Effects of ultrasonic root end preparation on resected root surfaces: SEM evaluation

Silvio Taschieri, MD, DDS,a Tiziano Testori, MD, DDS,b Luca Francetti, MD, DDS,c and Massimo Del Fabbro, PhD, BsC,d Milan, Italy
UNIVERSITY OF MILAN

Objective. The purpose of this study was to investigate the in vitro effect of ultrasonic retrotips on root end surfaces. Study design. Root end resection was performed on 45 single-root teeth endodontically treated after extraction. Setting the ultrasonic device at full power, a retrograde cavity was made by a stainless steel tip in 9 specimens (SS-FP). In another 9 samples a diamond tip was used (D-FP). Setting the intensity of the ultrasonic device at half power, 9 specimens were treated using stainless steel tips (SS-HP) and 9 using diamond tip (D-HP). Nine teeth were only apically resected and used as controls. Histologic serial sections were examined by scanning electron microsope to assess the number of root-face cracking, the marginal quality, and the crack type. Results. No signicant difference between diamond and stainless steel groups was found at a given power setting. Signicant differences were found between SS-FP and SS-HP group for both the number of cracks and the marginal quality. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;98:611-8)

The aim of root end preparation techniques during endodontic surgery is to create a well-shaped cavity to be lled, in order to seal the apical terminus of the root canal system.1 The ultrasonic retrotip has demonstrated many advantages over the traditional hand-piece used in surgical endodontics.2 They enable the long axis of the tooth to be followed, while preserving the morphology of the canal.3 Apical cavities may be shaped easily, safely, and with greater precision if compared to those obtained using conventional hand-pieces.1,4-6 In addition, the cutting bevel obtained on the resected root end can be quite perpendicular to the canal long axis. This might be benecial, because it decreases the number of exposed dentinal tubules at the resected root surface, minimising apical leakage.7-9 A better shaped root end cavity, which is more centrally placed and smaller than that produced by microhandpieces and burs, may also reduce the risk of root perforation in deeply uted roots.10

Head, Section of Endodontics, Department of Odontology, Galeazzi Institute, University of Milano, Milan, Italy. b Visiting Professor, Head of Section of Implant Dentistry and Oral Rehabilitation, Department of Odontology, Galeazzi Institute, University of Milano. c Researcher, Head of Section of Periodontology, Department of Odontology, Galeazzi Institute, University of Milano. d Researcher, Head of Section of Oral Physiology, Department of Odontology, Galeazzi Institute, University of Milano. Received for publication Oct 6, 2003; returned for revision Mar 8, 2004; accepted for publication Apr 12, 2004. 1079-2104/$ - see front matter 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.tripleo.2004.04.004

Several studies concerning ultrasonic retrotips have also documented improved cleaning of cavity walls when compared to conventional instruments, and a decreased volume of the smear layer following root canal preparation.5,11-12 Only a limited number of clinical studies have been published on periradicular surgery using microsurgical retrotips.13-17 All these studies reported high success rates for periradicular healing with follow-up periods ranging from 6 to 14 months. Despite the excellent results obtained by using ultrasonic tips, Saunders et al demonstrated that this technique was not free from contraindications.18 Subsequent studies demonstrated the occurrence of cracks on the surface of resected root ends after retrograde preparation with ultrasonic tips.19-33 All these in vitro studies showed limitations. It is difcult to transfer the results obtained from extracted teeth to the clinical situation. The periodontal ligament may act as a dampening and absorbing factor preventing the propagation of cracks caused by vibratory root end preparation with sonic or ultrasonic units.34 Layton et al reported that high-frequency ultrasonic root end preparation using a stainless steel tip produced signicantly more cracks per root than low-frequency preparation.22 Frank et al examined the effect of an ultrasonic device at medium and high power settings using stainless steel tips.21 The authors found the highest number of infractions when using an ultrasonic device with a high power setting. In addition, biconcave roots were more susceptible to infractions than oblong or round root ends were. However, no statistically signicant difference 611

