Publications by authors named "Alessio Zanza"

16 Publications

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In Silico Novel Drug Design Targeting the Oral Microbiome: Endodontic and Periodontal Pathogenic Bacteria.

Microorganisms 2021 Nov 22;9(11). Epub 2021 Nov 22.

Department of Oral and Maxillo Facial Sciences, University of Rome La Sapienza, 00161 Rome, Italy.

The oral cavity is composed of about 300 million species of bacteria that occupy various ecological niches [...].
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http://dx.doi.org/10.3390/microorganisms9112400DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8622311PMC
November 2021

Ultrasound Imaging in Dentistry: A Literature Overview.

J Imaging 2021 Nov 14;7(11). Epub 2021 Nov 14.

Department of Oral and Maxillofacial Sciences, Sapienza University of Rome, 00161 Rome, Italy.

(1) Background: the frequency with which diagnostic tests are prescribed with exposure to ionizing radiation, a cause of biological damage, has been studied, and with much more attention, patients are subjected to these diagnostic tests for diagnosis and follow-up. This review aimed, given the recent developments of this technology, to evaluate the possible use of ultrasound in different branches of dentistry. The possibility of applying ionizing-radiation-free diagnostic exams in dentistry, overcoming the limits of this application, has led scientific research in this area to obtain interesting results that bode well for the future. (2) Methods: a search for articles on the application of ultrasounds in dentistry was performed using the PubMed electronic database. (3) Results: only 32 studies were included, and these clearly stated that this examination is widely usable and in great progress. (4) Conclusions: regarding the modern application techniques of this diagnostic test, it is essential to consider technological evolution as an objective to reduce the damage and side effects of necessary diagnostic tests. The use of ultrasound in dentistry can represent a valid radiation-free alternative, in certain contexts, to the other most used exams.
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http://dx.doi.org/10.3390/jimaging7110238DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8624259PMC
November 2021

Role of the Crystallographic Phase of NiTi Rotary Instruments in Determining Their Torsional Resistance during Different Bending Conditions.

Materials (Basel) 2021 Oct 23;14(21). Epub 2021 Oct 23.

Department of Oral and Maxillo-Facial Sciences, Sapienza University of Rome, 00161 Rome, Italy.

The aim of this study was to assess the role of the crystallographic phase of Nickel-titanium (NiTi) rotary instruments in determining their torsional resistance during different bending conditions, such as different degrees and angles of curvature. 200 F-One 20.04 instruments (Fanta Dental, Shanghai, China) were used, 100 austenitic instruments and 100 martensitic instruments. Each group was divided in 5 subgroups according to the different bending conditions (straight canal, 90° or 60° of curvature degrees and 3 mm or 5 mm of radius of curvature). The static torsional test was performed by using a device composed of an electric motor capable of recording torque values (N·cm); a vice used to secure the instruments at 3 mm from the tip; and artificial canals, which allow instruments to remain flexed during test. Each instrument was rotated at 500 rpm with a torque limit set to 5.5 Ncm until its fracture. Torque at Fracture (TtF) was registered. A scanning electron microscopy (SEM) observation was conducted. The collected data confirm that an increase in the angle of curvature and a decrease in the radius of curvature of the artificial canals lead to an increase of TtF values with a statistically significant difference ( < 0.05), both in the austenitic and martensitic groups. Regarding the comparison between austenitic and martensitic groups in the same bending condition, a statistically significant difference was found only when the torsional test was performed in the canals with the degrees of curvature of 90° and the radius of curvature of 3 mm and 5 mm, with the austenitic instruments showing a higher TtF than the martensitic ones. In conclusion, it can be stated that the crystallographic phase influences the maximum torque at fracture when the instruments are subjected to severe bending and that the radius of curvature significantly influences their torsional resistance.
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http://dx.doi.org/10.3390/ma14216324DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8585440PMC
October 2021

Evaluation of the Effect of Long-term Use of Three Intracanal Medicaments on the Radicular Dentin Microhardness and Fracture Resistance: An study.

Acta Stomatol Croat 2021 Sep;55(3):291-301

Department of Oral and Maxillofacial Sciences, Sapienza University, University of Rome, Italy.

