Reduction in Fracture Resistance of the Root with Aging

Changes in the composition and mechanical properties of dentin in mouse models of diabetes

OBJECTIVES

This study employed mouse models of type 1 (T1D) and type 2 (T2D) diabetes to characterize the changes in tooth dentin composition and its mechanical properties.

METHODS

Thirty-two mice were used in this study and divided into T1D, T2D and corresponding control groups. Mandibles were extracted 12 weeks after the onset of diabetes, and dentin from the first molars was evaluated in varying regions of the root. The composition was assessed using Raman Spectroscopy. Nanoindentation and Vickers indentation were employed to study the mechanical properties of the tissue. Statistical significance was evaluated by two-way analysis of variance with respect to the diabetic group and region of the tooth (p ≤ 0.05).

RESULTS

In the T2D model, the mineral-to-collagen ratio, hardness, and storage modulus of the intertubular dentin were significantly reduced compared to tissue from the controls, especially in the cervical regions of the tooth. The reduction in the mineral-to-collagen ratio was also observed in the T1D model, but changes in nanomechanical properties were not evident. However, the bulk hardness of the teeth in the T1D model was lower than in the littermate controls. Optical microscopy revealed significant wear of the tooth crowns in both models of diabetes, which appear to result from parafunctional activities.

CONCLUSION

This study suggests that both type 1 and type 2 models of diabetes are associated with detrimental changes in dentin.

CLINICAL SIGNIFICANCE

Better understanding of how diabetes affects dentin and the contributing mechanisms will be key to improving treatments for people with diabetes.

Impact of Type 2 Diabetes Mellitus on the Occurrence of Vertical Root Fracture: A Case Control Study

INTRODUCTION

The aim of this case-control study was to examine the relationship between type 2 diabetes mellitus (DM) and the occurrence of VRFs. The crack extension, dentin sclerosis, and chemical characteristics of root dentin in teeth with VRF from patients with/without DM were also compared.

METHODS

One hundred and thirty-two patients diagnosed with VRF in crowned root filled posterior teeth were selected. The study was conducted in 2 parts. In Part-1: The cases were matched with control teeth (1:1) for age (±5 years), sex, tooth type, apical extent of root filling, time period after root filling to a diagnosis of VRF, presence or absence of intracanal post and abutment status. The presence or absence of type 2 DM (HbA1c > 6.5) was recorded. In Part-2: The extracted teeth with VRF from the case control study were used to evaluate the extension of VRF, presence of sclerotic dentin and isthmus using a microscopic analysis; while the levels of pentosidine, collagen cross-linking ratio and mineral-collagen ratio were determined by Fourier-transform infrared spectroscopy. The distribution of DM between cases and controls was analyzed using Pearson Chi-Square test and Odds Ratio estimated. Chemical composition data was analyzed using Mann-Whitney test. The extent of sclerotic dentin was analyzed using Pearson Chi-Square test.

RESULTS

When compared to patients without DM, patients with DM had 2.67 (95% CI: 1.6-4.45) folds higher odds for occurrence of VRF. Pentosidine (P = .014), collagen cross-linking ratio(P = .047), mineral-collagen ratio (P = .009) and sclerotic dentin extent (P = .0009) were significantly higher in patients with DM and VRF.

CONCLUSIONS

Type 2 DM was more often associated with VRFs in root canal treated teeth with crowns. Root dentin from patients with type 2 DM and VRF had higher levels of pentosidine, collagen cross-linking ratio, mineral to collagen ratio and sclerotic dentin.

Incidence and contributing factors of non-root canal treated teeth with chronic fatigue root fracture: A cross-sectional study

BACKGROUND/PURPOSE

Chronic fatigue root fracture describes a root fracture in a non-root canal treated (non-RCT) tooth. This study aimed to report the incidence and contributing factors of non-RCT teeth with chronic fatigue root fracture in a Taiwanese population.

METHODS

This cross-sectional study included teeth extracted at Taipei Veterans General Hospital in Taiwan between 2018 and 2019. The reasons for extractions were recorded and included vertical and horizontal root fractures (VRF and HRF). Comparisons of clinical factors between teeth with fatigue VRF and teeth with fatigue HRF were performed by chi-square or Fisher exact test, where appropriate.

RESULTS

Of the 4207 extracted teeth examined, 263 (6.25%) had tooth fracture. Thirty-two non-RCT teeth had chronic fatigue root fracture, including 16 with VRF and 16 with HRF. The incidence was 0.76% (32/4207). The occurrence of chronic fatigue root fracture was higher in males (83.9%). The mean age of the 31 patients with chronic fatigue root fracture was 71.7 ± 13.1 years. More than half of these teeth had intact crowns with severe attrition. The fatigue VRF occurred more frequently in molars (P = 0.003), in roots with a long oval cross-section (P = 0.037), and in terminal teeth (P = 0.013) than the fatigue HRF.

CONCLUSION

The incidence of chronic fatigue root fracture is 0.76%. Both VRF and HRF occur mainly in aged males, in posterior teeth with attrition, and in teeth without restoration. Tooth position, cross-section root morphology, and terminal tooth are contributing factors related to chronic fatigue root fracture.

Endodontic Dentistry: Analysis of Dentinal Stress and Strain Development during Shaping of Curved Root Canals

BACKGROUND

Endodontic shaping causes stress and strain in the root canal dentin. Dentin microcracks have the potential to be later followed by root fractures occurring under the occlusal load. The aim of our research was to theoretically determine the values of such dentinal states of stress and strain during the endodontic shaping of curved root canals using finite element analysis (FEA).

