Endo Journal Dec 08

ENDODONTOLOGY
ENDODONTOLOGY
ENDODONTOLOGY
ENDODONTOLOGY
Volume: 20 Issue 2 December 2008 1-76
Page 4
Editorial Original Research

A Comparison of the Relative Efficacies of Hand and Rotary Instruments in the Removal of Guttapercha from the Root Canal during Retreatment using Stereomicroscope - An In-Vitro Study To Analyze the Distribution of Root Canal Stresses after Simulated Canal Preparation of Different Canal Taper in Mandibular First Premolar by Finite Element Study An In Vitro Study. A Comparative Evaluation of Cyclic Fatigue Resistance of Two Rotary Nickel - Titanium Endodontic Systems - An In Vitro Study Dhanya Kumar N. M. Praveen Gokul Vasundhara Shivanna Dhanya Kumar N. M. Abhishek Singhania Vasundhara Shivanna Dr. Gaurav Garg Dr. Sanjay Miglani Dr. Seema Yadav Dr. Sangeeta Talwar Mithra N. Hegde Deepali S. Niranjan A. Vatkar Sucheta Sathe Vivek Hegde P. Senthil Kumar A. R. Vivekananda Pai Kundabala M. Swetha H. B. Shashikala K. Paluvary Sharath Kumar Vasundhara Shivanna Abhishek Parolia Kundabala M. Shashi Rasmi Acharya Vidya Saraswathi Vasudev Ballal Mandakini Mohan Sowmya Shetty
5-11
12-21
22-26
Coronal Microleakage of Four Restorative Materials Used in Endodontically Treated Teeth as A Coronal Barrier - An In Vitro Study In Vitro Evaluation of the Efficacy of Five Apex Locators
27-35 36-42
A Three-Dimensional Evaluation of Density and Homogeneity of Root Canal Obturation with Guttaflow using Backfilling Technique in Comparison with Conventional Lateral Compaction Technique using Spiral Computed Tomography - An In Vitro Study Comparative Evaluation of Radiopacity of Three Root Canal Sealers Using Conventional and Digital Radiographic Technique: An Invitro Study The Effect of File Sizes in the Presence of Sodium Hypochlorite and Blood on the Accuracy of Root Zx Apex Locator in Enlarged Root Canals - an In Vitro Study Sealing Ability of Four Materials in the Orifice of Root Canal Systems Obturated With Gutta-Percha
43-50
51-56
57-64
65-70
Current Endodontics Literature
71-74
ENDODONTOLOGY INDIAN ENDODONTIC SOCIETY

(Estd. 1988) President: Dr. A. P. Tikku Secretary General: Dr. K. S. Banga Joint Secretary: Dr. J. Dhillon Treasurer: Dr. S. H. Kulkarni President elect: Dr. Ravi Kapur Imm Past President: Dr. K. K. Wadhwani Vice President: Dr. Sukesh Kumar Dr. S. Balagopal Dr. S. Ramchandran
Editor: Dr. B. Sureshchandra
Executive committee
Permanent members: Dr.R.C.Kakkar Dr.Anil Kohli Members: Dr. Shenoy Kundabala Dr. Pradeep Jain Dr. J. S. Baath Dr. Sharad Kamat Dr. Kapil Loomba Dr. Mithra N. Hegde Dr. Roopa Nadig Dr. Arathi Ganesh Dr. Gopi Krishna Dr. Moksha Nayak Dr. Ida De Ataide Dr. Ashwini Dobhal
FORM IV RULE 8
1. Place of Publication 2. Periodicity of publication 3. Printers name, nationality and address : : : Mangalore Biannual Srinivas Prabhu at M/s. Sunline Enterprises Lower Car Street Mangalore - 575 001 Dr. Anil Kohli Indian Endodontic Society E-601, Greater Kailas - II Delhi - 110 048 Dr. B. Sureshchandra Department of Conservative Dentistry / Endodontics A. J. Institute of Dental Sciences N. H.-17, Kuntikana, Mangalore - 575 004, Karnataka. Indian Endodontic Society E-601, Greater Kailas - II Delhi - 110 048 Indian
4. Publishers name, nationality, and address
Indian
5. Editors name, nationality and Address
Indian
6. Name and address of the owner of the newspaper
Mangalore
Signature of publisher. Sd/Dr. K. S. Banga Secretary General Indian Endodontic Society E-601, Greater Kailas - II Delhi - 110 048
Date: 15/6/2005
ENDODONTOLOGY
Editor: Dr. B. Sureshchandra
ENDODONTOLOGY
Editorial Board Dr. Banga K. S. Dr. Choudhary M. Dr. Gopikrishna
A publication of Indian Endodontic society
Scientific Advisory Committee Dr. Govila C. P. (India) Dr. Gulabivala (U. K.) Dr. Gutmann James L. (U.S.A.)
Dr. Indira R. Dr. Kandaswamy D. Dr. Kohli Anil Dr. Laxminarayanan L. Dr. Mithra N. Hegde Dr. Naseem Shah Dr. Shenoy Kundabala Dr. Shivanna V. Dr. Tikku A. P. Dr. Usha H. L. Dr. Wadhvani K. K. Abstracts
Editorial Office Department of Conservative Dentistry / Endodontics A. J. Institute of Dental Sciences N.H.-17, Kuntikana, Mangalore - 575 004, Karnataka. Ph: 0824-2224938.Telefax: 0824-2224968. Clinic: 0824-2444041. E-mail: bsureshc@satyam.net.in
Dr. Sowmya Shetty
Endodontology is indexed in IndMED, the database of Indian Biomedical Journals, maintained by National Informatics Centre, Ministry of Information Technology, Govt. of India. Bibliographic details of the journal available in ICMR-NIC Centres IndMED database (http:// indmed.nic.in). Full text of articles, from 2000 onwards, being made available in MedlND database (http://medind.nic.in ). The journal is aIso listed with Indian National Scientific Documentation Centre (INSDOC), Qutab Institutional Area, New Delhi-110016 and English Serial Division, National Library, Kolkata.
ENDODONTOLOGY
Editorial
Dr. Spangberg is a household name among endodontists who are interested in pulp biology globally for his thoughts on PULPBIOLOGY. He belongs to that generation of endodontists who are concerned about their speciality in the future and not only the present. This is exactly what he has expressed quite frankly. I have for you a few glimpses of his gem of an editorial. An endodontist is supposed to be an expert on diseases thereof. Presently, however, the most common therapy for the exposed and/or diseased pulp is a total amputation. This crude therapy is unfortunate, because today there are restorative materials that rarely require post retention for large restorations, i.e., the root canal could still harbor a vital pulp if treated properly. Pulp capping, in the way it is commonly practiced, has a low rate of success. This is despite the fact that past research has clearly outlined how it should optimally be done to result in a high rate of success. This performance problem can often be tracked back to lack of basic training in pulp biology and insufficient treatment experience in dental school. Superficial pulp surgery on permanent teeth, although an endodontic procedure, is most frequently done in a general practice setting. Much research still remains to be done with this therapy to achieve a high level of success and predictability. This treatment appears to be of little interest, however, to endodontic organizations on any continent. The International Association for Dental Research Pulp Biology group has also shown little interest in the clinical application of their basic science research efforts. This leaves an important form of therapy without any active and progressive interest group behind it. This is a pity, because the tooth is probably better off with a functioning pulp that is healed by hard tissues rather than a root canal implant. During the last couple of years, much endodontic research has focused on implants and pulpal stem cells. A substantial amount of money is spent on these projects with little visible return for the endodontic patient with a diseased or injured endodontium. Endodontists are today infatuated by implants, and an undeserving amount of effort has been diverted from biologic endodontic research. We have been led to believe by implant proponents that the success rate of implants greatly surpasses the success of endodontic treatment. That has without doubt jolted the profession. Recent available literature does not support that conclusion, however. We often tend to compare the retention rate of implants with endodontic treatment success. This is comparing apples to oranges. Success for implant procedures is vaguely defined. Therefore, the term retention is commonly used when outcome is discussed. Implant retention does not exclude disease conditions. Recent studies clearly show that many retained implants experience progressive bone loss, inflammation, and infection. Retention rate for time periods beyond 5 years never exceed 92%. Comparable endodontic data of retained teeth can be gleaned from insurance data showing an endodontic retention rate of 96%-97% after 8 years, which is substantially better than implant data. In my opinion, the endodontists needs to be well informed about these issues and assure him/herself that the endodontic treatment provided is optimal and offers better outcome than implant replacement of restorable teeth. In addition, the endodontists needs to be less concerned about implants, which have their role in prosthodontics. Instead, they should broaden their role in pulpal diagnosis and the treatment of the dentin and the dental pulp. This would lead to new enhanced treatment options for the vital pulp beyond organ amputation. The intellectual component of endodontic practice would also be significantly improved by such changes. Stem cell research and scaffolding are now buzzwords in basic science pulp research. What is more important to remember, however, is the fact that in most cases where endodontic procedures are done after pulp exposure, a fully developed pulp already exists. Instead of amputating the organ and then rebuilding it, a better idea would be to treat and heal the diseased pulp that is already established. The endodontic community needs to enhance its clinical understanding of the vital pulp and dentin and embrace its treatment. Endodontic postgraduate students need vastly more education in this area to support their future practices and to function as future leaders of pulp biology in their dental communities. This field of endodontology needs drastically more support both in specialist knowledge and research grant support. This is an area the American Association of Endodontists Foundation ought to focus on as high priority. It may be exciting to attempt to build connective tissue inside the root canal but it is exceedingly more valuable to the patient to preserve a real pulp, which is already there. In my personal opinion quite a few endodontists have become over night implantologists since they probably find endodontics less financially viable. I would love to have the feed back on this editorial. You may send your opinions on bsureshc@satyman.net.in
Dr. B. Sureshchandra
Extract EDITORIAL; Who Cares About The Dental Pulp Triple O, Vol. 104, No. 5, Nov. 2007. LARZ S.W. SPANGBERG, SECTON EDITOR, ENDODONTOLOGY
ENDODONTOLOGY A Comparison of the Relative Efficacies of Hand and Rotary Instruments in the Removal of Guttapercha from the Root Canal during Retreatment using Stereomicroscope - An In-Vitro Study
DHANYA KUMAR N. M *# PRAVEEN GOKUL **# VASUNDHARA SHIVANNA ***#
ABSTRACT:
The purpose of this study was to determine the efficiency of Greater Taper, ProTaper & RaCe rotary instruments compared with Hedstrom files for removal of guttapercha from root canal during retreatment following an endodontic failure. 60 mandibular premolars were divided into 4 groups, each group consisting of 15 teeth. Group 1: Hedstrom files; Group 2: Greater Taper rotary (GT); Group 3: ProTaper; Group 4: with Reamer with alternate cutting edges (Race). The teeth were instrumented with K- type files and filled using lateral condensation technique with guttapercha and AH plus sealer. After repreparation with Gates Glidden drills and the test instruments the teeth were cleared. The area of remaining guttapercha/sealer on the root canal wall was measured from mesio-distal and bucco-lingual directions. The RaCe group showed significantly less obturation material than System GT, ProTaper and H-files (p<0.001). There was no significant difference between System GT and ProTaper in removing guttapercha/sealer. RaCe took the least time for removing guttapercha/sealer (p<0.05). One ProTaper files and one H-file separated. The study demonstrated that, RaCe NiTi rotary instruments cleaned the root canals after retreatment more efficiently than ProTaper, System GT and H-files. Keywords: Gutta-percha removal, Root canal retreatment, Nickel Titanium files, Rotary instrumentation.
INTRODUCTION
Nonsurgical endodontic retreatment consists of cleaning, shaping, and three-dimensional obturation of previously obturated root canals. It is the treatment of choice for the management of endodontic failures when access to the root canals is feasible 10 . To successfully accomplish retreatment, all of the obstructions - preventing a
direct straight line access to the root canals have to be removed. The major factors associated with endodontic failure are the persistence of microbial infection in the root canal system and/or the periradicular area. The clinician is often misled by the notion that procedural errors such as broken instruments,
* PROFESSOR, ** POST- GRADUATE STUDENT, *** PROFESSOR AND HEAD, DEPARTMENT OF CONSERVATIVE DENTISTRY AND ENDODONTICS, COLLEGE OF DENTAL SCIENCES (C.O.D.S.), DAVANGERE 577004, KARNATAKA.
ENDODONTOLOGY
A COMPARISON OF THE RELATIVE EFFICACIES OF HAND AND ROTARY INSTRUMENTS IN THE REMOVAL OF GUTTAPERCHA FROM THE ROOT CANAL DURING RETREATMENT USING STEREOMICROSCOPE - AN IN-VITRO STUDY
perforations, overfillings, underfillings, ledges and so on are the direct cause of endodontic failure. In truth, a procedural accident often impedes or makes it impossible to accomplish appropriate intracanal procedures5. Removal of guttapercha can be obtained with several techniques such as solvents, K-type or Hedstrom files, Gates Glidden drills, heat pluggers ,
3
calculus were mechanically removed from root surfaces. Access opening was made on each tooth with high speed round diamond bur no.2 with air- water spray. Working length was established l mm short of root apex and the crowns were sectioned so that working length was standardized to 18 mm. The canals were prepared using step-down technique. The cervical and middle-thirds were flared with Gates Glidden drills 1, 2 and 3 in a telescopic preparation. Canal instrumentation was completed using K-type files with a master apical file size of 30. The canals were debrided using sodium hypochlorite 5.25% and chlorhexidine 2% irrigants. The root canal of each tooth was dried with paper points and obturated using lateral compaction. A master gutta-percha cone size 30 was selected and tug-back was checked. AH Plus sealer (Dentsply DeTrey) was mixed according to the manufacturers instructions. The master cone was coated with sealer and positioned into the canal. Then accessory cones were laterally compacted until they could not be introduced more than 5 mm into the canal. The extension of the root canal filling was limited to 14 mm from the apex so that the volume of gutta-percha was nearly equal for all teeth. The access cavities were filled with the Cavit G (3M ESPE). All teeth were stored in a humidor at 37C for 2 weeks to allow complete setting of the sealer. Retreatment Technique All samples were randomly divided into four groups with 15 specimens each. All roots had 6 mm of obturation material removed from the cervical part of the canal using Gates Glidden drills
6
ultrasonic technique , and lasers . Additionally,

