Endodontic Practice US May/June 6.3 by MedMark, LLC

Performance Reﬁned

a shift up in performance

May/June 2013 – Vol 6 No 3

a shift up in performance New PROTAPER NEXT features the same variable tapered performance as the original PROTAPER, but is refined with: • New unique rotary motion that further enhances PROTAPER canal-shaping efficiency • Proven M-Wire® NiTi alloy for increased flexibility and resistance to cyclic fatigue • New rectangular cross-section design for greater strength Call 1-800-662-1202 now to experience PROTAPER NEXT performance. Or learn more at www.TulsaDentalSpecialties.com.

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Images Courtesy Dr. Cliff Ruddle

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What’s next? PROTAPER NEXT™

“Endodontics is a clinical game. You’re supposed to have fun.” –John West, DDS, MSD To me, it’s fun when you master a skill such as the mechanics of root canal shaping. It’s fun when you have a plan and you know how to get there. ProTaper NEXT (PTN) was produced with a plan in mind: an advanced technology that gives the clinician choices, confidence, competence, safety, efficiency, technique simplicity, and yes, fun!

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What makes ProTaper NEXT, next? PTN is a convergence of: 1) ProTaper Universal progressively tapered design, 2) M-Wire® refinements for added resistance to cyclic fatigue and increased flexibility, and 3) offset axis of rotation.* The resulting NiTi “envelope of motion” allows a newfound level of shaping control. With almost unanimity, these three critical distinctions have had many colleagues describing their shaping experience with words like: “sleek,” “smooth,” “enchanting,” and “magic.” However, the best endorsement in the world is your own.

The first step in successful endodontics is to decide which “tool” to use when, why, where, and how. Your plan gets you to where you’re going. The resulting artistry is the signature that sets you apart. Your signature becomes your reputation and your reputation ultimately becomes your endodontic legacy.

Technique Sequence I Used to Treat These Two Patients

Case A

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Case B *Following your online registration, a coupon code will be emailed to you for a 20% discount off one total online order, with a maximum discount of $200. This offer is good for one use only per qualified account and may not be combined with other promotions. DENTSPLY Tulsa Dental Specialties reserves the right to end the promotion at any time.

1. Design unimpeded smooth-walled access while fully

preserving essential ferrule.

2. Brush gently on the outward stroke with ProTaper Universal

SX to remove dentin triangles and restrictive dentin when present.

FIND WHAT YOU NEED. FAST. Pretreatment #12

Pretreatment #15

3. Prepare manual Glidepath with at least half canal length

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amplitude “super loose” #10 file. (confirm Glidepath with #15 file or mechanical file, if desired)

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4. Float, follow, and brush on the outstroke (“let it run and paint”

are useful watchwords) with PTN X1 to length. Usually 2-3 shaping waves are needed.

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length. Usually 2-3 shaping waves are needed.

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Perpendicular downpack #12

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If X2 flutes are visibly filled with dentin: irrigate, gauge, conefit or use a verifier to validate proper shape. Follow irrigation protocol then obturate with a vertical compaction of warm gutta-percha technique.

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6. If X2 flutes are nude of dentin, proceed with X3 and larger if

occasionally needed. All shapes presented were finished with X2 or X3. Note: PTN preserves proper root canal “Flow”.

*Ruddle CJ, Machtou P, West JD, The Shaping movement: fifth-generation technology. Dent Today. 2013;32(4):94-99.

Oblique downpack #12

Oblique posttreatment #15

s • technology reviews May/June 2013 – Vol 6 No 3

PROMOTING

EXCELLENCE

Endodontics in 3D Dr. Richard Kahan

Direct pulp capping with a bioactive dentin substitute Dr. Markus Firia

Corporate proﬁle

Ultradent Products, Inc.

ENDODONTICS Top Ten Tips

To determine length Dr. Tony Druttman

Endodontics in Jamaica: a fulﬁlling and challenging experience

Dr. Gary Glassman

Practice proﬁle

Dr. Nishan Odabashian

PAYING SUBSCRIBERS EARN 24 CONTINUING EDUCATION CREDITS PER YEAR!

S IT D ! E R E C SID E C IN

ASSOCIATE EDITORS Julian Webber BDS, MS, DGDP, FICD Pierre Machtou DDS, FICD Richard Mounce DDS Clifford J Ruddle DDS EDITORIAL ADVISORS Paul Abbott BDSc, MDS, FRACDS, FPFA, FADI, FIVCD Professor Michael A Baumann Dennis G Brave DDS David C Brown BDS, MDS, MSD L Stephen Buchanan DDS, FICD, FACD Gary B Carr DDS Arnaldo Castellucci MD, DDS Gordon J Christensen DDS, MSD, PhD B David Cohen PhD, MSc, BDS, DGDP, LDS RCS Stephen Cohen MS, DDS, FACD, FICD Simon Cunnington BDS, LDS RCS, MS Samuel O Dorn DDS Josef Dovgan DDS, MS Tony Druttman MSc, BSc, BChD Chris Emery BDS, MSc. MRD, MDGDS Luiz R Fava DDS Robert Fleisher DMD Stephen Frais BDS, MSc Marcela Fridland DDS Gerald N Glickman DDS, MS Kishor Gulabivala BDS, MSc, FDS, PhD Anthony E Hoskinson BDS, MSc Jeffrey W Hutter DMD, MEd Syngcuk Kim DDS, PhD Kenneth A Koch DMD Peter F Kurer LDS, MGDS, RCS Gregori M. Kurtzman DDS, MAGD, FPFA, FACD, DICOI Howard Lloyd BDS, MSc, FDS RCS, MRD RCS Stephen Manning BDS, MDSc, FRACDS Joshua Moshonov DMD Carlos Murgel CD Yosef Nahmias DDS, MS Garry Nervo BDSc, LDS, MDSc, FRACDS, FICD, FPFA Wilhelm Pertot DCSD, DEA, PhD David L Pitts DDS, MDSD Alison Qualtrough BChD, MSc, PhD, FDS, MRD RCS John Regan BDentSc, MSC, DGDP Jeremy Rees BDS, MScD, FDS RCS, PhD Louis E. Rossman DMD Stephen F Schwartz DDS, MS Ken Serota DDS, MMSc E Steve Senia DDS, MS, BS Michael Tagger DMD, MS Martin Trope, BDS, DMD Peter Velvart DMD Rick Walton DMD, MS John Whitworth BchD, PhD, FDS RCS

