Journal Pre-proof

Syringe irrigation in minimally-shaped root canals using three endodontic needles: a

Computational Fluid Dynamics study.

Christos Boutsioukis, DDS, MSc, PhD, Patricia Gutierrez Nova, DDS

PII: S0099-2399(21)00405-2
DOI: https://doi.org/10.1016/j.joen.2021.06.001
Reference: JOEN 4857

To appear in: Journal of Endodontics

Received Date: 21 January 2021

Revised Date: 1 June 2021
Accepted Date: 3 June 2021

Please cite this article as: Boutsioukis C, Nova PG, Syringe irrigation in minimally-shaped root canals
using three endodontic needles: a Computational Fluid Dynamics study., Journal of Endodontics (2021),
doi: https://doi.org/10.1016/j.joen.2021.06.001.

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Copyright © 2021 Published by Elsevier Inc. on behalf of American Association of Endodontists.

Syringe irrigation in minimally-shaped root canals using three
endodontic needles: a Computational Fluid Dynamics study.

Christos Boutsioukis, DDS, MSc, PhD

Patricia Gutierrez Nova, DDS

Department of Endodontology, Academic Centre for Dentistry Amsterdam (ACTA),

University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.

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Acknowledgments
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This project was funded by the European Society of Endodontology Annual Research Grant
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in 2017.
The authors deny any conflicts of interest related to this study.
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Author for correspondence:

Dr. Christos Boutsioukis
Department of Endodontology,
Academic Centre for Dentistry Amsterdam (ACTA),
University of Amsterdam and Vrije Universiteit Amsterdam,
Gustav Mahlerlaan 3004
1081 LA, Amsterdam, The Netherlands.
Tel: +31 20 59 80140
Email: c.boutsioukis@acta.nl
Abstract

Introduction: The aim of this study was to compare the irrigant flow in curved root canals
prepared to various apical sizes by constant-taper or variable-taper instruments during syringe
irrigation with three endodontic needles at two different flow rates.
Methods: Two matched curved mesial root canals of human mandibular molars were imaged
by micro-computed tomography after preparation to apical size 20, 25, and 30/.06 taper either
by constant-taper or variable-taper instruments. A Computational Fluid Dynamics model was
used to simulate the irrigant flow in the two root canals prepared to each apical size during
syringe irrigation with a 30G open-ended needle, a 30G and a 31G closed-ended needle at
0.05 and 0.15 mL/s.

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Results: The irrigant could not penetrate until working length in root canals prepared to

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apical size 20 or 25/.06 taper. The 30G open-ended needle combined with the low flow rate
allowed the irrigant to reach working length in size 30/.06 taper root canals while maintaining
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a relatively low apical pressure but the wall shear stress was very low. The 31G closed-ended
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needle combined with the high flow rate also delivered the irrigant till working length in size
30 root canals and developed higher wall shear stress but the apical pressure was also higher.
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Conclusions: Syringe irrigation using 30G and 31G needles was compromised in minimally-
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shaped root canals.

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Keywords: Flow, irrigation, minimally-shaped root canal, needle, syringe.

Introduction
Minimally Invasive Endodontics promotes the preservation of as much healthy hard
dental tissue as possible in an effort to maintain the strength and function of the tooth (1,2).
This concept is mainly applied to access cavity preparation (3-5) but it has also been
extended to root canal instrumentation (1,2,4,6). Minimal shaping of root canals to apical size
20-25 is advocated by instrument manufacturers (7-9) and it has been applied in several in
vitro studies (3,5,10).
However, the limited space available inside a minimally-shaped root canal may
compromise the effectiveness of syringe irrigation (1,2,4), the most widely used irrigation
method (11). Apical enlargement at least to size 30-35 is considered necessary in order to
achieve debridement and disinfection of the root canal system because it allows 27-30G

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irrigation needles to be inserted closer to working length (WL) and the irrigant to overcome

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viscosity-related effects that limit its penetration (12-20). Thirty-one gauge irrigation needles
have been proposed as a way to overcome these limitations (21) but the flow created by these
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needles has not been evaluated so far. Furthermore, numerical models have been used in the
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past to investigate root canal irrigation (17-19,22,23) but previous studies adopted a
univariate approach, so the effect of any interactions between the irrigant flow rate, the apical
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root canal size and taper, and the needle type, size and insertion depth remains largely
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unexplored.
Therefore, the aim of this study was to compare the irrigant flow in curved root canals
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prepared to various apical sizes by constant-taper or variable-taper instruments during syringe

irrigation with a 30G open-ended, a 30G and a 31G closed-ended irrigation needle at two
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different flow rates using a Computational Fluid Dynamics (CFD) model.