6 2
rotary instruments can also be used, such as the inflexible XGP drills, the canal finder3, or more recently flexible rotary nickel-titanium (NiTi) files in a slow-speed handpiece. More recently Ni-Ti retreatment rotary files have been introduced which have proved to be efficient and require less time when compared to hand instrumentation although complete removal
1
of guttapercha has not been attained with these instruments Currently, nickel titanium rotary
7.
instruments like Reamer with alternate Cutting edges (RaCe), ProTaper and Greater Taper (GT) rotary have an important role in the removal of guttapercha for their ability to simulate curved canals & effectively produce well tapered root canal form requiring less time. Purpose of this study is to evaluate the efficacy of H-file versus RaCe, ProTaper and Greater Taper (GT) NiTi rotary instruments in the removal of guttapercha from root canals, the time taken for removal and procedural errors i.e. separated instruments that occur during retreatment.
METHODOLOGY
Selection of teeth: Sixty freshly extracted human mandibular premolars were collected from Dept. of Oral and Maxillofacial Surgery, College of Dental Sciences, Davangere. Soft tissue and
ENDODONTOLOGY
2 and 3. After using the Gates Glidden drills, a drop of eucalyptol solvent was intro-duced into each canal to soften the gutta-percha. Two or three addi-tional drops of solvent were applied as required to reach the working length. Sodium hypochlorite 5% and chlorhexidine 2% irrigations were used after each instrument. Each root canal was irrigated with a total of 30 ml sodium hypochlorite and 30 ml chlorhexidine. System GT, Pro-Taper and RaCe rotary instruments were driven with a torque-con-trolled motor (X-Smart, Dentsply, Maillefer) according to the manufacturers instructions. The teeth were then rendered transparent by first decalcifying them in 5% Nitric acid then dehydrating them in 80% alcohol for 12hrs, 90% alcohol for 1hr and 100% alcohol for 3hrs. The teeth were then cleared using Methylsalicylate. Teeth were divided into 4 groups, each group consisting of 15 teeth. Group 1: (n=15) with Hedstrom files (Mani): ISO size 15 and 20 Hedstrom files were used for deep penetration until they reached the working length. The removal of gutta-percha was completed using size 25 to 35 Hedstrom files in a circumferential quarter-turn push-pull filing motion. Group 2: (n=15) with Greater Taper (GT) NiTi rotary instruments (Dentsply Maillefer): GT rotary instrument sizes 10.30, 08.30, 06.30, 04.30 were used in a crown-down technique according to manufacturers instructions to remove the guttapercha from the root canals. Group 3: (n=15) ProTaper NiTi rotary instruments (Dentsply Maillefer): As suggested by the manu-facturer, the gutta-percha was removed
7
DHANYA KUMAR N. M, PRAVEEN GOKUL, VASUNDHARA SHIVANNA
by the following se-quence using light apical pressure: Finishing files #3 (ISO size 30, taper O.O9-O.O5), #2 (ISO size 25, taper 0.08-0.055), and #l (ISO size 20, taper O.O7-O.O55) were used in a crown-down technique to remove the guttapercha until the working length was reached. Finishing files #2 and #3 were used again to the working length to complete gutta-percha removal and cleaning of the canal walls. Group 4: (n=15) RaCe NiTi rotary instruments (FKG Dentaire) RaCe rotary instruments sizes 10.40, 08.35, and 06.30 were used in a crown-down approach. Instrument size 04.25 reached working length. RaCe files 02.30 and 02.35 were used for apical enlargement. One set of instruments was used for repreparation of five root canals. Files were wiped regularly using gauze to remove obturation material and debris. Preparation was deemed complete when there was no gutta-percha/sealer covering the instruments. Each root canal was prepared, filled and retreated by the same operator to reduce interoperator variability.
Evaluation
For all roots, three types of data were recorded. 1. Canal Wall Cleanliness The amount of gutta-percha/ sealer on the canal walls was imaged in a standardized way in bucco-lingual and mesiodistal directions and measured in mm2 using image analyzer software connected to a stereomicroscope with 6.5 X magnification via a CCD-sensor. The evaluator was blinded to group assignment.
ENDODONTOLOGY
2. Time for Retreatment
DISCUSSION
The main goal of retreatment is to regain access to the constriction by complete removal of the root canal filling material, thereby facilitating sufficient cleaning and shaping of the root canal system and final obturation5, 8. Prognostic studies have indicated that endodontic surgery or extraction could be avoided by conventional retreatment12. Eucalyptol was used as a solvent in our study as it has been reported to be a safe and efficient alternative to chloroform11. Different methodologies have been reported during evaluation of remaining filling material including longitudinal cleavage of teeth which may displace filling material remnants; association of longitudinal and transverse cleavage for evaluation in thirds; and cleavage and photographic recordings; visual examination through cleavage and photography in association with radiographic examination. The pro-blems with sectioning teeth are that it can disturb the remaining filling material and it is unpredictable. In the present study, the roots were cleared to allow the measurement of the area of residual obturation material because remaining Gutta Percha or sealer might get lost by splitting the roots longitudinally4. In our study, direct visual scoring with the aid of a stereomicroscope was adopted for the evaluation of residual gutta-percha and sealer on the canal walls, as it was considered a simple and efficient assessment method9. The results of our study suggest that RaCe NiTi rotary instruments performed better when compared to the other instruments. There was no
8
The time elapsed from entering the canal with the first Gates Glidden bur until the completion of the reinstrumentation was measured with a stopwatch. 3. Procedural Errors The number and sort of fractured instruments were recorded Statistical analysis: Statistical analysis was performed for multiple group comparisons by means of Kruskal-Wallis ANOVA test followed by post hoc tests for pair wise comparisons
RESULTS
From the present invitro study the following results were obtained: 1. Remaining obturation material was observed in all groups. Imaged in a bucco-lingual and mesio-distal directions, specimens treated with RaCe showed least amount of remaining guttapercha/sealer. The Hedstrom group, System GT group and ProTaper group revealed significantly larger areas of obturation material than RaCe group (p<0.05). System GT group did not differ significantly from ProTaper group (p>0.05) in the removal of guttapercha/sealer from the root canals.( Table 1, Graphs 1-4) 2. Regarding the mean time for retreatment RaCe group took least time while System GT, ProTaper and H-files required significantly more time when compared to RaCe group. (Table 1, Graph 5). 3. One ProTaper file (size F1) and one H-file (ISO 25) separated during retreatment.
ENDODONTOLOGY
significant difference between System GT and ProTaper in removal of guttapercha when viewed in a mesio-distal direction. H-files performed poorly when compared to rotary instruments. Instrument separation occurred with H-files and ProTaper NiTi rotary files. The first two RaCe instruments (size 10.40 and 08.35) are made of stainless steel. Stainless steel files have a better cutting efficiency than nickeltitanium file. Probably this fact and the greater taper of these two files compared to the ProTaper, System GT and Hedstrom group might be a reason for the quick and effective gutta-percha removal. Other advantages of the RaCe instruments could be the alternating cutting edges which eliminate the unde-sirable screwing effect and the smooth surface of the instruments that is caused by the special chemical surface treatment. It is also possible that the gutta-percha adhered less to the flutes so that the file had a better cutting efficiency. GT instruments with their taper-centric shaping ability, Radial lands and U-type cross section cleaned canal walls better and took less time than H-files but was inferior than RaCe files and there was not much difference when compared to ProTaper.
With ProTaper group final apical preparation diameter was of size 30 (F3) compared to final apical diameter in the RaCe group which was of size 35 therefore its cleaning ability was less when compared to RaCe and there was not much difference when compared to System GT although the cleaning ability was better than hand files. Also ProTaper shaping files proved to be impossible to penetrate guttapercha without fractures of the files.
CONCLUSION
Within the limitations of this in-vitro study the following conclusions can be drawn from the results of this study: RaCe rotary system has alternating cutting edges which efficiently removed debris from the root canals and showed least remaining obturating material. During retreatment the risk of instrument fractures of ProTaper and H-files instruments seems to be higher than that of RaCe and System GT, the reason attributed could be that since RaCe files utilize reduced working torque there was no fracture of any instrument, and due to its inherent instrument design wherein cutting efficiency is increased RaCe took less time than ProTaper, System GT and H-files.
Mean areas of remaining obturation material imaged in mesio-distal and bucco-lingual direction with standard deviations (SD,mm2),mean time for retreatment (min) and number of fractured instruments
Method Hedstrom System GT ProTaper RaCe Mesio-distal Mean 5.49 3.81 3.79 1.48 SD 0.37 0.58 0.24 0.27 Bucco-lingual Mean 4.44 2.37 2.93 0.93 SD 0.63 0.32 0.38 0.27 Mean time Mean 12.29 9.31 8.23 7.16 SD 1.16 0.15 0.11 0.11 1 1 Fractures
ENDODONTOLOGY
GRAPHS
PHOTOS
Fig 1: STEREOMICROSCOPE READINGS WITH H-FILES MESIO-DISTAL BUCCO-LINGUAL
Fig 2: STEREOMICROSCOPE READINGS WITH SYSTEM GT MESIO-DISTAL BUCCO-LINGUAL
FIG 3: STEREOMICROSCOPE READINGS WITH ProTaper MESIO-DISTAL BUCCO-LINGUAL
FIG 4: STEREOMICROSCOPE READINGS WITH RaCe MESIO-DISTAL BUCCO-LINGUAL
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ENDODONTOLOGY
BIBLIOGRAPHY
1. Barrieshi-Nusair KM. Gutta-percha retreatment: effectiveness of nickel-titanium instru-ments versus stainless steel hand files. J Endod 2002; 28:454-6. 2. D.Viducic, S. Jukic, Z. Karlovic, Z. Bozic, I.Miletic & I. Anic. Removal of guttapercha from root canals using an Nd-YAG laser. Int Endod J 2003;36:670-3 3. Friedman S, Stabholz A, Tamse A. Endodontic retreatment: case se-lection and technique. Part 3: retreatment techniques. J Endod 1990; 16: 543-9. 4. Gergi R, Sabbagh C. Effectiveness of two nickel-titanium rotary instruments and a hand file for removing gutta-percha in severely curved root canals during retreatment: an ex vivo study. Int Endod J 2007;40:532-7 5. J.F. Siqueria Jr. Aetiology of root canal treatment failure: why well-treated teeth can fail. Int Endod J 2001; 34:1-10. 6. Krell KV, Neo J. The use of ultrasonic endodontic instrumentation in the re-treatment of a paste-filled endodontic tooth. Oral Surg Oral Med Oral Pathol 1985:60:100-2.
7. Kosti E, Lambrianidis T, Economides N, Neofitou C. Ex vivo study of the efficacy of H-files and rotary Ni-Ti instruments to remove gutta-percha and four types of sealer. Int Endod J 2006;39:48-54 8. Mandel E, Friedman S. Endodontic Retreatment: A Rational Approach to Root Canal Reinstrumentation. J Endod 1992;11:565-9 9. Schirrmeister JF, Wrbas KT, Meyer KM, Altenburger MJ, Heiiwig E, Efficacy of differ-ent rotary instruments for guttapercha removal in root canal retreatment. J Endod 2006;32:469-72. 10. Stabholz A, Friedman S. Endodontic retreatment: case selection and technique. Part 2: treatment planning for retreatment. J Endod 1988; 14:607-14. 11. Tamse A, Unger U, Metzger Z, Rosenberg M. Gutta-percha solvents: a comparative study. J Endod 1986;12:337-9 Tasdemir T, Er K, Yildirim T, Celik D. Efficacy of three rotary NiTi instruments in removing gutta-percha from root canals. Int Endod J 2007;41:191-6
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ENDODONTOLOGY To Analyze the Distribution of Root Canal Stresses after Simulated Canal Preparation of Different Canal Taper in Mandibular First Premolar by Finite Element Study An In Vitro Study.
DHANYA KUMAR N. M. * ABHISHEK SINGHANIA ** VASUNDHARA SHIVANNA ***
ABSTRACT
Was to Investigate stress distribution patterns in simulated biomechanically prepared mandibular first premolars with four different tapers at two different compaction forces and an occlusal load with finite element analysis. Six recently extracted, intact, non-carious, undestroyed mandibular premolars similar in-straight root canals were selected. Four finite element models were designed on the software varying only in canal taper of mandibular first premolars. Gutta-percha was compacted by vertical condensation technique in three separate vertical increments under two different vertical compaction forces that are 10N and 15N. Finite element meshes were generated with this model by using soft ware to know the pattern of distribution of radicular stresses during obturation. At last access opening will be filled by using simulated restorative material (composite). A masticatory load of 50N was applied; again Finite element meshes were generated. The highest circumferential and radial stresses were found during compaction of first gutta percha increment, while an increase in taper reduced the stress level for the same compaction force. During obturation, higher stresses were found at the canal surface, using the smallest taper, in apical third, during the first gutta percha increment and gradually decreased along the canal length. Root stresses during occlusal load application generates the highest stresses at external root surface and concentrate at cervical third, an increase taper size caused only slight lower root stresses. With increasing taper root stresses decreased during root canal obturation. Root fracture at the apical third is likely initiated during obturation. Root fracture at the cervical third is likely initiated during occlusal load. KEYWORDS: canal taper, compaction force, finite element analysis, occlusal load, root stresses, vertical compaction, vertical root fracture.
INTRODUCTION
After endodontic therapy, teeth are more prone to vertical root fracture because of loss of moisture (9%) and become more brittle when compared to vital tooth. Vertical root fracture can occur in teeth
during or subsequent to endodontic therapy. The causative factors for vertical root fractures are the compaction of gutta percha, placement of intraradicular posts, masticatory load, trauma, and traumatic injuries. Vertical root fractures are more
* PROFESSOR, ** POST GRADUATE, *** PROFESSOR & HEAD, DEPARTMENT OF CONSERVATIVE DENTISTRY AND ENDODONTICS, COLLEGE OF DENTAL SCIENCES ( C . O.D.S.), DAVANGERE 577004, KARNATAKA.
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ENDODONTOLOGY
common during the vertical condensation technique of obturation and often complicate or prevent subsequent restorative procedures. These fractures a count for the most serious complication of root canal treatment and often result in tooth extraction because of poor prognosis6. It is generally accepted that the strength of an endodontically treated tooth is directly related to the amount of remaining tooth structure. Several treatment procedures such as caries removal, access preparation, instrumentation of root canal, irrigation of root canal with sodium hypochlorite, and long term intracanal dressing with calcium hydroxide lead to loss of tooth structure or weaken the root dentine. The prevalence of Vertical root fracture is not equally distributed over the different tooth types. Maxillary and mandibular premolars have both recorded a high prevalence6. Stresses distribution in endodontically treated teeth can be measured by photoelastic method, strain gauge and instron testing machine. But the major disadvantage of all these methods in stresses can measured at selected sites only and not inside the root canal7. Finite element analysis is an engineering method for the numerical analysis of complex structures based on their material properties (Youngs modulus and Poisson ratio) to determine the distribution of stresses and strain pattern induced in internal structure of tooth / bone / implants / any living tissue .
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DHANYA KUMAR N. M., ABHISHEK SINGHANIA, VASUNDHARA SHIVANNA
compaction forces and an occlusal load with finite element analysis.
METHODOLOGY
Twenty four samples have been derived from six recently extracted, intact, non-carious, undestroyed mandibular first premolars. Six x-ray films were used to know the canal curvature of six mandibular first premolars. Optical scanner was used to digitalize the external surface morphology of six extracted mandibular first premolars on computer software that has been designed for Finite Element analysis.
GROUPING
Four finite element models were designed on the software varying only in canal taper of each mandibular first premolar. Each model carried six specimens. These models were assigned as: Group 1 with taper 2%, Group 2 with taper 4%, Group 3 with taper 6% and Group 4 with taper 12%. All other aspects of the models were held constant including boundary conditions, material properties, compaction forces during filling and magnitude / direction of applied occlusal load. The tooth model was created by digitizing the external surface of extracted human mandibular first premolar with an optical scanner in combination with Finite element analysis computer software (NISA). A straight root was chosen for this study to eliminate effects due to canal curvature. Guttapercha were compacted by vertical condensation technique in three separate vertical increments (apical 1/3, middle 1/3, cervical 1/3) under two different vertical compaction forces that are 10 Newton and 15 Newton for each increment. 200m thick periodontal ligament layer and a surrounding bone volume to support the root were created on
13
The purpose of the present study is to investigate stress distribution patterns in simulated biomechanically prepared mandibular first premolars with four different tapers at two different
ENDODONTOLOGY
finite element model.
TO ANALYZE THE DISTRIBUTION OF ROOT CANAL STRESSES AFTER SIMULATED CANAL PREPARATION OF DIFFERENT CANAL TAPER IN MANDIBULAR FIRST PREMOLAR BY FINITE ELEMENT STUDY AN IN VITRO STUDY.
tip-diameter that was 0.5 mm smaller than the canal diameter at each compaction increment. After complete simulated obturation, the simulated access space was closed using a simulated bonded restorative composite. The composite was filled; a 50 N occlusal load was applied in the buccolingual plane to the triangular ridge of the buccal cusp (functional cusp) at an angle of 600 with the vertical axis. The value of the occlusal force was chosen to represent a relatively high biting force and buccal cusp was selected because it is the functional cusp and lingual cusp is rudimentary in mandibular first premolar. During the analysis, the root was supported by the surrounding bone volume via the soft periodontal ligament layer, which was given incompressible properties to approximate fluid behavior. The mean value, standard deviation and one way ANOVA was used to evaluate the site of maximum stress concentration. Statistical analysis (ANOVA) was used for multiple comparison and correlation analysis to assess the relationship between different taper and radicular stresses.
Subsequently, a simulated standard access opening was made in the crown, and root canals were created that represented 2%, 4%, 6% and 12%. The 4% and 6% tapers were chosen for clinical relevancy, as these are incorporated into commonly used nickeltitanium rotary files and are representative of clinically imparted tapers on the canal space. The drastic 12% tapered canal preparation was chosen arbitrarily to simulate the effects of excessive canal preparation. All models were created with a final apical preparation of 0.35 mm at the point of constriction, 0.5 mm from what would be clinically perceived as the radiographic apex. All canal preparations were straight. Isotropic properties were applied for the dentine, periodontal ligament, supporting bone volume, gutta-percha and restorative composite. The periodontal ligament was modeled as a soft incompressible connective layer. An arbitrary range of friction coefficients (0.10 0.25) were evaluated to account for the friction between the gutta-percha and the root canal wall. The development of radicular stresses was analyzed during three consecutive filling steps as well as for an occlusal load after the root filling using finite element analysis. Warm gutta-percha was compacted in three separate vertical increments until the canal was filled. The gutta-percha temperature at the start of compaction was 60 C
o o o o
RESULTS
Four finite element models were designed on the software varying only in canal taper as- Group 1 with taper 2%, Group 2 with taper 4%, Group 3 with taper 6% and Group 4 with taper 12%. In group 1 with taper 2%, the highest mean value and standard deviation was at apical third followed by middle and cervical third under compaction force of 10 newton (Table-1). From group 1 to group 4, the highest mean value and standard deviation was at apical third of
and was gradually cooled down during the filling procedure until it reached 37 C . In this analysis, two vertical compaction forces were tested at 10 and 15 N for each increment. The forces were applied by means of a simulated plugger. The plugger surface had slightly rounded edges and a
14
ENDODONTOLOGY
2% taper (group-1) followed by middle and cervical third of 2% taper under compaction force of 10 Newton (Table-1). Similar results were obtained in different groups under compaction force of 15 Newton (Table-2). During occlusion load application (50N) in different group, highest mean was recorded in group 1 with 2 % taper and least in group 4 with 12% taper. Highly significant pairs were group 1 & 2, group 1 & 3 and group 1 & 4 (Table 3). On comparing the different tapers with each increment under compaction force of 10N shows the significant pairs apical third and coronal third for taper 2% ( P<0.05), apical third and middle third, apical third and coronal third for taper 6% and 12% taper (P<0.001) (Table 4). Also on comparing the different tapers with each increment under compaction force of 15N shows the significant pairs apical third and middle third, apical third and coronal third for taper 4%, 6% and 12% taper (P<0.001) (Table 5) Results: Highest circumferential and radial stresses were found during compaction of first gutta percha increment, while an increase in taper reduced the stress level for the same compaction force. During obturation, higher stresses were found at the canal surface and in apical third with smallest taper and during the first gutta percha increment and gradually decreased along the canal length. Root stresses distribution during occlusal load application generated the highest stresses at external root surface that concentrated at the tooth surface of the cervical third, an increase taper size caused only slight lower root stresses.
DISCUSSION
The prognosis of endodontically treated teeth depends not only on the success of the endodontic treatment but also on the amount of remaining dentine tissue, and the nature of final restoration. Fractures of restored endodontically treated teeth are a common occurrence in clinical practice and it is the second most frequent identifiable reason for loss of endodontically treated teeth4. The increased susceptibility of fracture in endodontically treated teeth had been attributed due to the increased brittleness of dentine, due to loss of moisture - Helfer et al reported that the moisture content of dentine from endodontically treated teeth was about 9% less than teeth with vital pulp. However, Papa et al emphasized the importance of conserving the bulk of dentine to maintain the structural integrity of post-endodontically restored teeth. Other studies have also emphasized that the loss of tooth structure is the key reason for the increase in fracture predilection of endodontically treated teeth1. The fracture resistance of the restored endodontically treated tooth is a function of the strength of the root (taper of prepared canal) and remaining coronal tooth structure.34 Tooth fracture has been described as a major problem in dentistry, and is the third most common cause of tooth loss after dental caries and periodontal disease. Generally, an endodontically treated tooth undergoes coronal and radicular tissue loss due to prior pathology, endodontic treatment, and/or restorative procedures. The loss of dentine tissue will compromise the mechanical integrity of the remaining tooth structure1. Mandibular premolars and maxillary premolars
15
ENDODONTOLOGY
have both recorded a high prevalence of vertical root fracture in endodontically treated teeth .
21
Assessment of stress levels patterns in root canal can be measured by a number of ways that includes Instron universal machine, photoelastic method, strain gauges and most recent one is finite element analysis10. Assessment of stress levels by measuring deformation patterns inside the root canal is extremely difficult, leaving investigators with indirect external observations at best extremely difficult. Finite element analyses have been utilized to address these difficulties and gain insight into internal stress distributions 7,2. Finite element analysis which is an engineering method for the numerical analysis of structure based on their material properties has been used for stress analysis. Material properties such as the Youngs modulus and Poisson Ratio can be utilized by computer generated analyses to describe the mechanical behavior of a structure5.
Vertical root fracture seems to be a more common reason for extraction of endodontically treated teeth.
2
Root canal biomechanical preparation can be done by a hand file or rotary file. Canal preparation involves dentin removal and may compromise the fracture strength of the roots25. The development of new design features such as varying tapers, noncutting safety tips and varying length of cutting blades in combination with the metallurgic properties of alloy nickel-titanium have resulted in a new generation of instruments and concepts33. Although no significant difference in the fracture load of hand and rotary nickel titanium canal preparation could be demonstrated .
3
Given increasing acceptance of rotary instrumentation as a technique for cleaning and shaping the canal space, it is important to examine the effect of specific tapers imparted by rotary instrumentation of the canal wall as it relates to vertical root fracture. The clinician must make a decision to use instruments which have an inherently larger or smaller taper based on the architecture present in a given canal. Choosing a smaller taper may reduce the risk of procedural accidents and untoward events during cleaning and shaping, but it may compromise the cleanliness of the canal system and placement of filling material. Choosing too large a taper may increase canal cleanliness (especially in the coronal and mid-root areas), but may also increase the potential for strip perforations, other procedural accidents, and may predispose the root to vertical fracture if, indeed, greater reduction of root structure increases stress in the canal wall.7
16
CONCLUSION
With in the limitation of this finite element analysis, the following conclusions were drawn. During simulated obturation, root stresses decreased as the root canal taper increases and stresses were greatest at the apical third and along the canal wall. After simulated root canal obturation was completed and occlusal force was applied, the generated stresses were greatest at the cervical portion of the root surface, and decreased as taper increases. It was likely that vertical root fractures initiated at the apical third as result of compaction forces, whereas vertical root fractures initiated cervically were a manifestation of subsequent masticatory load on the root canal obturated teeth. However additional in-vivo and in-vitro tests and clinical trial are desirable in order to elucidate the accuracy of finite element analysis.
ENDODONTOLOGY
10 NEWTON OF COMPACTION FORCE

Apical 1/3 Tapers 2% 4% 6% 12% Mean 0.789 0.713 0.667 0.646 SD 0.087 0.041 0.025 0.015 Mean 0.716 0.657 0.603 0.566 Middle 1/3 SD 0.067 0.022 0.029 0.030 Mean 0.669 0.587 0.608 0.484 Cervical 1/3 SD 0.025 0.032 0.134 0.025
Table-1: Compaction Force of 10N on Apical, Middle and Cervical Third in Different Tapers. 15 NEWTON OF COMPACTION FORCE
Apical 1/3 Tapers 2% 4% 6% 12% Mean 1.267 1.051 0.976 0.946 SD 0.373 0.038 0.018 0.017 Mean 1.135 0.972 0.893 0.847 Middle 1/3 SD 0.256 0.019 0.032 0.033 Mean 0.988 0.869 0.767 0.540 Cervical 1/3 SD 0.012 0.051 0.059 0.110
Table-2: Compaction Force of 15N on Apical, Middle and Cervical Third in Different Tapers.
Tapers 2% 4% 6% 12% P* Value, Sig Significant Pairs**
Mean 4.782 3.291 3.007 2.510 P<0.001 HS I&II, I&III,I&IV
Table-3: Comparision of Mean Occlusion Load of 50N in Different Tapers.
Tapers 2% 4% 6% 12%
Apical 1/3 0.789 0.713 0.667 0.646
Middle 1/3 0.716 0.657 0.603 0.566
Cervical 1/3 0.669 0.608 0.587 0.484
P* Value, Sig P<0.05 S P>0.05 NS P<0.001 HS P<0.001 HS
Significant Pairs** At & Ct At &Mt, At & Ct At &Mt, At & Ct
Table-4: Comparison Of Different Tapers With Each Increment To Evaluate Significant Pair Under Compaction Force Of 10N.
17
ENDODONTOLOGY
Tapers 2% 4% 6% 12% Apical 1/3 1.267 1.051 0.976 0.946 Middle 1/3 1.135 0.972 0.893 0.847
Cervical 1/3 0.988 0.869 0.767 0.540
P* Value, Sig P>0.05 NS P<0.001 HS P<0.001 HS P<0.001 HS
Significant Pairs** At &Mt, At & Ct At &Mt, At & Ct At &Mt, At & Ct
Table-5: Comparison Of Different Tapers With Each Increment To Evaluate Significant Pair Under Compaction Force Of 15N.
10
11
12
Fig 1 apical third g.p filling on model with taper 2% under compaction forces (10n) fig. 2 (15n). Fig 3.middle third g.p filling on model with taper 2% under compaction forces (10n).fig 4 (15n). Fig 5cervical third g.p filling on model with taper 2% under compaction forces (10n). Fig 6 (15n). Fig 7 occlusal load of 50n applied on model (2%), after filling the access cavity with composite (stress graph ).fig 8 occlusal load of 50n applied on model (2%), after filling the access cavity with composite (displacement graph). Fig 9 apical third g.p filling on model with taper 4% under compaction forces (15n). Fig 10 (10n). Fig 11middle third g.p filling on model with taper 4% under compaction forces ( 15n). Fig 12 (10n).
18
ENDODONTOLOGY
13 14 15
16
17
18
19
20
21
22
23
24
Fig 13 cervical third g.p filling on model with taper 4% compaction forces (15n) fig 14 (10n) fig 15 occlusal load of 50n applied on model (4%), after filling the access cavity with composite(stress graph ) fig 16 (displacement graph) fig 17 apical third g.p filling on model with taper 6% compaction forces ( 15n) fig 18 (10n) fig 19 middle third g.p filling on model with taper 6% under compaction forces ( 15n). Fig 20 (10n). Fig 21 cervical third g.p filling on model with taper 6% compaction forces (15n) fig 22 10 n fig 23 cervical third g.p filling on model with taper 6% compaction forces (10n) occlusal load of 50n applied on model (6%), after fiiling the access cavity with composite (stress graph ) fig 24occlusal load of 50n applied on model (6%), after fiiling the access cavity with composite (displacement graph)
25
26
27
28
19
ENDODONTOLOGY
29 30
31
32
Fig 25 apical third g.p filling on model with taper 12% under compaction forces (10n). Fig 26 (15n). Fig 27 middle third g.p filling on model with taper 12% under compaction forces (10n) fig 28 (15n). Fig 29 cervical third g.p filling on model with taper 12% under compaction forces (10n). Fig 30 (15n). Fig 31 occlusal load of 50n applied on model (12 %), after fiiling the access cavity with composite (stress graph ) fig 32 occlusal load of 50n applied on model (12 %), after fiiling the access cavity with composit e (displacement graph)
MATERIAL PROPERTIES APPLIED IN THE STRESS ANALYSIS (FEA)

