1 min (P > 0.05) (see Supporting Information, Table G).
Discussion
In this study, gaseous ozone in concentrations down to 1 g m)3 substantially and aqueous ozone down to 5 lg mL)1 completely eliminated the tested planctonic
(a)
(b)
(c)
Figure 3 Antimicrobial efcacy of ozone against endodontic pathogens associated in mono-species biolms in a root canal model. Mono-species biolms were grown inside of dental root canals of extracted single-rooted teeth for 3 weeks. In the following, the roots were cut into horizontal slices that were exposed to aqueous or gaseous ozone in different concentrations or established endodontic irrigants (NaOCl, CHX, H2O2) or PBS as a control for 1 min. After removal and suspension of the biolms, the remaining number of CFU were counted and calculated in % of the CFU counts after contact with the PBS control (100%, dotted line) (n = 4, mean SD) (see Supporting Information, Tables 46). (a) Antimicrobial efcacy against E. faecalis biolm. (b) Antimicrobial efcacy against C. albicans biolm. (c) Antimicrobial efcacy against P. aeruginosa biolm.
pathogens. Gaseous and aqueous ozone were dose- and strain-dependently effective against the microorganisms in biolms. Total elimination of the microorganisms in terms of the methods used here could be achieved by ozone gas at 32 g m)3 for 1 min or a lower concentration (4 g m)3) for longer contact
times (2.5 min) in case of E. faecalis (setting 2). Aqueous ozone in the highest concentration (20 lg mL)1, 1 min) nearly eliminated E. faecalis, C. albicans and P. aeruginosa biolms. The root canal model used in these experiments allowed for the growth of biolms inside the canal. To
(a)
(b)
Figure 4 Antimicrobial efcacy of ozone gas applied in two experimental settings to E. faecalis biolms and the effect of prolonged exposure times. The biolms were grown as described in Fig. 3. In setting 1, the horizontal root slices were laid at on glass beads in the gas box (see experiments in Fig. 3). In setting 2, the horizontal root slices were positioned upright with their cut surfaces in front of the gas inlet as to allow the gas streaming through the canals. (a) The antimicrobial effect of gaseous ozone in concentrations of 32 g m)3 and 4 g m)3 for 1 min on the E. faecalis biolms according to setting 1 (grey bars) and 2 (black bars) is shown in comparison. PBS served as control. The remaining CFU were counted and calculated in % of the PBS control which was dened as 100% (dotted line) (n = 3, mean SD). (b) The antimicrobial effect of ozone gas (4 g m)3) according to setting 2 for 1 min and prolonged contact times (2.5 min, 5 min and 10 min) is depicted (see Supporting Information, Table 7).
determine the efcacy of ozone as alternative antiseptic, it was compared with traditional endodontic irrigants (NaOCl, CHX and H2O2) by adding the agents for 1 min. The doseresponse experiments for ozone and additionally the time-course experiments for the ozone gas concentration currently used in dentistry (4 g m)3, HealOzone) were aimed at nding a dose-time-concentration that could completely eliminate the microorganisms in the test model as a basis for clinical study designs in the future. As a source of impreciseness in the present study, no chemicals were used to arrest the action of the agents. Therefore, the contact times, e.g. for CHX, which is known for its substantivity (Khademi et al. 2006), might be prolonged similar as in the clinical situation. Earlier studies reported in part contradictory results regarding the efcacy of ozone against endodontic pathogens: one group tested ozonated water
(4 lg mL)1, 10 min) against E. faecalis incubated on dentine blocks for 6 days (Nagayoshi et al. 2004). A signicant reduction was found but complete elimination was not observed as was the case with NaOCl 2.5%, which is consistent with the present results. Additionally, the trials reported here revealed that the highest concentration of ozonated water (20 lg mL)1) led to a near eradication of the microorganisms in the 3-week-old biolm and a complete elimination by gaseous ozone at a concentration of 32 g m)3 for 1 min or a lower concentration (4 g m)3) for contact times of at least 2.5 min (setting 2). Further, the biolm experiments revealed a near eradication of E. faecalis by CHX 2% whereas H2O2 was less efcient throughout. Another study found no signicant reduction of E. faecalis biolms (grown on membranes for 48 h) using ozonated water, but did so against planctonic bacteria (Hems et al. 2005). A reason for these differing
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results compared with the study mentioned above (Nagayoshi et al. 2004) and the present experiments revealing a CFU reduction when exposed to high concentrated ozonated water might be that a rather low ozone concentration was used in the other study (Hems et al. 2005). That is, ozone gas was bubbled through the water containing the biolm for only 4 min. The maximum concentration of ozonated water (20 lg mL)1) was achieved in the present study only after 15 min of ozonation (data not shown). Another recent study grew E. faecalis biolms over 60 days in root canals and applied ozonated water, ozone gas, NaOCl 2.5% or CHX 2% for 20 min (Estrela et al. 2007). Contrasting to the present results, none of the irrigants were found to have an antimicrobial effect. The effect of ozone against C. albicans has been reported primarily for denture cleaning (Murakami et al. 1996, Oizumi et al. 1998). More recently, C. albicans incubated on resin plates for 120 min was almost eliminated by use of ozonated water (2 and 4 lg mL)1, 1 min) with or without ultrasonication (Arita et al. 2005). As 120 min represents a short time interval for biolm formation, that study might be better compared with the present suspension experiments, in which a mean reduction of about 86% of C. albicans by 2.5 lg mL)1 ozonated water and a total elimination by 5 lg mL)1 ozonated water and a reduction of over 99% by ozone gas down to 1 g m)3 was achieved. In the present biolm experiments, C. albicans was found to be completely eliminated only by NaOCl (5.25%) and to over 96% by 53 g m)3 gaseous ozone (setting 1), 20 lg mL)1 ozonated water and CHX 2%. The effect of ozone against the anaerobe P. micros has not been evaluated before. Ozone gas in the tested minimum concentration (1 g m)3, setting 1) and aqueous ozone ( 2.5 lg mL)1) completely eliminated the suspended microorganisms. Biolm experiments were not performed with P. micros as the growth assembly could not be maintained in anaerobic conditions. The use of ozone as a disinfectant against P. aeruginosa in dental unit water lines has been reported, but there is no information about the required time and concentration for total elimination (Filippi 1995, Al Shorman et al. 2003). In present biolm experiments, total eradication was achieved by ozone gas concentrations of 32 g m)3 (setting 1) and NaOCl (2.25%, 1 min). High-concentrated aqueous ozone (20 lg mL)1, 1 min) and CHX 2% almost eliminated the viable microorganisms.
Conclusions
High-concentrated gaseous and aqueous ozone was dose-, strain- and time-dependently effective against the tested microorganisms in suspension and the biolm test model. However, NaOCl was the only method that completely eliminated all types of microorganisms.
Acknowledgements
The authors wish to acknowledge E. Thielke and C. Ko hler for technical project support. The study was nanced by the Medical Faculty, University of Munich (Fo FoLe Reg. Nr. 401), departmental funding and the KaVo Company.
Supporting information
Additional supporting information may be found in the online version of this article: Table S1 Antimicrobial efcacy of ozone and established endodontic irrigants (1 min) against the tested microorganisms in suspension or associated in biolms. The absolute number of remaining colony forming units (CFU abs) of 3 to 4 independent trials (n = 34) are given. The CFU are also given in % of the respective controls in parentheses and their means with the standard deviations of the independent trials (% control, mean SD) which correspond to Fig. 2, 3 and 4. NaOCl, sodium hypochlorite; CHX, chlorhexidine digluconate; H2O2, hydrogen peroxide; O3, ozone. The antimicrobial effects against E. faecalis (A), C. albicans (B), and P. micros (C) in suspension are shown as well as against E. faecalis (D), C. albicans (E) and P. aeruginosa (F) associated in biolms. Table G shows the antimicrobial efcacy of ozone gas in concentrations of 32 g/m3 and 4 g/m3 applied in two experimental settings to E. faecalis biolms and the effect of prolonged exposure times in setting 2 (1 min, 2.5 min, 5 min, 10 min). Please note: Wiley-Blackwell are not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing material) should be directed to the corresponding author for the article.
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doi:10.1111/j.1365-2591.2008.01481.x
Stress distribution of three NiTi rotary les under bending and torsional conditions using a mathematic analysis
T. O. Kim1, G. S. P. Cheung2, J. M. Lee3, B. M. Kim3, B. Hur1 & H. C. Kim1

1 Department of Conservative Dentistry, School of Dentistry, Pusan National University, Busan, Korea; 2Area of Endodontics, Faculty of Dentistry, The University of Hong Kong, Hong Kong; and 3Division of Precision Manufacturing Systems, Pusan National University, Busan, Korea
Abstract
Kim TO, Cheung GSP, Lee JM, Kim BM, Hur B, Kim HC.
Stress distribution of three NiTi rotary les under bending and torsional conditions using a mathematic analysis. International Endodontic Journal, 42, 1421, 2009.
Aim To compare and evaluate the stress distribution of three NiTi instruments of various cross-sectional congurations under bending or torsional condition using a nite-element analysis model. Methodology Three NiTi les (ProFile, ProTaper and ProTaper Universal) were scanned using Micro-CT to produce a three-dimensional digital model. The behaviour of the instrument under bending or torsional loads was analysed mathematically in software (ABAQUS V6.5-1), taking into consideration the nonlinear mechanical characteristic of NiTi material. Results ProFile showed the greatest exibility, followed by ProTaper Universal and ProTaper. The highest stress was observed at the surface near the
cutting edge and the base of (opposing) utes during cantilever bending. Concentration of stresses was observed at the bottom of the utes in ProFile and ProTaper Universal instruments in torsion. The stress was more evenly distributed over the surface of ProTaper initially, which then concentrated at the middle of the convex sides when the amount of angular deection was increased. Conclusion Incorporating a U-shaped groove in the middle of each side of the convex-triangular design lowers the exural rigidity of the origin ProTaper design. Bending leads to the highest surface stress at or near the cutting edge of the instrument. Stress concentration occurs at the bottom of the ute when the instrument is subjected to torsion. Keywords: bending, cross-sectional geometry, niteelement analysis, NiTi rotary le, stress distribution, torsion.
Received 19 March 2008; accepted 16 August 2008
Introduction
Root canal instruments manufactured with nickel titanium (NiTi) have been developed in an attempt to overcome the rigidity of instruments made from stainless steel alloys (Walia et al. 1988). NiTi instruments possess a lower modulus of elasticity and a superior resistance to torsional fracture, compared with stainless
Correspondence: Dr Hyeon-Cheol Kim, DDS, MS, PhD, Assistant Professor, Department of Conservative Dentistry, Pusan National University School of Dentistry, 1-10, Ami-dong, Seo-gu, Busan 602-739, Korea (Tel.: +82 51 240 7978; fax: +82 51 254 0575; e-mail: golddent@pusan.ac.kr).
steel instruments of similar size (Walia et al. 1988, Scha fer et al. 2003). The NiTi rotary instruments allow root canal preparation to be accomplished more expeditiously than hand instruments; a well-centred, tapered root canal form with minimal risk of transporting the original canal centre is often achieved (Glosson et al. 1995, Garip & Gunday 2001, Scha fer 2001, Chen & Messer 2002, Lee et al. 2003, Scha fer et al. 2004). To date, many NiTi rotary systems have been introduced to the market. Most brands, e.g. ProFile (Dentsply Maillefer, Ballaigues, Switzerland), K3 (SybronEndo, Orange, CA, USA), Mtwo (VDW, Munich, Germany) and Hero Shaper (Micro-Mega, Besanc on,
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Kim et al. Stress distribution of NiTi rotary les
France) have a regularly tapered shaft, but with different cross-sectional designs; some also possess radial lands (Scha fer 2001, Hata et al. 2002). Amongst these systems, the ProFile system is best known for its U-le design (i.e. with a concave, Ushaped utes in cross-section; Fig. 1a), and for its exibility and better centering ratio than some other systems (Park et al. 2003, Walsch 2004, Kim et al. 2005). In contrast, the ProTaper system (Dentsply Maillefer) has a unique design for its shaft with a progressively changing taper (Bergmans et al. 2003,
Clauder & Baumann 2004). The original cross-sectional conguration of the ProTaper system was triangular with convex sides (Fig. 1b). The sharp cutting edge (instead of a radial land) is claimed to reduce the contact area between the le and dentine, thus enhancing the cutting efciency of the instrument (Clauder & Baumann 2004). However, it has been reported that the ProTaper system tends to produce more aberrations, transportation or straightening of the canal (Yun & Kim 2003, Calberson et al. 2004, Scha fer et al. 2004). To overcome the problem, which
Figure 1 Schematic drawings of the cross-sectional and longitudinal geometry of three NiTi les after the real-size, threedimensional image from micro-CT: (a) ProFile size 30, 0.06 taper; (b) ProTaper F3 and (c) ProTaper Universal F3.
15
Stress distribution of NiTi rotary les Kim et al.
may be related to a slightly greater rigidity (partly because of the cross-sectional area; another factor being the taper of the instrument), compared with ProFile instruments of similar cross-sectional dimension, a new version with a modied cross-sectional design for the larger instruments of the original system has been marketed as ProTaper Universal. The F2 and F3 instruments of the ProTaper Universal system have incorporated an additional groove in the middle of each side of the convex-triangular cross-section in an attempt to increase its exibility (Fig. 1c). Clinically, there is a potential risk of rotary NiTi instruments fracturing in the canal even new instrument may demonstrate unexpected failure in use (Arens et al. 2003). On the other hand, little is known about the distribution of stresses, an important factor related to instrument fracture, when the instrument is subjected to bending or torsional load. It has been reported that fracture of an engine-le may occur in either one or a combination of two ways: torsional and exural (i.e. fatigue) (Sattapan et al. 2000, Cheung et al. 2005, Wei et al. 2007); the geometrical design is an important determinant because of the effect on the torsional and bending properties of the instrument (Camps et al. 1995). Several studies of the stresses generated in NiTi instrument have been completed using nite-element (FE) analysis (Turpin et al. 2000, 2001, Berutti et al. 2003); however, they evaluated a simulated, cylindrical shape and ignored the taper of the root canal instrument when constructing the models. Recently, Xu et al. (2006) have reported on the effect of cross-section conguration on the mechanical behaviour of root canal les by examining an idealized cross-sectional conguration with FE analysis, but they did not seem to have veried the actual geometry of the real product. Indeed, there could be discrepancies between the idealized design and the actual product (Low et al. 2006). Thus, the purpose of this study was to compare the stress distribution of the two ProTaper designs under bending and torsional stresses by inputting the actual shape of the instruments for three-dimensional (3D) FE analysis. A U-le design (ProFile) was also examined as a control.
were obtained by rst scanning them at 2-lm intervals in a micro-CT scanner (HMX; X-Tek Group, Santa Clara, CA, USA). Then, the outline of the instrument was extracted from the stacks of 3D data in software (IDEAS11 NX; UGS, Plano, TX, USA). Finally, a mesh of linear, eight-noded, hexahedral elements was overlaid onto the rendered 3D image. Such a 3D model consisted of 11880 elements with 16318 nodes for ProFile, 7560 elements with 9017 nodes for ProTaper, or 8964 elements with 10668 nodes for ProTaper Universal (Fig. 1). This numerical model of each instrument was entered into a 3D FE analysis package (ABAQUS V6.5-1; SIMULIA, Providence, RI, USA) with the z-axis running from the tip to the shaft of the instrument. A nonlinear, stressstrain behaviour of the NiTi material (Wang 2007) was entered for the NiTi material during the mathematical analysis (Fig. 2): OA represents the elastic deformation of austenite, AB the pseudoelastic range (plateau spanning over about 4% strain) because of stress-induced martensitic (SIM) transformation, BC the elastic deformation of martensite, and CD the plastic deformation of the transformed martensite. Plastic deformation (a result of because of crystallographic slip) is unrecoverable, whereas elastic and SIM transformation strains are mostly recoverable (Duerig & Pelton 1994). The Youngs modulus of the alloy was 36 GPa and the
Materials and methods Modeling of NiTi rotary le

Real-size, digitized models of three brands of NiTi instrument: ProFile size 30 (0.06 taper), ProTaper F3 and ProTaper Universal F3 (all from Dentsply Maillefer)
Figure 2 Stressstrain relationship of the NiTi material (from Wang 2007).
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Poissons ratio 0.3. The critical stress at the beginning of the SIM phase transformation was chosen to be 504 MPa and that at the end was 755 MPa (Wang 2007).
Experimental conditions of simulation

The behaviours of the three instruments were analysed numerically under the following simulated conditions in the FE analysis (Fig. 3): 1. Cantilever bending with a constant load deformation in the form of cantilever bending was simulated by applying a concentrated load of 1 N at the tip of the le with its shaft rigidly held in place (Fig. 3a). The vertical displacement was measured and the von Mises stress distribution was evaluated. 2. Stress distribution under cantilever bending at xed displacement under a similar condition as (a) above, the tip of the le was deected for a distance of 2 mm (Fig. 3b) and held there. The von Mises stress distribution was examined. 3. Application of a shear moment (torsion) a 2.5 Nmm moment of force was applied to the shaft in a clockwise direction normal to the long axis of the
instrument (Fig. 3c), whilst 4 mm of the tip was rigidly constrained. The stress distribution was evaluated. 4. Stress distribution at a xed angular deection the von Mises stress distribution over the instrument was examined after the instrument was rotated by 10 clockwise with its tip rigidly xed at 4 mm (Fig. 3d).
Results Cantilever bending

At a concentrated load of 1 N, the end deection for ProFile was 4.6 mm, ProTaper 2.5 mm and ProTaper Universal 3.1 mm, indicating a greater exibility for ProFile instrument. A maximum von Mises stress of 577 MPa was found at 8.4 mm from the tip of the ProFile instrument; the values were 349 MPa at 3.7 mm for ProTaper, and 547 MPa at 3.6 mm for ProTaper Universal (Fig. 4). The bending force required to deect the instrument from its resting position was greatest for ProTaper, followed by ProTaper Universal and ProFile (Fig. 5a). For the same amount of end deection (2 mm), a maximum von Mises stress of 387 MPa was noted for ProTaper Universal, again, at 3.6 mm from the instrument tip. The values were 350 MPa at 3.7 mm for ProTaper, and 275 MPa at 8.4 mm for ProFile instrument respectively (Fig. 6a). The highest stress was observed at the surface at the cutting edge of ProTaper, but at a very short distance from such edge for ProTaper Universal and ProFile, and at the base of the opposing ute during cantilever bending.
(a)
(b)
Figure 3 Simulated conditions applied in this study: (a) cantilever bending with a concentrated load of 1 N applied to the tip of the instrument; (b) cantilever bending until the tip was displaced by 2 mm; (c) Shear moment of 2.5 Nmm applied to the shaft, with the instrument rigidly xed at 4 mm from its tip and (d) Similar condition as (c) but with the torque applied until the shaft was rotated by 10.
(c)
Figure 4 Relative deection (to scale) of the tip, and stress distribution under cantilever loading (1 N applied to the tip) for each instrument: (a) ProFile; (b) ProTaper and (c) ProTaper Universal.
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Shear moment (torsion)

When a torque of 2.5 Nmm was applied, the original ProTaper design showed the lowest value (350 MPa) for the maximum von Mises stress, followed by 384 MPa for ProTaper Universal (Fig. 6b). The ProFile showed the highest stress of 455 MPa, running along at the base (bottom) of the U-shaped utes. The angular deection was 0.691, 0.826 and 0.995 degrees for ProTaper, ProTaper Universal and ProFile respectively. The resistance to torsion mirrored the exural rigidity of the instrument: a higher torque was required to angularly deect the ProTaper than the other two instruments (Fig. 5b). The highest von Mises stress (constrained region not compared) recorded for ProFile was 333 MPa, ProTaper 359 MPa and ProTaper Universal 388 MPa, all situated at the base of the utes in cross-section (Fig. 6c).
Discussion
In the last decade, the use of NiTi rotary instruments has grown in popularity and there has been an increasing number of proprietary systems introduced commercially. NiTi engine-les operate by way of continuous rotation in the root canal and, as such, are subjected to unidirectional torque (assuming no stalling). The value of the shear (torsional) stress varies depending on the canal size (Hu bscher et al. 2003, Peters et al. 2003), hardness of the dentine to be cut (Berutti et al. 2003) and the use of a lubricant (Boessler
Figure 5 (a) Bending moment needed to deect the tip and (b) the torque required to rotate each le under the restrained condition.
(a)
(b)
(c)
Figure 6 Distribution of von Mises stresses under various conditions for the three instruments tested, the maximum stress values (in MPa) for each case being: (a) ProFile 275, ProTaper 350, ProTaper Universal 387; (b). ProFile 455, ProTaper 350, ProTaper Universal 384 and (c) ProFile 333, ProTaper 359, ProTaper Universal 388.
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et al. 2007). The cross-sectional conguration is also an important determinant of the distribution of stresses on the instrument (Tripi et al. 2006). To avoid dimensional discrepancy, the three brands of NiTi instrument examined in this present study were rst scanned to obtain a real representation of the 3D shape prior to entry into the mathematical simulation. Studies of NiTi instrument breakage are usually completed by means of post-mortem SEM examination of the fracture mode after clinical or simulated use. Such evaluation would not reveal the stresses on the instrument during bending or rotation. Based on a mathematical comparison of the behaviour of two theoretical cross-sections of ProTaper and ProFile, it has been reported that ProTaper might be more suitable for enlarging the (coronal portion of) canals during the initial phase of shaping, and that ProFile might be more suitable for wider canals and in the nal phase of shaping (Berutti et al. 2003). Turpin et al. (2000) have studied the inuence of the idealized crosssectional prole (ProFile vs. Hero) on the torsional and bending stresses using a boundary integral method, and also suggested that instruments of different crosssectional design should be used for different procedures. The amount of end deection under cantilever loading is a measure of the instruments exural rigidity, the product of the elastic modulus of the material and second moment of inertia of the part (Timoshenko & Goodier 1970). ProFile had a greater deection than other systems, indicating that ProFile possesses a lower exural rigidity, i.e. higher exibility. As the mechanical property of the raw material is the same for the three designs (from the same manufacturer), the difference in exural rigidity of the various makes is a result of the different geometry. ProTaper had the greatest exural rigidity, lower end deection, and the least concentration of stress over the surface when subjected to a load of 1 N. Berutti et al. (2003) have also reported that ProTaper had lower and more evenly distributed stresses, compared with the ProFile model, under similar type of loading. However, in the clinical situation, the stress generated in an instrument arises from it having to conform to the root canal curvature (i.e. xed deection) but not due to an externally applied force. Thus, the situation where the various brands were subjected to the same amount of end deection (i.e. Fig. 3b) would be more relevant than application of an arbitrary load both the ProTaper and ProTaper Universal showed a greater value of internal stresses than ProFile. The highest stress concentration was found at the cutting edge of
ProTaper and ProTaper Universal, and near the cutting edge of the ProFile, and at the bottom of the directly opposite ute (see Fig. 6a). This is expected from the mechanics of bending a beam of triangular crosssection. Generally, exural (bending) deection is proportional to the bending moment and inversely proportional to sectional modulus (Timoshenko & Goodier 1970). A correlation between stiffness of an instrument and its cross-sectional area has been suggested in many studies (Ha kel et al. 1999, Turpin et al. 2000, Scha fer et al. 2003). In view of the similar longitudinal outline of the ProTaper and ProTaper Universal instrument, the addition of a groove (ute) at the centre of each side of the convex-triangular crosssection has effectively reduced the second moment of inertia for the latter. On the other hand, this groove seems to have served as a stress-raiser in torsion. The torsional rigidity, which is proportional to the applied torque and the polar moment of inertia of the part, was evaluated in the present study by measuring the angular deection of the instrument. ProTaper was the most rigid, whereas ProFile the least. However, unlike bending of the instrument being governed by the canal curvature, shear stresses are generated in an engine-le because of friction and the (resistance of dentine to) cutting action. Thus, it would be more logical to examine the stress distribution under a similar torsional moment (Fig. 6b) rather than at the same twist-angle (Fig. 6c). It seems that ProFile is going to experience a much greater stress than ProTaper instrument in such a situation (see Fig. 6c), a nding corrobating that of other studies using FE analysis (Turpin et al. 2000, 2001, Berutti et al. 2003, Xu et al. 2006). Concentrations of (torsional) stress were observed at the bottom of the U-shaped utes for ProFile and at the concave groove at each side of the triangular cross-section for ProTaper Universal, the stress of which was much higher than that for the original ProTaper. Hence, there is a greater chance of SIM transformation, and even plastic deformation of the transformed martensite there. This may explain a higher reported incidence of unwinding defects (with or without breakage) for discarded, clinically used, engine-driven ProFile than ProTaper (Shen et al. 2006) or K3 instrument (Ankrum et al. 2004). Enlarging the canal to a size of 15 or 20 before using the instrument would help to reduce the torsional stress experienced by the instrument (Hu bscher et al. 2003) and lower the risk of shear fracture. Incorporating a U-shaped groove for the original ProTaper design, i.e. ProTaper Universal, would lead to some stress concentration at the
19
bottom of the groove, as expected. It would be a weaker point than with the ProTaper, but still be better than ProFile in strength in order to resist torsion. The reaction stresses in an instrument (of the same material and dimensions) are dependent on the geometry of the working part relative to the operating load. Factors affecting the stress distribution include the cross-sectional conguration, the depth of the ute, area of the inner core and (the bulk of) peripheral mass in cross-section; all these inuence the magnitude of the second and polar moments of inertia. Not one of the systems studied was both highly exible and yet able to withstand and distribute the stress evenly in bending and torsion. Indeed, it is obvious that different parameters are operating when the fracture susceptibility of an instrument (because of torsion vs. rotational bending) is concerned (Cheung et al. 2005). Clinicians should understand not only the general guidelines for NiTi rotary instrumentation, but also the structural characteristics which might inuence the durability or the risk of an engine-le to fracture. To increase safety, endodontic educators must emphasize the need for mastering the skill for rotary instruments through appropriate, supervised training (Mandel et al. 1999, Yared et al. 2001). Despite a truer representation of the actual geometry of the instrument in this study, the actual stresses may differ when the instrument is actively ling against the dentine wall during clinical use. Further studies through other methods to verify the relationship between instrument design, stress distribution, fatigue fracture and the inuence of microscopic notches, are required.
References
Ankrum MT, Hartwell GR, Trutt JE (2004) K3 Endo, ProTaper, and ProFile systems: breakage and distortion in severely curved root of molars. Journal of Endodontics 30, 2347. Arens FC, Hoen MM, Steiman HR, Dietz GC Jr (2003) Evaluation of single-use rotary nickeltitanium instruments. Journal of Endodontics 29, 6646. Bergmans L, Van Cleynenbreugel J, Beullens M, Wevers M, Van Meerbeek B, Lambrechts P (2003) Progressive versus constant tapered shaft design using NiTi rotary instruments. International Endodontic Journal 36, 28895. Berutti E, Chiandussi G, Gaviglio I, Ibba A (2003) Comparative analysis of torsional and bending stresses in two mathematical models of nickeltitanium rotary instruments: ProTaper versus ProFile. Journal of Endodontics 29, 159. Boessler C, Peters OA, Zehnder M (2007) Impact of lubricant parameters on rotary instrument torque and force. Journal of Endodontics 33, 2803. Calberson FL, Deroose CA, Hommez GM, De Moor RJ (2004) Shaping ability of ProTaper nickeltitanium les in simulated resin root canals. International Endodontic Journal 37, 61323. Camps JJ, Pertot WJ, Levallois B (1995) Relationship between le size and stiffness of nickel titanium instruments. Endodontics and Dental Traumatology 11, 2703. Chen JL, Messer HH (2002) A comparison of stainless steel hand and rotary nickeltitanium instrumentation using a silicone impression technique. Australian Dental Journal 47, 1220. Cheung GS, Peng B, Bian Z, Shen Y, Darvell BW (2005) Defects in ProTaper S1 instruments after clinical use: fractographic examination. International Endodontic Journal 38, 8029. Clauder T, Baumann MA (2004) ProTaper NT system. Dental Clinics of North America 48, 87111. Duerig TW, Pelton AR (1994) TiNi shape memory alloys. In: Boyer R, Welsch G, Collings EW, eds. Materials Properties Handbook: Titanium Alloys. Materials Park: ASM International, pp. 103548. Garip Y, Gunday M (2001) The use of computed tomography when comparing nickeltitanium and stainless steel les during preparation of simulated curved canals. International Endodontic Journal 34, 4527. Glosson CR, Haller RH, Dove SB, del Rio CE (1995) A comparison of root canal preparations using NiTi hand, NiTi engine-driven, and K-Flex endodontic instruments. Journal of Endodontics 21, 14651. Ha kel Y, Serfaty R, Bateman G, Senger B, Allemann C (1999) Dynamic and cyclic fatigue of engine-driven rotary nickel titanium endodontic instruments. Journal of Endodontics 25, 43440. Hata G, Uemura M, Kato AS, Imura N, Novo NF, Toda T (2002) A comparison of shaping ability using ProFile, GT le, and Flex-R endodontic instruments in simulated canals. Journal of Endodontics 28, 31621.
Conclusions
This study examined the stress distribution under bending or torsional load using a 3D FE analysis for three NiTi instruments of various cross-sectional congurations. It is concluded that the U-le design had the lowest exural rigidity, compared with a convextriangular cross-section with or without an additional ute, but a higher magnitude of stress concentration at the bottom of the ute in torsion. Bending led to the highest surface stress at or near the cutting edge of all three instruments. The convex-triangular cross-section was able to distribute the shear stresses initially, but had similar stress concentrations at the same degree of angular deection. Incorporating a U-shaped groove for the ProTaper design results in an instrument with intermediate properties between the two.
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Hu bscher W, Barbakow F, Peters OA (2003) Root canal preparation with FlexMaster: assessment of torque and force in relation to canal anatomy. International Endodontic Journal 36, 88390. Kim HC, Park JK, Hur B (2005) Relative efcacy of three Ni-Ti le systems used by undergraduates. Journal of Korean Academy of Conservative Dentistry 30, 3848. Lee CH, Cho KM, Hong CU (2003) Effect of various canal preparation techniques using rotary nickeltitanium les on the maintenance of canal curvature. Journal of Korean Academy of Conservative Dentistry 28, 419. Low D, Ho AW, Cheung GS, Darvell BW (2006) Mathematical modeling of exural behavior of rotary nickel titanium endodontic instruments. Journal of Endodontics 32, 5458. Mandel E, Adib-Yazdi M, Benhamou LM, Lachkar T, Mesgouez C, Sobel M (1999) Rotary NiTi prole systems for preparing curved canals in resin blocks: inuence of operator on instrument breakage. International Endodontic Journal 32, 43643. Park SH, Cho KM, Kim JW (2003) The efciency of the NiTi rotary les in curved simulated canals shaped by novice operators. Journal of Korean Academy of Conservative Dentistry 28, 14655. Peters OA, Peters CI, Schonenberger K, Barbakow F (2003) ProTaper rotary root canal preparation: assessment of torque and force in relation to canal anatomy. International Endodontic Journal 36, 939. Sattapan B, Nervo GJ, Palamara JE, Messer HH (2000) Defects in rotary nickeltitanium les after clinical use. Journal of Endodontics 26, 1615. Scha fer E (2001) Shaping ability of Hero 642 rotary nickel titanium instruments and stainless steel hand K-Flexoles in simulated curved root canals. Oral Surgery Oral Medicine Oral Pathology Oral Radiology and Endodontics 92, 21520. Scha fer E, Dzepina A, Danesh G (2003) Bending properties of rotary nickeltitanium instruments. Oral Surgery Oral Medicine Oral Pathology Oral Radiology and Endodontics 96, 757 63. Scha fer E, Schulz-Bongert U, Tulus G (2004) Comparison of hand stainless steel and nickel titanium rotary instrumentation: a clinical study. Journal of Endodontics 30, 4325.
Shen Y, Cheung GS, Bian Z, Peng B (2006) Comparison of defects in ProFile and ProTaper systems after clinical use. Journal of Endodontics 32, 615. Timoshenko SP, Goodier JN (1970) Theory of Elasticity. New York: McGraw-Hill. Tripi TR, Bonaccorso A, Condorelli GG (2006) Cyclic fatigue of different nickeltitanium endodontic rotary instruments. Oral Surgery Oral Medicine Oral Pathology Oral Radiology and Endodontics 102, e10614. Turpin YL, Chagneau F, Vulcain JM (2000) Impact of two theoretical cross-sections on torsional and bending stresses of nickeltitanium root canal instrument models. Journal of Endodontics 26, 4147. Turpin YL, Chagneau F, Bartier O, Cathelineau G, Vulcain JM (2001) Impact of torsional and bending inertia on root canal instruments. Journal of Endodontics 27, 3336. Walia H, Brantley WA, Gerstein H (1988) An initial investigation of the bending and torsional properties of Nitinol root canal les. Journal of Endodontics 14, 34651. Walsch H (2004) The hybrid concept of nickeltitanium rotary instrumentation. Dental Clinics of North America 48, 183202. Wang GZ (2007) A nite element analysis of evolution of stressstrain and martensite transformation in front of a notch in shape memory alloy NiTi. Materials Science and Engineering A 460461, 38391. Wei X, Ling J, Jiang J, Huang X, Liu L (2007) Modes of failure of ProTaper nickeltitanium rotary instruments after clinical use. Journal of Endodontics 33, 2769. Xu X, Eng M, Zheng Y, Eng D (2006) Comparative study of torsional and bending properties for six models of nickel titanium root canal instruments with different cross-sections. Journal of Endodontics 32, 3725. Yared GM, Bou Dagher FE, Machtou P (2001) Inuence of rotational speed, torque and operators prociency on ProFile failures. International Endodontic Journal 34, 4753. Yun HH, Kim SK (2003) A comparison of the shaping abilities of 4 nickeltitanium rotary instruments in simulated root canals. Oral Surgery Oral Medicine Oral Pathology Oral Radiology and Endodontics 95, 22833.
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doi:10.1111/j.1365-2591.2008.01489.x
Ex vivo study on root canal instrumentation of two rotary nickeltitanium systems in comparison to stainless steel hand instruments
J. Vaudt1, K. Bitter1, K. Neumann2 & A. M. Kielbassa1

