Exploring access cavity through non-carious cervical lesions: Impacts on instrumentation, obturation, and fracture resistance in mandibular incisors.

AIM: To compare the effects of Cervical Access Cavity (CervAC) and Traditional Access Cavity (TradAC) on root canal preparation, root canal filling, and fracture resistance in mandibular incisors. METHODOLOGY: Twenty recently extracted and intact mandibular incisors were initially scanned using a micro-CT device. The specimens were anatomically matched to create two groups (n = 10). A wedge-shaped non-carious cervical lesion (NCCL) was created on the buccal aspect of all teeth using a double-faced segmented diamond disc. In group 1, a TradAC was prepared, whilst in group 2, access was created through the simulated NCCL using a round diamond bur 1012. After root canal preparation with Rotate instruments sizes 15/0.04, 20/0.04, and 25/0.04, the teeth were scanned again and evaluated for root canal volume and surface area, static voxels, volume of removed dental tissue, and dentine thickness. After that, the root canals were filled using the single-cone technique, teeth were restored with composite resin, and subsequently rescanned to calculate the volume of filling materials and voids. Then, the restored teeth were subjected to fracture resistance tests using a universal testing machine. Statistical comparisons between groups were performed with the Mann-Whitney test or the Student's t-test, with a statistical significance level of 5%. RESULTS: Statistical comparisons indicated no significant differences between groups in terms of root canal volume, surface area, static voxels, removed root dentine, root canal filling volume, percentage of voids, or fracture resistance load (p > .05). Conversely, teeth prepared with TradAC showed a significantly higher percentage of dental tissue removed from the crown (p = .001) and a greater volume of filling material remnants in the pulp chamber (p < .001) compared to the CervAC group. A significantly lower percentage reduction in dentine thickness was observed only on the mesial aspect of root at Level 1 in TradAC group (p = .008). CONCLUSIONS: CervAC can be considered a viable alternative approach in the presence of NCCL in mandibular incisors.

Dynamic Photoelastic Analysis of Stress Distribution in Simulated Canals Using Rotary Instruments with Varied Tip and Taper Sizes: A Quasi-3D Approach.

INTRODUCTION: To compare the stress produced on the walls of simulated canals by rotary instruments with varied tip and taper sizes. METHODS: Ninety isotropic transparent blocks, each containing a 60-degree curved canal, were distributed into 18 groups (n = 5) based on the instrument tip (sizes 10, 15, 20, 25, 30, and 35) and taper (sizes 0.02, 0.04, and 0.06). The blocks were fixed in a circular polariscope setup for dark field analysis. A digital camera was employed to capture the real-time birefringence patterns generated by each instrument. Digital image frames, corresponding to the instrument reaching the end of each canal third, were extracted and evaluated by 2 independent observers for the stress generation on canal walls. The data analysis employed a semi-quantitative scale ranging from 0 to 5. Cohen's Kappa coefficient test was used to determine the inter-observer agreement while the results were compared using Kruskal-Wallis test followed by an all-pairwise posthoc procedure (α = 5%). RESULTS: Inter-observer agreement was 0.95. A significant influence of the tip size on stress was observed across the coronal (P = .011), middle (P = .006), and apical (P = .026) thirds. In contrast, taper size did not affect the stress induced at the coronal (P = .509), middle (P = .958), or apical (P = .493) thirds. The variations in tip and taper sizes did not result in a significant stress differences among the thirds (P = .181). CONCLUSIONS: The stress significantly increased across all canal thirds with larger tip sizes of rotary instruments, whereas the taper sizes did not influence the stress when compared to the canal thirds.

Comprehensive Assessment of Cyclic Fatigue Strength in Five Multiple-File Nickel-Titanium Endodontic Systems.

The resistance of nickel-titanium endodontic instruments against cyclic fatigue failure remains a significant concern in clinical settings. This study aimed to assess the cyclic fatigue strength of five nickel-titanium rotary systems, while correlating the results with the instruments' geometric and metallurgical characteristics. A total of 250 new instruments (sizes S1/A1, S2/A2, F1/B1, F2/B2, F3/B3) from ProTaper Gold, ProTaper Universal, Premium Taper Gold, Go-Taper Flex, and U-Files systems underwent mechanical testing. Prior to experimental procedures, all instruments were meticulously inspected to identify irregularities that could affect the investigation. Using a stereomicroscope, design characteristics such as the number of spirals, length, spirals per millimeter, and average helical angle of the active blade were determined. The surface finishing characteristics of the instruments were examined using a scanning electron microscope. Differential scanning calorimetry was employed to establish the instruments' phase transformation temperatures, while energy-dispersive X-ray spectroscopy was utilized to analyze the elemental composition of the alloy. The instruments were subjected to cyclic fatigue testing within a stainless steel non-tapered artificial canal featuring a 6 mm radius and 86 degrees of curvature. Appropriate statistical tests were applied to compare groups, considering a significance level of 0.05. The assessed design characteristics varied depending on the instrument type. The least irregular surface finishing was observed in U-Files and Premium Taper Gold files, while the most irregular surface was noted in Go-Taper Flex. All instruments exhibited near-equiatomic proportions of nickel and titanium elements, whereas ProTaper Universal and U-Files instruments demonstrated lower phase transformation temperatures compared to their counterparts. Larger-sized instruments, as well as ProTaper Universal and U-Files, tended to display lower cyclic fatigue strength results. Overall, the design, metallurgical, and cyclic fatigue outcomes varied among instruments and systems. Understanding these outcomes may assist clinicians in making more informed decisions regarding instrument selection.

