Journal Pre-proof

Evaluation of Passive Ultrasonic Irrigation and GentleWave system as adjuvants in

endodontic retreatment

Bruno Monguilhott Crozeta, DDS, MSc, PhD, Letícia Chaves de Souza, Yara
Teresinha Correa Silva-Sousa, DDS, MSc , PhD, Manoel D. Sousa-Neto, DDS, MSc,
PhD, David Enrique Jaramillo, DDS, Renato Menezes Silva, DDS, MS, PhD
PII: S0099-2399(20)30389-7
DOI: https://doi.org/10.1016/j.joen.2020.06.001
Reference: JOEN 4569

To appear in: Journal of Endodontics

Received Date: 2 April 2020

Revised Date: 31 May 2020
Accepted Date: 4 June 2020

Please cite this article as: Crozeta BM, de Souza LC, Correa Silva-Sousa YT, Sousa-Neto MD, Jaramillo
DE, Silva RM, Evaluation of Passive Ultrasonic Irrigation and GentleWave system as adjuvants in
endodontic retreatment, Journal of Endodontics (2020), doi: https://doi.org/10.1016/j.joen.2020.06.001.

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Copyright © 2020 Published by Elsevier Inc. on behalf of American Association of Endodontists.

Evaluation of Passive Ultrasonic Irrigation and GentleWave system as
adjuvants in endodontic retreatment

Bruno Monguilhott Crozeta, DDS, MSc, PhD 1, Letícia Chaves de Souza 2, Yara
Teresinha Correa Silva-Sousa, DDS, MSc 3, PhD; Manoel D. Sousa-Neto, DDS,
MSc, PhD 4, David Enrique Jaramillo DDS 2, Renato Menezes Silva, DDS, MS, PhD 2

1
Department of Endodontics, Barretos University, SP, Brazil.
2
Department of Endodontics, School of Dentistry, University of Texas Health Science
Center at Houston, Houston, TX, USA.
3
University of Ribeirão Preto, Ribeirão Preto, SP, Brazil.
4
Department of Restorative Dentistry, School of Dentistry of Ribeirão Preto,
University of São Paulo, Brazil

Acknowledgement

Dr. David E. Jaramillo is a consultant for Sonendo Inc. All other authors (BMC; LCS,
YTCSS, MDSN and RMS) deny any conflicts of interest related to this study.

Key words: Endodontic retreatment; ultrasonic instruments, GentleWave system

Corresponding author:
Renato M Silva
Department of Endodontics,
School of Dentistry, University of Texas Health Science Center at Houston
7500 Cambridge Street, Suite 6411, Houston, TX, 77054, US
713- 486-4228 (office), 713- 486-0402 (fax), renato.m.silva@uth.tmc.edu
 1 ABSTRACT

2 Introduction: Nonsurgical endodontic retreatment continues to be a

3 challenge in endodontics, particularly when dealing with a complex tooth

4 anatomy. This study evaluated the efficacy of passive ultrasonic irrigation

5 (PUI) and the GentleWave system as supplementary techniques to remove

6 remaining filling materials from oval-shaped root canals.

7 Methods: Twenty distal roots of human mandibular molars with single and

8 oval-shaped canals were shaped with an R40 (40.06) instrument and filled

9 with gutta-percha and AHPlus sealer using warm-vertical obturation. Initial

10 filling material removal was performed with a R50 (50.05) instrument followed

11 by the use of PUI (n=10) or GentleWave system (n=10). Microcomputed

12 tomographic images were obtained after obturation, initial material removal

13 and after the use of PUI and GentleWave. The volume of remaining filling

14 material was calculated for the entire canal as well as for the coronal, middle

15 and apical thirds. Statistical analyses were performed using ANOVA, Kruskal-

16 Wallis and Mann-Whitney tests. P≤0.05 was considered significant.

17 Results: The use of PUI and GentleWave as supplementary techniques

18 significantly reduced the volume of remaining filling material after initial

19 instrumentation (P<0.05). However, none of these techniques was able to

20 render canals free from filling materials. PUI showed better performance by

21 removing 18% of the remaining filling material while The GentleWave system

22 was able to remove approximately 10% (P=0.02).