Material Enamel (principal direction) Enamel (transverse plane) Dentine Periodontal ligament Bone Gutta-percha Restorative composite Elastic Modulus (GPa) 84 42 14.7 0.00118 0.49 Temperature Dependent 14 Willems et al. (1992) 0.24 Craig & Powers (2002) Reference Craig & Powers (2002) Craig & Powers (2002) Sano et al. (1994) Dyment and Synge (1935) Moroi et al. (1993) Poissons Ratio Reference 0.33 0.31 0.50 0.30 0.30 0.30 (0 C0) 0.35 (30 C0) 0.40 (60 C0) 0.24 Craig & Powers (2002) Farah et al. (1989) Reference Farah et al. (1989) Farah et al. (1989) Farah et al. (1989)
GRAPHS
20
ENDODONTOLOGY
BIBLIOGRAPHY
1) Aviad Tamse. Vertical root fractures in endodontically treated teeth: diagnostic signs and clinical management. Endodontic Topics 2006;13:8494. 2) B. D. Rundquist & A. Versluis. How does canal taper affect root stresses? International Endodontic Journal. 2006;39:226237. 3) Chankhrit Sathorn, Joseph E.A. Palamara, and Harold H. Messer. Effect of root canal size and external root surface morphology on fracture susceptibility and pattern: A Finite Element Analysis. J Endod 2005;31:288-291. 4) Chankhrit Sathorn, Joseph E.A. Palamara, and Harold H. Messer. A comparison of the effect of two canal preparation technique on root fracture susceptibility and pattern, J Endod 2005;31:283-287. 5) Linda J.-William, Peter G. Fotos, Vijay K. Goel, James D. Spivey, Eric M. Rivera and Satish C. Khera. A-three dimensional finiteelement stress analysis of an endodontic prepared maxillary central incisor. J Endod 1995; 21:362-367. 6) Tannaz Zandbiglari et al. Influence of instrument taper on the resistance to fracture of endodontically treated roots. Oral surg oral med oral path oral radio endo 2006;101:126-31. 7) Yeera Lertchirakarm et al. Finite element analysis and strain gauge studies of vertical root fracture.J Endod 2003;29:529534.
21
ENDODONTOLOGY A Comparative Evaluation of Cyclic Fatigue Resistance of Two Rotary Nickel - Titanium Endodontic Systems - An In Vitro Study
DR. DR. DR. DR. GAURAV GARG * SANJAY MIGLANI ** SEEMA YADAV *** SANGEETA TALWAR ****
ABSTRACT:
The purpose of this study was to compare the fracture resistance of two different rotary Ni Ti instrument systems due to cyclic fatigue. The instruments compared were RaCe (FKG, La- Chaux De Fonds, Switzerland) and a new rotary system - Varitaper (Endomax, Equinox, Holland). The cyclic fatigue testing was conducted with the instrument rotating freely at two different angles of curvature 45 & 90 with maximum curvature at 5mm from the tip. Total 60 instruments were tested in the two groups for both angles of curvature. The instruments were rotated at 350 rpm using the ATR motor (Dentsply, Maillefer) set at maximum torque, until fracture occurred. The time until fracture was recorded in seconds by using a stopwatch, and the number of rotations to fracture was then calculated and results were statistically analyzed. RaCe (FKG, La- Chaux De Fonds, Switzerland) performed significantly better than Varitaper (Endomax, Equinox, Holland) in cyclic fatigue testing.
INTRODUCTION
Root canal preparation in narrow and curved canals is a great challenge. Rotary Ni- Ti files can be used to prepare curved canals as they are 2-3 times more elastic and flexible in bending & torsion and have Superior resistance to torsional fracture compared with similar size stainless steel files1. Despite the advantages of rotary Ni- Ti instruments, concern has been expressed by many authors and clinicians about the potential for rotary Ni- Ti instrument to fracture within the root canal system during endodontic treatment 2-4 . Although instrument fracture may not affect the prognosis when endodontic treatment can be performed to a high technical standard, it may present a problem
if microbial control is compromised3 or should excessive removal of tooth structure be required to eliminate the fragment4. Endodontic instrument fracture within canal is a complex event. Fracture occurs without warning and without any visible defects of previous permanent deformation. So Visible inspection is not reliable for Ni-Ti instruments.Two modes of fracture of rotary Ni-Ti endodontic instruments have been identified in the clinical situation: Torsional fracture and Flexural fracture 5. Among these flexural fatigue is an important factor in a clinical point of view. An understanding of factors that contribute to instrument fracture is important in
*P GS t u d e n t ,* *A s s t .P ro f e s s o r, * * *A s s o c . P ro f e s s o r, * * * *P ro f e s s o r&H e a do fD e p a rt m e n t ,D e p a rt m e n to fC o n s e r v a t i v ed e n t i s t r y&E n d o d o n t i c s ,M a u l a n aA z a dI n s t i t u t e of Dental Sciences ,MAMC Campus, New Delhi - 110002. Corre s p o n d e n c e :D r. G a u r a vG a rg (e-mail- gaurav1059@yahoo.co.in)
22
ENDODONTOLOGY
preventing its occurrence. These include the following: Root canal anatomy both in terms of radius & Degree of curvature (most Important), operator proficiency, operational speed and torque, previous use, sterilization procedures and cross sectional area and design of the instrument . Many
6
DR. GAURAV GARG, DR. SANJAY MIGLANI, DR. SEEMA YADAV, DR. SANGEETA TALWAR
The aim of this study was to evaluate & compare the cyclic flexural fatigue resistance of RaCe(FKG, La- Chaux De Fonds, Switzerland) and recently introduced rotary Ni-Ti system; Varitaper(Endomax, Equinox, Holland).
different rotary systems are available with difference in cross sectional shape and design, Taper and total number of instruments within system. But it is quite difficult to determine the best one. RaCe(FKG, La- Chaux De Fonds, Switzerland) is one of the system that has been used for severely curved canals with success due to its extreme flexibility and Good shaping ability with little transportation7,8. Varitaper (Endomax, Equinox, Holland) comprises of six safe ended instruments including three apical finishers with a gradual increasing taper of 3-6% and variable helical angles. It has a unique crosscut design over cutting edge to reduce stress on instrument and for efficient debris removal. Like RaCe (FKG, La- Chaux De Fonds, Switzerland) the cross section design of Varitaper is triangular but with slightly positive rake angle for efficient cutting of dentin as per manufacturers specifications.
MATERIALS AND METHODS

The instruments evaluated were RaCe (FKG, La-Chaux De Fonds, Switzerland) and Varitaper (Endomax, Equinox, Holland)(fig.1). All files were of tip size ISO 25 and 25 mm in length, but there was a difference in the taper among the two (fig.2).
Fig. 2- instruments evaluated-upper-RaCe,lower-Varitaper.
RaCe has a continuous taper of 0.02 throughout and Varitaper has a gradual increasing taper from 3-6%. A system was used that allowed fatigue test to be conducted in a manner similar to that of Youssef et al (1999)9. It comprises of three cylindrical steel blocks (one supporting block and two shaping block) attached on a 6mm thick acrylic sheet which was held vertically with the help of a vise. The positions of the shaping blocks was adjusted in order to get the desired degree of curvature (45 and 90) in the instrument in such a manner that maximum curvature was at 5mm from the tip (fig. 3 and fig.4). The angle of curvature was calculated by Schneiders method10, which defined the angle of
Fig.1- Armamentarium 23
curvature by drawing a line parallel to the long
ENDODONTOLOGY
axis of the canal and the outer line from the apical foramen to intersect with first line at a point wherein the canal began to leave the long axis of the canal.
A COMPARATIVE EVALUATION OF CYCLIC FATIGUE RESISTANCE OF TWO ROTARY NICKEL TITANIUM ENDODONTIC SYSTEMS - AN IN VITRO STUDY
Fifteen instruments were tested in each of the four experimental groups and for both angles of curvature to give a total of 60 instruments tested (table 1). The instruments were rotated at 350 RPM using the ATR motor (Dentsply, Maillefer). The time until fracture was recorded in seconds by using a stopwatch, and the number of rotations to fracture was than calculated using the simple formula: No. of rotation to fracture= 350/ 60 X time taken to fracture (in sec.). Because the study was a direct comparison of fatigue resistance among groups, a separate control group was not required. Results of cyclic fatigue test were analyzed by using Paired t test (SPSS Software) with level of significance at p< 0.05.
Fig.3-Instrument at 45curvature
RESULTS
The number of rotations to fracture, when the instruments were rotated at a 45 and 90angle of curvature, are presented in table 2 and mean & standard deviation is provided in table 3. Pairwise comparison showed that the number of rotations to failure for RaCe was significantly greater than that of VariTaper at both angles of curvature 45 and 90 with p-value .004 and .002 respectively. (Table 4).
Table 1
Experimental groups and no. of instruments in each group (n) Group 1 Fig.4- Instrument at 90curvature Group 2 Group 3 Group 4
VariTaper VariTaper RaCe RaCe (45), n=15 (90), n=15 (45), n=15 (90), n=15
24
ENDODONTOLOGY
Table 2 : Table of number of rotations at fracture at both angles of curvature for both instruments
VariTaper Samples 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 45
O
DR. GAURAV GARG, DR. SANJAY MIGLANI, DR. SEEMA YADAV, DR. SANGEETA TALWAR
DISCUSSION
The present study confirmed that the number of rotation to fracture an instrument largely depends on the degree of curvature with more incidence of breakage at greater degree of curvature as concluded by other studies11, 12. In endodontic treatment, Biomechanical preparation is very important as the outcome is largely depends on proper cleaning and shaping. A more tapered preparation results in enhanced cleaning as there is more removal of infected dentin and also endodontic irrigants can reach more apically and results in better microbial control and better debridement and also good quality obturation13. Varitaper has more taper (3-6%) as compared to RaCe (0.002) and theoretically might results in better apical preparation with gradually increasing taper. But in severely curved canals the instruments with greater taper generally fracture earlier as compared to 0.02 tapered instruments due to reduced flexibility14. The results of present study also confirmed this fact. The cross cut design incorporated in the Varitaper system might results in less cyclic fatigue than other instruments of similar taper as some of the values of Varitaper at 45 & 90are similar to as that of RaCe. As this was an in vitro study clinical trials should be carried out for more appropriate comparison. As Varitaper is a new system, further studies are required to analyze it with other various rotary systems according to various aspects.
RaCe
O
90
45
90
332 340 330 315 351 328 340 345 330 337 324 348 352 339 336
146 150 142 145 152 148 143 151 147 138 149 146 154 143 149
350 356 352 349 341 346 343 346 349 341 348 351 342 348 350
154 150 148 154 152 146 153 158 151 143 150 151 148 152 156
Table 3 : Table of means and standard deviations of number of rotations to fracture

VariTaper 45 Mean St. D
O
RaCe
O
90
45
90
336.47 10.29
146.87 4.24
347.47 4.32
151.07 3.84
Table 4: Table of pairwise comparison among groups, mean difference, standard deviation and p value
Pairs Pair 1 Pair 2 Varitaper 45- RaCe 45 Varitaper 90- RaCe 90 Mean Diff. 11 4.2 St. D 12.47 4.33 P -value 0.004 0.002
CONCLUSION
Under the limitations of present study we
25
ENDODONTOLOGY
concluded that RaCe performed significantly better than Varitaper at both degree of curvature.
References:
1. Walia H, Brantley W A, Gerstein H. An initial investigation of the bending and torsional properties of nitinol root canal files. JOE 1988; 14:346-51. 2. Huismann M, Peters OA,Dummer PMH. Mechenical preparation of root canals: shaping goals, techniques and means. Endod Topics 2005; 10:30-76. 3. Spili P, Parashos P, Messer HH. The impact of instrument fracture on outcome of endodontic treatment. J Endod 2005; 31:845-50. 4. Souter NJ, Messer HH. Complications associated with fractured file removal using an ultrasonic technique. J Endod 2005;31:450-2 5. Sattapan B, Nervo GJ, Palmara JEA, Messer HH. Defects in rotary nickel-titanium files after clinical use. J Endod 2000;26:161-5. 6. Margot E Anderson, John WH, Peter parashos. Fracture resistance of electropolished rotary nickel titanium endodontic instruments. J Endod 2007;33:1212-16. 7. Samantha, Renato Cremonse, Susan Bryant, Paul Dummer. Shaping ability of RaCe rotary Nickel-Titanium instruments
A COMPARATIVE EVALUATION OF CYCLIC FATIGUE RESISTANCE OF TWO ROTARY NICKEL TITANIUM ENDODONTIC SYSTEMS - AN IN VITRO STUDY
in simulated root canals. J Endod 2005;31:460-67. 8. F Paque, U Musch, M Hulsmann. Comparison of root canal preparation using RaCe and Protaper rotary Ni-Ti instruments. IEJ 2005;38:8-16. 9. Youssef Haikel, Rene Serfaty, Geoff Bateman, Bernard Senger, Claud Allemann. Dynamic and cyclic fatigue of engine driven rotary Nickel-Titanium endodontic instruments. J Endod 1999;25:434-440. 10. Schneider SW. A comparison of canal preparation in straight and curved root canals. Oral Surg 1971;32: 271-5. 11. Gabriela Zelada, P. Varela, B. Martin, Jose G., F.Magan, Saem Ahn. The effect of rotational speed and the curvature of root canals on the breakage of rotary endodontic instruments. JOE 2002; Vol.28, No.7. 12. Margot E.Anderson, John W.H. Price, Peter Parashos. Fracture resistance of electropolished rotary Nickel-Titanium endodontic instruments. JOE 2007; Vol. 33, No. 10: 12121216. 13. Najia Usman, J.Craig, J. Gordon. Influence of instrument size on root canal debridement. JOE 2004; Vol.30, No.2. 14. Y. Haikel, Rene Serfaty, G. Bateman, B. Senger, C. Allemann. Dynamic and cyclic fatigue of engine driven rotary Nickel-Titanium endodontic instruments. JOE 1999; Vol.25, No. 6: 434-40.
26
ENDODONTOLOGY Coronal Microleakage of Four Restorative Materials Used in Endodontically Treated Teeth as A Coronal Barrier - An In Vitro Study
DEEPALI S. * MITHRA N. HEGDE **
ABSTRACT
The present in vitro study was undertaken to evaluate sealing ability of access restoration using, four different dentin adhesives under composite with conventional glass ionomer cement and resin modified glass ionomer cement as intracoronal barrier 65 extracted human maxillary premolars were randomly divided into 15 teeth each in 4 experimental groups and 5 intact teeth each in control group. Following the biomechanical preparation,all teeth were obturated using Protaper gutta percha points and AH plus sealer. Once the sealer set, about 3mm of gutta-percha was removed from canal orifice in all the teeth. The base was placed till canal orifice extending 1mm coronally. All the specimens were thermocycled for 500 cycles at 50 550 c for 30 sec, and then placed in Rhodomine 6G fluorescent dye for 24 hrs. The coronal leakage was measured under a fluorescent microscope. Data obtained from the study were subjected to statistical analysis using one way Anova Test and Tukeys HSD test. RESULTS - It showed statistically significant difference in coronal leakage among all the groups, but with no statistically significant difference seen between high strength glass ionomer cement (Group I and Group II) and Ketac N 100 (group III and Group IV when placed as intraorifice barrier. CONCLUSION - Under the limitations of the present study the following conclusions were made that, Composite restoration with Xeno III adhesive and Ketac N 100 as intraorifice barrier showed better coronal sealing ability in access cavities.
INTRODUCTION
The most common cause for failure of root canal therapy is apical percolation or microleakage due to an inadequate apical seal. This allows periapical fluids, proteins, and bacteria access to the root canal. Through this interchange an inflammatory reaction is initiated which often results in radiographic or clinical signs of failure of root canal therapy. The question arises that if apical microleakage is a cause of endodontic failure, what
role might coronal microleakage plays in prognosis of root canal treatment. 1 Endodontic obturation is often thought of only in terms of an effective apical seal. However, the coronal seal may be equally important for the ultimate success of endodontic treatment. The apical seal may be adversely affected if coronal seal is lost or becomes defective.2 A three dimensional filling of the root canal
*P GS t u d e n t ,* *H e a do ft h eD e p a rt m e n t ,D e p a rt m e n to fC o n s e r v a t i v eD e n t i s t r y&E n d o d o n t i c s ,A . B .S h e t t yM e m o r i a lI n s t i t u t eo fD e n t a lS c i e n c e s ,D e r a l a k a t t e ,M a n g a l o re .
27
ENDODONTOLOGY
system will prevent the penetration of microorganism and toxins from the oral cavity via the root canal into the periradicular tissues. Weine has indicated that improper restoration leads to loss of more endodontically treated teeth than actual failure of endodontic therapy. Good coronal restoration resulted in significant healing of periradicular inflammation as compared to well obturated root canals.3 Composite resins are the most common choice for restoring access cavities. They can be bonded to tooth structure and most restoratives, and can provide a good match of color and surface gloss. Bonded composite materials can also strengthen existing coronal or radicular tooth structure, at least in the short time. Traditional glass ionomer cements are self cure and have very little polymerization shrinkage, although less than composite resins. Conventional glass ionomer cement and resin modified glass ionomer materials are useful for bulk filling access cavities. Placement of material over the coronal guttapercha to act as a barrier to coronal microleakage would be advantageous. The ideal intraorifice barrier has not been identified yet, or perhaps, not even developed.4 Hence there is a need to conduct a study to assess the coronal microleakage with permanent access restorative materials with an intraorifice barrier.
MITHRA N. HEGDE, DEEPALI S.
on the root surface and for exceptionally short and thin roots were excluded. All teeth were stored in 10% neutral buffered formalin for at least 2 weeks and then in distilled water until they were tested. The teeth were thoroughly cleaned with an ultrasonic scaler. Radiographs were taken to confirm the presence of two canals. Coronal access was achieved and working length for all teeth was determined by subtracting 0.5 mm from the length at which the file tip extruded apically. All the teeth were prepared using ProTaper files in a variable tip crown down sequence to an apical size of 0.25 mm (master apical file size .25 mm) at 0.5 mm from the canal terminus or apical foramen. All the teeth were instrumented with the ProTaper instruments according to the manufacturers direction. 15% EDTA (Glyde, Dentsply Co.) was used to coat the ProTaper files while they were used. The root canals were irrigated in between each file with 2.5% sodium hypochlorite (Vensons India) and physiologic saline using a long 27 gauge needle alternatively. The smear layer was removed using 3 ml of 17% EDTA followed by a final flush with 3 ml of 2.5% sodium hypochlorite. Upon completion of instrumentation, the canals were dried utilizing absorbent points. Upon completion of instrumentation, the canals were dried utilizing absorbent points. A master cone radiograph was taken and obturated using F2 gutta percha cone and accessory cones with lateral condensation using AH Plus root canal sealer.
METHODOLOGY
65, straight two rooted maxillary premolars with mature root apices and single canal extracted on periodontal or orthodontic grounds were used. Teeth with gross caries involving the root, cracks
28
Access restoration placement