Clinical strategies for successful palato-mesiobuccal canal management-Report of 2 cases.

AIM: To describe the management of the palato-mesiobuccal (PMB) canal in maxillary second molars with fused roots using conventional techniques. SUMMARY: Root canal treatment success hinges upon effectively addressing the intricate and variable anatomy of molar teeth. Failure to do so can lead to persistent infections and treatment failure. Recent advancements in imaging technologies have provided unparalleled insights into dental anatomy, especially in molars. Among these discoveries is the PMB canal, a unique anatomical variant recently reported for the first time in Endodontic literature. This canal, found in maxillary second molars with fused roots and originating from the coronal third of the palatal canal while traversing towards the mesiobuccal root presents challenges in clinical management due to its location. This article is the first to showcase the management of the PMB canal using conventional techniques. In the first case, a 38-year-old male patient presented with asymptomatic irreversible pulpitis in the maxillary second right molar. Following thorough instrumentation and irrigation, the presence of the PMB canal was discovered during root canal preparation. The canal was managed using rotary instruments and obturated successfully, resulting in a symptom-free tooth at an 8-year follow-up. The second case illustrates a similar scenario in a 23-year-old female patient presenting with symptomatic irreversible pulpitis in tooth 17. The PMB canal was identified during treatment and managed using rotary nickel-titanium instruments, leading to a favourable outcome at a 9-year follow-up. KEY LEARNING POINTS: In fused roots of maxillary second molars, a PMB canal might be expected. Exploration of the buccal wall of the palatal canal under magnification after shaping procedures can reveal the PMB canal orifice in fused roots. Small tapers are suggested for the enlargement of the PMB canal. Continuous bleeding spots in the palatal canal might indicate a possible PMB canal orifice in vital cases. The use of an apex locator is suggested for the differential diagnosis of the PMB canal orifice from a perforation site.

Multimethod analysis of large- and low-tapered single file reciprocating instruments: Design, metallurgy, mechanical performance, and irrigation flow.

AIM: To compare eight large- and low-tapered heat-treated reciprocating instruments regarding their design, metallurgy, mechanical properties, and irrigation flow through an in silico model. METHODOLOGY: A total of 472 new 25-mm E-Flex Rex (25/.04 and 25/.06), Excalibur (25/.05), Procodile (25/.06), Reciproc Blue R25 (25/.08v), WaveOne Gold Primary (25/.07v), and Univy Sense (25/.04 and 25/.06) instruments were evaluated regarding their design (stereomicroscopy, scanning electron microscopy, and 3D surface scanning), metallurgy (energy-dispersive X-ray spectroscopy and differential scanning calorimetry), and mechanical performance (cyclic fatigue, torsional resistance, cutting ability, bending and buckling resistance). Computational fluid dynamics assessment was also conducted to determine the irrigation flow pattern, apical pressure, and wall shear stress in simulated canal preparations. Kruskal-Wallis and one-way anova post hoc Tukey tests were used for statistical comparisons (α = 5%). RESULTS: Instruments presented variations in blade numbers, helical angles, and tip designs, with all featuring non-active tips, symmetrical blades, and equiatomic nickel-titanium ratios. Cross-sectional designs exhibited an S-shaped geometry, except for WaveOne Gold. Univy 25/.04 and Reciproc Blue displayed the smallest and largest core diameters at D3. Univy 25/.04 and E-Flex Rec 25/.04 demonstrated the longest time to fracture (p < .05). Reciproc Blue and Univy 25/.04 exhibited the highest and lowest torque to fracture, respectively (p < .05). Univy 25/.04 and Reciproc Blue had the highest rotation angles, whilst E-Flex Rec 25/.06 showed the lowest angle (p < .05). The better cutting ability was observed with E-Flex Rec 25/.06, Procodile, Excalibur, and Reciproc Blue (p > .05). Reciproc R25 and E-Flex Rec showed the highest buckling resistance values (p < .05), with WaveOne Gold being the least flexible instrument. The impact of instruments' size and taper on wall shear stress and apical pressure did not follow a distinct pattern, although Univy 25/.04 and E-Flex Rec 25/.06 yielded the highest and lowest values for both parameters, respectively. CONCLUSIONS: Low-tapered reciprocating instruments exhibit increased flexibility, higher time to fracture, and greater angles of rotation, coupled with reduced maximum bending loads and buckling strength compared to large-tapered instruments. Nevertheless, low-tapered systems also exhibit lower maximum torque to fracture and inferior cutting ability, contributing to a narrower apical canal enlargement that may compromise the penetration of irrigants in that region.