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Volume 6 Number 3

Endoscopic microsurgery for predicable and successful procedures The specialty of endodontics has improved so dramatically over the last several years, thanks to technology and to so many new instruments and products now available to us. Performing apical surgery has become such a predictable and successful procedure. Whereas once a procedure with no greater than 70% success, with the implementation of the surgical operating microscope, microsurgical hand instruments, ultrasonics, biocompatible root-end filling materials, and bone regeneration materials, endodontic microsurgery can now boast a success rate of greater than 90%. This author feels strongly that the “pendulum” is starting to swing back towards saving the natural dentition whenever possible, and therefore, one must include surgical endodontics into their armamentarium. Apical surgery is NOT a substitute for excellent conservative endodontics, but in an era of teeth that are heavily restored, and parts of longstanding fixed prosthetic work, often a surgical approach is the safer and more conservative approach. Many problems can occur during conventional endodontics, such as separated files, ledged, or apically perforated canals, canal transportation, etc., and a surgical approach can correct these issues. Teeth that contain large posts, which put the tooth at great risk for fracture if accessed conventionally, can be saved by surgical endodontics. Endodontic surgery prior to the microscope had fair success. Excess bone was removed in order to be able to see the roots; excess root structure was removed to be able to fit the handpiece inside in order to prepare the root end for an amalgam, which could then corrode and cause reinfection. Under the microscope, we are able to keep our osteotomies small; just large enough to gain access to be able to remove all the diseased tissue. Forty-five degree handpieces are used for easier viewing and only allow sterile water to enter the surgical site, while the air exits out the back of the handpiece head. Only 3 mm of the root is removed, and then the surface is stained with methylene blue dye to look for missed canals, microfractures, isthmuses between canals, and much more. The root ends are then prepared with ultrasonic tips, remaining in line with the long axis of the roots so as not to remove any unnecessary root structure, and then these apical preparations are filled with biocompatible filling materials such as mineral trioxide aggregate (MTA), or newer bioceramic materials. These root-end filling materials have been shown to not only allow new bone and cementum to reform, but they help to induce the formation of new cementum and bone, right up to the root. We also have the great advantage of incorporating 3D imaging into our treatment planning for endodontic surgery, thanks to the CBCT. This is an irreplaceable tool to help us see periapical lesions not seen on films, to measure the amount of bone necessary to drill through to access the apical portion of roots, as well as the proximity of roots to significant anatomical landmarks, such as the mental foramen and the sinuses. One can use the measuring tool on the CBCT to determine the distance between an MB and ML root, for example, on mandibular molars, or the B and P root on maxillary bicuspids, as well as the direction one has to go to find these sometimes elusive roots. Also, as endodontic surgeons, we should be knowledgeable about the various bone grafting and guided tissue regeneration materials available for those cases where there is a combination of an endodontic and periodontal lesion. Of course there are cases where the teeth are just not accessible surgically, such as the second molar region, where the bone is so dense on the mandible and the patient’s lip cannot be pulled back far enough, or those maxillary second molars that are completely in the sinuses. For cases like these, we must consider extraction/reimplantation, which has a documented success rate of over 80% when performed using modern protocol, proper case selection, and a transport medium such as Hanks Balanced Salt Solution, to maintain the viability of the PDL while the tooth is repaired extraorally. Unfortunately, as a practicing endodontist, approximately 25% of my cases are nonsurgical retreatments. These cases take the most time, are the most unpredictable, and have the highest postoperative flare-up rate. As a comparison, endodontic microsurgery is quicker, more predictable, especially in preserving the coronal restorations, and has a negligible flare-up rate. Yes, implants are successful and popular and predictable, but in the words of a well-known periodontist and former Dean of the University of Pennsylvania Dental School, Jan Linde, “Implants replace missing teeth… not teeth.” Endodontists are in the business of saving teeth, and therefore endodontic microsurgery should be something that all patients should be offered as a viable alternative to maintaining their own teeth.

Samuel I. Kratchman, DMD Exton Endodontics, Inc. Exton, Pennsylvania Endodontic practice 1

INTRODUCTION

May/June 2013 - Volume 6 Number 3

TABLE OF CONTENTS

Clinical

Practice profile

Dr. Nishan Odabashian: A focus on patients, colleagues, and family Technology, attention to detail, and knowledgeable mentors combine to help Dr. Odabashian provide a positive experience for patients

Endodontics in 3D In the second in a clinical series, Dr. Richard Kahan discusses targeted endodontics.................. 12 Effects of smear layer and debris removal with irrigation assisted by the EndoActivator and the Endo Brush Drs. Joseph M. Morelli, Mark Sakamaki, Ricardo Caicedo, and Stephen J. Clark compare debris and smear layer removal from instrumented root canals after irrigation...................................... 14

Case study Maxillary molar endodontic case

Corporate profile

presentation Dr. Rahul Bose presents the case report that won him the acclaimed title of Young Dentist Endodontic Award 2012................................. 18

Ultradent Products, Inc. Ultradent continues to lead the way through invention and innovation

2 Endodontic practice

Volume 6 Number 3

simple, adaptable

endodontic solutions

Files to fit your technique. And make apex location easy.

TiLOS hand files work with your technique

Don’t change your technique. Make it easier with TiLOS hand files.

No two root canal treatments are alike. Your techniques are tried and tested, and you perform them on the entire range of cases you see every day. So why not use the hand files that make every procedure faster and easier? Available in stainless steel and NiTi, TiLOS hand files do just that. And they’re made to work with your technique.

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The unique construction of the TiLOS hand files allows the apex locator to be attached to the top of the file rather than below the handle.

TiLOS

TABLE OF CONTENTS

Research The effect of different solvents on root canal sealers Drs. Ane Poly, Juliana Brasil, Paula Marroig, Fabiola Ormiga, Patrícia de Andrade Risso, Marcos Cesar Araújo, and Heloísa Gusman evaluate the ability of solvents used in endodontics to disintegrate different root canal sealers...........................................41

Aspiring endodontists in Jamaica

Case report Detection and endodontic treatment of a three-rooted maxillary second premolar Dr. Imran Cassim presents a case report detailing treatment of a multirooted maxillary second premolar .....................................................22

Endodontics in focus Top ten tips: Tip number 7 – To determine length Continuing his series on endodontics, Dr. Tony Druttman looks at the best ways to measure the length of a canal ....................................................26 4 Endodontic practice

Filling a need Continuing education Preserving the natural smile by immediate reattachment of a fractured tooth Drs. Ramesh Bharti, Deeksha Arya, Anil Chandra, Aseem Prakash Tikku, Rakesh Yadav, and Promila Verma present two case reports detailing the reattachment of a fractured tooth fragment for the restoration of function and esthetics....................28

Endodontics in Jamaica: a fulfilling and challenging experience Dr. Gary Glassman takes his endodontic experience on the road to help aspiring dentists.....................46

Product insight Barbed sutures Dr. Michael Norton discusses the barbed suture and its use in oral surgery .........................................50

Anatomy matters

Direct pulp capping with a bioactive dentin substitute Dr. Markus Firla discusses various solutions for pulp exposure............32

Do lateral canals really matter?

Technology

Diary.............................................54

3D Apical Cork – Part 2 In the second article of this series, Dr. Wyatt Simons discusses the technologic breakthroughs that the Cork delivery device brings to obturation......................................36

Part 6 Dr. John West explores the significance of the lateral canal......52

Materials & equipment ..............55

Ruddle on the radar The NITI shaping movement Fifth generation technology ...........56 Volume 6 Number 3

ORTHOPHOS XG 3D The right solution for your diagnostic needs.

