Journal of

Clinical Medicine

Article
Micro-Computed Tomography Evaluation of Minimally
Invasive Shaping Systems in Mandibular First Molars
Elio Berutti, Edoardo Moccia, Stefano Lavino, Stefania Multari , Giorgia Carpegna , Nicola Scotti ,
Damiano Pasqualini and Mario Alovisi *

Department of Surgical Sciences, Dental School, University of Turin, 10125 Turin, Italy
* Correspondence: mario.alovisi@unito.it

Abstract: The aim of this study was to compare the shaping ability of a modified ProTaper Next
technique (PTNm) with that of TruNatomy (TN) in lower molars mesial curved canals using micro-
computed tomography (Micro-CT). Sixty mesial canals of first mandibular molars were randomly
assigned between two groups (n = 30). After canal scouting with K-File #10, glide path and shaping
were carried out with TN or PTNm systems. The PTNm sequence consists of ProGlider, followed
by ProTaper Next X1 and apical finishing with NiTiFlex #25 up to working length (WL) to ensure
adequate apical cleaning. Samples were scanned using micro-CT and pre- and post-shaping volumes
were matched to analyse geometric parameters: the volume of removed dentin; the difference of
canal surface; centroid shift, minimum and maximum root canal diameters; cross-sectional areas;
the ratio of diameter ratios (RDR) and the ratio of cross-sectional areas (RA). Measurements were
assessed 2 mm from the apex and in relation to the middle and coronal root canal thirds. Data were
analysed using ANOVA (p < 0.05). No statistically significant differences were found between the
Citation: Berutti, E.; Moccia, E.;
groups for any parameter at each level of analysis, except for RA at the coronal level (p = 0.037). The
Lavino, S.; Multari, S.; Carpegna, G.;
Scotti, N.; Pasqualini, D.; Alovisi, M.
PTNm system showed the tendency to enlarge more in the coronal portion with a lower centroid shift
Micro-Computed Tomography at apical level compared with TN sequence (p > 0.05). Both PTNm and TN sequences demonstrated
Evaluation of Minimally Invasive similar maintenance of original anatomy during the shaping of lower molar mesial curved canals.
Shaping Systems in Mandibular First
Molars. J. Clin. Med. 2022, 11, 4607. Keywords: microtomography; molar; root canal therapy; dental pulp cavity; mechanical preparation;
https://doi.org/10.3390/ rotary instruments
jcm11154607

Academic Editors: Massimo Amato,

Giuseppe Pantaleo and Alfredo
Iandolo
1. Introduction
The primary purpose of endodontic treatment is decontamination of the root canal
Received: 17 July 2022
system from bacteria, pulp residues, organic substrates and shaping debris, while main-
Accepted: 4 August 2022
taining the root canal anatomy [1]. Establishing a hermetic seal via three-dimensional (3D)
Published: 8 August 2022
filling is mandatory to complete endodontic disinfection [1–3].
Publisher’s Note: MDPI stays neutral Root canal preparation is usually divided into different steps: canal scouting with
with regard to jurisdictional claims in stainless steel K-Files #08–10 provides the initial patency, while the subsequent glide path
published maps and institutional affil- minimizes the risk of placing torsional stress on the shaping instruments [4,5]. Glide path
iations. and shaping procedures require the use of manual or mechanical nickel-titanium (NiTi)
instruments [6], of which the latter may reduce operative time and canal transportation
compared with manual instruments, regardless of operator experience [7].
Modern endodontic techniques aim to simplify clinical procedures while optimizing
Copyright: © 2022 by the authors.
long-term tooth prognosis [8]. Therefore, endodontic instruments have been designed to
Licensee MDPI, Basel, Switzerland.
This article is an open access article
display less taper, exhibit greater flexibility due to metallurgical properties, and shorter se-
distributed under the terms and
quences with enhanced cyclic fatigue resistance compared with traditional instruments [9].
conditions of the Creative Commons ProTaper Next (PTN) rotary shaping instruments have a M-wire alloy, a rectangular
Attribution (CC BY) license (https:// section and an asymmetrical rotation center which provides a ‘swaggering’ movement.
creativecommons.org/licenses/by/ These features reduce contact between the instrument and the canal walls, facilitate ef-
4.0/). ficient debris removal and a give greater flexibility than previous generation shaping