1 Centrum 3; and 2Institute Department of Operative Dentistry and Periodontology, University School of Dental Medicine, Charite Centrum 4; Charite Universita for Biometry and Clinical Epidemiology, Charite tsmedizin Berlin, Berlin, Germany
Abstract
Vaudt J, Bitter K, Neumann K, Kielbassa AM. Ex vivo
study on root canal instrumentation of two rotary nickel titanium systems in comparison to stainless steel hand instruments. International Endodontic Journal, 42, 2233, 2009.
Aim To investigate instrumentation time, working safety and the shaping ability of two rotary nickel titanium (NiTi) systems (Alpha System and ProTaper Universal) in comparison to stainless steel hand instruments. Methodology A total of 45 mesial root canals of extracted human mandibular molars were selected. On the basis of the degree of curvature the matched teeth were allocated randomly into three groups of 15 teeth each. In group 1 root canals were prepared to size 30 using a standardized manual preparation technique; in group 2 and 3 rotary NiTi instruments were used following the manufacturers instructions. Instrumentation time and procedural errors were recorded. With the aid of pre- and postoperative radiographs, apical straightening of the canal curvature was determined. Photographs of the coronal, middle and apical crosssections of the pre- and postoperative canals were
taken, and superimposed using a standard software. Based on these composite images the portion of uninstrumented canal walls was evaluated. Results Active instrumentation time of the Alpha System was signicantly reduced compared with ProTaper Universal and hand instrumentation (P < 0.05; anova). No instrument fractures occurred in any of the groups. The Alpha System revealed signicantly less apical straightening compared with the other instruments (P < 0.05; MannWhitney U test). In the apical cross-sections Alpha System resulted in signicantly less uninstrumented canal walls compared with stainless steel les (P < 0.05; chi-squared test). Conclusion Despite the demonstrated differences between the systems, an apical straightening effect could not be prevented; areas of uninstrumented root canal wall were left in all regions using the various systems. Keywords: automated root canal preparation, NiTi instruments, root canal aberration, root canal shaping, working safety, working time.
Received 11 April 2008; accepted 16 September 2008
Introduction
The shaping ability of root canal instruments is often assessed in terms of the preservation of the original root canal curvature, and without creating iatrogenic
Correspondence: Juliane Vaudt, Abteilung fu r Zah Centrum 3 nerhaltungskunde und Parodontologie, Charite Universita fu ts r Zahn-, Mund- und Kieferheilkunde, Charite medizin Berlin, Amannshauser Strae 4-6, D-14197 Berlin, Germany (Tel.: +49-30-450 562 335 (332); fax: +49-30-450 562 932; e-mail: juliane.vaudt@charite.de).
events such as instrument fracture, external transportation, ledges, or perforations (Weine et al. 1975, 1976). Good canal shaping through mechanical instrumentation is generally considered essential because root canal shape may have an effect on the efcacy of chemical disinfection. In the last decade, several rotary nickeltitanium (NiTi) instruments with different congurations and designs have been developed with the aim to reduce the preparation time and to simplify the preparation procedure. Many of these systems have been investigated with regard to their shaping and cleaning ability,
22
Vaudt et al. Efcacy of two rotary NiTi instruments
handling safety, and working time (Guelzow et al. 2005, Schirrmeister et al. 2006, Sonntag et al. 2007). These studies have shown that NiTi instruments can effectively prepare continuously tapered and centred root canal forms exhibiting only minor deviations from et al. 2005, the main axis of the root canal (Paque Scha fer et al. 2006, Sonntag et al. 2007). Moreover, investigations have demonstrated that the use of NiTi instruments decreased the prevalence and degree of root canal transportation compared with hand instruments (Scha fer & Lohmann 2002, Scha fer et al. 2004). Nevertheless, these effects could not be entirely eliminated, and statistically signicant differences concerning the straightening effect between rotary NiTi instruments have been reported (Yun & Kim 2003, Yoshimine et al. 2005, Scha fer et al. 2006). In most studies the straightening effect has been analyzed radiographically in the bucco-lingual direction only et al. 2005, Scha (Guelzow et al. 2005, Paque fer et al. 2006). Limited data exist about three-dimensional morphological changes during preparation. Total postoperative cleanliness can only be evaluated histological or by using SEM techniques on longitudinal or horizontal sections of extracted teeth (Hu lsmann et al. 2005). In addition, the pre- and post-instrumented root canal cross sections can be analyzed with respect to unprepared canal walls, thus allowing for conclusions regarding the mechanical cleaning ability. The available literature reveals that rotary NiTi instruments shape the coronal and middle third of the root canal effectively, and create a smooth surface prole (Foschi et al. 2004, Prati et al. 2004). It has been reported that the apical third is the critical area of the root canal, and remaining pulpal and inorganic debris have been detected (Foschi et al. 2004, Prati et al. 2004). Interestingly, stainless steel hand instruments revealed equal or even better results concerning cleaning effectiveness when compared with NiTi instruments (Scha fer & Lohmann 2002, Prati et al. 2004). Various studies reported untreated root canal wall areas after preparation using rotary NiTi instruments (Peters et al. 2001, 2003). Root canal cleanliness is also dependent on the size of the root canal instrument. The available literature has revealed that the use of larger apical instruments led to an advantageous cleaning effect compared with smaller apical les (Wu & Wesselink 1995, Bartha et al. 2006, Weiger et al. 2006). However, root canal preparation with large size instruments can weaken the root, and does increase the risk of apical transportation (Wu et al. 2003).
In 2005, a newly developed rotary NiTi system (Alpha System; Brasseler, Lemgo, Germany), and in 2006, an advanced rotary NiTi system (ProTaper Universal; Dentsply Maillefer, Ballaigues, Switzerland) were introduced into the market; only limited data exist on the performance of these systems. The Alpha System consists of three different instrument sequences according to root canal anatomy (small, average and large canals). The basic set consists of ve instruments with descending tapers ranging from 10% to 2%, and sizes from 20 to 35. The instruments are provided with a titanium nitride coating, have a ve-edged (pentagon) cross-section as well as a noncutting safety tip. For coronal aring, an instrument with an increased taper, a square crosssection (kite-shaped) and large chip spaces is available (AF10; access reamer). ProTaper Universal represents an advancement of ProTaper, which has been previously investigated in several studies (Calberson et al. 2004, Guelzow et al. et al. 2005, Sonntag et al. 2007). The 2005, Paque basic sequence of ProTaper Universal exhibits an advanced ute design that combines multiple tapers within the shaft, a convex triangular cross-sectional design, blades close to the noncutting pilot tip as well as an increasing chip space (space for the accumulation of debris) from tip to shaft. A new design feature of ProTaper Universal NiTi system comprises the more rounded tips of the nishing les with the aim to increase the working safety as well as to improve shaping ability. Furthermore, the cross-section design has been modied. The convex lateral surfaces of F3 to F5 are machined to increase its inherent exibility. The aim of the present study was to investigate the instrumentation time, the working safety and the shaping ability in extracted mandibular molar teeth with curved root canals using the rotary NiTi systems Alpha System and ProTaper Universal in comparison to stainless steel hand instruments. A modied mufe system was used to enable evaluation both in the bucco-lingual and in the mesio-distal direction. The hypothesis was that the parameters instrumentation time, working safety and shaping ability would be inuenced by the instrumentation technique.
Materials and methods Selection of teeth and experimental set-up

A total of 45 human mandibular molars (extracted for periodontal reasons) with intact crowns and curved
23
Efcacy of two rotary NiTi instruments Vaudt et al.
mesial roots were selected. The study protocol conformed to the principles outlined in the Central German Ethics Committees statement (Zentrale Ethikkommission 2007) focusing on the use of human body material in medical research. Only teeth with completed root formation, intact root apices, and without visible apical resorption were included. Coronal access was achieved using diamond burs, and the mesial root canals were controlled for apical patency with a size 10 reamer (VDW, Munich, Germany). For evaluation of the several parameters a modication of the mufe-block, as previously described by Bramante et al. (1987), Campos & del Rio (1990) and Hu lsmann et al. (1999) was used. A mufe-block was constructed, which allows removal and exact repositioning of the complete specimen or sectioned parts of the latter (Fig. 1). Using this modied mufe, the exposure of radiographs under reproducible conditions in two directions (bucco-lingual and mesio-distal) was guaranteed to take radiographs before, during and after root canal preparation. The mufe consisted of a ground section, four lateral walls and a cover with eight vertical screws. The holder for the radiographic sensor (fabricated from clear epoxy resin) could be adjusted at the ground section of the mufe, and the positioner for the X-ray tube could be xed at the outside of the ground part of the mufe (Fig. 1).
Specimen preparation
The teeth were embedded into the mufe-block with acrylic resin (Technovit 4071; Heraeus Kulzer, Hanau, Germany), and shortened coronally to a length of 19 mm. Subsequently, specimens were sectioned horizontally at 3, 6, and 9 mm from the apex (Sa gemikrotom Leitz 1600; Leica Microsystem, Wetzlar, Germany). The horizontal segments were remounted into the mufe, and loss of material (300 lm, because of the thickness of the saw blade as well as the interslice thickness) was compensated using metal disks of the corresponding height (300 lm). An initial size 10 root canal instrument was inserted into the curved root canal. Standardized radiographs were taken prior to the instrumentation in a buccolingual as well as in a mesio-distal direction with a digital radiographic system (Planmeca intra; Planmeca, Hamburg, Germany), operating at 70 kV and 7 mA. Thus, the straightening of the instrumented root canals could be evaluated from two directions to describe the three-dimensional morphological changes during preparation. Root canal curvatures were measured according to a modied method (Hu lsmann & Stryga 1993) using the software AxioVision (Carl Zeiss MicroImaging; Jena, Germany). The specimens were divided into three groups according to the root canal curvature (<25, 2535, and >35). On the basis of the degree of the bucco-lingual curvature the teeth were randomized equally into three groups of 15 teeth each (stratied random sampling); thus, groups that were equal on the matching variable were created. With the aim to analyze the shaping ability and to draw conclusions regarding the mechanical cleaning ability of the systems photographs of the preoperative coronal, middle, and apical cross-sections of the root canals were taken using a stereo microscope (Stemi SV11; Carl Zeiss, Oberkochen, Germany) including a video camera attachment (JVC TK 1070E; Carl Zeiss) at 70 magnication.
Figure 1 Insight into the modied mufe system with xed
Instruments and preparation technique

According to the manufacturers instructions all root canals were initially prepared using a size 10 reamer followed by a size 15 reamer. Alpha System les were set into permanent rotation with a 4-level torque limit setting ENDOadvance handpiece (KaVo; Biberach, Germany), powered by an electric motor (MF-Perfecta; W&H, Buermoos, Austria), and using a working speed
positioner for the X-ray tube (p) and inserted sectioned parts of specimen (t), mounted for radiographic evaluation in vestibulo-oral direction. The holder (h) bearing the slot for the radiographic sensor (s) is adjusted at the ground section of the mufe. The inserted small photograph reveals the tooth specimen rotated at an angle of 90 to enable radiographic evaluation in mesio-distal direction (for presentation, front and side sections of the mufe-block have been removed).
24
Table 1 Total number of instruments used, sequence of preparation and working length (WL)
System Alpha System (Brasseler, Lemgo, Germany; ve instruments) Sequence Average canals (as indicated by the manufacturer) AF10.045 10% taper, size 45 (canal orice) AF06.025 6% taper, size 25 (crown down to the curvature) AF04.025 4% taper, size 25 (crown down to the curvature) AF02.025 2% taper, size 25 (WL) AF02.030 2% taper, size 30 (WL) S1 le (shaping le 1) - 211% taper, size 17 (canal orice) SX (auxiliary shaper le) - 319% taper, size 19 (canal orice) S1 (shaping le 1) - 211% taper, size 17 (WL) S2 (shaping le 2) - 411.5% taper, size 20 (WL) F1 (nishing le 1) - 75.5% taper, size 20 (WL) F2 (nishing le 2) - 85.5% taper, size 25 (WL) F3 (nishing le 3) - 95.5% taper, size 30 (WL) Reamer - 2% taper, size 15 (WL) Hedstro m le - 2% taper, size 15 Reamer - 2% taper, size 20 (WL) Hedstro m le - 2% taper, size 20 Reamer - 2% taper, size 25 (WL) Hedstro m le - 2% taper, size 25 Reamer - 2% taper, size 30 (WL) Hedstro m le - 2% taper, size 30
ProTaper Universal (Dentsply Maillefer, Ballaigues, Switzerland; seven instruments)
Stainless steel instruments (Vereinigte Dentalwerke, Germany; eight instruments)
(WL) (WL) (WL) (WL)
of 250 rpm (500 rpm for AF10). ProTaper Universal instruments were set into permanent rotation with a 4 : 1 reduction handpiece (WD-66 EM; W&H, Buermoos) powered by a low torque-limited electric motor (Endo IT control motor; VDW), and a working speed of 300 rpm was used. Instrumental sequences followed the manufacturers instructions (see Table 1). The instruments were kept rotating inside the root canal until they reached the working length and the instruments designed for crown down technique (AF10.045, AF06.025, AF04.025) were left in the root canal for a short period of time (58 s). The manual preparation technique was performed using stainless steel K-Reamers (VDW) as well as Hedstro m les (VDW). All root canals were preared in the coronal section with number 1 through three Gates Glidden burs. The K-Reamers were used in a reaming motion and manipulated in a clockwise rotation of about 90120 with a very light inward force until the le reached the full working distance, followed by a straight outward pull (turn-and-pull motion). Hedstro m les were used additionally with a withdrawing ling motion only. All instruments were pre-curved. No step-back method of instrument manipulation was used with the hand instruments. The individual working length for all specimens was obtained by measuring the length of the initial
instrument (size 10; VDW) at the apical foramen subtracting 1 mm. All les were used to instrument only one canal and coated with a lubricant containing EDTA (FileCare; VDW) before use. The root canals of all teeth were instrumented up to size 30. After each instrument, the root canal was irrigated with 2 mL of 1% NaOCl solution using a syringe and a 28-gauge needle. All canals were instrumented and analyzed by the same experienced operator.
Assessment of root canal preparation

Instrumentation time The active time for root canal instrumentation was recorded using a digital stopwatch (http://www.jumk. de/stoppuhr; Internetservice Kummer + Oster, Buchenberg, Germany). Time for instrument changes as well as irrigation times were not considered. Working safety The number of fractured instruments during instrumentation was documented. Shaping ability The assessment of the apical straightening effect for each system was carried out after preparation up to sizes 25 and 30, respectively. Radiographs were taken with a size 25 and 30 instrument from both directions
25
(a)
(b)
(c)
(d)
Figure 2 Representative example of a series of radiographs
taken in vestibulo-oral (a) and mesio-distal direction before (c) and after preparation up to ISO size 30 (b, d). The root canal curvature was measured prior to instrumentation with the initial instrument inserted (reamer ISO size 10) (a, c). Based on the radiographs taken after preparation up to ISO size 30 (b, d), canal curvature could be measured and apical straightening could be determined.
(bucco-lingual and mesio-distal) (Fig. 2). Based on the canal curvatures assessed pre- and postoperatively, the apical root canal straightening was determined as the difference between apical root canal curvatures before and after instrumentation using instruments of size 25 and 30, respectively. In the coronal, middle and apical cross-sections of the root canal the portion of uninstrumented canal walls was evaluated. After root canal preparation postoperative photographs of the cross sections were taken. Pre- and postoperative photographs were superimposed using reference marks (Fig. 3) (Corel Draw; Corel Corporation, Unterschleiheim, Germany). On the basis of these images the distance of contact between the pre- and postoperative root canal walls was measured, and the portion of uninstrumented root canal walls was determined (Fig. 3). According to the results, specimens were divided into four groups: Group 1: 025% contact between pre- and postoperative cross-section/root canal wall. Group 2: >25% contact between pre- and postoperative cross-section/root canal wall. Group 3: >50% contact between pre- and postoperative cross-section/root canal wall. Group 4: >75% contact between pre- and postoperative cross-section/root canal wall.
Statistical analyses
The statistical analysis was conducted using one-way anova with post hoc Tukey B tests for the active
Figure 3 Representative superimposi-
tion of the pre- and postoperative photographs of the root canal crosssections using reference marks (apical area). The bolts demonstrate the edge of the half-transparent superimposed photograph of the instrumented canal. The coloured lines show the traced root canal outlines (red = initial outline; black = outline after root canal preparation). Note that all root canal walls were instrumented in this specimen.
26
instrumentation time, and KruskallWallis test followed by pairwise comparisons using MannWhitney U tests for the straightening effect. The Wilcoxon test for paired samples was used for comparisons of both directions (bucco-lingual and mesio-distal) regarding the degree of straightening. The percentages of uninstrumented root canal walls were compared using chisquared test (exact test was used). The level of signicance was set at a = 0.05 (without adjusting for the respective comparisons, as the described proceeding is equivalent to the closed test procedure for the particular case of three study groups). All statistical analyses were performed using spss version 15.0 software (SPSS; Chicago, IL, USA).
Results Working time

The active time for root canal instrumentation (Table 2) was affected signicantly by the systems used (P < 0.0005; anova). The Alpha System required signicantly less time compared with the other systems (P < 0.05; Tukey B), whereas ProTaper Universal revealed a signicantly reduced instrumentation time compared with the manual technique (P < 0.05; Tukey B).
Working safety
During the preparation of the curved root canals, no fractures of any of the used instruments (stainless steel les as well as the NiTi instruments) could be observed.
general, straightening was more pronounced with size 30 instruments compared with size 25; differences amongst the groups were increased (as indicated by the P-values) after use of size 30 instruments. In both directions (bucco-lingual and mesio-distal), the use of stainless steel instruments resulted in signicantly increased (P < 0.05; Wilcoxon) straightening if compared with Alpha les; differences between ProTaper Universal and the manual technique were not significant. No statistically signicant differences between the two directions regarding the degree of straightening could be observed. The analysis of the pre- and postoperative crosssections revealed that all systems used left uninstrumented root canal walls in all regions. For the coronal and middle cross-sections no differences between the systems were found with respect to uninstrumented root canal walls (P > 0.05; KruskalWallis). The portion of uninstrumented root canal walls in the apical cross-sections was signicantly affected by the instrumentation system (P = 0.004; chi-squared test); the results are summarized in Table 4. Instrumentation using the Alpha System resulted in signicantly less unprepared root canal walls compared with the manual technique (P = 0.001; chi-squared test). Comparison between ProTaper Universal and stainless steel les did not reveal any signicant differences (P = 0.153; chi-squared test). ProTaper Universal left more unprepared root canal walls compared with Alpha System; however, this statistical difference was only weakly signicant (P = 0.043; chi-squared test).
Discussion
The aim of the present investigation was to compare the shaping ability of two recently introduced rotary NiTi instruments in contrast to a manual technique using stainless steel instruments. The results revealed signicant differences between the used systems with respect to their shaping ability as well as regarding the working time. Thus, the hypothesis of the present study concerning the differences between the systems regarding the evaluated parameters could not be rejected.
Shaping ability
The apical straightening of the curved root canals was signicantly affected by the instrumentation system (KruskallWallis). Results and P-values (for comparisons of all techniques, and with regard to the respective preparations sizes) are summarized in Table 3. In
Table 2 Mean active preparation time (in s) and standard deviation (SD)
System Alpha Systema ProTaper Universalb Manual techniquec
a,b,c
Study design
Previous investigations that focused on the shaping ability of NiTi instruments used either simulated root canals (Yun & Kim 2003, Yoshimine et al. 2005, Schirrmeister et al. 2006) or extracted human teeth et al. 2005, Scha (Paque fer et al. 2006). Simulated root
Mean 103.2 150.7 238.3
SD 13.5 18.9 35.1
Means with differing superscript letters indicate signicant differences at a = 0.05.
27
Table 3 Mean values (including standard deviations as well as minimum and maximum values) of apical straightening in
both directions (in degrees)

Straightening of vestibulo-oral direction (in degrees) ISO size 25 System Alpha System ProTaper Universal Manual technique P-value (Kruskal-Wallis) Mean 0.6 2.7a,b 2.9b 0.043
a
ISO size 30 SD 0.5 2.8 3.0 Min 0.0 0.0 0.1 Max 1.4 9.2 9.4 Mean 1.4 4.3b 4.4b 0.012
a
SD 1.0 3.4 3.7
Min 0.2 0.1 0.5
Max 3.8 12.5 13.2
Straightening of mesio-distal direction (in degrees) ISO size 25 System Alpha System ProTaper Universal Manual technique P-value (Kruskal-Wallis)
a,b,c
ISO size 30 SD 1.6 2.2 2.9 Min 0.0 0.0 0.1 Max 6.4 7.7 11.7 Mean 2.4a 4.4b 4.7b 0.019 SD 1.9 2.1 3.8 Min 0.1 0.2 0.8 Max 7.0 7.8 16.4
Mean 1.7a 3.4b 3.5b 0.028
Signicant differences (P < 0.05) according to comparisons using MannWhitney U test are indicated by different superscript letters.
Table 4 Portion of uninstrumented area between superim-
posed pre- and postoperative root canal walls in the apical region when viewed in cross-sections
Contact between pre- and postoperative cross-section (%) System Alpha System ProTaper Universal Manual technique Number percentage Number percentage Number percentage 025% 14 93.3% 8 53.3% 3 20.0% >25% 1 6.7% 5 33.3% 10 66.6% >50% 0 0.0% 2 13.3% 1 6.7% >75% 0 0.0% 0 0.0% 1 6.7%
canals using pre-fabricated resin blocks allow for standardization of degree, location and radius of root canal curvature in three dimensions as well as the root canal length (Peters 2004, Hu lsmann et al. 2005). However, the hardness and abrasion behaviour of acrylic resin and root dentine is not identical, and consequently does not reect the action of the instruments in root canals of real teeth (Peters 2004, Hu lsmann et al. 2005). Therefore, using extracted human teeth reects the clinical situation more adequately. Nevertheless, large variations concerning root canal morphology and dentine hardness complicate standardization of groups (Hu lsmann et al. 1999). Similar apical preparation diameters are required for the comparison of the shaping and cleaning ability of different root canal instruments. Thus, in all investigated groups of the present investigation, the nal apical preparation diameter was size 30. Moreover, to
reduce the wide range of variations in three-dimensional root canal conguration the present study used mesial root canals of rst and second mandibular molars. These teeth reveal root canal curvatures in most cases. Consequently, the measured degrees of the root canal curvature were categorized into three groups according to a modied method described by Schneider (Schneider 1971); this matched-group design allowed for minimization of high variations in the degree of curvature between the groups. To evaluate the quality of root canal preparation a study design is desirable that allows for standardization and facilitates simulation of the clinical situation. Additionally, all relevant parameters should be recorded. Root canal morphology and the effect of instrumentation have been studied via numerous techniques (Campos & del Rio 1990, Hu lsmann et al. 1999). A method has been introduced (Bramante et al. 1987) and modied (Campos & del Rio 1990, Hu lsmann et al. 1999) in which root canals can be analyzed before and after instrumentation using extracted teeth. Previously published literature has described the varying congurations of the used mufeblocks (Campos & del Rio 1990, Hu lsmann et al. 1999). Various elements, horizontal and vertical grooves in the walls of the mufe-blocks have been designed and integrated to guarantee the exact reposition of the specimen. In the present investigation a mufe-block was constructed to evaluate simultaneously both mechanical cleaning and shaping ability under
28
reproducible conditions. The elements were designed to facilitate removal and exact repositioning of the complete specimen or sectioned parts of the latter. On the basis of the tapered internal space, integrated positioning devices as well as a cover, the exact and nonrelocatable vertical and horizontal position of the specimen was guaranteed. After sectioning of the embedded teeth horizontally, the specimens were remounted into the mufe for instrumentation. The loss of material was predictable because of the use of the saw microtome, and could be compensated using spacers (metal disks) of the same height. The conguration of the used mufe system allowed for evaluation of the root canal cross-section prior, during and after instrumentation without changing the three-dimensional morphology of root canal. A further important improvement was the ability to evaluate the parameter straightening of curved root canals in two directions (bucco-lingual and mesiodistal) with the aim to describe the three-dimensional morphological changes during preparation. This parameter refers to the maintenance of the original shape of curved root canals, and provides information about the direction of removed material.
Shaping ability
This study showed that root canal preparation using stainless steel instruments as well as NiTi systems results in a pronounced apical straightening effect in the bucco-lingual as well as in the mesio-distal plane. No differences were found between the two directions regarding the degree of root canal transportation. Various investigations demonstrated that the use of NiTi instruments decreased the prevalence and degree of root canal transportation compared with stainless steel hand instruments (Scha fer & Lohmann 2002, Scha fer et al. 2004). However, other studies reported no differences between rotary NiTi systems and stainless steel hand instruments regarding root canal transportation (Guelzow et al. 2005, Hartmann et al. 2007). These divergent outcomes might be explained by differences in methodologies, methods of assessment, instruments and preparation techniques. A further aspect is the design of an instrument that might inuence the shaping ability. Stainless steel les are relatively stiff that will increase with larger instrument size and causes high lateral forces in curved root canals (Bergmans et al. 2001, Scha fer & Tepel 2001). The rigidity of an instrument could be responsible for straightening of and aberration from the root canal
(including ledges, zipping and perforations), along with leaving signicant portions of the root canal wall uninstrumented (Peters et al. 2003, Calberson et al. 2004). It has been assumed that NiTi instruments could improve shaping ability and minimize any et al. aberrations during root canal preparation (Paque 2005, Yoshimine et al. 2005, Schirrmeister et al. 2006, Sonntag et al. 2007). However, these effects could not be entirely eliminated, and differences amongst rotary NiTi instruments have been demonstrated (Yun & Kim 2003, Yoshimine et al. 2005, Scha fer et al. 2006). With regard to the reported outcomes, it has to be stressed that different rake angles of instruments should reveal varying cutting efcacies; indeed, most rotary les have negative rake angles with a predominantly scraping motion. In general, the shaping ability of root canal instruments is a complex interrelationship of various parameters such as cross-sectional design, chip removal capacity, helical and rake angle, metallurgical properties and surface treatment of the instrument (Scha fer 1999, Scha fer & Oitzinger 2008). The more rounded tip of the nishing les in the ProTaper Universal sequence has been developed to increase the working safety as well as to improve the shaping ability. Furthermore, the cross-section design has been modied to increase its inherent exibility. Obviously, the advanced design features of the ProTaper Universal system revealed similar results compared with previous studies evaluating the classic ProTaper les (Peters et al. 2003, Calberson et al. 2004, Sonntag et al. 2007). This study found a signicantly pronounced apical straightening effect in both directions using ProTaper Universal compared to Alpha System. The different instrument designs of these NiTi systems (i.e. progressive versus constant taper) could have inuenced the observed outcomes. Previously published studies demonstrated relationships between bending moment and cross-section, le size as well as taper of an instrument (Scha fer & Tepel 2001, Scha fer et al. 2003). The ProTaper Universal les have multiple and increased tapers within the shaft compared with the Alpha les presenting a less and constant taper. The apical transportation towards the outer aspects of the root canal could have been affected by the variable tapers along the cutting surface of the ProTaper Universal les (up to 11% at the tip) compared with the moderately tapered (2%) Alpha System instruments. An increasing taper is associated with increased crosssection areas and, accordingly, with decreased exibility of the les that could cause straightening and
29
root canal aberration during preparation (Bergmans et al. 2001). The decreasing taper sequence of the nishing les enhance the strength of the instruments, but increase the stiffness of their tips (i.e. ProTaper Universal size 30 is 9%, size 20 is 7%), thus resulting in high lateral forces. Previously published data about classic ProTaper les showed similar results compared with the present investigation and demonstrated varying degrees of root canal straightening and transportation (Peters et al. 2003, Yoshimine et al. 2005). These tended at the midpoint of the curvature towards the inner aspects and apically towards the outer aspects of the root canal (Calberson et al. 2004, Sonntag et al. 2007). An investigation comparing three rotary NiTi instruments has demonstrated a tendency to ledge or zip formation at the end-point of preparation using ProTaper compared with RaCe and K3 (Yoshimine et al. 2005). The RaCe and K3 groups showed favourable results, and the prepared root canals displayed a smooth shift to the original root canals at the end point. The authors recommended that more exible instruments, like K3 and RaCe, should be used in the apical preparation of curved root canals (Yoshimine et al. 2005). Comparisons amongst different rotary NiTi systems instruments revealed more root canal straightening after use of ProTaper compared to Mtwo, K3, ProFile, GT Rotary, and Quantec (Yun & Kim 2003, Sonntag et al. 2007). In contrast to these observations, other investigations found no statistical differences in root canal transportation using ProTaper compared with other rotary NiTi instruments after preparation of up to size 30 (Guelzow et al. 2005). et al. 2005, Paque The rotary NiTi Alpha System les provided a centred apical preparation and maintained the original shape of the curved root canals with only minor deviation from the main axis. The les are characterized by a pentagon-type cross-sectional design resulting in only slightly positive cutting angles and a comparable low chip space (Scha fer & Oitzinger 2008). The reduced root canal transportation could be explained by the high exibility of these instruments because of their minor and constant taper along the cutting surface. This superior exibility reduces the risk of root canal transportation during the enlargement of curved root canals (Scha fer et al. 2003). Furthermore, it has been shown that the crosssectional design as well as cross-sectional areas mainly inuenced bending properties of instruments (Scha fer & Tepel 2001, Scha fer et al. 2003). It has been reported that for identical working diameters, the
area of a triple-helix cross-section was found to be approximately 30% greater than that of triple-U le (Turpin et al. 2000). Because of the more massive structure of a triple helix le, this instrument was found to be less exible than the triple-U instrument (Turpin et al. 2000). The Alpha les used in the present study had a pentagon-type cross-section. It might be speculated that this form of cross-section results in a high core diameter and a high crosssectional area compared with other forms (i.e. triangular, square cross-section), and, consequently, in reduced exibility. Furthermore, the small chip space could lead to apical blockage caused by insufcient transportation of debris towards the orice (Bergmans et al. 2001). Alpha system les are the only known rotary NiTi systems with a pentagon cross-sectional design, and no published literature exists about this design feature up to now. Obviously, in the case of comparison between Alpha System and ProTaper Universal the taper had a greater inuence on the exibility than the cross sectional design. Under the conditions of the present study the use of the rotary NiTi Alpha System les resulted in minimal apical root canal transportation. However, the inuence of the individual geometric characteristics of the instruments on the cleaning and shaping ability remains speculative. It is well known that the surface hardness of NiTi instruments is lower than that of stainless steel instruments (Brockhurst & Hsu 1998, Scha fer & Oitzinger 2008). Consequently, the cutting efciency should be less compared with most stainless steel instruments (Brockhurst & Hsu 1998). With the aim to improve the surface hardness (and thereby increasing the shaping efciency of NiTi instruments) several surface engineering techniques have been used, i.e. physical vapour deposition (PVD) techniques. Recent studies have shown that the PVD technique is suitable to signicantly increase the cutting efciency of NiTi instruments (Scha fer 2002). However, those ndings did not corroborate the observation of a previously published study comparing the cutting efciency of different NiTi systems (Scha fer & Oitzinger 2008); here, the results revealed no signicant inuence of the PVD coating surface on the cutting efciency, and the Alpha System les showed a signicantly lower cutting efciency compared with Mtwo, RaCe, and Flexmaster (Scha fer & Oitzinger 2008). Thus, the inuence of the PVD coating on the cutting efcacy of NiTi instruments with different cross-sectional design remains unclear.
30
Unprepared root canal wall areas