Materials and Methods

Geometry of the root canals and irrigation needles
The use of extracted teeth was approved by the Institutional Ethics Committee
(2018042). Two human mandibular molars with separate, moderately-curved (20-40°) (24)
mesial root canals were obtained from a pool of extracted teeth. Two of these mesial root
canals were matched based on their length, curvature and diameter in the apical 5 mm, so
they were as similar as possible. These specimens were debrided and stored in a 0.05%
thymol solution.
The specimens were scanned by a micro-CT scanner (μCT 40, Scanco Medical AG,
Brüttisellen, Switzerland) operating at 70 kV and 114 μA using a 10-μm voxel size before
any intervention (initial scan). The scans were reconstructed, filtered and segmented using
Fiji 1.49m (25) to obtain three-dimensional renderings of the two root canals.
Standard access cavities were prepared in both specimens. The working length (WL)
was set 0.5 mm short of the major apical foramen. The apical 5 mm of the root canals were
sealed with cyanoacrylate (Pattex, Henkel, Dusseldorf, Germany). A glide path was prepared
using stainless-steel K-files of size 08-15 (Dentsply Maillefer, Ballaigues, Switzerland). One
of the two matched root canals was randomly allocated (www.randomizer.org) to the
constant-taper protocol and it was prepared by Mtwo rotary Ni-Ti files (VDW, Munich,
Germany) size 15/.05 taper, 20/.06, 25/.06 and 30/.06. The second matched root canal was
prepared by variable-taper V-Taper 2H rotary Ni-Ti files (17/.04, 20/.06, 25/.06, 30/.06) (SS
White Dental, Lakewood, New Jersey, USA), which have a decreasing taper from their tip

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towards their shaft in order to remove less dentin in the middle and coronal third of the root
canal (9). After every instrument the root canal was rinsed with 2% NaOCl (Orphi Farma,

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Lage Zwaluwe, The Netherlands) and distilled water. The distal root canals were left
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unprepared. The selection and chemomechanical preparation protocol is described in more
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detail in Appendix B. Each specimen was scanned three more times by micro-CT following
preparation of the matched root canals to apical size 20, 25 and 30.
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The geometry of 30G irrigation needles has already been described (22,26,27). The
geometry of the 31G closed-ended double-side-vented needle (Navitip, Ultradent) was
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obtained through examination under a stereoscopic microscope (Stemi SV-6; Zeiss,

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Göttingen, Germany).
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Computational Fluid Dynamics model

A previously validated CFD model (27,28) was employed in this study. In order to
cope with the irregular geometry of real root canals, the hexahedral mesh originally used in
the root canal was replaced by a hybrid mesh. The effect of this modification on the
predictions of the model was examined in a preliminary study as detailed in Appendix A.
The comparison of the time-averaged velocity magnitude and vectors along the root canal
between the new case with the modified mesh, the original case used for the validation of the
model and experimental Particle Image Velocimetry measurements (27) revealed a close
agreement, thereby confirming that the mesh modification did not affect the results.
The three-dimensional geometry of the two matched root canals after preparation to
apical size 20, 25 and 30 was imported into ANSYS Design Modeler 14.5 (ANSYS Inc,
Canonsburg, Pennsylvania, USA). The flow domain (Fig.1) included the complete root canal
from the orifice until the apical endpoint of instrumentation (WL), where a wall was defined.
The length of the root canals was standardized to 8.9 mm by removal of excess coronal
structure. The three selected needles, a 30G flat open-ended needle, a 30G and a 31G closed-
ended double-side-vented needle were modelled using the actual needles as references
[Navitip (30G), Ultradent Products Inc, South Jordan, UT, USA; Endo-Irrigation Needle
(30G), Transcodent, Neumünster, Germany; Navitip (31G), Ultradent]. The external and
internal diameter was standardized to 308 μm and 196 μm for the 30G needles and to 254 μm
and 156 μm for the 31G needles, respectively. The length of all needles was set to 31 mm.
The positioning and bending of each needle was based on a preliminary in vitro
experiment that determined the maximum attainable insertion depth (until binding) for each
needle in curved molar root canals prepared by constant-taper or variable-taper instruments to
apical size 20, 25 and 30 (Appendix B). The maximum attainable insertion depth was