Worldwide Anatomic Characteristics of the Mandibular Canine-A Multicenter Cross-Sectional Study with Meta-Analysis.

INTRODUCTION: This study aimed to examine the global prevalence of root and root canal morphologies in mandibular canines and analyze potential influences of region, ethnicity, sex, and age on the proportion of a second root and root canal configuration. METHODS: Observers from 44 countries screened 13,200 canines using cone-beam computed tomographic exams and gathered data on the percentages of 2 root canal morphologies and 2-rooted configurations (primary outcomes), as well as the root canal configurations (secondary outcome). Demographic factors (ethnicity, sex, and age) were collected for each participant. Primary outcomes were represented as odds ratios and untransformed proportions accompanied by 95% confidence interval (CI) forest plots. Meta-analysis compared subgroups and identified sources of heterogeneity. Intra- and inter-rater tests were conducted. Statistical significance was set at 5%. RESULTS: The worldwide prevalence of a second canal was 7.5% (95% CI, 6.3%-8.7%), ranging from 0.7% in Nigeria to 17.7% in Uruguay. The meta-analysis also revealed significant variations when comparing ethnicity, gender, and age (P < .05). The global prevalence of a second root was 1.9% (95% CI, 1.5%-2.3%), with the highest proportion observed in Spain (6.7%). Caucasian and Indian (south Asian) ethnic groups, females, and older patients exhibited higher proportions of 2 roots (P < .05). Meta-regression excluded side, voxel size, and field of view as sources of heterogeneity (P > .05). CONCLUSIONS: The prevalence of 2 root canals and 2-rooted configurations in the mandibular canine exhibited variations based on geographic location, ethnicity, sex, and age. The global prevalence of 2 root canals and 2-root configuration was 7.5% and 1.9%, respectively.

Worldwide Assessment of the Root and Root Canal Characteristics of Maxillary Premolars - A Multi-center Cone-beam Computed Tomography Cross-sectional Study With Meta-analysis.

INTRODUCTION: This worldwide study examined the root and root canal characteristics of maxillary premolars and explored how demographic factors impact the outcomes. METHODS: Observers from 44 countries assessed 26,400 maxillary premolars using cone-beam computed tomography and employed a standardized screening method to gather data on multiple canal morphology and 3-rooted configuration (primary outcomes), as well as secondary outcomes related to root and root canal anatomies. Demographic factors such as ethnicity, sex, and age were collected for each participant. The intra- and inter-observer tests ensured observer reliability. Primary outcomes were represented as odds ratios and untransformed proportions accompanied by 95% confidence interval (CI) forest plots. Meta-analysis compared sub-groups and identified sources of heterogeneity (α = 5%). RESULTS: The overall prevalence of multiple canal morphology in the first premolar was 93.5% (95% CI, 93.3%-94.7%), while in the second premolar, it was 49.7% (95% CI, 44.9%-54.6%). The proportion of 3-rooted configuration was 1.8% (95% CI, 1.4%-2.1%) in the first premolar and 0.4% (95% CI, 0.3%-0.5%) in the second. Asian countries generally displayed fewer roots and root canals, while European nations showed higher counts (P < .05). Males exhibited higher percentages and odds ratios for both outcomes in both premolars. Younger patients demonstrated lower percentages of multiple root canal morphologies (P < .05). Factors such as tooth side, voxel size and field-of-view did not influence the outcomes (P > .05). CONCLUSIONS: The worldwide assessment of root and root canal characteristics of maxillary premolars has revealed a discernible influence of various factors such as tooth type, geographical region, ethnicity, sex, and age.

To flat or not to flat? Exploring the impact of flat-side design on rotary instruments using a comprehensive multimethod investigation.