All the 65 prepared teeth were randomly divided into four experimental groups of 15 teeth
ENDODONTOLOGY
each as I, II, III and IV respectively, and control group of 5 teeth. Control group: 5 teeth used were intact teeth with periapical seal and coated with Nail Varnish completely Intra orifice space preparation - After drying the access, 3mm of gutta percha was removed from the coronal orifice (cemento-dentinal junction) using heated endodontic hand plugger of ISO size # 30. in all the teeth except control group.
CORONAL MICROLEAKAGE OF FOUR RESTORATIVE MATERIALS USED IN ENDODONTICALLY TREATED TEETH AS A CORONAL BARRIER - AN IN VITRO STUDY
All the four groups were then restored with Filtek Z 350 and cured for 20 seconds. Teeth were then placed in artificial saliva for 20 days, later subjected to thermocycling for 500 cycles at 5- 550c for dwell time 30 seconds. The samples were dried for 24 hours.
DYE LEAKAGE
For evaluation of the quality of the coronal seal, the teeth were subjected to dye leakage. Experimental groups were coated with two layers of nail varnish except at 2 mm area around access restoration. All teeth were then immersed in Rhodomine 6G fluorescent dye which was freshly prepared (According to the manufacturers instruction) for 48 hours. After this time the excess dye were washed off and varnish gently scraped away from the coronal surface. The coronal portion was then sectioned buccolingually in a longitudinal direction with a diamond disc under running water.
Intraorifice Barrier
Group I and Group II: 30 teeth were used in which 3mm intraorifice space was restored with High Strength Glass Ionomer Cement extending 1mm coronally. Group III and Group IV: 30 teeth were used in which 3 mm intraorifice space was Primed for 15 seconds and then air dried restored with Ketac N 100 and cured for 10 seconds extending 1 mm coronally.
Access Restoration:
Group I: 15 teeth used were etched with 37% phosphoric acid for 15 Seconds, Prime& Bond NT adhesive was applied and cured for 10 sec. Group II: In 15 teeth, Clearfil S3 adhesive was applied and left for 20 seconds, then Light cured for 10 sec. Group III: 15 teeth, G Bond was applied and left for 10 seconds and then light cured for 10 sec. Group IV: 15 teeth, Xeno III was mixed according to manufacturers Instructions, left undisturbed for 20 sec and light cured for 10 sec.
MICROSCOPIC EVALUATION
Color photographs were taken of the sectioned samples using Nikon S-10 camera attached to a fluorescent microscope and later the pictures were transferred to a personal computer. Digitized images were analysed using Image analysis software. The maximum degree of dye penetration was recorded for each section, the degree of leakage was determined from the coronal till the apex and the dye penetration was scored with scoring criteria.19
SCORING CRITERIA
0 = No leakage detected
29
ENDODONTOLOGY
1 = Slight, just reaching the pulp chamber 2 = Moderate, penetrating halfway into pulp chamber 3 = Extensive, with leakage extending upto the floor of the pulp chamber 4 = Gross, extending into the root canal and/ or furcation
DISCUSSION
The success of endodontic therapy depends on a thorough chemomechanical preparation for removal of necrotic debris and bacteria from the root canal followed by sealing the root canal to prevent ingress of bacteria and tissue fluids. Dow and Ingle stated that failure most commonly occurs due to inadequate apical seal. Studies have shown that a good coronal seal is equally important.5 Swarthz et al found that the failure rate was twice as high in cases without an adequate coronal restoration compared to cases which were adequately restored 6 Fractured teeth and leaking or missing temporary restorations are encountered clinically, leaving the access to the canals open to the oral cavity. Thus the potential exists for oral fluids and bacterial contamination of the root canal space due to dissolution of the coronal seal23. There are several methods that might possibly prevent microleakage through obturated root canals in the event the coronal restoration becomes defective or is lost. These include placement or an additional material such as IRM into the canal orifices after removal of portion of the gutta percha and sealer, sealing the entire chamber floor with a restorative material, or use of a root canal filling method that provides a seal without the addition of other sealing materials. In the present study, Multirooted maxillary premolar teeth with two root canals were selected to minimize anatomical variation, allow standardization and since accessory canals and lateral canals in furcation area though are not routinely obturated, may affect the prognosis of
RESULTS
The data obtained evaluating the coronal seal was subjected to statistical analysis using Anova test. The computed value of p is < 0.005, which indicates statistically significant difference between the groups under study. All the experimental groups exhibited maximum leakage in composite while the least leakage was in glass ionomer to radicular dentin. The mean values showed that the highest leakage in composite was seen in Group IV followed by Group III, while least was seen in group I. At the interface between the glass ionomer cement and interface, the mean value showed highest leakage in Group III and least was in Group IV. At the level of intraorifice barrier highest leakage was observed in Group I and least in Group IV. Furthermore, the data was subjected to Tukeys HSD test to determine the intergroup comparison. This test was done to compare the two groups, it was observed that there was no statistically significant difference when Group I was compared with Group II (p value = 0.347), and there was no statistically significant difference when Group III was compared with Group IV and (p value = 0.076).
30
ENDODONTOLOGY
endodontically treated tooth due to close proximity of furcation to gingival sulcus.
10
gutta percha and sealer upto 3mm has several advantages. 1. The coronal 3mm of the canal is an ideal small cavity that is surrounded by intact tooth structure and can be easily sealed. 2. There is no occlusal load in the orifice area. 3. There are no esthetic considerations in this method, because the material is placed within the canal. 14 This is more appropriate on posterior teeth; however on anterior teeth, more care is necessary because the suggested material can cause discoloration of teeth or interfere with future bonding agents that are usually used for the teeth. Glass ionomer cements are made primarily of alumina, silica and polyacrylic acid and self curing materials. They are the only restorative materials that depend primarily on a chemical bond to tooth structure. They form an ionic bond to hydroxyapatite at dentin surface and also obtain mechanical retention from micro porosities in the hydroxyapatite. Glass ionomer cements form lower initial bond strength to dentin than resins, (3-7Mpa). But unlike resins they form a dynamic bond as the interface is stressed, bonds are broken, but new bonds form .this is one factor that allows glass ionomer cements to succeed clinically, despite relatively low bond strength. But they could not overcome the following disadvantages: 1) they set slowly and must be protected from moisture and dehydration during the setting reaction which is not completed for 24 hours, 2) they rely on ionic bonding to hydroxyapatite, strong acids should be
31
The use of tracers is one of the oldest and most common methods of detecting microleakage in vitro. Fluorescent dyes are found to be useful as tracers because they are detectable in dilute concentrations, inexpensive, are easy to photograph, permit more reproducible results, contrast sharply with the natural fluorescence of teeth, permit direct observation of the total marginal interface during evaluation and scoring of leakage, and being nontoxic, can be used safely.16 Thermocycling is a standard protocol in restorative literature when bonded materials are evaluated, simulating in vivo aging by subjecting them to cyclic exposures of hot and cold temperatures. Resin composite restorative materials and adhesive systems are sensitive to thermocycling. Thermocycling stress may induce a significant amount of bond fatigue and microleakage at the tooth/restoration interface. Marginal leakage is believed to be result of a difference in coefficient of thermal expansion between restorative material and tooth.15.hence in accordance with study done by Korsali et al the samples were thermocycled 500 cycles at 50-550C for 30 seconds. The ideal properties of an intraorifice barrier have been proposed by Wolcott et al. to include the following characteristics: a) easily placed b) bonds to tooth structure c) seals against microleakage d) distinguishable from natural tooth structure and e) does not interfere with final restoration. Placement of an additional material such as Glass ionomer cement or amalgam in to the canal orifices after removal of a portion of the
ENDODONTOLOGY
avoided because they totally eliminate mineral from dentin surface. Hence could be sensitive to total etch adhesives for bonding.18 The present study showed no statistical significance difference between sealing ability of high strength glass ionmer cement groups. Nano resin modified glass ionomer cement contains an acid- degradable glass and aqueous solutions of polyacid and monomeric ingredients such as 2-hydroxyethyl methacrylate (HEMA). The nano resin modified glass ionomer restorative further contains a unique combination of two types of surface treated nanofillers (approximately 5-25 nm) and nanoclusters (approximately 1.0 to 1.6 microns). The setting reaction of the cement starts immediately upon mixing as an acid base reaction. Free radical polymerization of the monomeric components is then initiated by visible light irradiation. Each acrylate group can take part independently in the chain reaction, but the net effect is the formation of a covently cross-linked three-dimensional network. The set cement then consists of interpenetrating networks of, poly (HEMA) and polyacrylate salts. This photochemical reaction reduces the early sensitivity to moisture and dehydration associated with the early stage of the acid-base setting reactions of GICs. They have the clinical advantage of extended working time, increased mechanical strengths by as much as two or three times compared to GICs. The primer, contains HEMA modifies the smear layer which facilitate better penetration of polyacrylic acid aiding into increase bond strength compared to conventional GICs.23 The present study evaluated no statistical significance difference between sealing ability of Ketac N 100 groups.
Bonding to dentin with resin is more complex than bonding to enamel. Dentin consists of 50% inorganic mineral by volume, 30% organic components and 20% fluid. The wet environment and relative lack of mineralized surface made it a challenge to develop materials that bond to dentin. Microleakage of the restoration is a more important issue in endodontically treated tooth. None of the current adhesives systems are capable of preventing microleakage over long time. The current study concluded that all the adhesive system showed microleakage after 20 days, while Xeno III has shown the least leakage compared to Clearfil S3, Prime&Bond NT, G Bond. Self etch adhesives system have become increasingly popular in the last decade the combination of etchant and primer into one system is advantageous in that it reduces the application time and technique related sensitivity. On the other hand, there is on going debate regarding the efficacy of bonding to enamel with self-etch adhesives systems. While some authors support the manufactures recommendations that the adjunctive use of phosphoric acid etching is necessary when bonding to uncut enamel, while others argue that the bond strengths of self etch adhesives are equal to the bond strength of total-etch adhesives to unground enamel.20,22 Contemporary self etch adhesives systems can be categorized as mild, moderate and aggressive depending on the acid dissociation constants acidic resin monomers used and the concentration of monomers present in the adhesives. Van Meerbeek et al attributed least leakage is due to it being a intermediary self etch adhesive
32
ENDODONTOLOGY
with acidic PH of 1.5. This acidic nature results in better micromechanical interlocking to dentin compared to strong self etch adhesives. It is also suggested that the residual hydroxyappatite at the hybrid layer base may still allow for chemical intermolecularinteraction.
25
bonding is rather unlikely, because the functional groups of monomers may have only weak affinity to the hydroxyappatite depleted collagen. Such challenging monomer- collagen interaction could be the prime reason for microleakage. This is in accordance to the present study which concludes that, Prime & Bond NT showed the maximum leakage .25 G bond adhesive (HEMA free adhesive) showed the highest leakage, the reason could be attributed to the recent study phase where separation among the adhesives compositions was confirmed as droplets entrapped during solvent evaporation from HEMA free adhesives. That phenomenon could be explained by the evaporation of solvents such as acetone, which affected the balance of solvents and resin monomer and caused water separate from the composition of the adhesive.17 Spherical blisters within the resin film may be the outcome of the residual free water not completely evaporated and entrapped at the interfacial level. The convergence of small blisters into large ones tends to produce honeycomb structures that may jeopardize the bonded interface. In the present study, Filtek Z 350 showed leakage in all the groups it is in accordance with study done by Korsali et al, the reason was attributed to the sealing performance of nano composite which is affected in access cavities by cavity configuration (6:1), dimensional changes like polymerization shrinkage or thermal/hydroscopic expansion and bonding capacity of resin. Clinically, the quality of an access restoration cannot be determined. Although experimental studies cannot exactly reproduce clinical
33
Clearfil S3 shows better seal among the self etching adhesives but slightly lower than Xeno III (p>0.05). The reason attributed to this is the presence of MDP. This functional phosphate monomer to a large extent, determines its actual bonding efficiency and stability. MDP has two hydroxyl groups that may bind to calcium. Yoshida et al reported that MDP tightly adheres to hydroxyapatite and that its calcium salt hardly dissolved in water. Moreover MDP causes minimal dissolution of smear plugs and limited opening of tubules, reducing dentin permeability. It also facilitates penetration, impregnation, polymerization and entanglement of monomers with demineralized dentin to form a relatively thick hybrid layer. So the lower dye penetration observed in the samples could be attributed to difference in chemical compositions of self etch adhesives.
24
According to the study conducted by Van Meerbeek et al, at the dentin interface the phosphoric acid treatment exposes microporus network of collagen that is totally deprived of hydroxyappatite, EDAX have confirmed that nearly all calcium phosphates were removed or at least became under detection limit. As a result, the primary bonding mechanism of Etch & rinse adhesives to dentin is primarily diffusion-based and depends on hybridization or infiltration of resin within the exposed collagen fibril scaffold, which should be as complete as possible. True chemical
ENDODONTOLOGY
conditions, and the relationship of in vitro leakage measurements to the in vivo situation has not yet been established, the most reasonable way of testing the efficacy of coronal restoration is extrapolation of the data obtained from in vitro studies to clinical conditions and long term clinical evaluation of the results. 13
Shows comparison of the mean coronal leakage of five different groups
BAR GRAPH SHOWS COMPARISON OF MEAN APICAL LEAKAGE OF THE THREE GROUPS BY ANOVA TEST
CONCLUSION
In the present study microscopic evaluation was done to analyze the extent of coronal dye leakage using Rhodamine 6G fluorescent dye of access restoration in endodontically treated with a Composite material ( Filtek Z350) using Prime & Bond NT, Clearfil S3, G bond and Xeno III adhesives with High strength glass ionomer cements and Ketac N 100 as an intra orifice barrier. The following conclusions were drawn,
Figure 1: Bar graph shows comparison of mean coronal leakage of the five groups by ANOVA.
The coronal seal is better when Ketac N 100

is used as intraorifice barrier.
Maximal coronal sealing is critical for

successful endodontic therapy. In this simulated clinical setting, composite restoration with Xeno III as bonding adhesive and Ketac N 100 as intraorifice barrier offered the highest probability for achieving a maximal coronal seal.
Figure 2: Fluoroscent Microscope.
Table I DYE LEAKAGE
Table 1: Comparison of the Coronal Leakage of all the Experimental Groups and control Group. 34
Figure 3: Fluorescence of the dye showing extent of coronal leakage.
ENDODONTOLOGY
References
1. Swanson .K, Madison .S: An Evaluation of Coronal Microleakage in Endodontically Treated Teeth: Part I. time Periods. J Endod 1987; 13(2):56 59. 2. Derkson.G, Pashley.D.H, Derkson.M: Microleakage measurement of selected restorative materials: A new in vitro method. J Prosthet Dent 1986; 56(4):435 440. 3. Andersons.R.W, Powell.B, Pashley.D.H: Microleakage of three temporary endodontic restorations. J Endod 1988; 14(10):497 501. 4. Arnold.A.D, Wilcox.L.R: Restoration of endodontically treated anterior teeth: An evaluation of coronal microleakage of glass ionomer and composite resin materials. J Prosthet Dent 1990; 64:643 646. 5. Torabinejad.M, Borasmy.MS, Kettering.J.D: In vitro bacterial penetration of coronally unsealed endodontically treated teeth. J Endod 1990; 16(12):566 569. 6. Magura.M.E, Kafrawy.A.H, Brown.C.E, Newton.C.W: Human saliva coronal microleakage in obturated root canals: An in vitro study. J Endod 1991; 17(7):324 331. 7. Khayat A, Lee S-J, Torabinejad M. Human saliva penetration of unsealed obturated root canals. J Endo 1991; 17: 324-331. 8. Shetty M. B. Fracture resistance of intact and endodontically prepared human mandibular molars restored with three different combinations of restorative materials- An in-vitro study. Endo Society Intern Endo Journal.1993. 9. Wolcott.J.F, Hicks.L.M, Himel.V.T. Evaluation of pigmented intraorifice barrier in endodontically treated teeth. J Endod 1999; 25(9):589-592. 10. Tewari.S, Tewari.S. Evaluation of coronal microleakage in endodontically treated multirooted teeth. Endodont 2000; 12:18-22. 11. Wolanek.G.A, Loushine.R.J, Weller.N.R, Kimbrough.F.W, Volkmann.K.R. In vitro bacterial penetration of endodontically treated teeth coronally sealed with dentin bonding agent. J Endod 2001; 27(5):354-357. 12. Belli.S, Zhang.Y, Pereira P.N.R, Pashley.D.H. Adhesive sealing of pulp chamber. J Endod 2001; 27(8):521-526.
13. Ozturk B, Ozer F, Belli S. An in vitro comparison of adhesive systems to seal pulp chamber walls. Int Endo J 2004; 37:297-306. 14. Scott.M.M, Scott.B, Goodell.G. The effect of thermocycling on a colored glass ionomer intracoronal barrier. J Endod 2005; 31(7):5266-528 15. Korsali.D, Ziraman.F, Ozyurt.P, Cehrali.B. Microleakage of self etch primer/adhesives in endodontically treated teeth. J Am Dent Assoc 2008; 138(5):634-640 16. Bahareh Fathi, James Bahcall, James S. Maki. An In Vitro Comparison of Bacterial Leakage of Three Common Restorative Materials Used as an Intracoronal Barrier. J Endod. 2007; 33(7):872-874. 17. Saunders.WP, Saunders.EM: Coronal leakage as a cause of failure in root canal therapy: a review. Endod Dent Traumato1994; 10:105-108. 18. Schwartz R.S, Fransman R. Adhesive dentistry and endodontics : materials, clinical strategies and procedures for restoration of access cavities : a review. J Endo 2005;31:151165 19. Leinfelder, K. Current Developments in Dentin Bonding Systems. JADA 1993; 124: 40-42. 20. Christensen.G. Self-etching primers are here. J Am Dent Assoc 2001; 132(7):1041-1043 21. Smith.G. Surface deterioration of glass-ionomer cement during acid etching: An SEM evaluation. J Op. Dent 1988; 13:3-7. 22. Tay.F, Pashley.D.H. Aggressiveness of contemporary self etching systems. I: depth of penetration beyond dentin smears layers. Dent Mat 2001; 15:715-718. 23. Darvell.B, Yelamanchili.A. Network competition in resinmodified glass ionomer cement. Dent Mat 2008; 24:10651069. 24. Burke.T.F.J. Whats new in dentine bonding self-etch adhesives. Dent update 2004; 12:580-589. Meerbeek.B.V, et al. Adhesion to Enamel and dentin: current status and future challenges. J Op Dent 2003; 28(3):215-235.
35
ENDODONTOLOGY In Vitro Evaluation of the Efficacy of Five Apex Locators

NIRANJAN A. VATKAR * SUCHETA SATHE ** VIVEK HEGDE ***
ABSTRACT
Today in this field of new era with lot many innovations coming up daily, endodontics has taken a new paradigm shift. The earlier root canal technique of biomechanical preparation is now changing into chemobiomechanical preparation. Todays root canal treatment not only depends on proper cleaning and shaping procedures but also proper reaching of the irrigant upto the desired working length. Therefore it is absolutely essential to determine exact working length to achieve an optimum cleaning and shaping procedures. From the beginning of endodontics, many modalities and techniques have been devised for the determination of working length. With increased understanding of the relation of oral mucosa and periodontium to physics, the apex locator was invented which now is been used frequently. The present study was conducted to evaluate the efficacy of five different apex locators in determining the working length. Key words: apex locator, working model
INTRODUCTION
The ultimate success of any root canal treatment depends on multiple factors like the extent of caries, the biomechanical preparation, the obturation, the remaining tooth structure, etc. The proper instrumentation upto the apical constriction or also called as the cemento-dentinal junction (9) as seen earlier is also one of the vital factor for a good prognosis. The cemento-dentinal junction is a histological landmark and in clinical practice it is impossible to locate it. Therefore the apical constriction can be regarded as a clinical landmark on which we can depend upon. The apical constriction, when present, is the narrowest part of the root canal with the smallest diameter of blood supply and preparation to this point results in a small wound site and optimal healing
conditions (18). The traditional methods used till today rely on the apical tug back for the termination of any root canal instrumentation. Though this method is effective, it can also be deceptive as the tug back could also be possible because of any secondary curvatures present before the apical constriction. Also in some cases the canal may be sclerosed or the constriction has been destroyed by inflammatory resorption (19). The radiographs are definitely supportive for the instrumentation upto the apical constriction, but they can also prove deceptive due to improper angulation of the cone. Also, the image obtained is a two-dimensional image of a three dimensional object.
*S e c o n dy e a rp o s tg r a d u a t es t u d e n t ,* *P ro f e s s o r, * * *H e a do fD e p a rt m e n t ,D e p a rt m e n to fC o n s e r v a t i v eD e n t i s t r ya n dE n d o d o n t i c sa tM .A .R a n g o o n w a l aC o l l e g eo fD e n t a l S c i e n c e sa n d Re s e a rc hC e n t re, Azam Campus, Pu n e 1 .
36
ENDODONTOLOGY
The moisture on the absorbent point method can also give us false positive results as the draining above the apical constriction can happen. Keeping all the above limitations in mind, an electronic device for the determination of working length was investigated first in 1918 by Custer et al. His ideas were later revisited by Suzuki in 1942 (21) and Sunada in 1962 (20) for the invention of the modern electronic apex locator apex. The first electronic working length device measured the working length by calculating the electrical resistance between the periodontium and oral mucosa that gave a constant reading of 6 k. Later on many new devices were invented measuring the frequency, impedance and capacitance. The present study was conducted to evaluate the efficacy of five different apex locators in determining the working length.
IN VITRO EVALUATION OF THE EFFICACY OF FIVE APEX LOCATORS
2. Measurement of actual working length

A 15# K-file (Mani Inc.) was introduced inside the canal until it became visible at the apical foramen. The silicone stop was adjusted, the file was removed and the distance between the base of silicone stop and file tip was measured using a vernier caliper. To obtain the actual working length, 0.5 mm was subtracted from this measured length (1).
3. Working model for electronic working length determination

Two plastic rectangular boxes, 18 cm3 cm4 cm in dimension were used for preparing this model. Alginate was poured in each of this boxes that acted as an electroconductive medium (7, 10, 11, 17, 22). Ten teeth among the selected samples were mounted vertically upto the cementoenamel junction. All measurements were made within 2 hours of the model being prepared (15).