612 Taschieri et al was found for the occurrence of infractions as related to root tip morphology. Waplington et al reported an increase in chipping of root end preparations related to the use of an ultrasonic stainless steel tip.35 Chipping was observed more frequently when power intensity was increased. However the authors found no evidence of cracks on the root end surface using the entire spectrum of possible power settings. Min et al examined serial histological sections of root ends prepared at the lowest power setting of an ultrasonic device and at an intensity level midway between the lowest and highest power settings, using stainless steel tips.24 No differences were found in the crack length or depth between the 2 groups. Lin et al didnt observe cracks on any resected surface of roots after root end cavities preparation using a stainless steel tip with an ultrasonic device at the lowest power setting.27 Gray et al showed that varying power settings of an ultrasonic device between its lowest and highest intensity did not signicantly alter the occurrence of cracks and chipping using stainless steel retrotips.29 Peters et al, in a scanning electron microscope (SEM), study compared ultrasonic diamond-coated and stainless steel retrotips using an ultrasonic device at a medium power setting.30 The authors showed no signicant difference between the 2 groups. The time required to prepare the root end cavities was also evaluated. Navarre and Steiman didnt nd root end fractures produced by either stainless steel or zirconium nitridee coated retrotips using an ultrasonic device at full power.31 The time that the ultrasonic tips were in contact with tooth structure was recorded. Ishikawa et al evaluated and compared the efciency of root end preparations using ultrasonic retrotips coated with diamond and zirconium nitride and a stainless steel tip, setting an ultrasonic device only at maximum power.32 No signicant differences in the number of microcracks were found. The time required to prepare the root end cavity was recorded. The purpose of the present study was to investigate the effect of ultrasonic retrotips on root end surfaces and on retrograde cavities. We aimed at comparing samples that were prepared using 2 different retrotip designs (a diamond-coated tip and a stainless steel tip) and 2 different power levels of the ultrasonic device. We also evaluated the inuence of the different tip designs on the time required to prepare the cavities. We tested the null hypothesis of equivalence in the outcomes between the different techniques. MATERIAL AND METHODS Forty-ve human teeth with single straight roots and single canals were used in this study. All the teeth were

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vital and extracted for orthodontic and/or periodontal reasons, from subjects aged between 18 and 45 years. Only specimens without restorations, with intact roots and mature apexes free of defects and visible fractures were selected. Following extraction, soft tissue and debris were removed from the surfaces of the roots by hand scaling. The teeth were then thoroughly cleaned and placed in 5% sodium hypochlorite solution for 30 minutes. They were washed twice in PBS (Sigma Chemicals, St. Louis, Mo) for 2 minutes and immediately stored in 5% buffered formalin36 (Sigma Chemicals) for 24 hours. The pulp chambers were accessed and the working length of the root canal determined by observing a size 10 K-le at the foramen and withdrawing it for 0.5 mm. All teeth had a proximal radiograph taken with the le in situ to ensure straightness of the canal and to exclude canals with an unusual anatomy. Root canals were then cleaned and shaped using a crown-down technique. The prepared working width was #30 for all the specimens. All canals were then lled by vertical compaction of gutta-percha points. All 45 roots were resected at a 908 angle in respect to their longitudinal axis, 3 mm from the apex. To ensure that the section was made exactly as planned, a wax base with the section line already drawn was used. Each section was made using a tungsten-carbide straight ssure bur (Maillefer Zerkya; Dentsply-Maillefer Instruments, Ballaigues, Switzerland) used under constant water spray irrigation. All the teeth were held with saline-soaked gauzes to maintain root moisture while all procedures were accomplished.31 The 45 teeth were then assigned to one of 5 groups (each consisting of 9 specimens) according to a 1:1 computer-generated randomized table (Really Random Numbers; 2003 Sunny Beach Technology, Minneapolis, Minn). One group was used as a control (control group). The other 4 groups were treated as follows. Setting the ultrasonic device power at the maximum position (full power, FP) a retrograde cavity was made with a stainless steel ultrasonic retrotip (DS-017; EMS, Nyon, Switzerland) in 9 specimens (SS-FP group) and with a diamond-coated retrotip (EMS) in another 9 samples (D-FP group). In the other 2 experimental groups the intensity of the ultrasonic device was set at half power (HP). Nine specimens were treated with a stainless tip (SS-HP group) and the other 9 with a diamond-coated tip (D-HP group). All the 4 test groups had apical cavities prepared as follows. A 3-mm-deep root end preparation was made. Water spray irrigation was used to avoid overheating. The time required to prepare the root end cavities with both retrotips was recorded. The retropreparations were made using new tips for each specimen, to avoid a