The comparison of the pre- and postoperative photographs of root canal cross-sections enables conclusions on shaping ability as well as mechanical cleaning ability. The prepared root canal should include the original root canal dimensions, and no unprepared areas should remain (compare Fig. 3). In the present investigation analysis of the pre- and postoperative cross-sections showed that the manual technique using stainless steel instruments as well as the rotary NiTi systems left uninstrumented root canal walls in all regions. While the coronal and middle cross-sections demonstrated sufcient shaping outcomes with only minor untreated areas, the percentage of uninstrumented root canal walls in the apical cross-section was signicantly affected by the instrumentation system. Following preparation using the Alpha System the specimens showed the lowest percentage of unprepared root canal outlines compared with the manual technique using stainless steel instruments and the ProTaper Universal that ranged between the two previous groups. These ndings corroborate the results of previous studies. It has been reported that in the apical part of the root canal amounts of remaining pulpal and inorganic debris could be detected after using rotary NiTi instruments (Foschi et al. 2004, Prati et al. 2004). Furthermore, results indicated large untreated areas of the root canal walls (Peters et al. 2001, 2003). These areas tended to be on the convex curvature at mid-root and the concave side of the curvature more apically (Peters et al. 2003). Evaluation of the original ProTaper resulted in untouched areas ranging from 43% to 49% (Peters et al. 2003). The superior shaping efciency of the Alpha System could be attributed to the high elasticity characteristics of the instruments that resulted in minor root canal transportation during root canal preparation. Consequently, the les remove dentine uniformly on the outer and inner side of the root canal and only minor areas remain untouched. However, further studies should evaluate whether the preparation of wide root canals using the less tapered Alpha les will result in sufcient cleanliness. Nevertheless, the clinical signicance of the parameter prepared surface is not yet claried. However, when considering the fact that viable microbes may penetrate deep into the dentinal tubules and may persist during root canal treatment (Chuste-Guillot et al. 2006), the need of an efcient irrigation (in
addition to the shaping regime) to clean the root canals effectively is clearly highlighted.
Instrumentation time
The evaluation of the parameter working time should demonstrate the efcacy of a system and its clinical suitability. Studies that investigated the working time of various NiTi systems used the latter in different treatment sequences and changing number of les. Notwithstanding, working time depends on preparation technique and operator experience. Some investigations evaluated working time as the active instrumentation time (summation of time taken et al. for les to work inside the root canal) (Paque 2005). Other studies measured the working time including the active instrumentation time as well as the time for changing instruments and irrigation, thus resulting in considerably higher values (Schirrmeister et al. 2006). Evaluations of manual techniques and rotary NiTi instruments have demonstrated huge variations of working time, and cannot provide recommendations for one of the two techniques (Scha fer et al. 2004, Guelzow et al. 2005, Schirrmeister et al. 2006). The present investigation observed shorter working times for NiTi preparation compared with the manual instrumentation. The results indicate that the ProTaper Universal system required more time to prepare a root canal than the Alpha System. These results may be explained by the varying number of instruments. In the present investigation, root canal preparation was performed using eight stainless steel les for the manual technique, and seven les for ProTaper Universal. The ve Alpha System les exhibited the lowest number of required instruments for root canal enlargement.
Working safety
The reasons for fractures of rotary NiTi instruments are multifactorial, and complications can be attributed to instrument design, manufacturing process, canal conguration, applied force during instrumentation, preparation technique, operators skills and experience as well as the number of application inside the root canal (Parashos & Messer 2006). In the present investigation no fractures of the stainless steel les as well as the NiTi instruments could be observed. All instruments were used to instrument only one single root canal. It should be emphasized that the regimen used was owing to the objectives (to compare the cleaning and shaping ability
31
of different systems). Thus, this procedure does not adequately reect the clinical situation, and the clinical relevance concerning the working safety should be interpreted with caution.
Conclusion
Within the limitations of the present ex vivo study, the experimental results suggest that none of the rotary NiTi systems used was able to impede an apical straightening effect during root canal preparation; uninstrumented root canal wall areas were left in all regions with all systems. Few statistically signicant differences amongst the three instrumentation techniques could be revealed. Instrumentation of curved root canals to ISO size 30 using instruments with greater taper (Pro Taper Universal F2, F3) and stiffer instruments (Pro Taper Universal F3, stainless steel le of size 30) seemed to result in increased root canal transportation and in a higher portion of unprepared root canal walls compared with exible NiTi instruments (Alpha 02/30) that maintained the curvature of the root canal.
Acknowledgements
The authors are indebted to Brasseler (Lemgo, Germany), Dentsply Maillefer (Ballaigues, Switzerland) and Vereinigte Dentalwerke (Munich, Germany) for generously providing the instruments.
References
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Campos JM, del Rio C (1990) Comparison of mechanical and standard hand instrumentation techniques in curved root canals. Journal of Endodontics 16, 2304. Chuste-Guillot MP, Badet C, Peli JF, Perez F (2006) Effect of three nickel-titanium rotary le techniques on infected root dentin reduction. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics 102, 2548. Foschi F, Nucci C, Montebugnoli L et al. (2004) SEM evaluation of canal wall dentine following use of Mtwo and ProTaper NiTi rotary instruments. International Edodontic Journal 37, 8329. Guelzow A, Stamm O, Martus P, Kielbassa AM (2005) Comparative study of six rotary nickel-titanium systems and hand instrumentation for root canal preparation. International Endodontic Journal 38, 74352. Hartmann MS, Barletta FB, Camargo Fontanella VR, Vanni JR (2007) Canal transportation after root canal instrumentation: a comparative study with computed tomography. Journal of Endodontics 33, 9625. Hu lsmann M, Stryga F (1993) Comparison of root canal preparation using different automated devices and hand instrumentation. Journal of Endodontics 19, 1415. Hu lsmann M, Gambal A, Bahr R (1999) An improved technique for the evaluation of root canal preparation. Journal of Endodontics 25, 599602. Hu lsmann M, Peters OA, Dummer PMH (2005) Mechanical preparation of root canals: shaping goals, techniques and means. Endodontic Topics 10, 3076. F, Musch U, Hu Paque lsmann M (2005) Comparison of root canal preparation using RaCe and ProTaper rotary Ni-Ti instruments. International Endodontic Journal 38, 816. Parashos P, Messer HH (2006) Rotary NiTi instrument fracture and its consequences. Journal of Endodontics 32, 103143. Peters OA (2004) Current challenges and concepts in the preparation of root canal systems: a review. Journal of Endodontics 30, 55967. Peters OA, Schonenberger K, Laib A (2001) Effects of four Ni-Ti preparation techniques on root canal geometry assessed by micro computed tomography. International Endodontic Journal 34, 22130. Peters OA, Peters CI, Schonenberger K, Barbakow F (2003) ProTaper rotary root canal preparation: effects of canal anatomy on nal shape analysed by micro CT. International Endodontic Journal 36, 8692. Prati C, Foschi F, Nucci C, Montebugnoli L, Marchionni S (2004) Appearance of the root canal walls after preparation with NiTi rotary instruments: a comparative SEM investigation. Clinical Oral Investigations 8, 10210. Scha fer E (1999) Relationship between design features of endodontic instruments and their properties. Part 1. Cutting efency. Journal of Endodontics 25, 525. Scha fer E (2002) Effect of physical vapor deposition on cutting efciency of nickel-titanium les. Journal of Endodontics 28, 8002.
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Scha fer E, Lohmann D (2002) Efciency of rotary nickeltitanium FlexMaster instruments compared with stainless steel hand K-Flexole. Part 2. Cleaning effectiveness and instrumentation results in severely curved root canals of extracted teeth. International Endodontic Journal 35, 51421. Scha fer E, Oitzinger M (2008) Cutting efciency of ve different types of rotary nickel-titanium instruments. Journal of Endodontics 34, 198200. Scha fer E, Tepel J (2001) Relationship between design features of endodontic instruments and their properties. Part 3. Resistance to bending and fracture. Journal of Endodontics 27, 299303. Scha fer E, Dzepina A, Danesh G (2003) Bending properties of rotary nickel-titanium instruments. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics 96, 75763. Scha fer E, Schulz-Bongert U, Tulus G (2004) Comparison of hand stainless steel and nickel titanium rotary instrumentation: a clinical study. Journal of Endodontics 30, 4325. Scha fer E, Erler M, Dammaschke T (2006) Comparative study on the shaping ability and cleaning efciency of rotary Mtwo instruments. Part 2. Cleaning effectiveness and shaping ability in severely curved root canals of extracted teeth. International Endodontic Journal 39, 20312. Schirrmeister JF, Strohl C, Altenburger MJ, Wrbas KT, Hellwig E (2006) Shaping ability and safety of ve different rotary nickel-titanium instruments compared with stainless steel hand instrumentation in simulated curved root canals. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics 101, 80713. Schneider SW (1971) A comparison of canal preparations in straight and curved root canals. Oral Surgery, Oral Medicine, and Oral Pathology 32, 2715. Sonntag D, Ott M, Kook K, Stachniss V (2007) Root canal preparation with the NiTi systems K3, Mtwo and ProTaper. Australian Endodontic Journal 33, 7381.
Turpin YL, Chagneau F, Vulcain JM (2000) Impact of two theoretical cross-sections on torsional and bending stresses of nickel-titanium root canal instrument models. Journal of Endodontics 26, 4147. Weiger R, Bartha T, Kalwitzki M, Lost C (2006) A clinical method to determine the optimal apical preparation size. Part I. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics 102, 68691. Weine FS, Kelly RF, Lio PJ (1975) The effect of preparation procedures on original canal shape and on apical foramen shape. Journal of Endodontics 1, 25562. Weine FS, Kelly RF, Bray KE (1976) Effect of preparation with endodontic handpieces on original canal shape. Jounal of Endodontics 2, 298303. Wu MK, Wesselink PR (1995) Efcacy of three techniques in cleaning the apical portion of curved root canals. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics 79, 4926. Wu MK, van der Sluis LW, Wesselink PR (2003) The capability of two hand instrumentation techniques to remove the inner layer of dentine in oval canals. International Endodontic Journal 36, 21824. Yoshimine Y, Ono M, Akamine A (2005) The shaping effects of three nickel-titanium rotary instruments in simulated Sshaped canals. Journal of Endodontics 31, 3735. Yun HH, Kim SK (2003) A comparison of the shaping abilities of 4 nickel-titanium rotary instruments in simulated root canals. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics 95, 22833. Zentrale Ethikkommission (2007) The use of human body materials for the purposes of medical research. URL http:// www.zentrale-ethikkommission.de/page.asp?his=0.1.21 [accessed on 6th July 2008].
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doi:10.1111/j.1365-2591.2008.01490.x
Dislocation resistance of ProRoot Endo Sealer, a calcium silicate-based root canal sealer, from radicular dentine
B. P. Huffman1, S. Mai2, L. Pinna3, R. N. Weller4, C. M. Primus5, J. L. Gutmann6, D. H. Pashley7 & F. R. Tay4,7

1 School of Dentistry, Medical College of Georgia, Augusta, GA, USA; 2Guanghua School of Stomatology & Institute of Stomatological Research, Sun Yat-sen University, Guangzhou, China; 3Universita degli Studi di Cagliari, Reparto di Odontoiatria Conservatrice, Sardinia, Italy; 4Department of Endodontics, School of Dentistry, Medical College of Georgia, Augusta, GA, USA; 5 Primus Consulting, Bradenton, FL, USA; 6Department of Endodontics, Baylor College of Dentistry, Texas A&M University System Health Science Center, Dallas, TX, USA; and 7Department of Oral Biology, School of Dentistry, Medical College of Georgia, Augusta, GA, USA
Abstract
Huffman BP, Mai S, Pinna L, Weller RN, Primus CM, Gutmann JL, Pashley DH, Tay FR. Dislocation resistance
of ProRoot Endo Sealer, a calcium silicate-based root canal sealer, from radicular dentine. International Endodontic Journal, 42, 3446, 2009.
Aim To examine the dislocation resistance of three root canal sealers from radicular dentine with and without immersion in a simulated body uid (SBF), using a modied push-out test design that produced simulated canal spaces of uniform dimensions under identical cleaning and shaping conditions. Methodology Sixty single-rooted caries-free human canine teeth were used. Standardized simulated canal spaces were created using 0.04 taper ProFile instruments along the coronal, middle and apical thirds of longitudinal tooth slabs. Following NaOCl/ethylenediamine tetra-acetic acid cleaning, the cavities were lled with ProRoot Endo Sealer, AH Plus Jet or Pulp Canal Sealer. After setting, half of the cavities were tested with a bre-optic light-illuminated push-out testing device. The rest were immersed in SBF for 4 weeks
before push-out evaluation. Failure modes were examined with stereomicroscopy and eld emission (FE)scanning electron microscopy. Results Location of the sealer-lled cavities did not affect push-out strengths. ProRoot Endo Sealer exhibited higher push-out strengths than the other two sealers particularly after SBF storage (P < 0.001). Failure modes were predominantly adhesive and mixed for Pulp Canal Sealer and AH Plus Jet, and predominantly cohesive for ProRoot Endo Sealer. Spherical amorphous calcium phosphate-like phases that spontaneously transformed into apatite-like phases were seen in the fractured specimens of ProRoot Endo Sealer after SBF storage. Conclusions When tested in bulk without a main core, both sealer type and SBF storage were significant in affecting push-out results. The ProRoot Endo Sealer demonstrated the presence of spherical amorphous calcium phosphate-like phases and apatite-like phases (i.e. ex vivo bioactivity) after SBF storage. Keywords: calcium silicate-based sealer, dislocation resistance, in vitro bioactivity, thin-slice push-out test.
Received 1 June 2008; accepted 16 September 2008
Introduction
The use of a sealer and a thermoplastic core material for lling root canals is the accepted norm in contemCorrespondence: Dr Franklin R. Tay, Department of Endodontics, School of Dentistry, Medical College of Georgia, Augusta, GA, 30912-1129, USA (Tel.: +1 706 7212033; fax: +1 706 7216252; e-mail: ftay@mcg.edu).
porary root canal procedures. As leakage from the apical or coronal direction is a possible cause of root treatment failure (Madison & Wilcox 1988, De Moor & Hommez 2000), a root canal sealer should exhibit good sealing (Laghios et al. 2000) and adhesive properties (Wennberg & rstavik 1990, Gettleman et al. 1991, Timpawat et al. 2001, Lee et al. 2002a,b, Saleh et al. 2003, Tagger et al. 2003). A sealer may be
34
Huffman et al. Dislocation resistance of ProRoot Endo Sealer
conceptualized as a joint created between the radicular dentine and the lling material. Similar to other prosthetic joints in the body, the ability to resist dislocation during function is crucial to their survival (Scifert et al. 1999, Weale et al. 2002, He et al. 2007). For a root canal sealer, the ability to resist disruption of the established seal via micromechanical retention or friction is highly desirable during intraoral tooth exure (Panitvisai & Messer 1995) or preparation of cores or postspaces along the coronal- and middlethirds of canal walls (Mun oz et al. 2007). Predictable clinical results have been reported with the use of gutta-percha in conjunction with zinc oxide eugenol or epoxy resin-based root canal sealers (Salehrabi & Rotstein 2004, Tilashalski et al. 2004). Nevertheless, there is a continuous quest for alternative sealers or root lling materials with better seal and dislocation resistance. Although the correlation between the sealing property of a root canal sealer and its adhesive characteristics has not been rmly established, it is essential that the dislocation resistance of a root canal sealer to dentine is not adversely affected by the seepage of body uids when there is a breach of either the apical or coronal seal. ProRoot Endo Sealer (Dentsply Tulsa Dental Specialties, Tulsa, OK, USA) is an experimental calcium silicate-based root canal sealer that is designed to be used in conjunction with a root lling material in either the cold lateral, warm vertical or carrier-based lling techniques. The major components of the powder component are tricalcium silicate and dicalcium silicate, with the inclusion of calcium sulphate as a setting retardant, bismuth oxide as a radiopacier and a small amount of tricalcium aluminate. The liquid component consists of a viscous aqueous solution of a watersoluble polymer. Similar to other tricalcium silicate and dicalcium silicate-containing biomaterials, the sealer produces calcium hydroxide on reaction with water (Gou et al. 2005, Camilleri & Pitt Ford 2006, Wang et al. 2008). It is also anticipated that release of calcium and hydroxyl ions from the set sealer will result in the formation of apatites as the material comes into contact with phosphate-containing uids (Sarkar et al. 2005), via spontaneous transformation from initial amorphous calcium phosphate phases (Tay et al. 2007, Tay & Pashley 2008). Whereas the retentive potential of geosynthetics (Marques 2005), concrete reinforcements (Lee et al. 2002a,b) and rigid postsystems within canal spaces (Mitchell et al. 1994, Teixeira et al. 2006) may be evaluated en masse using conventional pull-out test
designs, thermoplastic root lling materials and sealers are not amendable to gripping that is a prerequisite for this type of mechanical testing (Goracci et al. 2007). Thus, the thin-slice push-out test has been used quite frequently for evaluating the dislocation resistance of root lling materials (Gesi et al. 2005, Sousa-Neto et al. 2005, Gancedo-Caravia & Garcia-Barbero 2006, Skidmore et al. 2006, Ungor et al. 2006, Bouillaguet et al. 2007, Fisher et al. 2007, Jainaen et al. 2007, Nagas et al. 2007, Sly et al. 2007, Ureyen Kaya et al. 2008). The strength of that experimental design is that each horizontal root slab being tested is derived from a root lled canal and contains a cross-section of the thermoplastic root lling material and sealer to be investigated. In the present study, a modied thin-slice push-out test was designed to evaluate the dislocation resistance of root canal sealers that were applied in bulk to simulated canal spaces without the use of thermoplastic material cores. The null hypothesis tested was that there are no differences in the dislocation resistance of three root canal sealers from radicular dentine when the set sealers are tested with and without immersion in a simulated body uid (SBF).
Materials and methods Preparation of simulated canal spaces

Sixty intact, caries-free human canine teeth were collected after the patients informed consents were obtained under a protocol reviewed and approved by the Human Assurance Committee of the Medical College of Georgia, Georgia, USA. For each tooth, a 0.90 0.05 mm thick longitudinal slab was prepared by making buccolingual sections parallel to the longitudinal axis of the tooth using a slow-speed diamond saw (Isomet; Buehler Ltd, Lake Bluff, IL, USA) under water-cooling. A Plexiglas platform containing a cylindrical well was afxed to the base of a mini drill press to generate vertically oriented, truncated cavities of uniform dimensions within the tooth slab (Fig. 1a). A 0.6 mm drill bit was rst used to prepare pilot holes in the radicular dentine adjacent to the dental pulp. Each pilot hole was carefully drilled so that it was equidistant from the cementum and the canal wall. Two pilot holes each were prepared in the coronal, middle and apical thirds of the root. Each hole was subsequently enlarged using a size 40, 25 mm long 0.04 taper ProFile nickel titanium rotary instrument (Dentsply Tulsa Dental Specialties). To ensure optimal cutting efcacy, a new instrument
35
Dislocation resistance of ProRoot Endo Sealer Huffman et al.
Figure 1 Experimental setup for the preparation of perpendicular truncated cavities of uniform dimensions in different locations
of a longitudinal tooth slab. (a) A mini drill press (D) with a 25 mm thick Plexiglas platform (B) afxed to its base (pointer). (b) A tooth slab was placed over a supporting well in the Plexiglas platform. A 0.04 taper size 40 Prole nickel titanium rotary instrument was inserted through a pre-drilled pilot hole in the tooth slab to create a truncated hole with the basal diameter corresponding to the D16 diameter (i.e. 1.04 mm) of the rotary instrument. The drill press was set to drill exactly to the same depth every time to ensure that each hole has the same circumference. (c) As slanted preparations are not amendable to push-out testing, the current setup ensured that all cavities were created perpendicular to the tooth slab. (d) Two tapered cavities each were prepared in the apical (Ap), middle (Mi) and coronal (Co) thirds of the root dentine. Pointer: cementoenamel junction; open arrowhead: cementum.
was used for each tooth slab. The drill press and the thickness of the Plexiglas platform were congured so that the rotary instrument penetrated the cylindrical well to the same depth every time (Fig. 1b). This permitted preparation of all truncated cavities to the D16 diameter of the rotary instrument (i.e. 1.04 mm) along the surface of the tooth slab. Inadvertent preparation of cavities with nonvertical extrusion paths was prevented by aligning the rotary instrument perpendicular to the tooth slab (Fig. 1c). The experimental design ensured that all cavities created in the coronal, middle and apical thirds of the roots had comparable dimensions. The articial canal spaces
were also completely devoid of calcospherites that are found along the mineralization front of the noninstrumented portions of natural root canal spaces. This eliminated the issue of unpredictable augmentation in sealer dislocation resistance that is caused by the presence of undercuts and increased contact areas in calcospherite-containing canal walls. The tooth slabs were divided randomly into six groups of 10 slabs each for evaluation of three endodontic sealers with or without immersion in a SBF. Six cavities were created in each tooth slab, with the two apical cavities residing in transparent, sclerotic radicular dentine (Fig. 1d). For each group, 20 simulated canal spaces were available
36
from each of the three respective radicular dentine locations (n = 20).
Filling of root canal sealers

The tooth slabs were immersed in 17% ethylenediamine tetra-acetic acid (EDTA) and ultrasonicated for 5 min to dissolve the smear layer created during the hole-shaping procedures. The slabs were further immersed in 6.15% sodium hypochlorite and ultrasonicated for 5 min to remove organic debris and the demineralized collagen matrix created during EDTA application. The rationale for en masse cleaning was to further ensure that differences in dislocation resistance of the sealers from different dentine locations were not caused by inadequate cleaning of the apical radicular dentine. The three sealers investigated in this study were Pulp Canal Sealer (SybronEndo; Sybron Dental Specialties Inc., Orange, CA, USA), AH Plus Jet (Dentsply Caulk, Milford, DE, USA) and the experimental ProRoot Endo Sealer. The former two sealers were mixed according to the manufacturers instructions. The calcium silicatebased sealer was mixed with a liquid-to-powder ratio of 1 : 2 and covered with moist gauze to avoid evaporation of the water component. All cavities from one tooth slab were lled with one type of sealer. Each tooth slab was placed over a Mylar strip (Angst & Pster, Geneva, Switzerland), which in turn was placed over a microscope glass slide. For Pulp Canal Sealer and ProRoot Endo Sealer, the sealer was mixed and placed inside a 19-gauge AccuDose Needle Tube (Centrix, Shelton, CT, USA). The sealer was dispensed into the cavities so that each hole was lled with excess sealer. For AH Plus Jet, the sealer was dispensed directly from the double-barrel mixing syringe via an intraoral tip attached to an auto-mixing tip. The surface of the tooth slab was then covered with another Mylar strip and a glass slide. The assembly was secured with binder clips so that excess sealer was expressed laterally from the surface and bottom Mylar strips. The assemblies were transferred to humidors and stored under 100% relative humidity for 1 week until all the sealers had completely set. The binder clips were released and the Mylar strips were removed from the tooth slab to expose the set sealers. The top and bottom surfaces of each tooth slab were polished with 800-grit silicon carbide papers under running water to remove the excess sealer. For each sealer, one subgroup of 10 tooth slabs was tested immediately after polishing, whilst the other subgroup
of 10 tooth slabs was immersed for 4 weeks at 37 C in a phosphate-containing SBF prior to testing. The SBF contained 136.8 mmol L)1 NaCl, 3.0 mmol L)1 KCl, 2.5 mmol L)1 CaCl26 H2O, 1.5 mmol L)1 MgCl26H2O, 0.5 mmol L)1 Na2SO410 H2O, 4.2 mmol L)1 NaHCO3 and 1.0 mmol L)1 K2HPO43H2O in deionized water (pH 7.4). To prevent bacterial growth, 0.02% sodium azide was also included in the SBF.
Dislocation resistance evaluation

The dislocation resistance of the set root canal sealers was evaluated using a thin-slice push-out test design (Chandra & Ananth 1995, Chandra & Ghonem 2001). Prior to testing, the thickness of each tooth slab was measured to the nearest 0.01 mm using a pair of digital calipers. A 0.7 mm diameter carbon steel cylindrical plunger was used for the push-out test. The plunger had a clearance of about 0.1 mm from either side of the dentinal wall when it is perfectly aligned with the apical part of the truncated hole. The plunger was attached to a 10 kg load cell that was connected to a universal testing machine (Vitrodyne V1000 universal tester; Liveco Inc., Burlington, VT, USA). The push-out device consisted of a clear Plexiglas platform with a vertical cylindrical channel, which served as the support for the tooth slab and provided space for the vertical movement of the plunger through the truncated hole (Fig. 2a). To ensure optimal alignment of the plunger with the sealer-lled hole, a horizontal channel was drilled through the Plexiglas platform into the vertical channel (Fig. 2b). A bre-optic light guide was inserted into the horizontal channel to provide high intensity illumination of the truncated hole during the alignment procedure. Each root slab was secured with sticky wax in an apical-coronal direction to the supporting Plexiglas platform, so that the smaller diameter apical side of the sealer-lled hole was facing the plunger. Each sealer-lled hole was subjected to compressive loading at a cross-head speed of 10 lm s)1 in order to displace the set sealer toward the coronal aspect of the hole. As the plunger contacts the set sealer on loading, shear stresses were introduced along the sealer-dentine interface, causing the set sealer to be dislocated from the walls of the radicular dentine. Failure was conrmed by the appearance of a sharp drop along the load/displacement curve recorded by the testing machine. After performing push-out testing of the rst hole, the tooth slab was carefully removed and realigned with the
37
Figure 2 Experimental setup for the thin-slice push-out test. (a) The plunger (P) was connected to a 10 kg load cell (L). The
plunger was aligned with the cylindrical well (arrow) of a clear Plexiglas stage. The latter had a side channel (open arrowhead) for the tting of a bre-optic light guide. (b) Each tooth slice was placed on top of the cylindrical well. The plunger had a diameter of 0.7 mm whilst the truncated hole had diameters of about 0.94 and 1.04 mm along its top and base. The use of light illumination ensured that the plunger was aligned with the centre of the hole so that the sealer was pushed out without the plunger contacting the wall of the hole. (c) Examples of adhesive failure, mixed failure and cohesive failure of the sealers, as observed through a stereomicroscope after the push-out test.
second hole. The procedures were repeated until the set sealers were dislodged from all the six cavities within a tooth slab. After the push-out test, each root slab was examined with a stereomicroscope at 30 magnication to determine the mode of failure. Failure modes were classied as: adhesive failure along the sealer-dentine interface; cohesive failure within the sealer, and mixed failure that consisted of partial adhesive failure along the dentinal walls and partial cohesive failure within the sealer (Fig. 2c). Digitized photographs of each tested hole were taken from the coronal and apical aspects of the tooth slab together with a millimetre scale for calibration purpose. Such a procedure was performed after completion of the push-out test as this permitted better contrast of the circumference of the cavities. The circumferences of the coronal (C) and apical aspects (A) of each cavity were measured from the digitized images using image analysis software (Image 4.01; Scion Corp., Frederick, MA, USA). The area of the sealer-dentine interface was approximated by 0.5 (C + A) h, where h represents the thickness of the tooth slab. Dislocation resistance of the sealer, as represented by the push-out strength, was computed by dividing the maximum load (N) derived from the load displacement curve with the sealerdentine interfacial area (mm2) and expressed in mega-
Pascals (MPa). The same procedures were applied to those tooth slabs that had been immersed in SBF for 4 weeks.
Statistical analysis
Each sealer-lled hole was treated as a statistical unit. For each of the six subgroups, data (n = 20) from the three radicular dentine locations (i.e. coronal, middle and apical thirds) were analysed using one-way anova to determine if dislocation resistance of a particular sealer was affected by the location of the sealer. As there were no differences in the dislocation resistance amongst dentine locations in all the six subgroups, data from the coronal, middle and apical aspects of each subgroup were pooled together for further analysis (n = 60). As the pooled data were not normally distributed, log10transformation of the data was performed to normalize the data before statistical evaluation. The transformed pooled data were evaluated using a two-way anova design, with sealer type and SBF storage as independent variables. Post hoc pair-wise comparisons were performed using Tukey multiple comparisons. The Student paired t-test was conducted within the same sealer type to examine if there was difference between the subgroup that was tested without SBF immersion and the other
38
that was tested after SBF immersion. Statistical signicance was set at a = 0.05.
Scanning electron microscopy

