doi:10.1111/iej.

12133

Formation and removal of apical vapor lock during

syringe irrigation: a combined experimental and
Computational Fluid Dynamics approach

C. Boutsioukis1,2, E. Kastrinakis3, T. Lambrianidis4, B. Verhaagen1,5, M. Versluis1,2,5 &

L. W. M. van der Sluis6
1
Physics of Fluids Group, Faculty of Science and Technology, University of Twente, Enschede; 2MESA+ Institute for
Nanotechnology, University of Twente, Enschede, The Netherlands; 3Chemical Engineering Department, School of Engineering,
Aristotle University of Thessaloniki, Thessaloniki; 4Department of Endodontology, Dental School, Aristotle University of
Thessaloniki, Thessaloniki, Greece; 5MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente,
Enschede; and 6Center of Dentistry and Oral Hygiene, University Medical Center Groningen, University of Groningen, the
Netherlands

Abstract Results were analysed by nonparametric tests at 0.05

Boutsioukis C, Kastrinakis E, Lambrianidis T,
Verhaagen B, Versluis M, van der Sluis LWM.
Formation and removal of apical vapor lock during syringe
irrigation: a combined experimental and Computational Fluid
Dynamics approach. International Endodontic Journal, 47,
191–201, 2014.
Aim (i) To evaluate the effect of needle type and
insertion depth, root canal size and irrigant flow rate
on the entrapment of air bubbles in the apical part of
a root canal (apical vapor lock) during syringe irriga-
tion using experiments and a Computational Fluid
Dynamics (CFD) model, (ii) to investigate whether the
irrigant contact angle affects bubble entrapment,
(iii) to examine if an established vapor lock can be
removed by syringe irrigation.
Methodology Bubble entrapment during irrigation
of straight artificial root canals of size 35 or 50 was
evaluated by real-time visualizations. The irrigant was
delivered by a closed-ended or an open-ended needle
positioned at 1 or 3 mm short of working length
(WL) and at a flow rate of 0.033–0.260 mL s 1.
significance. Selected cases were also simulated by a
two-phase CFD model.
Results A vapor lock was observed in 48% of the
cases investigated experimentally. Increasing the
apical size, using an open-ended needle, positioning
the needle closer to WL and delivering the irrigant at
higher flow rate resulted in significantly smaller vapor
lock. An increased contact angle resulted in the
entrapment of a larger bubble when a low flow rate
was used. Both brief insertion of the needle to WL
whilst irrigating at a flow rate of 0.083 mL s 1 and
delivering the irrigant at 0.260 mL s 1 without
changing the needle position were capable of remov-
ing an established vapor lock.
Conclusions Apical vapor lock may occur under
certain conditions, but appears to be easily prevented
or removed by syringe irrigation.
Keywords: Apical vapor lock, bubble, Computa-
tional Fluid Dynamics, needle, root canal irrigation,
syringe.
Received 10 February 2013; accepted 19 April 2013

Correspondence: Christos Boutsioukis, Physics of Fluids
Group, Faculty of Science and Technology, University of
Twente, PO Box 217, 7500 AE, Enschede, The Netherlands
(e-mail: chb@dent.auth.gr).
Introduction
Irrigation of root canals with antibacterial solutions is
considered an integral part of chemo-mechanical prep-
aration (Haapasalo et al. 2010). Irrigant penetration