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different cutting ability. A single operator, with over 10 years of experience in endodontic surgery, carried out all the preparations. Then a 3 mm section was cut perpendicular to the long axis, in a horizontal plane, with a precision saw (Isomet Low Speed Saw; Buehler, Lake Bluff, Ill). This was done also in the teeth belonging to the control group (that were not apically instrumented) that were assessed to test if the bur cut on the bevel surface might itself produce root cracking. The sectioned samples were washed 3 times for 10 seconds with 17% EDTA solution buffered at pH 7.5 (Ogna, Milan, Italy) to remove the smear layer. Each sample was then briey examined under stereomicroscope with ber optic transilluminating light source, at 243-723 magnication, for a preliminary analysis regarding the presence and type of dentin fractures. Each sample was photographed under different angulation, for our records. We did not use the results of optical observation for the statistical analysis. Specimens were then prepared for SEM analysis according to the method proposed by Janda37 for SEM investigation of human teeth. This method was designed to minimize the occurrence of artifacts related to the sample processing for SEM analysis. Briey, specimens were rst dehydrated in a water/ethanol mixture with increasing content of ethanol (70%, 80%, 96%, and 100% for 24 hours each), followed by mixtures of ethanol and acetone (increasing acetone content: 80%, 96%, and 100% for 24 hours each). Then they were dried for 24 hours in a dessiccator under vacuum with a glass lter pump. In this way critical-point drying may be avoided. Finally, the specimens were mounted on a single stub, and sputter coated with gold (SEM coating unit E 5100; Polaron Equipment, Whatford, UK). The SEM evaluation was performed with a Jeol 840A (Jeol, Tokyo, Japan). Specimens were coded for blind evaluation. Each specimen was photographed at magnication of 483 and independently scored by 2 blind examiners. Any disagreement between the 2 observers was resolved jointly by re-evaluating the sample under greater magnication (up to 15503) until a consensus was reached. The examiners assessed:  The number and type of root surface cracking produced by the ultrasonic retrotip.  The marginal integrity of the apical cavities. The number and the location of the cracks were scored for each tooth. Each item was scored in accordance with the cracks number in the following scale: A, absence of cracks; B, 1 to 3 cracks; C, 4 to 6 cracks; D, 7 or more cracks. The type of cracks was then classied as: complete, incomplete, and intradentinal, similar to Beling et al.23 Complete canal cracks extended from the canal space to the external root surface. Incomplete

canal cracks extended from the canal space to a variable distance into the dentin but ended short of the external root surface. Intradentinal cracks were conned to dentin and appeared to run in a facial-lingual direction either mesial or distal to the canal. The quality of root end cavity margins produced by ultrasonic retrotips was scored according to the degree of defects:  The ideal preparation (0 defects).  A single, visible defect produced by the contact between the angle of the tip and the cavity margin.  Chipped, ragged cavity margin.  Chipped, ragged cavity margin plus some defects due to the tips bouncing off the root face during root end preparation. Statistical analysis was carried out to evaluate the difference between groups using a software package (Statistica; Statsoft, Tulsa, Okla). Fisher exact test and Pearsons chi-squared were used to compare the effects of treatment between the experimental groups. Comparisons were made by means of 2 by 2, 2 by 3, or 2 by 4 crosstables, as appropriate. ANOVA and unpaired Students t-test were used to compare preparation times between groups. A value of probability P = .05 was considered as the signicance level. RESULTS Table I summarizes the results of the evaluation of the different parameters. Root face cracks number No cracks were observed in root bevel surfaces belonging to the control group. In the SS-FP group there was 1 specimen classied C and one D, whereas in the other groups all the samples were classied no worse than B. No statistically signicant differences could be found between diamond-coated and stainless steel retrotips, for both power settings, regarding the cracking number. Within roots treated using stainless steel retrotips we found that the FP group showed a signicantly higher number of cracks when compared to the HP group (P = .02). We also found a signicant difference between the D-FP and SS-HP groups (P = .03). No correlation was found between preparation times and the incidence of cracks (P [ .05). Types of cracks Figure 1 is an SEM microphotograph showing an example of an incomplete dentinal crack of a sample belonging to the SS-FP group. The distribution of the types of cracks among groups is shown in Table I. Only the SS-HP group had no samples with complete or