Implantologists

Endodontists

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will enjoy instantly viewable 3D volumetric images for revealing and measuring canal shapes, depths and anatomies.

will appreciate the seamless clinical workflow from initial diagnostics, to treatment planning, to ordering surgical guides and final implant placement.

General Practitioners will achieve greater diagnostic accuracy for routine cases.

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â&#x20AC;&#x153;With my Sirona 3D unit, I can see the anatomy of canals, calcification, extent of resorption, fractures, and sizes of periapical radiolucencies, all of which influence treatment plans for my patients. Combine that with the metal artifact reduction software that reduces distortions from metal objects, my treatment process is a lot less stressful. My patients benefit from the technology and my referrals appreciate the value.â&#x20AC;? ~ Dr. Kathryn Stuart, Endodontist - Fishers, Indiana

The advantages of 2D & 3D in one comprehensive unit ORTHOPHOS XG 3D is a hybrid system that provides clinical workflow advantages, along with the lowest possible effective dose for the patient. Its 3D function provides diagnostic accuracy when you need it most: for implants, surgical procedures and volumetric imaging of the jaws, sinuses and other dental anatomy.

For more information, visit www.Sirona3D.com or call Sirona at: 800.659.5977 www.facebook.com/Sirona3D

PRACTICE PROFILE

Dr. Nishan Odabashian A focus on patients, colleagues, and family What can you tell us about your background? I am the oldest son, second of four children, to parents of Christian Armenian descent whose families ended up in the Syrian Desert after the Armenian genocide of 1915. My father was the oldest son of five, of the oldest son of six. My mother was the youngest of 12, who lost her father at 6 months of age. Although my parents had humble beginnings, my father worked hard to improve his children’s chances of making a better future for themselves. His first major decision towards that goal was to leave Syria and immigrate to the U.S. We arrived in the U.S. from Damascus in 1977 to N. Providence, Rhode Island. I was 12. I quickly adapted to the American way of life by first picking up the English language, and soon becoming a Red Sox, Celtics, Bruins, and Patriots fan. We moved to California after the 1978 snow blizzard. I attended Hollywood High School, and then I realized my father’s dream by being the first from our extended family to attend a university at UCLA. I continued to Tufts University School of Dental Medicine and graduated with a DMD degree in 1991. After 8 years of general restorative dentistry, I went back to school and received a certificate of specialty and a Master’s Degree in Endodontics from Loma Linda University School of Dentistry (LLUSD) in 2001 under the leadership of two giants in the field of endodontics — Drs. Leif Bakland and Mahmoud Torabinejad. I have since had a practice in Las Vegas, Nevada and Bakersfield, California. In 2008, I returned to Glendale, California where I had practiced general dentistry. I run Glendale MicroEndodontics (GME) and work with a wonderful staff who all strive to provide a most positive experience for our patients. My biggest accomplishment in my life is my family. I am married to Lilit going into our tenth year of marriage. Lilit and I are blessed with three children, Galia, 8, Sérge, 5, and Noah, 3, who is a special-needs boy wonder.

Is your practice limited to endodontics? GME’s practice is limited to the specialty of 6 Endodontic practice

(Left to right) Lillia, Office Manager; Ingrid, Assistant; Elizabeth, Clinical Manager; Laura, Assistant in GME’s reception area

endodontics. However, we try to distinguish our office by practicing microscope-aided restorative endodontics. What this really means is that we recognize that endodontic treatment is only half of the treatment, and that the success of our treatment equally depends on the restorative treatment. To ensure our efforts have the maximum chance for success, we provide the permanent coronal restoration. Performing the coronal restoration protects our root canal treatment and reduces the likelihood of: 1.) recontamination of the root canal system, 2.) fracture of the tooth prior to the patient having the crown placed by the general dentist, 3.) procedural accidents during the removal of the temporary and post and core placement by the general dentist, and 4.) having appropriate post size and depth as needed. I also fabricate acrylic temporaries when needed, and make sure the patient returns to the referring doctor almost ready for his/her crown impressions.

Why did you decide to focus on endodontics? I owe my interest in endodontics to two very well-known endodontists from Santa Barbara, California — Drs. Cliff Ruddle and Stephen Buchanan. They were very influential in my becoming an endodontist, as I am sure they have been for many like me. When I graduated dental school, the

Dr. Odabashian’s children: Galia, 8, Sérge, 5, and Noah, 3 during Christmas 2012

“endo” requirement to graduate was to have treated nine canals with a minimum of one molar tooth. Needless to say, I felt inadequate with my root canal treatment abilities, and so I took several courses from Cliff and Steve, and began appreciating the complexity of root canal systems. The more I treated teeth endodontically, the more I enjoyed the challenges that came with treating each tooth. I was lucky enough to have been accepted to LLUSD’s Graduate Endodontics program (to a class of three residents) by Dr. Torabinejad and the rest of the faculty there. My program laid a solid foundation for being an endodontic clinician, an educator, researcher, and a critical thinker.

How long have you been practicing, and what systems do you use? I have been a dentist for over 22 years, a restorative dentist from 1991-1999, and an endodontist from 2001 till the present. I started my training using the Surgical Operating Microscope (SOM) in residency, and I continue to do so on 100% of the cases, from start to finish. I don’t know how it is possible to perform endodontic treatment at a high level without a SOM. I have heard some endodontists who don’t use the SOM say, “It’s just a tool!” I say “You don’t know what you don’t know!” Imagine walking in a pitch dark tunnel Volume 6 Number 3

What training have you undertaken? As I mentioned earlier, I was fortunate to be accepted to do my endodontic specialty training under the well-known Mahmoud Volume 6 Number 3

Torabinejad, the post-graduate program director at LLUSD. Dr. “T,” as he is known by his residents, is not only a program director, he is a clinician, a clinical and didactic instructor, a previous president of the American Association of Endodontists (AAE), inventor, and a father figure to his residents. Dr. T is the developer of Mineral Trioxide Aggregate (MTA), which has been a game-changing material that has allowed the successful repair of iatrogenic and resorptive inflammatory perforations during root canal treatment. When I began the program at LLU, Dr. Torabinejad advised me and the other two incoming residents to expect to spend 1618 hours a day in the program. He was very demanding of his residents, demanding for them to be the best they can be. For me, it was an honor to be one of his students.

Who has inspired you? Professionally, my inspiration comes from Dr. Gary Carr, an endodontist, an author, a visionary, the developer of The Digital Office (TDO) endodontic software, an inventor, and a mentor to hundreds of endodontists who are interested in performing endodontics at a high level. Dr. Carr has always challenged me to be the best that I can be, to always question dogma, and go beyond what is acceptable. I owe Dr. Carr much for being the endodontist that I have developed into. Personally, my inspiration comes from my children. They have taught me much also — patience, humility, sympathy, and understanding, among many other things. I am blessed to have them.

What is the most satisfying aspect of your practice? I am sure I am not alone when I say that the best satisfaction for a clinician is when the result of a treatment is positive, the patient is appreciative, and the referring dentist is glad that he/she is referring his/her patients to you. It is a great feeling when a patient writes a positive review on Yelp, Google, or your website, out of the blue! It is also very satisfying when you receive positive comments from referring doctors about the level of treatment you are providing to their patients. There is no greater professional reward for me.