© 2013 International Endodontic Journal. Published by John Wiley & Sons Ltd International Endodontic Journal, 47, 191–201, 2014 191
 Vapor lock formation-removal Boutsioukis et al.
to the full extent of the root canal system is
indispensible for mechanical and chemical action of
irrigation solutions on microbes, pulp tissue remnants
and dentine debris (Druttman & Stock 1989, Seal
et al. 2002), regardless of the delivery method and
type of irrigant.
Recently, concern has been expressed about the
possible presence of gas bubbles in the apical part of
the root canal that could block irrigant penetration
(de Gregorio et al. 2009, Parente et al. 2010, Susin
et al. 2010, Tay et al. 2010, Vera et al. 2012, Peeters
& Gutknecht 2013). This phenomenon, also termed
‘apical vapor lock’, has been partially demonstrated in
ex vivo experiments employing a sealed apical
foramen (de Gregorio et al. 2009, Tay et al. 2010)
and also clinically (Vera et al. 2012). Vapor lock has
been attributed to entrapment of air bubbles by the
advancing irrigant interface front during irrigant
delivery in a dry root canal (Gu et al. 2009, Peeters &
Gutknecht 2013) or to coalescence of gas bubbles
produced in situ during reaction between NaOCl and
organic material (Schoeffel 2008, Gu et al. 2009,
Vera et al. 2012). Although the latter has never been
proven, air entrapment during liquid-filling of micro-
channels is a widely known phenomenon (Berthier &
Silberzan 2010). Nevertheless, there seems to be
limited quantitative data on the size of these bubbles,
the extent of the root canal being blocked from irri-
gant penetration and the factors that may have an
influence on this procedure, as none of the previously
published studies aimed specifically to investigate
these aspects.
In addition, the removal of an established apical
vapor lock from the root canal may be challenging. It
has been argued that these bubbles cannot be
removed by conventional syringe irrigation (de Grego-
rio et al. 2009, Gu et al. 2009, Tay et al. 2010) and
that negative-pressure systems or activation tech-
niques are necessary to overcome this limitation
(Schoeffel 2008, Gu et al. 2009). However, this
assumption has not been fully investigated.
The aims of the present study were: (i) to evaluate
systematically the effect of needle type and insertion
depth, root canal size and irrigant flow rate on the
entrapment of air bubbles in the apical part of a
prepared root canal during syringe irrigation by in vitro
experiments and a Computational Fluid Dynamics
(CFD) model, (ii) to investigate the confounding effect of
irrigant contact angle on the root canal wall, to assess
the potential bias introduced by the use of artificial
root canals in experiments, (iii) to examine whether
192 International Endodontic Journal, 47, 191–201, 2014
established apical vapor lock can be removed by syr-
inge irrigation.
Materials and methods
Experimental setup
Twenty transparent resin blocks (Root canal models,
J. Morita Corp, Kyoto, Japan) were used to create
standardized straight artificial root canals of a uni-
form length of 18 mm. None of the canals penetrated
the full length of the resin block, therefore a ‘closed
system’ (Tay et al. 2010) was simulated at the apical
end in all cases. The root canals were randomly
divided (www.randomizer.org) into two groups
(n = 10) and were prepared with a crown-down tech-
nique using rotary Ni–Ti instruments (Race, FKG
Dentaire, La Chaux-de-Fonds, Switzerland) to either
size 35, 0.04 taper (group A) or size 50, 0.04 taper
(group B). Irrigation with 2 mL of distiled water was
performed between successive instruments using a
5-mL syringe (Ultradent Products Inc, South Jordan,
UT, USA) with a 30G open-ended needle (NaviTip,
Ultradent) placed at 3 mm short of working length
(WL). At the end of instrumentation each root canal
was irrigated with 10 mL of distiled water.
A stereoscopic microscope (Stemi 2000-C, Carl
Zeiss, G€ottingen, Germany) with an attached CCD
camera (Powershot A640, Canon Inc, Tokyo, Japan)
was used to record the flow and track the air-irrigant
interface during the experiments. The highest magni-
fication that permitted the view of the apical 2 or
4 mm of the root canal was used, depending on nee-
dle insertion depth. A combination of front- and back-
illumination built-in capabilities of the microscope
was employed to enhance visualization.
Two types of 30G irrigation needles, an open-ended
(NaviTip, Ultradent) and a closed-ended (KerrHawe
Irrigation Probe, KerrHawe SA), were used. Each nee-
dle was attached to a T-connector, which was
mounted on a custom-made translation stage to allow
accurate and stable positioning. The closed-ended nee-
dle was positioned in such a way that the outlet was
oriented towards the microscope objective. The artifi-
cial root canals were also mounted on the translation
stage so that the apical side faced upwards, to simulate
a maxillary position. The needle was positioned as
close as possible to the longitudinal axis of the root
canal and at either 1 or 3 mm short of WL. A rubber
stop was also applied to indicate the insertion depth.
The T-connector was further connected through a tef-
© 2013 International Endodontic Journal. Published by John Wiley & Sons Ltd