1. Preparation of samples Twenty freshly extracted single rooted single canal human teeth were chosen for the study. The teeth were stored in sodium hypochlorite for 24 hours to dissolve any tissue on the root surface. The teeth were then scaled with an ultrasonic scaler (EMS, Mectron) to remove any hard tissue if present on the root surface. Proper precautions were taken while scaling the apical part of all teeth. An access to the root canal of all teeth was prepared using a round and cylindrical bur (Mani Inc.). A 15# K-file (Mani Inc.) was used to negotiate the canal using sodium hypochlorite and normal saline.
4. Electronic working length measurement Five apex locators were chosen for this study, Dentaport ZX (Fig. 1; J. Morita Corporation, Japan), Root ZX (Fig. 2; J. Morita Corporation, Japan), Raypex 5 (Fig. 3; Roydent Dental Products, Johnson City, TN), Propex (Fig. 4; Dentsply), and E Magic Finder (Fig. 5; Densiti). Each tooth among the twenty samples was subjected to electronic working length measurement using all five apex locators. The entire technique was performed and the measurements were recorded by a single
37
ENDODONTOLOGY
operator. Care was taken to see that all the circuits, batteries and the operating modes of all five apex locators are fully functional. At first, canals were irrigated using 5.25% sodium hypochlorite placed with a syringe, then the pulp chamber was gently dried with an air syringe; cotton pellets were used to dry the tooth surface and eliminate excess irrigating solution. A 15# K-file with the file clip of the apex locator to be used, was attached to the file and inserted inside the canal until the apex locator showed the apex reading. The file was slightly pulled out until the apex locator showed the 0.5 mm reading. The silicone stop was adjusted and
NIRANJAN A. VATKAR, SUCHETA SATHE, VIVEK HEGDE
the file was removed and the distance between the base of silicone stop and file tip was measured using a vernier caliper. Measurements were considered as valid if they were stable for at least 5 seconds otherwise the value was recorded as an unstable measurement due to inability of the EALs to reveal a constant reading. The recorded values were tabulated. The actual length readings were compared to electronic working length readings. Statistical analysis of the recorded readings was done using a Sign test for nonparametric evaluation of the groups. Statistical readings were considered significant when p < 0.05.
RESULTS
The results obtained were tabulated as follows TABLE 1
TOOTH SAMPLE 1 2 3 4 5 6 7 8 9 10 *Length in mm ACTUAL LENGTH 21 24 22 23 22 21 21.5 23.5 19 24 PROPEX ROOT ZX 20.5 24 21.5 23 22 21 22 23 19 23.5 DENTAPORT ZX 20.5 23 23 24 22 20.5 22 23.5 18.5 23.5 E MAGIC FINDER 21 23.5 22 23 22 20.5 21.5 23.5 19 24 RAYPEX 5
21 23.5 21.5 23 21.5 20.5 21 23 19 23.5
21 24 22 23.5 22 20.5 21.5 23.5 18.5 23.5
38
ENDODONTOLOGY
TABLE 1
TOOTH SAMPLE 11 12 13 14 15 16 17 18 19 20 *Length in mm ACTUAL LENGTH 19.5 19.5 24.5 20.5 21 20 21 21 22 24.5 PROPEX ROOT ZX 19 19 24.5 20 21 20 21 21.5 22 24
DENTAPORT ZX 19 19 24.5 20 20.5 20 20.5 21 21.5 24
E MAGIC FINDER 19 19.5 24.5 20 21 19.5 21 21 22 24.5
RAYPEX 5
19 19 23.5 20 21 20 21 21 22 24.5
19.5 19 24 20 20.5 20 20 21 22 24
Accuracy was calculated only on stable measurements. There was a highly significant difference (p < 0.05) when the differences between measurements obtained with the Dentaport ZX, Raypex 5 and Propex and those obtained with the actual length readings were compared. The graphical representation of each apex locator compared with the actual length readings were are shown below. Table 1 and 2 shows that most measurements were within 0.5 mm of the actual length. One tooth each with Propex (tooth sample 13) and Raypex 5 (tooth sample 17) and three teeth with Dentaport ZX (tooth samples 2, 3, 4) gave readings that were beyond 0.5 mm. The statistical data was obtained as below. The dots above the line indicate the samples that the apex locator measured short of the apex. The dots
39
ENDODONTOLOGY
below the line indicate the sample that the apex locator measured beyond the apex. The dots on the line indicate the samples that the apex locator measured exactly at apex. The p value of each group is also indicated in each of the graph that was calculated statistically.
DISCUSSION
The use of electronic devices to determine working length has gained increasing popularity in recent years. Modern apex locators are able to determine an area between the minor and major apical foramina by measuring the impedance between the file tip and the canal with different frequencies and enables tooth length measurements in the presence of electrical conductive media in the root canals (12). As the mean foramen to apical constriction distance is approximately 0.51.0 mm for all teeth types (4, 8, 13), it was chosen in this study to record the actual working length by subtracting 0.5 mm from the measurement when the file appeared at the foramen.
40
ENDODONTOLOGY
Some authors have suggested that taking the instruments slightly long when using EALs and then retracting them may increase the accuracy of readings of EALs (5, 14). Thus, to confirm the measurement, the file was advanced upto the apex reading and then retracted to obtain the consistent 0.5 mm reading. All measurements were made within 2 hours of the model being prepared in order to ensure the alginate was kept sufficiently humid
[12]
exceeding the apical constriction (0.5 mm) (Table 1 and 2).
CONCLUSION
All these modern apex locators gave comparable results in comparison to actual working length. However Root ZX and E Magic Finder were the most precise, followed by Dentaport ZX, Raypex 5 and Propex. In conclusion, the modern newly advanced apex locators are gaining popularity because of their predictability, precision and ease of working. It helps you to know the apical constriction which you cannot see. These gadgets have definitely improved the quality of endodontics. This short study was performed to confirm the accuracy of five apex locators.
References
1. Kaufman A. Y., Keila S. & Yoshpe M. Accuracy of a new apex locator: an in vitro study. International Endodontic Journal 2002 35:186192. 2. Czerw RJ, Fulkerson MS, Donnelly JC. An in vitro test of a simplified model to demonstrate the operation of electronic root-canal measuring devices. Journal of Endodontics 1994 20:6056. 3. Czerw RJ, Fulkerson MS, Donnelly JC, Walmann JO. In vitro evaluation of the accuracy of several electronic apex locators. Journal of Endodontics 1995 21:5725. 4. Dummer PMH, McGinn JH, Rees DG. The position and topography of the apical canal constriction and apical foramen. International Endodontic Journal 1984 17:1928. 5. Dunlap CA, Remeikis NA, BeGole EA, Rauschenberger CR. An in vivo evaluation of an electronic apex locator that uses the ratio method in vital and necrotic canals. Journal of Endodontics 1998 24:4850. 6. Fouad AF, Reid LC. Effect of using electronic apex locators on selected endodontic treatment parameters. Journal of Endodontics 2000 26:3647. 7. Fuss Z, Assoline LS, Kaufman AY. Determination of root perforations by electronic apex locators. Oral surgery, Oral medicine, Oral Pathology and Endodontics 1996 82:324 329. 41
The relative stiffness of the alginate mould prevented fluid movement inside the canal that is responsible of premature electronic readings registered with previous models (2, 3, 6).
APEX LOCATOR Root ZX E Magic Finder Dentaport ZX Raypex 5 Propex P VALUE 1.109 0.063 0.035 0.021 0.001
The results of the present study confirmed that Root ZX and E Magic Finder can accurately determine the canal length within 0.5 mm from the apical constriction. The measurements obtained revealed that the EALs were able to measure the canal length with a precision compared with the actual length. If the estimated working length, i.e. actual length 0.5 mm is considered to be clinically acceptable, then the measurements made with the Root ZX and E Magic Finder were acceptable in virtually all cases. One tooth with Propex and one with Raypex 5 and three teeth with Dentaport ZX gave readings
ENDODONTOLOGY
8. Green D. Stereomicroscopic study of 700 root apices of maxillary and mandibular posterior teeth. Oral Surgery, Oral Medicine and Oral Pathology and Endodontics 1960 13:728 33. 9. Grove CJ The value of the dentinocemental junction in pulp canal surgery. Journal of Dental Research 1931 11:466 8. 10. Kaufman AY. Katz. Reliability of Root ZX apex locator tested by an invitro model. Journal of Endodontics 1993 19:201. 11. Keila S, Linn H, Katz A Kaufman AY. Morphometric analysis of working length determined by impedance type apex locators. Journal of Endodontics 1994 20:196 (Abstract). 12. Kobayashi C. Electronic canal length measurement. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontics 1995 79:22631. 13. Kuttler Y. Microscopic investigation of root apices. Journal of the American Dental Association 1955 50:54452. 14. Lee SJ, Nam KC, Kim YJ, Kim DW. Clinical accuracy of a new apex locator with an automatic compensation circuit. Journal of Endodontics 2002 28:7069. 15. Lucena-Martn C, Robles-Gijon V, Ferrer-Luque CM, Navajas- Rodrguez de Mondelo JM. In vitro evaluation of
the accuracy of three electronic apex locators. Journal of Endodontics 2004 30:2313. 16. Nekoofar M. H., Ghandi M. M., Hayes S. J. & Dummer P. M. H. The fundamental operating principles of electronic root canal length measurement devices: review. International Endodontic Journal 2006 39:595609. 17. Neguyen HQ, Kaufman AY, Komorowski R, Friedman S. Electronic length measurement using small and large files in enlarged canals. International Endodontic Journal 1996 29:359364. 18. Ricucci D, Langeland K. Apical limit of root canal instrumentation and obturation, Part II: A histological study. International Endodontic Journal 1998 31:394409. 19. Stock C. Endodontics-position of the apical seal. British Dental Journal 1994 176:329. 20. Sunada I. New method for measuring the length of the root canal. Journal of Dental Research 1962 41:37587. 21. Suzuki K. Experimental study on iontophoresis. Japanese Journal of Stomatology 1942 16:41129. 22. Tinaz AC, Maden M, Aydin C, Turkoz E. The accuracy of three different electronic root canal measuring devices: an in vitro evaluation. Journal of Oral Science 2002a 44:915.
42
ENDODONTOLOGY A Three-Dimensional Evaluation of Density and Homogeneity of Root Canal Obturation with Guttaflow using Backfilling Technique in Comparison with Conventional Lateral Compaction Technique using Spiral Computed Tomography - An In Vitro Study
P. SENTHIL KUMAR * A. R. VIVEKANANDA PAI ** KUNDABALA M. ***
ABSTRACT
The objective of the study was to three dimensionally compare the density and homogeneity of GuttaFlow using backfilling technique with conventional lateral compaction technique using spiral computed tomography. 30 human extracted maxillary central incisors were used for this study. Following access cavity preparation, working length was determined and root canal preparation was carried out using standard step-back technique. Root canal irrigation was performed using 2.5% NaOCl ,saline and final flushing with 17%EDTA and normal saline. After root canal preparation, the specimens were randomly divided into 3 groups with 10 teeth in each group. Specimens in Group-I were obturated with GuttaFlow using backfilling technique, Group-II were obturated by lateral compaction technique using GuttaFlow as the sealer and Group-III were obturated by lateral compaction technique using zinc-oxide and eugenol as the sealer. The specimens were then analyzed in both horizontal and vertical sections from the apex to the cemento-enamel junction of each specimen with section thickness of 1mm each using Spiral Computed Tomography. The data obtained was statistically analyzed using one way ANOVA test followed by FISHERS test and TUKEYS HSD test. Results showed that specimens of Group -I was denser, more homogenous compared to other groups and was statistically significant. In the evaluation of obturation in the apical, middle and coronal third individually, Group -I showed better results than other groups in apical and middle third which was statistically significant, but showed inferior results in the coronal third though it was not statistically significant. And Group-II and Group-III showed inferior results in the middle third when compared with Group-I and was statistically significant. From the results of the study it can be concluded that, Obturation done using GuttaFlow with backfilling technique is superior in the apical and middle third but is inferior in the coronal third of the root canal system when compared to lateral compaction technique. Spiral computed tomography is a very useful tool fo checking the density of obturation in endodontics. Key words: Gutta-Flow, Spiral Computed Tomography, Obturation density, Homogeneity.
*S p e c i a l i s t Re s i d e n t ,* *P ro f e s s o r,* *P ro f e s s o r&H e a d ,D e p a rt m e n to fC o n s e r v a t i v eD e n t i s t r y&E n d o d o n t i c s ,M a n i p a lc o l l e g eo fD e n t a lS c i e n c e s ,M a n g a l o re .
43
ENDODONTOLOGY
INTRODUCTION
The success of endodontic treatment depends on the complete obturation of the complex root canal system with an inert material1. To seal this system, the obturating material must adapt to all the portions of the root canal . The Washington
2
P. SENTHIL KUMAR, A. R. VIVEKANANDA PAI, KUNDABALA M.
The purpose of the study is to analyze the three-dimensional sealing ability of cold flowable gutta percha (GuttaFlow) and compare it with cold lateral compaction technique using spiral computed tomography.
study of endodontic success and failures indicates that nearly 60% of the failure is apparently caused by incomplete obturation of the radicular space3. Several materials and techniques have been developed for achieving a successful obturation, Gutta-percha is the most commonly used root canal obturation material and its physical properties have made it possible to use it in several different techniques4. One of the most recent techniques which uses cold flowable filling system for obturation of the root canal system is GuttaFlow which is combination of sealer and gutta percha powder. It consists of polydimethylsiloxane matrix highly filled with finely ground gutta-percha. Several studies have shown that GuttaFlow offers excellent flow and satisfactory physical properties5 according to ISO standards6.Unlike thermoplasticized guttapercha which shows shrinkage on cooling, GuttaFlow expands slightly by 0.2% on setting

Mechanical Preparation of the Teeth
Thirty freshly extracted single rooted human teeth with type I root canal anatomy were stored in normal saline. Following access cavity preparation, working length was determined and root canal preparation was carried out using standard step-back technique. Root canal irrigation was performed using 2ml of 2.5% NaOCl and normal saline and final flushing using 17%EDTA and normal saline. The apical portion of the canal was enlarged to a maximum of size 50. Any tooth requiring a size larger than #50 file was discarded. The coronal third of each canal was flared using a #2 and #3 Gates Glidden drills.
Obturation Techniques
After drying the canals with paper points, the teeth were randomly selected and divided into three experimental groups of 10 teeth each.
TABLE. 1 Experimental Groups

Groups I II Obturation technique Obturation using Gutta Flow (back filling technique) Obturation using using 2%ISO gutta percha points and Gutta Flow as sealer ( lateral compaction technique) Obturation using 2% ISO gutta percha points and zinc oxide eugenol sealer.( lateral compaction technique ) Number of teeth 10
further enhancing its sealing properties. Computed Tomography and Micro Computed Tomography are currently the leading technologies for endodontic research . With spiral computed
7
tomography three dimensional volume analyses are possible without sectioning the specimen and thus avoiding the loss of material during sectioning8 and it is possible to reconstruct overlapping structures at arbitrary intervals and thus the ability to resolve small objects is increased .
9
10
III
10
44
ENDODONTOLOGY
A THREE-DIMENSIONAL EVALUATION OF DENSITY AND HOMOGENEITY OF ROOT CANAL OBTURATION WITH GUTTAFLOW USING BACKFILLING TECHNIQUE IN COMPARISON WITH CONVENTIONAL LATERAL COMPACTION TECHNIQUE USING SPIRAL COMPUTED TOMOGRAPHY - AN IN VITRO STUDY
Analysis of the experimental specimens using Spiral Computed Tomography. All the experimental specimens were mounted on a wax block and placed on the couch of the computed tomography machine. It was moved longitudinally towards the gantry at the pitch of 1and exposure with 120kv and 180mA was done for one second. Both vertical and horizontal sections of 1mm thickness were made which was followed by three dimensional reconstruction of the sections. The specimens were further analyzed for variations in density in 1 to 5mm from apex ( SUBGROUP I), 6 to 10mm from the apex(Subgroup-II) and 11 to 16mm from the apex (Subgroup-III) individually in both vertical and horizontal sections.
and homogeneity. The values were recorded in both horizontal and vertical sections. The results were tabulated and graphically analyzed. All the experimental groups were compared statistically using ONE WAY ANOVA test and the sub groups were compared using TUKEYS HSD test. In all the groups (p>0.05) was considered statistically significant.
RESULTS
The Density was measured in HOUNSEFIELD UNITS TABLE. 3
Analysis of density among experimental groups in vertical section
TABLE. 2 Sub-Groups
SUB-GROUP -I SUB-GROUP II SUB-GROUP III 1 to 5 mm from the apex 6 to 10 mm from apex 11 to 16 mm from apex
TABLE. 4
Analysis of density among sub-groups in vertical section
The specimens were analyzed using Windows Advantage Work Station software for
z Density of the filling material. z Homogeneity and adaptation
to the canal wall.

z Voids.
TABLE. 5
Analysis of density among experimental groups in Horizontal section
The analysis of all the specimens was done followed by statistical analysis.
OBSERVATION AND RESULTS

