The effect of ultrasonic access cavity preparation on dentinal inner walls: a micro-CT study on cadaveric samples.

OBJECTIVE: The objective of this study is to evaluate the occurrence of coronal dentinal micro-cracks after access cavity refinement using high-speed burs and ultrasonic tips by means of micro-computed tomography (micro-CT) analysis. METHODS: In this study, 18 mandibular cadaveric incisors were divided into two groups according to the protocol of the preparation of the conventional access cavity. The diamond bur 802 # 12 was used until the perforation of the pulp roof. Then, the Endo-Z bur was used for the group #1 and the ultrasonic tip Start-X # 1 for the group #2 to finish and refine the access cavity. The preparation time of each access cavity has been recorded. The teeth underwent a micro-CT scan before and after the preparation of the access cavity. Fisher's exact test, the Chi-square test, the Kolmogorov-Smirnov test, the Mann-Whitney test, and the Student's test were used for statistical evaluation. RESULTS: The percentage of teeth with new micro-cracks is not significantly different between the two groups (-p-value < 0.5). The number of newly formed micro-cracks and extension size were not significantly different between the two groups. The direction of extension of the micro- cracks was occluso-apical. The average duration of the access cavity is significantly smaller with the Endo-Z system (-p- value < 0.001). The roughness of walls surfaces has no statistically difference between the two groups. CONCLUSION: The use of ultrasound, although slower, is considered safe in the creation of dentinal micro-cracks, in the preparation of the access cavity.

5-year retrospective evaluation of direct composite restorations in orthodontically treated patients.

OBJECTIVES: In patients affected by dimensional discrepancy between size of anterior maxillary and mandibular teeth, orthodontic therapy could be necessary to solve occlusal problems. However, anterior restorations are indicated to finalize the aesthetic aspect of the therapy. The aim of the present retrospective clinical study was to evaluate the long-term outcomes of direct additive composite restorations performed to correct anterior teeth discrepancies persisting after orthodontic treatment. METHODS: Patients with dimensional teeth discrepancy, subjected to a combined orthodontic-restorative treatment, between January 2009 and January 2019, were recalled for the present retrospective evaluation and divided in two groups according to the restoration performed: G1) diastema closure; G2) tooth shape modification. All patients, after ortho therapy, were subjected to a standardized restorative rehabilitation of the anterior area. All restorations were performed by a single experienced operator employing the same materials. During recall visits, two calibrated examiners evaluated the restorations and recorded USPHS data. Kaplan-Meier estimator and Cox-regression analysis were performed. Statistical significance was set for p < 0.05. RESULTS: 53 patient were included, with a total of 169 restoration (G1:110;G2:59). The mean study time period was 5 year (ranging from 6 month to 10 years). The overall survival rate of additive restoration was 2,59% (G1:2,07%; G2:0,47 p < 0.05). Chipping of the material was the most frequent adverse event (G1:13,64%; G2:1,69), followed by composite wear (G1:9,09%; G2:5,17). CONCLUSIONS: Based on the obtained results, good clinical performances were shown at a 5-year interval. A low number of failures were collected and most of them were classified as reparable. Only few cases needed complete reintervention. CLINICAL SIGNIFICANCE: Showing that a direct approach in restoring anterior teeth for diastema closure or shape modification is a valid alternative in terms of durability and aesthetics to more invasive procedure such as indirect restorations.

Postoperative quality of life following single-visit root canal treatment performed by rotary or reciprocating instrumentation: a randomized clinical trial.