lon tube to a 5-mL disposable syringe with a Luer-Lock
fitting (Plastipak, Becton Dickinson, Oxford, UK). A
custom-made electronic syringe pump was used to deli-
ver 2 mL of the irrigant at precise and clinically realis-
tic (Boutsioukis et al. 2007) flow rates of 0.033,
0.083, 0.166 and 0.260 mL s 1 during each experi-
ment, to maintain irrigation consistency. NaOCl 1%
was used as irrigant.
The artificial canals were dried by paper-points
before each experiment. In addition, the needle was
flushed with distiled water, and then the syringe, tub-
ing and needle were refilled with NaOCl, with special
care to avoid insertion of bubbles. The camera was
triggered 1 s before the syringe pump to record irri-
gant delivery into the root canal during the filling
phase and the possible entrapment and movement of
air bubbles. A series of 16 combinations of the three
within-group parameters (needle type, needle inser-
tion depth and irrigant flow rate) were tested on each
artificial canal of the two groups (A and B). All exper-
iments were repeated in triplicate, and the average
result was calculated. A new needle was used every
16 experiments.
In cases that an apical vapor lock was detected,
further tests were conducted to evaluate removal
strategies. The average length of the bubble was cal-
culated (see next paragraph), and bubbles of identical
length and position were repeatedly created in the
same root canal by carefully modifying the needle
insertion depth and the irrigant flow rate. Subse-
quently, the initial position of the needle was reset to
either 1 or 3 mm short of WL, same as during the
original experiment. Two removal strategies were
evaluated, also in triplicate:
1. Single advance of the needle to WL and return to
the initial position (either 1 or 3 mm short of
WL) at an approximate speed of 1 mm s 1 whilst
irrigating at a flow rate of 0.083 mL s 1.
2. Delivery of additional 2 mL of NaOCl at a flow
rate of 0.260 mL s 1 without changing the initial
needle position.
Real-time videos of all the procedures were recorded
at a speed of 30 frames/s and resolution of
640 9 480 pixels. Videos were subsequently analysed
by ImageJ 1.44 (National Institute of Health,
Bethesda, MD, USA) to determine the presence and
length of a bubble completely occupying a part of the
root canal adjacent to the apical terminus of the prep-
aration and blocking irrigant flow, at the end of each
experiment. The bubble length was recorded as
the distance between the WL and the air-irrigant
© 2013 International Endodontic Journal. Published by John Wiley & Sons Ltd
Boutsioukis et al. Vapor lock formation-removal
interface at the coronal side of the bubble. In case of
an oblique interface, the average of the maximum
and minimum length was used. The distance between
the needle tip and WL was used for calibration. All
dimensions were determined within 0.1 mm accu-
racy. The efficacy of the two removal strategies was
evaluated as a binary variable and was rated as
successful if no vapor lock remained after all three
repetitions of each removal strategy. All other results
were rated as unsuccessful (vapor lock remaining).
Statistical analysis
Due to the skewed distribution of the data and the
null variance in some cases, nonparametric tests were
employed. Regarding the entrapment of bubbles, the
effect of within-group parameters (needle type, needle
insertion depth and irrigant flow rate) was analysed
by the Friedman’s test and Wilcoxon Signed Rank
test. The effect of the between-group parameter (root
canal size) was analysed by Mann–Whitney U-test.
The null hypothesis was that needle type, needle
insertion depth, root canal size and irrigant flow rate
have no significant effect on the length of the
entrapped bubble. The McNemar’s test was used to
detect significant differences between the two removal
strategies. The null hypothesis was that there is no
significant difference between the two strategies. The
level of significance was set at P < 0.05. Bonferroni
correction for multiple comparisons was applied
where appropriate. Statistical analysis was performed
using SPSS 15.0 for Windows (SPSS Inc, Chicago, IL,
USA).
CFD simulations
A CFD model was used for further investigation of
selected cases (Table 1). Straight root canals of
18 mm were simulated as geometrical frustums of a
cone, similarly to a previous study (Boutsioukis et al.
2009). A ‘closed system’ (Tay et al. 2010) was
ensured by simulating the apical foramen as a rigid
and impermeable wall. The diameter of the root canal
at the apical end was either 0.35 or 0.50 mm (ISO
size 35 or 50), and the taper was 4%. The apical side
of the root canal faced upwards to simulate a maxil-
lary position. The root canal shapes and orientation
were consistent with the experiments. Two different
needle types, an open-ended and a closed-ended, were
modelled using commercially available 30G needles as
references (Navitip, Ultradent, South Jordan, UT, USA;
International Endodontic Journal, 47, 191–201, 2014 193
 Vapor lock formation-removal Boutsioukis et al.
Table 1 Summary of the cases studied using the CFD model.
The 1-mm position in the size 35 root canal was not studied
due to the very limited space available around the needle tip,
which hindered simulation. The root canal taper was 4% in
all cases. Needle insertion depth is reported as distance from
WL
Root Insertion Flow
canal depth rate
Case Needle type size (mm) (mL s 1)
1 Closed-ended 35 3 0.083
2 0.260
3 50 1 0.083
4 0.260
5 3 0.083
6 80
7 0.260
8 80
9 Open-ended 35 3 0.083
10 0.260
11 50 1 0.083
12 0.260
13 3 0.083
14 0.260
h, irrigant contact angle on root canal wall.
KerrHawe Irrigation Probe, KerrHawe SA, Bioggio)
(Boutsioukis et al. 2010b). Both needles were fixed
and centred within the canal, at either 1 or 3 mm
short of WL, based on previous reports of irrigant
penetration achieved by these needles (Boutsioukis
et al. 2010b,c).
The 3D geometry and the mesh were created by
the preprocessor software GAMBIT 2.4 (ANSYS Inc.,
Canonsburg, PA, USA). A structured hexahedral
mesh consisting of approximately 450 000–600 000
cells was used for each case. Grid independency was
verified by evaluating the results in successively finer
meshes until the vapor lock length did not change
significantly.
No-slip boundary conditions were imposed on the
walls of the root canal and of the needle, under the
hypothesis of rigid, smooth and impermeable walls. A
constant irrigant velocity of 2.75 or 8.60 m s 1 was
defined at the inlet of the needle, corresponding to flow
rates of 0.083 or 0.260 mL s 1, as used in the experi-
ments. Atmospheric pressure was imposed at the root
canal orifice. A two-phase flow was assumed inside the
root canal, involving ambient air [density
q = 1.135 kg m 3, viscosity l = 1.92
10 5 Pa s (Lide
2005)] and the irrigant, NaOCl 1% aqueous solution
[density q = 1040 kg m 3, viscosity l = 0.99