METHODS

To highlight the stress concentrations in dentin, two geometric models were created considering the volume of the curved dental root and the contact between the endodontic file and the root canal walls. The application of forces with different values was simulated both on a uniform curved root canal and on a root canal with an apical third curvature of 25° as they would be applied during the preparation of a root canal.

RESULTS

In the case of the first model, which was acted upon with a force of 5 N, the deformations of the root canal appeared along the entire working length, reaching the highest values in the apical third of the root, although there were no geometric changes in the shape of the root canal. Regarding the second root model, with an apical third curvature of 25°, although the applied force was 2 N, the deformations were accompanied by geometric changes in the shape of the root, especially in the upper part of the apical third. At a higher force of 7 N exerted on the endodontic file, the geometric shape changed, and the deformation reached extreme critical values. The resulting tensile stresses appearing in the experimental structure varied similarly to the deformations.

CONCLUSIONS

Significant stress and strain can develop, especially in the apical third of curved root canals during their shaping, and the risk of cracks is higher for endodontically treated teeth presenting severe curvatures in the apical third of the root.

Systematic review fracture resistance of endodontically treated posterior teeth restored with fiber reinforced composites- a systematic review

BACKGROUND

Large cavity designs and access cavities impair endodontically treated tooth fracture resistance. As the tooth's strength is known to reduce significantly after the root canal treatment, occlusal loading as a result of functions such as chewing, biting and certain parafunctional tendencies makes the endodontically treated tooth vulnerable to fracture. Hence, after endodontic treatment, it is vital to give adequate and appropriate restorative material to avoid tooth fractures. Accordingly, the choice of such restorative material should be dictated by the property of fracture resistance.

OBJECTIVE

The goal of this study was to conduct a systematic review and critical analysis of available data from in vitro studies examining the fracture resistance of endodontically treated posterior teeth restored with fiber-reinforced composites.

METHODOLOGY

The Preferred Reporting Items for Systematic Review and Meta-Analysis (PRIS-MA) Statement was used to guide the reporting of this systematic review A comprehensive literature search was performed using MEDLINE (via PubMed), Scopus, ScienceDirect, Google Scholar, and LILACS. A manual search of the reference lists of the articles was also performed. The databases provided a total of 796 studies from the electronic systematic search. The databases provided a total of 796 studies from the electronic systematic search. Two reviewers scrutinized the papers for eligibility based on inclusion/exclusion criteria and extracted data. The studies were assessed for their potential risk of bias. Based on modified JBI & CRIS (checklist for reporting in vitro studies) guidelines, along with the methodology and treatment objective, we have formulated 13 parameters specifically to assess the risk of bias. A total of 18 studies met the inclusion criteria and were included for qualitative analysis. Considering the high heterogeneity of the studies included, a meta-analysis could not be performed.

RESULTS

The majority of the included studies had a moderate or high risk of bias. When compared to traditional hybrid composites, fiber-reinforced composites showed increased fracture resistance of endodontically treated teeth in the majority of investigations. On the other hand, limited evidence was found for the bulk fill composites. Moreover, moderate evidence was found for the fracture resistance of inlays and fiber posts with fiber-reinforced composites for core build-up in endodontically treated teeth. No evidence could be found comparing the fracture resistance of endo crowns and fiber-reinforced composites in endodontically treated teeth.

CONCLUSION

According to the research, using fiber-reinforced composites instead of conventional hybrid composites improves the fracture resistance of endodontically treated teeth. However, there was a high risk of bias in the research considered. No judgments could be reached about the superiority of one material over another based-on comparisons between other core restorations.

Effects of cryopreservation on the biomechanical properties of dentin in cryopreserved teeth: An in-vitro study

This study focused on the biomechanical properties and microstructural changes in dentin of teeth in different age groups after cryopreserved for different durations. Ninety third molars from three age groups (youth group, middle-age group, and elderly group), were collected and randomly divided into three groups according to freezing time at -196 °C (7 days, 30 days, and 90 days). Control group was shored at ordinary temperature. After rewarming, the compressive strength and elastic modulus of the dentin were measured with an electronic universal tester. Scanning electron microscopy was used to evaluate the microstructure of dentin after cryopreservation. After cryopreservation, the compressive strength of the teeth in each experimental group was not significantly different from control group. With the increase of freezing time and age, dentin's elastic modulus showed a decreasing trend. There were statistically significances between the control group and freezing 90d group, freezing 7d and 90d group, youth and middle-aged group, youth and elderly group (P < 0.05). Both freezing time and age factors were significant for the elastic modulus of dentin(P＜0.05). There was no interaction effect for age and freezing time. In transverse sections of scanning electron microscopy, the dentinal tubule became narrower, partially occluded, and more easily adhered to impurities in the long freezing time and elderly group. In longitudinal sections, with freezing time and age, the inner wall of the dentinal tubules became rough especially in the aged group cryopreserved for 90 days. No significant microcracks exited in any of the longitudinal sections of dentin.

Biomechanical perspectives on dentine cracks and fractures: Implications in their clinical management

OBJECTIVES

The present review discussed the biomechanical properties of cracks and fractures in crown and root dentine and attempted to explain why cracked teeth and vertical root fractures are so frequent despite the existence of multiple crack toughening mechanisms in dentine. The implications of this knowledge were used to justify how these defects are managed clinically.

DATA, SOURCES AND STUDY SELECTION

Literature search was conducted on PubMed, Web of Science, and Scopus for a narrative review on fracture mechanics of crown and root dentine as well as the clinical management of cracked teeth and teeth with vertical root fracture.