Professionally, what are you most proud of? I am most proud of the fact that I have the

privilege of helping people; that I have the trust of my patients to take care of their endodontic needs. I am proud that I have built a reputation in my community of being very good in my chosen profession. I am proud that I don’t measure success with the amount of wealth that I amass, rather by the number of people I help. I am proud that I stand for what I believe in, and that I am not fearful of the consequences of doing so. I am also proud of the fact that, in a small way, I am able to contribute to dental education and organized dentistry. Whether it is at the local, state, national, or even the international level, I try to volunteer my time, knowledge, and expertise to help my chosen profession. As the saying goes, “If you are not part of the solution, then you are part of the problem.” I have been a part-time faculty member at LLUSD Department of Graduate Endodontics for the past 10 years. I currently have the privilege of serving as the President of the California State Association of Endodontists, as well as serving as the Chairman of the Bylaws Committee of the International Academy of Endodontics.

What do you think is unique about your practice? What I think is unique about my practice, at least in my immediate community, is that I am not in a hurry to complete a treatment. Also we use the latest technology to the patient’s advantage, whether it’s the microscope, cone beam CT, digital radiography, the Internet, or even social media. If we allow patients to register online or have them receive a text reminder of their appointment, doesn’t that make their lives easier? My endodontic practice is 50% initial treatment and 50% retreatment. Unfortunately, gone are the days where endodontists are referred routine cases. Generally speaking, endodontists are referred failing root canal treated teeth, severely curved or calcified teeth, teeth that have had procedural accidents, or patients who are generally either hard to manage or can’t afford treatment. It takes an office with an experienced doctor, and a knowledgeable and understanding staff to manage these types of referred patients, and at the same time to please the patient, the referring dentist, as well as oneself. I believe that we are able to accomplish this at Glendale MicroEndodontics. Endodontic practice 7

PRACTICE PROFILE

that has three-dimensional curves, where the goal is to reach the end of that tunnel; and now imagine projector lights turned on throughout the tunnel. Which method would you prefer to reach the end of the tunnel? Which would our patients prefer if the tunnel is inside their tooth that needs treatment? Dentistry in general is a profession that requires attention to detail at every step of treatment. One cannot pay attention to detail at a certain part of the treatment, and be sloppy, or even average at another part, and still provide high quality dentistry. For high quality treatment, an endodontist has to be detail-oriented from medical history to dental history, to proper use of radiography (two-dimensional, or 3D if needed), to diagnosis to proper treatment planning to anesthesia, to isolation to cleaning and shaping, to obturation to restoration, to postoperative care. There is not one step that is more important than the next to have a successful practice that is patient centered. In my opinion, there are a few fundamental “musts” as far as instruments and equipment for practicing endodontics at a high level: The SOM, an electronic apex locator (EAL), and more recently a cone beam computed tomography (CBCT) machine (when needed). There are numerous cleaning, shaping, and obturation systems out in the market, and it seems that almost daily, a new file, a new metal, or a new system is introduced, and hailed as the next panacea. These different systems all work if used in the manner in which they were designed. To me, these are mostly secondary. What is primary, in my opinion, is to take the time to listen to the patients and pick up clues about what is their chief complaint; to take the time and diagnose the culprit tooth; to understand that it takes time to perform quality and successful endodontics; to realize that the root canal system is very complex and cannot be dumbed down to three white stripes on a radiograph that can be achieved in 30 minutes; and to educate both patients and general dentists about what is possible with meticulous endodontic treatment.

PRACTICE PROFILE What has been your biggest challenge?

What advice would you give to budding endodontists?

My biggest challenge has been to deprogram general dentists from utilizing endodontists as providers of prescription root canal treatments. I try to get involved in the treatment planning of a patient’s teeth, and demonstrate that I can have valuable input in the total outcome of the dental treatment. It is very hard to get out of the image of a “technician” who does root canal treatment if endodontists do not get more involved in the decision making of the fate of teeth.

The best advice that I can give to budding endodontists is to have a mission statement that represents who they are, and keep striving to reach and maintain it. Keep their personal costs low at the outset of their career. Surround themselves with quality people, whether they are referring doctors or staff people. Practice with their patients’ best interests at heart. Make sure and learn things that were not taught in dental/endo school, such as the business aspects of running a practice and ergonomics. Make quality their priority; people will notice. Put patients first, and success will follow. Try to distinguish themselves from others. Have an online presence. Show concern for their patients, and mean it.

What would you have become if you had not become a dentist? Had I not chosen to become a dentist, I may have become an attorney, or a math teacher. I like to teach, and I like to help people. I especially like to help the weak, and those who have been wronged, or taken advantage of. Maybe that is why I am always rooting for the underdog team in sports competitions. Well, unless if it is my favorite team that is playing!

What is the future of endodontics and dentistry? I believe that endodontics has gone through its golden age. The specialty has challenges that are multifactorial. More than ever, there is the competition of tooth retention versus tooth extraction and replacement with an implant. There is competition with general dentists performing challenging root canal treatments that are beyond the scope of their training or expertise. There is competition with the corporate dental offices that have been sprouting around the nation; ones who mostly feed on newly graduated dentists/endodontists by pressuring them to perform complex or extensive treatments in short periods of time in order to increase production; corporations who only care about quarterly reports and profits for their shareholders and not for the health of their patients. There is competition with corporate-sponsored speakers who give weekend courses that promise to teach “Endodontics A to Z.” There is competition with endodontists who have conflicts of interest, promoting their products and giving their generaldentist audiences a false sense of simplicity to performing root canal treatments. And, finally, there is competition with endodontists delivering mediocre or average care to their patients for different 8 Endodontic practice

The Odabashian family: Wife, Lilit, Dr. Odabashian, Galia, Sérge, and Noah

reasons. Unless all endodontists get involved in teaching at the dental schools; unless we are more active in study clubs and contribute to treatment planning; unless we make high level of care a top priority, and use the available technology; unless we take the necessary time and address the complex root canal anatomy, and put the patient’s needs first; unless we get the message across to general dentists and patients, alike, that root canal treatment can be painless, predictable, yet requires skill and patience; and finally, unless we as endodontists understand that a successful tooth is much more important than a successful root canal treatment, and stop decoupling the endodontic treatment from the restorative treatment, it is going to be very challenging going forward and maintaining endodontics in the high esteem it has enjoyed in the past 50 years. I am hopeful that this will happen. I will do my part to educate my referring doctors and my patients. I am hopeful I can maintain a high standard of care of the specialty that I love.

What are your top tips for maintaining a successful practice? The best advice I can give for maintaining a successful practice is listen to your patients. Treat them with genuine care. Make sure you communicate with your referring doctors and colleagues. Be involved in the community. Educate general dentists and your patients. Always stay ahead of the curve.

