Clinical features and endodontic treatment of two-rooted mandibular canines: report of four cases


Stojanac, I.; Premović, M.; Drobac, M.; Ramić, B.; Petrović, L.

Srpski Arhiv Za Celokupno Lekarstvo 142(9-10): 592-596

2017


Predictable endodontic treatment depends on the dentist's knowledge about root canal morphology and its possible anatomic variations. The majority of mandibular canines have one root and root canal, but 15% may have two canals and a smaller number may have two distinct roots. The following clinical reports describe endodontic treatment of mandibular canines with two roots and two root canals. OUTLINE OF CASES Four clinical case reports are presented to exemplify anatomical variation in the human mandibular canine. Detailed analysis of the preoperative radiographs and careful examination of the pulp chamber floor detected the presence of two root canal orifices in all canines. Working length was determined with an electronic apex locator and biomechanical preparation was carried out by using engine driven BioRaCe Ni-Ti rotary instruments in a crown-down manner, followed by copious irrigation with 1% sodium hypochlorite. Definitive obturation was performed using cold lateral condensation with gutta-percha cones and Top Seal paste. The treatment outcome was evaluated using postoperative radiographs. Endodontists should be aware of anatomical variations of the treated teeth, and should never presume that canal systems are simple.

Srp
Arh
Celok
Lek.
2014
Sep-Oct;142(9-10):592-596
592
DPPIKA3
501IECHPIKA
/
CASE
REPORT
DOI:
10.2298/SARH14105925
UDC:
616.314.16-089.23
Clinical
Features
and
Endodontic
Treatment
of
Two-
Rooted
Mandibular
Canines:
Report
of
Four
Cases
Igor
Stojanacl,
Milica
Premovie,
Milan
Drobacl,
Bojana
Ramie,
Ljubomir
Petrovie
'Dental
Clinic
of
Vojvodina,
Faculty
of
Medicine,
University
of
Novi
Sad,
Novi
Sad,
Serbia;
'Faculty
of
Medicine,
University
of
Novi
Sad,
Novi
Sad,
Serbia
SUMMARY
Introduction
Predictable
endodontic
treatment
depends
on
the
dentist's
knowledge
about
root
canal
morphology
and
its
possible
anatomic
variations.The
majority
of
mandibular
canines
have
one
root
and
root
canal,
but
15%
may
have
two
canals
and
a
smaller
number
may
have
two
distinct
roots.The
following
clinical
reports
describe
endodontic
treatment
of
mandibular
canines
with
two
roots
and
two
root
canals.
Outline
of
Cases
Four
clinical
case
reports
are
presented
to
exemplify
anatomical
variation
in
the
human
mandibular
canine.
Detailed
analysis
of
the
preoperative
radiographs
and
careful
examination
of
the
pulp
chamber
floor
detected
the
presence
of
two
root
canal
orifices
in
all
canines.
Working
length
was
determined
with
an
electronic
apex
locator
and
biomechanical
preparation
was
carried
out
by
using
engine
driven
BioRaCe
Ni-Ti
rotary
instruments
in
a
crown-down
manner,
followed
by
copious
irrigation
with
1%
sodium
hypochlorite.
Definitive
obturation
was
performed
using
cold
lateral
condensation
with
gutta-percha
cones
and
Top
Seal
paste.The
treatment
outcome
was
evaluated
using
postoperative
radiographs.
Conclusion
Endodontists
should
be
aware
of
anatomical
variations
of
the
treated
teeth,
and
should
never
presume
that
canal
systems
are
simple.
Keywords:
anatomy;
endodontics;
mandibular
canine;
two
roots
Correspondence
to:
Igor
U.
STOJANAC
Faculty
of
Medicine
University
of
Novi
Sad
Hajduk
Veljkova
12
21000
Novi
Sad
Serbia
INTRODUCTION
A
comprehensive
knowledge
of
the
external
and
internal
anatomy
of
teeth
is
essential
to
ensure
predictable
endodontic
treatment
[1].