CONCLUSIONS

Although dentine is tougher and less brittle than enamel, it's facture toughness is considerably lower than most ductile metals. Because the initiation toughness of dentine is very low, cracks initiate from incipient damage under low stress While crack toughening mechanisms exist that enable dentine to resist crack extension, these mechanisms are often inadequate for protecting dentine from crack propagation that ultimately leads to catastrophic failure. Additional factors such as ageing also reduces the resistance of dentine to crack growth. Because dentine cracks are eventually filled with bacteria biofilms upon exposure to oral fluids, they enable rapid bacteria ingress into the dental pulp via open dentinal tubules. To date, treatment options for cracked teeth are limited. While most teeth with vertical root fracture are recommended for extraction, new strategies have been reported that appeared to achieve short-term success in preserving these teeth.

CLINICAL SIGNIFICANCE

Current strategies for the management for dentine cracks and fractures are limited and their long-term effectiveness remain uncertain. Understanding the characteristics, toughening mechanism and weakening factors of tooth cracks is helpful in designing better treatment.

Present status and future directions: The restoration of root filled teeth

This narrative review will focus on a number of contemporary considerations relating to the restoration of root filled teeth and future directions for research. Clinicians are now more than ever, aware of the interdependence of the endodontic and restorative aspects of managing root filled teeth, and how these aspects of treatment are fundamental to obtaining the best long-term survival. To obtain the optimal outcomes for patients, clinicians carrying out endodontic treatment should have a vested interest in the restorative phase of the treatment process, as well as an appreciation for the structural and biomechanical effects of endodontic-restorative procedures on restoration and tooth longevity. Furthermore, the currently available research, largely lacks appreciation of occlusal factors in the longevity of root filled teeth, despite surrogate outcomes demonstrating the considerable influence this variable has. Controversies regarding the clinical relevance of minimally invasive endodontic and restorative concepts are largely unanswered with respect to clinical data, and it is therefore, all too easy to dismiss these ideas due to the lack of scientific evidence. However, conceptually, minimally invasive endodontic-restorative philosophies appear to be valid, and therefore, in the pursuit of improved clinical outcomes, it is important that the efficacies of these treatment protocols are determined. Alongside an increased awareness of the preservation of tooth structure, developments in adhesive bonding, ceramic materials and the inevitable integration of digital dentistry, there is also a need to evaluate the efficacy of new treatment philosophies and techniques with well-designed prospective clinical studies.

3D-Printed Teeth in Endodontics: Why, How, Problems and Future-A Narrative Review

Three-dimensional printing offers possibilities for the development of new models in endodontics. Numerous studies have used 3D-printed teeth; however, protocols for the standardization of studies still need to be developed. Another problem with 3D-printed teeth is the different areas of literature requested to understand the processes. This review aims to gather evidence about 3D-printed teeth on the following aspects: (1) why they are advantageous; (2) how they are manufactured; (3) problems they present; and (4) future research topics. Natural teeth are still the standard practice in ex vivo studies and pre-clinical courses, but they have several drawbacks. Printed teeth may overcome all limitations of natural teeth. Printing technology relies on 3D data and post-processing tools to form a 3D model, ultimately generating a prototype using 3D printers. The major concerns with 3D-printed teeth are the resin hardness and printing accuracy of the canal anatomy. Guidance is presented for future studies to solve the problems of 3D-printed teeth and develop well-established protocols, for the standardization of methods to be achieved. In the future, 3D-printed teeth have the possibility to become the gold standard in ex vivo studies and endodontic training.

Insights Into Pulp Biomineralization in Human Teeth

Introduction

Mineralized pulp (MP) compromises tooth function and its causation is unknown. The hypothesis of this study is that pulp mineralization is associated with pulpal tissue adaptation, increased mineral densities, and decreased permeabilities of tubular dentin and cementum. Methods will include correlative spatial mapping of physicochemical and biochemical characteristics of pulp, and contextualize these properties within the dentin-pulp complex (DPC) to reveal the inherent vunerabilities of pulp.

Methods

Specimens (N = 25) were scanned using micro X-ray computed tomography (micro-XCT) to visualize MP and measure mineral density (MD). Elemental spatial maps of MP were acquired using synchrotron X-ray fluorescence microprobe (μXRF) and energy dispersive X-ray spectroscopy (EDX). Extracted pulp tissues were sectioned for immunolabelling and the sections were imaged using a light microscope. Microscale morphologies and nanoscale ultrastructures of MP were imaged using scanning electron (SEM) and scanning transmission electron microscopy (STEM) techniques.

Results

Heterogeneous distribution of MD from 200 to 2,200 mg/cc, and an average MD of 892 (±407) mg/cc were observed. Highly mineralized pulp with increased number of occluded tubules, reduced pore diameter in cementum, and decreased connectivity in lateral channels were observed. H&amp;E, trichrome, and von Kossa staining showed lower cell and collagen densities, and mineralized regions in pulp. The biomolecules osteopontin (OPN), osteocalcin (OCN), osterix (OSX), and bone sialoprotein (BSP) were immunolocalized around PGP 9.5 positive neurovascular bundles in MP. SEM and STEM revealed a wide range of nano/micro particulates in dentin tubules and spherulitic mineral aggregates in the collagen with intrafibrillar mineral surrounding neurovascular bundles. EDX and μXRF showed elevated counts of Ca, P, Mg, and Zn inside pulp and at the dentin-pulp interface (DPI) in the DPC.