AIM: To compare the impact of rotary and reciprocating instrumentation on postoperative quality of life (POQoL) after single-visit primary root canal treatment. METHODOLOGY: A randomized controlled clinical trial was designed and carried out in a University endodontic practice in northern Italy. Healthy subjects with asymptomatic irreversible pulpitis, symptomatic irreversible pulpitis or pulp necrosis with or without apical periodontitis (symptomatic or asymptomatic) scheduled for primary root canal treatment were enrolled. Single-visit root canal treatment was performed with ProTaper™ S1-S2-F1-F2 (rotary group, n = 23) and WaveOne™ Primary (reciprocating group, n = 24). Irrigation was performed with 5% NaOCl and 10% EDTA. Root canal filling was performed with the continuous-wave technique and ZOE sealer. POQoL indicators were evaluated for 7 days post-treatment. The variation of each indicator over time was compared using anova for repeated measures (P < 0.05). The impact of each variable on POQoL was analysed with a multivariate logistic regression model (P < 0.05). RESULTS: Pain curves demonstrated a more favourable time-trend in the rotary group (mean, P = 0.077; maximum, P = 0.015). Difficulty in eating (P = 0.017), in performing daily activities (P = 0.023), in sleeping (P = 0.021) and in social relations (P = 0.077), was more evident in the reciprocating group. Patients' perception of the impact of treatment on POQoL was more favourable in the rotary group (P = 0.006). Multirooted tooth type and pre-existing periradicular inflammation were associated with a decrease in POQoL. CONCLUSION: Reciprocating instrumentation affected POQoL to a greater extent than rotary instrumentation.

Longevity of class 2 direct restorations in root-filled teeth: A retrospective clinical study.

OBJECTIVES: To evaluate retrospectively the longevity of endodontically treated teeth restored with direct resin composite without cusp coverage, with or without the insertion of fibre posts. The null hypothesis was that direct restorations with fibre posts perform better than those without fibre posts. METHODS: Patients recruited for this study were treated in the Department of Cariology and Operative Dentistry, University of Turin, between 2008 and 2011. In total, 247 patients with 376 root treated posterior teeth, restored with direct resin composite, were recalled for a control visit. Only second-class cavities were considered. Two groups were defined based on the absence (Group A) or presence (Group B) of fibre post. Failures and complications, such as periodontal failure, endodontic failure, tooth extraction, root fracture, post fracture, post debonding, replacement of restoration, crown displacement, and coronal-tooth fracture, were noted. Functional restoration quality was evaluated following the modified USPHS criteria. Data were evaluated statistically with ANOVA. RESULTS: Group A consisted of 128 patients with 178 restorations (88 premolars, 90 molars) with a median follow-up of 34.44 months. Group B consisted of 119 patients with 198 teeth (92 premolars, 106 molars) with a median follow-up of 35.37 months. Direct restorations with fibre posts were statistically significantly more functional (95.12% success) than those without fibre posts (80% success) because of less marginal discolouration, better marginal integrity, and higher restoration integrity. CONCLUSIONS: The null hypothesis was accepted because direct post-endodontic restorations with fibre posts performed better than restorations without posts after 3 years of masticatory function. CLINICAL SIGNIFICANCE: An evaluation of the longevity of post endodontic direct restoration would seem to enhance the fiber post insertion within a composite restoration to reduce clinical failures.

Fibre post adaptation and bond strength in oval canals.

AIM: To evaluate ex vivo the bond strength and adaptation of fibre posts with oval and circular cross sections luted in oval canals with post spaces prepared using dedicated drills or ultrasonic tips. METHODOLOGY: Forty extracted premolars with oval canals were root filled, then randomly divided into four groups according to the post space preparation device and the shape of the luted fibre post: dedicated drill + round post, dedicated drill + oval post, ultrasonic tip + round post and ultrasonic tip + oval post. Posts were cemented with a self-adhesive cement (RelyX Unicem 2; 3M ESPE). Samples were sectioned in 1-mm-thick slices and observed under a microscope, and the area occupied by the post within the post space area was calculated. Bond strength was then measured using a push-out test, and the failure modes were evaluated with a stereomicroscope at 40× magnification. Fibre post adaptation and push-out test results were evaluated by analysis of variance (P < 0.05). RESULTS: Fibre posts, both round and oval, were better adapted to the apical region of the post space (P = 0.001). In oval canals, the bond strength was significantly higher in coronal regions, when the post space was prepared with a dedicated drill and an oval post was luted (P < 0.0001). Adhesive failures between cement and post were the most frequent type of failure in all groups. CONCLUSIONS: Circular and oval posts achieved similar adaptation to oval canals, but the use of ultrasonic tips and round posts resulted in reduced bond strength values.