Mandibular
canines
are
teeth
with
one
root
and
one
root
canal
occurring
in
a
very
high
rate
of
cases
[2].
However,
several
investiga-
tors
have
reported
the
presence
of
anatomical
variations
associated
with
mandibular
canines.
Pineda
and
Kuttler
[3],
Green
[4]
and
Vertucci
[5]
reported
that
the
occurrence
of
mandibular
canines
with
one
root
and
two
root
canals
is
about
15%.
The
occurrence
rate
of
mandibular
canines
with
two
roots
and
two
canals
ranges
from
1.7%
up
to
5%
of
all
examined
canines
[6,
7].
Laurichesse
et
al.
[8]
reported
the
pres-
ence
of
two
distinct
roots
and
two
root
canals
in
only
1%
of
analyzed
canines.
Despite
the
low
occurrence,
endodontists
should
be
aware
of
possible
variations
in
the
number
of
roots
and
root
canals
of
mandibular
canines.
The
following
clinical
reports
describe
en-
dodontic
treatment
of
four
mandibular
canines
with
two
roots
and
two
root
canals.
CASE
REPORTS
Case
1
A
42-year-old
male
patient
was
referred
to
the
Dental
Clinic
of
Vojvodina,
due
to
spontane-
ous,
severe
pain
in
the
mandibular
region
on
the
left
side.
A
history
of
the
condition
was
recorded
and
a
clinical
examination
and
di-
agnostic
tests
were
performed,
ending
with
a
diagnosis
of
irreversible
pulpitis
of
tooth
33.
Endodontic
treatment
was
proposed
to
the
patient.
After
the
patient's
consent,
the
treat-
ment
started
with
preoperative
radiography.
Careful
analysis
of
the
radiograph
revealed
a
two-rooted
canine
with
root
bifurcation
at
the
apical
third
of
the
root
according
to
Sharma
et
al.
[9]
and
recently
Versiani
et
al.
[10],
as
shown
in
Figure
la.
After
applying
local
anesthesia,
a
rubber
dam
was
placed.
An
access
cavity
preparation,
modified
to
take
into
account
the
two
canals,
was
performed
and
the
coronal
orifice
of
the
main
root
canal
was
found.
During
the
explo-
ration
of
the
root
canal
with
a
No.15
K-file
(FKG
Dentaire
S.A.,
Chaux-de-Fonds,
Swit-
zerland),
the
presence
of
two
branches
of
the
root
was
confirmed,
(buccal
and
lingual,
as
based
on
external
tooth
anatomy).
A
working
length
was
determined
radiographicaly
(with
no
rubber
dam
and
clamp
on
the
tooth
while
taking
the
radiograph)
for
both
canals
(Figure
lb)
and
confirmed
electronically.
Both
canals
were
prepared
in
a
crown-down
manner
ac-
cording
to
the
sequences
for
working
with
the
engine
driven
BioRaCe
Ni-Ti
rotary
instru-
ments
(FKG
Dentaire
S.A.,
Chaux-de-Fonds,
Switzerland);
BR1
15/0.05,
BR2
25/0.04,
BR3
25/0.06
and
BR4
35/0.04
at
the
end
of
prepara-
tion.
Copious
irrigation
with
1%
sodium
hy-
pochlorite
solution,
followed
by
saline
solution
(0.9%),
was
performed
after
each
step
of
the
instrumentation.
Paper
points
were
used
to
dry
593
Srp
Arh
Celok
Lek.
2014
Sep-Oct;142(9-10):592-596
(a)
I
M
il
e
(c)
Figure
1.
Case
1:
(a)
Preoperative
radiograph
of
tooth
33
indicating
two
roots;
(b)
diagnostic
length
files
placed
into
both
root
canals;
(c)
final
obturation
of
the
root
canals
using
lateral
compaction
of
gutta-percha.
the
canal.
Top
Seal
paste
(Dentsply
Maillefer,
Ballaigues,
Switzerland)
was
placed
in
the
canal
using
a
No.15
NiTi
K-file
(FKG
Dentaire
S.A.,
Chaux-de-Fonds,
Switzerland)
with
a
counter-clockwise
motion.