Conclusion

Colocalization of physical and chemical, and biomolecular compositions in MP suggest primary and secondary biomineralization pathways in pulp and dentin at a tissue level, and altered fluid dynamics at an organ level. Elevated counts of Zn at the mineralizing front in MP indicated its role in pulp biomineralization. These observations underpin the inherent mechano- and chemo-responsiveness of the neurovascular DPC and help elucidate the clinical subtleties related to pulpitis, dentin-bridge, and pulp stone formation.

Vertical root fractures in root treated teeth-current status and future trends

Vertical root fracture (VRF) is a common reason for the extraction of root filled teeth. The accurate diagnosis of VRF may be challenging due to the absence of clinical signs, whilst conventional radiographic assessment is often inconclusive. However, an understanding of the aetiology of VRFs, and more importantly, the key predisposing factors, is crucial in identifying teeth that may be susceptible. Thorough clinical examination with magnification and co-axial lighting is essential in identifying VRFs, and although CBCT is unable to reliably detect VRFs per se, the pattern of bone loss typically associated with VRF can be fully appreciated, and therefore, increases the probability of correct diagnosis and management. The prevalence of VRFs in root filled teeth is significantly greater than in teeth with vital pulps, demonstrating that the combination of loss of structural integrity, presence of pre-existing fractures and biochemical effects of loss of vitality, are highly relevant. Careful assessment of the occlusal scheme, presence of deflective contacts and identification of parafunctional habits is imperative in both preventing and managing VRFs. Furthermore, anatomical factors such as root canal morphology, may predispose certain teeth to VRF. The influence of access cavity design and root canal instrumentation protocols should be considered although the impact of these on the fracture resistance of root filled teeth is not clearly validated. The post-endodontic restoration of root filled teeth should be expedient and considerate to the residual tooth structure. Posts should be placed 'passively' and excessive 'post-space' preparation should be avoided. This narrative review aims to present the aetiology, potential predisposing factors, histopathology, diagnosis and management of VRF and present perspectives for future research. Currently, there are limited options other than extraction for the management of VRF, although root resection may be considered in multi-rooted teeth. Innovative techniques to 'repair' VRFs using both orthograde and surgical approaches require further research and validation. The prevention of VRFs is critical; identifying susceptible teeth, utilizing conservative endodontic procedures, together with expedient and appropriate post-endodontic restorative procedures is paramount to reducing the incidence of terminal VRFs.

The stoic tooth root: how the mineral and extracellular matrix counterbalance to keep aged dentin stable

Aging is a physiological process with profound impact on the biology and function of biosystems, including the human dentition. While resilient, human teeth undergo wear and disease, affecting overall physical, psychological, and social human health. However, the underlying mechanisms of tooth aging remain largely unknown. Root dentin is integral to tooth function in that it anchors and dissipates mechanical load stresses of the tooth-bone system. Here, we assess the viscoelastic behavior, composition, and ultrastructure of young and old root dentin using nano-dynamic mechanical analysis, micro-Raman spectroscopy, small angle X-ray scattering, atomic force and transmission electron microscopies. We find that the root dentin overall stiffness increases with age. Unlike other mineralized tissues and even coronal dentin, however, the ability of root dentin to dissipate energy during deformation does not decay with age. Using a deconstruction method to dissect the contribution of mineral and organic matrix, we find that the damping factor of the organic matrix does deteriorate. Compositional and ultrastructural analyses revealed higher mineral-to-matrix ratio, altered enzymatic and non-enzymatic collagen cross-linking, increased collagen d-spacing and fibril diameter, and decreased abundance of proteoglycans and sulfation pattern of glycosaminoglycans . Therefore, even in the absence of remodeling, the extracellular matrix of root dentin shares traits of aging with other tissues. To explain this discrepancy, we propose that altered matrix-mineral interactions, possibly mediated by carbonate ions sequestered at the mineral interface and/or altered glycosaminoglycans counteract the deleterious effects of aging on the structural components of the extracellular matrix. STATEMENT OF SIGNIFICANCE: Globally, a quarter of the population will be over 65 years old by 2050. Because many will retain their dentition, it will become increasingly important to understand and manage how aging affects teeth. Dentin is integral to the protective, biomechanical, and regenerative features of teeth. Here, we demonstrate that older root dentin not only has altered mechanical properties, but shows characteristic shifts in mineralization, composition, and post-translational modifications of the matrix. This strongly suggests that there is a mechanistic link between mineral and matrix components to the biomechanical performance of aging dentin with implications for efforts to slow or even reverse the aging process.

[Mechanisms of age-related changes in the morphology of the pulp system of the first lower molars]

OBJECTIVE

To study the coupling of age-related systemic changes in inflammation-mediated apoptosis with the features of the anatomy of the pulp system of the first mandibular molars in patients with chronic pulpitis and periodontitis.

MATERIAL AND METHODS

The study included 55 patients of both sexes from 18 to 75 years of age in three age groups - young (18-44 years) (n=17), middle (45-59 years) (n=18), elderly (60-74 years) (n=20) with indications for endodontic treatment. Diagnostic measures were supplemented with New Tom 3G cone-beam tomography. The concentration of anitapoptotic protein Bcl-XL and tumor necrosis factor-a (TNF-a) was determined in the blood, and the level of the nuclear transcription factor NF-KB subunit p65 was determined in the lysates of mononuclear cells.

RESULTS

As a result of the analysis of the sections, significant obliteration of the pulp was revealed throughout and an increase in the frequency of occurrence of slit-shaped channels in the distal root of the first molar of the mandible in elderly patients.

CONCLUSION

The pathogenetic factors leading to a change in the morphology of the pulp system include old age and an imbalance in the system of anti-inflammatory cytokine transcription mechanisms, which contributes to increased apoptosis and the protracted nature of inflammation.