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converted to minimum attainable distance from WL. The average values per case were
increased by 1 mm in order to prevent needle binding during irrigation and they were used to

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define the fixed position of each needle inside the modelled root canals. The needles were
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positioned in the root canals as centered as possible.
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ANSYS Mesh 14.5 (ANSYS Inc.) was used to create the hybrid mesh of the flow
domain (1.1-1.8 million cells). The mesh was refined near the walls and in areas where high
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velocity gradients were anticipated. Grid-independence of the results was verified. No-slip
boundary conditions were applied to all the walls, which were assumed to be rigid, smooth
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and impermeable. A velocity inlet boundary condition was applied at the inlet of the needle
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and flat velocity profiles corresponding to a flow rate of 0.05 or 0.15 mL/s were prescribed.
Atmospheric pressure was imposed at the root canal orifice. Sodium hypochlorite 2.5% was
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used as irrigant [density = 1060 kg/m3; viscosity = 1.073·10-3 Pa·s (29)] and it was modeled
as an incompressible Newtonian fluid. The needle and the root canal were filled with the
irrigant. Gravity was defined so as to mimic the orientation of the mesial root canals of a
mandibular molar when the patient is lying horizontally during treatment.
ANSYS Fluent 14.5 (ANSYS Inc.), a finite volume solver, was used to solve the
time-dependent Navier-Stokes equations in three dimensions. An unsteady isothermal flow
was assumed and no turbulence model was used. A steady-state solution was obtained first
and then used as initial condition for the unsteady simulations. All transport equations were
discretized to be at least second-order accurate. For temporal discretization, a first-order
implicit formulation was used. The convergence criterion was set to 10-4 of the maximum
scaled residuals. Pressure, velocity and vorticity were also monitored to ensure adequate
convergence in every time-step. A time-step of 10-6 s was used throughout the calculations,
which were carried out for a real flow time of 20 ms on a workstation with a 14-core Intel
Xeon 2.5 GHz processor (Intel, Santa Clara, California, USA) and 32 GB of RAM. The flow
fields calculated for each of the 36 cases were compared in terms of irrigant velocity, wall
shear stress and apical pressure.

Results
Root canal anatomy
The initial total length of the matched root canals assigned to the constant and
variable-taper preparation protocols was 11.1 and 9.8 mm, respectively. This was reduced to
10.4 and 9.3 mm following preparation to apical size 30. The curvature of the root canals was
37.0 and 36.7 degrees (24) before preparation, and it decreased to 29.6 and 31.8 degrees after

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preparation, respectively. Details on the diameter of the root canals in the apical 5 mm are

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provided in Figure 1.

Flow pattern
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A steady flow was developed by all needles in low-flow-rate cases and also by the
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30G closed-ended needle in the high-flow-rate cases. The flow was unsteady in the high-
flow-rate cases that involved the 30G open-ended or the 31G closed-ended needle. The 30G
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open-ended needle created a high-velocity irrigant jet directed apically with a slight diversion
towards the outside of the root canal curvature. The closed-ended needles created smaller jets
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at both outlets directed towards the apex at an angle of almost 45° to the needle axis. Most of
the irrigant flowed through the outlet most proximal to the tip [30G needle, 0.05 mL/s: 61.0%
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(1.3%); 0.15 mL/s: 70.4% (3.2%); 31G needle, 0.05 mL/s: 59.1% (2.5%); 0.15 mL/s: 72.1%
(1.5%); data presented as time average (standard deviation)]. The jet velocity in the 31G-
needle cases was higher than in the 30G-needle cases. All jets were more intense in high-
flow-rate cases. The main flow pattern was not affected by the apical preparation size or the
instrument type (Fig.2).

