Endo Tribune Middle East & Africa Edition No. 2, 2021
Reducing microleakage with Er,Cr:YSGG and/or Nd:YAG lasers
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DTMEA_No.2. Vol.11_ET.indd
NL
Y
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LS
NA
IO
SS
FE
O
PR
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AL
DE
www.dental-tribune.me
Published in Dubai
March-April 2021 | No. 2, Vol. 11
Reducing microleakage with
Er,Cr:YSGG and/or Nd:YAG lasers
An evaluation
By Drs Mina Mazandarani, Maziar
Mir & Masoud Shabani, Iran; Prof.
Norbert Gutknecht, Germany
Introduction
In endodontics, effective cleaning
of the root canal system is essential
for ensuring successful root canal
therapy with long-lasting treatment
outcomes.1–3 During endodontic
instrumentation, various morphological changes occur on the root
canal walls, including organic and
mineral debris4–7 and smear layer
formation.2,4,7 Therefore, not only
are conventional cleaning and removal of debris and the smear layer
important steps in endodontic procedures,1,2 but chemical irrigation
is strictly recommended for use in
conjunction with mechanical in-
strumentation in order to dissolve
debris and the smear layer.8,9 In fact,
the methods employed to clean
and shape root canal spaces create
a smear layer, which may harbour
microorganisms that ultimately result in periapical pathosis.3,7 Many
irrigant solutions, such as sodium
hypochlorite and ethylenediaminetetraacetic acid (EDTA), are used.
Sodium hypochlorite is effective in
removing organic tissue remnants,8
while EDTA is effective in removing
the inorganic portion of the smear
layer.9 However, both irrigants are
unable to remove the smear layer effectively.1,3,10
A successful root canal therapy is
based on a number of factors: reduction of microorganisms to the mini-
mum, sufficient and proper root
canal instrumentation and disinfection, as well as well-adapted root
canal obturation.11 A crucial disadvantage of irrigant solutions is that
their bactericidal effect is limited to
the main root canal. Because of the
narrow diameter of the dentinal tubules and the high surface tension
of the liquid solutions, they are able
to penetrate only a small distance
into the tubules. The penetration
depth of chemical disinfection only
reaches 100μm into the adjacent
dentinal tubules.12,13 However, the
bacteria can penetrate over 1,000μm
from the canal lumen,12 as described
by Kouchi et al.14 and Ando & Hoshino.15 Therefore these bacteria are
protected in the deeper layers of dentine. In this protected area, we find
Gram-negative bacteria, which are
characterised by their unusual migration qualities and their resistance
to chemical irrigant solutions. They
maintain their virulence against conventional endodontic techniques.
And we find that, from this bacterial
reservoir, the bacteria will spread to
the periapical areas of the tooth,
causing inflammation and infection.12 Since conventional root canal
therapy is not always successful, new
methods could perhaps enhance the
long-term prognosis and overcome
the short- comings of conventional
instrumentation methods.11
Today, lasers are used in endodontics
to dramatically improve the prognosis of root-filled teeth.12 Laser irradiation produces different effects on the
same tissue, and the same laser can
produce various effects in different
tisues. Er:YAG and Er,Cr:YSGG lasers
have been reported to ablate dental
hard tissue16–21 with minimum injury to the pulp and surrounding
tissue.17–19,22–25 The Er:YAG laser has
been reported to ablate enamel and
dentine effectively, because of its
highly efficient absorption in both
water and hydroxyapatite,16,20,21 and
the Er,Cr:YSGG laser, which uses a
pulsed beam system, fibre delivery
and a sapphire tip bathed in a mixture of air and water vapour, has
been shown to be effective for cutting enamel, dentine18,20 and bone.18
Moreover, this specific property,
ÿPage A2
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[2] =>
DTMEA_No.2. Vol.11_ET.indd
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ENDO TRIBUNE
Dental Tribune Middle East & Africa Edition | 2/2021
◊Page A1
combined with a water spray for
both lasers, enables the effective
removal of debris and the smear
layer.23,26–31 The surface morphology
of root canals can be altered by using
a 1,064nm Nd:YAG laser. Remaining soft tissue as well as the smear
layer can be partially or completely
removed, depending on the energy
level used.11
The Nd:YAG laser seems to be the laser of choice in root canal therapy. It
is also the best-documented laser in
the literature for root canal sterilisation. Most of the studies concerned
with the Nd:YAG laser in endodontics deal with the quantitative evaluation of bacteria reduction.12 Laser
irradiation has been widely introduced in endodontic treatments as
an aid to disinfection and the removal of debris and the smear layer from
instrumented root canal walls and
might be a solution for the various
limitations and shortcomings of mechanical and chemical disinfection.