AIM: To assess the influence of a flat-side design on the geometry, metallurgy, mechanical performance and shaping ability of a novel nickel-titanium rotary instrument. METHODOLOGY: Sixty-five new 25-mm flat-side rotary instruments (size 25, taper 0.04) and their nonflat-side prototypes (n = 65) were assessed for major deformations and examined regarding macroscopic and microscopic design, determination of nickel and titanium elements ratio, measurement of phase transformation temperature and evaluation of mechanical performance parameters including time/cycles to fracture, maximum torque, angle of rotation, maximum bending and buckling strengths and cutting ability. Additionally, unprepared canal areas, volume of hard tissue debris and percentage reduction of dentine thickness were calculated for each tested instrument after preparing mesial canals of mandibular molars (n = 12), using micro-CT imaging. Statistical analyses were performed using the U-Mann-Whitney test and independent Student t-test (α = 5%). RESULTS: The number of spirals (n = 8) and blade direction (clockwise) were similar between both flat and nonflat instruments, whilst the helical angles were equivalent (⁓25°). Flat-instruments showed inconsistencies in the homogeneity of the gold colour on the flat-side surface, blade discontinuity, and incomplete and variable S-shaped cross-sections. The titanium-to-nickel ratios were equivalent, but significant differences in the R-phase finish and austenitic start phase transformation temperatures were observed between the flat and nonflat-side instruments. The flat-side instruments demonstrated superior cutting ability compared to the nonflat instruments, as well as, significantly lower values for time to fracture, rotation to fracture and maximum torque to fracture (p < .001). No statistical difference was observed between tested instruments regarding angle of rotation (p = .437), maximum bending (p = .152) and buckling load (p = .411). Preparation protocols using flat and nonflat instruments did not show any statistically significant differences (p > .05). All flat-side instruments exhibited deformation after shaping procedures. CONCLUSIONS: The flat-side instrument showcased enhanced cutting ability compared to its nonflat counterpart. However, it exhibited inferior performance in terms of time, rotation and maximum torque to fracture, along with distinct phase transformation temperatures. No differences were observed in the titanium-to-nickel ratios, angle of rotation, maximum bending, buckling load, preparation time, percentage of untouched canal walls, volume of hard tissue debris and percentage reduction of dentine thickness.

Quasi-3D dynamic photoelastic analysis of stress distribution during preparation of simulated canals with 13 mechanical preparation systems.

AIM: The aim of this study is to compare the stress produced on the internal walls of simulated canals by nine rotary and four reciprocating systems. METHODOLOGY: Sixty-five isotropic transparent blocks containing a 60° curved and tapered simulated canal were selected and distributed into 13 groups (n = 5) according to the preparation system: BioRace, HyFlex EDM, iRaCe, Mtwo, One RECI, ProTaper Next, RaCe EVO, Reciproc, Reciproc Blue, R-Motion, VDW.ROTATE, XP-Endo Rise Shaper, and XP-Endo Shaper. Each resin block was mounted in a vice and a digital camera recorded the entire sequence of each preparation system through a circular polariscope set for dark field analysis. The video frames when each instrument reached the end of the coronal, middle, and apical thirds of the canal were extracted from the recordings and analysed by two independent observers regarding the stress generated on the canal walls using a semi-quantitative evaluation on a 0-5 scale. Intra- and inter-observer agreement were subjected to the Cohen's Kappa coefficient test, whilst the experimental results were compared using Kruskal-Wallis test post hoc pairwise comparisons with Bonferroni correction (α = 5%). RESULTS: The inter- and intra-observer agreement were 0.98 and 1, respectively. Most instruments demonstrated acceptable performance (scores ≤ 2) in all thirds. Other instruments, such as the HyFlex EDM 25.12 (coronal and middle thirds), Reciproc Blue R25 and Reciproc R25 (coronal and apical thirds), R-Motion 30.04 (apical third), and VDW.ROTATE 20.05 (apical third) showed scores higher than 3. Statistical analysis revealed a significant difference amongst the tested systems at the coronal, middle, and apical thirds (p < .05). CONCLUSION: None of the canal instrumentation protocols were stress-free, showing varying levels of stress concentrations. Various factors seemed to influence the magnitude of stress and its distribution pattern on the canal walls. Overall, instruments characterized by a larger taper, lower speed, reciprocating motion, and made of heat-treated NiTi alloy exhibited higher patterns of stress distribution.

3D Surface Scanning-A Novel Protocol to Characterize Virtual Nickel-Titanium Endodontic Instruments.