Antibacterial efficacy and drug-induced tooth discolouration of antibiotic combinations for endodontic regenerative procedures.

Elimination of microbial contamination from the root canal system is a precondition for successful root canal treatment. Teeth with immature root development, necrotic pulps and apical periodontitis present multiple challenges for successful treatment. Disinfection is achieved by irrigation followed by the placement of an intracanal medicament. A mixture of ciprofloxacin, metronidazole and minocycline (3-MIX S) has been shown to be very effective in eliminating endodontic pathogens in vitro and in vivo. Among the components of the mixture, minocycline can induce tooth discolouration after long-term oral use. Therefore, the elimination of minocycline from the above-mentioned combination has been suggested to prevent the occasion of this undesirable effect. The aim of this study was to investigate the potential antimicrobial efficacy of alternative antibiotic combinations [3-MIX C (clarithromycin); 3-MIX F (fosfomycin)] against bacteria from infected root canals. An additional objective was to evaluate their discolouration potential as possible alternatives to minocycline-based intracanal medicaments. Our in vitro results clearly demonstrated that 3-MIX C and 3-MIX F had a greater antimicrobial activity than 3-MIX S, underlying that clarithromycin still had a higher capacity to kill endodontic pathogens in vitro compared to fosfomycin. Both 3-MIX C and 3-MIX F were able to avoid the permanent staining effect of the crown.

Active application of liquid etching agent improves adhesion of fibre posts to intraradicular dentine.

AIM: To assess the effectiveness of an active application of liquid etching, compared with the standard gel formulation on smear layer removal from post space walls and push-out bond strength of luted fibre posts. METHODOLOGY: Human extracted teeth were collected and root filled. After post space preparation and cleaning with 10% ethylenediaminetetraacetic acid for 30 s, teeth were assigned to four groups (n = 11) according to etching procedure: (i) 37% phosphoric acid (H3 PO4 ) gel; (ii) 37% H3 PO4 liquid applied with an endodontic needle; (iii) 37% H3 PO4 liquid applied with an Endovac; (iv) no etching procedure (control group). Three teeth per group were sectioned longitudinally and prepared for SEM examination to evaluate the presence of smear layer, debris, sealer/gutta-percha remnants, and the number of open tubules. Eight teeth per group were bonded with an etch-and-rinse adhesive, and fibre posts were luted with a resin-based cement. After cutting, specimens were prepared for a push-out test. Data were analysed by anova and post hoc tests (P < 0.05). RESULTS: Improved smear layer removal was obtained in Group 2, followed by Group 1, Group 3, and the control group (P < 0.05). The mean values for the bond strength of the push-out test were: Group 1, 8.3 ± 2.9 MPa (coronal); 7.7 ± 3.0 (middle); 3.3 ±1.9 MPa (apical); Group 2, 7.8 ± 2.1 MPa (coronal); 6.9 ± 3.9 MPa (middle); 3.7 ± 1.3 MPa (apical); Group 3, 9.7 ± 2.8 MPa (coronal); 8.6 ± 2.1 MPa (middle); 6.9 ± 2.3 MPa (apical); and Group 4, 2.9 ± 3.0 MPa (coronal); 2.6 ± 2.0 MPa (middle); 1.1 ± 2.0 MPa (apical). CONCLUSIONS: Liquid phosphoric acid applied with an endodontic needle yielded better canal wall smear layer removal and higher bond strength values when an etch-and-rinse system was used.

Atypical facial pain related to apical fenestration and overfilling.