614 Taschieri et al Table I. Results of the evaluation of the quantity and quality of cracks
Full power (FP) Group: No of cracks per sample 0 1-3 4-6 $7 Type of crack Intra-dentinal Incomplete Complete Quality of cavity margin No defects 1 defect Chipped, ragged Chipped + defects Control 9 0 0 0 D-FP 2 7 0 0 4 0 3 4 5 0 0 SS-FP 2 5 1 1 4 2 1 2 5 1 1 Half power (HP) D-HP 5 4 0 0 2 0 2 5 3 1 0 SS-HP 7 2 0 0 2 0 0 7 2 0 0

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Total 25 18 1 1 12 2 6 18 15 2 1

D = diamond coated; SS = stainless steel.

Fig 1. A microphotograph (magnication 483) taken with SEM, showing an example of an incomplete crack. The sample belonged to the SS-FP group. The crack starts from the canal margin, as pointed by one of the 2 arrows, and ends into the dentin at a distance indicated by the other arrow.

stainless steel retrotip at high frequency level scored 1 sample with chipped margin and another with chipped margin and defects. The latter is shown in Fig 4. When using diamond retrotip at high power setting no sample with chipped margins was observed. No signicant difference was found between diamond-coated and stainless steel retrotips for this parameter, at both power settings. It was observed that the 3 samples that presented chipped margins required almost 4 minutes for the retrograde cavity preparation, while the preparation was accomplished in shorter times for most of the other samples. No statistically signicant difference was found for margin quality between diamond coated and stainless steel retrotips. Within the groups using stainless steel retrotips, the samples treated by the full-power setting displayed a poorer quality of cavity margin when compared to half-power-treated teeth (P = .02). Time required to prepare root end cavity Table II reports the mean time required for cavity preparation for the 4 experimental groups. We found that, on the average, diamond-coated retrotips allowed faster retrograde preparation than stainless steel retrotips, at both half and full power setting (P \ .05 in each case). DISCUSSION Recently, ultrasonic root end preparation techniques for endodontic surgery have gained popularity in endodontics practice. In contrast to bur-prepared root end cavities, those shaped using ultrasonic retrotips are deeper, rarely deviate from the canal space, and require smaller bony crypts and smaller bevel angles for preparation.35 However, any approach that could prevent or minimize adverse effects of the root end preparation

incomplete canal cracks. Two complete cracks were observed in the D-HP (one of them is showed in Fig 2), 1 in the SS-FP, and 3 in the D-FP group. All groups had specimens showing intradentinal cracks. Figure 2, A is a picture taken under stereomicroscope prior to SEM analysis, showing a branching pattern of cracks very similar to that observed under SEM (Fig 2, B). Figure 3 represents a sample belonging to the D-FP group, showing several dentinal cracks. No signicant difference between groups was outlined for crack type (P [ .05). No correlation between preparation times and type of cracks was observed (P [ .05). Marginal quality of retrograde cavity Table I also reports the scores for marginal chipping produced using retrotips. Figure 2 illustrates an example of preparation without marginal defects. Teeth treated by

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Fig 2. A, A specimen observed under stereomicroscope prior to preparation for SEM analysis. The branching pattern of dentinal crack in this sample is the same as later observed under SEM. B, Sample belonging to the D-HP group, showing a complete canal crack. The inner and the outer ends of the crack are indicated by the arrows. In the sample are visible several dentinal branches of the principal crack.

such as the occurrence of dentinal cracks should be considered. Recently some attempts to improve the performance of ultrasonic instruments were carried out. The introduction of diamond-coated and zirconiumcoated retrotips represents an important issue in this eld. This in vitro study investigated the effect of different ultrasonic retrotip designs and different ultrasonic device amplitude levels as related to the number of root end surface cracks, the type of cracks, and the marginal quality of retrograde cavity.
Fig 3. Intradentinal cracks (arrows) of a sample belonging to the D-FP group.