Objectives: The aim of this research was to evaluate the effect of long-term use of three intracanal medicaments on the radicular dentin microhardness and fracture resistance.

Material And Methods: A chemomechanical preparation was done using the Protaper rotary instruments up to F3. The teeth were stored in an incubator at 37°C at 100% humidity and were categorized in three groups by random allocation, namely: Triple Antibiotic Paste (TAP), Calcium hydroxide paste (Apexcal) and Ledermix. Following medicament application, the access openings of all teeth were sealed with 4 mm thickness of cavit. The samples were stored for periods of 1 week, 1 month and 3months. Two dentin cylinders measuring 5mm and 3mm were obtained from each sample. The cervical third was used for fracture resistance and the middle third was used for micro hardness evaluation. The microhardness testing was done using a Knoop microhardness tester, and the fracture resistance testing was done using the universal testing machine.

Results: Calcium hydroxide showed maximally negative effect on the physical properties of radicular dentin compared to TAP (p= 0.0100 at one month and Ledermix (p=0.0001 at one month). With an increase in the application time, there was an increased deterioration in the physical properties of radicular dentin.

Conclusion: Long-term placement of calcium hydroxide, Triple Antibiotic Paste, and Ledermix (p= 0.0001at 3 months) significantly affects the microhardness and fracture resistance of radicular dentin.
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http://dx.doi.org/10.15644/asc55/3/6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8514225PMC
September 2021

An Update of the Possible Applications of Magnetic Resonance Imaging (MRI) in Dentistry: A Literature Review.

J Imaging 2021 Apr 21;7(5). Epub 2021 Apr 21.

Department of Oral and Maxillofacial Sciences, Sapienza University of Rome, 00161 Rome, Italy.

This narrative review aims to evaluate the current evidence for the application of magnetic resonance imaging (MRI), a radiation-free diagnostic exam, in some fields of dentistry.

Background: Radiographic imaging plays a significant role in current first and second level dental diagnostics and treatment planning. However, the main disadvantage is the high exposure to ionizing radiation for patients.

Methods: A search for articles on dental MRI was performed using the PubMed electronic database, and 37 studies were included. Only some articles about endodontics, conservative dentistry, implantology, and oral and craniofacial surgery that best represented the aim of this study were selected.

Results: All the included articles showed that MRI can obtain well-defined images, which can be applied in operative dentistry.

Conclusions: This review highlights the potential of MRI for diagnosis in dental clinical practice, without the risk of biological damage from continuous ionizing radiation exposure.
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http://dx.doi.org/10.3390/jimaging7050075DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8321370PMC
April 2021

Using the Exploratory Sequential Mixed Methods Design to Investigate Dental Patients' Perceptions and Needs Concerning Oral Cancer Information, Examination, Prevention and Behavior.

Int J Environ Res Public Health 2021 07 16;18(14). Epub 2021 Jul 16.

Department of Maxillofacial Surgery and Diagnostic Sciences, Division of Oral Pathology, College of Dentistry, Jazan University, Jazan 45142, Saudi Arabia.

Objectives: The objective of this study was to investigate dental patients' behavior, thoughts, opinions and needs for oral cancer information, and dentists' behavior regarding prevention and examination of oral cancer.

Materials And Methods: This study utilized an exploratory sequential mixed methods design. Semi-structured interviews with open-ended questions were conducted for forty dental patients of both sexes. Based on the qualitative analysis, a structured questionnaire was developed and distributed among the participants. Data were analyzed for 315 participants to quantify their thoughts, needs, behavior and behavior expected from dentists regarding oral cancer. Frequency, percentages and cumulative percentages were calculated.

Results: This study reveals that patients' oral cancer knowledge levels were adequate, but most reported that their dentist had never examined them for oral cancer. Additionally, the participants had never performed self-examinations for oral cancer, nor were they aware of the possibility of doing so. Participants showed a preference for being examined and educated by their dentist about oral cancer and believed it would help early detection.