A critical analysis of research methods and experimental models to study dentinal microcracks

The purpose of this narrative review was to discuss the scientific milestones that led to the current understanding of the root dentinal microcrack phenomenon based on the interplay between the usage of micro-computed tomography (micro-CT) as an analytical tool alongside a close-to-mouth experimental model. In 2009, reports on the development of dentinal microcracks in extracted teeth after root canal preparation triggered an awareness of the potential for vertical root fractures (VRFs) of endodontically treated teeth could be developed from defects created by the mechanical stress of nickel-titanium preparation systems on dentine. This assumption was taken for granted, even though no cause-effect relationship had been scientifically demonstrated. Since then, several studies using the sectioning method with extracted teeth have been published and the large discrepancy amongst their outcomes soon become evident. Moreover, the high frequency of reported dentinal microcracks largely contrasted with the clinical incidence of VRFs, raising doubts on their methodological reliability. Using micro-CT technology, it was demonstrated by several studies that, in extracted teeth, dentinal defects already existed before the endodontic procedures, indicating that the initial reports framed a non-existing cause-effect relationship between canal preparation and dentinal microcracks. Although these new findings contributed to a better comprehension of this phenomenon, the misconception that microcracks were the starting point for VRFs was only surpassed with a new in situ approach using fresh cadavers. Surprisingly, microcracks were not identified in sound teeth. As a conclusion, dentinal microcracks in extracted teeth can be considered a non-natural occurrence observed only in a laboratory set-up as a consequence of dehydration and storage conditions. Thus, dentinal microcracks shall not be considered as the starting point for VRFs as they do not manifest in non-extracted teeth. Identifying dentinal microcracks as a laboratory phenomenon highlights the impact of recent scientific developments to disclaim the clinical relevance of laboratory-obtained outcomes.

A machine learning approach to investigate the materials science of enamel aging

Understanding aging of tooth tissues is critical to the development of patient-centric oral healthcare. Yet, the traditional methods for analyzing the composition-structure-property relationships of hard tissues have limitations when considering aging and other factors.

OBJECTIVE

To apply unsupervised machine learning tools to pursue an understanding of relationships between the composition and mechanical behavior of aging enamel.

METHODS

Molar teeth were collected from primary (age ≤ 8), young adult (24 ≤ age ≤ 46) and old adult (55 ≤ age) donors. The hardness and elastic modulus were quantified using nanoindentation as a function of distance from the Dentin Enamel Junction (DEJ) within the cervical, cuspal and inter-cuspal regions of the enamel crown. Similarly, a co-located analysis of the chemical composition and structure was performed using Raman spectroscopy. A Self-Organizing Maps (SOMs) algorithm was implemented to identify multi-dimensional composition-property relationships.

RESULTS

The hardness and elastic modulus are positively correlated to crystallinity and negatively correlated with carbonate substitution. Furthermore, the effects from fluoridation on the age-dependent properties of enamel is non-linear and depends on its location. The contributions of fluoridation to the enamel properties are different in the cervical and non-cervical regions and appear to be unique within primary and senior adult teeth.

SIGNIFICANCE

Based on the findings, unsupervised learning methods can reveal complicated non-linear structure-property relationships in tooth tissues and help to understand the materials science of aging and its consequences.

Fracture Resistance of Titanium and Fiber Dental Posts: A Systematic Review and Meta-Analysis

PURPOSE

The fracture resistance of dental post systems is influenced by the material of the post. The purpose of this systematic review and meta-analysis was to assess if there is a difference in fracture resistance between prefabricated dental titanium posts and fiber posts.

METHODS

An online electronic search was performed using the PubMed, Scopus, and Web of Science databases for in vitro studies published from 2010 to 2020 in English. The retrieved eligible studies that compared the fracture resistance of titanium and fiber posts on human teeth were selected. The pooled standardized mean difference (SMD) with a 95% confidence interval was calculated. In addition, the trial sequential analysis (TSA) was performed to test if the available studies are sufficient to make conclusive evidence.

RESULTS

Of the 1165 retrieved studies, 17 studies were included in the qualitative analysis, while 16 studies were included in the quantitative analysis. Because of the high heterogeneity among studies, data from 10 studies were pooled and submitted to TSA. A total of 852 teeth were evaluated for fracture of the posts in 27 independent comparison groups. The pooled effect of the residual studies revealed no significant difference between titanium and fiber posts (SMD = -0.12; 95% CI = -0.30, 0.06; p = 0.20). Results of the TSA revealed no conclusive evidence.

CONCLUSIONS

The results of the current evidence revealed no significant difference between fiber and titanium posts. The evidence is insufficient, and more standardized in vitro studies are required.

Influence of obturating techniques on root dentin crack propagation: A micro-computed tomography assessment

Aim:

The aim is to assess and compare the microcrack formation in radicular dentin after obturating the root canals with cold lateral condensation (CLC), warm vertical condensation (WVC), and injectable gutta-percha (IGP) techniques using micro-computed tomography (CT).

Materials and Methods:

Human extracted mandibular premolar teeth (n = 60) were haphazardly assigned based on the obturation technique into three experimental groups (n = 20 each). Root canals are cleaned and shaped with M Two rotary files and 3% sodium hypochlorite irrigant. Cross-sectional images were taken with Micro-CT to record the baseline defects present on root samples. After root canal obturation either with CLC or WVC or injectable obturation techniques, micro-CT images were captured again to analyze the increase in the number and type of dentinal defects. Statistical analysis of data was performed using the Mann–Whitney U test and the Mcnemar test at 5% significance level.