J. Clin. Med. 2022, 11, 4607. https://doi.org/10.3390/jcm11154607 https://www.mdpi.com/journal/jcm

J. Clin. Med. 2022, 11, 4607 2 of 9

instruments [10–13]. TruNatomy (TN) describes a novel sequence of NiTi instruments with
post-manufacturing thermal treatment, an off-centred parallelogram cross section, a regres-
sive taper, and a small initial wire blank of 0.8 mm diameter in the shaping files [14,15].
The aim of this study was to evaluate a modified ProTaper Next sequence (PTNm)
as a shaping technique for use in narrow canals and long and thin roots with accentuated
curvatures. The modified sequence consists of ProGlider, followed by PTN X1 instrument
and apical finishing with NiTiFlex #25 up to working length (WL) to ensure adequate apical
cleaning. This technique was compared with TN shaping with Prime instrument, due to
their ability to shape difficult anatomies and the micro-computed tomography (micro-CT)
analysis of the resultant post-shaping geometries was performed.
The study was designed to test the null hypothesis that the TN technique and the
PTNm sequence would not differ in their abilities to preserve the original root canal
anatomy during the shaping of curved lower molar mesial canals.

2. Materials and Methods

2.1. Samples Selection
Mandibular first molars with a fully formed apex that had not previously undergone
endodontic treatment were selected in accordance with the local ethics committee (Protocol
number CS2_1053_2022). The teeth were extracted for periodontal reasons, and they were
free of caries, cracks, and artificial alterations. A sample size of 30 per group was calculated
with G*Power 3.1.4 (Kiel University, Kiel, Germany) considering alpha-error = 0.05 and
ß = 0.95.
After root debridement with Gracey curette 7/8 (Hu-Friedy, Chicago, IL, USA), the
specimens were immersed in 0.01% NaOCl (Niclor 5, OGNA, Muggiò, Italy) at 4 ◦ C for
24 h before storage in saline solution. The teeth were placed on a customized support to
perform a preliminary low resolution micro-CT scan to obtain an overall outline of the canal
anatomy and to select teeth that met the inclusion criteria (SkyScan 1172, Bruker micro-CT,
Kontich, Belgium). Preliminary scans were conducted as follows: 450 projections through a
225◦ rotation (180◦ plus cone angle of the X-ray source) using a 1.0 mm thick aluminum
filter, voltage = 100 kV, current = 80 µA, source-to-object distance = 80 mm, source-to-
detector distance = 220 mm, pixel binning = 8 × 8, exposure time/projection = 0.2 s. Axial
sections were reconstructed with isotropic voxels and morphological parameters of the
mesial canals were obtained. Mesial-separated canals measuring 12 ± 2 mm from the canal
orifice to the apical foramen, with 20◦ –40◦ primary mesio-distal curvature, 10◦ –30◦ bucco-
lingual canal curvature and 4 < r ≤ 8 mm main curvature radius were selected [16,17]. The
point of maximum curvature was located within the middle third of each root canal. Teeth
with confluent canals, accentuated isthmuses or significant calcifications were excluded,
as were any that did not concur with the above inclusion criteria. Of 48 teeth assessed for
eligibility, 18 were excluded due to anatomical features, and 30 were included in the study,
each with two separated mesial canals for a total of 60 mesial canals equally distributed in
two groups.