What are your hobbies, and what do you do in your spare time? My favorite thing to do besides spending time with my family and performing endodontic treatment is playing bridge. Whether it is social bridge or tournamentstyle bridge, I forget about the rest of the world when I am playing it. One day, I would like to travel the world, and play at national and international tournaments. I also like to watch sporting events especially live. Every chance I get, I take my kids, five nephews, and two nieces to professional basketball, baseball, and hockey games. I want to one day attend the French Open, Wimbledon, the Australian Open, and the U.S. Open tennis tournaments in the same year! EP

TOP FAVORITES My wife Lilit, and my children, Galia, Sérge and Noah Reading the Bible Playing bridge Having a successful outcome on teeth that would have been deemed not treatable by other clinicians TDO Clinical Forum The Surgical Operating Microscope, without which I don’t think I could practice endodontics Traveling Cars Learning Teaching To contact Dr. Odabashian, email nishan@glendalemicroendodontics.com.

Volume 6 Number 3

h t s I

s e s

d n n a o i t ls a a ig n r r a I C e l al d r e e e t La n N e ha t T a

r er t e tt n e e B P

Ultrasonic Irrigator • Distributes and ultrasonically activates sodium hypochlorite to increase debridement of lateral canals and isthmuses • Ratcheting syringe permits controlled delivery of 0.2 ml of solution with each audible click Benefits of Continuous Ultrasonic Irrigation: • Removes significantly more debris from narrow isthmuses better than conventional needle irrigation* • Significantly increases the penetration of irrigation solutions into lateral canals** *Adcock et al, J.Endod. 2011; 37 (4) **Castelo-Baz et al, J. Endod. 2012; 38 (5)

235 Ascot Parkway | Cuyahoga Falls, OH 44223 Tel. USA & Canada 800.221.3046 | 330.916.8800 | coltene.com PATENT PENDING

CORPORATE PROFILE

History of Ultradent Dr. Dan E. Fischer is the founder and president of Ultradent Products, Inc., a dental manufacturer with a 35-year history of innovation and quality. Now an international leader in the dental industry, Ultradent began humbly — in Dr. Fischer’s basement with his children as its first employees. Following graduation from Loma Linda University in 1974 and starting his own dental practice, Dr. Fischer realized that rapid, profound hemostasis was imperative for quality tissue management and operative dentistry. Because there were no products on the market that predictably controlled bleeding and sulcular fluid, he decided to develop one. Using his naturalborn insight, determination, and willingness to work after hours, Dr. Fischer began experimenting with different chemistries, even drawing his own blood to test their hemostatic effects. Within a short time, Dr. Fischer came up with what are now Ultradent’s flagship tissue management products, Astringedent®, and later ® ViscoStat . Business grew rapidly, and over the next 35 years, Ultradent expanded from a home operation to a 220,000-squarefoot facility, which presently houses more than 1,000 employees. Ultradent is the most vertically integrated dental company in the world — manufacturing over 90% of its products (which includes over 500 materials, devices, and instruments) at its South Jordan, Utah, headquarters. Ultradent prides itself on its technologically advanced way of doing things. In fact, with the exception of the auto industry, Ultradent uses more robotics than any other company west of the Mississippi. Instead of saving on production costs through outsourcing, which many U.S. manufacturers do, Dr. Fischer firmly believes in the opposite. He says, “The more one outsources, the more one ships production, or R&D, or other aspects to other parts of the world, the more one loses touch with what has made them who they are.” Ultradent continues to lead the way through invention and innovation. The company holds numerous U.S. patents (both granted and pending) and continues to expand internationally into many parts 10 Endodontic practice

of Europe, Asia, and South America. Beyond its humble beginnings in tissue management products, Ultradent’s product family now includes world-class adhesives, composites, tooth whitening systems, and more. Ultradent has also expanded its reach to orthodontics, serving as the parent company of Opal Orthodontics. Its South Jordan headquarters even boasts an onsite orthodontic clinic. Although Ultradent strives to offer the latest and greatest in technology, Dr. Fischer’s passion for a minimally invasive approach to dentistry has and will continue to guide the development of every new product created in the future.

Ultradent Endodontics Like the story behind the conception of Astringedent, Ultradent’s endodontic solutions were born out of necessity. Dr. Fischer noticed a need for a successful endodontic protocol that could be done with the minimally invasive criteria he is so passionate about. The result was Endo-Eze® AET™ (Anatomic Endodontic Technology) classic stainless steel files, which utilize a reciprocating motion. These uniquely designed files proved very effective in following the natural canal shape and minimizing apical transportation and ledging. This new approach paved the way to the array of endodontic products Ultradent offers the clinician today.

Building on the success of the EndoEze AET classic stainless steel files, Ultradent developed the world’s first hydrophilic and self-priming resin sealer, EndoREZ® canal sealer. When paired with the NaviTip® — with its flexible, stainless steel cannula, designed to easily navigate curved canals — EndoREZ canal sealer offers easier obturation in less time, has the same radiopacity as the gutta percha, and consistently delivers a complete, thorough seal. It’s also worth noting that the NaviTip was the first tip on the market capable of safely delivering irrigants to the apex.

Building on the success of the AET files, Ultradent created the Endo-Eze® AET™ TiLOS® system — a hybrid of stainless steel and NiTi files optimized for the company’s 30-degree reciprocating handpiece, Endo-Eze® Arios®. The awardwinning TiLOS system features a userfriendly, straightforward instrumentation sequence, and comes in autoclavable, preconfigured packs. The RediPack offers tools to address each canal according to its unique anatomy and is equipped to treat 90% of endodontic cases. TiLOS’ ribbonshaped, ovoid handles also provide more comfort and ease of grip to the clinician than ever before. The Endo-Eze Arios’ reciprocating motion facilitates rapid, complete, uniform instrumentation of all the walls in an irregularly shaped canal, while preserving more tooth structure than traditional rotary systems. The pairing of Arios with the TiLOS files thus accomplishes a “milling” action, instead of a “drilling” action, while also eliminating file breakage. Ultradent’s vision to “Improve Oral Health Globally” through minimally invasive dentistry and to design products as an

answer to the call of clinicians worldwide continues to shape the success of the company in this, its 35th year in the industry. To learn more about the endodontic products mentioned or the wide array of additional endodontic solutions provided by Ultradent, please visit ultradent.com, or call 800-552-5512. EP This information was provided by Ultradent Products, Inc. Volume 6 Number 3

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TDO IS CONE-BEAM INTEGRATED Turns out there’s a correlation between quality of care and quality of life. TDO software is now seamlessly integrated with both the J. Morita and Kodak CBCT units, and both endodontists and patients alike couldn’t be more pleased. For patients, TDO CBCT means being able to review scans chairside in the comfort of your office. For you, it means scans are saved to each patient’s chart, and a comprehensive TDO CBCT report is generated within just three minutes—a function no other software provides. Find out how TDO can save you time, money, and most importantly, headaches. Switch to the only endodontic software that is truly CBCT integrated—TDO. “With TDO’s CBCT integration, all of my volumes are acquired and saved within each patient’s chart, so they can be pulled up effortlessly without searching. I am able to review these volumes with my patients chair-side immediately after acquisition. I could not imagine using CBCT imaging without TDO integration. It saves a tremendous amount of time.” — Dr. Robert Corr, Colorado Springs, CO