After push-out testing, two slabs from each of the six subgroups were air-dried, sputter-coated with gold/ palladium, and examined using a eld emission scanning electron microscope (Model XL-30 FEG; Philips, Eindhoven, The Netherlands) at 15 KeV. The objective of the morphologic examination was not to reiterate the assessment of failure modes that had been performed using stereomicroscopy. Rather, the higher resolution of a eld emission microscope was utilized to substantiate whether calcium phosphate-like phases and their phase transformation could be identied after the calcium silicate-based sealer was immersed in the phosphate-containing SBF.
Results
Representative loaddisplacement curves of the three root canal sealers are shown in Fig. 3a. Despite the differences in the magnitude of the maximum load achieved in the three sealers, their loaddisplacement curves demonstrated were characterized by four regions. There was an initial linear increase in load (zone I) that corresponded with the increase in shear stresses along the sealer-dentine interfaces as the compressive load was applied from the base of the inverted truncated sealer core. Prior to reaching the maximum compressive load, the shear stresses reached a critical value whereupon delamination was initiated from the top of the inverted core. The increase in Poissons ratio along the nondelaminated part of the core (i.e. expansion) resulted in increased work to continue the delamination and hence a change in the slope of the loaddisplacement curve (zone II). Upon reaching the maximum load, propagation of shear stresses toward the bottom of the interface resulted in complete interfacial delamination and a sudden sharp drop in the recorded load (zone III). During the nal push-out phase (zone IV), resistance to displacement by sliding friction and surface roughness of the delaminated sealer core resulted in a progressive, less abrupt decline in the recorded load as the delaminated core was displaced out of the truncated hole. For each sealer with or without SBF immersion, no signicant differences were observed amongst the pushout strengths obtained from different dentine locations (Fig. 3b). Thus, data from the apical, middle and
coronal thirds of the roots were pooled to provide a more robust analysis of the effects of sealer type and SBF immersion on push-out strengths (Fig. 3c). When the specimens were tested without SBF immersion, signicant differences (P < 0.001) were observed amongst the three sealers, with the calcium silicatebased sealer producing the highest push-out strength (16.2 6.5 MPa) followed by AH Plus Jet (3.5 1.7 MPa) and Pulp Canal Sealer (0.7 0.6 MPa) in decreasing order. Signicant differences in push-out strength was also observed for specimens that were tested after they were immersed in SBF for 4 weeks (P < 0.001), following the same order as previously described (calcium silicate-based sealer 22.4 5.0 MPa; AH Plus Jet 6.6 1.7 MPa; Pulp Canal Sealer 0.4 0.3 MPa). Interaction of these two factors were also signicant (P < 0.001). For the AH Plus Jet and the calcium silicate-base sealer, Student paired t-tests revealed signicant differences (P < 0.05) between the push-out strengths generated from specimens that were tested without SBF immersion and those that were tested after immersion in SBF. The per cent distribution of failure modes amongst the six subgroups is presented in Fig. 4. No cohesive failure was observed for Pulp Canal Sealer. This sealer also exhibited an increase in the percentage of adhesive failure after storage in SBF. A preponderance of mixed failures was seen in AH Plus under the two storage conditions, whilst cohesive failures within the sealer were predominantly identied for the calcium silicatebased sealer. Under scanning electron microscopy, failures classied as adhesive failures in the Pulp Canal Sealer groups invariably contained some sealer remnants along the dentinal walls (not shown). However, the overall impressions of those dentinal walls were still relatively smooth when compared with the mixed failures observed in the other sealer groups. A cohesive failure in AH Plus Jet after SBF immersion is shown in Fig. 5a. A high magnication view of the fractured sealer surface revealed characteristic multi-faceted llers that were partially embedded, amongst other smaller llers, within a resinous matrix (Fig. 5b). A mixed failure mode in the calcium silicate-based sealer after SBF immersion is depicted in Fig. 6a. Spherical bodies were identied along the sealerdentin interface as well as the surface of the fractured sealer (Fig. 6b). These spherical phases were not observed from fractured specimens of the same sealer that had not been immersed in SBF (not shown). Very high magnication views of the specimens that had been immersed in SBF
39
(a) Load-displacement curves of endodontic sealers 70 II 60 50 Load (N) 40 30 20 10 0 0 200 600 800 400 Displacement (m) 1000 I IV III
ProRoot Endo Sealer AH Plus Jet Pulp Canal Sealer
(b) 30 25 20 15 10 5 0
Push out strength of endodontic sealers Ap: Apical third Mi: Middle third Co: Coronal third
Before immersion in SBF After immersion in SBF for 4 weeks
Ap
Mi
Co
Ap
Mi
Co
Ap
Mi
Co
Pulp Cancal Sealer (c) 25 Dislocation resistance (MPa) 20 15 10 5

3 C
AH Plus Jet ProRoot Endo Sealer
Figure 3 Push-out strength results. (a) Representative loaddisplacement curves of the three sealers that were tested in bulk without an accompanying gutta-percha core. Load is expressed as Newtons (N) and displacement is expressed as microns (lm). Zone I: initial linear increase in load; zone II: change in slope of the loaddisplacement curve before reaching maximum load; zone III: initial sudden sharp drop in recorded load upon interfacial delamination; zone IV: nal push-out phase. When magnied, the four regions described for ProRoot Endo Sealer could also be seen in the load displacement curves of AH Plus Jet and Pulp Canal Sealer. (b) dislocation resistance (expressed as MPa) of the three sealers in the apical third (Ap), middle third (Mi) and coronal third (Co) of the root dentine with and without storage in a simulated body uid (SBF) (n = 20/location/storage subgroup). As there were no statistical differences in the push-out strengths of each sealer amongst different locations at each time period, data from the three locations were pooled (n = 60) for subsequent statistical comparisons. (c) The pooled data was analysed using a two-way anova design with sealer type and SBF storage as independent variables. For specimens tested without SBF immersion, sealers with different numerals above their corresponding data columns represent signicant differences (P < 0.001). For specimens that were tested after they were immersed in SBF, sealers with different upper case letters above their corresponding data columns represent signicant differences (P < 0.001). For each sealer type, a horizontal bar above the respective columns for the two immersion protocols indicates no statistical difference (P > 0.05).
MPa
Push out strength of endodontic sealers (pooled results; N = 60) A

1 Before immersion in SBF After immersion in SBF for 4 weeks
B 2
Pulp Cancal Sealer
AH Plus Jet ProRoot Endo Sealer
before testing revealed phase transformation of the spherical bodies to spherules with clustered polycrystalline surfaces (Fig. 6c). Individual crystallites that protruded from the surface of these spherules were about 4070 nm in diameter (Fig. 6d).
Discussion
This study utilized a modied push-out protocol that was designed specically to examine the retentive
potential of sealers in radicular dentine. Although the study design is far removed from clinical practice, the results indicate that under identical cleaning and shaping conditions that may not be easily achieved under a clinical setting, the dislocation resistance of a particular sealer is independent of the location of the radicular dentine. Moreover, the dislocation resistance of the three sealers were signicantly different from each other and that two of the three sealers exhibited higher dislocation resistance after immersion in SBF. Thus, the null hypothesis has to be rejected. Although a modied push-out test design was used in this study, it is interesting to note that the relatively low push-out strengths for AH Plus and Pulp Canal Sealer were similar to the range reported for similar sealers (2.00 0.65 MPa for AH Plus and 0.79 0.52 MPa for Kerr EWT sealer) in a previous study (Fisher et al. 2007). Although testing designs that involve the use of natural canal spaces have obvious pragmatic appeal to clinicians, there are severe limitations from a materials science perspective. First, the application of a compressive load on top of a thermoplastic material, which has
40
Failure modes of push out tests Adhesive Before immersion in SBF Mixed Cohesive After immersion in SBF for 4 weeks 20% Pulp Canal Sealer 38.3% 61.7% 80%
17.3% AH Plus Jet
8.6% 36.6% 74.1%
6.7%
56.7%
5%
Figure 4 Distribution of adhesive, mixed
and cohesive failures of the three sealers in specimens that were tested without immersion in simulated body uid (SBF) and specimens that were tested after immersion in SBF for 4 weeks.
ProRoot Endo Sealer
100%
95%
Figure 5 Scanning electron microscopy (SEM) of AH Plus after immersion in simulated body uid (SBF) and push-out testing. (a) Low magnication SEM of a cohesive failure mode exhibited by a specimen from the AH Plus Jet group after SBF immersion. (b) A higher magnication view showing the presence of large, multi-facet llers (open arrowheads) that are characteristic of the AH Plus sealer. These llers were embedded in a resinous matrix together with other ne ller particles.
the tendency to ow during testing generates results that are susceptible to erroneous interpretation. Unless the rheological properties of the materials being compressed are equivalent (Kohyama et al. 2003, To rnqvist et al. 2004), statistical comparison of the results
derived from two thermoplastic root lling materials is virtually meaningless. This could also have been responsible, in part, for the recent report that sealers tested in thin lms using the thin-slice push-out test were considerably weaker than when the same sealer
41
Figure 6 Scanning electron microscopy (SEM) of ProRoot Endo Sealer after immersion in simulated body uid (SBF) and push-out
testing. (a) Low magnication SEM of a mixed failure mode exhibited by a specimen from the ProRoot Endo Sealer group after SBF immersion. Sealer remnants (pointer) could be seen on part of the wall. The remaining part of the walls was devoid of sealer remnants and appeared comparatively smooth (arrow). (b) A higher magnication view of the sealer remnants, showing the presence of spherical bodies on sealer surface. These spherical bodies were previously shown to be amorphous calcium phosphatelike spheres that were formed by the reaction of calcium hydroxide released by the calcium silicate with the phosphate ions present in the SBF. (c) A very high magnication view showing that some of the amorphous calcium phosphate-like spheres (arrow) were spontaneously transformed into apatite-like clusters along the surface of those spheres (pointer). (d) A close-up view of a spherical apatite-like cluster showing the presence of individual apatite-like crystallites (open arrowheads).
was tested in bulk by eliminating the thermoplastic core material from the canal space (Jainaen et al. 2007). The important results generated by those authors provided incontestable substantiation that the so-called push-out bond strength produced by the conventional thin-slice push-out test is not a material property. It is prudent to emphasize that the mechanical and physical properties of engineering and biomaterials such as exural strength, fracture toughness or melting point should exhibit a consistent range of values under identical testing conditions (Callister 1994). To minimize the shortcoming of applying a compression stress over a compliant material, the largest plunger that corresponds to the size of the thermoplas-
tic root lling material is usually selected for the thinslice push-out test (Gesi et al. 2005, Bouillaguet et al. 2007) Whilst this is a legitimate compromise, the procedure succinctly requires the use of different diameter plungers for different depths of a tapered root canal. As the contact surface areas of the plungers are different, data generated from different parts of the canal walls are nonstandardized. Thus, it is futile to statistically compare the results generated by a conventional thin-slice push-out test from the coronal third, versus those generated from the middle and apical thirds of the canal walls. The third limitation involves the testing of root llings that comprise multiple, nonuniform interfaces. Whilst the uneven distribution of stress elds around
42
interfaces with variable circumferential thickness cannot be over-emphasized (Shirazi-Adl & Forcione 1992, Mequid & Zhu 1995), the uncertainty with respect to which interface was consistently dislodged imposes rigorous challenges when specic hypotheses such as the dislocation resistance of sealers from radicular dentine are to be tested. The fourth limitation is that one is almost certain to nd noninstrumented areas that co-exist with instrumented areas in an oval-shaped canal that has been cleaned and shaped (Peters 2004). For the noninstrumented areas that are treated with sodium hypochlorite as an irrigant, one should expect increases in both undercut retention and surface contact areas within the calcospherite-containing regions (Wakabayashi et al. 1993, Tatsuta et al. 1999) that inadvertently augments the dislocation resistance of the sealer being investigated. For example, comparing the results generated from a natural canal space with 50% noninstrumented canal walls versus one that has 20% noninstrumented canal walls may result in erroneous conclusions on the dislocation resistance of various sealers from radicular dentine. It is unrealistic to quantify the extent of noninstrumented natural canal walls from a root slab either before or after a push-out test. Because of these limitations, a modied push-out strength testing design was utilized in the present study. Even without SBF immersion, the calcium silicatebased sealer was approximately 16 times as difcult to be dislodged from the radicular dentine walls as Pulp Canal Sealer, and almost four times as resistant to dislodging as AH Plus Jet. This may be due, in part, to the hardness of the calcium silicate-based sealer after setting in the presence of 100% relative humidity. As natural root canals cannot be completely dehydrated (Amyra et al. 2000, Hosoya et al. 2000) due to the retention of moisture within the dentinal tubules, similar hardness should be expected of the set sealer when it is used for lling natural canals. The tenacity of this sealer to radicular dentine cannot be solely attributed to sealer penetration into the dentinal tubules following depletion of the smear layer, as the dentine from the apical third of the roots is often highly sclerotic. It is beyond the scope of this study to provide denitive annotations on whether the increased dislocation resistance is caused by the frictional resistance or micromechanical/chemical adhesion of the sealer to dentine (Shirazi-Adl 1992, Goracci et al. 2005). This issue should be further investigated in the future using more advanced transmission electron microscopy and
chemoanalytical techniques. Nevertheless, the increased dislocation resistance of the calcium silicate-based sealer to radicular dentine should be advantageous in maintaining the integrity of the sealerdentine interface during tooth exure, as well as during the preparation of postholes within the lled canal spaces. The concern on whether the dislocation resistance of root canal sealers is adversely affected by the contamination of body uids was simulated in the present study by immersing the specimens in a SBF. This is an exaggerated simulation as the entire tooth slab was immersed in the SBF after the cavities were lled with sealers. The increase in dislocation resistance of the AH Plus Jet is probably caused by swelling of the epoxy ndez-Garresin component after water sorption (Ferna c a & Chiang 2002, Do mo to r & Hentschke 2004). For the calcium silicate-based sealer, continuous maturation of the material (Andriamanantsilavo & Amziane 2004) may also have increased the materials dislocation resistance. However, the occurrence of spherical phases along the sealerdentine interface and within the remnant fractured sealer after the specimens were immersed in the phosphate-containing SBF is notable. These spherical phases have previously been identied as amorphous calcium phosphate when Portland cement was immersed in a phosphate-containing uid (Tay et al. 2007). Amorphous calcium phosphate phases undergo spontaneous transformation to carbonated apatites (Gadaleta et al. 1996), producing hollow spherules of apatite clusters (Eanes 2001, Tay & Pashley 2008) that contributed to the ex vivo bioactivity of calcium silicate-containing materials when they interact with phosphate ions. Similar apatite-containing clusters had been observed when Mineral Trioxide Aggregate was immersed in phosphate-containing uids (Sarkar et al. 2005). The apatitic composition in these spherules has also been established using x-ray diffraction (XRD) and Fourier transform-infrared spectroscopy (FT-IR) (Tay et al. 2007). No attempt was made to analyse the comparatively smooth spherical phases and the crystallitecontaining spherules in this study, as these phases were present adjacent to calcium-phosphate rich dentine and on the surface of the fractured sealer. The use of energy dispersive X-ray analysis to analyse these surface phases would have yielded information that includes the subsurface elemental composition of the dentine and sealer components. Likewise, these phases were not amendable for collection and purication for XRD and FT-IR analyses. Thus, they are only referred to as
43
amorphous calcium phosphate-like and apatite-like in the present study. Generation of these reaction phases only in specimens that were immersed in the SBF could also have resulted in the increase in frictional resistance of the sealerdentin interface. Although it is presumptuous to correlate the in vitro bioactivity (i.e. the ability to form carbonate hydroxyapatite on the surface of a biomaterial when it is exposed to SBF) (LeGeros 2002, Zhao et al. 2005, Panzavolta et al. 2008) observed in the present study with clinical bioactivity (i.e. the property of the material to develop a direct, adherent and strong bonding with the bone tissue) (Hench et al. 1978, Hench 1994), the issue of clinical bioactivity associated with the use of endodontic sealers in general is of practical clinical interest and should be duly investigated.
Conclusion
Within the limits of the modied push-out testing design utilized in the present ex vivo study, it may be concluded that: Under identical cleaning and shaping conditions, the dislocation resistance of ProRoot Endo Sealer, AH Plus Jet and Pulp Canal Sealer are independent of the location of the radicular dentine. The dislocation resistance of the three sealers are in descending order: ProRoot Endo Sealer, AH Plus Jet and Pulp Canal Sealer. Both ProRoot Endo Sealer and AH Plus Jet exhibited higher dislocation resistance after immersion in a SBF. ProRoot Endo Sealer exhibited amorphous calcium phosphate-like phases that spontaneously transformed into apatite-like phases after immersion in the phosphate-containing SBF. This phenomenon probably accounts for the in vitro bioactivity of this calcium silicate-based sealer.
Acknowledgements
This study was supported by Dentsply Tulsa Dental Specialties. Dr Primus and Dr Gutmann served as consultants for Dentsply Tulsa Dental Specialties. The authors are grateful to Miss Anna Lam for her secretarial support.
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doi:10.1111/j.1365-2591.2008.01492.x
Inuence of post t and post length on fracture resistance
L. Bu ttel, G. Krastl, H. Lorch, M. Naumann, N. U. Zitzmann & R. Weiger

Department of Periodontology, Endodontology and Cariology, School of Dentistry, University of Basel, Basel, Switzerland
Abstract
Bu ttel L, Krastl G, Lorch H, Naumann M, Zitzmann NU, Weiger R. Inuence of post t and post length on fracture
resistance. International Endodontic Journal, 42, 4753, 2009.
Aim To investigate (i) the impact of post t (formcongruence) and (ii) the inuence of post length on the fracture resistance of severely damaged root lled extracted teeth. Methodology Ninety-six single-rooted human teeth were root lled and divided into four groups (n = 24 per group). Post spaces were prepared with a depth of 6 mm (group 1, 3) and 3 mm (group 2, 4). Form-congruence with a maximal t of the post within the root canal space was obtained in groups 1 and 2, whereas there was no form-congruence in groups 3 and 4. In all groups, glass bre reinforced composite (FRC) posts were adhesively cemented and direct composite crown build-ups were fabricated without a ferrule. After thermo-mechanical loading
(1200000, 550 C), static load was applied until failure. Loads-to-failure [in N] were compared amongst the groups. Results Post t did not have a signicant inuence on fracture resistance, irrespective of the post length. Both groups with post insertion depths of 6 mm resulted in signicantly higher mean failure loads (group 1, 394 N; group 3, 408 N) than the groups with post space preparation of 3 mm (group 2, 275 N; group 4, 237 N). Conclusions Within the limitations of this study, the fracture resistance of teeth restored with FRC posts and direct resin composite crowns without ferrules was not inuenced by post t within the root canal. These results imply that excessive post space preparation aimed at producing an optimal circumferential post t is not required to improve fracture resistance of roots. Keywords: endodontic post, form-congruence, fracture resistance, in vitro study, post space.
Received 20 May 2008; accepted 22 September 2008
Introduction
As root lled teeth often have insufcient coronal tooth structure, placement of a post is occasionally necessary to provide adequate retention for the core and nal restoration. Alternatives to cast post-and-cores have been developed and include the use of pre-fabricated posts and custom-made cores with composite that facilitate a chair-side restorative procedure (Heydecke et al. 2002). In particular, bre-reinforced composite (FRC) posts luted with adhesive materials have become
Correspondence: Leonard Bu ttel, Department of Periodontology, Endodontology and Cariology, School of Dentistry, University of Basel, Hebelstrasse 3, CH-4056 Basel, Switzerland (Tel.: +41 61 2672623; fax: +41 61 2672659; e-mail: leonard.Buettel@unibas.ch).
more popular because of their favourable mechanical and aesthetic properties. For example, the elastic modulus of FRC posts is close to that of dentine, and results in the stress transmitted by a bre post to the root dentine being lower than that caused by other materials such as titanium or zirconia (Duret et al. 1990). There is a controversy as to whether stress transmission and post rigidity has an impact on the fracture resistance and/or failure mode of root lled teeth with posts (Isidor et al. 1996, Akkayan & Gulmez 2002, Fokkinga et al. 2004). In addition to the presence of a post, other factors possibly inuencing the load capability of root lled teeth are tooth morphology, restorative techniques and crucially the amount of tooth tissue lost (Trope et al. 1985, Gutmann 1992, Sornkul & Stannard 1992, Fernandes & Dessai 2001).
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Form-congruence of endodontic posts Bu ttel et al.
When placing posts in accordance with standard clinical protocols, pilot drills are used to create a formcongruent root canal up to the apical third of the root to ensure primary post t and retention. This optimized post t can be termed form-congruence (Schmage et al. 2005) and aims to create maximal adaptation of the post to the surrounding root canal walls with a thin and even post dentine cement interface. It is believed that form-congruence facilitates stress distribution along the canal wall during clinical function (Morgano 1996). Schmage et al. (2005) examined the form-congruence of ve pre-fabricated titanium posts luted with zinc phosphate cement and found that the mean cement gap varied between 33 and 62 lm, depending on the post system. For root lled teeth with cast post-and-cores and crowns luted with zinc phosphate cement, a signicant increase in fracture resistance was reported when a maximum adaptation of a tapered post to the residual root structure was present (Sorensen & Engelman 1990). This effect was not observed when parallel-sided posts were used. Preparing post spaces, however, poses several risks. The individual curvature and cross-section of the root canal may interfere with this preparation and create additional weakening of the root or even root perforation. Lang et al. (2006) investigated the impact of endodontic procedures on the deformation of anterior maxillary teeth and found that their stability decreases with every stage of the root canal preparation. A signicant decrease in stability was observed when the post space was prepared, particularly following the transformation of the conical post preparations to a cylindrical form. It was concluded that if excessive amounts of tooth structure are removed and the natural geometry of the root canals are altered, this will have a destabilizing effect on root lled teeth. A recent study using computational, experimental and fractographic analyses has substantiated the impact of so called inner dentine located adjacent to the root canal on fracture resistance of teeth (Kishen et al. 2004). Obviously, it is not only the thickness of the dentine wall that stabilizes the root but also the presence of inner dentine with a lower elastic modulus than the more mineralized outer dentine. Particularly in irregular root canals with an oval cross-section, large diameter drills are required to ensure a circumferential post t, and thereby excessive amounts of inner dentine are removed. Selecting a post that corresponds best to the natural root canal diameter without preparation, however, aims to preserve the inner dentine substance and may be associated with a
loose-tting post in irregular canals (no form-congruence). As soon as posts are luted adhesively to the root canal walls, an ideal post t within the canal (formcongruence) is probably less important as any spaces are lled with the luting composite. However, shrinkage of the thicker resin cement lm by nontting posts may impair the clinical performance in the long term. Otherwise, even after standardized post space preparation (using the post hole drills supplied by the manufacturers) and optimal bonding procedures, the high-cavityconguration factor may lead to gap formation either along the cement-dentine interface or the cement-post interface (Pirani et al. 2005). To reduce the thickness of resin cement in irregular post spaces, Grandini et al. (2003, 2005) suggested a pre-cementation relining of the post with owable composite (anatomical post) for the cementation of bre posts to improve its t to the canal space. In the light of this background, the use of adhesive techniques for post cementation and a minimal invasive post space preparation minimizing the loss of hard tissue are clinically preferable. The aim of the present investigation was to study the inuence of the form-congruence of adhesively luted glass FRC posts and of post length on the fracture resistance of root lled teeth. The null hypothesis was that (i) providing a form-congruence between post and post space preparation and/or (ii) reducing the post length would have no inuence on the fracture load of root lled teeth restored with adhesively luted glass FRC posts and direct composite crowns.
Materials and methods

Ninety-six extracted single-rooted human teeth (maxillary lateral incisors and mandibular second premolars) were selected that fullled the following criteria: straight, sound roots, completely formed apices, absence of root caries and no visible fracture lines along the root. Teeth with similar dimensions at the cementoenamel junction (CEJ) in terms of root diameter and thickness of the dentine wall were distributed equally amongst the four groups. The teeth were stored in 0.1% thymol solution until further processing. The clinical crowns were removed 1 mm below the buccal CEJ using a diamond bur, leaving a root length of 13 1 mm. All roots were cleaned with scalers. Root canal preparation was performed using NiTi rotary instruments (Race, FKG, La Chaux-de-Fonds, Switzerland) under intermittent rinsing with 1%
48
Bu ttel et al. Form-congruence of endodontic posts
sodium hypochlorite to an apical size 45. The canals were then dried with paper points and lled with vertically compacted gutta-percha (Obtura II, Obtura Corp, Fenton, MO, USA) using an epoxy sealer (AH plus, Dentsply De Trey, Konstanz, Germany). For each group, pre-fabricated glass FRC posts (FRC Postec, Ivoclar Vivadent, Schaan, Liechtenstein) with a 9.3% taper were used. Post spaces were prepared using appropriate drills with the same taper in a slow-speed contra-angle handpiece at 1000 rpm. For the 3 mm post length (group 2 and 4), the apical 3 mm of the post was cut off to obtain similar dimensions of the post diameter in the cervical region of all specimens (Fig. 1). In groups 1 and 2, the size and shape of the bur corresponded to the FRC post to ensure optimal post t (form congruence between post and post space). In groups 3 and 4, a more extensive post space preparation was created to simulate missing form-congruence between post and post space. For that reason, the pilot drill was shortened by 3 mm apically (group 2) and 6 mm (group 4). Because of the conical shape of the drill, the diameter of the post space preparation increases by about 300 lm along the whole length. This discrepancy between post space and post diameter results theoretically in a circumferential space width of
150 lm provided that the post is centered in the post space. The coronal part of the post was reduced in each group at the same level, i.e. 2.5 mm above the root canal orice.
Restorative procedures
Prior to post cementation, the post space was rinsed with water for 30 s and dried with an air blow for 5 s and with paper points. Subsequently, all dentine surfaces were etched with one step (Ultra-etch, 35% phosphoric acid) for 15 s, rinsed with water spray for 15 s and dried carefully with an air stream for 5 s and with paper points, leaving the surface slightly moist. A dual-cure adhesive system (Excite DSC, Ivoclar Vivadent) was mixed and applied to the sample surface for 30 s. A gentle air stream was used to evaporate the dissolution uid. The FRC posts were cleaned with alcohol and silanated (Monobond-S, Ivoclar Vivadent) for 60 s. A dual-curing resin luting material (Multicore Flow, Ivoclar Vivadent) was mixed and injected into the prepared root canal with an appropriate tip (C-R NeedleTubes, Centrix, Shelton, CT, USA). Subsequently, the post was seated using nger pressure for 10 s. Excess cement was spread with a brush in a thin layer
Figure 1 Schematic drawing of the post space preparation and the bre reinforced composite post in the four groups.
49
so that it covered the occlusal surface of the specimens. The cement was light-cured (Optilux 500, Demetron/ Kerr, Danbury, CT, USA) for 40 s in an occlusal direction. To restore the coronal part of the teeth, direct composite crowns were built up with the same material (Multicore Flow). Despite slight differences in the cervical diameter of the roots, standardized crowns (4 mm height) were fabricated using transparent moulds (Pella crowns, Odus, Dietikon, Switzerland) with anatomically formed occlusal surfaces. Composite resin was placed free of bubbles in the mould, adapted to the tooth surface and then light-cured from each side for 40 s. Finally, the excess composite resin in the cervical area was removed and the margins of the restoration were nished using ne diamond burs. In each specimen, the tip of the post was covered with a layer of resin composite approximately 1.5 mm in height.
Simultaneously, thermal stress was applied (3000 thermal cycles between 5/50 C). These conditions are believed to simulate approximately 5 years of clinical service (Krejci et al. 1994). After thermo-mechanical loading (TML), the fracture resistance was tested using a universal testing machine (Zwick, Ulm, Germany). Specimens were xed in a metal holder with the long-axis of the roots at an angle of 45 to the load direction. A tin foil (0.5-mm thick) was placed between the steel sphere and the crown to avoid load peaks on the composite resin crown surface. The linear compressive load was applied (cross-head speed = 0.5 mm min)1) at the central ssure of the occlusal surface in the direction of the buccal cusp until failure.
Statistical analysis
Primary outcome variable was failure during TML (fatigue testing). Second, loads-to-failure (in N) were compared when the specimens survived TML. Therefore, mean values and condence intervals were calculated for the nonfailing specimens of each group. A signicant difference between two groups is given when the condence intervals do not overlap.
Mechanical loading
The roots of all specimens were coated with an airthinned 0.3-mm layer of polyvinylsiloxane (President ` ne-Whaledent AG, Altsta light body, Colte tten, Switzerland) to simulate a periodontal ligament (PDL). The specimens were xed with a light-curing composite on custom-made metallic holders (Provac, Balzers, Liechtenstein). The roots were then embedded in self-curing acrylic resin (Demotec 20, Demotec Siegfried Demel, Nidderau, Germany) so that the CEJ was situated approximately 1.5 mm above the simulated bone level (i.e. the upper margin of the embedding medium). After embedding, the samples were stored in water until loading. All specimens were loaded mechanically at the centre of the occlusal surface using a computercontrolled masticator (CoCoM 2, PPK, Zurich, Switzerland). Stressing comprised 1.2 million occlusal loads of 49 N at 1.7 Hz obtained by using human cusps.
Results
Two specimens, one in group 2 and one in group 4, were lost because of failures in technical handling. All remaining teeth and restorations survived TML without loss of retention or visible fractures and were further tested for fracture resistance in the universal testing machine. Mean fracture loads after static loading are given in Table 1. There was no statistical signicant difference between specimens with 6 mm post length without form-congruence (group 3) and group 1 (6 mm, form-congruence). Signicantly, lower values were recorded for specimens with a 3-mm short post (groups 2 and 4). The lowest load values were
Table 1 Failure loads in the four groups