Conclusions: The study participants are aware of oral cancer and its risk factors. The practice of oral cancer examinations and patient education of its risk factors by dental practitioners is limited. Patients feel a need for more attention to be paid to oral cancer examinations, preventive measures and targeted information on oral cancer risk factors.
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http://dx.doi.org/10.3390/ijerph18147562DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8307210PMC
July 2021

Angle of Insertion and Torsional Resistance of Nickel-Titanium Rotary Instruments.

Materials (Basel) 2021 Jul 4;14(13). Epub 2021 Jul 4.

Department of Oral and Maxillo-Facial Sciences, Sapienza University of Rome, 00161 Rome, Italy.

Previously published studies have investigated the influence of instrument access on cyclic fatigue resistance. However, no studies have evaluated the relationship between angulated access and torsional resistance. The aim of this study was to investigate the influence of the angle of access on the torsional resistance of endodontic instruments. One hundred and eighty instruments were selected: 90 F-One Blue 25/04 and 90 HeroShaper 25/04 instruments. Three subgroups ( = 30) for each instrument type (A and B) were established according to the angle of insertion of the instruments inside the artificial canal (0°, 10° and 20°). The tests were performed using a custom-made device consisting of the following: a motor that can record torque values of 0.1 s; interchangeable stainless-steel canals with different curvature (0°, 10° and 20°) that allow the instrument's angulated insertion and keep it flexed during testing procedures; and a vise used to secure the instrument at 3 mm from the tip. Torque limit was set to 5.5 Ncm, and each instrument was rotated at 500 rpm until fracture occurred. Torque to fracture (TtF) was registered by the endodontic motor, and the fragment length (FL) was measured with a digital caliper. Fractographic analysis was performed using a scanning electron microscopy (SEM) evaluation to confirm the cause of failure. TtF values and fragment length (FL) values were statistically analyzed using one-way analysis of variance (ANOVA) test and the Bonferroni correction for multiple comparisons across the groups with significance set to a 95% confidence level. Regarding the F-One Blue instruments, the results showed a higher TtF for group A3 (20°) than for group A1 (0°) and group A2 (10°), with a statistically significant difference between group A3 and the other two groups ( < 0.05), whereas no statistically significant difference was found between group A1 and group A2 ( > 0.05). Regarding the HeroShaper instrument, the results showed the highest TtF for group B3, with a statistically significant difference between the three subgroups B1, B2 and B3 ( < 0.05). The results showed that the torsional resistance increases as the angle of instrument access increases with a varying intensity, according to the crystallographic phase of the instrument selected.
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http://dx.doi.org/10.3390/ma14133744DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8269838PMC
July 2021

Five Years Follow-up of Short Implants Placed in Atrophic Maxilla with Simultaneous Sinus Floor Transcrestal Elevation.

Acta Stomatol Croat 2021 Jun;55(2):177-185

Department of Oral and Maxillo-Facial Sciences, "Sapienza" University of Rome, Italy.

Objective: Many authors have tried to face the anatomical limitations resulting from maxillary bone atrophy. Up to five millimeters bone height, the lateral sinus floor elevation is the most commonly used and validated strategy to achieve the prosthetic rehabilitation. However, the disadvantages of this technique are its invasiveness and delayed rehabilitation. The aim of this paper was to assess 5 years clinical outcome of implants placed with a technique that allows the percrestal sinus floor elevation and the immediate implant placement.

Materials And Methods: 30 transcrestal sinus floor elevations with immediate implant placement were performed in severely atrophic maxillae. Implant survival, marginal bone level variation, harvested bone height variation and periodontal indices were assessed.

Results: After a five year follow up none of the thirty implants were lost. The mean value of vertical harvested bone loss was 5%. The mean crestal bone loss was -0.33 mm (Standard Deviation (SD) 0.11 mm). The mean value of periodontal indices was respectively: PD 1.22 mm (SD 0.72 mm), PI 17.47% (SD 15.01 mm), BOP 9, 87%.,(SD 19.17 mm).

Conclusion: The results obtained are comparable with success criteria in implant rehabilitation. The reported technique proved to be successful in the population observed, with minimal trauma and reduced invasiveness.
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http://dx.doi.org/10.15644/asc55/2/7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8255046PMC
June 2021

Application and Performance of Artificial Intelligence Technology in Oral Cancer Diagnosis and Prediction of Prognosis: A Systematic Review.