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CLINICAL

Endodontics in 3D In the second in a clinical series, Dr. Richard Kahan discusses targeted endodontics

his series of case discussions highlights the use of cone beam computed tomography (CBCT) in clinical endodontics, and how it is used to enhance diagnosis, decision-making, treatment planning, and the treatment itself. In the first article in the series, which appeared in Endodontic Practice US, September/October 2012, Volume 5, No. 5, I explained the reason why periapical and periradicular lesions might not show on conventional 2D radiographs. This would explain the relatively poor scores of 55-77% for sensitivity in diagnosing such lesions (Bohay, et al., 2000; Estrela, et al., 2008). The accuracy of CBCT elevating sensitivity to 91% in one study (de PaulaSilva, et al., 2009) means that as well as providing the ability to detect disease and find “hidden lesions,” it can be used accurately to confirm the lack of disease. This is particularly useful in endodontic retreatment cases showing signs of failure. In many cases, the endodontic treatment objectives have been satisfactorily achieved in all but missed anatomy, with a lesion only associated with an untreated canal. In a situation where presence or lack of disease cannot be absolutely confirmed, it would be necessary to retreat the entire canal system. With CBCT, a lesion can be accurately traced to its source, possibly a single root of a multi-rooted tooth; therefore, sometimes treatment can be targeted at the diseased root leaving the other canals intact. This principle of Targeted Endodontics has benefits in time, cost to the patient, simplicity, and reducing the chances of

Richard Kahan, BDS, MSc (Lond), LDS RCS (Eng), is a specialist endodontist working in Harley Street, London, and the former Director of Endodontic Courses at UCL Eastman CPD. He has lectured widely on endodontics and technology and has recently set up the Academy of Advanced Endodontics to teach the fundamentals of endodontics to GDPs through extended mentoring within his practice. With 5 years’ experience of endodontic CBCT using the Morita Veraviewepochs 3D, his clinic has become a referral center for complex cases used by both endodontists and GDPs. For more information visit www.endodontics.co.uk.

12 Endodontic practice

Figure 1: Preoperative periapical radiograph. Distal radiolucency associated with the LL4. Mesial radiolucency at LL6

Figure 2: CBCT saggital slice – confirming distal positioning of the periapical lesion at LL4. The mental foramen is below the LL5. The periapical lesion at the LL6 relates to recent treatment

iatrogenic damage to sound roots during retreatment for no benefit.

scan confirmed the presence of a small lesion at the distal part of the root apex of the LL4 (Figure 2). The coronal slice (Figure 3) confirms the periodontal ligament space beneath the root filling is intact. The axial slice (Figures 4A and 4B) reveals the source of the lesion to be a separate untreated distolingual canal. Vertucci (1978) quotes a frequency of 74% for two separate canals in a lower first premolar. Importantly in this case, although deficient in terms of a gap between the post and apical extent of the root filling, there were no signs of apical pathology associated with the filled mesial canal (Figure 3). The position of the mental foramen, which is an important consideration in surgical planning, was found to be inconsequential (Figure 2).

Clinical details The patient was a 57-year-old male with no relevant medical history, complaining of mild pain associated with his post-crowned and root-filled LL4. The tooth had been treated and restored many years previously and had an unblemished history until this point. The porcelain-bonded crown was esthetically and functionally satisfactory with a good marginal seal. Clinically, there was some minor tenderness to percussion from both an occlusal and buccal direction without any tenderness to palpation. The surrounding periodontal condition was satisfactory and soft tissues healthy. The periapical radiograph (Figure 1) revealed a post-crown restoration with an associated root filling just sealing the apical 3 mm of the root. The post was relatively wide with a post-crown ratio of 2:1. Beyond the post and down to the root filling was a void of approximately 4-5 mm. Both the post and the root filling were asymmetrically positioned in the root, suggesting some form of anatomical deviation in the distal segment of the root. A small apical lesion was associated with distal part of the root apex. Also noted was a satisfactory root filling in the LL5. A periapical lesion was present at the mesial root of the LL6 that had been recently root treated. Both the LL5 and LL6 were found to be clinically asymptomatic. The limited volume 4 cm x 4 cm CBCT

Treatment considerations If we take the perspective given to us by the periapical radiograph alone, the best treatment option here is limited to the removal of the crown, post removal, retreatment of the existing root-filled canal (due to the gap and possibility of apical pathology), along with a search for any further canal(s) in the distal root segment. This would entail significant time and expense in deconstruction, temporization, and an eventual new post-crown, as well as the risk of root fracture on post removal and weakening tooth structure hunting for further canal anatomy. The surgical option runs the risk of mental nerve damage and leaving large Volume 6 Number 3

CLINICAL

Figure 3: CBCT coronal slice - The periodontal ligament space below the root filled canal is intact and healthy

Figures 4A and 4B: CBCT axial slices – The cross-sectional shape of the root of the LL4 is a figure eight with an untreated canal in a distolingual position

Figure 6: Successful location of the distolingual canal orifice in the LL4

segments of contaminated canal untreated, with only the apical retro seals blocking these off from the periapical tissues. Once these inevitably leak, the lesion will return. With the view that CBCT confers, the fact that the unsatisfactory-looking root filling can be confirmed as not contributing to the pathological process liberates us from the necessity to involve the mesial canal and its post in the treatment plan. Treatment can be targeted precisely at the cause of the pathology, which is an untreated distal canal. This allows us a faster, safer, and cheaper plan, guided by axial CBCT slices acting as a positioning system, to locate and treat the distal canal only.

Treatment Although faster and potentially safer, the treatment process was not without technical difficulty as lining up a cavity through a crown and cast core is fraught with possibilities of missing the distal canal orifice and perforating the root. The safest means of guiding a bore hole through the crown to the distal canal orifice would be using a drilling jig built on a 3D printed model of the tooth, in a similar way to guided implant placement. However, this was not feasible as it was impossible to produce the accurate stereolithographic files necessary for a 3D printing with the metallic artifact and beam Volume 6 Number 3

Figure 7: Check periapical confirming location and negotiation of untreated distolingual canal in the LL4

hardening around the post-crown. In practice, I use a “Heads-Up display” (HUD) means of working (Figure 5), with positioning in the tooth constantly being checked against landmarks on enlarged scan slices. Through this technique, I was able to successfully drill down to the distal canal orifice (Figure 6) and check that I had correctly entered the root canal (Figure 7). Endodontic treatment was completed in a single session following chemomechanical preparation using Hedstrom files and a hybrid ProTaper (Dentsply) and GT® hand file protocol (Dentsply Tulsa Dental Specialties), together with heated sodium hypochlorite and EDTA irrigation. Gutta percha and Roth’s sealer cement obturation was carried out using System B™ (SybronEndo) vertical heat condensation with a Calamus® backfill. The orifice was countersunk with a Gates-Glidden No. 5 bur, and a permanent amalgam alloy post core was placed through the access cavity (Figures 8 and 9).