95% Condence interval for mean failure load (N) Group 1 2 3 4 (6 (3 (6 (3 mm, mm, mm, mm, form-congruence) form-congruence) no form-congruence) no form-congruence) n 24 23 24 23 Mean failure load (N) 393.99 275.47B 408.06A 236.74B
A
SD (N) 98.89 75.61 130.20 96.27
Lower bound 352.23 242.77 353.08 195.11
Upper bound 435.75 308.16 463.04 278.37
Values exhibiting the same subscript number indicate no signicant difference between the groups.
50
registered in group 4. In the current experimental setup, form-congruence had no impact on fracture resistance, irrespective of the post insertion depth.
Discussion
The present study was conducted to evaluate the inuence of form-congruence between post and post space as well as reduced post length in severely damaged root lled teeth. It was observed that post t did not have a signicant impact on fracture resistance, whilst short post length decreased load values signicantly, meaning that they fractured more easily. To gain information about the potential need for a maximum adaptation of the post to the canal wall, a lack of form-congruence was created in the current material by cementing a post in an over-enlarged root canal. The resulting gap was lled with owable resin, which was concurrently used for the crown build-up to simplify the procedure. This is in accordance with a recent study suggesting that such materials lead to better retention than luting cement and therefore recommending them as alternatives for post cementation (Ohlmann et al. 2008). The results of the present study using resin cement clearly demonstrated that missing form congruence did not impair fracture loads. In contrast to these ndings, Schmage et al. (2005) reported that only a post closely adapted to the root canal wall resulted in high retention and prevented stress peaks. They applied conventional luting material (zinc phosphate cement) and found that a thin homogeneous cement layer, where the lm thickness was <50 lm, was essential to improve post retention. However, when the composite was used as a luting material, a mismatch between the diameter of the post space and that of the post did not impair retention (Assif & Bleicher 1986, Hagge et al. 2002), even when shrinkage of the thicker resin cement lm resulted in more stress at the interface between the dentine and the post (Alster et al. 1997). Perez et al. (2006) investigated the impact of the resin cement thickness on the bond strength to the root canal dentine. Obviously, increased cement thickness did not reduce the bond strength signicantly when FRC posts were inserted. These ndings are in line with those of a recent study demonstrating that the accuracy of t between post and root canal did not inuence bond strength (Perdigao et al. 2007). With the exception of the two technical failures, in the current experiment, all the teeth and restorations survived without loss of post retention or crown
fracture. When loaded to failure, fracture loads in all groups were found to exceed the chewing forces normally associated with adults, which ranges from 7 to15 kg (Tortopidis et al. 1998). Teeth with 6-mm deep post preparations (groups 1 and 3) exhibited similar failure loads regardless of whether there was formcongruence between the post and the root canal. Specimens restored with 3 mm post length with or without form-congruence (groups 2 and 4) yielded signicantly lower values. Again, the form-congruence of the FRC-posts had no inuence on the load capability of root lled teeth. During the last decade, the use of resin composite for direct crowns in root lled teeth has been recommended only for temporary restorations. Laboratory investigations of the fracture resistance of resin composite crowns (with or without endodontic posts) have, however, yielded promising results, which suggest that their clinical application is appropriate (Krejci et al. 1994, Fokkinga et al. 2005). In a 5-year prospective clinical study on core restorations without crowns, Creugers et al. (2005a) demonstrated that only two out of 99 restorations failed. They found that direct composite build-up restorations exhibited high durability and a survival rate similar to that of crowned buildup restorations in the parallel trial (Creugers et al. 2005b). To mimic a human periodontium (PDL), the roots of the tested teeth were covered with a layer of cured polyvinylsiloxane. The presence of this simulated PDL was found to signicantly affect the results of fracture testing (Soares et al. 2005). The extracted human teeth used in the present study were sectioned 1 mm below the buccal CEJ, thereby removing the enamel completely. The remaining dentine surface is deemed to provide poorer bonding characteristics than enamel (Van Meerbeek et al. 2003). The prepared roots were provided with posts of different lengths and direct composite crown build-ups, but no ferrule was achieved. The advantage of a ferrule is that it generally facilitates a stabilizing effect by embracing the dentine. The tooth morphology established here, however, simulated that of a severely damaged root lled tooth. This situation is, according to the established clinical guidelines (Schwartz & Robbins 2004), ideally restored with a post and core build-up and a custom-made laboratory crown with circular ferrule (Stankiewicz & Wilson 2002). In most laboratory studies (Heydecke et al. 2002, Fokkinga et al. 2006, Salameh et al. 2007), this clinical recommendation is taken into account and the tested specimens revealed fracture loads higher than that in the current investigation. The ferrule
51
design of crowns is generally considered to be one of the most important factors to improve the load resistance of root lled teeth (Sorensen & Engelman 1990, Assif et al. 1993, Isidor et al. 1999, Akkayan 2004, Naumann et al. 2007). The present results reect, therefore, the performance of the post and core alone, without being confounded by the additional value of a ferruled crown. In the current material, TML was conducted to fatigue the samples prior to static loading. A repeatedly applied load in an aqueous environment simulates clinical conditions better than static loading alone. Using this environment, factors such as fatigue stresses or ageing, which inuence the survival of materials can be taken into account (Naumann et al. 2005). However, the test designs of laboratory studies can only partially reect the clinical situation. Clinically, loading is a dynamic process and loading forces, frequency and direction vary greatly. Because of the large number of other variables involved, including tooth condition, tooth type, applied restorative procedures and restorative materials used, it is almost impossible to compare the fracture resistance values obtained in different laboratory studies. In particular, the most unpredictable factor is the tooth conditions, which are mainly related to dentine (Kinney et al. 2003). This is an inherent drawback associated with the use of human teeth. It has been reported that testing human teeth results in a large standard deviation (Krejci et al. 2003), whilst articially manufactured teeth are much more consistent (Ottl et al. 2002). In the present study, a sample size of 24 human teeth was chosen for each group to reduce the SD and to achieve more reliable results. The ndings of the present study strongly suggest that excessive post space preparation to maximize post t and to reduce the amount of resin cement is not necessarily required. These results are particularly encouraging for teeth with oval or long oval root canal cross-sections. In such cases, not attempting to achieve a good circumferential post t helps to preserve inner dentine and avoids additional weakening of the root. Further investigations should be conducted to study the effect of more oval pre-fabricated posts on the load capability.
preparation and a tting post are not required to improve fracture resistance.
Acknowledgements
The authors gratefully acknowledge the Swiss Society of Odontology (SSO Kuratorium, research project no. 220) for the generous nancial support. The authors would also like to thank Svend Galli, dental technician and Andres Izquierdo for their valuable help.
References
Akkayan B (2004) An in vitro study evaluating the effect of ferrule length on fracture resistance of endodontically treated teeth restored with ber-reinforced and zirconia dowel systems. Journal of Prosthetic Dentistry 92, 15562. Akkayan B, Gulmez T (2002) Resistance to fracture of endodontically treated teeth restored with different post systems. Journal of Prosthetic Dentistry 87, 4317. Alster D, Feilzer AJ, de Gee AJ, Davidson CL (1997) Polymerization contraction stress in thin resin composite layers as a function of layer thickness. Dental Materials 13, 14650. Assif D, Bleicher S (1986) Retention of serrated endodontic posts with a composite luting agent: effect of cement thickness. Journal of Prosthetic Dentistry 56, 68991. Assif D, Bitenski A, Pilo R, Oren E (1993) Effect of post design on resistance to fracture of endodontically treated teeth with complete crowns. Journal of Prosthetic Dentistry 69, 3640. Creugers NH, Kreulen CM, Fokkinga WA, Mentink AG (2005a) A 5-year prospective clinical study on core restorations without covering crowns. International Journal of Prosthodontics 18, 401. Creugers NH, Mentink AG, Fokkinga WA, Kreulen CM (2005b) 5-year follow-up of a prospective clinical study on various types of core restorations. International Journal of Prosthodontics 18, 349. Duret B, Reynaud M, Duret F (1990) A new concept of coronoradicular reconstruction, the Composipost (2). Le ChirurgienDentiste de France 60, 6977. Fernandes AS, Dessai GS (2001) Factors affecting the fracture resistance of post-core reconstructed teeth: a review. International Journal of Prosthodontics 14, 35563. Fokkinga WA, Kreulen CM, Vallittu PK, Creugers NH (2004) A structured analysis of in vitro failure loads and failure modes of ber, metal, and ceramic post-and-core systems. International Journal of Prosthodontics 17, 47682. Fokkinga WA, Le Bell AM, Kreulen CM, Lassila LV, Vallittu PK, Creugers NH (2005) Ex vivo fracture resistance of direct resin composite complete crowns with and without posts on maxillary premolars. International Endodontic Journal 38, 2307. Fokkinga WA, Kreulen CM, Le Bell-Ronnlof AM, Lassila LV, Vallittu PK, Creugers NH (2006) In vitro fracture behavior of
Conclusions
Severely damaged root lled teeth restored with FRC posts and direct resin composite crowns without a ferrule revealed similar fracture resistance irrespective of the t of the post, i.e. irrespective of form-congruence or no form-congruence. This suggests that post space
52
maxillary premolars with metal crowns and several post-andcore systems. European Journal of Oral Sciences 114, 2506. Grandini S, Sapio S, Simonetti M (2003) Use of anatomic post and core for reconstructing an endodontically treated tooth: a case report. Journal of Adhesive Dentistry 5, 2437. Grandini S, Goracci C, Monticelli F, Borracchini A, Ferrari M (2005) SEM evaluation of the cement layer thickness after luting two different posts. Journal of Adhesive Dentistry 7, 23540. Gutmann JL (1992) The dentin-root complex: anatomic and biologic considerations in restoring endodontically treated teeth. Journal of Prosthetic Dentistry 67, 45867. Hagge MS, Wong RD, Lindemuth JS (2002) Effect of dowel space preparation and composite cement thickness on retention of a prefabricated dowel. Journal of Prosthodontics 11, 1924. Heydecke G, Butz F, Hussein A, Strub JR (2002) Fracture strength after dynamic loading of endodontically treated teeth restored with different post-and-core systems. Journal of Prosthetic Dentistry 87, 43845. Isidor F, Odman P, Brondum K (1996) Intermittent loading of teeth restored using prefabricated carbon ber posts. International Journal of Prosthodontics 9, 1316. Isidor F, Brondum K, Ravnholt G (1999) The inuence of post length and crown ferrule length on the resistance to cyclic loading of bovine teeth with prefabricated titanium posts. International Journal of Prosthodontics 12, 7882. Kinney JH, Marshall SJ, Marshall GW (2003) The mechanical properties of human dentin: a critical review and reevaluation of the dental literature. Critical Reviews in Oral Biology and Medicine 14, 1329. Kishen A, Kumar GV, Chen NN (2004) Stress-strain response in human dentine: rethinking fracture predilection in postcore restored teeth. Dental Traumatology 20, 90100. Krejci I, Mueller E, Lutz F (1994) Effects of thermocycling and occlusal force on adhesive composite crowns. Journal of Dental Research 73, 122832. Krejci I, Duc O, Dietschi D, de Campos E (2003) Marginal adaptation, retention and fracture resistance of adhesive composite restorations on devital teeth with and without posts. Operative Dentistry 28, 12735. Lang H, Korkmaz Y, Schneider K, Raab WH (2006) Impact of endodontic treatments on the rigidity of the root. Journal of Dental Research 85, 3648. Morgano SM (1996) Restoration of pulpless teeth: application of traditional principles in present and future contexts. Journal of Prosthetic Dentistry 75, 37580. Naumann M, Sterzenbach G, Proschel P (2005) Evaluation of load testing of postendodontic restorations in vitro: linear compressive loading, gradual cycling loading and chewing simulation. Journal of Biomedical Materials Research. Part B, Applied Biomaterials 74, 82934. Naumann M, Preuss A, Frankenberger R (2007) Reinforcement effect of adhesively luted ber reinforced composite versus titanium posts. Dental Materials 23, 13844.
Ohlmann B, Fickenscher F, Dreyhaupt J, Rammelsberg P, Gabbert O, Schmitter M (2008) The effect of two luting agents, pretreatment of the post, and pretreatment of the canal dentin on the retention of ber-reinforced composite posts. Journal of Dentistry 36, 8792. Ottl P, Hahn L, Lauer H, Fay M (2002) Fracture characteristics of carbon bre, ceramic and non-palladium endodontic post systems at monotonously increasing loads. Journal of Oral Rehabilitation 29, 17583. Perdigao J, Gomes G, Augusto V (2007) The effect of dowel space on the bond strengths of ber posts. Journal of Prosthodontics 16, 15464. Perez BE, Barbosa SH, Melo RM et al. (2006) Does the thickness of the resin cement affect the bond strength of a ber post to the root dentin? International Journal of Prosthodontics 19, 6069. Pirani C, Chersoni S, Foschi F et al. (2005) Does hybridization of intraradicular dentin really improve ber post retention in endodontically treated teeth? Journal of Endodontics 31, 8914. Salameh Z, Sorrentino R, Ounsi HF et al. (2007) Effect of different all-ceramic crown system on fracture resistance and failure pattern of endodontically treated maxillary premolars restored with and without glass ber posts. Journal of Endodontics 33, 84851. Schmage P, Ozcan M, McMullan-Vogel C, Nergiz I (2005) The t of tapered posts in root canals luted with zinc phosphate cement: a histological study. Dental Materials 21, 78793. Schwartz RS, Robbins JW (2004) Post placement and restoration of endodontically treated teeth: a literature review. Journal of Endodontics 30, 289301. Soares CJ, Pizi EC, Fonseca RB, Martins LR (2005) Inuence of root embedment material and periodontal ligament simulation on fracture resistance tests. Brazilian Oral Research 19, 116. Sorensen JA, Engelman MJ (1990) Effect of post adaptation on fracture resistance of endodontically treated teeth. Journal of Prosthetic Dentistry 64, 41924. Sornkul E, Stannard JG (1992) Strength of roots before and after endodontic treatment and restoration. Journal of Endodontics 18, 4403. Stankiewicz NR, Wilson PR (2002) The ferrule effect: a literature review. International Endodontic Journal 35, 575 81. Tortopidis D, Lyons MF, Baxendale RH, Gilmour WH (1998) The variability of bite force measurement between sessions, in different positions within the dental arch. Journal of Oral Rehabilitation 25, 6816. Trope M, Maltz DO, Tronstad L (1985) Resistance to fracture of restored endodontically treated teeth. Endodontics and Dental Traumatology 1, 10811. Van Meerbeek B, De Munck J, Yoshida Yea (2003) Adhesion to enamel and dentin: current status and future challenges. Operative Dentistry 28, 21535.
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doi:10.1111/j.1365-2591.2008.01494.x
Root canal morphology of mandibular rst premolars in an Indian population: a laboratory study
N. Velmurugan & R. Sandhya

Department of Conservative Dentistry & Endodontics, Meenakshi Ammal Dental College & Hospital, Chennai, Tamil Nadu, India
Abstract
Velmurugan N, Sandhya R. Root canal morphology of
mandibular rst premolars in an Indian population: a laboratory study. International Endodontic Journal, 42, 5458, 2009.
Aim To determine the root canal morphology of mandibular rst premolar teeth in an Indian population using a decalcication and clearing technique. Methodology One hundred extracted adult mandibular rst premolar teeth were studied following decalcication and clearing. The shape of the canal orice, root canal pattern and length of the teeth were determined. Results The mandibular rst premolars were identied to have a round orice (38%), oval orice (44%), attened orice (17%) and C-shaped orice (1%). The canal patterns were classied as Type I (72%), Type II
(6%), Type III (3%), Type IV (10%) and Type V (8%) according to Vertuccis classication. C-shaped canals were identied in one tooth (1%). The average length of the teeth was 21.6 mm. Fourteen per cent of the teeth had mesial invaginations of the root. Conclusions Type I canal patterns were the most frequently occurring in mandibular rst premolars amongst the Indian population. 85.7% of the teeth with mesial invagination of the root had either two canals or division of canals. Keywords: canal orice, decalcication and clearing, length of the teeth, mandibular rst premolar, mesial invagination.
Received 7 March 2008; accepted 29 September 2008
Introduction
Understanding root canal morphology and its complexity is essential during endodontic therapy. Variation in the morphology of root canal systems occurs commonly and can be considered as normal (Cohen & Hargreaves 2006). Amongst the human permanent dentition, Brescia (1961) reported that the mandibular rst premolar teeth had the most variable canal pattern. A study at the University of Washington assessed the failure rate of nonsurgical root canal therapy in all teeth. The mandibular rst premolar had the highest failure rate and this may be attributed to the frequent variations in the root canal morphology
and the inability to access extra canals (Ingle & Taintor 1985). It is a well known fact that the root canal system varies with race (Trope et al. 1986, Ahmed et al. 2007), and gender (Sert & Bayirli 2004). Earlier studies on root canal systems were completed most commonly on teeth from Caucasian populations. Similar studies amongst the Indian population are rare (Reuben et al. 2008). The aim of this study was to determine the root canal morphology of mandibular rst premolar teeth in an Indian population using a decalcication and clearing method.
Materials and methods

One hundred extracted human adult mandibular rst premolar teeth from an Indian population were collected. The age and gender of the patients were not known. Teeth with deep caries, metallic restorations,
Correspondence: Dr N. Velmurugan, # 2, 95th Street, 21st Avenue, Ashok Nagar, Chennai 600083, Tamil Nadu, India (Tel.: 9840164167; fax: 044 2378 1631; e-mail: vel9911 @yahoo.com).
54
Velmurugan & Sandhya Root canal morphology
fracture, incompletely formed roots and those which were root lled were not included. Handling of the teeth was carried out according to Occupational Safety and Health Administration guidelines and regulations. The teeth were preserved in 10% formalin (Western India Chemical, Udupi District, Karnataka, India). All attached soft tissue and calculus were removed using an ultrasonic scaler. The length of the teeth was measured using vernier caliper from the tip of the crown to the apex of the root. In case of a curved root, tangents were drawn to the curved portions of the tooth. The length was then measured by connecting the points of tangency. The teeth were decalcied and rendered transparent using the technique reported by Robertson et al. (1980) to obtain a 3D view of the root canal system. Access cavities were prepared using a round bur (No. 2 round bur) and the shape of the canal orice was observed with the naked eye. Following this, the teeth were placed in 3% sodium hypochlorite (Merck Limited, Mumbai, Maharashtra, India) for 48 h. The teeth were agitated manually to ensure complete removal of the pulp tissue. The teeth were then washed in running water for 2 h and then transferred to 5% nitric acid (Merck Limited) for decalcication. The teeth were placed in acid for 72 h, with the acid being changed every 24 h and stirred once every 8 h. The end-point of decalcication was determined by taking a radiograph of three sample teeth, which showed uniform decalcication of the teeth. The teeth were then washed in running water and dehydrated using ascending grades (70%, 80%, 90% and 100%) of isopropyl alcohol (Leonid Chemicals Pvt Ltd, Bangalore, Karnataka, India) for 2 days. Finally, they were rendered transparent by immersion in methyl salicylate (Sipali Chemicals, Chennai, Tamilnadu, India) and an oilbased dye was injected into the access cavity. The
a) (b) (c)
anatomy of the root canal was observed and classied based on the Vertuccis classication (Vertucci 1984). The supplementary canals present at the apical third were grouped as accessory canals and those in the middle third as lateral canals. Fourteen teeth in the study had invagination of the root surface on its mesial aspect. These teeth were analysed to check for any specic variations of the canal anatomy that could be associated with this feature.
Results Canal orice

The shape of the canal orices were round in 38% of the teeth, oval in 44% of the teeth, attened ribbon shaped in 17% of the teeth and C-shaped in 1% of the teeth. Two canal orices were seen in 2% of the teeth.
Canal type
Amongst the 100 mandibular rst premolar teeth, 72% had a Type I canal pattern (Fig. 1a) with Type II, Type III, Type IV and Type V canals being identied in 6%, 3%, 10% and 8% of the teeth respectively (Fig. 1be, Table 1). One tooth had Category III c-shaped canal (1%) (Melton et al. 1991). Lateral canals were observed in 4% of the samples and another 4% of the samples had accessory canals. Intercanal communication was identied in only one tooth sample (1%).
Position of the apical foramen

Amongst the teeth with a single canal at the apex (n = 82), the apical foramen was located at the apex of the root in 83% teeth, 0.5 mm from the apex in 6%
(d) (e)
Figure 1 Various canal patterns in mandibular rst premolars. (a) Type I, (b) Type II, (c) Type III, (d) Type IV, (e) Type V.
55
Root canal morphology Velmurugan & Sandhya
Table 1 Pattern and percentage of canals

Type of canal Type Type Type Type Type Type Type Type Cb
a b
Canal pattern 1 2-1 1-2-1 2 1-2 2-1-2 1-2-1-2 3 1-3-1
% of Occurrence (n = 100) 72 6 3 10 8 0 0 0 1
mandibular rst premolar teeth was 21.6 mm, the median and mode were 21.3 mm.
Ia IIa IIIa IVa Va VIa VIIa VIIIa
Mesial invagination of the teeth

Mesial invagination of the root was found in 14% of the teeth. Amongst them, 7 teeth had Type IV canal pattern; 3 had Type V canal pattern and 2 had Type I canal pattern (Fig. 2 Table 2). One tooth with Type II and one tooth with Type III canal pattern were also identied. 85.7% of the teeth with mesial invagination had either two canals or division of canals. The mean distance from the cusp tip to the point of initiation of invagination was 14.6 mm.
Vertucci (1984). Melton et al. (1991).
teeth, 1 mm from the apex in 9.7% teeth and 2 mm from the apex in 1.2% teeth.
Discussion
This study analysed the canal morphology of mandibular rst premolar teeth amongst an Indian population using a decalcication and clearing technique. Previous studies report a high occurrence of Type I canal pattern (Vertucci 1984). Studies on root canal anatomy have
Length of teeth
The longest tooth in this study was 25.2 mm and the shortest was 17.7 mm. The average length of the
(a)
(b)
(c)
(a1)
(b1)
(c1)
Figure 2 Mandibular rst premolars with mesial invagination of the root (a, b, c) and their root canal patterns (a1, b1, c1).
56
Velmurugan & Sandhya Root canal morphology
Table 2 Mesial invagination of the teeth

Canal type Type Type Type Type Type I II III IV V No. of teeth 2 1 1 7 3 Average point of initiation of invagination (mm)a 16.5 14.4 15.3 13.8 15.1
a Point of initiation of invagination measured from the cusp tip. Average: 14.6 mm; median: 14.4 mm; mode: 15.3 mm; variance: 2.5; SD: 1.59.
been conducted using methods, such as radiography (Pineda & Kuttler 1972, Willershausen et al. 2006), decalcication and clearing (Caliskan et al. 1995, Rwenyonyi et al. 2007), direct observation with microscope (Sempire & Hartwell 2000), 3D reconstruction (Mikrogeorgis et al. 1999), computed tomography (Robinson et al. 2002, Reuben et al. 2008) and macroscopic sections (Baisden et al. 1992, Lu et al. 2006). It has been mentioned that the most detailed information can be obtained by demineralization and clearing technique (Vertucci 1984). Moreover, it is simple, acceptable and an inexpensive procedure (Rwenyonyi et al. 2007). The most prevalent canal pattern in the present study was Type I occurring in 72% of the mandibular rst premolars (Fig. 1a, Table 1). In an earlier study (Vertucci 1984) in Caucasian population, the prevalence was 70%, whereas other studies have reported a Type I canal pattern in 67.2% to 86.3% of teeth(Zillich & Dowson 1973, Trope et al. 1986). A Type II canal was encountered in 6% of the samples and Type V in 8% of the samples (Fig. 1, Table 1). Vertucci (1984) did not report any Type II canal patterns, but 24% of the teeth in his study had a Type V canal pattern. These variations may be attributed to the racial or genetic factors. Vertucci (1984) reported the occurrence of C-shaped canal in 0.5% of the samples, whereas in the present study, it was identied in one tooth (1%) (Table 1). Melton et al. (1991) classied C-shaped canals into three types. The C-shaped canal identied in this study was Category III sub division I, where the canal divided into three in the middle third and reunited at the apical region to exit through one foramen. A previous study reported the average length of mandibular rst premolar teeth to be 21.6 mm (Cohen & Hargreaves 2006). The average length of the teeth in the present study was also found to be 21.6 mm. In this
study there were 14 teeth with a mesial invagination of the root. The point of initiation and the depth of the invagination varied. According to Ash (1999), these are deep developmental grooves found on the mesial surface of the root. Radiographic studies on canal anatomy have not reported on mesial invaginations of roots as it is impossible to identify its presence in clinical radiographs. The only in vivo study that reported their occurrence using spiral computed tomography concluded that 15% of mandibular premolars had invagination (Robinson et al. 2002). According to that study, the mesial invagination gave a false radiographic line that one can mistake for an extra canal. In this study, amongst the 14 teeth having mesial invagination of the root, 8 teeth had two canals, 4 teeth had bifurcation of canal and 2 teeth had a single canal. The teeth with two canals (Type II and Type IV) had the mesial invagination initiating from the cervical half of the tooth root. The teeth with canal bifurcation (Type III and Type V) and single canal (Type I) had the invagination in the apical half of the root, with the single canal specimen having the invagination apically. In these teeth, the lingual canal after bifurcation was smaller in diameter when compared with the buccal canal. The location of the canal bifurcation varied in accordance with the location of the point of initiation of invagination. There seems to be some anatomical correlation between mesial invagination of the root and canal pattern which requires further analysis.
Conclusion
A Type I canal pattern was found to be the most prevalent in mandibular rst premolar teeth amongst this Indian population. More than one canal was commonly found in the teeth with mesial invagination of the root.
References
Ahmed HA, Abu-bakr NH, Yahia NA, Ibrahim YE (2007) Root canal morphology of permanent mandibular molars in a Sudanese population. International Endodontic Journal 40, 76671. Ash M (1999) Wheelers Dental Anatomy, Physiology and Occlusion, 7th edn. Philadelphia: W.B. Saunders Company, pp. 2289. Baisden MK, Kulild JC, Weller RN (1992) Root canal conguration of the mandibular rst premolar. Journal of Endodontics 18, 5058.
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Root canal morphology Velmurugan & Sandhya
Brescia NJ (1961) Applied Dental Anatomy. St. Louis: CV Mosby Co., pp. 468. Caliskan MK, Pehlivan Y, Sepetcioglu F, Turkun M, Tuncer SS (1995) Root canal morphology of human permanent teeth in Turkish population. Journal of Endodontics 21, 2004. Cohen S, Hargreaves KM (2006) Pathways of the Pulp, 9th edn. St. Louis: Mosby Elsevier, pp. 2167. Ingle JI, Taintor JF (1985) Endodontics, 3rd edn. Philadelphia: Lea & Febiger, pp. 2752. Lu TY, Yang SF, Pai SF (2006) Complicated root canal morphology of mandibular rst premolar in a Chinese population using the cross section method. Journal of Endodontics 32, 9326. Melton DC, Krell KV, Fuller MW (1991) Anatomical and histological features of C- shaped canals in mandibular second molars. Journal of Endodontics 17, 3848. Mikrogeorgis G, Lyroudia KL, Nikopoulos N, Pitas I, Molyvdas I, Lambrianidis TH (1999) 3D computer-aided reconstruction of six teeth with morphological abnormalities. International Endodontic Journal 32, 8893. Pineda F, Kuttler Y (1972) Mesiodistal and buccolingual roentgenographic investigation of 7,275 root canals. Oral Surgery Oral Medicine and Oral Pathology 33, 10110. Reuben J, Velmurugan N, Kandaswamy D (2008) The evaluation of root canal morphology of the mandibular rst molar in an Indian population using spiral computed tomography scan: an in vitro study. Journal of Endodontics 34, 121249. Robertson D, Leeb J, Mckee M, Brewer E (1980) A clearing technique for the study of root canal systems. Journal of Endodontics 6, 4214.
Robinson S, Czerny C, Gahleitner A, Bernhart T, Kainberger FM (2002) Dental CT evaluation of mandibular rst premolar root congurations and canal variations. Oral Surgery Oral Medicine Oral Pathology Oral Radiology and Endodontics 93, 32832. Rwenyonyi CM, Kutesa AM, Muwazi LM, Buwembo W (2007) Root and canal morphology of maxillary rst and second permanent molar teeth in a Ugandan population. International Endodontic Journal 40, 67983. Sempire HN, Hartwell GR (2000) Frequency of second mesiobuccal canals in maxillary molars as determined by use of an operating microscope: a clinical study. Journal of Endodontics 26, 6734. Sert S, Bayirli GS (2004) Evaluation of the root canal congurations of the mandibular and maxillary permanent teeth by gender in the Turkish population. Journal of Endodontics 30, 3918. Trope M, Elfenbein L, Tronstad L (1986) Mandibular premolars with more than one root canal in different race groups. Journal of Endodontics 12, 3435. Vertucci FJ (1984) Root canal anatomy of the human permanent teeth. Oral Surgery Oral Medicine Oral Pathology Oral Radiology and Endodontics 58, 58999. Willershausen B, Tekyatan H, Kasaj A, Marroquin BB (2006) Roentgenographic in vitro investigation of frequency and location of curvatures in human maxillary premolars. Journal of Endodontics 32, 30711. Zillich R, Dowson J (1973) Root canal morphology of mandibular rst and second premolars. Oral Surgery Oral Medicine Oral Pathology 36, 73844.
58
doi:10.1111/j.1365-2591.2008.01497.x
Necrotic pulp tissue dissolution by passive ultrasonic irrigation in simulated accessory canals: impact of canal location and angulation
, T. Attin & M. Zehnder A. Al-Jadaa, F. Paque