Results:

An increase in the number of radicular micro-cracks was identified in samples obturated with lateral condensation technique (1.66%). No change in the percentage of micro-cracks was recorded after obturation with warm vertical or injectable guttapercha (IGP) techniques (P > 0.05). The three obturation techniques were not statistically different in the occurrence of micro-cracks after obturation.

Conclusion:

The three obturating techniques tested showed no significant increase in radicular dentin defects' occurrence or propagation.

Comparative Evaluation of Dentinal Microcrack Formation before and after Root Canal Preparation Using Rotary, Reciprocating, and Adaptive Instruments at Different Working Lengths-A Micro-computed Tomographic Study

INTRODUCTION

This study aimed to compare root dentinal microcrack formation after root canal shaping using rotary, reciprocating, and adaptive instruments at different working lengths using micro-computed tomographic imaging.

METHODS

One hundred eighty extracted mature mandibular molar mesial roots with 2 separate canals were selected. The mesial roots were resected at the cementoenamel junction and randomly divided into 4 groups (n = 45) based on the nickel-titanium file system used: ProTaper Universal (Dentsply Maillefer, Ballaigues, Switzerland), ProTaper Gold (Dentsply Maillefer), Twisted File Adaptive (SybronEndo, Orange, CA), and Reciproc Blue (VDW, Munich, Germany). Each of the 4 groups were then subdivided into 3 groups (n = 15) depending on the working length used for root canal preparation (ie, instrumentation 1 mm short, flush, and 1 mm beyond the major apical foramen). The roots were imaged with micro-computed tomographic scanning before and after root canal preparation. The cross-sectional images generated were screened to detect the presence of new microcracks.

RESULTS

The ProTaper Universal system significantly increased the number of postinstrumentation microcracks at all working lengths (P ≤ .05). No significant increase (P > .05) in postinstrumentation microcracks was observed in the ProTaper Gold, Twisted File Adaptive, or Reciproc Blue groups.

CONCLUSIONS

Rotary instrumentation induced a higher number of dentinal microcracks compared with reciprocating and adaptive instruments. Instrumentation at different working lengths did not significantly influence the formation of dentinal microcracks.

Shrinkage Strains in the Dentin of Endodontically Treated Teeth with Water Loss

INTRODUCTION

Dehydration has been considered as a potential contributor to vertical root fractures (VRFs) after root canal treatment (RCT). A loss of water could cause embrittlement of dentin and detrimental shrinkage strains. Senior patients have the highest risk of VRF. In this study, we characterized the spatial distribution in shrinkage of tooth roots with respect to donor age and prior RCT.

METHODS

Single-rooted human teeth with and without prior RCT were collected from young (age <25 years) and old (age >60 years) adults. Transverse slices were sectioned from the apical, middle, and coronal thirds of the roots, and digital image correlation was used to evaluate shrinkage during free convection. Crack initiation and growth analysis was performed via optical microscopy, and bound water in dentin was characterized by Raman spectroscopy.

RESULTS

The rate of shrinkage was significantly higher (p ≤ .05) in the apical third than in the middle and coronal thirds of all teeth regardless of donor age. The highest shrinkage strain occurred in the apical third of old donor teeth with prior RCT. In addition, the RCT-treated old teeth suffered the highest percentage of water loss with dehydration. Cracks initiated from the root surface and extended toward the canal with loss of water and shrinkage.

CONCLUSIONS

The apical third undergoes significantly larger shrinkage strains with dehydration than the remainder of the root. Prior RCT exacerbates the extent of shrinkage, particularly in the teeth of seniors and after clinical function, which could increase the propensity for VRF.

Aging and Senescence of Dental Pulp and Hard Tissues of the Tooth

The ability to consume a meal using one's own teeth influences an individual's quality of life. In today's global aging society, studying the biological changes in aging teeth is important to address this issue. A tooth includes three hard tissues (enamel, dentin, and cementum) and a soft tissue (dental pulp). With advancing age, these tissues become senescent; each tissue exhibits a unique senescent pattern. This review discusses the structural alterations of hard tissues, as well as the molecular and physiological changes in dental pulp cells and dental pulp stem cells during human aging. The significance of senescence in these cells remains unclear. Thus, there is a need to define the regulatory mechanisms of aging and senescence in these cells to aid in preservation of dental health.

Occurrence of Vertical Root Fractures after Apical Surgery: A Retrospective Analysis

INTRODUCTION

Vertical root fractures (VRFs) are among the most frequent causes of tooth loss, mainly of endodontically treated teeth. However, very few data is available about the occurrence of VRFs following apical surgery.

METHODS

Patient charts from 864 patients with 1058 teeth treated with apical surgery (September 1999 to December 2018) were retrospectively evaluated, if a VRF had occurred after surgery. The following, possibly influencing factors were analyzed: sex and age, type of treated tooth, primary versus resurgery, technique of root-end preparation, and timepoint of VRF diagnosis. Endpoints were either tooth extraction or the last follow-up.

RESULTS

The study cohort (55% women, 45% men) had a mean age of 52.00 ± 13.97 years (range 9-93 years). The overall rate of VRFs after apical surgery was 4% (42 of 1058 teeth). Among these 42 teeth, 33.3% were mandibular first molars and 26.2% were maxillary second premolars. The most frequently affected root was the mesial root of mandibular first molars (28.6%). With regard to the study parameters, significant differences of VRF rates were observed only for the type of tooth treated.

CONCLUSIONS

A low VRF rate of 4% was observed in this study. VRFs commonly occurred in maxillary premolars and mandibular molars, with the mesial root of mandibular first molars affected most frequently. This is in line with previous reports about VRFs in endodontically treated teeth without additional apical surgery.