Irrigant penetration
None of the needles was able to deliver the irrigant till WL in size 20 or 25 root canals
irrespective of the flow rate (Fig.3). The 30G open-ended and the 31G closed-ended needles
performed similarly and both were more effective than the 30G closed-ended needle in these
canals. The irrigant penetrated until WL in size 30 root canals when the 30G open-ended
needle was used regardless of the flow rate. The same was noted for the 31G closed-ended
needle but only at the higher flow rate; a stagnation area was evident apically when the lower
flow rate was used. To the contrary, the 30G closed-ended needle could not deliver the
irrigant until WL even in the size 30/.06 taper root canals. The higher flow rate improved
irrigant penetration when the closed-ended needles were used but not in the case of the open-
ended needle. Irrigant penetration was comparable in root canals prepared with either type of
instruments with minor differences that were attributed to the slightly different needle
insertion depths.

Wall shear stress

Low wall shear stress was developed in the apical 1-2 mm of root canals prepared to
size 20 or 25. Slightly higher values were calculated in size 30 root canals (Fig.4). The 30G
open-ended needle developed high shear stress in a small area within 0.5 mm apically to its

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tip. The two closed-ended needles developed a different pattern with two local maxima next
to their outlets, on the two opposite sides of the root canal wall. The 30G open-ended and the

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31G closed-ended needles developed higher wall shear stress in the apical part of the root
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canals compared to the 30G closed-ended needle. The wall shear stress was considerably
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higher in the high-flow-rate cases compared to the low-flow-rate ones but it was not affected
by the instrument type.
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Apical pressure
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The irrigant pressure at the apical end of the root canal increased from size 20 to size
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25 but in most cases it decreased from size 25 to 30 (Fig.5). The maximum values were
similar for the 30G open-ended needle and the 31G closed-ended needle; the 30 closed-ended
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needle developed lower maximum pressure. High-flow-rate cases resulted in higher apical
pressure than the low-flow-rate ones. The pressure was similar in root canals prepared by
either type of instruments.

Discussion
The main research hypothesis tested in this study was that irrigant penetration and the
wall shear stress developed in the apical third during syringe irrigation are compromised in
minimally-shaped root canals when 30G or 31G needles are used. The results of the computer
simulations confirmed this hypothesis.
Curved mesial root canals of mandibular molars were selected as a sufficient
challenge for root canal preparation and needle placement in the apical third. Modelling the
irregular geometry of real root canals required modifications of the mesh that could affect the
validity of the model. Therefore the predictions of the current model were compared both to
the predictions of the original model and to the experimental measurements used for its
validation (27) to confirm that the modified meshing strategy did not introduce additional
error to the results. Previous research has shown that different subtypes of open-ended
needles create very similar irrigant flow and the same applies to closed-ended needles (22).
Consequently, only one 30G open-ended and one 30G closed-ended needle were included in
this study to represent each type and also to allow comparisons with the 31G closed-ended
needle that had not been evaluated before. The selected irrigant flow rates fall within the
range applied by clinicians when 30G needles are used (30). Since there was no such
information concerning 31G needles, the same flow rates were used in order to facilitate
comparisons.

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Fresh irrigant is carried apically to the needle only by the axial component of the
irrigant velocity (the component in the direction of the root canal axis at each level), so the