2.2. Samples Preparation

Both mesial canals in each sample were shaped with one of the tested techniques. The
mesio-lingual (ML) and mesio-buccal (MB) canals were randomly assigned to shaping
with PTNm (n = 30) or TN (n = 30) using a computer-generated randomization system.
Instrumentation was carried out by a single expert operator skilled in both techniques
and calibrated for pecking motion amplitude and pressure on the handpiece. As shaping
sequences require specific settings and techniques, it was not possible to blind the operator.
However, a single operator, blinded to the aim of the study, checked randomization,
allocation, and performed the statistical analyses.
The traditional access cavity was prepared, and canal scouting was accomplished in all
mesial canals with #10 K-File at WL using Glyde (Dentsply Sirona, Ballaigues, Switzerland)
J. Clin. Med. 2022, 11, 4607 3 of 9

lubricating gel (0.80 mg). WL was established with 10X magnification (OPMI Pro Ergo,
Carl Zeiss, Oberkochen, Germany) when the tip was visible at the apical foramen.
In the PTNm group, the glide path was performed with rotary single file ProGlider
(PG) (0.16, taper from 0.02 to 0.085) (Dentsply Sirona Maillefer) and shaped with PTN X1
(0.17, taper from 0.04 to 0.075) (Dentsply Sirona Maillefer) up to WL. Both PG and PTN
X1 utilized an endodontic X-Smart Plus engine (Dentsply Sirona, Ballaigues, Switzerland)
with 16:1 contra angle (300 rpm, 4 Ncm) in continuous rotation up to WL. Apical finishing
was then achieved manually with a NiTi-file #25 (Dentsply Sirona Maillefer) with a ‘feed-it
and pull’ movement to WL.
In the TN group, pre-flaring was performed with TN Orifice Modifier (020, taper 0.08)
(Dentsply Sirona Maillefer) and glide path was achieved with the TN Glider (017, taper
0.02) (Dentsply Sirona Maillefer). Root canal shaping was completed with TN Prime (026,
taper 0.04 variable) up to WL. Each instrument utilized an endodontic X-Smart Plus engine
(Dentsply Sirona, Ballaigues, Switzerland) with 16:1 contra angle (500 rpm, 1.5 Ncm) in
continuous rotation up to WL, according to manufacturer’s instructions.
New instruments were used for each canal (30 sets of instruments per group) and
operated according to the manufacturer’s instructions using ‘in and out’ movements
without intentional brushing effects.
Irrigation was performed without engaging canal walls up to 4 mm from the WL
using a manual syringe with a dedicated 30 G flexible endodontic needle, alternating 5%
NaOCl and 10% EDTA, to a total of 10 mL per sample. Recapitulation with a #10 K-File
was conducted between each instrument. The samples were then stored in saline solution
prior to micro-CT scanning.

2.3. Micro-Computed Tomography Analysis

The samples underwent high resolution scanning before and after instrumentation
to analyze geometrical modifications to the root canal (SkyScan 1172® : © Bruker microCT,
Kontich, Belgium). Samples were mounted on a customized support and micro-CT scans
were performed at 100 kV and 100 µA, at an isotropic resolution of 15 µm/pixel, over
approximately 4 h and 2 min for each. The scans were performed with a rotation step of 0.2◦
and a frame averaging of 4, with a 360◦ full rotation, using an aluminium and copper filter
for beam hardening. Each scan produced 3600 cross-sections per sample, at a resolution
of 1000 × 666 pixels. The canal paths were analysed with high resolution 3D renderings
through orthogonal axial sections to ensure the homogeneity of the samples at baseline.
The images were reconstructed using the NRecon software (SkyScan 1172, Bruker
micro-CT, Kontich, Belgium) with standard parameters for beam hardening and ring
artifact correction. The bi-dimensional (2D) and 3D root canal geometrical parameters were
calculated using the Materialize Mimics 20.0 software (Materialize NV, Leuvren, Belgium),
reducing manual bias. The increase in canal volume and surface area was calculated for each
sample through 3D renderings. Bi-dimensional parameters were measured starting from
orthogonal cross sections: root canal centroid shift, the ratio of diameter ratios (RDR), and
the ratio of cross-sectional areas (RA) [9,18] RDR represents the tendency of an instrument to
asymmetrically enlarge the root canal in one direction: RDR = (D/d)post/(D/d)pre, where
(D/d)post is the post-preparation ratio of the major diameter (D) to the minor diameter
(d) and (D/d)pre is the pre-preparation ratio of D to d. Therefore, when the values are close
to 1, they represent greater maintenance of the original canal geometry. RA quantifies the
ability of an instrument to enlarge the root canal space: RA = Apost/Apre, where Apost and
Apre are the post-preparation and the pre-preparation cross-sectional areas, respectively.
Values closer to 1 correspond to a smaller difference between pre- and post-instrumentation
measurements, indicating in a more conservative instrumentation [7,19]. Root sections
orthogonal to canal axis were set at three different levels of analysis: apical (A, 2 mm from
the apical foramen), middle (M, set at the point of maximum curvature), and coronal (C,
set in correspondence to the middle portion of the root canal coronal third defined by 3D
J. Clin. Med. 2022, 11, 4607 4 of 9