10 3 Pa s, surface tension c = 75
10 3 N m 1 (Gueri-
194 International Endodontic Journal, 47, 191–201, 2014
soli et al. 1998)]. Both the air and the irrigant were
modelled as incompressible Newtonian fluids and were
considered immiscible. In the main set of simulations,
the contact angle of the irrigant on the root canal wall
was set to h = 22ο (Hu et al. 2010), simulating a
hydrophilic surface, whilst a contact angle of h = 80ο
was imposed between the irrigant and the outer wall of
the needle (Meylheuc et al. 2006, Raulio et al. 2008),
ho
which is made of stainless steel.
22 To evaluate the effect of using artificial root canals
instead of teeth on bubble entrapment, two additional
cases were studied (Table 1 – cases 6, 8), based on
22 the CFD results from the main set of simulations. In
these cases, a higher contact angle was defined
22 between the irrigant and the root canal wall (h = 80o
instead of 22ο), which was more realistic for the
22
acrylic resin surface of the artificial root canal (Ihrig
& Lai 1957, Good & Koo 1979, Rubio et al. 1991).
The commercial CFD code FLUENT 6.3 (ANSYS Inc.,
Canonsburg, PA, USA) was used to set up and solve
the problem and to analyse the results. The uncoupled
Navier–Stokes equations that describe the time-depen-
dent, three-dimensional, incompressible flow were
solved by an implicit iterative solver. The numerical
solution method used a finite volume approach. An
unsteady isothermal flow was assumed. The Volume
of Fluid (VOF) method (Hirt & Nichols 1981) was used
to simulate the two-phase flow and to track the move-
ment of the air-irrigant interface. No turbulence model
was used, as the flow under these conditions was
expected to be laminar (Boutsioukis et al. 2009,
2010a, Verhaagen et al. 2012). All transport
equations were discretized to be at least second-order
accurate. The convergence criterion was set at 10 4
of the maximum scaled residuals. A time step of 10 7
s was used throughout the calculations.
Fourteen cases were simulated in total (Table 1). At
the beginning of each simulation, the root canal was
assumed to be filled with ambient air and the needle to
be filled with the irrigant. The initial velocity was set to
zero for both fluids. The simulation was continued
until no further change in the length of the vapor lock
was noted for at least 5
104 time steps. Computations
were performed in a computer cluster (45 dual-core
AMD Opteron 270 processors) running 64-bit Suse Li-
nux 10.1 (kernel version 2.6.16). Subsequently, the
position of the air-irrigant interface at the end of each
simulation was plotted and the length of the apical
vapor lock was compared to the experimental findings.
The same definition of the term ‘apical vapor lock’ was
used as in the experiments.
© 2013 International Endodontic Journal. Published by John Wiley & Sons Ltd

Results
Vapor lock formation – experiments
An overview of the experimental results is depicted in
Fig. 1. Overall, apical vapor lock was detected in 100
of 160 experiments using the closed-ended needle and
54 of 160 experiments with the open-ended needle.
The length of the vapor lock was either 0–1 or
0–3 mm when the needle was positioned at 1 or
3 mm short of WL, respectively. Effect sizes are
reported as absolute values of Pearson’s correlation
coefficient r.
For the closed-ended needle, a flow rate of
0.033 mL s 1 resulted in complete occupation of the
space apically to the needle tip by a vapor lock regard-
less of root canal size or needle insertion depth. At this
flow rate, the insertion depth (1 or 3 mm short of WL)
had a significant effect on the length of the vapor lock
(P = 0.002, r = 0.71). At a flow rate of 0.083 and
0.166 mL s 1, a significant effect was noted for both
the insertion depth (P = 0.002, r = 0.63) and the root
canal size [P < 0.001, r = 0.90 (0.083 mL s 1 -
1 mm); P < 0.001, r = 0.85 (0.083 mL s 1 - 3 mm);
P = 0.003, r = 0.69 (0.166 mL s 1 - 1 mm);
P < 0.001, r = 0.77 (0.166 mL s 1 - 3 mm)]. Placing
the needle closer to WL and increasing the size of the
root canal resulted in smaller vapor lock. Neither size
nor depth had a significant effect at a flow rate of
0.260 mL s 1 (P > 0.05). No vapor lock was detected
in most cases at this flow rate, apart from the 3-mm
Figure 1 Average apical vapor lock length formed during irrigation with a closed-ended or an open-ended needle according to
experiments and computer simulations. Error-bars indicate standard deviation. The position of the needle is depicted by the dot-
ted horizontal line in each case.
© 2013 International Endodontic Journal. Published by John Wiley & Sons Ltd
Boutsioukis et al. Vapor lock formation-removal
position in a size 35 canal, where the detected bubble
length was 0.1  0.1 mm.
For the open-ended needle at 0.033 mL s 1, a sta-
tistically significant effect was identified for both the
insertion depth (P = 0.002, r = 0.63) and the root
canal size [P < 0.001, r = 0.90 (1 mm), r = 0.85
(3 mm)]. The extent of the vapor lock increased with
increasing distance between the needle tip and the WL
or decreasing root canal size. At flow rates of 0.083 or
0.166 mL s 1, the 3-mm position in a size 35 root
canal led to significantly larger vapor lock than either
the 1-mm position in a size 35 canal (P = 0.002,
r = 0.63) or the 3-mm position in a size 50 root canal
(P < 0.001, r = 0.90), indicating a significant effect of
both root canal size and needle insertion depth. No
vapor lock was detected when a 0.260 mL s 1 flow
rate was used and neither size nor insertion depth
showed a significant effect (P > 0.05).
The open-ended needle was more effective than the
closed-ended needle in preventing vapor lock at a flow
rate of 0.033 mL s 1 regardless of canal size or inser-
tion depth (P = 0.002, r = 0.63). A similar advantage
of the open-ended needle was also identified at flow
rates of 0.083 and 0.166 mL s 1 (P < 0.003,
r = 0.63), apart from the 1-mm position in a size 50
root canal (P = 1.000). No significant difference was
detected between the two needle types at a flow rate
of 0.260 mL s 1 (P > 0.247).
Regarding the effect of flow rate, the difference
between 0.033 and 0.083 mL s 1 was statistically
significant in most cases [Closed-ended needle:
International Endodontic Journal, 47, 191–201, 2014 195
 Vapor lock formation-removal Boutsioukis et al.