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magnitude of this component was used to determine the extent of irrigant penetration in the
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apical third, similarly to earlier studies (16,22). Irrigant penetration and exchange are related
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to the chemical effect of irrigation (31). The shear stress developed on the root canal wall was
used as a surrogate for the mechanical cleaning effect of irrigation (19,22,23). Recently, the
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CFD-calculated magnitude of the total irrigant velocity, which contains information about
both the chemical and mechanical effects of irrigation, was correlated to biofilm removal
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from artificial isthmuses and lateral canals in vitro (32). The irrigant pressure at WL was used
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as an indicator of the relative risk for inadvertent irrigant extrusion towards the periapical
tissues (18,19,22,23). Nevertheless, it should be emphasized that, without a validated
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pressure threshold for NaOCl accidents, it is not possible to determine in which of these cases
an accident would actually occur.
Several interesting results were generated by the numerical model. Firstly, the irrigant
could not penetrate until WL in root canals prepared to apical size 20 or 25 irrespective of the
type and size of the needle and the flow rate. Clinically, a small amount of irrigant may still
be transported along the files during instrumentation but both the chemical and mechanical
effects will be very limited in this area. Thus, it is very unlikely that the apical third of
minimally-shaped root canals can be sufficiently cleaned and disinfected by syringe irrigation
even when a 31G needle is used. A minimum apical size 30 was required in order for the
irrigant to reach WL. These findings are in agreement with earlier studies that modeled
simplified root canals and 30G needles (17,33) and are also consistent with the trend reported
by in vitro studies that evaluated 27-30G needles regarding the effect of apical size on
irrigant penetration, root canal cleaning and disinfection (12-14,20).
 Overall, the 30G closed-ended needle was the least effective type of needle. It could
not be placed within 1 mm from WL without binding (16,22) and the irrigant did not
penetrate until WL in any of the simulated cases. The flow developed by the 30G open-ended
needle could reach WL in size 30 root canals even at the lower flow rate while maintaining a
relatively low apical pressure but the wall shear stress was also very low. Under these
conditions the 30G open-ended needle appeared to be less likely to extrude irrigant through
the apical foramen than the closed-ended needles examined here, a finding that contradicted
earlier studies (17,18,22,34). Nonetheless, only a single flow rate was evaluated in these
earlier studies and all needles were inserted at the same distance from WL. This contradiction
highlighted the importance of the concurrent evaluation of several parameters in the same
study and accounting for differences in the attainable insertion depth between the needles.

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The 31G closed-ended needle combined with the higher flow rate was the most effective
option when considering both the chemical and the mechanical effects. In this case, the

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irrigant penetrated till WL in size 30 root canals and the wall shear stress was maximized.
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However, the apical pressure was higher than any of the low-flow-rate cases, which may
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indicate an increased risk of irrigant extrusion through the apical foramen.
An interaction was found between the flow rate and the needle type regarding irrigant
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penetration. A higher flow rate improved irrigant penetration for the closed-ended needles but
not for the open-ended one, which is in agreement with an earlier in vitro study (35).
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However, increasing the flow rate from 0.05 to 0.15 mL/s led to a large increase in the wall
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shear stress in all cases, thus a higher flow rate may still provide an advantage even when an
open-ended needle is used. It is noteworthy that irrigant flow rate had a significant effect on
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biofilm removal from artificial isthmuses and lateral canals during syringe irrigation with an
open-ended needle in vitro (32).
The flow was not distributed equally between the two side vents of the closed-ended
needles. Most of the irrigant passed through the vent closer to the tip, which is in line with
earlier findings (22). Still approximately 30-40% flowed through the second vent, with more
irrigant flowing through in the low-flow-rate cases. This was considerably higher than the
previously reported 6.5% (22). The difference could be attributed to the lower flow rate used
in this study and to the smaller root canals that resisted the flow through the proximal vent,
thereby favoring the path through the second vent.
The apical pressure decreased in size 30 root canals compared to size 25 when the
31G closed-ended needle was used. This decrease could be due to the 25-50% additional
space that was available around the tip of the needle for the back-flow of the irrigant (17). A
similar, yet less-pronounced decrease was also noted in the root canal prepared with variable-
taper instruments when a 30G needle was used.
One of the strengths of this study compared to earlier work was that the needles were
inserted as close as possible to WL without binding based on in vitro measurements rather
than assumptions in order to study irrigation under optimum clinically-realistic conditions. As
a result, they were placed up to 0.5 mm closer to WL in the root canal prepared with
constant-taper instruments compared to the one prepared with variable-taper instruments.
This difference may have improved irrigant penetration slightly in these cases (16) but the
current study design could not provide conclusive evidence about the effect of the insertion
depth on the flow because other parameters were varied at the same time.
Constant-taper and variable-taper instruments created similar shapes in the apical

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third of the matched root canals. Size 20 and 25 variable-taper instruments were slightly more
conservative than the corresponding constant-taper instruments but the opposite was true for