Number of root face cracks Cracks on resected root surface of extracted teeth occur not only during in vitro procedures of root end cavity preparation but also because of resulting dehydration of the dentin.10 In fact, dehydration of dentin may alter its mechanical properties so that it becomes more prone to developing cracks when compared to hydrated dentin.38 In this study only freshly extracted teeth were used and attention was paid to keep the samples moist during the root end preparation, as suggested by other authors.31 Moreover, important factors peculiar to in vitro studies, such as stresses exerted during extraction, inappropriate storing, and careless handling of extracted teeth may predispose to dentin alterations.39 A further limitation of the in vitro approach is the absence of periodontal ligament, which could dissipate some of the stress to which the root is subjected during instrumentation.34 Therefore, in the present study we could have obtained an overestimation of cracks.

The preparation of a sample for SEM analysis is one of the most critical aspects of this method of investigation. In fact, dehydration and drying procedures may create artifacts in hard tissues. Prior to gold sputtering of the sample, 2 different approaches may be identied for sample preparation. These 2 approaches were compared in the past by Janda.37 The direct approach consists of the dehydration and drying of the original sample. The indirect approach is carried out by taking impressions of the tooth surfaces with appropriate materials (such as polysiloxane). A positive model is then manufactured from the impression using a transparent resin or an epoxy resin. The replica is then gold sputtered and examined. Even if the indirect method should avoid creation of artifacts and preserve the original sample, Janda found that this approach does not provide detailed information of the original tooth surface, especially when examining tooth structures at high magnication ( $ 4003) using

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Fig 4. A, A specimen observed under stereomicroscope prior to preparation for SEM analysis. The crack pattern and margin defects are the same as observed with SEM. B, Microphotograph of a sample belonging to the SS-FP group, classied as D for the marginal quality. In this picture are visible: a defect produced by the contact between the angle of the tip and the cavity margin (1), defects due to the tip bouncing off the root face during root end preparation (2), and chipped, ragged cavity margin (3).

Table II. Time required for retrograde preparation

Group: Mean time, minutes Standard deviation Range (min-max) D-FP 1.5 .5 1.2-2.6 SS-FP 2.2 .6 1.6-3.6 D-HP 1.8 .6 1.4-3.2 SS-HP 2.8 .5 2.2-3.3

SEM.37 The direct method proposed by this author involves effective dehydration and drying of the sample so that critical point drying can be avoided. In this way he found that the possibility of artifacts is greatly reduced.37 Other authors stated that any kind of dehydration and drying process causes artifacts, and recommend the indirect method.39-40 We are aware that the risk for technique problems leading to artifact cracks may always exist. In our investigation we followed the preparation method suggested by Janda that associates a low risk for artifacts to a high sample denition. Furthermore, the preliminary observation of the samples under stereomicroscopy allowed us to identify some peculiar patterns of dentin fracture. The same patterns were observed when the samples were examined by SEM as showed in Figs 2 and 4. Finally, in the samples of the control group we never detected dentin cracks, suggesting that the main cause for root face cracks in our case was retrograde preparation. We found a signicant difference between the SS-FP and SS-HP groups: A higher incidence of cracks was observed in the group using the full power setting. Few studies have investigated the effect of ultrasonic retrotips on resected root surfaces after root end prep-

aration with the ultrasonic device set at different power levels. Some researchers have used only stainless steel retrotips and showed controversial results.22,24,29,35 Other studies investigated the possible differences between diamond coating, stainless steel, and zirconium nitride coating on root end preparation of resected root surfaces.30-31 These studies adopted only a single power setting. No signicant differences were found between results obtained with different kind of retrotips. In the present study, when a given power setting was considered, no signicant difference was observed between diamond and stainless steel retrotips. Peters et al found a correlation between the incidence of cracks and the time needed to accomplish root end preparation.30 In the present study no correlation was observed between preparation times and the incidence of cracks using either medium power or full power settings. There is little evidence in the literature about this subject, and it would appear that further investigation is needed to make clear the inuence of the preparation time on the occurrence of dentinal cracks. Types of cracks A further aim of this study was to assess if stainless steel and diamond-coated retrotips produced different types of cracks. Only the specimens treated with a stainless steel retrotip at half power did not show complete or incomplete dentinal fractures. Conversely, 3 complete canal fractures were found when using diamond tips at the full power setting. However, maybe