Follow-up The patient was checked the next day, and no ill effects were reported. One week later, he reported that the area was comfortable, and that the dull ache in the lower left quadrant had resolved. A further appointment for a review radiograph was scheduled for 6 months.

Figure 5: Super-large clinical Heads-Up Display (HUD)

Figure 8: View of the coronal gutta percha in the distolingual canal of the LL4

Figure 9: Postoperative periapical radiograph

Summary An elegant and simple endodontic treatment plan can sometimes become accessible if accurate diagnostic information is made available. In this case, CBCT was used to target the pathology and allow us to ignore an expensive and potentially risky alternative that would have no impact on the disease process. EP

References Vertucci F J. Root canal morphology of mandibular premolars. J Am Dent Assoc. 1978;97(1):47-50. Bohay R N. The sensitivity, specificity, and reliability of radiographic periapical diagnosis of posterior teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2000;89(5):639-642. Estrela C, Bueno MR, Leles CR, Azevedo B, Azevedo JR. Accuracy of cone beam computed tomography and panoramic and periapical radiography for detection of apical periodontitis. J Endod. 2008;34(3):273-279. de Paula-Silva FW, Wu MK, Leonardo MR, da Silva LA, Wesselink PR. Accuracy of periapical radiography and cone-beam computed tomography scans in diagnosing apical periodontitis using histopathological findings as a gold standard. J Endod. 2009;35(7):1009-1012.

Endodontic practice 13

CLINICAL Effects of smear layer and debris removal with irrigation assisted by the EndoActivator and the Endo Brush: A comparison with unassisted standard syringe irrigation with 5.25% NaOCl and 17% EDTA Drs. Joseph M. Morelli, Mark Sakamaki, Ricardo Caicedo, and Stephen J. Clark compare debris and smear layer removal from instrumented root canals after irrigation Abstract Cutting of dentin during root canal therapy produces a debris layer that coats the dentin. This has been termed “smear layer.” The purpose of this study was to compare smear layer or debris removal from instrumented root canals using assisted and unassisted irrigation methods. Eighty single canal teeth were decoronated and hand instrumented to a No. 20 K-file. Instrumentation was then completed with .04 rotary K3 (SybronEndo) files to a Master Apical File (MAF) of size No. 40. One ml of 5.25% NaOCl was used to irrigate canals between file sizes in all groups. Samples were divided into four groups. After instrumentation, all canals were irrigated with 1 ml of 17% EDTA for 1 minute followed by a final rinse of 3 ml of 5.25% NaOCl. This was accomplished using a 3cc syringe and Monoject 27 gauge irrigation needle. Group one was designated the control group. In the three experimental groups, irrigation was also assisted with either the Endo Brush®(Roeko) in standard low-speed handpiece (Group

Joseph Morelli received his DDS degree from Loyola University and his Endodontic certificate from Tufts University. He is currently an Associate Professor of Endodontics at the University of Louisville and a Diplomate of American Board of Endodontics. Mark Sakamaki received his DDS degree from the University of Colorado and his Endodontic certificate from the University of Louisville in 2008. He is currently in private practice in Floyds Knobs, Indiana. Ricardo Caicedo received his Dr Odont degree from the Colegio Odontologico Colombiana in Bogota, Colombia and his endodontic certificate from the University of Louisville. He is currently an Associate Professor of Endodontics at the University of Louisville. Stephen Clark received his DMD degree and endodontic certificate from the University of Kentucky and is currently a Professor of Endodontics at the University of Louisville. He is a Diplomate of the American Board of Endodontics.

14 Endodontic practice

Figure 1: SEM of dentin at 500X wth smear layer (left) and SEM of dentin at 500X after smear layer removal showing less debris and patent dentin tubules

2), the EndoActivator® (Group 3) [Dentsply Tulsa Dental Specialties], or the Endo Brush® in Sonicare® toothbrush (Group 4). Samples were scored for remaining debris using digital photography and Adobe® Photoshop® software. These samples were submitted for statistical analysis. Four samples from each group were randomly selected and submitted for SEM analysis. The EndoActivator group was found to be somewhat more efficient, but there was no statistical significance between the groups when comparing debris or quantity of smear layer removal.

Introduction The smear layer has been a subject of interest to investigators since the 1970s (Figure 1). There is lack of agreement to the significance of the smear layer and whether it should be removed. There is further lack of agreement regarding the significance of smear layer on instrumentation, obturation, and clinical outcome. Conflicting results have been obtained in numerous in vitro studies. Orstavik and Haapasalo1 showed in an in vitro study that removal of smear layer with resultant patent dentinal tubules decreased time necessary for disinfection of the dentin with intracanal medicaments. Other studies have shown better adhesion of obturation materials to canal walls after smear layer removal.2,3 Other studies have shown no effect of smear layer removal on microleakage of root canals with various

sealers and obturation techniques.4-7 Timpawat, et al.,8 showed conflicting results. This study reported that removal of the smear layer has adverse effects on microleakage of filled root canals. Despite conflicting studies, Torabinejad in a review article,9 states that “One may deem it prudent to remove the initially created smear layer in infected root canals and to allow penetration of intracanal medicaments into the dentinal tubules of these teeth.” Various methods have been used to remove smear layer. McComb and Smith were the first investigators that showed REDTA (a commercially available solution of EDTA) can remove smear layer.10 Goldman reported that REDTA alone removes the inorganic layer but does not remove the organic constituent.11 In later studies, Goldman, et al., as well as Yamada, et al., and Baumgartner and Mader showed that alternating the use of EDTA and NaOCI is an effective method of removing the smear layer.12-14 Other studies have tested various mixtures and concentrations of chemicals and application times.16-17 Products continue to come to the market claiming the ability to enhance smear layer removal. The Endo Brush (Figures 2 and 3) has been developed to mechanically assist the cleaning of the smear layer within the root canal. It is a synthetic brush thin enough to fit into a root canal and can be attached to the handle of a Sonicare toothbrush or Volume 6 Number 3

CLINICAL

THE FUTURE HAS RETURNED.

THE ORIGINAL PLASTIC ENDODONTIC ROTARY FINISHING FILE IS BACK. MANUFACTURER DIRECT.

Figure 2: Roeko Endo Brush as supplied from manufacturer

MADE IN THE U.S.A.