A
master
gutta-percha
cone
35/0.06
(FKG
Dentaire
S.A.,
Chaux-de-Fonds,
Swit-
zerland)
and
accessory
gutta-percha
cones
were
laterally
compacted
into
the
root
canal.
Excess
gutta-percha
was
re-
moved
with
a
heat-carrier
and
the
remaining
gutta-percha
was
vertically
compacted.
The
access
cavity
was
temporary
sealed
with
IRM
Ivory
(Dentsply/DeTrey,
Konstanz,
Ger-
many).
The
postoperative
radiograph
showed
two
well-
obturated
root
canals,
ending
at
the
electronically
located
apices
(Figure
1c).
Case
2
A
38-year-old
female
patient
was
referred
to
the
Dental
Clinic,
with
a
chief
complaint
of
slight
unspecific
pain
in
the
mandibular
region
on
the
left
side
which
had
lasted
for
two
months.
Clinical
examination
and
diagnostic
tests
revealed
slight
percutory
and
palpatory
sensitivity
of
tooth
33,
which
was
part
of
a
fixed
prosthesis.
Careful
analysis
of
preoperative
radiographs
revealed
a
periradicular
radi-
olucency
and
a
periodontal
pocket
associated
with
the
left
mandibular
canine.
Radiographs
also
indicated
the
pres-
ence
of
two
roots
and
two
root
canals,
of
which
only
one
was
previously
endodontically
treated
(Figure
2a).
Upon
clinical
examination,
the
treatment
options
were
presented
to
the
patient,
including
the
removal
of
the
fixed
prosthe-
sis,
followed
by
endodontic
and
periodontal
therapy
of
the
left
mandibular
canine.
After
the
patient's
consent,
the
fixed
prosthesis
was
removed
and
endodontic
treatment
was
initiated
with
the
administration
of
local
anesthesia
and
placing
a
rubber
dam.
An
access
cavity
was
prepared
to
preserve
as
much
of
the
coronal
part
of
the
tooth
as
possible,
but
to
provide
unobstructed
instrumentation
of
(a)
(b)
33
Figure
2.
Case
2:
(a)
Preoperative
radiograph
of
tooth
33
indicating
the
presence
of
two
roots,
one
of
which
was
previously
endodontically
treated,
as
well
as
a
periradicular
radiolucency;
(b)
final
obturation
of
the
mandibular
left
canine
with
two
roots
and
two
canals.
both
canals.
The
root
canals
were
separated
in
the
coro-
nal
third,
which
made
the
treatment
relatively
easier.
The
remnants
of
the
existing
root
canal
filling
were
removed
using
engine
driven
rotary
re-treatment
files
(ProTaper
Universal
Retreatment
Kit,
Dentsply/Maillefer,
Ballaigues,
Switzerland)
and
the
X-Smart
endomotor
(Dentsply/
Maillefer,
Ballaigues,
Switzerland)
with
the
speed
of
800
rpm.
A
working
length
for
both
root
canals
was
deter-
mined
electronically.
Both
canals
were
then
instrumented
using
a
crown-down
technique
and
obturated
as
described
previously
(Figure
2b).
Case
3
A
44-year-old
female
patient
was
referred
to
the
Dental
Clinic,
because
of
spontaneous,
sharp
pain
in
the
man-
dibular
region
on
the
left
side,
which
lasted
for
about
ten
days.
The
patient
could
not
localize
the
pain,
but
a
clinical
nvw.srp-arh.rs
Stojanac
I.
et
al.
Clinical
Features
and
Endodontic
Treatment
of
Two-Rooted
Mandibular
Canines:
Report
of
Four
Cases
(b)
Oa
Figure
3.