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size 30 instruments. These observations should be interpreted with caution because only two
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root canals were evaluated but they may indicate that using an instrument of variable taper
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does not always result in less dentin removal or a variable-taper root canal shape, at least in
the apical third. However, it should be noted that the variable-taper instruments used in this
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study had a constant 0.06 taper near their tip (9), which could explain the similarities in the
shape of the apical third. The lack of significant differences in the flow between the two root
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canals could also be attributed to this fact since the shape of the apical third determines
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irrigant penetration to a large extent (17,33) and the current analysis of the flow focused on
that area. On the other hand, the variable-taper instruments were more conservative 5 mm
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away from WL. This did not seem to affect the flow but it could explain the differences in the
attainable needle insertion depth between the two root canals.

Conclusions
Preparation of curved root canals to apical size 20 or 25/.06 taper did not allow
sodium hypochlorite to reach WL. When the apical size was increased to 30/.06 taper, a 30G
open-ended needle allowed the irrigant to reach WL even when irrigation took place at a low
flow rate (0.05 mL/s). The 31G closed-ended needle combined with the high flow rate (0.15
mL/s) also delivered the irrigant till WL in size 30 root canals. Whilst this gave rise to higher
wall shear stress it also developed higher apical pressure.
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27. Boutsioukis C, Verhaagen B, Versluis M, Kastrinakis E, van der Sluis LWM. Irrigant
flow in the root canal: experimental validation of an unsteady Computational Fluid
Dynamics model using high-speed imaging. Int Endod J 2010;43:393-403.
28. Verhaagen B, Boutsioukis C, Heijnen GL, van der Sluis L, Versluis M. Role of the
confinement of a root canal on jet impingement during endodontic irrigation. Exp Fluids
2012;53:1841-53.
29. Guerisoli DMZ, Silva RS, Pecora JD. Evaluation of some physico-chemical properties of
different concentrations of sodium hypochlorite solutions. Braz Endod J 1998;3:21-3.

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30. Boutsioukis C, Lambrianidis T, Kastrinakis E, Bekiaroglou P. Measurement of pressure
and flow rates during irrigation of a root canal ex vivo with three endodontic needles. Int

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Endod J 2007;40:504-13.
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31. van der Sluis L, Boutsioukis C, Jiang LM, et al. Root canal irrigation. In: Chávez de Paz
L, Sedgley CM, Kishen A. eds. The root canal biofilm. 1st ed. New York: Springer;
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2015:259-302.
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32. Pereira TC, Boutsioukis C, Dijkstra RJB, et al. Biofilm removal from an artificial
isthmus and lateral canal during syringe irrigation at various flow rates: a combined
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experimental and Computational Fluid Dynamics approach. Int Endod J 2021;54:427-

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33. Boutsioukis C, Gogos C, Verhaagen B, et al. The effect of root canal taper on the irrigant
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flow: evaluation using an unsteady Computational Fluid Dynamics model. Int Endod J
2010;43:909-16.
34. Psimma Z, Boutsioukis C, Kastrinakis E, Vasiliadis L. Effect of needle insertion depth
and root canal curvature on irrigant extrusion ex vivo. J Endod 2013;39:521-4.
35. Park E, Shen Y, Khakpour M, Haapasalo M. Apical pressure and extent of irrigant flow
beyond the needle tip during positive-pressure irrigation in an in vitro root canal model.
J Endod 2013;39:511-5.
Figure legends

Figure 1. Geometry of the matched root canals after preparation to apical size 20, 25 and 30
(left) and charts depicting the diameter of the root canals in the apical 5 mm (right). The slope
of each line represents the root canal taper. A dashed line indicating a constant 0.06 taper has
been added to the charts as a reference.

Figure 2. Triads of time-averaged irrigant velocity contours (top) and vectors (middle) along
the z-y plane and streamlines indicating the route of massless particles released downstream
from the needle inlet and colored according to time-averaged velocity magnitude (bottom) in
the root canal prepared with Mtwo files to apical size 25. Particle trajectories provide

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visualization of the main fresh irrigant flow in three dimensions. Needles are coloured in red.