23 Conclusions: The use of supplementary techniques optimized filling material

24 removal after initial instrumentation. PUI enhanced the overall cleaning of the

25 root canal system during endodontic retreatment in oval-shaped canals.

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26

27 Key words: Endodontic retreatment; GentleWave system; Ultrasonic

28 Instruments; PUI, microcomputed tomographic (micro-CT)

29

30 INTRODUCTION

31 Nonsurgical endodontic retreatment is considered a good treatment

32 option when endodontic therapy fails. Persistence of microorganisms within

33 the root canal system, inadequate root canal filling and coronal restoration are

34 listed as main causes of treatment failure (1-3).

35 Endodontic retreatment aims to establish a favorable environment for

36 periapical healing through the complete removal of the existing filling

37 materials, debris and microorganisms (4-6). However, complete removal of

38 endodontic filling materials from the root canal system is still considered one

39 of the main challenges in endodontics (7).

40 Hand and mechanized instruments with different cross-section

41 designs, alloys and kinematics (5, 8-13), lasers (14), sonic and ultrasonic

42 devices (9, 15-17) have been proposed to optimize the removal of filling

43 materials during retreatment procedures, however current techniques and

44 instruments are still unable to render canals completely free from filling

45 materials (12, 18, 19).

46 Endodontic retreatment seems to be more complicated particularly

47 when dealing with a complex tooth anatomy (20). While endodontic

48 instruments may effectively remove root fillings material from straight, narrow

49 canals with round cross-sections, studies have emphasized the inability of

50 these instruments to touch the flattening polar areas in oval shaped canals

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51 (7,11). In addition, endodontic instruments may also push residual materials

52 and debris to these polar areas resulting in poor treatment outcomes.

53 The GentleWave (Sonendo Inc, Laguna Hills, CA) is a new irrigation

54 system developed to clean the root canal with minimal shaping procedures

55 (21). It creates a strong hydrodynamic cavitation that generates a broad

56 spectrum of sound waves within the degassed fluid inside the tooth (22).

57 Recently, it was suggested that the GentleWave system may be considered a

58 good option for endodontic retreatment (21).

59 This study evaluated the efficacy of passive ultrasonic irrigation and the

60 GentleWave system as supplementary techniques to remove remaining filling

61 materials from oval-shaped root canals.

62

63 MATERIALS AND METHODS

64 Samples selection

65 After Institutional Ethics Committee approval (66941817.1.0000.5419),

66 sixty extracted human mandibular molars were selected from a tooth bank

67 and evaluated clinically and radiographically for the presence of a patent

68 single distal canal with no internal calcifications and no previous endodontic

69 treatment. Microcomputed tomographic (micro-CT) images (SkyScan 1176;

70 Bruker-microCT, Kontich, Belgium) were obtained to determine the distal

71 canal morphology and to select oval canals. All images acquisition used the

72 following parameters: 90 kV, 276 mA, isotropic resolution of 16.7μm, 180°.

73 The NRecon software v.1.6.6.0 (Buker-microCT) was used for the

74 reconstruction of the axial sections, followed by the confirmation of a single

75 canal with CTAn software v.1.14.4.1 (Bruker-microCT).

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 76 The larger and smaller root canal diameter were obtained at 2 and 5

77 mm from the apical foramen using the Individual Object Analysis (2D space)

78 tool (23, 24). Twenty mandibular molars with a distal root length measuring

79 approximately 15mm from the cementoenamel junction (CEJ) to the root apex

80 and with oval distal canals (following the ratio larger diameter/ smaller

81 diameter between 1.5 - 2.0mm and circularity between 0.45 – 0.60mm) were

82 selected for this study.

83 SigmaPlot 11.0 statistical software (Systat Software Inc., San Jose,

84 CA) was used for sample size calculation with a minimum detectable

85 difference between means of 0.40 and coefficient of variation of 0.20 (based

86 on a pilot study). Considering a probability level of α = 0.05 and statistical

87 power = 0.8, the estimated minimum sample size was determined to be six

88 specimens per group. With 20 teeth previously selected, n=10 was used per

89 supplementary technique group (PUI or GentleWave system).