Microleakage continues to be a main
reason for failure of root canal thera-
py, where the challenge has been to
achieve an adequate seal between
the internal tooth structure and the
main obturation material, gutta-percha.32 It has been found that approximately 60% of endodontic failures
are due to inadequate obturation of
the root canal system.33,34 Although
gutta-percha is the most popular
core material used for obturation, it
cannot be used as the sole filling material because it lacks the adherent
properties necessary to seal the root
canal space. Therefore, a sealer and
cement are always needed for the
final seal.35,36 The Resilon/Epiphany
system uses a new obturation material that bonds chemically with
the internal tooth structure, thereby
decreasing the possibility of microleakage.32
The scientific investigation of fundamental problems plays a decisive
role in understanding the mechanisms of action of exposing biological materials to laser irradiation and
their consequences.37 The purpose
of this study is to analyse microleak-
age differences when removal of the
smear layer is done conventionally,
chemically (with and without EDTA)
and with Er,Cr:YSGG and/or Nd:YAG
laser irradiation and Resilon/Epiphany is used as the obturation material.
Materials and methods
In this study, 72 freshly extracted
caries- and restoration- free singlecanal bovine teeth38,39 stored in normal saline (0.9%) at 4°C were used,
after scaling with scalpels or hand
instruments to remove residual tissue and calculus and rinsing thoroughly with tap water. Samples were
randomly divided into six groups of
12 teeth each. The working lengths
were established as 1mm short of the
apexes. The canals were hand instrumented with Kerr files (Maillefer) to
the size of ISO 30 to this length in order to create an apical stop. The root
canals were thoroughly rinsed with
saline solution and gently dried using paper points (Dentsply Sirona).
Then Groups 1 to 4 were irradiated
by laser, and EDTA (Produits Dentaires; 15 ml, LOT 6217 FL) was used
to remove the smear layer for some
groups, followed by a final rinse with
saline solution (Table 1).
All 72 samples were prepared for obturation using the Resilon/Epiphany
system. The canals were dried with
absorbent paper points (Dentsply Sirona). A dry paper point was soaked
with self-etching primer (SybronEndo; 6ml, ref. No. 972-2007) and used
to coat the root canal walls. The size
of the Resilon master cones was then
determined. An appropriate amount
of the dual-polymerising Resilon
sealer (SybronEndo; 4 ml) from the
automix syringe was expressed on
to a slab. The canals were coated
with the sealer using the automix
syringe, pre-measured Resilon master cones and a file. The viscosity of
the sealer was modified by adding a
drop or two of RealSeal thinning resin
(SybronEndo, ref. No. 972-2006). Subsequent accessory points of Resilon
core material were also coated with
the sealer and inserted into the canal
and compacted through lateral condensation. Once the obturation was
completed, the coronal surface was
light-polymerised for 40 seconds.
The coronal portions of all samples
were then restored.