P = 0.001, r = 0.63 (size 35 – 1 mm), P = 0.004,
r = 0.60 (size 35 – 3 mm), P = 0.002, r = 0.71 (size
50 – 1 mm), P = 0.001, r = 0.63 (size 50 – 3 mm);
Open-ended needle: P = 0.002, r = 0.63 (size 35),
P = 0.001, r = 0.63 (size 50 – 3 mm)], except when
the open-ended needle was positioned at 1 mm in a
size 50 canal (P = 1.000). No significant difference
was detected between 0.083 and 0.166 mL s 1
(P > 0.05). However, there was a statistically signifi-
cant difference between 0.166 and 0.260 mL s 1 for
the closed-ended needle at 3 mm in both root canal
sizes (P = 0.002, r = 0.63) and the open-ended nee-
dle at 3 mm in the size 35 canal (P = 0.002,
r = 0.63). In general, an increase in the flow rate led
to a decrease in the length of the vapor lock.
Vapor lock formation – CFD simulations
Computer simulations confirmed the trends identified
during the experiments on vapor lock formation
(Fig. 2, Movies S1, S2). In general, a good agreement
in terms of apical vapor lock length was evident
between the experiments and CFD simulations, apart
from cases 5 and 9 (Table 1), where a difference of
approximately 1 mm in the bubble length was noted.
Case 5 was further investigated to clarify the possible
effect of contact angle at low flow rate
(0.083 mL s 1). It appeared that the discrepancy
could be attributed to the higher contact angle of the
irrigant on the artificial root canal wall, which
resulted in larger vapor lock in this case (Fig. 2).
However, when a higher flow rate was used
(0.260 mL s 1) under the same conditions (Table 1 –
case 8), the increased contact angle did not result in
larger vapor lock compared to the low contact angle
case (Table 1 – case 7). No bubble entrapment was
identified in both of these cases.
Vapor lock removal – experiments
Removal attempts were made in 154 experiments fol-
lowing vapor lock formation. Brief insertion of the
needle to WL whilst irrigating at 0.083 mL s 1 (Movie
S3) resulted in complete removal of the bubble in all
154 cases, regardless of needle type. Additional deliv-
ery of 2 mL of irrigant at a flow rate of 0.260 mL s 1
without moving the needle (Movie S4) was successful
in 151 cases. The difference between the two methods
was not statistically significant (P = 0.250).
Discussion
The problem of air entrapment during passive filling
of closed-ended cavities after immersion into a large

Figure 2 Comparison between CFD simulations and experiments for the closed-ended needle positioned at 1 or 3 mm short of
WL in a size 50, 0.04 taper root canal. The cases are numbered according to Table 1. The air-irrigant interface is depicted as
a blue surface in the CFD simulations. Large bubbles occupying completely a part of the apical root canal were found in some
cases and were considered a vapor lock (stars). Smaller bubbles floating in the irrigant or moving with the irrigant towards
the coronal orifice (arrows) were not considered as vapor lock because they could not block irrigant penetration to any part of
the root canal. A good agreement between simulations and experiments is evident for cases 3, 4 and 7. A discrepancy was
noted for case 5. A simulation assuming a higher wall contact angle (case 6) showed improved agreement with the
experiments.