The assessment was done using spiral computed tomography for variation in the density
45
ENDODONTOLOGY
TABLE. 6
Analysis of density among sub-groups in Horizontal section
adaptation because of increased flowablity and the fact that material expands slightly by 0.2% on setting11. Since GuttaFlow is a cold flowable material, there is no need for rise in the temperature of the material like thermo plasticized materials and as per manufacturers instructions there is no need for compaction of the material during obturation and hence there is no disadvantages like shrinkage on
DISCUSSION
Achieving a complete seal of the root canal system is of greatest importance in endodontic therapy, The Washington study has concluded that nearly 60% of all endodontic failure is due to incomplete obturation of the root canal10. The voids and crevices in the obturating mass can interconnect with each other opening up either apically or coronally. Further the tissue fluids, proteins and bacteria can seep into these empty spaces which act as a reservoir of irritants leading to failure of endodontic treatment. In the present study was used GuttaFlow as an obturating material. The ingredients include gutta-percha powder, polydimethylsiloxane matrix, silicone oil, paraffin oil, platinum catalyst, zirconium dioxide, nano -silver(preservative) and coloring agents.GuttaFlow is obtained by adding nano silver particles to its initial version Roekoseal ( Coltene / Whaledent) . The material is cold flowable and sets within 10 minutes. It is supposed to be easily applied using lentulo spirals or application syringes. The material flows into the smallest dentinal tubules, because of the small particle size (< 0.9microns). The manufacturer claims a better seal and good
46
cooling, vertical fractures due to undue forces and is relatively easy to use compared to other systems. However it should be noted that GuttaFlow belongs to the category of root canal filling pastes, which has a high risk of void formation,over filling or under filling. There fore this material (GuttaFlow) was chosen to study the flowablity, density, homogeneity. Spiral computed tomography was chosen over other diagnostic aids for analysis of the specimens because of its various advantages like ThreeDimensional volume measurements are possible without sectioning the specimens and thus avoiding the loss of material during sectioning8 and threedimensional reconstructions9. Here we chose 30 freshly extracted maxillary central incisors and divided into three groups with 10 teeth each. This allowed adequate statistical analysis and comparison with earlier studies. the canals of all the groups were prepared using a step back technique such that a continuously tapering funnel shape from the apical third to the coronal third was obtained. This facilitated for the ease of obturation with the two techniques in the study. In this study alternating solutions of NaOCl and normal saline were used for canal irrigation.
ENDODONTOLOGY
The canals were finally irrigated with 17% EDTA and normal saline to facilitate removal of dentin debris and smear layer from the root canal12. The specimens were then mounted on a wax block and subjected for analysis using Spiral Computed Tomography. Each section was analyzed for variations in the density in the obturation in Hounsefield Units (HU), and for voids if any. It was observed that the Hounsefield units increase from the apex to the cementoenamel junction in vertical sections. This could be attributed to the increase in the obturation mass from the apex to the CEJ. Similarly there was a decrease in the Hounsefield units from the centre towards the periphery in horizontal sections. This could be due to due to the decrease in the obturation mass towards the periphery. These findings were observed in all the samples. However there were no voids in any of the specimens. According to the result of the present study, Group - I showed the best results among the experimental groups with denser and more homogeneous obturation in both vertical and horizontal sections which was statistically significant. This can be attributed to Highly filled homogeneous matrix, good flow, 0.2% expansion on setting ,ability to penetrate into the dentinal tubules due to small particle size of the fillers and apart from fluid and injectable nature of GuttaFlow , use of a master cone could also be the
than Group-I which was statistically very highly significant in the horizontal section and statistically significant in the vertical section. This could be attributed to the studies done earlier by Torabinajed15 and others reported that a pattern of voids was frequently noticed in the case of lateral compaction where the fillings adapted reasonably well at the apical and coronal parts and showed longitudinal voids in the mid root section, thus confirming earlier findings by Goldman and associates and Schilder16 noted that with lateral compaction at no time a homogenous mass is developed. The final filling consists of a large number of separate gutta-percha cones tightly compressed together and joined by frictional grip and cementing substance only. The results showed that among the subgroupIII, Group-I showed inferior results than Group-II and Group-III but was statistically insignificant. This could be due to the reason that vertical condensation using a cold plugger in the coronal third was not done to the specimens in Group-I as per manufacturers instructions,and the possible reason for Group-II and Group-III to give better results might be due to the vertical compaction of the gutta-percha using a cold plugger following lateral compaction. The present study was done in vitro on teeth with straight canals, further in vivo studies are required to find its applicability in curved and narrow canals before accepting this material for routine obturation procedure.
reason for the denser obturation. This finding is supported by studies done earlier by MarthaG and Taranu R 14. Group-II and Group-III showed inferior results
47
13
CONCLUSION
From the results of the study it can be concluded that
ENDODONTOLOGY
1. Obturation done using GuttaFlow with backfilling technique is better than lateral compaction technique. 2. Obturation done using GuttaFlow with backfilling technique is superior in the apical and middle third of the root canal system but is inferior in the coronal third. 3. Lateral compaction is better in the coronal third of the root canal, and is inferior in the middle third compared to GuttaFlow with backfilling technique 4. GuttaFlow when used as sealer is comparable to zinc-oxide eugenol sealer.
GRAPH - III
Comparison of mean density (HU) Vertical section Sub group wise
GRAPH - IV
Comparison of mean density (HU) Horizontal section Sub group wise
GRAPH - I
Comparison of mean density (HU) Vertical section
GRAPH - II
Comparison of mean density (HU) Horizontal section
FIGURE 1 - Spiral computed tomography machine used for analysis of the specimens
48
ENDODONTOLOGY
FIGURE 2 - Image showing horizontal sections of the specimens FIGURE 5 - Section showing minimum value in Group-I.
REFERENCES:
1. Cohen S, Burns CR. Pathways Of The Pulp, 6th Edition, Mosby, St Louis , Missouri, Page 219. 2. Dow PR, Ingle JI. Isotopes Determination of Root Canal Failure. Oral Surgery 1955:8:1100-4. 3. Ingle JI. Endodontics, 4th Edition, Philadelphia, PA, U.S.A., Lea & Febiger, Page 25. 4. Brayton SM, Davis SR, Goldman M. Gutta-Percha Root Canal Fillings. Oral Surgery 1973; 35:226-31. 5. Rizzo F, Nocca G. In Vitro Evaluation of a New Experimental Endodontic Sealer. The 33rd Annual Meeting of the AADR, 2004; March 10-13, Honolulu, USA. FIGURE 3 - Image showing vertical sections of the specimens. 6. Eldeniz AU, Orstavik D. Physical Properties of Newly Developed Root Canal Sealers. International Endodontic Journal 2005; 38: 928. 7. Uyanik OM. Comparative Evaluation Of Three NickelTitanium Instrumentation Systems In Human Teeth Using Computed Tomography. Journal Of Endodontics 2006; 32:668-70. 8. Nandini S, Kandhaswamy D. Removal Efficiency Of Calcium Hydroxide Intra Canal Medicament With Two Calcium Chelators: Volumetric Analysis Using Spiral CT - An In Vitro Study. Journal of Endodontics 2006; 32: 1097-1100. 9. Gopikrishna V, Bhargavi N. Endodontic Management of Maxillary First Molar with a Single Root and Single Canal Diagnosed With the Aid of Spiral CT: A Case Report. Journal of Endodontics 2006; 32:687-90. FIGURE .4 - Section showing maximum value in Group-I. 10. Ingle JI. Endodontics, 4th Edition, Philadelphia, PA, USA. Lea& Febiger, 1994; Page 228.
49
ENDODONTOLOGY
11. Elayoti A, Achleitthner C. Homogeneity and Adaptation of a New Gutta-Percha Paste to Root Canal Walls. Journal of Endodontics 2005; 31:687-89. 12. Pashley D. Smear Layer; Physiological Considerations. Operative Dentistry Supplement 3, 1984; 13-29. 13. Martha Brackett G. Comparision of Seal After Obturation Techniques Using a Polydimethylsiloxane Based Root Canal Sealer. Journal of Endodontics 2006; 32:1188-1190.
14. Taranu R, Wegerer U. Leakage Analysis of Three Modern Root Filling Materials after 90 Days of Storage. International Endodontic Journal 2005;38:928. 15. Torabinajed M, Skobe Z. Scanning Electron Microscopic Study of Root Canal Obturation Using Thermoplasticized Gutta-Percha. Journal of Endodontics 1978;245-50. 16. Schilder H. Filling Root Canals in Three Dimensions. Dental Clinics of North America 1967; 11:723-44
50
ENDODONTOLOGY Comparative Evaluation of Radiopacity of Three Root Canal Sealers Using Conventional and Digital Radiographic Technique: An Invitro Study
SWETHA H.B. * SHASHIKALA K. **
ABSTRACT:
To compare and evaluate the radiopacity of three different root canal sealers using conventional and digital radiographic technique. The sealers tested were AH Plus, Endoflas and Pulpdent, by conventional and digital radiographic methods. The sealers were mixed and placed in a stainless steel ring moulds. Aluminium step wedge was placed along side of specimen for the measurement of radiopacity of sealers. Radiographic films were used for conventional method and the images were obtained after the films were developed from x-ray developing solutions. For digital radiographic technique the images were obtained from radiovisiograph. The images obtained from both the techniques were directly transferred to the analytical imaging software to determine the radiopacity of sealers using grey-pixel values. All tested materials showed radiopacity above 3mm of aluminium recommended by ANSI / ADA Specification 57. Higher mean radiopacity was observed in AH Plus followed by Endoflas and Pulpdent respectively. Conventional method showed a lower value of radiopacity compare to digital radiographic technique. The mean values of tested sealers were varying in both the methods. All tested materials showed radiopacity above 3mm of aluminium recommended by ANSI / ADA Specification 57. Digital radiography was better than the conventional radiographic method in evaluating the radiopacity of root canal sealers. KEY WORDS - Radiopacity, Digital radiography, Root canal sealers.
INTRODUCTION:
Root canal obturation is a critical determinant of the success or failure of the endodontic treatment, as it directly affects the outcome of the endodontic therapy. Majority of endodontic failures have been caused by incomplete sealing of the root canal. Obtaining a hermetic seal in root canal is extremely difficult. However, with the use of root canal sealers along with well adapted gutta-percha
gives a clinician a better chance to reach this goal.1 Many different root canal sealers are currently being used in combination with gutta-percha to fill the root canal after biomechanical preparation. From many years, gutta-percha has been used as a core material with zinc oxide eugenol based sealer.2 However zinc oxide based sealers shrink upon setting and disintegrate over a period of time and there by compromises the quality and the life
*P GS t u d e n t ,** P ro f. a n dH e a d ,D e p t .O fC o n s e r v a t i v eD e n t i s t r ya n dE n d o d o n t i c s ,D .A . P .M . R . V. D e n t a lC o l l e g ea n dH o s p i t a l ,B a n g a l o re
51
ENDODONTOLOGY
expectancy of the apical seal. Recently, a few new endodontic sealers have been developed with improvement in the sealing and bonding ability to the root dentin. These improvements depend on the incorporation of resin monomer into the sealer.3 The ideal root canal sealer of any types should meet certain general requirements according to International Organization of Standardization. In ascending order of importance, they should be nontoxic, compatible with living tissues, and exhibit chemical, physical and radiographic properties suitable for clinical use.4 Dental diagnosis relies mainly on radiology. In order to identify and distinguish a root canal filling materials from the surrounding anatomical structures, they should be radiopaque.The root canal filling materials should have sufficient radiopacity to see clearly the root canal filling to detect its presence, extent and apparent condensation.5 Earlier, conventional periapical radiography was the most common method used for the evaluation of the technical quality of the obturated canal. In the conventional radiographic method, the radiographic images were obtained by the chemical processing and the radiopacity was evaluated by an optical densitometer. 6 However, the digital imaging technique is an emerging area of radiology that offers many potential benefits over conventional method for the evaluation of radiopacity of root canal sealers.7 In the past, many of the literature mainly emphasized on the solubility, adhesion and antibacterial activity of different root canal sealers. But there are a few studies on radiographic properties of root canal sealers. Hence, an attempt is made to study the radiopacity of root canal sealers using both
52
SWETHA H.B., SHASHIKALA K.
conventional and digital radiographic technique.1 The aim of the present study was to compare and evaluate the radiopacity of three different root canal sealers (Pulpdent sealer, Endoflas sealer and AH Plus sealer) using conventional and digital radiographic techniques.

Three root canal sealers were evaluated in this study: AH Plus, Pulpdent and Endoflas (Table 1). The sample size for each method is eighteen {n= 18}. Six tests are conducted for each sealer in a method. The sealers were mixed according to the manufacturers recommendations and then introduced immediately in to two stainless steel ring moulds (Diameter 10mm, Height 1mm). The application of the sealers was accomplished with the use of a syringe to avoid the air bubbles. An aluminum step wedge made of 1100 alloy, with a thickness varying 1 to 12mm, in uniform steps of 1mm each was positioned along side the specimen on a glass slide. For the conventional method, the specimens were placed on the radiographic film (Kodak speed Poly soft). Dental X-ray machine operating at 70 KVp and 10mA with a focus to target distance of 30 cm (ANSI/ADA 2000) was used to take the radiographic images (fig 1). The exposure was standardized to 0.6 s. and the films were developed with standard x-ray developing solutions which were maintained at constant temperature. Where as for digital imaging technique, the images were taken using an RVG sensor (fig 2). The images obtained from both the methods are transferred to a computer for the radiopacity evaluation of radiopacity.
ENDODONTOLOGY
RADIOPACITY ASSESSMENT
The digital images were analyzed with the Pro plus 4.1 analytical software system. The bone density tool was applied to the region of the radiographs containing the sample. Care was taken to analyze only those regions, which were free of air bubbles and other anomalies. The bone density tool produced a graph of the grey- scale value of each pixel 0(black) to 255(white) in the analyzed segment, were recorded. Six radiographic images are taken for each sealer for both conventional and digital radiographic method. The mean value was determined and tabulated for both methods (Table 2 & 3). Data were submitted to statistical analysis using two-way analysis of variance and post hoc test of Bonferroni (p<0.001).
COMPARATIVE EVALUATION OF RADIOPACITY OF THREE ROOT CANAL SEALERS USING CONVENTIONAL AND DIGITAL RADIOGRAPHIC TECHNIQUE: AN INVITRO STUDY
relies mainly on radiology. In order to identify and distinguish a root canal filling materials from the surrounding anatomical structures, the root canal sealers should be radiopaque. The sealer should contribute to the radiopacity of the root filling for visualization on radiographs and evaluation of obturation of lateral canals and apical ramification. According to International Organization for Standardization, the radiopacity of root canal sealers should be more than or equivalent to 3mm of aluminium.9 In the past, conventional periapical radiography was the most common method used for the evaluation of radiopacity of root canal sealers. In the conventional radiographic method, the radiographic images were obtained by the chemical processing of radiographic film, using developing and fixation solution which is time consuming.6 However, digital imaging technique is an emerging area of radiology that offers many potential benefits such as better contrast, visualization, sharp images and it is a quick procedure. 11 Digital imaging technique offer computer based image processing and analysis for the radiographic evaluation. The images can be easily stored and retrievable compare to conventional method.10 In this present study, the root canal sealers were compared and evaluated for radiopacity using both conventional and digital radiographic technique. When digital radiographic method was compared with conventional radiographic method, it does not need any conventional periodical radiographic film or the radiographic chemical processing, thus saving time and decreasing the stages that could interfere with the radiographic quality. In addition, digital radiographic method gives three dimensional images compare to
53
RESULTS
In both the methods, analysis of variance showed a statistically significant difference between the radiopacity means of the tested sealers (p<0.001). All tested materials showed radiopacity above 3mm of aluminium as recommended by ANSI/ ADA Specification 57. However higher mean radiopacity was observed in AH Plus (D9.15mm, C-8.92mm) followed by Endoflas(D6.67mm,C-5.02mm) and Pulpdent(D-5.78mm,C4mm) respectively (Table 4). The mean values of tested sealers were varying in both the methods used. Conventional method showed a lower value of radiopacity compare to digital radiographic technique. The difference between them was found to be statistically significant (p<0.001).
DISCUSSION
Radiopacity is widely acknowledged as a desirable property of all intraoral materials, including the endodontic sealers.8 Dental diagnosis
ENDODONTOLOGY
conventional method, which gives only two dimensional images. It also reduces the operators exposure to radiation and provides detailed analysis of digital images.
5
final radiographic quality.5 Tagger and Katz found that, the digital radiographic method can provides more consistent results in evaluating the radiopacity of root canal sealers.9 In the present study, the highest mean radiopacity was observed in AH plus followed by Endoflas and Pulpdent respectively. The root canal sealers vary in their radiopacity, depending primarily on their thickness, molecular structure, density, atomic number and the most important their composition. 5 The radiopacifier agents compatible with high atomic weight, determines the radiopacity of the sealers. Endoflas and Plupdent root canal sealer consists of Zinc oxide and barium sulphate as radiopacifying agents. Where as AH Plus root canal sealer has newer fillers like zirconium oxide and iron oxide. This could contributes to greater radiopacity of AH Plus sealer when compared to the other sealers tested.6
In this study, aluminium step wedge is used to compare the radiopacity of root canal sealers. It is well established that the radiopacity of pure (99.5%) aluminium is very close to that of human dentine. Aluminium step wedge is fabricated by creating several steps of 1mm thickness in increasing order from a single aluminium block. In this present study, the steps were created up to 12mm thickness from a single aluminium block. These steps have the added benefit of speeding the measurement process.8 According to Steven et al the aluminium is used for the step wedge because it has a linear absorption coefficient similar to that of the enamel, relating the similarity in the variation of aluminium to hydroxyapetite.5 Results of the present study showed that all tested materials showed radiopacity above 3mm of aluminium which is recommended by ANSI/ ADA Specification 57. Conventional method showed a lower value of radiopacity compare to digital radiographic technique for the tested sealers. This variation may be due to the radiographic chemical processing which can interfere with the
CONCLUSIONS
All tested materials showed radiopacity above 3mm of aluminium recommended by ANSI/ ADA Specification No. 57. AH Plus root canal sealer exhibited highest radiopacity followed by Endoflas.F.S. and Pulpdent root canal sealer in both the techniques. However, digital radiographic method showed more consistent results than the
TABLE 1. Materials used

Product AH Plus Composition Diepoxide,Calcium tungstate, Zirconium oxide, Aerosil, Pigment, 1-adamantane amine, N, N-dibenzyl-5-oxa-nonandiamine-1,9, Diamine ,Calcium tungstate ,Zirconium oxide, Aerosil ,Silicone oil Barium sulphate, zinc oxide, iodoform, eugenol, calcium hydroxide, zinc acetate Zinc oxide, calcium phosphate, barium sulphate, zinc stearate, Eugenol, Canada balsam 54 Manufacturer
Dentsply Sanlor Pulpdent Corporation
Endoflas Pulpdent
ENDODONTOLOGY
conventional radiographic method in evaluating the radiopacity of root canal sealers. Hence, the growing acceptance of digital technology as an
COMPARATIVE EVALUATION OF RADIOPACITY OF THREE ROOT CANAL SEALERS USING CONVENTIONAL AND DIGITAL RADIOGRAPHIC TECHNIQUE: AN INVITRO STUDY
alternative to conventional radiography in day to day clinical practice reveals demands for the development of international standards for electronic imaging.
TABLE 2 Conventional Radiographic Technique

AH PLUS 9 mm 8.5 mm 9 mm 9 mm 9 mm 9 mm ENDOFLAS 5 mm 5 mm 5 mm 5 mm 5 mm 5.1 mm PULPDENT 4 mm 4 mm 4 mm 4 mm 4 mm 4 mm
TABLE 3 Digital Imaging Technique

AH PLUS 10.9 mm 11 mm 11 mm 11 mm 10.8 mm 1 mm ENDOFLAS 7 mm 6.9 mm 6.9 mm 7 mm 7 mm 7 mm PULPDENT 5.8 mm 5.7 mm 5.8 mm 5.8 mm 5.8 mm 5.8 mm
TABLE 4 Results of Bonferroni Test

Technique Digital Endoflas Pulpdent Conventional Endoflas Pulpdent Sealer AH Plus 6.67 5.78 AH Plus 5.02 4.00 Mean 9.15 0.52 0.04 8.92 0.04 0.00 Std Dev 4.01 6.00 6.00 0.20 5.00 4.00 Min 1.00 7.00 6.00 8.50 5.00 4.00 Median 11.00 7.00 6.00 9.00 5.10 4.00 9.00 2798.115 <0.001* Max 11.00 F 3.352 P-value 0.063
FIGURE 1:
Stainless steel ring mould
Aluminium step wedge
Root canal sealer
B Conventional radiographic images of A. AH plus sealer B. Endoflas sealer C. Pulpdent sealer 55
ENDODONTOLOGY
FIGURE 2:
Digital radiographic images of A. AH plus sealer B. Endoflas sealer C. Pulpdent sealer
REFERENCES:
1. Gianluca Gambarini, Luca Testarelli, Giancarlo Pongione. Radiographic and rheological properties of a new endodontic sealer. Aust Endod J: 2006; 32: 31-34. 2. M.A.Verasiani, J.R.Carvalho-Jr. A comparative study of physicochemical properties of AH Plus and Epiphany root canal sealants. Int Endod J: 2006; 39: 464-471. 3. AH Plus sealer. Scientific compendium: DENTSPLY; 2005:4-19. 4. M.Tanomaru-Filho, E.G.Jorge, M.Goncalves. Evaluation of the radiopacity of calcium hydroxide and GIC based root canal sealers. Int Endod J:2008;41:50-53. 5. Steven Gu, Brain J, Barry Lee Musikant. Radiopacity of dental materials using digital X-ray system. Dent Mater: 2006; 22: 765-770. 6. J.R.Carvalho-Jr, L.Correr-Sobrinho, M.D.Sousa-Neto. Radiopacity of root filling materials using digital radiography. Int Endod J: 2007; 40: 514-520.
7. Mario Tanomaru-Filho, Erica Gouveia Jorge. Radiopacity evaluation of new root canal filling materials by digitalization of images. J Endod: 2007; 33: 249-251. 8. D.C.Watts, J.F.McCabe. Aluminium radiopacity standards for dentistry: an international survey. 1999,Dec:30 9. Michael Tagger, Alexander Katz. Radiopacity of endodontic sealers: Development of a new method for direct measurement. J Endod: 2003; 29: 751-755. 10. J Sabbagh, J Vreven, G Leloup. Radiopacity of resin based materials measured in film radiographs and storage phosphor plate (Digora). Operative Dentistry: 2004; 29: 677-684. 11. B.Guniz Baksi, Tan Firat, Bilge Hakan Sen, Necdet Erdilek. The effect of three different sealers on the radiopacity of root fillings in simulated canals. Oral Surg Oral Med Oral Pathol Oral Radiol Endod: 2007; 41: 103-138. 12. M.Tagger, A.Katz. A standard for radiopacity of root end/ retrograde filling materials is urgently needed. Int Endod J: 2004; 37: 260-264.
56
ENDODONTOLOGY The Effect of File Sizes in the Presence of Sodium Hypochlorite and Blood on the Accuracy of Root Zx Apex Locator in Enlarged Root Canals - an In Vitro Study
PALUVARY SHARATH KUMAR * VASUNDHARA SHIVANNA **
ABSTRACT:
The purpose of this study is to assess the effects of file size in the presence of Sodium hypochlorite and blood on the efficacy of Root ZX apex locator in enlarged root canals. The study sample comprised of 40 extracted straight, single rooted human lower premolars were used. The crowns of the teeth were removed with a low speed diamond saw. The actual canal length was determined by introducing size 10 K-file in the canal until the tip of the file became visible at the major apical foramen under a digital microscope at 10X magnification. Teeth were divided randomly into two groups, Group A (6% NaOCl) and Group B (Human blood containing EDTA as anticoagulant) of 20 teeth each (n=20). All the teeth were instrumented in three different stages. Stage I: A 40 K-file was used as MAF, Stage II: A 60K-file was used as MAF. Stage III: A 80 K-file was used as MAF. Each tooth of both Groups of all stages and Root ZX apex locator were subsequently connected together in the experimental set-up. Before electronic canal measurements, the canals were irrigated with 6% NaOCl in group A, while in group B the canals were filled with human blood containing EDTA as an anti-coagulant. Then the readings were taken with 10 K-File to the respective MAF sizes of the respective stages. The obtained readings were compared with the actual canal lengths and statistically analyzed using three way ANOVA and Bonferroni tests. Three way ANOVA and Bonferroni test showed that file size, stage of preparation and type of irrigant all had a significant influence on the measurement error (P<0.0001), with all the interactions between these three factors being significant. The present study indicates that, even in fully controlled in vitro study conditions, there is some inconsistency in the EAL measurements. Because of this potential inconsistency, EALs should not be used to replace the routine radiographic confirmation of the canal length in endodontic therapy. Keywords: Agar, blood, electronic apex locator, file size, root length determination, root canal preparation, sodium hypochlorite solution.
*P .G .S t u d e n t ,* *P ro f e s s o r&H e a d ,D e p t .o fC o n s e r v a t i v eD e n t i s t r ya n dE n d o d o n t i c s ,C o l l e g eo fD e n t a lS c i e n c e s ,D a v a n g e re - 5 7 7 0 0 4 ,K a r n a t a k a .
57
ENDODONTOLOGY
INTRODUCTION
Determination of working length is the first important step in root canal debridement. It is imperative that root canal debridement procedure be confined to the canal in order to prevent irritation of the periapical tissues and possible overextension of the root canal filling (Ingle et al. 1994).2 Many reports show a mean apex-to-apical foramen distance of around 0.5-1 mm8. However, this site can be misinterpreted on a two dimensional film. In cases where the apical foramen is eccentric to the root apex ie., exit deviates bucco-lingually14, or superimposition of normal anatomical features and pathological changes on apical tooth, such as impacted teeth, tori, the zygomatic arch, excessive bone density, overlapping roots, or shallow palatal vaults. In 1942 Suzuki reported a device that measured the electrical resistance between the periodontal ligament and the oral mucosa and registered a consistent value of approximately 6.5 k&!3. First generation models which work on electrical resistance were considered not accurate in the presence of conductive fluids in the canal. Consequently, one manufac-turer placed plastic insulation over the electronic probe to prevent electrical conductance through moist canal contents. However, the thickness of the insulating material prevented entry of the probe into tight and tortuous canals, especially at midroot and the apical level5. The recently developed Root ZX (J. Morita Co) electronic apex locator which works on the ratio
58
VASUNDHARA SHIVANNA, PALUVARY SHARATH KUMAR
method can ac-curately measure the canal length even under electro conductive conditions23. The ratio method simultaneously measures the impedances of the canal using two different frequency (400 Hz and 8 Hz) currents and calculates the quotient of the impedances11. Usually for electronic canal measurements with EALs requires the file size to be comparable to the diameter of the canal. But the manufacturer claims that the canal measurements with Root ZX can be done with a much smaller file compared to the diameter of the root canal2. So in this study we check the effect of file sizes in the presence of sodium hypochlorite and blood on the accuracy of Root ZX apex locator in enlarged root canals (In Vitro Study).