The nickel-titanium (NiTi) instruments' geometry plays an important role in their performance and behavior. The present assessment intends to validate and test the applicability of a 3D surface scanning method using a high-resolution laboratory-based optical scanner to create reliable virtual models of NiTi instruments. Sixteen instruments were scanned using a 12-megapixel optical 3D scanner, and methodological validation was performed by comparing quantitative and qualitative measurements of specific dimensions and identifying some geometric features of the 3D models with images obtained through scanning electron microscopy. Additionally, the reproducibility of the method was assessed by calculating 2D and 3D parameters of three different instruments twice. The quality of the 3D models created by two different optical scanners and a micro-CT device was compared. The 3D surface scanning method using the high-resolution laboratory-based optical scanner allowed for the creation of reliable and precise virtual models of different NiTi instruments with discrepancies varying from 0.0002 to 0.0182 mm. The reproducibility of measurements performed with this method was high, and the acquired virtual models were adequate for use in in silico experiments, as well as for commercial or educational purposes. The quality of the 3D model obtained using the high-resolution optical scanner was superior to that acquired by micro-CT technology. The ability to superimpose virtual models of scanned instruments and apply them in Finite Element Analysis and educational purposes was also demonstrated.

Worldwide Prevalence of the Lingual Canal in Mandibular Incisors: A Multicenter Cross-sectional Study with Meta-analysis.

INTRODUCTION: This cross-sectional study assessed the influence of patient demographics on the worldwide prevalence of a lingual canal in mandibular incisors. METHODS: Twenty-six thousand four hundred mandibular incisors were evaluated using cone-beam computed tomography imaging by precalibrated observers from 44 countries. A standardized screening method was employed to collect data on the presence of a lingual canal, the anatomic configuration of the root canal, and number of roots. Patient demographic information (age, sex, and ethnicity) was also recorded. Multiple intra and interrater tests assessed the reliability of the observers and groups, and a meta-analysis was used to examine differences and heterogeneities (α = 5%). RESULTS: The prevalence of the lingual canal in mandibular central and lateral incisors varied from 2.3% (0.06%-4.0%; Nigeria) to 45.3% (39.7%-51.0%; Syria) and from 2.3% (0.06%-4.0%; Nigeria) to 55.0% (49.4%-60.6%; India), respectively. Ethnicity had a significant impact on the prevalence of the lingual canal, with African, Asian, and Hispanic groups having the lowest proportions (P < .05), while Caucasians, Indians, and Arabs showed the highest (P < .05) for both incisor groups. Additionally, males had a significantly higher odds ratio for both the central (1.334) and lateral (1.178) incisors, while older patients had a lower prevalence for both tooth groups (P < .05). The side and tooth group did not influence on the outcomes. CONCLUSIONS: The prevalence of lingual root canals in mandibular incisors varies significantly based on geographic location, ethnicity, age, and gender. The overall prevalence was 21.9% for mandibular central incisors and 26.0% for lateral incisors.

Success rate of permanent teeth pulpotomy using bioactive materials: A systematic review and meta-analysis of randomized clinical trials.

BACKGROUND: The results of vital pulp treatments in permanent teeth have been encouraging. Currently, pulpotomy treatment for permanent teeth primarily utilizes mineral trioxide aggregate (MTA) as the dressing material, followed by calcium hydroxide. While other calcium-silicate-based cements have been suggested for pulpotomy, there is a limited number of studies evaluating their long-term effectiveness. OBJECTIVES: The objective of this systematic review and meta-analysis was to evaluate the success rate of pulpotomies performed on permanent teeth, comparing the use of ProRoot MTA with that of calcium hydroxide and other bioceramic materials. METHODS: A comprehensive search was conducted in several electronic databases, including PubMed, Cochrane Library, Scopus, Web of Science, Embase and Science Direct until December 2022. The search was guided by PICOS criteria, including only randomized clinical trials (RCTs) that evaluated the success rate of pulpotomy treatments in permanent teeth using ProRoot MTA in comparison to calcium hydroxide and other bioceramic materials. The quality of the included studies was assessed using the RoB-2 tool to evaluate the risk of bias, and relevant data were extracted and analysed in RevMan software 5.3 using fixed-effect models. The GRADE tool was used to determine the overall quality of evidence. RESULTS: The initial search retrieved 1072 studies and, after eliminating duplicates, 677 studies were screened and 28 studies were considered for eligibility. In the final selection process, 16 studies were included in the systematic review, with 10 being determined as having a high risk of bias. Pulpotomy showed an overall mean success rate of 92% after 1 year. The meta-analysis indicated a significantly higher success rate for pulpotomies utilizing MTA in comparison with calcium hydroxide, while no significant difference was seen between MTA and calcium-enriched mixture (CEM) or Biodentine. The GRADE assessment revealed an overall low level of evidence for the included studies. DISCUSSION: Most randomized controlled trials exhibited a significant absence of control over confounding factors. CONCLUSIONS: This systematic review and meta-analysis demonstrate that pulpotomy is a highly effective treatment for managing permanent teeth. The results indicate that the success rate of pulpotomy using ProRoot MTA is significantly higher than when using calcium hydroxide. However, the certainty of evidence supporting these findings is low, and there is a need for well-designed RCTs to assess the long-term outcomes of pulpotomy using newer bioceramic materials. REGISTRATION: This systematic review was registered in the PROSPERO database (registration number CRD42023393970).