calculation of the root canal length from apex to orifice). An automated minimum threshold
was set to avoid manual errors [18,20].

2.4. Statistical Analyses

The normal distribution of the data was analyzed with a Shapiro–Wilk normality test.
Geometrical differences at baseline between groups were analyzed with a Kruskal–Wallis
and post hoc Dunn’s tests (level of significance: p < 0.05). One-way ANOVA and post hoc
Turkey–Kramer tests were used to analyze the increase of canal surface area and volume,
the centroid shift, and the impact of instrumentation on RDR and RA at each level of
analysis (p < 0.05). All the statistical analyses were conducted with the Minitab 15 software
package (Minitab Inc., State College, PA, USA).

3. Results
The mean (±standard deviation) canal curvature was 32.1◦ ± 2.2◦ (min = 25◦ , max = 37◦ )
in the PTNm group and 31.3◦ ± 1.9◦ (min = 24◦ , max = 35◦ ) in the TN group, with no
statistical difference between the groups (p = 0.12). Similarly, the radii of curvatures showed
no differences between groups (p > 0.05). Baseline canal volume, surface area, and apical
diameter also displayed homogeneity between groups (p > 0.05) and are presented in
Table 1. The 3D and 2D pre- and post-operative geometrical parameters are shown in
Table 2. No statistically significant differences were found between the groups for any
parameter at each level of analysis, except for RA at the coronal level (p = 0.037). A
higher tendency to remove dentin was observed in the PTNm group, especially in the
coronal portion. The TN sequence demonstrated a higher centering ability at coronal level
(p > 0.05), while PTNm system showed a lower centroid shift in the apical third (p > 0.05)
(Figures 1 and 2). No instruments were fractured during instrumentation.

Table 1. Sample baseline characteristics of the 60 mesial canals were included in the study.
a Apical diameters 1 mm from apical foramen. PTNm, modified ProTaper Next technique; TN,

TruNatomy technique.

PTNm (Mean ± SD) TN (Mean ± SD) p

Canal volume (mm3 ) 3.02 ± 0.59 3.01 ± 0.55 0.23
Canal surface area (mm2 ) 24.23 ± 1.94 24.59 ± 3.67 0.19
Apical diameter a (mm) 0.15 ± 0.09 0.18 ± 0.05 0.11

Table 2. 3D and 2D parameters utilized for post-shaping analysis in each group. Different superscript
letters indicate statistical significance: a,b p < 0.05. For 2D parameters (centroid shift, RDR, and
RA) significance was compared for the same level of analysis (coronal, middle, or apical). PTNm,
modified ProTaper Next technique; RA, Ratio of Cross-Sectional Areas; RDR, Ratio of Diameters
Ratios; TN, TruNatomy technique.