196 International Endodontic Journal, 47, 191–201, 2014 © 2013 International Endodontic Journal. Published by John Wiley & Sons Ltd

liquid container has been widely studied within the
field of fluid dynamics (Bankoff 1958, Zukoski 1966,
Szekely et al. 1971, Deutsch 1979, Dovgyallo et al.
1989, Migun & Azuni 1996, Migun & Shnip 2002,
Pesse et al. 2005, Fazio & Iacono 2009). However,
this procedure is markedly different from root canal
irrigation. Root canals are typically filled from the
inside by active delivery of irrigants through a needle
positioned near the closed apical end. In addition, the
dimensions of the investigated cavities in several stud-
ies were considerably smaller (1–10 lm) (Dovgyallo
et al. 1989, Migun & Azuni 1996, Migun & Shnip
2002, Pesse et al. 2005) or larger (5–178 mm)
(Zukoski 1966) than the usual diameter of a prepared
root canal. The dimensions of the cavity affect the
contribution of surface tension forces (which resist
bubble removal) and viscous and inertia forces (which
assist bubble removal) acting on the air-irrigant inter-
face (Berthier & Silberzan 2010). Thus, it is important
that air entrapment is studied during typical irriga-
tion in root canals of realistic dimensions.
There seems to be no unanimous definition for the
term ‘apical vapor lock’. A recent clinical study (Vera
et al. 2012) evaluated the presence of large bubbles
entirely occupying a part of the root canal in the
coronal or middle third. Apparently, these bubbles
could not block irrigant penetration, because irrigant
was detected apically in all cases, therefore, their sig-
nificance may be questioned. In the present study,
only bubbles occupying completely a portion of the
apical root canal were evaluated (Fig. 2 – stars), as
they could effectively block irrigant penetration. No
bubbles with such properties could be detected coro-
nally to the tip of the needle in any of the experi-
ments. It may be hypothesized that the irrigant flow
created by both needle types (Boutsioukis et al.
2010b, Verhaagen et al. 2012) was capable of remov-
ing large air bubbles from these areas. In addition,
small bubbles completely surrounded by irrigant or in
contact with the root canal wall on one side (Fig. 2 –
arrows) were ignored because they were mobile and
could not block irrigant penetration to any part of the
root canal. Such bubbles might even provide an
advantage in case of ultrasonic activation, by enhanc-
ing local cleaning due to stable cavitation (Brennen
1995).
The range of flow rates tested in the present study
was based on the findings of a previous study that
investigated the flow rate applied by different
endodontists when asked to perform syringe irrigation
ex vivo (Boutsioukis et al. 2007). Flow rates ranging
© 2013 International Endodontic Journal. Published by John Wiley & Sons Ltd
Boutsioukis et al. Vapor lock formation-removal
from minimum up to mean values were included in
this study (0.033–0.260 mL s 1). Higher flow rates
up to 0.800 mL s 1 were also reported, but they
were considered extreme values and were not tested
in the present study. During syringe irrigation with a
30G needle, a flow rate up to 0.260 mL s 1 can be
achieved clinically, provided that 5-mL syringes or
smaller are used.
Introduction of bias appears to be inevitable when
studying the entrapment of air bubbles in root
canals. Direct observation in vivo or ex vivo during
irrigation with clinically used solutions is currently
not feasible; thus, modifications need to be made to
the system under investigation. Several studies have
employed radiopaque contrast agents or their mix-
ture with commonly used irrigants, to allow detec-
tion of vapor lock by periapical radiographs or
micro-CT (de Gregorio et al. 2009, Tay et al. 2010,
Vera et al. 2012, Peeters & Gutknecht 2013). This
artificial change in the irrigant composition probably
led to intrusive changes of its physical properties,
such as density, viscosity, surface tension and the
contact angle on the dentine wall, which may have
favoured the formation of vapor lock. In addition,
evaluation could not be conducted in real time, and
in the case of micro-CT, the scanning time was con-
siderably longer than a few seconds. Therefore, it is
possible that the size and position of an entrapped
bubble may have changed due to buoyancy or vibra-
tion of the specimens. Changes in temperature could
also have affected the results, due to expansion or
contraction of the air within the bubble or due to
changes in the surface tension of the irrigant (Tilton
1999, Berthier & Silberzan 2010). Frequent and
extensive bubble entrapment was reported by these
studies.
In another ex vivo approach, the tooth-clearing
technique was used to render roots transparent and
allow direct observation of a mixture of irrigant and a
dye (de Gregorio et al. 2009). In addition to artificial
changes in the irrigant physical properties, the proce-
dure of tooth clearing (Robertson et al. 1980, Venturi
et al. 2003) also introduced artificial changes on the
dentine surface because of decalcification in strong
acids, drying and replacement of the inorganic
components by a hydrophobic organic oil (methyl
salicylate). The resulting dentine surface was probably
less hydrophilic (higher irrigant contact angle) than
intact dentine (Marshall et al. 1997, Rosales et al.
1999, Huang et al. 2012), so it is also very likely that
bubble entrapment was favoured. This study also