90

91 Endodontic treatment procedures

92 A board-certified endodontist (BC) was responsible for all

93 treatment/retreatment procedures in order to eliminate inter-operator

94 variability. All endodontic procedures were performed with the aid of an

95 operating microscope (Global Surgical A-SeriesTM Corporation, Saint Louis,

96 USA). In this study tooth crowns were not removed because the GentleWave

97 system requires the presence of a tooth crown to work properly. After access

98 cavity preparation, the root canals were rinsed with 1.5 ml of 2.5% sodium

99 hypochlorite using a syringe with a 27-G NaviTip needle (Ultradent Inc., South

100 Jordan, UT). Apical patency was determined by inserting a size 10 K-

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101 instrument (Dentsply Maillefer, Ballaigues, Switzerland) into de root canal until

102 the tip was visible at the apical foramen. The working length (WL) was

103 determined to be 0.5 mm short of this measurement.

104 In oval distal canals of mandibular molars, the median canal diameter

105 (in mm) at 1mm and 2 mm from the apex are 0.46mm and 0.50mm (Buccal-

106 Lingual) and 0.35mm and 0.34 mm (Mesial - Distal) (25). All canals were

107 shaped with Reciproc R40 (40/06) instruments (VDW GmbH, Munich,

108 Germany) used with in-and-out movements (3 mm amplitude) by using the

109 ‘reciproc all’ mode in an electric motor (VDW Silver, VDW GmbH). After three

110 pecking motions, the instrument was removed from the canal and cleaned

111 with an alcohol pad. The irrigation needle was inserted 1 mm short of the WL

112 and the canals were irrigated with 2.5 mL of 2.5% NaOCl, followed by a final

113 irrigation with 2 ml of 17% EDTA (Ultradent, South Jordan, UT, USA) for 5

114 minutes and 2 ml distilled water for 1 minute. Next, the canals were dried with

115 Reciproc R40 paper points (VDW) and filled with Reciproc R40 gutta-percha

116 points (VDW) and AH Plus sealer (Dentsply De Trey, Konstanz, Germany)

117 using warm vertical obturation technique. Periapical radiographs in ortho-

118 radial and mesiodistal directions were used to ensure consistency of the root

119 filling procedure and absence of voids in all samples. Access cavities were

120 sealed with composite resin (PermaFlo Purple, Ultradent). The specimens

121 were stored in 100% humidity at 37ºC for 2 weeks.

122

123 Initial μ-CT scanning (Initial μ-CT)

124 After root canal obturation, all roots were scanned using the 1176

125 SkyScan μ-CT (Bruker micro-CT) at 90 kV, 276 mA, 8.6 µm isotropic

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126 resolution, 360° rotation around vertical axis, 0.7° rotation pitch, total amount

127 of 4 frames, with 0.1 mm thick copper filter. The two-dimensional images were

128 reconstructed using the NRecon v.1.6.6.0 software. The CTAn v.1.14.4.1 +

129 software was used for image processing and analysis, determining the area of

130 filling material between the cementoenamel junction (CEJ) and the anatomical

131 apex of the distal root. The volume of the filling material (mm3) for the entire

132 root canal system as well as from the different root thirds (coronal, middle and

133 apical) were obtained by using the 3D analysis tool.

134

135 Endodontic Retreatment Procedures

136 A Reciproc 50.05 instrument (VDW) was introduced into the canal until

137 resistance of the filling material was felt and then activated in reciprocating

138 motion generated by a 6:1 contra-angle handpiece (Sirona, Bensheim,

139 Germany) powered by an electric motor (VDW Silver). The instrument was

140 moved in the apical direction by using light pressure with an in-and-out

141 pecking motion with approximately 3 mm amplitude and combined with

142 brushing action against the root canal walls. After 3 pecking motions, the

143 instrument was removed from the canal and carefully cleaned with an alcohol

144 pad. These procedures were repeated until the instrument reached WL and

145 when there was no evidence of filling material on the instrument. Irrigation

146 was performed with 5 mL of 2.5% NaOCl using a disposable syringe and a

147 NaviTip 30-G needle (Ultradent) positioned 1 mm from the WL. Debris

148 aspiration was performed with micro-cannulas using high-volume suction.