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Figure 3: Maximum time-averaged axial irrigant velocity in the apical 5 mm of the root
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canal as a function of distance from WL for each needle type, instrument type, apical
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preparation size and flow rate, indicating the irrigant penetration front. The scale of the
vertical axis has been adjusted to 0-0.5 m/s to highlight differences in the area apically to the
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needles. Colored dots on the horizontal axis indicate the position of the needle tip for each
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root canal size. Velocities higher than 0.1 m/s (dotted horizontal line) were considered to
indicate clinically relevant penetration.
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Figure 4: Maximum time-averaged irrigant shear stress applied on the root canal wall as a
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function of distance from WL for the various needle types, instrument types, apical
preparation sizes, and flow rates. Colored dots on the horizontal axis indicate the position of
the needle tip for each root canal size. Examples of contours of time-averaged irrigant shear
stress on the root canal wall of size 25 root canals irrigated at 0.15 mL/s are provided above
each graph to illustrate the shear stress pattern. A shadow of the needle is shown behind the
root canal wall. The colormap on the right side refers to the contours.

Figure 5: Time-averaged irrigant pressure at the apical end of the root canal as a function of
needle distance from WL for the various needle types, instrument types, apical preparation
sizes, and flow rates.
APPENDIX

A. Effect of the modified meshing strategy on model predictions

The hexahedral mesh used originally in the root canal (27,28) was replaced by a
hybrid mesh combining tetrahedral cells in the lumen of the root canal and a thin layer of
prismatic cells near the boundaries in order to cope with the irregular geometry of real root
canals. The effect of this modification on the predictions of the model was examined in a
preliminary study. One additional case unrelated to the aim of the main study was prepared
and simulated using the modified meshing strategy. This case involved syringe irrigation with
distilled water at 0.26 mL/s through a 30G side-vented needle placed at 3 mm from WL in a
simplified straight root canal with apical size 45 and 6.2% taper and it was identical to case S

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that was used previously for the experimental validation of the model (27). Comparison of

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the time-averaged irrigant velocity magnitude and vectors along the root canal between the
case with the modified mesh, the original case S and Particle Image Velocimetry
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measurements (27) revealed a close agreement (Fig. S1). Therefore, it was concluded that the
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modified meshing strategy did not affect the results.
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Figure S1: Contours of time-averaged velocity magnitude (A) and time-averaged velocity vectors (B) along the
root canal for the case with the modified mesh (left), the original case S with the hexahedral mesh (middle), and
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the results of Particle Image Velocimetry (PIV) experiments (right) from the model validation study (27).
Comparisons were made in three different locations (I, II, III) in the apical part of the root canal and they
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revealed a close agreement. The needle is coloured in black. Reprinted and modified with permission from
Wiley (27).
B. In vitro measurement of the minimum attainable distance of each needle from WL.
Sixteen human mandibular molars with fully formed apices were obtained from a pool
of extracted teeth. These specimens included the two specimens that were used to obtain the
root canal geometry for the numerical model as described in the Materials & Methods. The
specimens had two separate mesial root canals that ended up in separate apical foramina.
Examination under a stereoscopic microscope (Stemi SV-6; Zeiss) (×40), preoperative
radiographs, and the initial micro-CT scan were used to confirm the root canal anatomy and
the absence of extensive restorations, resorption, calcification, root caries, fractures or cracks.
The mesial root canals had a moderate curvature (20-40°) (24) that affected at least the apical
and middle third of the root canal and it was limited to a single plane. Double-curved (S-
shaped) root canals were excluded. These specimens were immersed in 2% NaOCl for 10

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minutes to remove organic debris. Subsequently, they were debrided with an ultrasonic
scaler, washed with distilled water and then stored in a 0.05% thymol solution until use.