International Endodontic Journal, 47, 191–201, 2014 197
 Vapor lock formation-removal Boutsioukis et al.
reported the entrapment of large bubbles in the apical
part of the root canal.
In the present study, real-time observations were
conducted in transparent resin blocks. Substitution of
dentine by acrylic resin also resulted in altered sur-
face properties and primarily a more hydrophobic
behaviour, leading to an increase in irrigant contact
angle by 30o–60o (Ihrig & Lai 1957, Good & Koo
1979, Rubio et al. 1991, Hu et al. 2010). Thus, the
experiments may have overestimated the formation of
vapor lock, as shown by the CFD simulations compar-
ing two contact angles (Fig. 2 – cases 5 and 6). The
main set of CFD simulations were conducted assum-
ing a realistic contact angle between the irrigant and
dentine wall (Hu et al. 2010), so their results may
involve less bias than the corresponding experiments.
However, due to excessive requirements in computa-
tional resources, only selected cases were simulated to
allow for a sufficient understanding of this problem.
Contrary to previous reports, vapor lock was identified
in less than half of the experiments conducted during
the present study and was frequently related to very
low irrigant flow rate (0.033 mL s 1), near the low-
est end in the range employed by clinicians (Boutsiou-
kis et al. 2007). Apart from increasing the flow rate,
further enlargement of the root canal, use of an open-
ended needle and insertion of the needle closer to WL
also appeared to limit or prevent bubble entrapment
in the apical part of the root canal in many cases. In
addition, entrapped bubbles could be easily removed
by either of the two methods investigated. These find-
ings revealed an effect opposite to the bias introduced
in the experiments; therefore, they are likely to reflect
a true effect.
A further source of bias in favour of vapor lock for-
mation could be the orientation of the root canals in
the present study. In all cases reported here, the api-
cal end of the root canal faced upwards, to simulate a
maxillary position, which is the most challenging for
the removal of an air bubble, due to buoyancy. How-
ever, this orientation may be encountered rarely dur-
ing clinical practice. The patient usually lies on the
dental chair at an almost horizontal position, and the
orientation of most teeth is likely to be nearly hori-
zontal; thus, removal of air bubbles in many clinical
cases is expected to be easier than reported in the
present study.
Vapor lock formation has been demonstrated
previously by micro-CT following the delivery of a
radiopaque solution in a size 50, .04 taper straight
root canal mounted at a mandibular position (Tay
198 International Endodontic Journal, 47, 191–201, 2014
et al. 2010). A 30G closed-ended needle was inserted
to 1 mm short of WL, and the flow rate was
0.083 mL s 1. In the present study, an almost identi-
cal case was studied by both experiments and com-
puter simulation, but sodium hypochlorite was used
as the irrigant and a maxillary position was selected.
During the experiments, dentine was substituted by a
more hydrophobic material (acrylic resin). However,
it was not possible to replicate the vapor lock forma-
tion (Fig. 2 – case 3). In addition to the limitations
discussed above, it may be speculated that hand con-
trol of the syringe in the previous study may have
introduced variation in the flow rate, which is difficult
to standardize manually (Boutsioukis et al. 2007).
Furthermore, it is unclear whether the glue used to
seal the apical foramen was prevented from entering
the apical part of the root canal, because suitable
positive controls were not used. No specific criteria
were described for determining the presence of a
vapor lock, either. Thus, bubbles other than the ones
defined in the present study may have been reported
as vapor lock.
The importance of flow rate for adequate irrigant
refreshment has been emphasized in previous studies
(Boutsioukis et al. 2007, 2009, Verhaagen et al.
2012). In the present study, higher flow rates were
correlated to decreased apical vapor lock. In addition,
irrigating at 0.260 mL s 1 was found to be an effi-
cient method for the removal of an established vapor
lock. Nevertheless, a higher flow rate has also been
linked to increased irrigant pressure at the apical
foramen (Verhaagen et al. 2012), which may be
interpreted as increased risk of irrigant extrusion. It is
commonly believed that a high flow rate will result in
irrigant extrusion and a low flow rate will prevent
such accidents, regardless of other anatomy-related or
technique-related factors. However, the terms ‘high’
and ‘low’ reveal a subjective evaluation, because
there is no widely accepted value for these terms. A
recent systematic review (Boutsioukis et al. 2012)
reported that extrusion accidents were associated with
both ‘low’ and ‘high’ flow rate. Furthermore, a lack
of ex vivo data about the effect of flow rate on the
amount of extruded irrigant was identified. This effect
was evaluated in a subsequent study (C. Boutsioukis,
Z. Psimma, E. Kastrinakis, submitted). An increase in
the flow rate from 0.140 to 0.260 mL s 1 resulted in
increased volume of extruded irrigant; however, the
effect of the flow rate was comparable to the effect of
needle type and insertion depth and considerably infe-
rior to the effect of periapical tissue conditions (Psim-
© 2013 International Endodontic Journal. Published by John Wiley & Sons Ltd