Increase in Increase in
Centroid Shift
Canal Volume Canal Surface RDR (Ratio) RA (Ratio)
(mm−1 )
(mm3 ) Area (mm2 )
Level of
Group Mean ± SD Mean ± SD Mean ± SD Mean ± SD Mean ± SD
Analysis
Coronal 1.25 ± 0.94 a 0.60 ± 0.16 a 1.82 ± 0.71 a
PTNm 1.40 ± 0.80 a 3.37 ± 2.17 a Middle 0.76 ± 0.47 a 0.73 ± 0.18 a 1.28 ± 0.22 a
Apical 0.83 ± 0.45 a 0.76 ± 0.21 a 1.33 ± 0.36 a
Coronal 0.77 ± 0.46 a 0.61 ± 0.23 a 1.30 ± 0.21 b
TN 0.91 ± 0.44 a 2.24 ± 1.48 a Middle 0.67 ± 0.29 a 0.75 ± 0.14 a 1.26 ± 0.16 a
Apical 1.45 ± 0.27 a 0.68 ± 0.26 a 1.29 ± 0.22 a
 Apical 0.83 ± 0.45 a 0.76 ± 0.21 a 1.33 ± 0.36 a

Coronal 0.77 ± 0.46 a 0.61 ± 0.23 a 1.30 ± 0.21 b

TN 0.91 ± 0.44 a 2.24 ± 1.48 a Middle 0.67 ± 0.29 a 0.75 ± 0.14 a 1.26 ± 0.16 a
J. Clin. Med. 2022, 11, 4607 5 of 9
Apical 1.45 ± 0.27 a 0.68 ± 0.26 a 1.29 ± 0.22 a

J. Clin. Med. 2022, 11, x FOR PEER REVIEW 6 of 9

Figure1.1.2D
Figure 2Dmatching
matchingof
ofpre-operative
pre-operative(green)
(green)and
andpost-shaping
post-shaping(red)
(red)canal
canalsections
sectionsat
atthe
theapical
apical
(A),point
(A), pointof
ofmaximum
maximumcurvature
curvature(M),
(M),and
andcoronal
coronal(C)
(C)levels
levelsofofanalysis
analysisininboth
bothgroups.
groups.

Figure 2.
Figure 2. (a).
(a). 3D
3Dmatching
matchingofofpre-operative
pre-operative(green)
(green)and post-shaping
and post-shaping(red) canal
(red) volumes,
canal andand
volumes, (b).
the the
(b). pre-operative (green)
pre-operative andand
(green) post-shaping (red)
post-shaping rootroot
(red) canal centroids
canal in the
centroids mesial
in the canals.
mesial canals.

4. Discussion
The purpose of this study was to evaluate the outcomes of root canal preparation of
severely curved canals using two different shaping sequences with distinct taper and
design but leading to similar apical size. Both tested shaping systems produced a well-
centred preparation that respected the original canal anatomy, and the null hypothesis
was generally accepted.
J. Clin. Med. 2022, 11, 4607 6 of 9