Comparative analysis of reciprocating and flat-side heat-treated rotary single-file systems: Design, metallurgical characteristics, and mechanical performance.

AIM: To compare two flat-side single-file rotary instruments with three single-file reciprocating systems through a multimethod assessment. METHODOLOGY: A total of 290 new NiTi single-file rotary (AF F One Blue 25/0.06 and Platinum V.EU 25/0.06) and reciprocating (One Files Blue R25, Reciproc Blue R25, Reciproc R25) instruments were selected, carefully examined for any major deformations, and evaluated regarding their macroscopic and microscopic design, nickel and titanium elements ratio, phase transformation temperatures, and mechanical performance (time/rotation to fracture, maximum torque, angle of rotation, microhardness, maximum bending, and buckling strengths). One-way anova post hoc Tukey, T-test, and nonparametric Mood's median tests were used for statistical comparisons (α = 5%). RESULTS: Tested instruments had identical blade counts and near-identical helical angles of approximately 24° (rotary instruments) and 151° (reciprocating instruments). The flat-side analysis revealed a few inconsistencies, such as discontinuity segments, different orientations, and gaps in the homogeneity of the bluish colour. Microscopically, flat-side instruments exhibited blade discontinuity and an incomplete S-shaped cross-section. The surface finish was smoother for One Files Blue and more irregular for both rotary instruments. There were distinct phase transformation temperatures amongst all instruments. All heat-treated instruments were in R-phase arrangement, and Reciproc was in R-phase plus austenite at test temperature (20°C). Compared with the reciprocating instruments, both flat-side instruments exhibited lower results in the cyclic fatigue tests using two different clockwise kinematics, maximum torque, angle of rotation, and maximum buckling strength (p < .05). The rotary systems also exhibited low flexibility (p < .05). AF F One Blue had the lowest microhardness, whilst Reciproc had the highest value. CONCLUSION: This multimethod investigation revealed that the flat-side rotary instruments underperformed the reciprocating instruments regarding cyclic fatigue (with two different clockwise kinematics), maximum torque, angle of rotation, maximum buckling strength, and flexibility. Manufacturing inconsistencies were also observed in some of the flat-side instruments, including discontinuity segments, different orientations, and in the homogeneity of their bluish colour given by the heat treatment.

Identification and Characterization of a Previously Undiscovered Anatomical Structure in Maxillary Second Molars: The Palato-Mesiobuccal Canal.

INTRODUCTION: This report aims to communicate the discovery of a novel anatomy in a 3-rooted maxillary second molar, named as palato-mesiobuccal canal. METHODS: The tooth selected for this report was found incidentally as a result of a study on extracted maxillary molars that was being conducted for an unrelated purpose and involved hundreds of teeth. This 3-rooted maxillary second molar was scanned using a micro-computed tomography device set at a pixel size of 13.68 µm. The images were reconstructed with previously tested parameters resulting in the acquisition of 1655 axial cross-sections. Three-dimensional (3D) models of the internal and external anatomies were generated in Standard Tessellation Language (STL) format and were texturized to simulate the pulp tissue. The inner structure of the tooth was analyzed through the axial cross sections and the 3D volume was qualitatively evaluated. RESULTS: The analysis of the 3D models revealed that the maxillary second molar under examination has 3 independent roots and 4 root canals. Each root (mesiobuccal, distobuccal, and palatal) contains 1 canal, while the fourth canal follows a unique path, originating in the coronal third of the palatal canal and proceeding in a buccal direction ultimately exiting through an independent foramen at the apex of the mesiobuccal root, near the mesiobuccal canal. CONCLUSIONS: This brief communication reports the discovery of a novel anatomy in a 3-rooted maxillary second molar, named as palato-mesiobuccal canal, and provides important insights into the complexity of the root canal system in this group of teeth.

Multimethod analysis of three rotary instruments produced by electric discharge machining technology.