AIM: To report a case of apical fenestration and overfilling in which unusual pain characteristics made differential diagnosis challenging. SUMMARY: A 32-year-old woman with diffuse, spontaneous, moderate pain in the maxillary left posterior sector, exacerbated by masticatory and facial muscle movement, with intense sporadic electric-shooting pain, underwent clinical examination and 3D cone beam computed tomography (CBCT). Apical fenestration with protrusion of the mesial root of tooth 26 beyond the buccal cortical plate, extrusion of canal filling material into the soft tissues and a periosteal reaction were detected. Surgery was performed under the operating microscope. The filling material and surrounding fibrous tissue were located, dissected from healthy soft tissues and removed. The mesiobuccal root apex was resected with a bur to within the bony crypt. A root end was prepared and filled with Tech Biosealer RootEnd™ (Isasan, Como, Italy). At the 2-week recall, the patient had complete resolution of the symptoms and good soft-tissue healing. The 1-year recall examination and intra-oral radiography confirmed complete resolution of the symptoms and health of periradicular tissues. KEY LEARNING POINTS: Apical fenestration may occur in 9% of cases and may be considered an anatomic predisposing factor for persistent pain after root canal treatment. This complication provides a considerable differential diagnostic challenge and is often misdiagnosed and mistreated. When correctly diagnosed through an accurate, multidisciplinary approach, it may be managed with a simple surgical procedure in which the endodontist should play a key role. Misdiagnosis and over treatment of apical fenestration, through the surgical management of chronic facial pain conditions, could lead to severe exacerbation of chronic pain, which may potentially become persistent or, indeed, intractable.

Comparative evaluation of the enamel margins roughness obtained with different finishing devices.

AIM: The aim of this in vitro study was to compare the surface roughness of enamel margins resulting by the use of rotating, sonic and ultrasonic devices for cavity margins finishing. METHODS: Forty-eight anterior intact teeth were selected for this study. Each item was sectioned 1 mm below the CEJ, perpendicular to the long axis of the tooth, with the carborundum separating disk mounted on the high-speed handpiece. With the same bur the crown was separated into two parts along the midline vertically. At the end 96 "half-crowns" were obtained. The samples were divided into 6 groups of 8 samples each, according to enamel margin's finishing technique (A and B: diamond ultrasonic tip; C: multisteel ultrasonic tip; D: fine diamond rotating bur; E: ultra-fine diamond rotating bur; F: sonicflex prep). The surface roughness evaluation of the enamel of each sample has been carried out by using a profilometer. The statistical analysis was performed with a balanced hierarchical ANOVA. RESULTS AND CONCLUSION: The results of this in vitro study showed that the enamel roughness obtained with sonic and ultrasonic devices was significantly higher than roughness obtained with rotating burs. Within the sonic and ultrasonic tips, the multisteel ones gave better results, that were comparable to diamond sonic device.

Influence of sodium hypochlorite on fracture properties and corrosion of ProTaper Rotary instruments.

AIM: To evaluate the influence of immersion in NaOCl on resistance to cyclic fatigue fracture and corrosion of ProTaper NiTi Rotary instruments. METHODOLOGY: A total of 120 new ProTaper NiTi Rotary files (F2) were randomized and assigned to three different groups of 40 each. Group 1 was the control group; 20 mm (excluding the shaft) of group 2 instruments were immersed in 5% NaOCl at 50 degrees C for 5 min; instruments in group 3 were completely immersed in 5% NaOCl at 50 degrees C for 5 min. All instruments were then tested for cyclic fatigue, recording the time in seconds to fracture. Data were analysed by the Kruskall-Wallis test and post-hoc multiple comparisons (P < 0.05). Micromorphological and microchemical analyses were also completed by means of a field emission scanning electron microscopy (SEM) on those instruments in group 3 that had undergone early fracture. RESULTS: Instruments in group 3 had a significantly lower resistance to fracture because of cyclic fatigue than those in groups 1 and 2 (P < 0.001). In some instruments in group 3, early fracture occurred after only a few seconds of fatigue testing. SEM observations revealed evident signs of corrosion of the fractured instruments. CONCLUSION: Group 3 had significantly reduced resistance to cyclic fatigue compared with instruments in groups 1 and 2. The phenomenon of early fracture may be attributed to galvanic corrosion induced by the presence of dissimilar metals, where one acts as the cathode of a galvanic couple, established when the instrument is immersed in NaOCl solution. The NiTi alloy may acts as the anode and thus undergoes corrosion.