Case
3:
(a)
Preoperative
radiograph
of
tooth
33
shows
the
presence
of
two
roots,
one
of
which
has
an
inadequate
root
canal
fill;
(b)
final
obturation
of
the
mandibular
left
canine
using
cold
lateral
compaction
of
gutta-percha.
examination
and
clinical
diagnostic
tests
revealed
highly
expressed
percutory
sensitivity
associated
with
the
left
mandibular
canine;
pain
was
particularly
expressed
to
the
cold
test,
and
electrical
pulp
test
showed
decreased
values.
Preoperative
radiographs
showed
the
presence
of
two
separated
roots
of
the
left
mandibular
canine,
one
of
which
was
previously
endodontically
treated,
while
the
other
one
was
not
treated
at
all
(Figure
3a).
Previous
en-
dodontic
therapy
was
not
successful
as
the
remnants
of
the
pulp
tissue
were
inflamed
and
gave
the
symptoms
of
acute
pulpitis.
After
the
administration
of
local
anesthesia
and
isolation
with
a
rubber
dam,
an
access
cavity
was
pre-
pared
and
modified
to
take
into
account
the
two
canals,
both
buccal
and
lingual.
The
existing
canal
filling
material
was
removed
from
the
root
canal
which
had
been
previ-
ously
treated,
as
described
in
Case
2,
using
engine
driven
rotary
re-treatment
files.
Both
root
canals
were
explored
with
No.
10
K
files
(FKG
Dentaire
S.A.,
Chaux-de-Fonds,
Switzerland),
and
the
working
length
determination,
ir-
rigation,
instrumentation
and
obturation
were
performed
as
described
previously
(Figure
3b).
Case
4
A
46-year-old
female
patient
was
referred
to
the
Dental
Clinic
because
of
intense,
throbbing
pain
in
the
periradic-
ular
region
of
the
right
mandibular
canine,
which
lasted
for
two
days.
The
tooth
was
highly
sensitive
to
pressure,
percussion
and
palpation,
the
electric
pulp
test
was
nega-
tive,
and
radiograph
examination
revealed
a
periapical
radiolucency
associated
with
tooth
43
and
the
presence
of
two
roots
(Figure
4a).
The
diagnosis
of
chronic
apical
periodontitis
was
es-
tablished.
Drainage
of
the
unanaesthetized
tooth
was
performed
using
a
round
diamond
bur,
the
roof
of
the
pulp
chamber
was
removed
and
the
release
of
exudates
provided
the
patient
with
immediate
relief.
After
two
days,
the
patient
had
no
more
subjective
symptoms
and
endodontic
therapy
was
continued.
The
root
canals
were
separated
in
the
coronal
third,
which
made
the
endodontic
treatment
easier.
After
obtaining
a
dry
operating
field,
the
canal
orifices
were
extended
using
the
#2
Gates-Glidden
bur,
the
working
length
was
determined
electronically
and
instrumentation
was
done
using
a
crown-down
technique,
as
described
previously.
Irrigation
was
performed
using
1%
sodium
hypochlorite
solution
and
medication
was
per-
formed
using
calcium-hydroxide
paste
(Septodont,
Saint
Maure
des
Fosses
Cedex,
France)
for
seven
days.
Final
obturation
was
performed
as
described
previously
with
gutta-percha
cones
(FKG
Dentaire
S.A.,
Chaux-de-Fonds,
Switzerland)
and
Top
Seal
paste
(Dentsply
Maillefer,
Bal-
laigues,
Switzerland)
using
the
cold
lateral
condensation
technique.
The
postoperative
radiograph
showed
two
well-
(b)
(c)
(a)
,
111
i
6-
r
k.
Figure
4.
Case
4:
(a)
Preoperative
radiograph
examination
revealing
periapical
radiolucency
and
the
presence
of
two
roots;
(b)
final
obtura-
tion
of
both
root
canals
in
the
mandibular
right
canine
using
cold
lateral
compaction
of
gutta-percha;
(c)
a
6-month
postoperative
radiograph
showing
the
progression
of
hard
tissue
healing
in
the
periapical
region.
doi:
10.2298/SARH14105925
Srp
Arh
Celok
Lek.