Acid etching was done using a 35%
orthophosphoric acid-etch gel for
15 seconds. After acid etching, all
cavities were coated with a layer of
primer (Syntac Primer, Ivoclar Vivadent), adhesive (Syntac Adhesive,
Ivoclar Vivadent) and bonding agent
(Heliobond, Ivoclar Vivadent) and
light-polymerised (Translux, Kulzer)
for 20 seconds. Then a composite
(Ivoclar Vivadent; Shade A3) was
used in increments to seal the coronal 2 mm of the roots and was lightpolymerised for 40 seconds. For the
dye penetration test, the samples
were first coated with two layers of
nail polish (Sally Hansen, Del Laboratories), except for the last apical
2mm, which was left exposed so that
the dye could only penetrate the
canal via the apical region. The samples of each group were then kept in
separate containers of distilled water
and incubated at 37°C for five days, to
stimulate clinical conditions.
After incubation, the samples of each
group, again in separate containers,
were immersed in an aqueous solution of 2% methylene blue at 37 °C
for seven days so that the root canals
would be filled with dye solution by
capillary action. After this time, the
teeth were removed from the dye
and rinsed under running water for 5
minutes and incubated again in distilled water at 37 °C for 24 hours. After
incubation, the teeth were removed
from the dye-containing solution,
rinsed and dried. The samples were
dehydrated in a sequence of alcohol
solutions (70% for 24 hours, 96 % for
24 hours and 100 % for 48 hours).
Then they were kept in a histological cleaning agent (Histo- Clear II,
National Diagnostics) for 2 hours and
embedded in resin (K Plast) in groups
in separate containers and stored in a
water bath for four to seven days until the resin had set. The glass containers were broken to remove the resinembedded samples, and Vaseline
was applied into a self-made former
container for each sample, to avoid
sticking of acrylic to the container.
Table 1: All groups of laser-irradiated root canals and control (n = 72)
Dye leakage was assessed after immersion in methylene blue, by
examining vertical and horizontal
sections under a transmitted-light
microscope (Leica DMRX with an
integrated Hitachi HV-C20A camera,
Leica Microsystems) at an objective
lens magnification of 0.63x (optical
lens magnification of 10x) by means
of a computer programme (Diskus,
Hilgers Technisches Büro). Then horizontal cuts of 500 μm in thickness
were made, splitting the roots into
ÿPage A3
Table 2: Graded average dye penetration depths (μm). Gr. = grade
Fig. 1: Average dye penetration depth (μm) in all six groups
Fig. 2: Average dye penetration depth (μm) in all six groups based on the images of the vertical cuts of the roots
[3] =>
DTMEA_No.2. Vol.11_ET.indd
ENDO TRIBUNE
A3
Fig. 3: Average dye penetration depth (μm) in all six groups according to the images that resulted from the horizontal sections
Fig. 5: A sample of cross-section cuts under the microscope. Dye penetration depth was
measured by a computer programme.
Dental Tribune Middle East & Africa Edition | 2/2021
◊Page A2
Fig. 4: The average dye penetration depth in the apical thirds was greater than in the middle thirds in Group 1, but the standard
deviation shows that the difference could not be considered statistically significant (p>0.05)
three portions: coronal third, middle
third and apical third. The horizontal
sections were examined under the
transmitted-light microscope at an
objective lens magnification of 2 x
(optical lens magnification of 10 x)
by means of the same computer pro-
gramme, to assess dye penetration,
and the data was saved. It is necessary to note that the digital camera,
which connects the microscope to
the PC and software, will magnify
the image, but the power of magnification is not easy to calculate.
Therefore, the final magnification of
the image that is shown on screen or
printed out depends on the size of
screen. That is why we only report
Fig. 6: A sample of vertical cuts of roots. Measurements are not as accurate as for
horizontal views.
ÿPage A4
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DTMEA_No.2. Vol.11_ET.indd
A4
ENDO TRIBUNE
Dental Tribune Middle East & Africa Edition | 2/2021
◊Page A3
Fig. 7: The apical region can be seen with more detail in vertical cuts, but even so, the
measurements could not be done as accurately as for horizontal cross sections.
objective lens and optical lens magnification in such cases.
comfort compared with using an optical microscope.