Department of Preventive Dentistry, Periodontology and Cariology, University of Zu rich Center of Dental Medicine, Zu rich, Switzerland
Abstract
F, Attin T, Zehnder M. Necrotic pulp Al-Jadaa A, Paque
tissue dissolution by passive ultrasonic irrigation in simulated accessory canals: impact of canal location and angulation. International Endodontic Journal, 42, 5965, 2009.
Aim To evaluate whether passive ultrasonic irrigation (PUI) of 2.5% NaOCl would dissolve necrotic pulp tissue from simulated accessory root canals (SACs) better than passive placement of the irrigant, when temperature was equilibrated between the two treatments. Methodology Transparent root canal models (n = 6) were made from epoxy resin. SACs of 0.2 mm diameter were placed at dened angles and positions in the mid-canal and apical area. SACs were lled with necrotic bovine pulp tissue. PUI was performed ve times for 1 min each with irrigant replenishment after every minute. Main canal temperature was measured after each minute, and a digital photograph was taken. In control experiments, mock treatments were performed with the same set-up without activation of the le using heated NaOCl to mimic the temperature
created by PUI. Experiments were repeated ve times. Digital photographs were analysed for the distance of dissolved tissue into the SACs in mm. Overall comparison (sum of dissolved tissue from all ve accessory canals) between treatments was performed using paired t-test. Differences between SAC angulation and position after PUI were investigated using anova/ Bonferroni (alpha < 0.05). Results Passive ultrasonic irrigation caused a rise in irrigant temperature in the main canal to 53.5 2.7 C after the fth minute. PUI dissolved a total of 6.4 2.1 mm, mock treatment controlled for heat: 1.4 0.6 mm (P < 0.05). No signicant inuence of SAC position or angulation was found. Conclusions Passive ultrasonic irrigation promotes positive tissue-dissolving effects beyond a rise in irrigant temperature. Keywords: sodium hypochlorite, passive ultrasonic irrigation.
Received 30 July 2008; accepted 3 October 2008
Introduction
Disinfection and debridement of root canals is an important aspect of endodontic treatment. Based on the fact that mechanical preparation alone cannot fully
Correspondence: Matthias Zehnder, PD Dr med dent PhD, Department of Preventive Dentistry, Periodontology and Cariology, University of Zu rich Center for Dental Medicine, Plattenstrasse 11, CH 8032 Zu rich, Switzerland (Tel.: +41 44 632 8610; fax: +41 44 634 4308; e-mail: matthias. zehnder@zzmk.uzh.ch).
achieve this aim (Bystro m & Sundqvist 1981), the chemo-mechanical principle using topically applied substances during and after instrumentation was established. In this context, the correct choice of the chemicals to be used and their ideal mode of application are of interest. Sodium hypochlorite is the root canal irrigant of choice for many practitioners, as it dissolves necrotic tissue (Naenni et al. 2004) and has a superior antimicrobial effect compared with most other disinfectants that have been used in the root canal system (Vianna et al. 2006). It has been shown that the local efcacy of hypochlorite preparations can be improved
59
PUI in accessory canals Al-Jadaa et al.
by heating the solution to be applied (Sirtes et al. 2005). Alternatively, the irrigant can be activated mechanically. Amongst the mechanical methods for irrigant activation, passive ultrasonic irrigation (PUI) is probably the most established method (van der Sluis et al. 2007). Ultrasound was rst introduced to endodontics in 1957 for mechanical root canal and root-end preparation (Richman 1957). Later, it was realized that ultrasonic activation could be benecial in enhancing the efcacy of irrigants in the root canal (Martin 1976, Martin & Cunningham 1985). The main effects in this context are (transitional) cavitation and streaming (Walmsley 1987). Both phenomena are well known to enhance the effectiveness of antiseptics, especially sodium hypochlorite (Martin & Cunningham 1985, Blume & Neis 2005). Whilst streaming undoubtedly occurs, it is unclear whether cavitation actually occurs in the root canal system (Ahmad et al. 1987, Lumley et al. 1988). A third, often overlooked, effect of the application of ultrasonic energy in the root canal is the general increase in irrigant temperature (Cunningham et al. 1982, Cameron 1988). Researchers have extensively studied the inuence of ultrasonic irrigant activation on the appearance of root canal walls as observed by scanning electron microscopy (Ahmad et al. 1987, Abbott et al. 1991). Others used a scoring model of the stained organic debris and smear layer (Cheung & Stock 1993). It was found that ultrasonic activation increases the debridement activity of sodium hypochlorite (Cameron 1987). Using articially prepared grooves lled with dentine debris in the walls of human root canals as well as in articial canals, it has been shown that PUI has the potential to remove debris from canal extensions and irregularities (van der Sluis et al. 2005). It was also shown in situ that the soft tissue debridement of sodium hypochlorite is greatly enhanced by ultrasonic activation in the isthmus areas of human mandibular molars (Burleson et al. 2007). However, until now the impact of PUI on accessory canals is still unclear because of the lack of studies with such observations. It has been shown that clinically, these areas are especially difcult to clean (Nair et al. 2005). The lack of studies on irrigant action in lateral or accessory canals can be related to the difculty in carrying out such investigations on natural teeth, as the accessory canal position and status before treatment are difcult to determine. Consequently, there appears to be a need for standardized models simulating accessory canals with multiple controlled variables yielding repeatable results. The aim of this
study was to establish a model especially tailored for this purpose.
Materials and methods Fabrication of model

A suitable model that would allow the observation and direct quantitative measurement of pulp tissue before and after irrigation was not available. A transparent model was prepared using a wax mould that was lled with epoxy resin (Stycast, Emerson & Cuming, Westerlo, Belgium). To ensure reproducibility of the model, a sheet of paper with a drawing representing the main canal, position and angulation of accessory canals was used as reference to assemble the parts in the proper position using super glue before transferring them to a box made of pink plate wax with a dimension of 30, 20 and 15 mm length, width and height, respectively (Fig. 1a,b). The main canal was simulated using a D-size nger spreader (Dentsply Maillefer, Ballaigues, Switzerland). This instrument had a length of 25 mm, a tip diameter of 0.35 mm, and a 0.06 taper (Brisen o Marroqu n et al. 2001). Accessory canals were created by 0.2-mm stainless steel wires (Fig. 1b,c). The length of the canal was determined by allowing 5 mm of the wire to extrude from a 22-gauge needle (Ultradent Products, Inc. South Jordan, UT, USA), The needle was used later to carry the necrotic pulp tissue and apply it into the canal by means of injection. A pair of canals were placed at distances of 1 mm and 9 mm from the main canal apex opposing each other, one of these was made perpendicular to the main canal, the other created at a 45 angle with the apical extension of the main canal. In addition, an accessory canal that continued in the direction of the main canal (180) was created. A millimetric paper scale was placed parallel to the long access of each simulated accessory canal to ensure a precise measurement of the length of tissue dissolution. Eight models were fabricated to be used in the study. Before any of the models were used, continuity of simulated accessory canals with the main canal was ensured by introducing a 0.2-mm wire inside each accessory canal until it appeared in the main canal. Finally, a simulated pulp chamber and reservoir for the passively placed irrigant was created using a rubber tube with a length of 7 mm and 3 mm internal diameter, which was glued over the main canal entrance. This reservoir ensured that the whole canal remained lled with irrigant after the passive ultrasonic activation procedure described below. A model ready to
60
Al-Jadaa et al. PUI in accessory canals
(a)
(b)
(c)
(d)
Figure 1 Preparation of an epoxy resin model used in this study: (a) template to ensure similar simulated accessory canal position and angulation between the models; (b) positioning of the nger spreader and the wires; (c) mould made of pink wax lled with epoxy resin; (d) nished model.
be lled with necrotic pulp tissue is depicted in Fig. 1, panel d.
Bovine pulp tissue preparation

The accessory canals of seven models were lled with bovine pulp tissue. The tissue was obtained from bovine anterior teeth of animals that were raised and slaughtered for food production according to the Swiss standards of animal welfare. Consequently, this study was not considered an animal study and the internal review board had no objections to the current protocol. Pulps were extirpated after decoronation of the teeth
and then frozen at )20 C. Frozen tissue was thawed, dried with paper tissues, and then each piece was immersed in liquid nitrogen to achieve a solid dry material. Subsequently, tissue was transformed into ne particles using a scalpel to scratch the hard surface. Sometimes it was required to re-immerse the piece into liquid nitrogen several times to maintain its solid consistency. When a sufcient amount of tissue was prepared, a 22-gauge needle (Ultradent Products) was used to aspirate part of it and then the needle was inserted in its place in the model until it reached the outer end of the simulated accessory canal. The tissue was injected in the accessory canal until part of it
61
extruded into the main canal. Excess tissue was placed in the wide entrance of the carrying needle to obtain a passive closure simulating a pathosis rather than a tight seal of the simulated accessory canals. This procedure was repeated in all the ve simulated accessory canals in each model. The models were re-lled for the control experiments with heated NaOCl and NaOCl at room temperature (see below) after removing the old tissue from accessory canals and extensive rinsing with tap water.
Control experiments on temperature

It is well known that ultrasonic irrigant activation is associated with heat generation (Cunningham et al. 1982, Cameron 1988). An increase in temperature can enhance the efcacy of NaOCl (Sirtes et al. 2005). To discern between pure temperature and other ultrasonic effects on NaOCl, the temperature associated with PUI in the current model was determined. A preliminary study was carried out using one of the models fabricated for the study. The temperature was recorded after each 1 min of activation and also after each ush with 1 mL 2.5% (wt/vol) NaOCl using a thin couple wire connected to a calibrated temperature measuring device (Testo Term 9010, Lenzkirch, Germany). This procedure was carried out over 5 min and repeated thrice. After the intracanal temperature created by PUI in the current set-up was known, the irrigant temperature to be used in the second part of the study was determined by trial. The irrigant was heated by placing the irrigation syringe inside a water bath and the temperature was measured after each irrigation by 1 mL of 2.5% NaOCl and after 1 min of irrigation. After that 1 min the syringe was returned to the water bath to ensure a stable temperature. The irrigant temperature inside the syringe was measured by introducing the couple wire through its opening just before irrigation. The temperature was raised gradually until the suitable temperature inside the canal was achieved. This procedure was repeated thrice.
(Nikon D200, Tokyo, Japan) mounted on a stand in front of the model was taken to ensure the complete lling of the simulated accessory canals with pulp tissue and to allow comparison later on. The irrigation protocol was as follows: 1 mL of 2.5% NaOCl at room temperature was introduced to full canal length by a long irrigation needle with 30-gauge diameter (Max-iProbe, Hawe Neos, Bioggio, Switzerland). Care was exercised that the opening at the needle tip was not directed towards the accessory canals directly. An ultrasonic device (EMS 400, EMS, Nyon, Switzerland) with its power set at the of the scale, with an ultrasonic stainless steel K-type le size 15 (Endosonore, Dentsply Maillefer) mounted on an ultrasonic adaptor (Piezon, 90 Endo File Holder, EMS) was used to activate the irrigant in the canal with an up and down motion by hand at a ratio of 10 mm s)1 to the full length of the canal minus half a millimeter, for 1 min. Subsequently, a photo was taken and the main canal was irrigated with 1 mL of sodium hypochlorite at room temperature. The same procedure was repeated every minute for 5 min. At the end of the fth minute, the temperature inside the canal was measured to ensure that the ultrasonic le was active. The ultrasonic le was replaced for each model to avoid fracture, whilst the ultrasonic adaptor was replaced after two models. This protocol was carried out on the seven models. In the control experiments, the models were relled with tissues as described before and the same procedure was carried out except for the NaOCl temperature which was 6869 C in the second experiment and at room temperature the third time. The le was introduced in the canal without ultrasonic activation in these two experiments. The experiment for the second and third parts was carried out only on six models because one of the models was lost because of a fractured le in the rst part. Results from that model were discarded.
Data generation and analysis

Data from the temperature experiments are presented as means and standard deviations (n = 3). The photos were analyzed using the ImageJ program (nih.gov; National Institute of Health, Bethesda, MD, USA). The outcome variable assessed here was distance of tissue dissolution in simulated accessory canal, measured from the canal entrance to the closest tissue-irrigant interface. Measurements were performed by one operator, who was tested for his accuracy by analysing the same images ten times after different
Main experiment
The model was held on a cone especially designed to direct light through it to have a contrast facilitating the interpretation of results and to prevent artefacts caused by over-exposure of light. Halogen light (Intralux 4000-1, Volpi AG, Schlieren, Switzerland) was introduced from behind the model and through the cone. An initial photograph using a 10-megapixel camera
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intervals. The error of the individual measurement was < 0.05 mm. Consequently, data pertaining to tissue dissolution were rounded to 0.1 mm. To compare overall tissue dissolution at room temperature with the corresponding values obtained by PUI and in the temperature-controlled experiments, the sums of distances of tissue dissolution in all accessory canals per model were averaged for each mode (n = 6) and compared by a paired t-test. To compare the impact of accessory canal position and angulation on tissue dissolution by PUI, mean values per simulated accessory canal were compared by one-way analysis of variance (anova). Bonferronis correction was applied for multiple testing. The alpha-type error was set at 0.05.
necessitated a regular replacement of the adaptor. As an extra precaution the temperature was measured after the fth and nal minute of PUI in each individual model as an indicator of the ultrasonic activity inside the canal.
Tissue dissolution
The mean sums of dissolved tissue from simulated accessory canals after 5 min of PUI or the mock treatments were: PUI: 6.4 2.1 mm, mock treatment at room temperature: 0.8 0.3 mm, and mock treatment controlled for heat: 1.4 0.6 mm. The difference between the heated irrigant and the counterpart administered at room temperature was not signicant at the 0.05 level, whilst there was a signicant (P < 0.05) difference between both these treatments and PUI, indicating a clear PUI effect. When the inuence of simulated accessory canal position and angulation on tissue dissolution by PUI was studied (Table 1), it was noted that regardless of accessory canal position or angulation, a plateau was reached after the third minute of activation. Furthermore, there was no signicant difference in tissue dissolution between different simulated accessory canals at any time.
Results Temperature
Passive ultrasonic irrigation caused a rise in hypochlorite temperature in the main canal to 53.5 2.7 C after the fth min (Fig. 2). For the temperature-control experiment, the suitable irrigant temperature in the syringe was found to be 6869 C, which was achieved by placing the 5-mL irrigation syringe in a water bath of 75 C for 5 min. This resulted in an overall temperature in the canal that was similar to the one observed with PUI (Fig. 2). One of the observations, which might affect the clinical usability of PUI, was that after multiple usage of the ultrasonic adaptor (usually after 1214 min of activation), the temperature suddenly dropped, indicating a loss of ultrasonic energy transmitted to the irrigant in the canal. After multiple trials and by exclusion it was found that the rubber ring between the two parts of the ultrasonic adaptor wore out so that there was less activation of the ultrasonic le. This observation
Discussion
The current study showed a positive effect of PUI in conjunction with a sodium hypochlorite irrigant on pulp tissue dissolution from simulated accessory canals in an epoxy resin model. This effect was not explained by a simple rise in overall irrigant temperature. The current study is limited by the fact that epoxy resin is a completely different material from human dentine, and direct clinical conclusions can therefore not be drawn from the results presented here. Further-
Figure 2 Temperatures (C) measured in
the simulated main canal after passive ultrasonic irrigation (blue) and during the mock treatment with a heated sodium hypochlorite solution (red) over time. Dots indicate means, error bars standard deviations (n = 3).
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Table 1 Distance in mm of dissolved tissue as measured from the simulated accessory canal entrance after passive ultrasonic
irrigation (means and standard deviations, n = 6)