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owing to the small number of cracks examined, no signicant differences were found between diamond tips and stainless steel at both power settings. Few other studies observed the different types of cracks produced after root end preparation with ultrasonic retrotips. Rainwater et al, using a stainless steel and a diamond retrotip (Amadent, Cherry Hill, NJ) and setting the ultrasonic device at low power, found no signicant difference between the 2 kinds of tips for both the number and the type of cracks.28 Most cracks consisted of intracanal or extracanal types, and a lower number were of communicating type. Beling et al, using a stainless-steel retrotip (EIE, San Diego, Calif) and setting the ultrasonic device at low power, found intradentinal and incomplete but not complete cracks following root end preparation.23 Furthermore, no differences were recorded in the incidence of cracks in canals which were lled or unlled prior to root end cavity preparation. It is difcult to compare results of studies with dissimilar experimental design. In fact using different types of retrotip design and material could represent an important source of variability. A further point is the variation in oscillation of the retrotip according to the tip design, in particular to angulation and position of bend.35 Differences between ultrasonic devices could change the vibratory pattern of the tips.41 Finally, different apical diameter of the specimens used in the various studies could also lead to increased variability in outcomes. Until standardization in experimental study design is obtained, a comparison between heterogeneous reports will occur and may lead to awed conclusions.

that the margin quality was signicantly worse in roots sectioned at a 458 bevel. Very few chipped margins were observed in the present study. Owing to this fact, no correlation may be attempted with preparation time. However, we observed that the time needed to accomplish cavity preparation in the 3 samples that presented chipped and ragged margins was higher than the average of the respective groups. It is possible that the longer the preparation time the higher the chance of producing chipped margins, but this subject would need further investigation and a larger number of observations. Chipping of the cavity margin may affect sealing of the root end lling, or favor the harboring of bacteria. This issue needs to be evaluated in further leakage studies to clarify the relation of chipping to long-term sealing at the apex. Preparation time We found that cavity preparation is completed in a faster time when using diamond-coated retrotips as compared to stainless steel ones. This result is in line with previous observation by Peters et al30 but does not correspond to a different incidence of cracks between the 2 types of retrotips. CONCLUSIONS 1. Root face cracks number: Comparing diamondcoated and stainless steel tip groups, no signicant differences were found in the number of cracks produced at both full and half power setting. In the groups using stainless steel retrotips the FP group showed a signicantly higher number of cracks than the HP group. 2. Type of cracks: No signicant difference was found between diamond-coated tips and stainless steel tips at both power setting. 3. Marginal quality of retrograde cavity: No signicant differences were found comparing the results of diamond-coated tip groups versus stainless steel ones. Samples treated by stainless steel tips displayed better margin quality when using half power instead of full power settings. 4. Time required to prepare root end cavities: Diamond retrotips were faster than stainless steel ones to prepare root end cavity, independent of power setting.
REFERENCES
1. Gutmann JL, Pitt Ford TR. Management of the resected root end: a clinical review. Int Endod J 1993;233:273-83. 2. Carr GB. Advances in apical surgery [videotape]. San Diego (CA): Pacic Endodontic Research Foundation; 1990.

Marginal quality of the retrograde cavity The quality of cavity margins produced either using diamond coated tips or stainless-steel ones was very similar. In the former case the margin quality didnt seem to be inuenced by the power setting of the ultrasonic device. Conversely, when using the stainless steel tips a better cavity margin quality was observed in those samples treated by half power compared to full power. Only the latter in fact displayed specimens with chipped margins. Gray et al, using stainless steel retrotips, found that when increasing the power setting of the ultrasonic unit chipping is not increased.29 These conclusions, however, are dissimilar to those of several other studies.21-22,35 The retrotip coating might be as important as power setting to chipping production. It has been suggested by Lloyd et al that some defects observed might be due to the tips bouncing off the root face during root end preparation.20 They also showed

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