2014
Sep-Oct;142(9-10):592-596
obturated
root
canals
(Figure
4b).
At
a
6-month
recall,
the
patient
was
asymptomatic
and
a
6-months
postoperative
radiograph
showed
progression
of
hard
tissue
healing
in
the
periapical
region
(Figure
4c).
DISCUSSION
Clinicians
should
never
assume
that
a
given
tooth
will
con-
tain
a
specific
number
of
canals
[11].
Endodontists
should
be
aware
of
the
possibility
of
additional
root
canals,
which
must
be
detected;
otherwise
treatment
failure
is
extremely
possible
[12,
13].
Only
three
case
reports
of
endodontic
treatment
of
mandibular
canines
with
two
roots
have
been
reported
[11,
14].
Heling
et
al.
[15]
presented
a
case
report
of
a
man-
dibular
canine
with
two
roots
and
three
root
canals,
while
Holtzman
[16]
reported
a
case
of
root
canal
treatment
of
a
mandibular
canine
with
three
root
canals.
Over
the
past
four
years
of
dinical
practice
of
the
current
authors,
the
percentage
of
endodontically
treated
mandibu-
lar
canines
with
rare
anatomical
variations
was
2.5%
(4/161).
All
of
these
clinical
cases
are
presented
in
this
artide.
The
endodontic
treatment
of
mandibular
canines
with
two
roots
and
two
distinct
canals
requires
accurate
diagno-
sis
based
on
the
medical
and
dental
history
of
the
patient,
dinical
examination,
careful
analysis
of
preoperative,
di-
agnostic
radiographs
from
different
angles
and
a
detailed
plan
of
therapy
[17].
High
quality,
preoperative
radiographs
taken
from
dif-
ferent
angulations,
and
their
correct
interpretation,
are
an
indispensable
factor
for
identifying
all
significant
details
and
darifying
uncertainties.
If
the
mandibular
canine
has
two
roots,
they
are
positioned
buccally
and
lingually.
The
superposition
of
roots
and
canals
on
radiographs,
espe-
cially
in
the
presence
of
agonist
teeth,
can
cause
that
the
dinician
easily
overlooks
the
existence
of
additional
roots/
canals.
In
these
current
cases,
radiographs
from
differ-
ent
angles
usually
indicated
two
clearly
visible
buccal
and
lingual
roots.
A
careful
analysis
of
the
continuity
of
the
periodontal
ligament
can
infer
the
presence
of
an
extra
root
or
canal.
Clinicians
should
observe
the
direction
of
a
root
canal
and
if
sudden
interruption
of
its
continuity
exists,
it
can
indicate
branching
of
the
canal
[18].
REFERENCES
1.
Setzer
FC,
Boyer
KR,
Jeppson
JR,
Karabucak
B,
Kim
S.
Long-term
prognosis
of
endodontically
treated
teeth:
a
retrospective
analysis
of
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factors
in
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J
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2011;
37:21-5.
2.
Bergenholtz
G,
Florsted-Bindslev
P,
Reit
C.
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2nd
ed.
Oxford:Wiley-Blackwell
Publishing
Ltd;
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3.
Pineda
F,
Kuttler
Y.
Mesiodistal
and
buccolingual
roentgenographic
investigation
of
7,275
root
canals.
Oral
Surg
Oral
Med
Oral
Pathol
Oral
Radiol
Endod.
1972;
33:101-10.
4.
Green
D.
Double
canal
in
single
roots.
Oral
Surg
Oral
Med
Oral
Pathol
Oral
Radiol
Endod.
1973;
35:689-96.
5.
Vertucci
FJ.
Root
canal
anatomy
of
the
human
permanent
teeth.
Oral
Surg
Oral
Med
Oral
Pathol
Oral
Radiol
Endod.
1984;
58:589-99.
A
careful
examination
of
the
pulp
chamber
floor
and
manual
exploration
of
the
root
canal
system
with
an
ap-
propriate
endodontic
file
is
the
reliable
way
to
identify
the
exact
configuration
of
the
root
canal
system.