Time 1st min 2nd min 3rd min 4th min 5th min 90, mid-canal 0.2 1.1 1.4 1.4 1.5 0.3 0.5 0.5 0.5 0.6 45, mid-canal 0.1 0.8 1.0 1.1 1.2 0.2 0.6a 0.6 0.6 0.6 90, apex 0.0 0.9 1.1 1.2 1.3 0.0 0.3 0.3 0.3 0.3 45, apex 0.4 1.3 1.5 1.6 1.7 0.6 0.8 0.9 0.8 0.8 180, apex 0.1 0.5 0.7 0.8 0.9 0.1 0.6 0.7 0.8 0.9
No statistically signicant differences were found between canals at any given time (P > 0.05, anova, Bonferroni).
more, the simulated main canal in the current model was straight. This type of anatomy is rarely encountered in natural teeth. However, the aim of this study was to discern between mere temperature and other PUI effects in the cleansing of accessory canals. For this purpose, the model appeared adequate. However, despite the standardization of the models that were used, data variation pertaining to the distance of dissolved tissue in simulated accessory canals was still relatively large as indicated by the high standard deviations (Table 1). This can be explained by the difculty in obtaining completely homogenous and standardized lls of necrotic tissue in these thin canals. On the other hand, the density of necrotic tissue in infected natural accessory canals might also vary. It is a common observation when dealing with natural tissues such as the bovine pulps that were used in the current investigation that outcomes vary. In addition, because the ultrasonic tip was guided by hand, it was impossible to control where it touched the canal wall, which may also have contributed to the variance in outcome. A further limitation of this study is the fact that the average width of accessory canals is not known or published (De Deus 1975). However, based on our own observations on micro-computer tomographies of human teeth, 200 lm appeared to be a fair approximation. The temperature that was measured in the current study was somewhat higher than that measured in natural teeth, which may be because of the fact that thermal transducing properties of dentine differ from those of epoxy resin (Brown et al. 1970) and also because of the potential cooling effect of the blood circulation around natural teeth. Using PUI with intermittent ushes, temperatures of up to 45 C were measured in root canals of natural teeth after 30 s of ultrasonic irrigant activation (Cameron 1988). Considering the shorter activation times, there appears to be little variance between these published data and the current results. However, other researchers found the temperature rise in the root canal promoted by PUI to be minimal (Ahmad 1990). However, a root canals
were widened to an ISO-size 80 in that study, and there was continuous ow of irrigant during ultrasonic activation which might explain the differences. The exact mechanism by which ultrasonic hypochlorite activation can affect the tissue in accessory canals is still unclear. One hypothetical mechanism is the collapse of bubbles during transient cavitation that produces a pressure-vacuum effect, which sucks the canal content to the inside rather than pushing it further in the canal. This will be followed by diffusion of the irrigant in the main canal to substitute the space created (Martin & Cunningham 1985). Another possibility is that the streaming around the activated le because of the cohesion between uid particles inside the accessory canal and the irrigant in the main canal sucks the content of the accessory canals into the main canal with uid ow toward the main canal (Ahmad et al. 1992). The third possibility is a local temperature effect because of the collapse of bubbles during transitional cavitation. It has been shown that locally, the temperature can reach up to 5000 C with heating and cooling rates greater than 109 K/s during cavitation (Suslick 1990). Consequently, a great part of the ultrasonic effect may still be thermal, but just not measurable by assessing the overall irrigant temperature. However, it is still unclear at this point whether transient cavitation occurs in the root canal. Based on preliminary observations with dye solutions of different colours in the model described here, it was noted that little streaming occurred in the apical area, especially in the simulated accessory canal at 180 at the apical end of the main canal (not shown). Nevertheless, tissue dissolution was similar regardless of accessory canal position or angulation in the current study. Consequently, it may be so that cavitation was, at least in part, responsible for the observed phenomenon of tissue dissolution by PUI. This again highlights what has been pointed out more than 20 years ago, namely that further studies are required to elucidate the phenomena behind ultrasonic effects that might or might not occur in the root canal.
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One further observation that was made during the current study was that because of the high corrosive potential of hypochlorite and the heat that is generated during ultrasonic activation, material wear out occurred rapidly. Initially, noncutting nickel-titanium tips were used, but these fractured so frequently that it was decided to use the cheaper stainless-steel les. Results between the two types of instruments were similar (data not shown).
Conclusions
A model allowing the quantitative assessment of necrotic pulp tissue dissolution in simulated accessory canals was presented. The temperature generated in the main canal of this model by passive ultrasonic activation of a 2.5% NaOCl solution was over 50 C. This rise in overall temperature could not be responsible for the effectiveness of PUI. Tissue dissolution by PUI was irrespective of simulated accessory canal position or angulation.
References
Abbott PV, Heijkoop PS, Cardaci SC, Hume WR, Heithersay GS (1991) An SEM study of the effects of different irrigation sequences and ultrasonics. International Endodontic Journal 24, 30816. Ahmad M (1990) Measurements of temperature generated by ultrasonic le in vitro. Endodontics and Dental Traumatology 6, 2301. Ahmad M, Pitt Ford TR, Crum LA (1987) Ultrasonic debridement of root canals: an insight into the mechanisms involved. Journal of Endodontics 13, 93101. Ahmad M, Roy RA, Kamarudin AG (1992) Observations of acoustic streaming elds around an oscillating ultrasonic le. Endodontics and Dental Traumatology 8, 18994. Blume T, Neis U (2005) Improving chlorine disinfection of wastewater by ultrasound application. Water Science and Technology 52, 13944. Brisen o Marroqu n B, Wolter D, Willershausen-Zo nnchen B (2001) Dimensional variability of nonstandardized greater taper nger spreaders with matching gutta-percha points. International Endodontic Journal 34, 238. Brown WS, Dewey WA, Jacobs HR (1970) Thermal properties of teeth. Journal of Dental Research 49, 7525. Burleson A, Nusstein J, Reader A, Beck M (2007) The in vivo evaluation of hand/rotary/ultrasound instrumentation in necrotic, human mandibular molars. Journal of Endodontics 33, 7827. Bystro m A, Sundqvist G (1981) Bacteriologic evaluation of the efcacy of mechanical root canal instrumentation in end-
odontic therapy. Scandinavian Journal of Dental Research 89, 3218. Cameron JA (1987) The synergistic relationship between ultrasound and sodium hypochlorite: a scanning electron microscope evaluation. Journal of Endodontics 13, 5415. Cameron JA (1988) The effect of ultrasonic endodontics on the temperature of the root canal wall. Journal of Endodontics 14, 5549. Cheung GS, Stock CJ (1993) In vitro cleaning ability of root canal irrigants with and without endosonics. International Endodontic Journal 26, 33443. Cunningham WT, Martin H, Forrest WR (1982) Evaluation of root canal debridement by the endosonic ultrasonic synergistic system. Oral Surgery, Oral Medicine, and Oral Pathology 53, 4014. De Deus QD (1975) Frequency, location, and direction of the lateral, secondary, and accessory canals. Journal of Endodontics 1, 3616. Lumley PJ, Walmsley AD, Laird WR (1988) An investigation into cavitational activity occurring in endosonic instrumentation. Journal of Dentistry 16, 1202. Martin H (1976) Ultrasonic disinfection of the root canal. Oral Surgery, Oral Medicine, and Oral Pathology 42, 929. Martin H, Cunningham W (1985) Endosonics- the ultrasonic synergistic system of endodontics. Endodontics and Dental Traumatology 1, 2016. Naenni N, Thoma K, Zehnder M (2004) Soft tissue dissolution capacity of currently used and potential endodontic irrigants. Journal of Endodontics 30, 7857. Nair PN, Henry S, Cano V, Vera J (2005) Microbial status of apical root canal system of human mandibular rst molars with primary apical periodontitis after one-visit endodontic treatment. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics 99, 23152. Richman MJ (1957) The use of ultrasonics in root canal therapy and resection. Journal of Dental Medicine 12, 128. Sirtes G, Waltimo T, Schaetzle M, Zehnder M (2005) The effects of temperature on sodium hypochlorite short-term stability, pulp dissolution capacity, and antimicrobial efcacy. Journal of Endodontics 31, 66971. van der Sluis LW, Wu MK, Wesselink PR (2005) The efcacy of ultrasonic irrigation to remove articially placed dentine debris from human root canals prepared using instruments of varying taper. International Endodontic Journal 38, 7648. van der Sluis LW, Versluis M, Wu MK, Wesselink PR (2007) Passive ultrasonic irrigation of the root canal: a review of the literature. International Endodontic Journal 40, 41526. Suslick KS (1990) Sonochemistry. Science 247, 143945. Vianna ME, Horz HP, Gomes BP, Conrads G (2006) In vivo evaluation of microbial reduction after chemo-mechanical preparation of human root canals containing necrotic pulp tissue. International Endodontic Journal 39, 48492. Walmsley AD (1987) Ultrasound and root canal treatment: the need for scientic evaluation. International Endodontic Journal 20, 10511.
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doi:10.1111/j.1365-2591.2008.01452.x
CLINICAL ARTICLE
A preliminary study of the use of peripheral quantitative computed tomography for investigating root canal anatomy
` 1 & A. Rubinacci3 M. T. Sberna1, G. Rizzo2, E. Zacchi3, P. Cappare
1
Department of Odontoiatrics; 2IBFM-CNR, Department of Nuclear Medicine; and 3Bone Metabolic Unit, Scientic Institute H San Raffaele, Milan, Italy
Abstract ` P, Rubinacci A. A preliminary study of the use of Sberna MT, Rizzo G, Zacchi E, Cappare
peripheral quantitative computed tomography for investigating root canal anatomy. International Endodontic Journal, 42, 6675, 2009.
Aim To evaluate the use of peripheral quantitative computed tomography (pQCT) for qualitative and quantitative analysis of root canal anatomy and for assessing the extent of canal enlargement during root canal instrumentation. Summary The volume variation achieved by S1 ProTaper instruments in the coronal third of the root canals was analysed using peripheral computed tomography. The tooth was scanned in the horizontal plane producing 36 consecutive cross-sectional images. All images were the result of 360 projections with a section thickness of 250 lm, a distance between slices of 0.5 mm and an in-plane pixel size of 70 70 lm. The evaluation was completed before and after S1 ProTaper instrumentation (with or without circumferential ling) of one root canal of a freshly extracted maxillary rst premolar tooth. The acquired images were realigned geometrically and processed using a 3D visualization software. pQCT scanning allowed 3D reconstruction of the root canal anatomy and the assessment of the extent of canal enlargement during root canal instrumentation with lateral displacement of canal walls and hence volume change being greater than the coefcient of variation. The densitometry evaluation showed uniform density along the root canal wall. Key learning points pQCT scanning allowed 3D reconstruction of the root canal anatomy and the assessment of the extent of canal enlargement during root canal instrumentation. pQCT shows promise for allowing qualitative and quantitative analysis of endodontic procedures. Keywords: 3D imaging, peripheral quantitative computed tomography, qualitative and quantitative methodology, root canal instrumentation, root canal preparation. Received 17 July 2007; accepted 2 June 2008
Correspondence: Alessandro Rubinacci, Bone Metabolic Unit, Scientic Institute H San Raffaele, via Olgettina, 60, 20132 Milan, Italy (Tel.: +39 0226432320; fax: +39 0226433038; e-mail: lessandro.rubinacci@hsr.it).
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Introduction Precise morphological mapping of the root canal system is a prerequisite for the evaluation of endodontic instruments and procedures. A detailed understanding of the root canal system is, in fact, critical for the characterization of all factors that might have a signicant impact on the volume of root canals and pulp chambers and in the development of successful therapeutic strategies. Conventional destructive approaches based upon 3D computer-based reconstructions of histological sections do not allow a longitudinal assessment of the endodontic therapy, are limited by the poor precision of the volumetric algorithms, and do not permit a systematic mapping of the endodontic volumes (Walton 1976). Several non-destructive approaches have been developed more recently. For example, computed tomography has been applied extensively to the detection of enamel thickness from an anthropological perspective (Gantt et al. 2006), but the available resolution did not allow a precise mapping of the root canal nor the estimation of the canal volumes that were usually overestimated (Gantt et al. 2006). The inability of conventional imaging techniques to visualize the root canal system drove the development of alternative imaging modalities. In this context, two procedures have proven to be suitable for the non-destructive exploration of both teeth and the volumetry of the root canals, namely magnetic resonance microscopy (MRM) and X-ray computed microtomography (lCT). Magnetic resonance microscopy, a high-resolution magnetic resonance spectroscopy system, constitutes a powerful tool for a detailed analysis of teeth without applying ionizing radiation (Tseng et al. 2007). However, standard methodologies require a strong proton signal of the surrounding liquid to produce a boundary surface image to visualize the mineralized tissue. Magnetic resonance tomography (MRT) with stray eld imaging (STRAFI) (Baumann et al. 1993) can achieve this directly, in a very short T2 time, but with poor resolution and the different hard tooth tissue components cannot be differentiated as in the case of MRM. Imaging of all structural components of a tooth with one system and one image was not possible until the demonstration that constant-time imaging (CTI) techniques enabled the detection of magnetic signals from the hard tooth tissues, as well as from the proton- and signal-intensive pulpal tissue. By presenting both signals in one image with a resolution as low as 195 lm, CTI combines the advantages of both the standard MRM and the STRAFI (Appel & Baumann 2002), but it might be limited in the qualitative and quantitative description of the smallest components of the pulpal chamber. The lCT is a miniaturized form of conventional computerized tomography. The lCT scanner uses an X-ray tube as radiation source and a 3D reconstruction algorithm. Recently, lCT has been introduced to evaluate not only cross-sections of roots but also 3D shapes of canal systems at resolutions as high as 36 lm (Dowker et al. 1997, Bjrndal et al. 1999, Rhodes et al.1999, Peters et al. 2000, 2001, Bergmans et al. 2001, Gluskin et al. 2001, Gao et al. 2006, Lee et al. 2006). This innovation was achieved because new hardware and software were available to evaluate the metrical data created by lCT, thus allowing geometrical changes in prepared canals to be determined more precisely. This technique has two disadvantages: it is limited to the processing of two extracted teeth at a time because of the small size of the gantry and has a long scanning time up to 6 h (Peters et al. 2003). New developments include high-resolution X-ray computed tomography (HRXCT) and at panel-based volume computed tomography (fpVCT). HRXCT is applied to the 3D reconstruction of enamel thickness, and of dentine and pulp chamber volumes at a resolution ranging from 5 to 100 lm by exporting two-dimensional digitized images obtained by combining modular energy sources (125450 kV) and modular detectors (Gantt et al. 2006). The fpVCT has also been found suitable for the qualitative visualization of the root canal system despite its low spatial resolution of 150 lm. This
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technique is in fact able to visualize dentine, enamel and the root canal system in 3Dimage reconstruction that, because of the size of the gantry (40 cm in diameter), might include several teeth at the same scanning time (Hannig et al. 2006). However, a systematic evaluation of endodontic instruments and procedures based upon these instruments is not practicable, given their high cost and limited availability. Therefore, the following study is designed to evaluate the feasibility of applying peripheral quantitative computed tomography (pQCT) to the qualitative and quantitative analysis of root canal anatomy and for assessing the extent of canal enlargement during root canal instrumentation. pQCT has been originally designed for the diagnosis of osteoporosis in humans, rats and mice (Schmidt et al. 2003). The unit works with a specially developed X-ray tube having a minute focal spot whilst the detector system consists of a series of miniature semiconductor crystals. The device is equipped with a special detector collimator that can be switched up to four collimator sizes corresponding to the four section thicknesses (100, 250, 500 and 750 lm). Although the planar resolution of pQCT (70 70 lm) does not have the same resolution as lCT, it might provide a nondestructive morphological investigation at low cost and shorter scanning times.
Materials and methods Specimen selection and preparation The study is preliminary in nature, with only one tooth analysed. One root canal of a maxillary rst premolar tooth, freshly extracted for clinical reasons and not relating to this study, was selected. After preparing a standard access cavity, the canal was passively negotiated with sizes 10 and 20 K-les to the apical foramen; the working length was determined visually. Canal preparation was completed by a single operator using NiTi rotary instrumentation; the S1 ProTaper (Dentsply Maillefer, Ballaigues, Switzerland) was mounted on an ATR Tecnika Vision system (motor and handpiece) (ATR, Pistoia, Italy). For assessing the extent of canal enlargement during root canal instrumentation, two different applications of S1 ProTaper on the coronal third of the root canal were considered: the rst in compliance with the manufacturers protocol and the other arbitrarily modied to produce a loss of the canal wall structure. Therefore, S1 ProTaper was used, for approximately 9 s, until reaching 1 mm from the working length, centering and avoiding any lateral movement (rst phase), then applying lateral displacement (second phase) for a further 9 s. The instrumentation was deliberately applied to one side of the root canal system, leaving the other side untreated as a control.
Scanning Tomographic tooth scanning and measurements were obtained before and after each instrumentation phase. A pQCT scanner was used for the measurements (Research SA+; Stratec Medizintechnik GmbH, Pforzheim, Germany). This translation rotation scanner works with a specially developed X-ray tube with a 50-lm spot size (high voltage 50 kV, anode current <0.3 mA, mean X-ray energy 37 keV, energy distribution after ltration 18 keV full width half maximum [FWHM]). The detector-system consists of 12 miniature semiconductor crystals with ampliers. The precision error supplied by the manufacture for density measurement in vivo is around 1.5%. The tooth was scanned in the horizontal plane producing 36 consecutive cross-sectional images at a distance of 0.5 mm.
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All images were obtained with 360 projections, with a section thickness of 250 lm and at an in-plane pixel size of 70 70 lm at a scan speed of 3 mm s)1. Total scanning time was 4 h. Operator time was limited to 10 min. Scanning of a selected region of the root canal was also obtained with a section thickness of 100 lm. As no additional information was available, this scanning procedure was aborted. To orientate the long axes of the tooth parallel to the image planes, the tooth was xed with manufacturer-made plastic holders. The correct longitudinal positioning was determined by means of an initial scout scan.
CLINICAL ARTICLE
Qualitative data analysis To correct the possible mispositioning of the specimen in the pQCT gantry, the acquired studies were geometrically realigned using a registration technique based on the maximization of mutual information implemented in a home-made software package (Rizzo et al. 2005). After registration, the studies corresponded geometrically, with subvoxel accuracy, and could be compared correctly. The registered images were then processed using 3D visualization software (amira 4.1; Mercury Computer System Inc., Chelmsford, MA, USA) to generate 3D rendering of the tooth external surface and the root canal, for the qualitative evaluation of the modication of the root canal size, produced by the S1 ProTaper. The coefcient of variation of the reconstructed volumes after repositioning was assessed by performing the quantitative analysis on the actual cross-sections of the root canal that had not undergone to instrumentation. It varied from 3.3% to 7.1%.
Quantitative data analysis A quantitative assessment of the canal volume variations induced by the instrumentation was carried out using the 3D analysis software analyze (Biodynamic Research Unit, Mayo Clinic, Rochester, MN, USA) (Robb et al. 1989). From each registered image, the root canal volume, corresponding to the area of interaction of S1 ProTaper (coronal third of the root canal), was extracted, by calculating, on each slice, the isocontour corresponding to the same isovalue. The volume of the dentine removed was then obtained by subtracting the canal volumes after and before treatments. Furthermore, a densitometry evaluation was performed, with the pQCT scanner, which directly provided sectional images accurately calibrated in terms of density. Dentine density in each scan was calculated by analyze. For this purpose, densities <500 mg cm)3 corresponding to the tooth canal or >2000 mg cm)3 corresponding to the tooth enamel were excluded.
Results Qualitative evaluation In Fig. 1, the 3D representation of the external tooth surface and the root canal is shown for each study, after spatial registration. From the qualitative analysis it is possible to note the effect of using ProTaper in a lateral displacement mode: the size of the treated canal area is enlarged (see arrow). The same effect can be seen in Fig. 2, which visualizes the surface of the canals, before and after the treatments. The increment of canal volume is evident when ProTaper is used in a lateral displacement mode (Fig. 2e) but is not noticeable when ProTaper is used more passively (Fig. 2d).
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Figure 1 Representative 3D rendering of the external tooth surface and canal for each experimental condition. Left: treatment with K-le 20 instrumentation. Middle: treatment with S.1 ProTaper instrumentation used as protocol. Right: treatment with S.1 ProTaper instrumentation used by lateral displacement. The enlargement of treated area (arrow) is clearly visible in the third situation.
(a)
(b)
(c)
(d)
(e)
Figure 2 Comparison of 3D rendering of the canal surfaces in different conditions. Top row: (a) K-le 20 (white), (b) S1 ProTaper as protocol (green), (c) S1 ProTaper with lateral displacement (red). Bottom row: (d) superposition of S1 ProTaper as protocol and K-le 20, (e) superposition of S1 ProTaper as lateral displacement and K-le 20. In this last gure, the enlargement of canal using S1 ProTaper as lateral displacement results in an evident red area on the reference K-le 20 white surface.
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Quantitative evaluation Figure 3 shows orthogonal views corresponding to the 3D conditions after registration, with the region of interest (treated area) superimposed as red overlay. The measured volume sizes for each slice belonging to the treated area are shown in Fig. 4. Lateral displacement produced volume changes far above those detected when ProTaper is used more passively. By applying lateral displacement between the K-le and S1 used in a brushing mode, volume changes ranged from +0.09 mm3 (38 voxels) in slice
Figure 3 Tooth cross-sectional views corresponding to the three different experimental conditions. Top row: treatment with K-le 20. Middle row: treatment with S1 ProTaper used as protocol. Bottom row: treatment with S1 ProTaper used as lateral displacement. The red overlay corresponds to the treated area.
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Figure 4 Comparison of tooth canal volumes in the three different experimental conditions. Volumes were measured in all the slices belonging to the treated area (slice 2326, total longitudinal extension: 2000 lm).
23 to +0.18 mm3 (72 voxels) in slice 26, whereas without lateral displacement volume changes ranged from )0.030 mm3 (or 12 voxels) in slice 23 to +0.049 mm3 (or 20 voxels) in slice 26. The measured volume sizes for the reconstructed treated area were 2.56 mm3 before S1 ProTaper, 2.63 mm3 after S1 ProTaper without lateral displacement, and 3.10 mm3 after S1 ProTaper with lateral displacement. This resulted in an increment of 2.66% of the canal volume when ProTaper was used more passively, and in an increment of 21% when lateral displacement was applied. Whilst the former increment was in the range of the coefcient of variation, as assessed on the root canal not undergoing to instrumentation (3.37.1%), the latter was far above. As not more than one tooth was used, no signicant statistical calculation can be presented. The cross sectional densitometric analysis was able to identify the dentinoenamel junction that was represented in Fig. 5. The density distribution pathway clearly distinguished dentine density from enamel. The longitudinal densitometric analysis globally shows no differences in the density of dentine: as illustrated in Fig. 6, the prole is at and only small density gradients can be observed for the rst curve points, principally because of partial volume effects induced by slice thickness.
Figure 5 Typical cross-sectional density prole showing the density of the enamel and dentine. The abrupt drop in the density prole corresponds to the dentinoenamel junction.
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Figure 6 Dentine density measured in the scan correspond to K-le 20 treatment. Slices 1 and 36 are not considered, as they contain very few voxels of dentine.
Discussion The study has shown that pQCT instruments, developed for bone mineral analysis and having a spatial resolution of 70 70 250 lm, show promise for allowing a precise and reliable mapping of the root canal system by producing contiguous slices of teeth. The 3Dimage reconstruction and the measurements of volumes and densities obtained by pQCT scanning appear to be suitable for the qualitative and quantitative assessment of the changes in root canal shape following instrumentation. The application of a pQCT system to endodontic imaging offers advantages over current NMR and lCT techniques, mainly relating to its lower cost and wider availability, whilst scanning time is only marginally reduced (4 h vs. 6 h). pQCT allows direct visualization of tooth tissues, i.e. dentine, enamel and root canal system, which are clearly distinguishable in the 3D images, and can determine the impact of spatial distribution of the dental volumetric density (enamel versus dentine) on dental pathology. This has not been systematically evaluated and offers potential advantages on our current understanding of the genetic and environmentally related differences in dentine signalling that could alter enamel structure with an impact on dental health. A minor advantage of pQCT is related to its large scanner gantry opening (9 cm) that can include several teeth at the same scanning time as fpVCT (Hannig et al. 2006), whereas lCT systems can allow evaluation of two teeth only (Peters et al. 2001). The acquired data at each repositioning were realigned geometrically before comparison using a registration technique based on the maximization of mutual information implemented in a home-made software package (Rizzo et al. 2005). As the registered sections were geometrically aligned with sub-voxel accuracy, the comparisons should be considered precise and reliable. The detection of volume changes at the side of the root canal system, only where they were expected to be found after adequate instrumentation, sustains a potential application of the developed methodology in the clinical setting. When pQCT, lCT and histomorphometry were compared, the results showed that a pQCT scanning at 500-lm thickness can yield satisfactory precision and accuracy in microstructural representation of the scanned bone site (Schmidt et al. 2003). The highest agreement was found between pQCT and lCT being based on the measurement of the same physical property as X-ray absorption. However, a rigorous analysis of the limits of the pQCT in reconstructing small canals should be outlined. The larger pixel size (70 70 lm), and the consequent lower resolution of the pQCT versus lCT, introduces larger partial volume effects that might
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affect the volumetric evaluation of the pulp chamber and root canals as well as the denition of the dentinoenamel junction and the derived parameters as density. Even if the object of theoretical correction (Rittweger et al. 2004), this limitation is critical and is applied when projecting a continuous object on a discrete grid. Hence, quantitative image analysis is prone to errors where the edge of the object is within the sampling grid. The segmentation process can overestimate sharp edges depending upon the voxel volumes as the partial volume effect increases with voxel size (i.e. at lower image resolution) and decreases with the object size. This implies that side and/or accessory canals as well as main canals smaller than the voxel size are not detectable with sufcient accuracy, thus hampering correct visualization and analysis. The spatial resolution of the pQCT methodology applied is critical to the reliability of volume change measurements. It is generally accepted that half voxel size for each voxel forming the volume surface contributes to the uncertainty range in volume estimate, because of spatial resolution. It follows that, in the case of the root canal system, the uncertainty varies along the canal and is related to its size. By approximating to a cylinder the shape of the root canal represented in a single tomographic slice, the measurement uncertainty of the volume changes observed should be expected ranging from 10% to 11% (from 28 to 31 voxels) for canal volume ranging from 250 to 298 voxels (slices 2326). This quantitative analysis suggests that the volume changes observed when lateral displacement was applied were reliable and, as a consequence, lateral displacement should be avoided to preserve optimal mechanical strength of tooth. In fact, the potential for the root lled teeth to fracture increases proportionally with the amount of dentine removed (Pilo et al. 1998).
Conclusion This study has presented an innovative and nondestructive methodology to illustrate canal morphology and canal volume changes after instrumentation by applying pQCT analysis. The 3D reconstruction methodology based on pQCT images described here deserves further systematic evaluation to fully validate its application in the clinical setting as a tool for qualitative and quantitative analysis of the endodontic procedures.
Disclaimer Whilst this article has been subjected to Editorial review, the opinions expressed, unless specically indicated, are those of the author. The views expressed do not necessarily represent best practice, or the views of the IEJ Editorial Board, or of its afliated Specialist Societies.
Acknowledgements We wish to acknowledge Johannes Willnecker, Stratec Medizintechnik GmbH, Pforzheim, Germany, for providing the technical information required for the development of the study.
References
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Bergmans L, Van Cleynenbreugel J, Wevers M, Lambrechts P (2001) A methodology for quantitative evaluation of root canal instrumentation using micro computed tomography. International Endodontic Journal 34, 3908. Bjrndal L, Carlsen O, Thuesen G, Darvann T, Kreiborg S (1999) External and internal macromorphology in 3D-reconstructed maxillary molars using computerized X-ray microtomography. International Endodontic Journal 32, 39. Dowker S, Davis G, Elliott J (1997) X-ray microtomography-non-destructive three-dimensional imaging for in vitro endodontic studies. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics 83, 5106. Gantt DG, Kappleman J, Ketcham RA, Alder ME, Deahl TH (2006) Three-dimensional reconstruction of enamel thickness and volume in humans and hominoids. European Journal of Oral Sciences 114, 3604. Gao Y, Fan B, Cheung GS, Gutmann JL, Fan M (2006) C-shaped canal system in mandibular second molars part IV: 3-D morphological analysis and transverse measurement. Journal of Endodontics 32, 10625. Gluskin AH, Brown DC, Buchanan LS (2001) A reconstructed computerized tomography comparison of NiTi rotary GT les versus traditional instruments in canals shaped by novice operators. International Endodontic Journal 34, 47684. Hannig C, Krieger E, Dullin C et al. (2006) Volumetry of human molars with at panel-based volume CT in vitro. Clinical Oral Investigations 10, 2537. Lee JK, Ha BH, Choi JH, Heo SM, Perinpanayagam H (2006) Quantitative three-dimensional analysis of root canal curvature in maxillary rst molars using micro-computed tomography. Journal of Endodontics 32, 9415. Peters OA, Laib A, Ru egsegger P, Barbakow F (2000) Three dimensional analysis of root canal geometry using high resolution computed tomography. Journal of Dental Research 79, 14059. Peters OA, Scho nenberger K, Laib A (2001) Effects of four NiTi preparation techniques on root canal geometry assessed by micro computed tomography. International Endodontic Journal 34, 22130. Peters OA, Peters CI, Sho nenberger K, Barbakow F (2003) ProTaper rotary root canal preparation: effects of canal anatomy on nal shape analysed by micro CT. International Endodontic Journal 36, 8692. Pilo R, Corcino G, Tamse A (1998) Residual dentin thickness in mandibular premolars prepared with hand and rotary instruments. Journal of Endodontics 24, 4014. Rhodes JS, Pitt Ford TR, Lynch PJ, Liepins PJ, Curtis RV (1999) Micro-computed tomograpy: a new tool for experimental endodontology. International Endodontic Journal 32, 16570. Rittweger J, Michaelis I, Giehl M, Wusecke P, Felsenber D (2004) Adjusting for the partial volume effect in cortical bone analyses of pQCT images. Journal of Musculoskeletal and Neuronal Interactions 4, 43641. Rizzo G, Castiglioni I, Arienti R et al. (2005) Automatic registration of PET and CT studies for clinical use in thoracic and abdominal conformal radiotherapy. Quarterly Journal of Nuclear Medicine 49, 26779. Robb RA, Hanson DP, Karwoski RA, Larson AG, Workman EL, Stacy MC (1989) Analyze: a comprehensive operator-interactive software package for multi-dimensional medical image display and analysis. Computerized Medical Imaging and Graphics 13, 43354. Schmidt C, Priemel M, Kohler T et al. (2003) Precision and accuracy of peripheral quantitative computed tomography (pQCT) in the mouse skeleton compared with histology and microcomputed tomography (CT). Journal of Bone and Mineral Research 18, 148696. Tseng YH, Tsai YL, Tsai TW et al. (2007) Double-quantum ltered heteronuclear correlation spectroscopy under magic angle spinning. Solid State Nuclear Magnetic Resonsance 31, 5561. Walton RE (1976) Histologic evaluation of different methods of enlarging the pulp canal space. Journal of Endodontics 1, 25562.
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CASE REPORT
Endodontic management of badly broken down teeth using the canal projection system: two case reports
A. S. Bhomavat, R. K. Manjunatha, R. N. Rao & K. H. Kidiyoor
Department of Conservative Dentistry and Endodontics, S.D.M. College of Dental Sciences and Hospital, Dharwad, Karnataka, India
Abstract Bhomavat AS, Manjunatha RK, Rao RN, Kidiyoor KH. Endodontic management of
badly broken down teeth using the canal projection system: two case reports. International Endodontic Journal, 42, 7683, 2009.
Aim Teeth that have been weakened by caries and require root canal treatment to maintain their functional integrity may present with minimal coronal tooth structure and are a challenge for isolation and restoration. The aim of this clinical report is to demonstrate the management of badly broken down teeth using the Projector Endodontic Instrument Guidance System (PEIGS). Summary The PEIGS is an adjunct to root canal treatment designed to enhance the ease of treatment delivery. Use of this system facilitates projection of canal orices from the oor of the pulp chamber to the cavosurface, providing direct visualization of and physical access to the projected canals. This report demonstrates the use of this novel device for the management of two badly broken down teeth. Key learning points Use of the endodontic projection system has the following advantages: Projects the canal orice from the oor of the pulp chamber to the cavosurface, thereby enhancing visualization and access to the canals. The bonded coronal build up reduces the risk of interappointment crack initiation and coronal-radicular fracture of weakened tooth structure. Permits individualization of canals especially when they lie in close proximity to each other on the chamber oor. Isolation may be facilitated by ease of clamp retention, rendering many structurally debilitated teeth endodontically treatable. Keywords: broken down teeth, endodontic canal projection, isolation, pre-endodontic build-up, projector. Received 15 September 2007; accepted 13 July 2008
Correspondence: Dr Anisha S. Bhomavat, Department of Conservative Dentistry and Endodontics, S.D.M. College of Dental Sciences and Hospital, Sattur, Dharwad 580009, Karnataka, India (Tel.: +91 9314130001, +91 22 28330846; fax: +91 836 2467612; e-mail: a_bhomavat@rediffmail.com).
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Introduction Technical and scientic advances in endodontics have resulted in retention of teeth, which were earlier deemed untreatable (Johns et al. 2006). It is universally accepted that preservation of a natural tooth with a good prognosis is superior to tooth loss and replacement (Roda & Gettleman 2006). The current techniques employed to manage severely broken down teeth include the use of special clamps with specic designs, surgical exposure of the cervical tooth structure to facilitate clamp placement, use of orthodontic bands, preformed copper bands, pin or adhesive retained amalgam, composite and glass ionomer buildups. However, these have inherent disadvantages (Madison et al. 1986, Jeffrey & Woolford 1989). Presence of minimal coronal structure can risk further damage to the crown during rubber dam clamp placement thereby compromising isolation and causing subsequent coronal leakage (Jeffrey & Woolford 1989, Zerr et al. 1996). Pre-endodontic build-up of the coronal tooth structure following caries removal and identication of the canal orices can facilitate the endodontic process by providing a strong core and coronal seal (Kurtzman 2004). The canal projection technique using the Projector Endodontic Instrument Guidance System (PEIGS) (CJM Engineering, Santa Barbara, CA, USA) provides pre-endodontic reconstruction of debilitated coronal and radicular tooth structure whilst preserving individualized access to canals (Kurtzman 2004, http://www.cjmengineering.com). This case report introduces the innovative concept of using the Projector which projects the canal orices from the chamber oor to the cavosurface providing better visibility and access (Weathers 2004), and also ensures optimum isolation and reinforcement of the tooth structure.
Case reports Case report 1 A 36-year-old female reported to the Department of Conservative Dentistry and Endodontics, S.D.M. College of Dental Sciences, Dharwad, India, complaining of a dull, mild intermittent pain in the right maxillary posterior region for 2 months. Intra-oral examination revealed the presence of a grossly decayed tooth, 16 (FDI), with three walls missing (Fig. 1a). Pulp sensibility testing elicited a negative response. The preoperative radiograph (Fig. 1b) revealed deep occlusal caries involving the pulp and widening of the periodontal ligament space in relation to the palatal root. A diagnosis of pulpal necrosis and chronic periradicular periodontitis was made. Root canal treatment was then planned using the PEIGS as rubber dam isolation was challenging. The Projector is a small, black, cone-shaped plastic device, which slides onto an endodontic le (Fig. 1d). It has a central lumen, an apical bevel and is made of a specially formulated plastic (linear low-density polyethylene) which is nonadherent to dental restorative materials. It is available in two sizes; regular which is used in cases where the size of the access cavity is adequate to accommodate the medium-sized device, and skinny which is used in cases where the size of the access cavity is not adequate to accommodate the medium-sized device (Table 1). After securing adequate anaesthesia and application of rubber dam with a clamp with apically inclined beaks, caries was excavated. Access cavity preparation was performed and four canal orices were identied (Fig. 1c). The canals were enlarged to a size 20 le using the standardized method of cleaning and shaping. Canal orices were dimpled with a slow speed round bur (Mani Inc., Tochigi-Ken, Japan) of diameter 1 mm, to facilitate placement of the projectors and to prevent ow of adhesive into the canals.
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(a)
(b)
(c)
(d)
(e)
(f)
(g)
(h)
(i)
Figure 1 (a) Preoperative photograph: severely broken down tooth 16 (mirror view). (b) Preoperative radiograph: deep occlusal caries and chronic periradicular periodontitis, tooth 16. (c) Access opening completed under rubber dam, four orices detected. (d) Files are prepared with projectors. (e) Composite built up around projectors to occlusal surface. (f) Files removed leaving projectors in place. (g) Projectors are removed using H-le. (h) Final result: orices projected to occlusal surface. (i) Postobturation radiograph.
A stainless steel automatrix band (Hawe Supermat; KerrHawe, Lugano, Switzerland) was placed followed by the application of phosphoric acid gel (Scotchbond Etchant gel; 3M ESPE, St Paul, MN, USA) to etch the exposed dentine and enamel. Rinsing and drying was accomplished after 30 s. The Projectors were placed on four endodontic les and slid up toward the le handles, so that 58 mm of each le tip protruded beyond the tip of the Projector. Different sizes of les were used to aid in identication of the projected orices. Size 20 was used for the mesiobuccal canal, size 15 for the second mesiobuccal canal, size 25 for the distobuccal canal and size 30 for the palatal canal. Each le with a Projector was then inserted into its respective orice and the Projector was pressed into place with cotton pliers until it seated precisely and snugly into the dimple created at the orice. A dentine bonding agent (Adper Single Bond, 3M ESPE) was then applied and light-cured.
Table 1 Details of the dimensions of the PEIGS
Regular Overall length Diameter 1 mm from apical end Large diameter Tapered lumen full length Skinny Overall length Diameter 1 mm from apical end Large diameter Tapered lumen full length PEIGS, Projector Endodontic Instrument Guidance System. c. 10.00 mm c. 1.20 mm c. 2.00 mm
c. 13.00 mm c. 0.80 mm c. 1.14 mm
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The build-up was placed in increments using a hybrid composite (Filtek Z100, 3M ESPE) and light-cured (Fig. 1e). Following curing, the les were removed by counter-rotation, leaving the Projectors in place (Fig. 1f). A high speed, bull-nosed diamond (Mani, Inc) was used to level the occlusal surface providing ideal endodontic reference points. The nal result was a stable coronal structure with straight-line access into each canal with maximum structural reinforcement. A size 60 Hedstrom hand le was then used to remove the Projectors from the core, by rotating it clockwise, to engage the utes in the lumen of each Projector and withdrawing (Fig. 1g). Thus, a pre-endodontic build-up with individualized access to each canal was achieved successfully (Fig. 1h). The original hand le was introduced into each projected orice and a working length radiograph was taken. Standard instrumentation was performed to clean and shape the canals. Interim coronal seal of the canals was simplied by snipping 3 mm from the large diameter end of each Projector, reinserting them into their respective projected orices and then sealing each with Cavit (3M ESPE). At the subsequent visit, the small Cavit seals were removed with a round bur, and the submerged Projectors were easily removed by engaging them with a Hedstrom le and withdrawing. Following canal preparation and lling to the level of the chamber oor (Fig. 1i), the composite in the projected canals was freshened with a diamond bur (Mani, Inc.) and additional composite resin was bonded directly over gutta percha to the level of the cavosurface. The pre-endodontic build-up itself was used as a core and full crown preparation was performed followed by crown cementation at a subsequent appointment. Application of this technique created a conical projected orice which was easily visualized and accessed and consistently delivered the tip of the endodontic le to the respective canal whilst maintaining independence of canals from each other. This technique, once mastered, takes minimal time and greatly enhances treatment of badly broken down teeth.
Case report 2 A 21-year-old female attended with the complaint of a mildly painful tooth in the mandibular right posterior region for the past 4 months. Intra-oral examination revealed a grossly decayed tooth, 46 (FDI). Pulp sensibility tests elicited a negative response. The preoperative radiograph showed deep occlusal caries involving the pulp space and slight widening of the periodontal ligament space. The pulp was diagnosed as necrotic, associated with chronic periradicular periodontitis. Root canal treatment was initiated using the PEIGS. The procedure for management of this badly broken down tooth was similar to that described above. Figure 2ae demonstrates the steps undertaken.
Discussion The dentist may often be confronted with severely compromised teeth. High quality root canal treatment and reconstructive procedures are prerequisites to ensure long-term maintenance of such teeth (Ricucci & Grosso 2006). In such difcult cases, canal Projectors can facilitate adequate access and preparation of root canals during root canal treatment. This technique enhances management of complexities including severe coronal breakdown, tipped/rotated teeth, limited mouth opening and near proximity of orices on the chamber oor (Weathers 2004). In cases of severe coronal breakdown, various methods of isolation have been suggested, including the use of clamps with apically inclined beaks, the Silker-Glickman clamp (The Smile Center, Deerwood, MN, USA), or the split-dam technique (Kurtzman
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(a)
(b)
(c)
(d)
(e)
Figure 2 (a): Preoperative photograph: severely broken down tooth 46. (b) Preoperative radiograph: deep occlusal caries and periradicular periodontitis. (c) Access opening completed under rubber dam, three orices detected, matrix band placed. (d) Final result: orices projected to occlusal surface. (e) Postobturation radiograph.
2004). However, multiple tooth isolation can be less effective than single tooth isolation and often requires the use of other aids such as oss ligation and/or sealants (Scott 2002). Occasionally, periodontal or restorative procedures may be necessary to simplify placement of the rubber dam (Ingle et al. 2002). These procedures include clamping of anaesthetized attached gingiva, surgical crown lengthening procedure such as gingivoplasty or alveoloplasty (Gutmann & Lovdahl 1997) and the composite donut technique (Heydrich 2005). Restorative methods may also be considered to build up the tooth so that a retainer can be placed properly (Lovdahl & Gutmann 1980, Lovdahl & Wade 1997). A preformed copper or orthodontic band or a temporary crown may be cemented over the remaining natural crown. However, the disadvantages include inferior sealing ability, blockage of canal systems by cement during access opening or instrumentation and periodontal inammation if improperly placed/contoured.
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Occasionally, so little tooth structure remains that even band or crown placement is not possible. In such cases, it becomes necessary to replace missing tooth structure to facilitate placement of the rubber dam clamp to prevent contamination of the working eld (Lovdahl & Gutmann 1980, Lovdahl & Wade 1997, Scott 2002). The tooth can be built up with hard, fast-setting temporary cement (e.g. Ketac-Fil, ESPE, Seefeld, Germany; TERM, LD Caulk, Milford, DE, USA), pin-retained amalgam or composites (Ingle et al. 2002, Scott 2002). However, these restorative methods are time consuming; they can impede endodontic access and may require replacement when they are weakened by endodontic access procedures. To overcome these challenges, the canal projection technique was developed and offers the following advantages: (i) it projects the canal orice from the oor of the pulp chamber to the cavosurface, thereby enhancing visualization and access to the canals, (ii) permits individualization of canals and therefore can simplify management of canals that lie in close proximity to each other on the chamber oor, (iii) can allow for ease of isolation as canal projection essentially replaces missing tooth structure thereby facilitating clamp retention and thus rendering many structurally debilitated teeth treatable and (iv) allows les to be inserted easily, particularly nickeltitanium les which are sometimes difcult to insert into mesial canals as they are unable to retain a bend, as the canals are no longer obscured by prominent marginal ridges and other visual obstructions. The bonded composite coronal build-up decreases coronal leakage (Uranga et al. 1999, Heling et al. 2002, Schwartz & Fransman 2005) and also reduces the risk of coronalradicular fracture during endodontic therapy thereby reinforcing the tooth (Hurmuzlu et al. 2003, Daneshkazemi 2004). Furthermore, the bonded core seals the accessory canals that exit the chamber oor (Niemann et al.1993, Luglie & Sergente 2001, Haznedaroglu et al. 2003), providing a degree of protection to the chamber oor in cases where extensive decay has left an area of the oor thin. This prevents leakage of contaminants to the furcation through what would otherwise be a temporary seal between treatment visits. The technique can also reinforce perforation repairs by overlaying mineral trioxide aggregate (MTA) with a bonded resin prior to root canal treatment, preventing re-aggravation of the perforation site during subsequent procedures (Ford et al. 1995). Canal projection allows correction of misdirected access cavities by essentially reconstructing the walls and oors around Projectors which act as internal matrix barriers. It insulates les from metallic coronal restorations to facilitate accurate electronic length determination (Carrotte 2004, Kim & Lee 2004) and also prevents ingrowth of tissues in cases where cervical tooth structure has been destroyed. The canal projection process elongates the hydraulic chamber of each canal, offering advantages during the hydraulic condensation of obturating materials, especially whilst using warm vertical condensation techniques (Glickman & Pettiette 2006). It should be noted that, as with many useful techniques, canal projection is a techniquesensitive procedure and may have its limitations; in fact, the obturation may not be limited to the canal orices and initially it may be time consuming. However, once mastered, the technique can be performed with speed and precision, and it can signicantly enhance the balance of treatment, particularly in cases of severe coronal break down.
Conclusion Management of teeth with minimal coronal structure can be a challenging task when root canal treatment is required as a part of oral rehabilitation. Coronal leakage, isolation complexities and risk of interappointment coronal-radicular fracture may be major contributors to endodontic failure. This case report demonstrates the use of an
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innovative technique, canal projection, as an efcient method for managing these complex cases.
Conict of interest The authors afrm that they have no commercial interest in the materials used or their method of use as discussed in this manuscript.
Acknowledgements The authors would like to thank Dr C. John Munce for providing the Projector Endodontic Instrument Guidance System for undertaking this case report as well as his keen guidance in the preparation of this manuscript. Thanks to Dr Bhasker Rao, Principal, S.D.M. College of Dental Sciences, Dharwad, India for his kind cooperation and support.
References
Carrotte P (2004) Endodontics: Part 7. Preparing the root canal. British Dental Journal 197, 60313. Daneshkazemi A R (2004) Resistance of bonded composite restorations to fracture of endodontically treated teeth. The Journal of Contemporary Dental Practice 5, 518. Glickman GN, Pettiette MT (2006) Preparation for treatment. In: Cohen S, Hargreaves K, eds. Pathways of the Pulp, 9th edn. St Louis, MO, USA: Mosby, pp. 97135. Gutmann JL, Lovdahl PE (1997) Problems encountered in tooth isolation and access to the pulp chamber space. In: Gutmann JL, Dumsha TC, Lovdahl PE, Hovland EJ, eds. Problem-Solving in Endodontics: Prevention, Identication and Management, 3rd edn. St Louis, MO, USA: Mosby, pp. 4767. Haznedaroglu F, Ersev H, Odabasi H et al. (2003) Incidence of patent furcal accessory canals in permanent molars of a Turkish population. International Endodontic Journal 36, 5159. Heling I, Gorl C, Slutzky H, Kopolovic K, Zalkind M, Slutzky-Goldberg I (2002) Endodontic failure caused by inadequate restorative procedures: review and treatment recommendations. The Journal of Prosthetic Dentistry 87, 6748. Heydrich R W (2005) Pre-endodontic treatment restorations. A modication of the donut technique. Journal of the American Dental Association 136, 6412. Hurmuzlu F, Kiremitci A, Serper A, Altundasar E, Siso SH (2003) Fracture resistance of endodontically treated premolars restored with ormocer and packable composite. Journal of Endodontics 29, 838 40. Ingle JI, Walton RE, Malamed SF, et al. (2002) Preparation for endodontic treatment. In: Ingle JL, Bakland LK, eds. Endodontics, 5th edn. Hamilton, Ontario, Canada: B. C. Decker, pp. 357404. Jeffrey IW, Woolford MJ (1989) An investigation of possible iatrogenic damage caused by metal rubber dam clamps. International Endodontic Journal 22, 8591. Johns BA, Brown LJ, Nash KD, Warren M (2006) The Endodontic Workforce. Journal of Endodontics 32, 83846. Kim E, Lee SJ (2004) Electronic apex locator. Dental Clinics of North America 48, 3554. Kurtzman GM (2004) Restoring teeth with severe coronal breakdown as a prelude to endodontic therapy. Endodontic Therapy 4, 212.
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Lovdahl PE, Gutmann JL (1980) Periodontal and restorative considerations prior to endodontic therapy. General Dentistry 28, 3845. Lovdahl PE, Wade CK (1997) Problems encountered in tooth isolation and periodontal support for the endodontically compromised tooth. In: Gutmann JL, Dumsha TC, Lovdahl PE, Hovland EJ, eds. Problem-Solving in Endodontics: Prevention, Identication and Management, 3rd edn. St Louis, MO, USA: Mosby, pp. 20327. Luglie PF, Sergente C (2001) SEM study of morphology and incidence of accessory canals in the furcation region of permanent molars. Minerva Stomatologica 50, 639. Madison S, Jordan RD, Krell KV (1986) The effects of rubber dam retainers on porcelain fused to-metal restorations. Journal of Endodontics 12, 1836. Niemann RW, Dickinson GL, Jackson CR, Wearden S, Skidmore AE (1993) Dye ingress in molars: furcation to chamber oor. Journal of Endodontics 19, 2936. Pitt Ford TR, Torabinejad M, McKendry DJ, Hong CU, Kariyawasam SP (1995) Use of mineral trioxide aggregate for repair of furcal perforations. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics 79, 75663. Ricucci D, Grosso A (2006) The compromised tooth: conservative treatment or extraction? Endodontic Topics 13, 10822. Roda RS, Gettleman BH (2006) Non surgical retreatment. In: Cohen S, Hargreaves K, eds. Pathways of the Pulp, 9th edn. St Louis, MO, USA: Mosby, pp. 9441010. Schwartz RS, Fransman R (2005) Adhesive dentistry and endodontics: materials, clinical strategies and procedures for restoration of access cavities: a review. Journal of Endodontics 31, 15165. Scott GL (2002) Isolation. In: Walton RE, Torabinejad M, eds. Principles and Practice of Endodontics, 3rd edn. Philadelphia, PA, USA: W.B. Saunders, pp. 11829. Uranga A, Blum JY, Esber S, Parahy E, Prado C (1999) A comparative study of four coronal obturation materials in endodontic treatment. Journal of Endodontics 25, 17880. Weathers A K (2004) Endodontics from access to success, part 1 access, the important rst step. Dentistry Today 23, 7885. Zerr M, Johnson WT, Walton RE (1996) Effect of rubber-dam retainers on porcelain fused to metal. General Dentistry 44, 1324.
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CASE REPORT
Pulp revascularization of necrotic bilateral bicuspids using a modied novel technique to eliminate potential coronal discolouration: a case report
K. Reynolds, J. D. Johnson & N. Cohenca
Department of Endodontics, School of Dentistry, University of Washington, Seattle, WA, USA
Abstract
Reynolds K, Johnson JD, Cohenca N. Pulp revascularization of necrotic bilateral bicuspids using
a modied novel technique to eliminate potential coronal discolouration: a case report. International Endodontic Journal, 42, 8492, 2009.
Aim To present a case report in which the pulp of two bilateral mandibular premolars with dens evaginatus were revascularized using a modied novel technique to avoid undesired crown discolouration. Summary Recently, regeneration of necrotic pulps has become an alternative conservative treatment option for young permanent teeth with immature roots and is a subject of great interest in the eld of endodontics. This novel procedure exploits the full potential of the pulp for dentine deposition and produces a stronger mature root that is better able to withstand the forces than can result in fracture. However, the current protocol has potential clinical and biological complications. Amongst them, crown discolouration, development of resistant bacterial strains and allergic reaction to the intracanal medication. In the case presented, a modied technique to avoid undesired crown discolouration was applied sealing the dentinal tubules of the chamber, thus avoiding any contact between the tri-antibiotic paste and the dentinal walls. Key learning points Sealing the dentinal tubules of the chamber prevents the undesirable crown discolouration produced by tri-antibiotic medication whilst maintaining the revascularization potential of the pulp. Further research is warranted to seek an alternative infection control protocol capable of preventing possible allergic reactions and development of resistant strains of bacteria, as well as a biological material capable of inducing angiogenesis and allow a more predictable scaffold and tissue regeneration.
Correspondence: Dr Nestor Cohenca, Department of Endodontics, University of Washington, POB 357448, Seattle, WA 98195 7448, USA (Tel.: 1 206 543 5044; fax: 1 206 616 9085; e-mail: cohenca@u.washington.edu).
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CASE REPORT
Keywords: crown discoloration, immature permanent tooth, open apex, pulp revascularization, vital pulp therapy. Received 1 April 2008; accepted 19 July 2008
Introduction stby & Hjortdal performed studies that can be considered the In 1971, Nygaard-O forerunner of pulpal regeneration (Nygaard-Ostby & Hjortdal 1971). The studies were aimed at determining how periodontal tissue would react, if the entire pulp was removed from the main canal and the apical part subsequently allowed to be lled with blood. Skoglund et al. (1978) further demonstrated that in a traumatic avulsion, blood vessels slowly grow from the apex toward the pulp horn by replacing the necrosed pulp left behind after the avulsion injury. Since then, human avulsion case series (Kling et al. 1986) and controlled animal studies (Cvek et al. 1990a,b, Ritter et al. 2004) have shown radiographic and histological evidence of successful revascularization of immature permanent teeth after replantation. In this situation, the necrotic uninfected pulp acts as a scaffold for the in-growth of new tissue from the periapical area. The absence of bacteria is critical for successful revascularization because the new tissue will stop at the level it meets bacteria in the canal space (Myers & Fountain 1974, Yanpiset & Trope 2000). Studies to test the ability of topical antibiotics to improve revascularization outcomes in experimental avulsions (Yanpiset & Trope 2000, Ritter et al. 2004) have shown that topical doxycycline and minocycline can improve radiographic and histological evidence of revascularization in immature avulsed permanent teeth. Extrapolating from this information, it is hypothesized that once the canal infection is controlled, it resembles the avulsed tooth that has a necrotic but sterile pulp space. The blood clot is then introduced so as to mimic the scaffold that is in place with the ischeamic necrotic pulp in the avulsed tooth and the access cavity is restored with a bacteria-tight seal. However, in necrotic cases with apical periodontitis it must be recognized that the vital tissue might not be normal pulp tissue, despite the fact that the root development continues and dentine maturation occurs. In teeth with open apices and necrotic pulps, it is possible that some vital pulp tissue and Hertwigs epithelial root sheath remain. When the canal is properly disinfected, the inammatory process reverses and these tissues may proliferate. Recently, the concept of revascularization of necrotic pulps regained interest and became an alternative conservative treatment option for young permanent teeth with immature roots (Sato et al. 1993, Hoshino et al. 1996, Sato et al. 1996, Iwaya et al. 2001, Banchs & Trope 2004, Windley et al. 2005, Thibodeau et al. 2007). As well stated by Windley et al. (2005), revascularization of immature teeth with apical periodontitis depends mainly on: (a) disinfection of the canal; (b) placement of a matrix in the canal for tissue in-growth; and (c) a bacterial tight seal of the access opening. Since the infection of the root canal system is considered to be polymicrobial, a combination of drugs would be needed to treat the diverse ora. Thus, the recommended protocol combines the use of metronidazole, ciprooxacin and minocycline. Hoshino et al. (1996) performed a laboratory study testing the antibacterial efcacy of these drugs alone and in combination against the bacteria of infected dentine, infected pulps and periapical lesions. Alone, none of the drugs resulted in complete elimination of bacteria. However, in combination, these drugs were able to consistently sterilize all samples. In addition, a study by Sato et al. (1996) found that this drug combination was effective in killing bacteria in the deep layers of root canal dentine.
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This novel procedure exploits the full potential of the pulp for dentine deposition and produces a stronger mature root that is better able to withstand fracture but has the potential for clinical and biological complications. Amongst them, crown discolouration (Windley et al. 2005), development of resistant bacterial strains (Greenstein & Polson 1998, Eickholz et al. 2002, Slots 2002) and allergic reaction to the intracanal medication (de Paz et al. 1999, Hausermann et al. 2005, Jappe et al. 2005, Isik et al. 2007, Madsen et al. 2007). Although coronal discolouration is not often reported in the literature in association with the use of this tri-antibiotic medication, it is believed that the marked discolouration may to be related to the use of minocycline. Kim et al. (2000) demonstrated that Ledermix (Lederle Pharmaceuticals, GMBH Wolfratshausen, Germany), an intracanal medication containing tetracycline, caused discolouration of immature teeth in a greater degree than in mature teeth. A case report is presented in which the pulps of bilateral mandibular premolars became necrotic because of dens evaginatus and were revascularized using a modied novel technique to avoid undesired crown discolouration.
CASE REPORT
Case report An 11-year-old Asian girl was referred to the graduate endodontic clinic by her dentist for evaluation and root canal treatment of her mandibular second premolars. The medical history was non-contributory. A review of the dental history revealed that the patient had sought dental care 3 months prior because of swelling and pain in the mandibular left premolar region. The patient was prescribed penicillin VK 1000 mg daily by her general dentist. The pain and swelling subsided within a week. Upon clinical examination, an occlusal tubercle consistent with dens evaginatus (Fig. 1a,b) was diagnosed. Intraoral sinus tracts, buccal to the mandibular left and right second premolars were present (Fig. 1c,d). No caries were clinically detected. Pulp sensibility tests using 1, 1, 1, 2-tetrauoroethane (Endo-Ice; Hygenic Corp., Akron, OH, USA) produced no response from either mandibular second premolars whilst the adjacent mandibular rst molars and premolars responded to cold without lingering. Neither mandibular second premolars were sensitive to percussion or palpation. Periodontal probing afrmed normal attachment with no probing depths >3 mm and normal physiological mobility. No crown discolouration was observed. Radiographically both mandibular second premolars had a similar appearance, with widened periodontal ligament space, incomplete root formation and diffuse periapical radiolucencies 6 6 mm in size (Fig. 2a,b). No carious lesions were diagnosed (Fig. 2c) and the root development appeared arrested with wide open apices in both mandibular second premolars. A gutta-percha point was used to trace the sinus tract and a periapical radiograph taken, demonstrating the association between the drainage and the periradicular radiolucency (Fig. 2d). Based on the results of clinical and radiographic examination, the pulpal and periradicular diagnosis of the mandibular left and right second premolars was determined as pulpal necrosis with chronic suppurative periradicular periodontitis. Taking into consideration the stage of root development, the maturation of the dentinal walls and the wide-open apices, the treatment plan included pulp revascularization of both mandibular second premolars. After a comprehensive discussion of the risks, complications and possible outcomes of this treatment, parental consent was obtained. Following administration of local anaesthesia, the mandibular left second premolar was isolated with rubber dam. Under a dental-operating microscope, access preparation was performed and a single orice with a wide canal was revealed. No purulent exudates or haemorrhage were observed in the chamber (Fig. 3a). Length was estimated
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CASE REPORT
Figure 1 (a,b) Clinical photographs showing an occlusal tubercle consistent with dens evaginatus in both mandibular second premolars. (c,d) An intraoral localized swelling buccal to the mandibular left and right second premolars is noted.
radiographically using a size15 K-le. The selection of the le size was made to avoid any damage to the canal walls. The irrigation protocol included a slow and careful irrigation of 20 mL of 6% sodium hypochlorite, 2 mm back from working length. This was followed by a 5 mL rinse of saline and then a nal irrigation of 10 mL of 2.0% chlorhexidine gluconate (Vista Dental, Racine, WI, USA). A modication of the current clinical protocol (Sato et al. 1996, Banchs & Trope 2004) was established to avoid crown discolouration. This novel approach seals the dentinal tubules of the chamber, thus avoiding any contact between the tri-antibiotic paste and the dentinal walls. The inner surfaces of the coronal access were etched for 20 s with 35% phosphoric acid (Ultra-Etch; Ultradent, South Jordan, UT, USA) and rinsed. Bonding agent was applied (Single Bond 3M, Minneapolis, MN, USA) to the etched surfaces and cured for 20 s. Then, a Root Canal Projector (CJM Engineering Inc., Santa Barbara, CA, USA) with a size 20 K-le inside the projector was placed into the prepared access to maintain patency. The space between the projector and the coronal dentine was sealed with owable composite (PermaFlo DC; Ultradent, South Jordan, UT, USA) and lightcured for 30 s (Fig. 3b). The projector was then removed by engaging it with a Hedstro m le. The tri-antibiotic paste was prepared immediately prior to treatment by mixing 250 mg of Ciprooxacin, 250 mg of Metronidazole and 250 mg of Minocycline with sterile water (Fig. 3c). A 20G needle was set 2 mm short of working length and used to introduce the medication into the canal using a backll approach up to the level of the cemento-enamel junction (CEJ) (Fig. 3d). The tooth was then temporarily sealed with a cotton pellet and Cavit (3M ESPE, Seefeld, Germany). One month later, the patient presented with localized swelling and pain on her mandibular right quadrant associated with the mandibular right second premolar. The
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CASE REPORT
(a)
(b)
(c)
(d)
Figure 2 (a,b) Radiographic examination demonstrated incomplete root formation and diffuse periapical radiolucencies of 6 6 mm in size in both mandibular second premolars. (c) No carious lesion was diagnosed. (d) A gutta-percha point was used to trace the sinus tract and a periapical radiograph was taken, demonstrating the association between the drainage and the periradicular radiolucency.
swelling was visible extraorally along the lower border of the mandible in the submandibular space, tender to palpation and non-uctuant. The patients temperature was 36.6 C. Under local anaesthetic and rubber dam isolation, the mandibular right second premolar was accessed for treatment. Upon access, no purulent exudate was noted and only some minor haemorrhage. After working length was determined, the canal was carefully irrigated with 10 mL of 6% sodium hypochlorite up to 2 mm from working length at which time the access was sealed with a cotton pellet and Cavit as a temporary restoration. In case of persistent pain, the patient was instructed to take ibuprofen 200 mg. Incision and drainage was not indicated, as the draining sinus tract was still present and the swelling was non-uctuant. At the same appointment, it was noted that the mandibular left second premolar was asymptomatic and was not sensitive to palpation and percussion. The sinus tract associated with the mandibular left second premolar had healed. Four-days later the swelling was signicantly reduced, as well as the patients complain of pain in the mandibular right quadrant. The sinus tract stoma associated with the mandibular right second premolar was still present. At this appointment it was decided to continue treatment of the mandibular left second premolar as previously planned. Under local anaesthesia and rubber dam isolation, the tooth was re-accessed. No purulent drainage or haemorrhage was noted upon access and the tri-antibiotic paste was removed with 6% sodium hypochlorite with the irrigation needle tip 2 mm short of the working
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CASE REPORT
(a)
(b)
(c)
(d)
Figure 3 (a) Mandibular left second premolar was accessed under a dental-operating microscope, without evidence of purulent exudates or haemorrhage. (b) A Root Canal Projector with a size 20 K-le inside the projector was placed into the prepared access to maintain patency. The space between the projector and the coronal dentine was sealed with owable composite and cured for 30 s. (c) The triantibiotic paste was prepared immediately prior to treatment and loaded in a syringe with a 20G needle and a rubber stopper. (d) The canal was dressed using a backll approach up to the level of the cemento-enamel junction (CEJ) and the tooth was then temporarily sealed. Notice the owable composite sealing the access walls up to the level of the CEJ.
length. With the root canal infection controlled, the regenerative process was initiated. A sterile size 20 K-File was introduced 2 mm past the working length to stimulate bleeding and create a biological scaffold for pulpal regeneration. The intracanal haemorrhage was controlled below the CEJ by applying pressure with a sterile saline-soaked cotton pellet until a clot was established. ProRoot grey MTA (Dentsply Tulsa Dental, Johnson City, TN, USA) was then mixed with sterile water and carefully placed above the blood clot up to the level of the CEJ. The access was sealed with a moist cotton pellet and Cavit. At the same appointment, the mandibular right second premolar was anaesthetized and isolated with rubber dam. No purulent drainage or haemorrhage was observed upon access of the mandibular right second premolar. At this time, the same clinical protocol used to treat the mandibular left second premolar was used on the mandibular right second premolar. Using the same novel technique mentioned previously to avoid discolouration, owable composite was applied to the coronal dentine sealing the dentinal tubules preventing contact with the tri-antibiotic paste. The tri-antibiotic dressing was placed into the canal with a syringe set at 2 mm from the working length. The access was then sealed with a cotton pellet and Cavit. Two weeks following the last appointment, the patient returned asymptomatic and without swelling or sinus tract stomas on either side of the mandible. Under local anaesthesia and rubber dam isolation in the mandibular left quadrant, the temporary restoration was removed from the mandibular left second premolar and the coronal
89
access rened, cleaned and restored with resin-bonded composite (Prisma TPH; Dentsply Culk, York, PA, USA). Four weeks after the tri-antibiotic medication was placed on the mandibular right second premolar, the patient was asymptomatic and without swelling or sinus tract stomas on either side. Under local anaesthesia and rubber dam isolation, the tooth was treated using the same clinical protocol used for the mandibular left second premolar. Briey, sodium hypochlorite irrigation was used for removal of the tri-antibiotic paste followed by stimulation of haemorrhage, clot formation and MTA placement. The tooth was then temporized and the patient was rescheduled for the nal composite restoration which was place 2 weeks later without incident or change in symptoms. During the 18-month follow-up period the patient remained asymptomatic. Clinically, both mandibular second premolars responded within normal limits to cold test using 1, 1, 1, 2-tetrauoroethane. No tenderness to percussion or palpation was noted and the periodontal examination revealed no pocket depths over 3 mm and normal physiological mobility. The radiographs demonstrated evidence of periradicular bone healing and signicant root development with maturation of the dentine as compared with the preoperative radiographs (Fig. 4a,b). Clinically, the mandibular right second premolar teeth showed no change in shade or colour (Fig. 4c), although mandibular left second premolar revealed a slight cervical discolouration possibly related to the use of grey MTA (Fig. 4d).
CASE REPORT
Discussion An immature tooth with early irreversible pulp involvement presents with thin divergent or parallel dentinal walls. This situation creates clinical challenges in disinfection, and as a result, affects the long-term outcome of the treatment. Traditionally, calcium hydroxide has been used as the intra-canal medicament in apexication procedures. However, because of its high pH it will cause necrosis of tissues that can potentially differentiate into new pulp. Moreover, even if rendered successful, apexication procedures will leave a short root with thin dentinal walls with a high risk of root fracture. Revascularization of a pulp-like tissue for dentine deposition will allow further development of the root and dentinal structure with a better long-term prognosis. As shown in the present case, clinical and radiographic evaluation at 6-month intervals is stressed after revascularization therapy, so as to assess pulp vitality and progression of root development. Current vitality tests still depend on neurological stimulation and its reliability on immature teeth is considered questionable (Fulling & Andreasen 1976, Fuss et al. 1986). The radiographic diagnosis of periapical pathosis may also become difcult in immature teeth because of the normal radiolucency of the developing root sheath which occurs apically as the root matures. Comparison of root formation with the contralateral teeth should always be performed to evaluate treatment outcome. If crown discolouration occurs, treatment by intracoronal bleaching with sodium perborate should be attempted. In addition, the use of white MTA instead of grey MTA should also be considered. The modied protocol described in the present article is an attempt to avoid the undesired crown discolouration. It also describes a safer and more reliable technique for antibiotic dressing using a 20G needle with a backll approach. This novel approach prevents the undesirable crown discolouration produced by the triantibiotic medication, whilst maintaining the revascularization potential of the pulp. Taking in consideration the importance of aesthetics, this technique could be consider for all anterior teeth in which the use of the tri-antibiotic paste is indicated for revascularization purposes. Further research is warranted to seek an alternative infection control protocol capable of preventing possible allergic reactions and development of resistant strains of
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CASE REPORT
(a)
(b)
(c)
(d)
Figure 4 Eighteen-month follow-up. (a, b) Both mandibular second premolars demonstrated significant root development with maturation of the dentine. (c) Clinically, the mandibular right second premolar presented no crown discolouration whilst (d) the mandibular left second premolar showed a slight cervical discolouration related to the use of grey MTA.
bacteria, as well as a biological material capable of inducing angiogenesis and allow a more predictable scaffold and tissue regeneration.
References
Banchs F, Trope M (2004) Revascularization of immature permanent teeth with apical periodontitis: new treatment protocol? Journal of Endodontics 30, 196200. Cvek M, Cleaton-Jones P, Austin J, Lownie J, Kling M, Fatti P (1990a) Pulp revascularization in reimplanted immature monkey incisorspredictability and the effect of antibiotic systemic prophylaxis. Endodontics and Dental Traumatology 6, 15769. Cvek M, Cleaton-Jones P, Austin J, Lownie J, Kling M, Fatti P (1990b) Effect of topical application of doxycycline on pulp revascularization and periodontal healing in reimplanted monkey incisors. Endodontics and Dental Traumatology 6, 1706. Eickholz P, Kim TS, Burklin T et al. (2002) Non-surgical periodontal therapy with adjunctive topical doxycycline: a double-blind randomized controlled multicenter study. Journal of Clinical Periodontology 29, 10817. Fulling HJ, Andreasen JO (1976) Inuence of maturation status and tooth type of permanent teeth upon electrometric and thermal pulp testing. Scandinavian Journal of Dental Research 84, 28690.
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Fuss Z, Trowbridge H, Bender IB, Rickoff B, Sorin S (1986) Assessment of reliability of electrical and thermal pulp testing agents. Journal of Endodontics 12, 3015. Greenstein G, Polson A (1998) The role of local drug delivery in the management of periodontal diseases: a comprehensive review. Journal of Periodontology 69, 50720. Hausermann P, Scherer K, Weber M, Bircher AJ (2005) Ciprooxacin-induced acute generalized exanthematous pustulosis mimicking bullous drug eruption conrmed by a positive patch test. Dermatology 211, 27780. Hoshino E, Kurihara-Ando N, Sato I et al. (1996) In-vitro antibacterial susceptibility of bacteria taken from infected root dentine to a mixture of ciprooxacin, metronidazole and minocycline. International Endodontic Journal 29, 12530. Isik SR, Karakaya G, Erkin G, Kalyoncu AF (2007) Multidrug-induced erythema multiforme. Journal of Investigational Allergology & Clinical Immunology 17, 1968. Iwaya SI, Ikawa M, Kubota M (2001) Revascularization of an immature permanent tooth with apical periodontitis and sinus tract. Dental Traumatology 17, 1857. Jappe U, Schnuch A, Uter W (2005) Rosacea and contact allergy to cosmetics and topical medicaments retrospective analysis of multicentre surveillance data 19952002. Contact Dermatitis 52, 96101. Kim ST, Abbott PV, McGinley P (2000) The effects of Ledermix paste in discolouration of immature teeth. International Endodontic Journal 33, 2337. Kling M, Cvek M, Mejare I (1986) Rate and predictability of pulp revascularization in therapeutically reimplanted permanent incisors. Endodontics and Dental Traumatology 2, 839. Madsen JT, Thormann J, Kerre S, Andersen KE, Goossens A (2007) Allergic contact dermatitis to topical metronidazole 3 cases. Contact Dermatitis 56, 3646. Myers WC, Fountain SB (1974) Dental pulp regeneration aided by blood and blood substitutes after experimentally induced periapical infection. Oral Surgery Oral Medicine Oral Pathology 37, 44150. Nygaard-Ostby B, Hjortdal O (1971) Tissue formation in the root canal following pulp removal. Scandinavia Journal of Dental Research 79, 33349. de Paz S, Perez A, Gomez M, Trampal A, Dominguez Lazaro A (1999) Severe hypersensitivity reaction to minocycline. Journal of Investigational Allergology Clinical Immunology 9, 4034. Ritter AL, Ritter AV, Murrah V, Sigurdsson A, Trope M (2004) Pulp revascularization of replanted immature dog teeth after treatment with minocycline and doxycycline assessed by laser Doppler owmetry, radiography, and histology. Dental Traumatology 20, 7584. Sato T, Hoshino E, Uematsu H, Noda T (1993) In vitro antimicrobial susceptibility to combinations of drugs on bacteria from carious and endodontic lesions of human deciduous teeth. Oral Microbiology & Immunology 8, 1726. Sato I, Ando-Kurihara N, Kota K, Iwaku M, Hoshino E (1996) Sterilization of infected root-canal dentine by topical application of a mixture of ciprooxacin, metronidazole and minocycline in situ. International Endodontic Journal 29, 11824. Skoglund A, Tronstad L, Wallenius K (1978) A microangiographic study of vascular changes in replanted and autotransplanted teeth of young dogs. Oral Surgery Oral Medicine Oral Pathology 45, 1728. Slots J (2002) Selection of antimicrobial agents in periodontal therapy. Journal of Periodontal Research 37, 38998. Thibodeau B, Teixeira F, Yamauchi M, Caplan DJ, Trope M (2007) Pulp revascularization of immature dog teeth with apical periodontitis. Journal of Endodontics 33, 6809. Windley W, Teixeira F, Levin L, Sigurdsson A, Trope M (2005) Disinfection of immature teeth with a triple antibiotic paste. Journal of Endodontics 31, 43943. Yanpiset K, Trope M (2000) Pulp revascularization of replanted immature dog teeth after different treatment methods. Endodontics and Dental Traumatology 16, 2117.
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doi:10.1111/j.1365-2591.2008.01460.