149

150

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151 Intermediate μ-CT scanning (R50 μ-CT)

152 After initial filling material removal with reciproc instruments, an

153 intermediate μ-CT scanning was obtained (R50 μ-CT), with the same

154 parameters previously described for the initial μ-CT scanning. From the

155 volume values of root canal obturation (Initial μ-CT) and after initial material

156 removal with R50 instruments (R50 μ-CT), the partial volume (%) of the

157 remaining filling material was obtained for the entire canal and also for the

158 coronal, middle and apical root thirds. Once all μ-CT readings were originally

159 obtained in mm3, the equation (R50 μ-CT %= R50 μ-CT x100/Initial μ-CT) was

160 used to calculate filling materials % volumes inside the canals.

161 For the qualitative analysis of the presence and location of the

162 remaining filling material, DataViewer v.1.5.1.2 (Bruker-microCT) and CTVol

163 v.2.2.3.0 (Bruker-microCT) software were used for two- and three-dimensional

164 evaluation, respectively.

165 Once the volume (%) of the remaining filling material was determined

166 for all 20 samples, data was analyzed using One-Way ANOVA (P> 0.05),

167 which confirmed similar content of remaining filling material volume (%) in all

168 teeth. Twenty samples were divided in two subgroups (n = 10) according to

169 the supplementary technique to be used.

170

171 Supplementary Techniques

172 Prior to the implementation of the supplementary techniques the root

173 apex of each teeth (n=20) was sealed using a hot glue to create a closed root

174 canal system as previously described (26).

175

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176 Passive Ultrasonic Irrigation Group (n=10)

177 The E1-Irrisonic Power ultrasonic instrument (size 20, 0.01 taper; no cutting

178 blades; Helse Ultrasonic, Orlando, FL, US) was used in an ultrasonic unit (P5

179 XS Bled Newtron; Satelec Acteon, Mérignac, France) and inserted into the

180 root canal 2 mm short from the WL and then activated for 30s at 30% power.

181 According to the manufacturer, 30% power is enough to promote debris

182 removal from root canal walls avoiding instrument breakage. When using an

183 ultrasonic insert, changes in generator power (low, medium, high) will change

184 the length, or amplitude, of the oval/elliptical produced at the insert tip, but not

185 number of cycles per second.

186 This procedure was repeated three times. In the first and third cycles, 5

187 ml of 3% NaOCl was used. In the second cycle, 5 ml of 17% EDTA was used.

188 A final flush was performed using 5 ml of distilled water.

189

190 GentleWave Group (n=10)

191 The SoundSeal composite material (Sonendo) was used to create an

192 occlusal platform according to manufacturer’s instructions. The GentleWave

193 machine was set to the retreatment procedure, which consisted of irrigation

194 with 3% NaOCl for 5 minutes, followed by water rinse for 30 seconds, 8%

195 EDTA for 2 minutes and a final water rinse for 30 seconds. According to the

196 manufacturer, there is approximately 50 mL fluid delivered per minute.

197

198 Final Micro-CT Scanning

199 After supplementary techniques, all specimens were scanned using the

200 previously described parameters, reconstruction, processing and analysis.

8
201 The capacity of root filling material removal (%) was quantified considering the

202 entire root canal length as well as coronal, middle and apical root thirds

203 (approximately 5 mm each).

204

205 Scanning electron microscope (SEM) analysis

206 SEM was used to verify the presence of remaining filling materials on

207 dentin walls and also to verify the exposure and cleanliness of dentin tubules.

208 Each tooth (n=20) was sectioned longitudinally by using a diamond disc. Both

209 root halves were dehydrated at 37 °C for 7 days and sputter coated with gold

210 (Bal-Tec, SCD 050 Sputter Coater, Fürstentum, Liechtenstein). Images of the

211 coronal, middle and apical thirds of all roots were obtained using SEM (Zeiss,

212 EVO 50, Cambridge, UK) at 10–20.000 kV and with standard magnification of

213 2000X. The SEM images were scored by two blinded/calibrated evaluators

214 following the criteria previously described in the literature (9): Score 0 – more

215 than 75% of the tubules were visibly exposed; Score 1 – remaining filling

216 material/smear layer present with less than 75% of tubules visibly exposed;

217 Score 2 – remaining filling material/smear layer present in a limited area with

218 less than 50% of tubules visibly exposed; Score 3 – The majority of the

219 dentine covered with remaining filling material/smear layer with no visible

220 dentin tubules (Figure 2).