The effect of high-frequency electrical pulses on organic tissue in root canals.

AIMS: To evaluate debris and smear layer scores after application of high-frequency electrical pulses produced by the Endox Endodontic System (Lysis Srl, Nova Milanese, Italy) on intact pulp tissue and organic and inorganic residues after endodontic instrumentation. METHODOLOGY: The study comprised 75 teeth planned for extraction. The teeth were randomly divided into two groups (60 teeth) and a control group (15 teeth): group 1 (30 teeth) was not subjected to instrumentation; group 2 (30 teeth) was instrumented by Hero Shaper instruments and apical stops were prepared to size 40. Each group was subdivided into subgroups A and B (15 teeth); two electrical pulses were applied to subgroups 1A and 2A (one in the apical third and one in the middle third, respectively, at 3 and 6 mm from the root apices); four electrical pulses were applied to subgroups 1B and 2B (two in the apical third, two in the middle third). The control group (15 teeth) was prepared with Hero Shapers and irrigated with 5 mL of EDTA (10%) and 5 mL of 5% NaOCl at 50 degrees C but not subjected to the electrical pulse treatment. Roots were split longitudinally and canal walls were examined at 80x, 200x, 750x, 1500x and 15,000x magnifications, using a scanning electron microscope. Smear layer and debris scores were recorded at the 3 and 6 mm levels using a five-step scoring scale and a 200-microm grid. Means were tested for significance using the one-way anova model and the Bonferroni post-hoc test. The differences between groups were considered to be statistically significant when P < 0.05. RESULTS: The mean value for debris scores for the three groups varied from 1.80 (+/-0.77) to 4.50 (+/-0.68). The smear layer scores for group 2 and the control specimens varied from 2.00 (+/-0.91) to 2.33 (+/-0.99). A significant difference was found in mean debris scores at the 3 and 6 mm levels between the three groups (P < 0.001). The Bonferroni post-hoc test confirmed that the difference was due to group 1. In the two subgroups treated with four high-frequency pulses (1B and 2B) a substantial reduction in mean debris scores was found at the 3 and 6 mm level; subgroup 2B was practically free of organic residue. No significant differences for mean smear layer and debris scores were recorded between group 2 and the control group at the two levels; a significant difference was found only for mean smear layer scores at the 3 mm level between subgroup 2B and the control group (P < 0.05). CONCLUSIONS: The Endox device used with four electrical pulses had optimal efficacy when used after mechanical instrumentation. Traditional canal shaping and cleaning was essential to ensure an effective use of high-frequency electrical pulses in eliminating residues of pulp tissue and inorganic debris.

Penetration ability of different irrigants into dentinal tubules.

Dentinal tubules of human root canal walls were infected with a known bacterial isolate. The teeth were divided into two groups and the root canals instrumentated. Different types of canal irrigant were used for each group. In group A, 5% NaOCl was followed by a 10% EDTA rinse and neutralized with a final physiological solution rinse. In Group B, 10% EDTA, a tensioactive agent (TRITON), and 5% NaOCl were used in sequence, with a final physiological solution rinse to neutralize the action of the agents used. Histological examination of group A specimens showed a residual area of infection extending from the canal lumen to a mean depth of 300 microns. Histological examination of group B specimens showed an infection-free area of tubules to a mean depth of 130 microns. Below this was an infected area of variable extent. In some group B sections, no infection was found.