Diagnostics (Basel) 2021 May 31;11(6). Epub 2021 May 31.

Department of Maxillofacial Surgery and Diagnostic Sciences, Division of Oral Pathology, College of Dentistry, Jazan University, Jazan 45142, Saudi Arabia.

Oral cancer (OC) is a deadly disease with a high mortality and complex etiology. Artificial intelligence (AI) is one of the outstanding innovations in technology used in dental science. This paper intends to report on the application and performance of AI in diagnosis and predicting the occurrence of OC. In this study, we carried out data search through an electronic search in several renowned databases, which mainly included PubMed, Google Scholar, Scopus, Embase, Cochrane, Web of Science, and the Saudi Digital Library for articles that were published between January 2000 to March 2021. We included 16 articles that met the eligibility criteria and were critically analyzed using QUADAS-2. AI can precisely analyze an enormous dataset of images (fluorescent, hyperspectral, cytology, CT images, etc.) to diagnose OC. AI can accurately predict the occurrence of OC, as compared to conventional methods, by analyzing predisposing factors like age, gender, tobacco habits, and bio-markers. The precision and accuracy of AI in diagnosis as well as predicting the occurrence are higher than the current, existing clinical strategies, as well as conventional statistics like cox regression analysis and logistic regression.
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http://dx.doi.org/10.3390/diagnostics11061004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8227647PMC
May 2021

Viability of Quercetin-Induced Dental Pulp Stem Cells in Forming Living Cellular Constructs for Soft Tissue Augmentation.

J Pers Med 2021 May 18;11(5). Epub 2021 May 18.

Department of Maxillofacial Surgery and Diagnostic Sciences, Division of Oral Pathology, College of Dentistry, Jazan University, Jazan 45142, Saudi Arabia.

Autogenous gingival grafts used for root coverage or gingival augmentation procedures often result in donor site morbidity. Living cellular constructs as an exogenous alternative have been proven to be associated with lower morbidity. With the available background information, the present study aims to assess if quercetin-induced living cell constructs, derived from dental pulp stem cells, have the potential to be applied as a tool for soft tissue augmentation. The characterized dental pulp stem cells (positive for CD73, CD90, and negative for CD34, HLA-DR) were expanded in Dulbecco's Modified Eagle's medium (DMEM) supplemented with 10 mM quercetin. The handling properties of the quercetin-induced dental pulp stem cell constructs were assessed by visual, and tactile sensation. A microscopic characterization using hematoxylin and eosin staining, and qRT-PCR-based analysis for stemness-associated genes (OCT4, NANOG, SOX2, and cMyc) was also performed. Dental pulp stem cells without quercetin administration were used as the control. Dental pulp stem cell constructs induced by quercetin easily detached from the surface of the plate, whereas there was no formation in the control cells. It was also simple to transfer the induced cellular construct on the flattened surface. Microscopic characterization of the constructs showed cells embedded in a tissue matrix. Quercetin also increased the expression of stemness-related genes. The use of quercetin-induced DPSC living constructs for soft tissue augmentation could provide an alternative to autogenous soft tissue grafts to lower patient morbidity and improve esthetic outcomes.
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http://dx.doi.org/10.3390/jpm11050430DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8158115PMC
May 2021

Psychological Distress among Undergraduate Dental Students in Saudi Arabia and Its Coping Strategies-A Systematic Review.

Healthcare (Basel) 2021 Apr 7;9(4). Epub 2021 Apr 7.

Department of Maxillofacial Surgery and Diagnostic Sciences, Division of Oral Pathology, College of Dentistry, Jazan University, Jazan 44512, Saudi Arabia.