221

222 Statistical Analysis

223 For the Micro-CT evaluation, data was analyzed for normal distribution

224 (Shapiro-Wilk) and homogeneity of variance (Levene test), which indicated

225 the use of Mann-Whitney test to compare the efficacy of remaining filling

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226 material removal (both intragroup and when comparing supplementary

227 technique groups). Kruskal-Wallis was used to compare the percentage of

228 filling material removal between coronal, middle and apical thirds. Statistical

229 tests were performed using SigmaPlot 11.0 software (Systat Software, Inc.,

230 Chicago, IL, USA). Significance level was set to 0.05.

231 Intra-examiner agreement (SEM analysis) was obtained by two

232 consecutive readings performed in a two weeks interval. Intra-examiner

233 calibration and inter-examiner agreement were verified using the Kappa test.

234 The intra-examiner and inter-examiner concordances evaluated by the kappa

235 test showed satisfactory values of 0.778, 0.799 and 0.788, respectively.

236 Scores were submitted to a normality test that indicated the use of

237 nonparametric tests. Kruskal-Wallis and Dunn’s multiple comparison tests

238 were used to compare the SEM scores for each third within the retreatment

239 groups. Mann-Whitney test was used to compare the efficacy of the

240 retreatment techniques in the different thirds. Statistical tests were performed

241 using GraphPad Prism 6 (GraphPad Software Inc., La Jolla, CA). Significance

242 level was set to 0.05.

243

244 RESULTS

245 The volume (%) of remaining root canal filling material after endodontic

246 retreatment with the instrument R50 showed to be similar in all teeth. Samples

247 were equally distributed into the two supplementary technique testing groups.

248 The intragroup analysis showed that both the GentleWave system

249 (P=0.03) and PUI (P=0.02) were able to reduce the remaining filling material

10
250 volume. However, none of these techniques completely removed all

251 remaining filling material from the root canal system.

252 The GentleWave system was able to remove approximately 10% of the

253 remaining filling material from the entire canal while PUI showed a better

254 performance by removing 18% (P=0.02). When considering the different root

255 thirds, the PUI provided greater removal of filling material when compared to

256 GentleWave in the middle (P=0.04) and apical thirds (P=0.03). No statistical

257 difference was observed between the tested groups in the coronal third

258 (P=0.2; Table 1). Qualitative analysis of the three-dimensional models and the

259 axial sections of the distal roots showed remaining filling material in all teeth,

260 regardless the supplementary technique employed (Figure 1).

261 SEM photomicrographs confirmed that regardless of the

262 supplementary technique, remnants of filling material with few exposed

263 dentinal tubules were present in all samples. There were no significant

264 differences between ultrasonic instruments and GentleWave system when

265 comparing the cleanliness of the coronal, middle and apical thirds (P>0.05).

266

267 DISCUSSION

268 In this study, we investigated the efficacy of two irrigant activation

269 systems, PUI and GentleWave, as adjuvants in the removal of remaining

270 filling materials from the root canal system during nonsurgical endodontic

271 retreatment procedures.

272 The use of ultrasonic instruments is well-accepted and has been

273 reported to improve the overall cleaning of the root canal system during

274 endodontic retreatment (7, 9, 10). The GentleWave system was designed to

11
275 enhance the overall root canal cleaning through strong hydrodynamic

276 cavitation (21, 22).

277 Nonsurgical endodontic retreatment is often challenging because no

278 instrument or technique can completely remove root canal filling materials

279 from the root canal system (7, 8, 11, 12, 16, 20, 27, 28). In oval-shaped root

280 canals, removing filling materials from the canal polar areas represents an

281 additional challenge (11, 15, 16, 20, 23). While supplementary retreatment

282 techniques may increase filling material removal, further research is

283 warranted (9, 14, 29).

284 The results of this study showed that both techniques improved

285 removal of remaining filling material from the root canal system, albeit not

286 completely. Whereas significant statistical difference was found between the

287 amount of filling material removed with PUI (18%) and GentleWave (10%)

288 (P=0.02), these differences may not translate into clinical significance.