Data analysis was performed using
StatView software (SAS Institute Inc.),
and the extent of leakage in each
group was investigated in both vertical and horizontal cuts to gain a near
3D view. The scores were statistically
evaluated by three calibrated examiners using the Kruskal–Wallis test to
determine the statistical differ- ences among the groups (p<0.05), and
comparison of paired groups was
done using the Wilcoxon signed rank
test (p<0.05). The three examiners
were unaware of the grouping of the
teeth, and differences were reconciled by agreement. Since the magnification achieved by this technique
was equal to 0.63 x for the vertical
cuts and 2 x for the horizontal cuts,
all the examiners could evaluate the
samples at the same time with more
The extent of the leakage was scored
as follows: – 0: no penetration
– 1: penetration up to 500μm
– 2: penetration up to 1,000μm
– 3: penetration more than 1,000μm.
Results
Figure 1 shows the average dye penetration depth in the various groups.
In this graph, Group 4 shows a lower
amount of dye penetration compared with Groups 3, 5 and 6, but has
a similar average to that of Group 2.
As is seen in Figure 2, the general finding is that in Group 1 the apical thirds
show more dye penetration, but in
the other groups, we cannot state
such an observation. The difference
between Group 1 and Groups 5 and 6
was statistically significant (p < 0.05),
but the differences between Groups
AD
1, 2, 3 and 4 were not statistically
significant (p > 0.05). In the vertical
cross sections of the roots, besides
the apical and middle thirds, the
coronal thirds were examined as well
(Fig. 3). In Groups 1 and 2, there was a
greater average leakage in the apical
thirds than in the middle and coronal
thirds. Overall, there was no reportable difference between the coronal
and middle thirds of all the roots. In
the vertical cross sections, the apical,
middle and coronal thirds were compared regarding the different kinds of
laser irradiation and irrigation.
For better understanding of these
findings, the depth of penetration
was categorised as is shown in Table 2. The middle thirds of Group 1
show the lowest amount of dye penetration. The difference between the
groups was not statistically significant (p > 0.05). However, the comparison between the apical thirds
of the first three groups with the
middle or coronal thirds of the same
groups showed a statistically significant difference (p < 0.1). This result
was narrower in Group 1. Therefore,
the most valid result is that in Group
1, for which both lasers were used,
the lowest penetration depths were
reported. In this group, the apical
thirds showed significantly higher
dye penetration depths compared
with the middle and coronal thirds
(Fig. 4).
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Discussion
No study has reported on the combined use of laser and Resilon. In
studies that used Resilon as a filling
material, a similar efficacy to that of
gutta-percha was observed. Thus, the
concern of the current investigation
was to determine whether Resilon
would show an acceptable integrity
with the dentinal walls after laser therapy. The graphs and standard deviation overlaps of the six groups show
that only the group treated with both
lasers plus EDTA had a statistically
significantly lower amount of leakage. The difference between the apical
thirds and middle thirds of the same
group was not statistically significant. As the average dye penetration
depths in various areas in each cross
section were reported as the resulting
raw data of that slide, the horizontal
images show more accurate and more
reliable results (Fig. 5). But, as is seen
in Figures 6 and 7 in vertical section
imaging, the depth of penetration is
not as easy and clear to measure as it
is in horizontal samples. Therefore, for
future studies, the use of horizontal
cross sections only is recommended.
Conclusion
Resilon as an adhesion-based filling material shows good results in
combination with EDTA and both
Er,Cr:YSGG and Nd:YAG lasers according to the criteria of this study.
Editorial note:
This article was originally published
in roots-international magazine of
endodontics, Issue 4/2020.
About the author
Dr Mina Mazandarani
She holds a DDS and an M.Sc. in Lasers
in Dentistry from the Aachen Dental Laser Center at RWTH Aachen University in
Germany. She is a PhD candidate in the
Clinic for Dental Conservation, Periodontology and Preventive Dentistry at RWTH
Aachen University hospital. She can be
contacted at mina.m83@gmail.com.
DentsplySirMF_TruNatomy Ad_3April2019_ASL.indd 1
5/16/19 7:49 AM
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