Age-dependent root canal instrumentation techniques: a comprehensive narrative review

The aim of this article was to review age-dependent clinical recommendations for appropriate root canal instrumentation techniques. A comprehensive narrative review of canal morphology, the structural characteristics of dentin, and endodontic outcomes at different ages was undertaken instead of a systematic review. An electronic literature search was carried out, including the Medline (Ovid), PubMed, and Web of Science databases. The searches used controlled vocabulary and free-text terms, as follows: 'age-related root canal treatment,' 'age-related instrumentation,' 'age-related chemo-mechanical preparation,' 'age-related endodontic clinical recommendations,' 'root canal instrumentation at different ages,' 'geriatric root canal treatment,' and 'pediatric root canal treatment.' Due to the lack of literature with practical age-based clinical recommendations for an appropriate root canal instrumentation technique, a narrative review was conducted to suggest a clinical algorithm for choosing the most appropriate instrumentation technique during root canal treatment. Based on the evidence found through the narrative review, an age-related clinical algorithm for choosing appropriate instrumentation during root canal treatment was proposed. Age affects the morphology of the root canal system and the structural characteristics of dentin. The clinician's awareness of root canal morphology and dentin characteristics can influence the choice of instruments for root canal treatment.

Influence of different irrigation protocols on microhardness and flexural strength values of young and aged crown dentin

OBJECTIVE

To investigate the effect of different irrigation protocols on microhardness (MH) and flexural strength (FS) values of young and aged crown dentin.

BACKGROUND

In addition to ageing, root canal irrigation might also affect the mechanical properties of coronal dentin walls.

MATERIALS AND METHODS

One hundred and twenty dentin bars (2 mm × 2 mm × 8 mm) were obtained from the crowns of extracted, non-caries, human molars of young and older patients (n = 60 bars; average patient ages: 16.7 and 65.4, respectively). Subgroups were formed as follows: 2.5%NaOCl(sodium hypochlorite)+5%EDTA(ethylenediaminetetraacetic acid), 2.5%NaOCl + 15%EDTA, 2.5%NaOCl, 5%EDTA, 15%EDTA and Saline. NaOCl and saline were used for 20 minutes and EDTA solutions for 1 minute. MH values of each sample were measured before and after the irrigation protocols. The same samples were also submitted for FS analysis. The data were statistically analysed.

RESULTS

Young samples had lower MH values at pre- and post-treatment compared to aged samples (P < .05). A significant decrease was observed in MH values of aged samples exposed to 2.5%NaOCl and both NaOCl + EDTA combinations (P < .05). FS values of the young saline-treated group were statistically higher than aged ones (P < .05). Both NaOCl + EDTA combinations caused a significant decrease in FS values of young samples compared to saline (P < .05).

CONCLUSION

Ageing has a significant effect on the MH and FS values of crown dentin samples. 5% EDTA solutions revealed similar results to 15%EDTA regarding MH and FS values of crown dentin in both age groups. The NaOCl + EDTA combination had a prominent effect than EDTA alone, on MH values of young-, and FS values of aged dentin samples.

The effect of NaOCl and heat treatment on static and dynamic mechanical properties and chemical changes of dentine

OBJECTIVES

To determine the effect of heat on flexural strength (FS), maximum strain (MS), storage modulus (SM), tan delta (TD) and chemical changes through micro-Raman spectroscopy of dentine exposed to 2.5% NaOCl or saline.

METHOD

ology: Dentine bars were randomly allocated to 8 test groups. Half (groups 2,4,6,8) were treated with NaOCl for 20 min; the rest (groups 1,3,5,7) remained in saline. FS/MS were measured in groups 1-4 (n = 15) (3/4 were also heated to 200 °C & re-hydrated in saline). Micro-Raman spectroscopy was performed on bars from groups 1-4. SM/TD were measured in 5-8: in 5/6 (n = 10), repeated after heating (200 °C), then following re-hydration; in 7/8 (n = 3) after heating to 25-185 °C.

RESULTS

Increase in MS on heat and FS/MS on heat + NaOCl was not significant (P > 0.05). SM increased (P = 0.06) after heat treatment but reduced to initial state after rehydration (P = 0.03). TD did not change (P = 0.4) after heat (200 °C) treatment but rehydration increased it compared with pre-treatment state (P = 0.001). For dentine bars pre-treated with NaOCl, SM did not change (P = 0.6) after heat (200 °C) treatment or rehydration but TD significantly increased (P = 0.02) upon re-hydration compared with pre- (P=0.007), or post- (P = 0.03) heat-treatment states. SM and TD varied between 25-185 °C with no consistent trend amongst the NaOCl pre-treated bars. Micro-Raman only detected chemical changes following NaOCl treatment in the mineral phase.

CONCLUSIONS

Exposure of dentine bars to heat and NaOCl produced only moderate changes to quasi-static but marked changes to viscoelastic properties, which may be explained by chemical alterations.

Effect of intracanal cryotherapy on the fracture resistance of endodontically treated teeth

OBJECTIVE

The aim of this study is to evaluate the effect of intracanal cryotherapy on the fracture resistance of endodontically treated teeth.