AIM: This study aimed to compare three rotary instruments produced by the EDM process with the heat-treated ProTaper Gold system regarding design, metallurgy, mechanical properties and shaping ability. METHODOLOGY: HyFlex EDM (25/~), Neoniti (25/.06), EDMax (25/.06) and ProTaper Gold (25/.08v) instruments (n = 58 per group) were compared regarding design, metallurgy and mechanical performance. Unprepared canal areas were calculated for each system after preparation of mesiobuccal, mesiolingual and distal canals of mandibular molars (15 canals per group) using micro-CT technology. Statistical analyses were performed using One-way anova post-hoc Tukey and Kruskal-Wallis post-hoc Dunn's tests (α = 5%). RESULTS: All instruments had asymmetrical blades, no radial lands, no major defects and almost equiatomic nickel/titanium ratios, but different cross-section designs, tip geometries and surface appearances. Although instruments had distinct transformation temperature curves, they showed crystallographic martensitic arrangement at 21°C and mixed austenite plus R-phase at body temperature. Neoniti and HyFlex EDM showed similar results in all mechanical tests (p > .05), while EDMax and ProTaper Gold had similar time to fracture (p = .841), maximum bending load (p = .729), and cutting ability (p = .985). ProTaper Gold showed the highest torque to failure (p < .001) and HyFlex EDM had the lowest buckling resistance (p < .001). Mean percentages of unprepared canal areas ranged from 20.4% to 25.7% in the mesial canals, and from 20.8% to 26.2% in the distal canal, with no statistical differences among systems (p > .05). CONCLUSIONS: Instruments' geometry and phase transformation temperatures influenced the results of the mechanical tests, but not their shaping ability.

Taper 0.06 Versus Taper 0.04: The Impact on the Danger Zone.

INTRODUCTION: This study aimed to evaluate the effects of root canal enlargement on the danger zone (DZ) of mandibular molars. METHODS: Thirty mesial roots of mandibular first molars were scanned in micro-computed tomography (S1). Canals were sequentially enlarged with rotary instruments up to sizes 30/0.04 (S2) and 30/0.06 (S3). The dentin thickness was measured at 0.1-mm intervals after each preparation step (n = 2964 slices). Root level and position of the DZ were also recorded. Data were compared using analysis of variance with Bonferroni pairwise comparison, Cochran's Q method, and Pearson's test (α = 5%). RESULTS: Comparing the specimens before (S1) and after (S2 and S3) preparations showed a significant reduction in the thickness of the DZ (P < .05), as well as between S2 and S3 steps (P < .05). At S1, the DZ was mostly located in the middle third of the root, but after preparation, it shifted toward the coronal direction (P < .05). Both S2 (P = .004, r = 0.508) and S3 (P = .004, r = 0.506) preparation steps showed a positive correlation between canal length and the root level of the DZ. At S1, the DZ was positioned toward the distal and mesial in 73.4% (n = 22) and 26.6% (n = 8) of the specimens, respectively. After S3, the number of specimens with DZ positioned toward the mesial aspect of the root significantly reduced to 3.3% (n = 1), whereas none of the specimens with DZ positioned toward the distal changed its position after root canal enlargements (P > .05). CONCLUSION: Overall, the enlargement of mesial canals of mandibular first molars with final instruments sizes 30/0.04 and 30/0.06 affected the thickness, root level, and position of the DZ.

Diamondlike Carbon Surface Treatment Improves the Fatigue Resistance of Ultrasonic Tips.

INTRODUCTION: The aim of this study was to compare E1-Irrisonic (Helse Ultrasonics, Ocoee, FL) and Irri Black (Helse Ultrasonics), a novel ultrasonic tip with diamondlike carbon treatment, regarding their design, metallurgy, microhardness, bending resistance, and time to fracture under the oscillatory fatigue test. METHODS: A total of 17 E1-Irrisonic and 17 Irri Black new ultrasonic tips were selected. The tip geometry and surface finishing were assessed using scanning electron microscopy. The elemental composition was defined by energy-dispersive X-ray spectroscopy. Hardness Knoop was calculated using a microhardness tester. The maximum load required to displace the instrument in 45° was recorded in gram/force, oscillatory fatigue was measured in seconds at the moment of instrument fracture, and the size of the separate fragments was determined in millimeters. The Student t test was used for statistical comparison (α = 5%). RESULTS: Scanning electron microscopic analyses revealed that E1-Irrisonic had a flat end tip, whereas a noncutting rounded tip was observed in Irri Black. The surface of E1-Irrisonic was smoother than Irri Black, which was irregular. Energy-dispersive X-ray spectroscopic analyses showed that the elemental compositions of the E1-Irrisonic and Irri Black tips were consistent with stainless steel and titanium-aluminum alloys, respectively. Irri Black showed significantly higher bending load resistance, time to fracture under oscillatory motion, and hardness Knoop than the E1-Irrisonic tip (P < .05), whereas the length of fragments was similar (P > .05). CONCLUSION: Diamondlike carbon treatment improved hardness Knoop and reduced the flexibility of the Irri Black ultrasonic tip, improving its time to fracture under oscillatory motion compared with the nontreated E1-Irrisonic tip.