A total of 40 extracted, straight, single-rooted human lower premolars with complete root formation and stored in distilled water containing 10% formalin were used. Dental digital X-ray images were taken in both buccolingual and mesiodistal directions to evaluate the root canal anatomy. The crowns of the teeth were removed with a low speed diamond saw to standardize the root length to 14.5mm and to allow access to the root canal and establish a level surface to serve as a stable and unequivocal reference for all measurements. The actual canal length was determined by introducing a size 10 K-file in the canal until the tip of the file became visible at the major apical foramen under a digital microscope at x10 magnification. A rubber stop was then carefully adjusted to the reference level and the distance between the rubber stop and the file tip was measured and recorded. Gates Glidden drills
ENDODONTOLOGY
THEEFFECT OF FILE SIZES IN THE PRESENCE OF SODIUM HYPOCHLORITE AND BLOOD ON THE ACCURACY OF ROOT ZX APEX LOCATOR IN ENLARGED ROOT CANALS - AN IN VITRO STUDY
(size 1-4, Mani, Tochigi, Japan) were then used to prepare the coronal portion of the canal, while the middle and apical portions of the canal were prepared using size 10 K-files with six per cent NaOCl for irrigation.
In stage I, a size 40 K-file was used as the master apical file (MAF) and it was confirmed that the larger size (>40 K-file) did not reach the apex. The apical portion of the canal was then instrumented using the step-back sequence by decreasing the working length of larger files by 0.5mm. The canal was irrigated with 2ml NaOCl using an endodontic syringe with a 27 gauge needle in an up-down motion. In stage II, the teeth were removed from the specimen bottles and the canals were instrumented in same manner and enlarged using a size 60 Kfile as the MAF. In stage III, the teeth were removed again from the specimen bottles and the canals were instrumented in same manner and enlarged using
Experimental set up:
(a) K File. (b) Self cure acrylic. (c) Lid. (d) Polystyrene specimen bottle. (e) Tooth. (f) 1% agar which simulates as artificial periodontium.
a size 80 K-file as the MAF. All the teeth in each stage are connected to the Root ZX as shown in experimental set up and readings were taken with 10 K-file to MAF size of the respective stage. The electronic measurement was taken three times for each file and the average value was calculated. For each average reading, the error in measurement was calculated as the absolute difference between the electronically measured canal lengths and the actual canal lengths. Threeway ANOVA was conducted to investigate the influence of file size, stage of preparation and the type of irrigant on the measurement error. Multiple comparisons were performed with Bonferroni test. To compensate for the influence of differences in the actual canal lengths on the measurement errors, the actual canal length was set as a covariant in the statistical analysis.
59
Each tooth was fixed to the lid of a polystyrene specimen bottle with self-curing resin. A stainless steel rod is screwed into the body of the specimen bottle, was used as a neutral electrode. The specimen bottles were then filled with one per cent concentration of heated agar. The caps were immediately placed over specimen bottles and the model assemblies were refrigerated for two hours to allow the agar to set. Each tooth and Root ZX is connected together and used to take readings. The teeth were divided into 2 groups (Group A and Group B) depending upon the contaminants used in the canals ie, 6% NaOCl and human blood containing EDTA as anticoagulant. The canal preparation of both Group A and Group B teeth were done in three stages.
ENDODONTOLOGY
RESULTS
Table 1 & 2 shows the mean and standard deviation of length and initial canal length measurements obtained before canal enlargement for both groups A and B. Three-way ANOVA and Bonferroni test showed that the file size, stage of preparation and type of irrigant had a significant influence on the measurement error (P< 0.000l) with all the interactions between these factors being significant (P<0.0001). At stage 3, the measurement error showed the largest absolute difference in group B (1.11mm) when a size 10 Kfile was used. At all stages in both groups A and B, the measurement error was less than 0.03mm when the MAF were used.
used clinically for more than 40 years as an aid to determine the file position in the canal. These devices when attached to a file are able to detect the point at which the file leaves the tooth and enters the periodontium. EALs obviate this problem because their readings are not related to the apical vertex but rather to the apical foramen.1 Early EALs were based upon the work of Suzuki and Sunada. They relied on the principle that the electrical resistance between the oral mucosa membrane and the periodontium remained constant ie, 6.5 k&!, regardless of the age of the patient and type and shape of the tooth.3 These devices allowed measurement of the canal length by comparing the electrical resistance that was built into the apex locator with the resistance between the tip of the file and that of the periodontal membrane.11 McDonald notes that resistance type EALs should be operated in a reasonably dry canal or may be used with RC Prep. NaOCl or saline irrigants, being ionic solutions, are electrical conductors that could cause false readings. When using ionic irrigants and the resistance type EALs, additional time must be taken to dry the canals before taking as electronic measurement.9 A frequency dependent apex locator has recently been introduced. Two electric frequencies are normally used and the impedance difference between the two frequencies reaches its maximum at the apical constriction of the root canal. A modification of this device is the Root ZX apparatus. It is based on the principle that the ratio of electrical impedance between two frequencies is nearly equal when the tip of the file approaches the apical constriction and expresses this quotient in terms
60
DISCUSSION
Methods for the canal length determination are either the manual or the radiographic approaches for the precise localization of apical narrowing. The manual technique obviously depends on the sensitivity of the operator, whereas in the radiologic approach, the calculation of the working length is made with respect to the position of the radiographic apex which not only does not coincide with apical narrowing or even with the apical foramen, but also depends on the series of factors: tooth inclination, film position, length of the beam cone, vertical and horizontal cone angulation, and so forth. Nevertheless, the main inconvenience is that both approaches are entirely subjective and therefore scantly reproducible16. Using radiography followed by subsequent tooth extraction and sectioning, Stein and Corcoran found that the radiographically established working length did not actually coincide with the true apical vertex. Electronic apex locators (EAL) have been
ENDODONTOLOGY
of the position of the electrode (file) inside the canal. This quotient is hardly affected by the type of electrolyte in the canal.8 The Root ZX needs no calibration. The microprocessor of the device corrects the calculated quotient so that the position of the tip and the meter reading are directly related. This occurrence means that root canal enlargement can easily be performed while the length of the root canal is simultaneously monitored.23 However, it has been proven that the pathological changes in the pulp lead to changes in the concentration of ions. Consequently, its electrophysiological characteristics are changed, which affects the accuracy of EALs. These changes can be recorded by physical parameters, such as measurement of the electronic potential of pulp, electric conduction, or analysis of cations. Thus it is possible to say that biological changes, effect on the EAL measurements.15 In the present study, the apical portion of the canal was enlarged and the apical constriction was destroyed, although the conical shape of the canal was still maintained. Group A showed statistically significant better scores than Group B. In the presence of NaOCl, the Root ZX was accurate and the length measurements obtained with small and large size files were comparable. The results of Group A confirmed those of Nguyen et al., who found that the Root ZX was accurate even when the file was much smaller than the diameter of the canal. Many studies have used a 0.5mm error range to assess the accuracy of the EALs. Measurements obtained with this tolerance are
61
considered highly accurate. Other studies rely on a more lax clinical range of 1.0mm to the foremen. One reason cited for accepting a 1.0mm margin of error is the wide range seen in the shape of the apical zone. The results obtained in Group B with the smaller size files may not be clinically acceptable because the measurement error showed the largest absolute difference value (1.11mm) when a size 10 K-file was used. And it is recommended that the use of files with sizes comparable with the root canal diameter, claiming that this would result in more accurate readings. The results showed that file size, stage of preparation and the type of irrigant all had a significant influence on the measurement errors (P<0.0001) with all the interactions between these three factors being significant (P<0.0001). In Stage III, the measurement error showed the largest absolute difference in both Groups A (0.19mm) and B (1.11mm) when a size 10 K-File was used. At all stages in both Groups A and B, the measurement error were less than 0.03mm when the MAFs were used. The present study and previous studies appear to indicate that, even in fully controlled in vitro study conditions, there is some inconsistency in the EAL measurements. Because of this potential inconsistency, EALs should not be used to replace the routine radiographic confirmation of the canal length in endodontic therapy
CONCLUSION
As the diameter of the root canal increased, the measured length with the smaller size files became shorter. This suggests that the size of the root canal diameter should be estimated with a snug-fitting file should be chosen for root canal
ENDODONTOLOGY
length measurement in the presence of blood, and possibly serum or pus. In the presence of NaOCl, the Root ZX was highly accurate even when the file was much smaller than the diameter of the canal.
The present study, there is some inconsistency in the EAL measurements. Because of this potential inconsistency, EALs should not be used to replace the routine radiographic confirmation of the canal length in endodontic therapy. Further clinical studies are needed to evaluate EALs.
Table No. 1: Comparison of Stage I, II, & III of Group A

Group A 10 15 20 25 30 35 40 45 50 55 60 70 80 Stage I 0.10 0.08 0.07 0.05 0.04 0.03 0.02 Stage II 0.16 0.15 0.14 0.13 0.12 0.10 0.08 0.08 0.06 0.05 0.02 Stage III 0.19 0.17 0.15 0.15 0.12 0.12 0.11 0.11 0.10 0.10 0.08 0.06 0.02
Table No. 2: Comparison of Stage I, II, & III of Group B

Group B 10 15 20 25 30 35 40 45 50 55 60 70 80 Stage I 0.37 0.30 0.24 0.16 0.11 0.07 0.03 Stage II 0.91 0.78 0.65 0.50 0.47 0.38 0.30 0.20 0.16 0.10 0.03 Stage III 1.11 1.05 1.00 0.91 0.87 0.75 0.70 0.65 0.58 0.45 0.28 0.22 0.03
62
ENDODONTOLOGY
Fig. 1. Decoronated teeth of Group A
Fig. 2. Decoronated teeth of Group B
Fig. 3. Group A samples embedded in Agar material
Fig. 4. Group B samples embedded in Agar material
Fig. 5. Experimental
Fig. 6. Stereomicroscope
63
ENDODONTOLOGY
REFERENCES:
1. Ebrahim AK, Yoshika T, Kobayashi C, Suda H. Australian Dental Journal 2006;51(2):153-157 2. Nguyen HQ, Kaufman AY, Komorowski RC, Friedman S. International Endodontic Journal 1996;29:359-364 3. Anthony Meares W, Robert Steiman H. Journal of Endodontics 2002:28(8);595-598 4. Joslyn A. Jenkins, William A.Walker, William G. Schindler, Christopher M. Floes. Journal of Endodontics 2001:27(3);209211 5. Ounsi H F, Naaman A. International Endodontic Journal 1999:32;120-123 6. Kaufman A V, Katz A Journal of Endodontics (AAE Abstract of Papers) 1993:19(4);201 7. Roland Weiger, Christoph John, Heiner Geigle, Zahnarzt, Claus Lost. Journal of Endodontics 1999:25(11);765-768 8. Vajrabhaya L, Tepmongkol P. 1997:13;180-2. Endod Dent Traumatol and James O. Walmann.
JOE 1995: 21(11); 572-575
10. Fabio Luiz D Assuncao, Diana Santana de Albuquerque, and Linalda Correia Ferreira. JOE 2006:32(6);560-562 11. Jose L. Ibarrola, brent L. Champman, James H. Howard, Kenneth I. Knowles, and Marvin O. Ludlow. JOE 1999:25(9); 625-626 12. Chihiro Kobayashi, and Hideaki Suda. 1994:20(3);111-114. JOE
13. Craig A. Dunlap, Nijole A. Remeikis, Ellen A. BeGole, and Cindy R. Rauschenberger. JOE 1998: 24(1); 48-50. 14. Shahrokh Shabahang, William W.Y. Goon, and Alan H. Gluskin. JOE 1996:22(11);616-618. 15. Maja Kovacevic, and Tomislav Tamarut. JOE 1998; 24(5): 346-351. 16. Lucena Martin C, Robles-Gijon, Ferrer-Luque C M, and Navajas-Rodriguez de Mondelo J M. JOE 2004;30 (4):231233. 17. Marat Tselnik, Craig Baumgartner J, and Girdon Marshall J. JOE 2005; 31 (7): 507-509.
9. Russell J. Czerw, Michael S. Fulkerson, Jerome C. Donnelly,
64
ENDODONTOLOGY Sealing Ability of Four Materials in the Orifice of Root Canal Systems Obturated With Gutta-Percha
ABHISHEK PAROLIA * KUNDABALA M. ** SHASHI RASMI ACHARYA *** VIDYA SARASWATHI **** VASUDEV BALLAL ***** MANDAKINI MOHAN ******
ABSTRACT
Failure to maintain the coronal as well as apical seal may expose obturated canals to microbes that could retard healing and create infection in the periodontal ligament or supporting osseous structures. 50 single rooted teeth (Type I canal anatomy) were randomly assigned to 4 experimental and 2 control groups. Ten specimens each were sealed with Mineral Trioxide Aggregate (MTA), Tetric Flow, Glass Ionomer Cement (GIC) and Light Cure Glass Ionomer cement (LC GIC). After creation of uniform orifice diameter, the smear layer was removed and the canal systems obturated using lateral compaction of gutta-percha (GP). GP was removed to the depth of 3.5 mm, experimental materials placed in orifice and the roots submerged in Rhodamine-B dye in vacuum for one week. Specimens were longitudinally sectioned and leakage measured using a 10X stereomicroscope and graded for depth of leakage. According to the result of the present study LC GIC demonstrated significantly better seal (p<.01) than MTA however there was no statistically significant difference in leakage (p>.01) between Tetric Flow, GIC and LC GIC and in between MTA, Tetric Flow and GIC. Key Words: Orifice barrier, Tetric flow, GIC, LC GIC, MTA, Dye under vacuum
INTRODUCTION
Coronal microleakage can produce complete bacterial penetration in nonsurgical root canal treated teeth ( 1, 2). It has been reported that 59.4% of endodontically treated teeth failed because of lack of an adequate post endodontic restoration (3). Loss of coronal seal may occur due to leakage of temporary filling material or fracture of the permanent restoration. Perhaps the use of a material to seal the orifice, in addition to the restoration, could mitigate this bacterial leakage if that restoration was lost or became unserviceable. It has been reported that root canal treated teeth
without coronal barrier had significantly more failure rate than teeth with coronal barrier of amalgam, composite resin, glass ionomer or intermediate restorative material (4).Despite research supporting the effectiveness of coronal barriers, a universally accepted protocol that incorporates a coronal barrier after root canal therapy is nonexistent. Thus, the addition of another barrier between the oral environment and the root canal system appeared to have a positive effect in reducing leakage and increasing possibilities for success. Hence the purpose of this investigation was
*A s s i s t a n tP ro f e s s o r,* *P ro f e s s o ra n dH O D ,* * * P ro f e s s o ra n dH O D ,* * * * A s s o c i a t eP ro f e s s o r, * * * * * Re a d e r, * * * * * * A s s i s t a n tP ro f e s s o r,D e p t .o fP ro s t h o d o n t i c s , M a n i p a lC o l l e g eo fD e n t a lS c i e n c e s ,M a n g a l o re .K a r n a t a k a .I n d i a .
65
ENDODONTOLOGY
ABHISHEK PAROLIA, KUNDABALA M., SHASHI RASMI ACHARYA, VIDYA SARASWATHI, VASUDEV BALLAL, MANDAKINI MOHAN
to evaluate and compare the sealing ability of four experimental materials as an intra-orifice barrier after obturation of root canal system.
Group Group I Group II Group III (GIC) Group IV +ve Control
Number of teeth 10 10 10 10 5
Experimental Intraorifice sealing material Mineral Trioxide Aggregate (MTA) Tetric Flow Glass Ionomer Cements Light cured Glass Ionomer Cements (LC GIC) Instrumented and obturated teeth with gutta-percha at the level of the orifice. Instrumented and obturated teeth with three coats of nail polish

50single-rooted teeth, with Type I canal system, stored at 100% humidity were used. Crowns were removed at the cementoenamel junction using diamond disc. A #10 K-file (Denstply Maillefer, Swiss made, Ballaigues) was inserted and advanced until it was visualized at the apical foramen. The file was retracted 1 mm and working length was established at this level. A ProTaper SX file (Denstply Maillefer, Swiss made, Ballaigues) was used to flare the orifice. 5.25% NaOCl (Vishal Dentocare Pvt Ltd, India) and RC Prep (Medical Products Laboratories INC) were used in between each instrument. ProTaper SI, S2, Fl, F2, and F3 files were used sequentially per manufacturers instructions in a crown down technique. A uniform orifice diameter of 1.3 mm, at its widest point, was made using a #5 Gates Glidden bur (MANI, INC Japan) to a depth of 3.5mm. Once instrumentation was completed, the canal was rinsed with two ml of 5.25% NaOCl, followed by 2 ml of 17% EDTA solution, and with a final rinse of chlorhexidine 0.2%w/v (ICPA Health Products LTD, India). Canals were dried with sterile paper points and obturated with .02 taper gutta-percha points (Denstply Maillefer Swiss made, Ballaigues) and AH plus sealer (Denstply DeTrey gMbH Germany) in lateral compaction technique. 40 teeth randomly divided into four experimental groups, with the remaining ten teeth being divided equally between positive and negative controls.
-ve Control
Heat carrier was used to remove gutta-percha to the depth of 3.5 mm and verified the depth with a periodontal probe. ProRoot MTA (Dentsply/tulsa Dental Products), Tetric flow (Ivoclar Vivadent), GIC (GC Corporation Tokyo, Japan) and LCGIC (GC Corporation Tokyo, Japan) were placed into the orifice as per manufacturers directions in samples of respective groups. Each tooth was placed into a coded container and allowed for sealer and all experimental materials to set. All these samples were kept in humidor for 48 hrs. Three layers of nail varnish were placed on all experimental teeth coating their root surface from root apex to the level of the cementoenamel junction. Positive controls were obturated, but not coated with nail varnish. Negative controls were obturated and completely coated with nail polish, including the orifice. Samples were submerged in a vacuum flask containing Rhodamine-B dye, subjected to vacuum pressure of 75 torr for 30 minutes, and allowed to remain in the dye for seven days (5). After exposure to the dye, samples were rinsed with running water to remove dye from the external surface. Nail varnish was gently removed
66
ENDODONTOLOGY
SEALING ABILITY OF FOUR MATERIALS IN THE ORIFICE OF ROOT CANAL SYSTEMS OBTURATED WITH GUTTA-PERCHA
with a# 15 disposable safety scalpel .These samples were longitudinally sectioned using diamond disc and samples were observed and leakage was measured to the greatest penetration using a 10X stereomicroscope (Olympus) using micrometer from the coronal extent of the orifice material. Results were tabulated and data were analyzed using ANOVA & Tukey Tests.
material faster than bacteria and they also extended the caveat: the need for an immediate and proper coronal restoration after root canal treatment is therefore reinforced (7). At University of Tennessee, the Himel group reported that the teeth without an intraorifice barrier leaked significantly more than the teeth with glass Ionomer barrier (8). So the present study is undertaken to evaluate and compare the sealing ability of four experimental which have been shown to have good sealing ability with coronal as well as radicular dentin (9, 5,10). Dye penetration method to check the microleakage is a simple, easier and cost effective method so we decided to use this method. This study used Rhodamine-B dye as it has small particle size, better penetration, water solubility, diffusability and hard tissue non-reactivity (11).we have used dye under vacuum penetration method, It has been reported that vacuum helps to remove entrapped air which can prevent complete dye penetration (12). It has been reported that 3.5 mm of material to be the minimum thickness required in coronal restorations to prevent leakage so in this study material thickness of 3.5 was taken to seal the canal orifice (13). The results of this study indicated that LC GIC demonstrated a significantly better seal than MTA, Tetric Flow and GIC. This could be due to command setting and better adhesion with tooth structure. Resin modified glass ionomers set by two mechanisms: acid-base reaction common to all glass ionomers and a photochemical polymerization of water soluble monomers and methacrylate groups(14).Polymerization shrinkage still occurs in these materials due largely to resin
67
RESULTS
Positive controls leaked at least 5 mm into the gutta-percha, and no leakage was observed in the negative control group. Table 1 shows mean depth of penetration, in millimeters, for each material. MTA has shown the maximum leakage, at 1.6 mm mean penetration while LC GIC has shown the least, at 1.1 mm mean penetration which showed statistically significant difference between MTA and LC GIC. There was no statistically significant difference in leakage (p>.01) between Tetric Flow, GIC and LC GIC and in between MTA, Tetric Flow and GIC.
DISCUSSION
An efficient seal to prevent leakage in the root canal system from both oral fluids & peri-radicular tissues is prerequisite for the success of endodontic treatment. Teeth obturated with gutta-percha and sealer, in the absence of a temporary restoration, showed leakage ranging from 70% to 85% of the root length within 56 days, when exposed to saliva(2). It has also been pointed out the importance of the temporary seal lasting even after root canal therapy is completed, emphasizing the importance of early final restoration of the tooth (6). Iowa group found that endotoxin can penetrate obturating
ENDODONTOLOGY
component; however immature cement continues to take up fluid from dentin, causing the material to expand which compensates polymerization shrinkage(15).The adhesion of LC GIC appears to be by development of an ion-exchange layer adjacent to the dentin similar to conventional glass ionomer materials(16). Moreover the shear bond strength of LC GIC is said to be higher than conventional GIC (17, 18). This is due to the slow acid-base reaction in LC GIC and availability of polyacid for a longer time So this might have contributed for the better sealing ability. In the present study MTA has shown statistically significantly more leakage than LC GIC, this could be attributed to the absence of tissue fluid in root canal treated teeth which could interfere in growth of hydroxyapatite crystals, responsible for chemical bonding (19).It has also
been found that a secondary seal was required over MTA in furcation restorations to minimize leakage as MTA was easily discerned from dentin and easy to remove with ultrasonics (20). Conventional GIC and Tetric Flow have shown more leakage than LC GIC but it is not statistically significant. This could be due to weaker bonding of conventional GIC (17) than LC GIC and more polymerization shrinkage of Tetric Flow than LC GIC (21). So, the present study concludes that double seal is required which could be achieved by using an intra-orifice barrier. In this study LC GIC has found to be superior over other experimental materials as an intra-orifice barrier. However, further research such as a long-term study using other methods of microleakage detection, may confirm better clinical results.
Table1. Comparison of marginal means of depth of penetration for experimental materials