ma et al. 2012). Therefore, the flow rate should be
considered in combination with other technique-
related and anatomy-related factors when assessing
the risk of irrigant extrusion accidents.
In the present study, all combinations of needle
types, insertion depths and flow rates were tested to
evaluate systematically bubble entrapment. Both nee-
dles were also inserted to WL whilst examining their
ability to remove an established vapor lock. Based on
the results, it seems reasonable to avoid using open-
ended needles closer than 2–3 mm from WL, espe-
cially when irrigating at a high flow rate
(0.260 mL s 1); prevention or removal of the vapor
lock can be achieved from this position, so inserting
the needle closer to WL may increase irrigant extru-
sion (Psimma et al. 2013, C. Boutsioukis, Z. Psimma,
E. Kastrinakis, submitted) without additional benefit.
On the other hand, closed-ended needles could be
inserted to 1 mm short of WL to prevent the forma-
tion of a vapor lock, because they pose a reduced risk
of irrigant extrusion compared to open-ended ones
(Psimma et al. 2013, C. Boutsioukis, Z. Psimma, E.
Kastrinakis, submitted). These needles can also be
used to briefly reach WL whilst irrigating at a con-
trolled flow rate (0.083 mL s 1) to remove an estab-
lished vapor lock. Commercially available needles of
size 30G or 31G [external diameter 0.32 or 0.26 mm
(ISO 9626 2001)] may facilitate insertion even to WL
in many cases; pre-bending the needles may be neces-
sary prior to insertion in curved root canals. In addi-
tion, needles made of Ni–Ti may provide further
advantages in case of severely curved root canals.
Nevertheless, lateral space should always be ensured
to allow reverse flow of the irrigant towards the ori-
fice and reduce the risk of extrusion (Psimma et al.
2013).
The length of the vapor lock was limited to 0–1 or
0–3 mm, depending on the needle insertion depth,
because no vapor lock extended coronally to the nee-
dle tip. These limits may have created a floor/ceiling
effect (Russo 2003). It is possible that in certain
cases the vapor lock was either too easy or too diffi-
cult to remove by the flow, so no difference in the
removal efficiency could be identified regardless of
the conditions tested. An example of a floor effect
could be the high-flow-rate case simulated with a
low or high contact angle (Table 1 – cases 7,8,
Fig. 1).
In view of the findings from the present study, api-
cal vapor lock may be formed under certain condi-
tions during syringe irrigation, but its prevention or
© 2013 International Endodontic Journal. Published by John Wiley & Sons Ltd
Boutsioukis et al. Vapor lock formation-removal
removal seem straightforward by adhering to simple
guidelines during syringe irrigation. Thus, contrary to
previous reports (Schoeffel 2008, Gu et al. 2009),
there seems to be limited need for additional methods
like manual dynamic activation with a well-fitting
Gutta-percha point or negative-pressure systems to
achieve this purpose. Furthermore, it appears that the
poorer performance of irrigation methods in closed-
ended root canals as compared to open-ended ones
(de Gregorio et al. 2009, Gu et al. 2009, Parente et al.
2010, Susin et al. 2010, Tay et al. 2010) should not
be directly attributed to the presumed vapor lock
without demonstrating its presence. Rather, this
difference in performance could be explained by the
large differences in irrigant flow between these two
types of flow domains (White 1999, Boutsioukis et al.
2010a, Verhaagen et al. 2012).
Conclusions
Apical vapor lock may occur under certain conditions
during syringe irrigation. Increasing the apical size,
using an open-ended needle, positioning the needle
closer to WL and delivering the irrigant at higher flow
rate appeared to result in smaller vapor lock. An
increased contact angle may result in increased bubble
entrapment when combined with a low flow rate.
Both brief insertion of the needle to working length
whilst irrigating at a flow rate of 0.083 mL s 1 and
delivering irrigant at 0.260 mL s 1 without moving
the needle were capable of removing an established
apical vapor lock.
Acknowledgements
C.B. was supported by a Marie Curie Intra-European
Fellowship for Career Development. B.V. was funded
by the Dutch Technology Foundation (STW) through
grant 07498.
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Supporting Information
Additional Supporting Information may be found in
the online version of this article:
Movie S1. Irrigant delivery at 0.260 mL s 1
through a closed-ended needle positioned at 3 mm
short of WL in a size 50, 0.04 taper root canal,
according to CFD simulation. The air-irrigant inter-
face is depicted as a blue surface. No apical vapor lock
was formed, but several small bubbles moving within
the irrigant are evident.
Movie S2. Irrigant delivery at 0.260 mL s 1
through an open-ended needle positioned at 3 mm
short of WL in a size 50, 0.04 taper root canal,
according to CFD simulation. The air-irrigant inter-
face is depicted as a blue surface. No apical vapor lock
was formed, but several small bubbles moving within
the irrigant are evident.
Movie S3. Removal of an established apical vapor
lock by brief insertion of the closed-ended needle to
WL in a size 50, 0.04 taper root canal, whilst irrigat-
ing at 0.083 mL s 1.
Movie S4. Removal of an established apical vapor
lock using an open-ended needle at 3 mm short of
WL in a size 50, 0.04 taper root canal by additional
delivery of 2 mL of irrigant at a flow rate of
0.260 mL s 1.
International Endodontic Journal, 47, 191–201, 2014 201