Effectiveness of ozone against endodontopathogenic microorganisms in a root canal biolm model

2008 International Endodontic Journal

International Endodontic Journal 42, 313, 2009

Ozone and endodontic biolms Huth et al.

Materials and methods Microorganisms

International Endodontic Journal, 42, 313, 2009

2008 International Endodontic Journal

Huth et al. Ozone and endodontic biolms

Testing ozone against microorganisms in biolms grown in human root canals

Testing ozone against microorganisms in suspension

2008 International Endodontic Journal

International Endodontic Journal, 42, 313, 2009

Ozone and endodontic biolms Huth et al.

International Endodontic Journal, 42, 313, 2009

2008 International Endodontic Journal

Huth et al. Ozone and endodontic biolms

Effect of ozone on microorganisms in biolms

Results Effect of ozone on microorganisms in suspension

Establishment of the anatomical biolm model

2008 International Endodontic Journal

International Endodontic Journal, 42, 313, 2009

Ozone and endodontic biolms Huth et al.

International Endodontic Journal, 42, 313, 2009

2008 International Endodontic Journal

Huth et al. Ozone and endodontic biolms

2008 International Endodontic Journal

International Endodontic Journal, 42, 313, 2009

Ozone and endodontic biolms Huth et al.

International Endodontic Journal, 42, 313, 2009

2008 International Endodontic Journal

Huth et al. Ozone and endodontic biolms

2008 International Endodontic Journal

International Endodontic Journal, 42, 313, 2009

Ozone and endodontic biolms Huth et al.

International Endodontic Journal, 42, 313, 2009

2008 International Endodontic Journal

Huth et al. Ozone and endodontic biolms

2008 International Endodontic Journal

International Endodontic Journal, 42, 313, 2009

T. O. Kim1, G. S. P. Cheung2, J. M. Lee3, B. M. Kim3, B. Hur1 & H. C. Kim1

International Endodontic Journal, 42, 1421, 2009

2009 International Endodontic Journal

Kim et al. Stress distribution of NiTi rotary les

2009 International Endodontic Journal

International Endodontic Journal, 42, 1421, 2009

Stress distribution of NiTi rotary les Kim et al.

Materials and methods Modeling of NiTi rotary le

International Endodontic Journal, 42, 1421, 2009

2009 International Endodontic Journal

Kim et al. Stress distribution of NiTi rotary les

Experimental conditions of simulation

Results Cantilever bending

2009 International Endodontic Journal

International Endodontic Journal, 42, 1421, 2009

Stress distribution of NiTi rotary les Kim et al.

Shear moment (torsion)

International Endodontic Journal, 42, 1421, 2009

2009 International Endodontic Journal

Kim et al. Stress distribution of NiTi rotary les

2009 International Endodontic Journal

International Endodontic Journal, 42, 1421, 2009