Microleakage of human saliva through dentinal tubules exposed at the cervical level in teeth treated endodontically.

This study investigated the possibility of saliva recontamination occurring between the root canal wall and sealer through dentinal tubules exposed after the cementum was removed at the cervical level by root planing and treatment with citric acid. Thirty-four extracted human maxillary anterior teeth were randomly placed into five groups after chemomechanical preparation and obturation with gutta-percha and sealer; the sealer was allowed to set for 48 h. A ring 3 mm high, at the cervical level, was subjected to root planing, with complete removal of the cementum. All specimens were coated with two layers of nail polish and two layers of sticky wax, except for the ring subjected to root planing that was treated with citric acid for 30 s. The specimens were exposed to human whole saliva for 20 to 80 days and then immersed in dye to determine microleakage. Specimens were cleared and measurements made to the maximum point of dye penetration. All of the specimens exposed to saliva showed leakage except for the negative control, wherein no dye penetration was seen. Where leakage was found, the dye penetrated between the canal walls and the sealer to increasing depths, proportional to the time of exposure to the saliva. Statistical analysis confirmed these data, evidencing a difference between the means, which was highly significant for all pairs.

A scanning electron microscopic evaluation of the debridement capability of sodium hypochlorite at different temperatures.

The effect of raising the temperature of the irrigant solution on the smear layer was evaluated in the middle and apical third of 22 human upper incisors. A 5% sodium hypochlorite (NaOCl) solution was used at 21 degrees C and at 50 degrees C. After hand instrumentation and treatment with the irrigant, teeth were fractured into halves and examined by scanning electron microscopy. Characteristics of the smear layer in the two groups of specimens were compared. In the middle third, where NaOCl had been used at 50 degrees C, the smear layer was thinner and made of finer, less well-organized particles than where it had been used at 21 degrees C. In the apical third, the smear layer was of almost the same thickness in the two groups of specimens, although the particles were finer where the NaOCl had been used at 50 degrees C.

Computerized analysis of the instrumentation of the root canal system.

A method is proposed for a three-dimensional visualization of the root canal system before and after the cleaning and shaping procedure to analyze the relationships of the root canal walls. The first part of the study provided cross-sections of the root perpendicular to the root canal. A system for remounting the sections of the root before and after instrumentation was set up. Micrographs of the sections were transferred to a graphics computer which rebuilt and elaborated the sections, providing a three-dimensional model of the root with the image of the root canal system before and after instrumentation. This experimental computerized model enables sections of all kinds to be produced, with great possibilities for measurement and analysis.

Thickness of cementum/dentin in mesial roots of mandibular first molars.

The mesial roots of 15 human first lower molars, along with the corresponding half of the tooth crown, were studied to determine the thickness of dentin-cementum. A device was developed whereby these could be embedded in resin with a precisely known orientation in space. The roots were radiographed in mesiodistal and vestibular-lingual projections, then sectioned perpendicular to the canal axis in the coronal third. Thickness of dentin-cementum was compared on sections and radiograms; results showed that the amount of hard tissue is effectively about one fifth less than that appearing on the radiogram.

[Respecting apical foramina in the endodontic treatment of confluent canals]. / Il rispetto dell'apice dentario nella strumentazione dei canali confluenti.

Many dental components (lower incisors, mesial roots of the lower molars, upper bicuspids, the mesiobuccal root of the upper bicuspids, the mesiobuccal root of the upper first molars) have two root canals at cavity level to which two main canals correspond. These two canals either have two separate apical foramina or they merge in the apical third and have a single apical foramen. The endodontist's failure to recognize the latter anatomical characteristic results in deformation of the shared portion of the root canal and laceration of the apical foramen. This in turn leads to disappearance of the tapering cone shape, which acts as a "stop" for the filling material during condensation.