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Traditional access cavities were prepared in all specimens and a size 08 K-file
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(Dentsply Maillefer, Ballaigues, Switzerland) was introduced into each mesial root canal
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until it was just visible at the major apical foramen under the stereoscopic microscope. The
working length (WL) was determined 0.5 mm short of this position. The apical 5 mm of the
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root canals were then sealed with two layers of cyanoacrylate (Pattex, Henkel, Dusseldorf,
Germany) to simulate an apically-closed system.
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Root canal shaping was performed by a single operator. A glide path was prepared
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first using stainless-steel K-files of size 08, 10 and 15 (Dentsply Maillefer). Each one of the
two mesial root canals in every specimen was randomly allocated (www.randomizer.org) to
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group A (constant-taper instruments) or B (variable-taper instruments). Root canals in group

A were prepared by Mtwo rotary Ni-Ti files (VDW, Munich, Germany), which have a
constant taper throughout their cutting part. Size 15/.05 taper, 20/.06, 25/.06 and 30/.06 files
were progressively inserted till WL with a pecking motion. Root canals in group B were
prepared by variable-taper V-Taper 2H rotary Ni-Ti files (17/.04, 20/.06, 25/.06, 30/.06) (SS
White Dental, Lakewood, New Jersey, USA), which have a .04 or .06 taper at their tip which
decreases gradually towards the shaft in order to remove less dentin in the middle and coronal
third of the root canal (9). These files are advocated for minimal root canal shaping. All Ni-Ti
files were driven by a torque-control motor (VDW Silver, VDW, Munich, Germany)
according to each manufacturer’s recommendations. A size 10 K-file (Dentsply Maillefer)
was used for recapitulation to WL. After every instrument the root canal was rinsed with 2
mL of NaOCl 2% (Orphi Farma, Lage Zwaluwe, The Netherlands) and 5 mL of distilled
water at a flow rate of 0.15 mL/s using a 10-mL syringe (Terumo Europe, Leuven, Belgium)
and a 31G closed-ended needle (NaviTip, Ultradent Products Inc, South Jordan, UT, USA).
The needle was pre-bent, it was inserted in the canal until slight resistance was felt and then it
was retracted 1 mm before irrigant delivery. The distal root canals were left unprepared.
The maximum attainable needle insertion depth (until binding) in the prepared mesial
root canals was measured in vitro for the three irrigation needles that were simulated by the
numerical model: the 30G flat open-ended needle (Navitip, Ultradent, South Jordan, UT,
USA), the 30G closed-ended double-side-vented needle (Endo-Irrigation Needle,
Transcodent, Neumünster, Germany), and the 31G closed-ended double-side-vented needle
(Navitip, Ultradent). Based on a series of pilot tests, each needle was first pre-bent to an
angle of 10°-15° approximately 3 mm from the tip in order to maximize the insertion depth in
the curved root canals without compromising its structural integrity. Double-side-vented

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needles were always bent so that the outlet most proximal to the tip was located on the
outside of the curve. Next, the needles were inserted by the same operator in each root canal

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of both groups in a random order (www.randomizer.org) after preparation to apical size 20,
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25 and 30. Each needle was gently advanced in the root canal until slight resistance was felt,
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the depth at that position was marked by a rubber stop and the needle was carefully retracted.
A second operator measured the depth to the nearest 0.25 mm using precision calipers
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(Vernier Calipers 530-316, Mitutoyo, Japan) and a stereoscopic microscope (Stemi SV-6;
Zeiss). The measured depth was converted to the minimum attainable distance of each needle
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from WL in each root canal. A new needle was used in each root canal. The root canals were
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full of distilled water during this process. The results of these measurements are presented in
Table S1. The average minimum attainable distance from WL for each needle was used to
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define its insertion depth in the numerical model.

Apical preparation size

Needle Mtwo (n=16) V-Taper 2H (n=16)
20 25 30 20 25 30

30G open-ended 3.2 (1.3) 1.4 (0.7) 0.5 (0.3) 3.7 (1.5) 1.3 (1.1) 0.7 (0.7)

30G closed-ended 1.9 (0.9) 1.1 (0.4) 0.4 (0.3) 2.3 (0.7) 1.3 (1.1) 0.6 (0.4)

31G closed-ended 1.1 (0.7) 0.6 (0.4) 0.2 (0.3) 1.5 (0.9) 0.5 (0.3) 0.2 (0.2)

Table S1: Minimum attainable distance (in mm) of each needle from WL in curved mesial root canals of
mandibular molars in vitro prepared to apical size 20, 25, and 30 by Mtwo or V-Taper 2H files. Data are
presented as mean (standard deviation).
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