The objective of this paper was to evaluate the studies that have reported on psychological issues among dental students in Saudi Arabia and to develop coping strategies to overcome these mental health-related issues. The present systematic review is in accordance with the guidelines for Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The search for the articles was carried out in the electronic databases by four independent researchers. The data search was performed in the electronic search engines like PubMed, Google Scholar, Web of Science, Scopus, Medline, Embase, Cochrane and Saudi Digital Library for scientific research articles published from January 2000 until December 2020. STROBE guidelines were adopted for qualitative analysis of six articles which met the eligibility criteria. The analysis of the literature revealed that most of the studies included were conducted in the past 8 years in different regions of Saudi Arabia. Findings of this systematic review clearly state that dental students in Saudi Arabia experience higher levels of depression, stress and anxiety and stress during their education period, with a higher stress for female students compared to male students. There is an urgent need to introduce interventional programs and preventive strategies to overcome the long-term effects.
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http://dx.doi.org/10.3390/healthcare9040429DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8068084PMC
April 2021

A Paradigm Shift for Torsional Stiffness of Nickel-Titanium Rotary Instruments: A Finite Element Analysis.

J Endod 2021 Jul 27;47(7):1149-1156. Epub 2021 Apr 27.

Department of Oral and Maxillo-Facial Sciences, Sapienza University of Rome, Rome, Italy.

Introduction: The aim of this study was to investigate the influence of mass and the polar moment of inertia on the torsional behavior of nickel-titanium rotary instruments to understand which parameter of cross-sectional design had a key role in terms of torsional resistance.

Methods: Four different instrument models were designed and meshed using computer-aided engineering software (SolidWorks; Dassault Systems, Waltham, MA). Instrument models shared the same characteristics, except for cross-sectional design; triangle, rectangle, square, and hollow square geometry was selected. Finite element analysis was performed simulating a static torsional test using the FEEPlus internal solver (Solid Works). Von Mises stress and torsional load at fracture were calculated by the software. Linear regression analysis was performed to investigate the relationship of the polar moment of inertia, cross-sectional area, inner core radius, and mass per volume on the torsional resistance of nickel-titanium rotary instruments.

Results: The polar moment of inertia positively affected the maximum torsional load with the highest level of correlation (R = 0.917). It could be stated that the higher the polar moment of inertia is, the more maximum torsional load at fracture is present. Mass and cross-sectional area had a lower level of correlation compared with the polar moment of inertia (R = 0.5533). According to this, 2 instruments with the same mass/mm and/or cross-sectional area could have different torsional resistance.

Conclusions: The polar moment of inertia can be considered as the most important cross-sectional factor in determining the torsional resistance of rotary instruments over metal mass and cross-sectional area.
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http://dx.doi.org/10.1016/j.joen.2021.04.017DOI Listing
July 2021

Influence of shaft length on torsional behavior of endodontic nickel-titanium instruments.

Odontology 2021 Jul 27;109(3):568-573. Epub 2020 Nov 27.

Department of Oral and Maxillo-Facial Sciences, "La Sapienza" University of Rome, Via Caserta 6, 00161, Rome, Italy.

Torsional stresses are one of the most frequent causes of intracanal separation of nickel-titanium endodontic instruments, which represents a great concern of endodontists. For this reason, torsional resistance of rotary instruments has been deeply investigated by determining all parameters that can influenced it, that can be summarized in: (1) Tooth-related factors, (2) Strategy-related factors and (3) Instrument-related factors. This study was conducted to examine the influence of shaft length on torsional resistance of a nickel-titanium rotary instrument and if it should be considered as an Instrument-related factor. With this aim, 120 Twisted Files Adaptive M-L (TFA M-L) NiTi instruments (SybronEndo, Orange, CA, USA) were divided into 6 experimental groups (n = 20), according to instruments length and size: Group 1, 20 TFA M-L1 25/08 23 mm; Group 2, 20 TFA M-L1 25/08 27 mm; Group 3, 20 TFA M-L2 35/06 23 mm; Group 4, 20 TFA M-L2 35/06 27 mm; Group 5, 20 TFA M-L3 50/04 23 mm; and Group 6, 20 TFA M-L3 50/04 27 mm. All instruments were submitted to a static torsional test, blocking each instrument at 3 mm from the tip and rotating it until its fracture. Torque to Fracture (TtF) and fragments length were registered and all data were statistically analyzed. Results showed that Groups 2, 4 and 6 had a higher TtF, respectively, than Groups 1, 3 and 5, which differ from the former just for shaft length. Group 6 showed the highest torsional resistance (1.31 ± 0.08 Ncm), whilst Group 1 the lowest (0.40 ± 0.08 Ncm). According to that, it can be stated that the longer the instrument, the higher the torsional resistance is, proving that shaft length should be considered as an important factor about torsional resistance.
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http://dx.doi.org/10.1007/s10266-020-00572-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8178130PMC
July 2021

Effect of Flexural Stress on Torsional Resistance of NiTi Instruments.