Effects of root canal enlargement on unprepared areas and coronal dentine thickness of three-rooted maxillary first premolars with different root configurations: A stepwise micro-CT study.

AIM: To evaluate the effects of progressive root canal enlargements on the unprepared surface area and remaining dentine thickness of three-rooted maxillary first premolars with different root configurations. METHODOLOGY: Thirty three-rooted maxillary first premolars with three root configurations (n = 10) were selected and scanned in a micro-CT device. The root canals were sequentially enlarged with rotary instruments sizes 30.02 (step 1), 30.04 (step 2) and 30.06 (step 3). After each step, a new scan was taken. Analysed parameters included morphometric measurements (length, volume and surface area), number of static voxels and minimal dentine thickness. Statistical analyses were performed with one-way anova post hoc Tukey tests and paired sample t-test at a significance level of 5%. RESULTS: No statistical differences were observed amongst groups regarding the morphometric parameters and static voxels (p > .05). The minimal dentine thickness of the distobuccal root significantly changed depending on the root configuration (p < .05), whilst no differences were observed in the other roots (p > .05). A great variation in the position of the minimal dentine thickness was observed after preparation. Overall, mean percentage reduction in dentine thickness was higher in the buccal roots than in the palatal root (p < .05). In the mesiobuccal and distobuccal root, the number of slices with minimal dentine thickness lower than 0.05 mm increases 2 to 3 times and 3 to 4 times, respectively, from steps 1 to 3. CONCLUSIONS: Instruments sizes 30.02 and 30.04 can be safely and effectively used to enlarge the buccal and palatal canals of three-rooted maxillary first premolars.

A Multimethod Assessment of a New Customized Heat-Treated Nickel-Titanium Rotary File System.

This study aimed to compare three endodontic rotary systems. The new Genius Proflex (25/0.04), Vortex Blue (25/0.04), and TruNatomy (26/0.04v) instruments (n = 41 per group) were analyzed regarding design, metallurgy, and mechanical performance, while shaping ability (untouched canal walls, volume of removed dentin and hard tissue debris) was tested in 36 anatomically matched root canals of mandibular molars. The results were compared using one-way ANOVA, post hoc Tukey, and Kruskal−Wallis tests, with a significance level set at 5%. All instruments showed symmetrical cross-sections, with asymmetrical blades, no radial lands, no major defects, and almost equiatomic nickel−titanium ratios. Differences were noted in the number of blades, helical angles, cross-sectional design, and tip geometry. The Genius Proflex and the TruNatomy instruments had the highest and lowest R-phase start and finish temperatures, as well as the highest and lowest time and cycles to fracture (p < 0.05), respectively. The TruNatomy had the highest flexibility (p < 0.05), while no differences were observed between the Genius Proflex and the Vortex Blue (p > 0.05). No differences among tested systems were observed regarding the maximum torque, angle of rotation prior to fracture, and shaping ability (p > 0.05). The instruments showed similarities and differences in their design, metallurgy, and mechanical properties. However, their shaping ability was similar, without any clinically significant errors. Understanding these characteristics may help clinicians to make decisions regarding which instrument to choose for a particular clinical situation.

Multimethod Assessment of Design, Metallurgical, and Mechanical Characteristics of Original and Counterfeit ProGlider Instruments.

A multimethod study was conducted to assess the differences between original (PG-OR) and counterfeit (PG-CF) ProGlider instruments regarding design, metallurgical features, and mechanical performance. Seventy PG-OR and PG-CF instruments (n = 35 per group) were evaluated regarding the number of spirals, helical angles, and measuring line position by stereomicroscopy, while blade symmetry, cross-section geometry, tip design, and surface were assessed by scanning electron microscopy. Energy-dispersive X-ray spectroscopy and differential scanning calorimetry were used to identify element ratio and phase transformation temperatures, while cyclic fatigue, torsional, and bending testing were employed to assess their mechanical performance. An unpaired t-test and nonparametric Mann−Whitney U test were used to compare instruments at a significance level of 5%. Similarities were observed in the number of spirals, helical angles, blade symmetry, cross-sectional geometries, and nickel−titanium ratios. Measuring lines were more reliable in the original instrument, while differences were noted in the geometry of the tips (sharper tip for the original and rounded for the counterfeit) and surface finishing with PG-CF presenting more surface irregularities. PG-OR showed significantly more time to fracture (118 s), a higher angle of rotation (440°), and a lower maximum bending load (146.3 gf) (p < 0.05) than PG-CF (p < 0.05); however, maximum torque was similar for both instruments (0.4 N.cm) (p > 0.05). Although the tested instruments had a similar design, the original ProGlider showed superior mechanical behavior. The results of counterfeit ProGlider instruments were unreliable and can be considered unsafe for glide path procedures.