Analysis of forces developed during obturations. Wedging effect: Part I

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.

Effect of dentine cutting efficiency on the lateral force created by torque-controlled rotary instruments

AIM

To study the impact of dentine cutting efficiency of rotary instruments on the lateral force they create when instrumenting simulated root canals in bovine dentine.

METHODOLOGY

Lateral cutting efficiency of austenitic files (ProTaper Universal) was compared to that of counterparts of a reported identical geometrical design with a martensite phase component (ProTaper Gold) in bovine dentine disks (n = 6). Instrument shapes were studied using digital microscopy. The intracanal lateral force exerted by the two systems in simulated premolars (n = 9) made from bovine incisor roots containing a standardized narrow root canal of 16 mm length was monitored using a testing apparatus equipped with a torque-controlled endodontic motor/handpiece. Data were compared using parametric statistics, alpha error = 0.05.

RESULTS

The geometrical design of the two systems under investigation was found to be identical. The martensitic nickel-titanium rotary files had a significantly (t-test, P < 0.05) higher lateral cutting efficiency than austenitic counterparts. This difference, however, did not impact the lateral force that was created when instrumenting simulated premolar root canals. Furthermore, lateral force peaks were generated with the progressively tapered instruments under investigation towards the full working length. Even though a glide path was prepared, the first instrument in the full-length sequence (S1) created the highest lateral force (anova/Tukey's HSD, P < 0.05).

CONCLUSIONS

The current experimental set-up allows the study of the lateral force generated during root canal instrumentation. This force was not influenced by the dentine cutting efficiency of the instruments under investigation, but rather by their geometrical design.

Comparison of continuous wave and cold lateral condensation filling techniques in 3D printed simulated C-shape canals instrumented with Reciproc Blue or Hyflex EDM

Aim

To compare the efficiency of continuous wave obturation and cold lateral condensation techniques and filling time in C-shape canals of 3-dimensional (3D)-printed resin teeth shaped with Reciproc Blue (VDW) or Hyflex EDM (Coltene/Whaledent).

Methodology

One tooth with C1-type orifice and root canal morphology and one with C2-type orifice and C2-C3 root canal morphology were selected based on CBCT. Two replicas of selected teeth were manufactured with a 3D-printer and their canals were instrumented with Reciproc Blue or Hyflex EDM. These 4 instrumented replicas were scanned with CBCT. Identical 10 replicas of each group (total of 40) were produced using a 3D-printer and randomly divided into 2 groups (n = 5), root filled with either continuous wave obturation (CW) or cold lateral condensation (LC). Horizontal cross-sections of C1-type were made at 2, 4, 6, 8 mm and C2-type at 2, 4, 6 mm from the apical foramen. Gutta-percha, sealer and void areas were evaluated with image analysis sofware. Data were analysed using nonparametric Kruskal-Wallis and Mann Whitney-U tests and the Factorial ANOVA was used for interaction effects. Time required to fill canals was evaluated using the Mann-Whitney U test.

Results

For C1-type, LC had more gutta-percha and less sealer compared to CW in 2-mm sections (p<0.05). CW had greater percentages of gutta-percha and lower percentages of sealer compared with LC group in 4, 6, 8 mm sections and total area (p<0.05). LC group had higher percentages of voids compared to CW group in 2 and 4 mm sections (p<0.05). For C2-type, CW had more gutta-percha and less sealer versus LC group in all sections and total area (p<0.05). LC had the least gutta-percha and greatest sealer percentages at 6-mm sections (p<0.05). There was no statistically significant difference in the percentages of voids at any level of sections between the filling techniques (p>0.05). In both C-types, there was no significant difference in the percentages of gutta-percha, sealer and voids between Reciproc Blue and Hyflex EDM-shaped groups at any level (p>0.05). Time spent for the LC technique and filling C1-type was significantly longer than when using the CW technique and filling C2-type (p<0.05).

Conclusions

Continuous wave obturation was more effective than lateral condensation in both C1- and C2-type, except for the apical 2 mm section of C1-type, suggesting the need for a modified CW technique.

Dentinal Microcrack Formation During Root Canal Treatment with Mtwo Instruments and MicroSeal Filling Technique

Objective:

The purpose of this study was to evaluate dentinal microcrack formation during root canal treatment using Mtwo NiTi rotary instruments and MicroSeal filling technique.

Materials and Methods:

Forty-five single-rooted teeth were selected for the present study and divided into 3 different groups ( n = 15): Group 1, in which root canals were instrumented with Mtwo rotary files; Group 2, in which root canals were instrumented with Mtwo rotary files and filled using the MicroSeal technique; and Group 3, that acts as a control group in which no instrumentation nor obturation were performed. Then, roots were sectioned 3 mm, 6 mm, and 9 mm from the apex and the cut surface has been observed under a stereomicroscope to check for the presence or absence of dentinal microcracks. Number of dentinal microcracks was registered for each group at different levels and data were statistically analyzed using the Chi-square test with a level of significance set at P < .05.