MATERIALS AND METHODS

Sixty single-rooted maxillary lateral incisor teeth with single root canals were selected and randomly divided into two groups (n = 30). The specimens were immersed in distilled water, which was heated to 37 °C during the procedures. The root canals were chemomechanically prepared up to the apical size of 50 and assigned to either the control group or the cryotherapy group. The specimens in the cryotherapy group were irrigated with 20 mL sterile cold (2.5 °C) saline solution, which was delivered with an EndoVac system for 5 min, whereas the specimens in the control group received a sterile saline solution at room temperature. The fracture resistance of the specimens was then tested with a universal testing machine. The data was analyzed using the independent sample t test with a 5% significance threshold.

RESULTS

The fracture strength of the specimens in the intracanal cryotherapy group was significantly lower than that of the control group (p< .05).

CONCLUSIONS

Application of intracanal cryotherapy as a final irrigant reduced the vertical fracture resistance of prepared roots when compared to the control group.

The fate of root canals obturated with Thermafil: 10-year data for patients treated in a master's program

OBJECTIVES

Retrospective description of the 10-year success rate of endodontic treatments with Thermafil (TF).

MATERIALS AND METHODS

Patients treated by postgraduate students in an Endodontics Master's Program (2006-2008) were enrolled. All treated root canals were filled with TF and AH Plus. Teeth satisfying the inclusion criteria (206 teeth in 89 patients) were reexamined clinically and radiographically to estimate a 10-year survival and periapical health. Demographic and medical data were registered; collected information included pre-, intra-, and postoperative variables. Teeth were classified as "healthy" (PAI ≤ 2 in absence of signs/symptoms), "endodontically diseased" (presenting at least one of the following: PAI ≥ 3, signs/symptoms, retreated in the course of the follow-up, or extracted for endodontic reasons), or "non-endodontically diseased" (extracted for non-restorable fractures or periodontal disease). For teeth lost during the 10-year follow-up, details and reason of extraction were analyzed. Two PAI-calibrated examiners assessed outcomes blinded to preoperative status. Bivariate and multilevel analyses were performed (α level set at 0.05).

RESULTS

At 10 years, 179 (87%) teeth survived and 27 were extracted: 20 for non-endodontic reasons (excluded from success analysis) and 7 for endodontic reasons (considered "endodontically diseased"). Multilevel analysis revealed that the probability of extraction was increased by the presence of preoperative pain (odds ratio = 6.720; 95% confidence interval, 1.483-30.448) and by maxillary location (odds ratio = 2.950; 95% confidence interval, 1.043-8.347). Concerning periapical status, 159/186 teeth (85%) were assessed as "healthy." Multilevel analysis confirmed that maxillary location (odds ratio = 3.908; 95% confidence interval, 1.370-11.146), presence of flare up (odds ratio = 9.914; 95% confidence interval, 2.388-41.163), and fracture occurrence (odds ratio = 35.412; 95% confidence interval, 3.366-372.555) decreased the odds of healing, respectively.

CONCLUSIONS

After 10 years, teeth filled with Thermafil in a specialist master's program presented a survival and a periapical health comparable to cohorts where root canals were filled with other obturation techniques.

CLINICAL RELEVANCE

Carrier-based techniques provide time savings for clinicians while satisfying clinical quality criteria for the root filling and consequently the clinical outcome.

Effect of cryopreservation of teeth on the structural integrity of dentin

The autotransplantation of teeth after cryopreservation has become an increasingly viable method for whole tooth replacement. While the immediate success rates are quite high, damage introduced by cryopreservation within the dentin or enamel could be detrimental to the durability of these teeth.

OBJECTIVE

to determine whether cryopreservation alters the microstructure of dentin or causes a reduction of its resistance to mechanical failures.

METHODS

Third molars were obtained from young donors (18≤age≤30yrs) and subjected to a cryopreservation protocol involving storage for 10days in cryoprotectant solution at -196°C. After treatment, the mid-coronal dentin was characterized in terms of its elastic modulus, strength and fatigue behavior. Scanning electron microscopy and Raman spectroscopy were used to evaluate the microstructure and integrity of collagen after cryopreservation.

RESULTS

There was no significant difference in the elastic modulus or flexural strength between dentin from the cryopreserved and non-cryopreserved (control) teeth. However, the cryopreservation treatment caused a significant decrease in the fatigue strength of dentin with respect to the controls, with average reduction of nearly 20%. While there were no differences apparent in the collagen matrix or fracture surfaces between the cryopreserved and control groups, the microstructure of dentin from the cryopreserved teeth exhibited unique features and damage that appear to have caused the decrease in durability.

SIGNIFICANCE

Autotransplantation of cryopreserved teeth may be a viable option for whole tooth restorations, but hidden damage within the dentin could render these teeth more susceptible to mechanical failures by fatigue and fracture.

Deformation behaviour of aged coronal dentin

OBJECTIVE

This study aimed to identify the changes in the time-dependent deformation response of coronal dentin with ageing and its relationship with changes in chemical composition.

BACKGROUND

The structural behaviour of dentin with ageing is affected by changes in the density and diameter of its dentinal tubules (ie porosity), as well as changes in chemical composition throughout the tooth. However, little is known about the time-dependent deformation behaviour of aged dentin and the importance of its hierarchical structure and variations in chemical composition.

MATERIALS AND METHODS

The spherical indentation response of aged coronal dentin was analysed in the outer, middle and inner regions, and its time-dependent deformation response was modelled in terms of its microstructure and chemical composition using a model recently proposed for young dentin.

RESULTS

The viscous deformation behaviour of aged dentin followed a power-law response with a decrease in the stress exponent when compared to young dentin. These results can be explained by cross-linking of the collagen present in the tissue.

CONCLUSION

A decrease in the deformation ability of aged dentin was found. This behaviour could be a result of a dissolution process and reprecipitation of the minerals present in intertubular dentin into the dentinal tubules.