Using
augmentative
equipment,
such
as
magnifying
loupes
or
an
endodontic
microscope
is
very
helpful
during
the
diagno-
sis
of
the
canal
system.
The
practice
of
extending
the
ac-
cess
cavity
bucco-lingually
is
mandatory
to
find
extra
and/
or
hidden
canals.
If
the
endodontic
instrument
is
inclined
too
buccally
or
lingually
and
cannot
be
removed
from
the
canal
in
an
opposite
direction,
the
eventual
presence
of
two
canals
might
be
indicated
[19].
With
regards
to
the
root
canals,
engine-driven,
rotary,
endodontic
instruments
made
of
Ni-Ti
alloys
are
capable
of
achieving
faster
and
easier
root
canal
preparation
with
a
predictable
treatment
outcome,
even
in
complicated
root
canal
systems
[20].
According
to
Sharma
et
al.
[9]
and
recently
Versiani
et
al.
[10],
the
second
root/canal
of
the
mandibular
canine
can
branch
from
the
apical,
middle
(as
described
in
Case
1)
or
coronal
thirds
(Cases
2,
3
and
4).
If
a
branching
of
root/canal
is
located
more
apically,
the
case
is
more
dif-
ficult
to
diagnose
and
treat
[21].
When
one
of
the
lower
anterior
teeth
has
a
complicated
canal
system,
a
detailed
analysis
of
external
and
internal
anatomy
of
the
surrounding
teeth
and
the
eventual
detec-
tion
of
similar
cases
is
required.
Despite
the
fact
that
mandibular
canines
are
usually
composed
of
a
single
root
and
a
single
root
canal,
it
is
very
important
for
clinicians
to
consider
all
the
possible
tooth
anatomy
variations
(external
and
internal)
and
to
have
an
individual
approach
to
each
endodontic
therapy.
Careful
and
detailed
clinical
and
radiograph
examination
are
an
essential
factor
in
detecting
morphological
varia-
tions.
Only
obturation
of
the
entire
root
canal
system
can
provide
predictable
and
long-term
dinical
success.
ACKNOWLEDGMENTS
This
research
was
supported
by
a
grant
from
the
Ministry
of
Education,
Science
and
Technological
Development
of
Serbia
(Grant
No.
174005),
for
research
on
the
"Viscoe-
lasticity
of
fractional
type
and
optimization
of
shape
in
rod
theory".
6.
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JD,
Sousa
Neto
MD,
Saquy
PC.
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Lumley
PJ,
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MA,
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JD,
Sousa-Neto
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rooted
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canines
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44:682-7.
www.srp-arh.rs
5tojanac
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et
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Mandibular
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Report
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11.
D'Arcangelo
C,
Varvara
G,
De
Fazio
P.
Root
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treatment
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a
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2001;
34:331-4.
12.
Hoen
MM,
Pink
FE.
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retreatments:
an
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J
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13.
Jovanovid-Medojevid
M,
2ivkovk
S.
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ancillary
foramina
within
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Srp
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14.
Victorino
FR,
Bernades
RA,
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.fil,
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IG,
Bernardinelli
N,
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RB,
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Braz
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15.
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I,
Gottlieb-Dadon
I,
Chandler
NR
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Endod
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16.
Holtzman
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treatment
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-
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17.
Vujakovid
M,
Karadlid
B,
Miletid
V.
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second
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Srp
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18.
Ingle
11,
Walton
RE,
Malamed
SF,
Coil
JM,
Khademi
JA,
Kahn
FH,
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JI,
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LK,
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Soares
LR,
Arruda
M,
de
Arruda
MP,
Range
AL,Takano
E,
Carvalho-
Junior
JR,
et
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with
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Braz
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20:424-7.
20.
Stojanac
I,
Drobac
M,
Petrovic
L,
Atanackovic
T.
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"in
vivo"
failure
of
rotary
nickel-titanium
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under
cyclic
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Dent
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21.
Haapasalo
M,
UdnaesT,
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U.
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doi:
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