Results:

No statistically significant differences were registered among groups ( P < .05). No microcracks were detected in Groups 1 and 3, while two dentinal microcracks were registered in Group 2.

Conclusions:

Mtwo rotary instruments and the MicroSeal root canal filling technique did not significantly induce dentinal microcrack formation.

Root-originating dentinal defects: methodological aspects and clinical relevance

It was in the 1980s when the association between root-filling procedures and dentinal microcracks was made. Nowadays, root-originating microcracks, also known as dentinal defects, are recognized as a possible precursor that is part of the longitudinal process of root-originating fractures. The presence of dentinal defects has been shown to significantly decrease the outcome through a periapical microsurgery model. Several in vitro articles have been published in the past years in regards to dentinal defects, but most of them have serious methodology concerns that will be discussed in this review.

A total grasp of the development and the role dentinal defects play in endodontics is crucial to the specialty. This review aims to discuss dentinal defects and their causative factors and the research models that have been used and their clinical significance. Through a comprehensive critical review of the literature, this article will express the need for further in vivo clinical research and better ex vivo methods that can replicate the clinical setting to answer several remaining questions about the development of and the role dentinal defects play in endodontics.

Effects of root canal preparation, various filling techniques and retreatment after filling on vertical root fracture and crack formation

AIM

To investigate the incidence of cracks in root dentin after rotary instrumentation and filling with cold lateral condensation (CL), single-cone obturation (SC), and warm vertical compaction (WV) and retreatment of each filling system.

METHODOLOGY

One-hundred sixty mandibular incisors were selected. Twenty teeth were left unprepared and served as a control, and the remaining 140 teeth were instrumented. Twenty teeth were assigned to an only prepared group. The remaining 120 teeth were assigned to three root canal filling groups and three retreatment groups (n = 20), as follows: CL, WV, SC, and retreatment of each filling system. All the roots were sectioned perpendicular to the long axis at 2, 4, 6, and 8 mm from the apex, and the sections were then observed under a stereomicroscope. The absence/presence of cracks and vertical root fractures were recorded, and the data were analyzed with a Pearson's chi-square test (P = 0.05).

RESULTS

No complete vertical root fractures were observed in the unprepared and only prepared groups. However, vertical fractures were observed in the filling and retreatment groups. There were significantly more cracks in the retreatment after WV group than the other groups, with the exception of the retreatment after SC, WV, and CL resulted in significantly more cracks than the only prepared and SC.

CONCLUSIONS

The filling techniques (except SC) caused more cracks than preparation only. The SC caused fewer cracks compared to the other filling techniques. The retreatment following the different filling techniques (except CL) caused more cracks than the original fillings.

Device and materials for in vitro evaluation of forces developed to teeth and periodontal structures during dental practices

This study aimed at providing a gauge device (Ekontak et al Gauge K-Device) in order to analyze the forces applied to teeth and periodontal tissues during dental practices in vitro. This force gauge device can be used in the investigation of the possible defect generation to tooth structures when overloaded forces are applied during dental procedures in vitro. Ekontak et al Gauge K-Device consists of three units: the specimen's holder, a high-performance digital force gauge, and the support frame. The holder was fabricated by an Al alloy providing a steady detachable attachment between the specimens and the force gauge's pin connector. The clinical simulation was achieved with the use of a proper silicone material, selected to provide similar elastic behavior with the human periodontal ligament and to join the teeth inside a solid matrix of an acrylic resin. The digital force gauge is a high-speed collection and recording (1000 Hz) product coupled with data recording software. The forces developed to 15 specimens' root canals during lateral condensation and vertical compaction of cold gutta-percha obturation procedures were monitored, saved as graphs, CSV, and excel files and presented over time. The forces developed during vertical compaction (mean maximum force per obturation circle = 13.22 N) were more excessive than those during lateral condensation (mean maximum force per obturation circle = 10.14 N). In conclusion, Ekontak et al Gauge K-Device is provided as a modern gauge device, capable of performing clinical simulation in vitro, under the terms of its protocol.

Incidence of dentinal defects after root canal filling procedures

AIM

To compare the incidence of dentinal defects (cracks and craze lines) after root canal preparation, lateral compaction and continuous wave compaction of gutta-percha and AH26 sealer.