289 Previous studies showed the effectiveness of ultrasonic activation after

290 initial filling material removal (9, 10, 17). The instrument vibration provides the

291 potential for additional mechanical debridement, which induces acoustic

292 streaming and cavitation bubbles, and ultimately, the displacement of

293 remaining material from the root canal walls (7, 9, 10, 17).

294 The GentleWave system produces strong hydrodynamic cavitation

295 generating a broad spectrum of sound waves within the degassed fluid with

296 different frequencies, which allows the solution to reach areas usually

297 untouched by endodontic instruments (22). The present study includes off-

298 label usage of the GentleWave Technology as it was not designed or intended

299 to be used to remove obturation material during endodontic retreatment.

12
300 However, it is approved by the U.S. Food and Drug Administration (FDA) as a

301 device to clean and disinfect root canal systems of retreatment cases after the

302 obturation material is removed. The fact that the ultrasonic energy can be

303 attenuated and absorbed in the presence of viscoelastic materials, such as

304 gutta-percha, may reduce its effectiveness in retreatment procedures (30, 31).

305 The effectiveness of the GentleWave system in endodontic retreatment

306 was recently reported (31). The GentleWave system was able to remove

307 more remaining filling material when compared to the use of EndoVac and

308 side-vented needles in mesial canals of mandibular molars. However, the

309 mesial canals of mandibular molars were shaped to a 20/.06 master apical

310 instrument while the present study used a 40/.06 master apical instrument,

311 suggesting a greater amount of filling material to be removed from the canals.

312 The micro-CT analysis was not able to measure the extent of smear

313 layer removal and the overall cleanliness of the dentinal tubules. Therefore,

314 we performed a SEM analysis in an attempt to detect and quantify filling

315 material and debris remaining inside the dentinal tubules (9). All thirds

316 showed remaining filling materials covering the dentin walls, with only a few

317 exposed dentinal tubules, regardless of the supplementary technique used.

318 Among the strengths of this study was the use of the use of micro-CT,

319 which allowed for equitable tooth selection of single and oval-shaped distal

320 canals (11, 24), thus minimizing the effects of variable root canal anatomy and

321 improving sample standardization (32). Further, micro-CT facilitated an equal

322 sample distribution between the experimental groups based on the remaining

323 volume of filling material. The limitations of this study include the difficulty in

13
324 standardization of irrigant volumes given that the GentleWave system delivers

325 approximately 50 mL of irrigation solution per minute.

326 The development of new techniques/protocols to enhance root canal

327 cleanliness during nonsurgical endodontic retreatment is needed to improve

328 treatment outcomes. The use of PUI and GentleWave as supplementary

329 techniques during endodontic retreatment in oval-shaped canals significantly

330 improved filling material removal after initial instrumentation. PUI enhanced

331 the overall cleaning of the root canal system.

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423 21. Haapasalo M, Wang Z, Shen Y, Curtis A, Patel P, Khakpour M. Tissue

424 dissolution by a novel multisonic ultracleaning system and sodium

425 hypochlorite. J Endod 2014; 40:1178-81.

426 22. Molina B, Glickman G, Vandrangi P, Khakpour M. Evaluation of Root

427 Canal Debridement of Human Molars Using the GentleWave System. J

428 Endod 2015; 41:1701-05.

429 23. Versiani MA, Leoni GB, Steier L, De-Deus G, Tassani S, Pecora JD, et

430 al. Micro-computed tomography study of oval-shaped canals prepared with

431 the self-adjusting file, Reciproc, WaveOne, and ProTaper universal systems. J

432 Endod 2013; 39:1060-66.

433 24. Wu MK, R'Oris A, Barkis D, Wesselink PR. Prevalence and extent of

434 long oval canals in the apical third. Oral Surg Oral Med Oral Pathol Oral

435 Radiol Endod 2000; 89:739-43.

436 25. Vertucci FJ. Root canals morphology and its relationship to endodontic

437 procedures. Endodontic Topics 2005; 10:3-29.

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438

439 26. Tay FR, Gu LS, Schoeffel GJ, Wimmer C, Susin L, Zhang K, et al.

440 Effect of vapor lock on root canal debridement by using a side-vented needle

441 for positive-pressure irrigant delivery. J Endod 2010; 36:745-50.

442 27. Akbulut MB, Akman M, Terlemez A, Magat G, Sener S, Shetty H.