Materials MTA Tetric flow GIC Light cured GIC Number 10 10 10 10 Mean 1.6375 1.4250 1.265 1.1125 Std.Deviation 0.60955 0.38819 0.51603 0.45505 Minimum Dye Penetration (mm) 0.50 1.00 0.50 0.50 Maximum Dye Penetration (mm) 2.50 2.25 2.10 2.00
Table 2
Mean Difference MTA Tetric flow GIC LC GIC GIC LC GIC GIC P= .01s LC GIC 0.2125 0.3750 0.5250 0.1625 0.3125 0.1500 P 0.540 0.092 0.008 s 0.735 0.207 0.780
Figure1. Mean dye penetration in respective groups (Stereomicroscope 10 X)
Tetric flow
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ENDODONTOLOGY
SEALING ABILITY OF FOUR MATERIALS IN THE ORIFICE OF ROOT CANAL SYSTEMS OBTURATED WITH GUTTA-PERCHA
MTA
Tetric Flow
GIC
REFERENCES:
1. Swanson K, Madison S. An evaluation of coronal microleakage in endodontically treated teeth. Part I: time periods. J Endod 1987; 13:56-9. 2. Madison S, Swanson K, Chiles SA. An evaluation of coronal microleakage in endodontically treated teeth. Part ll: sealer types. J Endod 1987; 13:109-12. 3. Vire DE. Failures of endodontically treated teeth: classification and evaluation. J Endod. 1991; 17:338-42. 4. Carman JE, Wallace JA. An invitro comparison of microleakage of restorative materials in the pulp chamber of human molar teeth. J Endod 1994; 20:571-75. 5. Jenkins S, Kulild J, Williams K. Sealing ability of three materials in the orifice of root canal systems obturated with gutta-percha. J Endod 2006; 32:225-27. 6. Khayat A, Lee SJ, Torabinejad M. Human saliva penetration 69
LC GIC
of coronally unsealed root canals. J Endod 1993; 19(9):45861. 7. Alves J, Walton R, Drake D. Coronal leakage: Endotoxin penetration from mixed bacterial communities through obturated post-prepared root canals.J Endod 1998; 24(9):58791. 8. Wolcott JF, Hicks ML, Himel VT. Evaluation of pigmented intraorifice barriers in endodotically treated teeth. J Endod 1999; 25(9):589-92. 9. Barrieshi-Nusair KM, Hammad HM. Intracoronal sealing comparision of mineral trioxide aggregate and glass Ionomer. Quint Int 2005; 36:539-45. 10. Barthel CR, Strobach A. Leakage in roots coronally sealed with different temporary filling. J Endod 1999; 25(11):73134. 11. Wu MK, Wesselink PR. Endodontic leakage studies
ENDODONTOLOGY
reconsidered. Part I. Methodology, application and relevance. Int Endod J 1993; 26: 3743. 12. Wimonchit S et al. A comparison of techniques for assessment of coronal dye leakage. J Endod 2002;28(1):1-4. 13. Webber RT , del Rio CD, Brady JM, Segall RO. Sealing quality of a temporary filling material.Oral Surg Oral Med Oral pathol. 1978; 46:123-30. 14. Seiler KB. An evaluation of glass ionomer paste restorative material as temporary restorations in endodontics. Gen Dent 2006; Jan-Feb: 33-6. 15. Wilson AD. Resin modified glass ionomer cements. Int J Prosthodont 1990; 3:425-9. 16. Lin A, McIntyre NS, Davidson RD. Studies on adhesion of glass Ionomer cements on dentin. I Dent Res 1992; 71:1836-41. 17. Burgess JO, Barghi N, Chan DCN, Hummert T. A
comparative study of three glass Ionomer base materials. Am J Dent 1993; 6:137-41. 18. Kerby RE, Knobloch L. The relative shear bond strength of visible light curing and chemical curing glass Ionomer cement to composite resin. Quint Int1992; 23:641-44. 19. Sarkar NK et al. Physicochemical basis of the biologic properties of mineral trioxide aggregate. J Endod 2005; 31(2):97 100. 20. Hardy I, LIewehr FR, Joycc AP, Agee K, Pashley DH. Sealing ability of one-up bond and MTA with and without a secondary seal as; furcation perforation repair materials. J Endod 2004; 30:658-61. 21. Miguez PA, Pereira PN, Foxton RM, Walter R, Nunes MF, Swift EJ Jr. Effects of flowable resin on bond strength and gap formation in Class I restorations. Dent Mater. 2004 Nov; 20(9):839-45.
70
ENDODONTOLOGY Current Endodontics Literature

Sowmya Shetty, Associate Professor, Department of Conservative Dentistry and Endodontics, A. J. Institute of Dental Sciences, Mangalore
Clinical Studies of Fiber Posts: A Literature Review

Maria C. Cagidiaco, MD, DDS, PhDa/Cecillia Goracci, DDS, PhDb/Franklin Garcia-Godoy, DDS, MSc/Marco Ferrai, MD, DDS, PhDd (2008) This literature review aimed to find answers to relevant questions regarding the clinical outcome of endontically treated teeth restored with fiber posts. All clinical studies published since 1990 in journals indexed in MEDLINE were retrieved by searching PubMed with the query terms fiber posts and clinical studies. The reference list of the collected articles was also screened for further relevant citations. The strength of the evidence provided by the reviewed papers was assessed according to the criteria of evidence-based dentistry. Five randomized controlled trials (RCTs) on fiber posts have been published in peer-reviewed journals. A meta-analysis is not applicable to these studies since they do not address the same specific clinical question. Retrospective and prospective trials without controls are also available. Two RCTs indicate that fiber-reinforced composite posts outperform metal posts in the restoration of endontically treated teeth. However, this evidence cannot be considered as conclusive. Longer-term RCTs would be desirable. The placement of a fiber-reinforced composite post protects against failure, especially under conditions of extensive coronal destruction. The most common type of failure with fiber-reinforced composite posts is debonding. Int J Prosthodont; 21:328-336,2008
Association between Bifidobacteriaceae and the clinical severity of root caries lesions
M. Mantzourani, M. Fenlon, D.Beighton The isolation of members of the family Bifidobacteriaceae (bifids) from oral samples has been sporadic and a recent cloning study has suggested that they are not detectable in root caries lesions. To better understand the presence of bifids in root caries we obtained clinical samples (15 of each) from sound exposed root surfaces, leathery remineralizing root lesions, and soft active root lesions. We investigated each for the presence of bifids using a mupirocin-containing selective medium and identified the isolates using 16S recombinant RNA sequencing. The proportion of bifids, as a percentage of the total anaerobic count, was significantly related to the clinical status of the sites sampled, being 7.881.93 in the infected dentine from soft lesions, 1.61 0.91 in leathery lesions, and 0.050.39 in plaque from sound exposed root surfaces. Bifids were isolated from all soft lesions, 13 of 15 leathery lesions, and five of the plaque samples. Bifidobacterium dentium was isolated from four of the plaque samples, from 13 samples from leathery lesions, and from 12 of the 15 samples of infected dentine from the soft active lesions. Parascardovia denticolens and Scardovia genomospecies C1 were each isolated from samples associated with all three clinical conditions whereas Scardovia inopicata and Bifidobacterium subtile were both isolated from
71
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the infected dentine of the leathery and soft lesions. Bifidobacterium breve was isolated from the infected dentine of soft root caries lesions. Bifids may be routinely isolated from root caries lesions using appropriate cultural methods. Oral Microbiology and Immunology, 24 (1):32-37,2008. Published Online 12 December 2008 Journal compilation 2008 Blackwell Munksgaard Ltd.
Vascularization of Engineered Teeth

A. Nait Lechguer, S. Kuchler-Bopp, B. Hu, Y. Haikel and H. Lesot The implantation of cultured dental cell-cell re-associations allows for the reproduction of fully formed teeth, crown morphogenesis, epithelial histogenesis, mineralized dentin and enamel deposition, and root-periodontium development. Since vascularization is critical for organogenesis and tissue engineering, this work aimed to study (a) blood vessel formation during tooth development, (b) the fate of blood vessels in cultured teeth and re-associations, and (c) Vascularization after in vivo implantation. Ex vivo, blood vessels developed in the dental mesenchyme, from the cap to bell stages and in the enamel organ, shortly before ameloblast differentiation. In cultured teeth and reassociations, blood-vessel-like structures remained in the peridental mesenchyme, but never developed into dental tissues. After implantation, both teeth and re-associations became revascularized, although later in the case of the reassociations. In implanted re-association, newly formed blood vessels originated from the host, allowing for their survival, and affording conditions organ growth, mineralization, and enamel secretion. Key Words: tooth tissue engineering vasculatization VEGFR CD31 J Dent Res 87(12):1138-1143, 2008
Effects of Er: YAG Laser Irradiation on Biofilm-forming Bacteria Associated with Endodontic Pathogens In Vitro.
Noiri Y, Katsumoto T, Azakami H, Ebisu S (2008). With the development of dental laser delivery systems that can enter into the root canals, it is possible to use Er: YAG lasers to remove the residual biofilm associated with infected root canals. We examined their effects against biofilms made of Actinomyces naeslundii, Enterococcus faecalis, Lactobacillus casei, Propionibacterium acnes, Fusobacterium nucleatum, Porphyromonas gingivalis, or Prevotella nigrescens in vitro. After Er:YAG laser irradiation with energy densities ranging between 0.38-0.98 J/cm2, the biofilm samples on hydroxyapatite disks were quantitatively and morphologically evaluated. The Er: YAG laser was effective against biofilms of 6 of the bacterial species examined, with the exception of those formed by L. casei. After irradiation, the numbers of viable cells in the biofilms were significantly decreased, whereas atrophic changes in bacterial cells and reductions in biofilm cell density were seen morphologically. Er: YAG lasers might be suitable for clinical application as a suppressive and removal device of biofilms in endodontic treatments Journal of Endodontics34 (7):826-829, 2008.
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Dental Pulp Stem Cells: A Promising Tool for Bone Regeneration
dAquino R, Papaccio G, Laino G, Graziano A (2008). Human tissues are different in term of regenerative properties. Stem cells are a promising tool for tissue regeneration, due to proliferation, differentiation and plasticity. Although several loci or niches within the adult human body are colonized by a significant number of stem cells, access to these potential collection sites is often limited. Interaction with biomaterials is important for therapeutic use of stem cells. Dental pulp stem cells (DPSCs) have shown to meet these requirements. Access to the collection site of these cells is easy and produces very low morbidity. Extraction of stem cells from pulp tissue is highly efficient. These cells have extensive differentiation ability and the demonstrated interactivity with biomaterials makes them ideal for tissue reconstruction. SBP-DPSCs are a multipotent stem cell subpopulation of DPSCs which are able to differentiate into osteoblasts, synthesizing 3D woven bone tissue chips in vitro and that are capable of differentiating into osteoblasts and endotheliocytes. Several studies have found that these are multipotent stromal cells that can be safety cryopreserved, used with several scaffolds, and have a long lifespan and build in vivo an adult bone with Haversian channels and an appropriate vascularization. A definitive proof of their ability to produce dentin has not been yet done. Interestingly, they seem to possess immune privileges as they can be grafted into allogenic tissues and seem to exert anti-inflammatory abilities, like many other mesenchymal stem cells. The easy management of dental pulp stem cells makes them feasible for use in clinical trials on human patients Stem Cell Reviews 4(1):21-26, 2008
The Sodium Hypochlorite Accident: Experience of Diplomates of the American Board of Endodontics
Kleier DJ, Averbach RE, Mehdipour O (2008). To better understand the etiology associated with sodium hypochlorite accidents, the authors surveyed diplomates of the American Board of Endodontics. Of the 314 diplomates who responded, 132 reported experiencing a sodium hypochlorite accident. Questions asked involved those about the age and sex of the patient as well as the tooth being treated, preoperative signs, symptoms, diagnosis, and radiographic appearance. Data was analyzed by chi-square tests. Significantly more women experienced sodium hypochlorite accidents compared with men (p < 0.0001). More maxillary teeth than mandibular teeth (p < 0.0001) and more posterior than anterior teeth (p < 0.0001) were involved. A diagnosis of pulp necrosis with radiographic findings of periradicular radiolucency were positively associated with such accidents (p < 0.0001). Most respondents reported that patient signs and symptoms completely resolved within a month. The occurrence of an accident, by itself, did not adversely affect the endodontic prognosis of the involved tooth. Anatomic variations may contribute significantly to the occurrence of a sodium hypochlorite accident Journal of Endodontics 34(11):1346-1350, 2008
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The Effect of Mineral Trioxide Aggregate on the Mineralization Ability of Rat Dental Pulp Cells: An In Vitro Study.
Yasuda Y, Ogawa M, Arakawa T, Kadowaki T, Saito T (2008). The aim of this study was to investigate the effect of mineral trioxide aggregate (MTA) on cell viability and mineralization ability of rat dental pulp cells. The pulp capping materials, such as MTA, Dycal (Dentsply Caulk, Milford, DE), and Superbond C&B (SB; Sun Medical, Shiga, Japan) were placed on transwell inserts and cultured with rat dental pulp cells. MTA and SB exhibited no cytotoxicity, whereas almost all cells had died after 72 hours of culture with Dycal. MTA significantly stimulated mineralization by 60% compared with the control. MTA and Dycal significantly upregulated by two-fold the level of bone morphogenetic protein (BMP)-2 messenger RNA expression compared with the control. Furthermore, MTA increased BMP-2 protein production by about 40%, whereas Dycal significantly reduced it. Although MTA and Dycal increased the concentration of extracellular calcium by about 0.4 mmol/L, SB had no effect. These results suggest that BMP-2 may play an important role in mineralization stimulated by MTA Journal of Endodontics 34(9):1057-1060, 2008.
Stem cells and tooth tissue engineering

Yen A, Sharpe P (2008). The notion that teeth contain stem cells is based on the well-known repairing ability of dentin after injury. Dental stem cells have been isolated according to their anatomical locations, colony-forming ability, expression of stem cell markers, and regeneration of pulp/dentin structures in vivo. These dental-derived stem cells are currently under increasing investigation as sources for tooth regeneration and repair. Further attempts with bone marrow mesenchymal stem cells and embryonic stem cells have demonstrated the possibility of creating teeth from nondental stem cells by imitating embryonic development mechanisms. Although, as in tissue engineering of other organs, many challenges remain, stem-cell-based tissue engineering of teeth could be a choice for the replacement of missing teeth in the future. Cell and Tissue Research 331(1):359-372, 2008
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ENDODONTOLOGY Notes:
ENDODONTOLOGY
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ENDODONTOLOGY

Volume: 20 Issue 2 December 2008 1-76

Editorial Original Research

Current Endodontics Literature

ENDODONTOLOGY INDIAN ENDODONTIC SOCIETY

Editor: Dr. B. Sureshchandra

4. Publishers name, nationality, and address

5. Editors name, nationality and Address

6. Name and address of the owner of the newspaper

A publication of Indian Endodontic society

Dr. Sowmya Shetty

ultrasonic technique , and lasers . Additionally,

DHANYA KUMAR N. M, PRAVEEN GOKUL, VASUNDHARA SHIVANNA

DHANYA KUMAR N. M, PRAVEEN GOKUL, VASUNDHARA SHIVANNA

Fig 2: STEREOMICROSCOPE READINGS WITH SYSTEM GT MESIO-DISTAL BUCCO-LINGUAL

FIG 3: STEREOMICROSCOPE READINGS WITH ProTaper MESIO-DISTAL BUCCO-LINGUAL

FIG 4: STEREOMICROSCOPE READINGS WITH RaCe MESIO-DISTAL BUCCO-LINGUAL

DHANYA KUMAR N. M, PRAVEEN GOKUL, VASUNDHARA SHIVANNA

DHANYA KUMAR N. M., ABHISHEK SINGHANIA, VASUNDHARA SHIVANNA

compaction forces and an occlusal load with finite element analysis.

DHANYA KUMAR N. M., ABHISHEK SINGHANIA, VASUNDHARA SHIVANNA

DHANYA KUMAR N. M., ABHISHEK SINGHANIA, VASUNDHARA SHIVANNA

10 NEWTON OF COMPACTION FORCE

Tapers 2% 4% 6% 12% P* Value, Sig Significant Pairs**

Mean 4.782 3.291 3.007 2.510 P<0.001 HS I&II, I&III,I&IV

Table-3: Comparision of Mean Occlusion Load of 50N in Different Tapers.

Apical 1/3 0.789 0.713 0.667 0.646

Middle 1/3 0.716 0.657 0.603 0.566

Cervical 1/3 0.669 0.608 0.587 0.484

P* Value, Sig P<0.05 S P>0.05 NS P<0.001 HS P<0.001 HS

Significant Pairs** At & Ct At &Mt, At & Ct At &Mt, At & Ct

Cervical 1/3 0.988 0.869 0.767 0.540

P* Value, Sig P>0.05 NS P<0.001 HS P<0.001 HS P<0.001 HS

Significant Pairs** At &Mt, At & Ct At &Mt, At & Ct At &Mt, At & Ct

DHANYA KUMAR N. M., ABHISHEK SINGHANIA, VASUNDHARA SHIVANNA

MATERIAL PROPERTIES APPLIED IN THE STRESS ANALYSIS (FEA)

DHANYA KUMAR N. M., ABHISHEK SINGHANIA, VASUNDHARA SHIVANNA

MATERIALS AND METHODS

Fig. 2- instruments evaluated-upper-RaCe,lower-Varitaper.

curvature by drawing a line parallel to the long

Table 3 : Table of means and standard deviations of number of rotations to fracture

MITHRA N. HEGDE, DEEPALI S.

Access restoration placement

MITHRA N. HEGDE, DEEPALI S.

MITHRA N. HEGDE, DEEPALI S.

MITHRA N. HEGDE, DEEPALI S.

Shows comparison of the mean coronal leakage of five different groups

The coronal seal is better when Ketac N 100

Maximal coronal sealing is critical for

Table I DYE LEAKAGE

Figure 3: Fluorescence of the dye showing extent of coronal leakage.

ENDODONTOLOGY In Vitro Evaluation of the Efficacy of Five Apex Locators

IN VITRO EVALUATION OF THE EFFICACY OF FIVE APEX LOCATORS

2. Measurement of actual working length

3. Working model for electronic working length determination

MATERIALS AND METHODS

NIRANJAN A. VATKAR, SUCHETA SATHE, VIVEK HEGDE

21 23.5 21.5 23 21.5 20.5 21 23 19 23.5

21 24 22 23.5 22 20.5 21.5 23.5 18.5 23.5

IN VITRO EVALUATION OF THE EFFICACY OF FIVE APEX LOCATORS

DENTAPORT ZX 19 19 24.5 20 20.5 20 20.5 21 21.5 24

E MAGIC FINDER 19 19.5 24.5 20 21 19.5 21 21 22 24.5

NIRANJAN A. VATKAR, SUCHETA SATHE, VIVEK HEGDE

S p e c i a l i s t Re s i d e n t , P ro f e s s o r, *P ro f e s s o r&H e a d ,D e p a rt m e n to fC o n s e r v a t i v eD e n t i s t r y&E n d o d o n t i c s ,M a n i p a lc o l l e g eo fD e n t a lS c i e n c e s ,M a n g a l o re .