METHODOLOGY

Two hundred mandibular premolar teeth were divided into four groups with similar average canal diameters (n=50). One group was left untreated and served as the control. The other three groups were prepared with ProTaper rotary instruments up to size F4. After preparation, one group was left unfilled while two groups were filled with gutta-percha and AH26 using either lateral compaction or the continuous wave technique. Roots were then sectioned at 3, 6 and 9 mm from the apex and inspected under a microscope. The appearance of dentinal defects was noted as well as the minimum and mean remaining dentine thickness. Chi-square tests were performed to compare the incidence of dentinal defects between the groups (α=0.05), and Pearson correlation test was performed to check the correlation between defects and root level or remaining dentine thickness.

RESULTS

The unprepared control group had no dentinal defects. The other groups exhibited significantly more defects than the unprepared group (P<0.05). There was no difference in the incidence of defects between the two filling techniques. There was no correlation between the appearance of defects and level of the root or remaining dentine thickness.

CONCLUSIONS

In extracted teeth, dentinal defects were observed in roots filled with gutta-percha and AH26 using the lateral compaction and continuous wave techniques.

An ex vivo comparison of three different gutta-percha cones when compacted at different temperatures: rheological considerations in relation to the filling of lateral canals

AIM

To compare ex vivo the penetration of three brands of gutta-percha cones, compacted under a constant force and heated to different temperatures, into artificial lateral canals.

METHODOLOGY

Resin blocks with simulated main canals, each having two lateral canals (C at 6.5 and A at 13 mm from the surface of the resin block), were selected. A gutta-percha cone, either Mynol MF, Hygenic MF or GT Tulsa 0.04 was compacted into each main canal for 5 s using a wire rod with a diameter of 0.7 mm soldered to the bottom of a metal cylinder, with a force of 2.7 kg at controlled temperatures of 37, 42, 47, 52, 60 degrees C. The penetration of each brand of gutta-percha into 60 lateral canals (10 at each temperature) was measured using a stereomicroscope. Statistical analysis was performed using the ANOVA, the Scheffè test and the t-test.

RESULTS

None of the three brands of cones entered up to 0.1 mm within either lateral canal until a temperature of 47 degrees C was reached; at that temperature only Mynol cones (P < or = 0.05) penetrated in four of 10 A-level canals (mean 0.13 +/- 0.19 mm) and in all 10 C-level canals (mean 0.43 +/- 0.12 mm). The A-level lateral canals were penetrated at 52 degrees C by Mynol cones (mean 0.76 +/- 0.34 mm) to a significantly greater distance (P < or = 0.05) than Tulsa cones (mean 0.31 +/- 0.12 mm) and Hygenic cones (mean 0.11 +/- 0.08 mm). At 60 degrees C the Mynol cones (mean 1.93 +/- 0.34 mm) penetrated significantly more (P < or = 0.05) than the Tulsa cones (mean 0.86 +/- 0.22 mm) and Hygenic cones (mean 0.67 +/- 0.19 mm). The C-level lateral canals were penetrated at 52 degrees C by Mynol cones (mean 0.91 +/- 0.29 mm) to a significantly greater distance (P < or = 0.05) than Tulsa cones (mean 0.47 +/- 0.16 mm) and Hygenic cones (mean 0.46 +/- 0.15 mm), whilst no significant difference was found at 60 degrees C.

CONCLUSIONS

When heated and compacted, the three gutta-percha cones penetrated the lateral canals to different degrees. They penetrated more than 0.43 mm into the lateral canals only at temperatures higher than 47 degrees C.

Analysis of the endogrammes developed during obturations on extracted teeth using system B

The ability of an obturation technique to fill the root canal system tridimensionally depends partially on the timing and intensity of force applications. The aim of this study was to use the Endographe to analyze the forces and wedging effects developed in the root canal using a new obturation technique: System B. This system uses a heat plugger that simultaneously heats and pushes gutta-percha. The plugger was used to soften and move the gutta-percha apically during the down-pack stage. Two different methods, however, were used to withdraw the plugger from the compacted gutta-percha. One used the burst heat method, and the other was cold withdrawal. Five endodontists performed 50 obturations of prepared extracted teeth and 50 obturations of the "wedging effect" holder of the Endographe. The practitioner-obturation assignment was randomized. For each obturation the biggest plugger possible in relationship to the shape of the canal was chosen. For the obturation of the special holder the same tip was chosen. Endogrammes showed the force application and wedging effect sequences. The mean values for the vertical and horizontal forces and the wedging effect were, respectively, 16 +/- 2 N, 5 +/- 1 N, and 9 +/- 1 N. These results suggest that System B is one of the best techniques in terms of the developed vertical forces (low values) and the resulting wedging effect (high values) in relationship to the plasticity of the gutta-percha. The Endogrammes provide a new approach to the analysis of obturation techniques and a means to demonstrate correct and optimal manipulation of the new System B plugger.