443 Efficacy of Twisted File Adaptive, Reciproc and ProTaper Universal

444 Retreatment instruments for root-canal-filling removal: A cone-beam

445 computed tomography study. Dent Mater J 2016; 35:126-31.

446 28. Oltra E, Cox TC, LaCourse MR, Johnson JD, Paranjpe A. Retreatability

447 of two endodontic sealers, EndoSequence BC Sealer and AH Plus: a micro-

448 computed tomographic comparison. Restor Dent Endod 2017; 42:19-26.

449 29. Silva E, Belladonna FG, Zuolo AS, Rodrigues E, Ehrhardt IC, Souza

450 EM, et al. Effectiveness of XP-endo Finisher and XP-endo Finisher R in

451 removing root filling remnants: a micro-CT study. Int Endod J 2018; 51:86-91.

452 30. Siu C, Baumgartner JC. Comparison of the debridement efficacy of the

453 EndoVac irrigation system and conventional needle root canal irrigation in

454 vivo. J Endod 2010; 36:1782-85.

455 31. Wright CR, Glickman GN, Jalali P, Umorin M. Effectiveness of Gutta-

456 percha/Sealer Removal during Retreatment of Extracted Human Molars Using

457 the GentleWave System. J Endod 2019; 45:808-12.

458

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459 32. Solomonov M, Paqué F, Kaya S, Adigüzel O, Kfir A, Yiğ it-Özer S.

460 Self-adjusting files in retreatment: a high-resolution micro-computed

461 tomography study. J Endod 2012; 38:1283‐ 7.

462

463

464

465 FIGURE LEGENDS

466 Figure 1. Samples of three-dimensional models of oval shaped canals from

467 distal roots of human mandibular molars showing the initial (after root canal

468 obturation), intermediate (after initial removal with the reciprocating

469 instrument) and final (after supplementary approach with ultrasonic

470 instruments or GentleWave system) micro-CT images.

471

472 Figure 2. Scanning electron microscope photomicrographs of the root dentin

473 surface from coronal, middle and apical root canal thirds (2000X).

474

475

476
477
478
479
480
481

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482
483
484
485
486
487
488

489

490 Table 1. Median (interquartile range), volume (mm3) and percentage (%) of
491 filling material removal by GentleWave system and PUI.
492
GentleWave PUI p-value*
Third
mm³ % mm³ %

Coronal 0.05 (0.2) 10.8 (6.7) a 0.07 (0.1) 16.0 (33.1) a 0.29

Middle 0.06 (0.1) 8.0 (8.9) a 0.15 (0.2) 23.1 (14.7) a 0.04

Apical 0.01 (0.1) 3.6 (8.1) b 0.05 (0.1) 15.1 (18.5) a 0.03

Total 0.19 (0.3) 10.1 (8.4) 0.35 (0.2) 18.3 (8.6) a 0.02

493
494 * Mann-Whitney test
495 Different letters indicate statistical difference in the columns for the Kruskal-Wallis test (P
496 <0.05).
497

498
499
500
501
502
503
504
505

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506
507
508

509 Table 2. SEM analysis showing median (minimum and maximum) values of
510 the scores assigned for cleanliness of the root canal walls in the different
511 anatomical root thirds.
512
PUI GentleWave p-value*

Coronal 3 (1-3) 3 (1-3) 0.99

Middle 2 (1-3) 3 (1-3) 0.59

Apical 2 (2-3) 3 (2-3) 0.36

p-value* 0.7142 0.7967

513
514 * Kruskal-Wallis and Dunn’s multiple comparison tests

22
CRediT author statement

• Bruno Monguilhott Crozeta: Conceptualization; Methodology; Investigation;

Formal analysis; Writing - Original Draft

• Letícia Chaves de Souza: Methodology; Investigation; Writing - Original Draft;

Formal analysis; Writing - Review & Editing

• Yara Teresinha Correa Silva Sousa: Investigation; Resources; Formal analysis

• Manoel D. de Sousa-Neto: Investigation; Resources; Formal analysis

• David Eduardo Jaramillo: Methodology; Resources

• Renato Menezes Silva: Conceptualization; Methodology; Resources; Writing -

Review & Editing; Supervision