J Endod 2021 Mar 21;47(3):472-476. Epub 2020 Oct 21.

Department of Oral and Maxillo-Facial Sciences, Sapienza University of Rome, Rome, Italy.

Introduction: Previously published studies have deeply investigated the characteristics of flexural and torsional resistance of nickel-titanium rotary instruments, but none of them investigated the relationship between the 2 stresses. The objective of the present study was to evaluate the influence of flexural stresses over torsional resistance.

Methods: Sixty S-One 20.04 files (Fanta Dental, Shanghai, China) were used in the present study (N = 60) and divided into 3 test groups of 20 files. A customized device made of a mobile structure with a connection that holds the handpiece and the artificial canal was used for the experiment to make the measurements repeatable. The artificial canals were created with a 90° curvature, a 60° curvature, and lastly a straight canal. Each file was rotated at 300 rpm with a maximum torque value of 5.5 Ncm with the apical 2 mm firmly secured in a vise. The torque at fracture and the time to fracture were recorded by the software integrated in the handpiece and evaluated through statistical analysis.

Results: Statistical analysis found significant differences in the values of torque to fracture (TtF) between these 3 groups (P < .05). The 90° curved canal group showed the highest TtF value, and the 60° curved canal group showed a higher TtF value than the straight canal group.

Conclusions: The results of the present study demonstrated a positive influence of flexural stresses over torque at fracture of rotary files. When nickel-titanium instruments were used in a 90° or 60° curvature, the values of torque at fracture increased compared with the same instruments that rotated in the straight canal.
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http://dx.doi.org/10.1016/j.joen.2020.10.011DOI Listing
March 2021

Possible Complications of Endodontic Treatments.

J Contemp Dent Pract 2020 May 1;21(5):473-474. Epub 2020 May 1.

Department of Oral and Maxillofacial Sciences, Sapienza University of Rome, Rome, Italy, Phone: +39 338 1504134, e-mail:

Endodontic treatments tend to have very high successful rates in spite of the fact that they are quite an invasive, difficult procedure, especially in complex anatomies. Some complications can arise during or after a root canal procedure due to poor understanding of the anatomy and iatrogenic errors mainly during instrumentation. While some of these problems can be anticipated, many can never really be predicted. As a consequence, retreatment has become a well-defined field of knowledge and expertise in endodontics, since most complications can be solved with proper surgical or nonsurgical retreatments. Reinfection or persistent infections: Root canal treatment can fail due to a persistent bacterial infections or reinfections. These include inadequate shaping, cleaning, and obturation procedures, poor restorations, and exposure through a fracture. The remedies are dependent on the primary cause of the reinfection and the affected parts. Persistent infection is the major cause of short-term endodontic failures..
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May 2020

How to Improve Properties of Nickel-Titanium Rotary Instruments.

J Contemp Dent Pract 2020 Apr 1;21(4):351-352. Epub 2020 Apr 1.

Department of Oral and Maxillofacial Sciences, Sapienza University of Rome, Italy, Phone: +39 338 1504 134, e-mail:

In the last decades, the use of nickel-titanium (Ni-Ti) rotary instruments has become the most effective and popular method among endodontists for shaping root canals, even if there are still concerns regarding the increased risks of intracanal breakage or weakening of the instruments. So manufacturers started to modify the cross-sectional geometrical aspects of the files in order to improve their resistance to torsional and cyclic fatigue. Design is a major feature in determining instruments' properties including cutting efficiency, removal of debris, stresses generated during instrumentation, and the relative resistance to these stresses; however, a perfect design is not existing and any change in design is likely to provide some advantages but also some disadvantages..
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April 2020
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