4. Discussion
The purpose of this study was to evaluate the outcomes of root canal preparation
of severely curved canals using two different shaping sequences with distinct taper and
design but leading to similar apical size. Both tested shaping systems produced a well-
centred preparation that respected the original canal anatomy, and the null hypothesis was
generally accepted.
The PTNm technique utilizes a manual #25 NiTiFlex file for the finishing of the apical
third. The use of this flexible 0.02 taper finishing file is tried to maintain canal curvatures
minimizing apical transportation. This preserves the original canal anatomy by reducing
excessive canal instrumentation in complex cases with pronounced curvatures, while ensur-
ing the effectiveness of irrigant cleansing [21–23]. Nevertheless, it has been demonstrated
that an apical diameter #25–30 is necessary to rise the efficacy of the endodontic irrigants,
without the need to increase the taper during shaping [21–23]. Therefore, the possibility of
maintaining lower-tapered preparations is dependent on the maintenance of an adequate
apical diameter, especially in highly curved canals. However, the rationale for the use a
PTNm sequence could be related to the use of one single system for the shaping of curved
mesial and oval distal lower molar canals without the risk not to touch the coronal root
canal portions.
An extracted tooth model is usually transferable to the clinical setting and pre-
operative homogeneity between samples is essential to ensure an adequate standard-
ization [7,24]. In this micro-CT study, baseline homogeneity for 3D and 2D parameters was
assumed, in agreement with previous observations [25]; however, the small sample number
could be considered a limitation. Micro-CT analysis enables the non-invasive evaluation of
pre- and post-operative root canal morphology, being an effective indicator of instrument
shaping ability [7,26,27]. In this study, the superposition of the scanned volumes and the
analysis of the root canal cross sections resulted in an accurate comparison of the shaping
outcomes for the tested instruments in the apical, maximum curvature, and coronal levels
of lower molar mesial canals [28]. These levels were selected as those most representative
of the critical shaping portions [29], especially in the lower molar mesial canals that tend to
require the most involved endodontic treatment of any teeth, with their complex anatomy
often leading to procedural aberrations [30].
Root canal transportation can occur during endodontic treatment involving excessive
dentin removal [31]. Furthermore, the straightening of the canal curvature leads to a
reduction in the thickness of the dentinal walls and reduces the long-term prognosis of a
tooth [1,29–32]. Therefore, the maintenance of the distal coronal third of the mandibular
molar mesial root, known as the ’danger zone‘, is an important prognostic factor [33,34].
In this study, an intentional brushing motion was avoided, and a glide path was
created to reduce the volume of dentin removed and to decrease the number of pecking
motions required to reach the full WL [7,35,36]. Gel-chelating agents were used for canal
scouting, while 10% EDTA and 5% NaOCl were used as alternating irrigants during glide
path and shaping. This irrigation protocol replicated previously reported experimental
conditions, even if the effects of different EDTA concentrations on shaping outcomes remain
unclear and may represent a limitation of this study [12,37].
The two tested techniques are clinically indicated for the shaping of narrow and
severely calcified canals, long and thin roots and accentuated curvatures, due to their
advantage of imparting a low taper to canals. Generally, it is necessary to use carrier-based
obturation techniques or single cone with bioceramic sealers to fill low-taper root canals,
as it is not possible to use the vertical condensation technique, which requires a greater
taper [38].
From these analyses, it may be hypothesized that the PTNm technique created a
more tapered preparation compared with TN, due to the geometric difference in the
coronal portion of the instruments with taper 0.02 and 0.075 for TN and PTN systems,
respectively. This is supported by the significant difference observed between groups for
the RA parameter at the coronal level of analysis. This aspect seems in agreement with a
J. Clin. Med. 2022, 11, 4607 7 of 9

recent study which reported that TN system touched a low percentage of root canal surface
during shaping of lower molar mesial canals [9]. Moreover, the results of the RDR outcomes
demonstrated that the techniques equally respected the original canal anatomy, without
significant transportation, nor the risk of removing a considerable amount of dentin in
correspondence of the furcation. Recently, Kabil et al. showed that TN- and PTN-shaping
systems had similar transportation and centering abilities in the coronal and apical root
canal portions [39]. However, in the present study, the analysis of the centroid shift suggests
that PTNm was more centred at the apical level, although this was not significant. This
may relate to the different techniques adopted for the shaping of the apical third, whereby
the use of a shorter sequence and a manual NiTi instrument #25 could have resulted in a
more conservative approach in the PTNm group. This aspect could be related to different
outcomes in terms of post-operative pain and quality of life, but it was not investigated
due to the ex vivo study limits [40,41].
In conclusion, the results of this study demonstrate that PTNm and TN exhibit com-
parable maintenance of the original canal anatomy, supporting the use of both shaping
techniques for the instrumentation of curved lower molars mesial canals.

Author Contributions: Conceptualization: E.B., M.A. Methodology: S.L., S.M., G.C. Software: E.M.,
S.L. Data Analysis: E.M., S.L., S.M., G.C. Visualization: N.S., D.P. Supervision and Project Adminis-
tration: M.A., E.B. Writing: M.A., S.L., S.M., G.C. Reviewing and Editing: E.B., M.A., N.S., D.P. All
authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Teeth were extracted for periodontal reasons and all samples
were collected with informed consent. The Ethical Committee of the University of Turin approved
the study protocol (Approval code: CS2_1053_2022; Approval date: 14 January 2022).
Informed Consent Statement: Not applicable.
Acknowledgments: Micro-CT scans were performed at the C.I.R. Dental School–University of Turin (Italy).
Conflicts of Interest: The authors confirm that any conflict of interest is disclosed.

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