Figure 3: Roeko Endo Brush in prototype handpiece

standard low-speed handpiece. When activated, the brush rotates within the canal during irrigation. The EndoActivator (Figure 4) uses a flexible, noncutting polymer tip attached to a special handpiece that vibrates the tip up to 10,000 cpm, thus agitating the irrigation solution. Manufacturers of both of these products claim enhanced smear layer removal. Solaiman, et al.,18 compared a brush covered needle (NaviTip® FX®, Ultradent) to irrigation with a standard needle without the brush cover. They found cleaner coronal thirds of instrumented root canals compared to the control group, but no significant differences for the middle and apical third of the canals. Uroz-Torres, et al.,19 evaluated the EndoActivator system in removing smear layer after rotary instrumentation, with and without a final flush of 17% EDTA in the coronal, middle, and apical thirds of canals. They found no significant differences. The purpose of the present study was to compare debris and smear layer removal from instrumented root canals after irrigation with 5.25% NaOCI and 17% EDTA, either unassisted or assisted by the Endo Brush in a standard low-speed handpiece, Endo Brush in the Sonicare toothbrush, or with the EndoActivator. Methods and Materials: This study followed the method previously used by Crumpton, et al.20 Eighty single canal anterior and premolar human teeth were stored in 1:10 dilution of 5.25% NaOCI. Volume 6 Number 3

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Teeth were decoronated, and the root length standardized at 15 mm. Working length was established with a No. 10 K-file placed in the canal until just visible at the apex and 1 mm subtracted from this length. All teeth were hand instrumented to a size 20 K-file, then instrumented to working length with rotary instrumentation using K3 0.04 taper files in a crown-down technique to a MAF size No. 40. One ml of 5.25% NaOCI was used to irrigate each canal between files. The samples were then divided into four groups of 20 teeth: Group 1: (control) Samples were irrigated with 1 ml of 17% EDTA for 1 minute followed by a final rinse of 3 ml of 5.25% NaOCI. Group 2: Samples were irrigated with 1 ml of 17% EDTA with mechanical assistance by the Endo Brush in a standard slowspeed handpiece for 1 minute followed by a final rinse of 3 ml of 5.25% NaOCI. When used, the Endo Brush was placed into the canal to within 2 mm of the working length and activated. A pumping motion was used to move the Endo Brush in 2-3 mm vertical strokes for 60 seconds. Group 3: Samples were irrigated with 1 ml

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of 17% EDTA with mechanical assistance by the EndoActivator for 1 minute followed by a final rinse of 3 ml of 5.25% NaOCI. When used, the EndoActivator was placed into the canal to within 2 mm of the working length, and run at 10,000 cpm. A pumping motion was used to move the EndoActivator in 2-3 mm vertical strokes for 60 seconds. Group 4: Samples were irrigated with 1 ml of 17% EDTA with mechanical assistance by the Endo Brush in a Sonicare electric toothbrush followed by a final rinse of 3 ml of 5.25% NaOCI. When used, the Endo Brush was placed into the canal to within 2 mm of the working length and activated. A pumping motion was used to move the Endo Brush in 2-3 mm vertical strokes for 60 seconds. Teeth were longitudinally grooved with a diamond disk and split buccolingually. A digital photograph was taken of the split tooth using a Canon EOS 10D camera with Canon Macrolens EF 100mm. Magnification Ration: 1:1. (Figures 5 and 6). This image was imported into Adobe Photoshop 7.0 and magnified X10 using the zoom tool. Canal area and debris were outlined using the Lasso tool. The Endodontic practice 15

CLINICAL

Figure 4: The EndoActivator, Advanced Endodontics

Figures 5-6: Canon EOS 10D camera and set up to photograph tooth specimens

Type III Sum of Squares

Mean Square

Hypothesis

.434

Error

.090

2.009

.045

Hypothesis

.037

.012

Error

.154

6.066

.025

Hypothesis

.090

.045

Error

.153

6.041

.025

Hypothesis

.152

.025

Error

3.852

196

.020

Partial Eta Squared

Sig.

9.713

.089

.829

.482

.707

.192

1.766

.249

.369

1.293

.262

.038

Intercept

Group

Evaluator

Group * Evaluator

Figure 7: Means Plot of different group means of percent debris

histogram function was used to calculate the percentage of debris remaining in the coronal, middle, and apical thirds. Four samples from each group were randomly selected and prepared for SEM analysis. A representative sample from the coronal, middle, and apical thirds of each root was examined. Smear layer was scored according to criteria used by Torabinejad, et al.21 The three evaluators were two full-time endodontic faculty and one endodontic resident.

Results A Linear Univariate Analysis was done to test for a significant difference in means among the four test groups and among the three evaluators (Figure 7). There was no significant difference among all groups interacted with all the evaluators. Because of the small sample size for the photomicrographs, no statistical analysis was performed. The evaluatorsâ&#x20AC;&#x2122; scoring indicated a similar number of clean canals in the coronal and middle sections for all 16 Endodontic practice

test groups. With all techniques, clean or moderately clean canals were seen in the coronal and middle third of the specimens. High levels of debris were seen in the apical thirds in all groups. Scores of 3 (high level of debris) were most common in apical third specimens for all groups. Representative photomicrographs are shown in Figure 9.

Discussion This study compared smear layer and debris removal from instrumented root canals using assisted and unassisted irrigation methods. Although there was no statistical significance, the EndoActivator tended to produce cleaner canals (Figure 8). Perhaps with a larger sample size, there would have been some significance. Evaluation of the photomicrographs indicated that all methods produced similar results and were capable of rendering clean or moderately clean canals. All photomicrographs showed some remaining debris even in sections judged as clean with little or none. Unlike the Solaiman

Figure 8

study in which no significant difference was found between coronal, middle, and apical thirds, this study found most debris in the apical third for all methods. This study did not compare coronal, middle, and apical segments of the canals. However, all methods appeared to be more effective in the coronal and middle segments of the instrumented canals. A future study could test for significance at different canal levels. Volume 6 Number 3

CLINICAL

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References

Figures 9A-9D: A. Group 1, apical third, 1000X. B. Group 2, apical third, 1000X C. Group 3, apical third, 750X. D. Group 4, middle third, 750X

1. Orstavik D, Haapasalo M. Disinfection by endodontic irrigants and dressings of experimentally infected dentinal tubules. Endod Dent Traumatol. 1990;6(4):142-149. 2. Tidmarsh BG. Acid-cleansed and resin-sealed root canals. J Endod. 1978;4(4):117-121. 3. White RR, Goldman M, Lin PS. The influence of the smeared layer upon dentinal tubule penetration by plastic filling materials. J Endod. 1984;10(12):558-562. 4. Evans JT, Simon JH. Evaluation of the apical seal produced by injected thermoplasticized Gutta-percha in the absence of smear layer and root canal sealer. J Endod. 1986;12(3):101-107.

Conclusions There was no significant difference among test groups. Assisted irrigation with the EndoActivator appeared to produce the cleaner instrumented canals although the differences were not significant. It would seem that the addition of sonic aggitation to standard irrigation with syringe does increase the efficiency of removing debris and smear layer from instrumented canals. Further studies are necessary to find methods of improvng the cleanliness of instrumented canals at the apical third level as current methods produce the least desirable results at this level. EP Volume 6 Number 3

5. Saunders WP, Saunders EM. Influence of smear layer and the coronal leakage of Thermafil and laterally condensed gutta-percha root fillings with a glass ionomer sealer. J Endod. 1994;20(4):155-158. 6. Madison S, Krell KV. Comparison of ethylenediamine tetraacetic acid and sodium hypochlorite on the apical seal of endodontically treated teeth. J Endod. 1984;10(10):499-503. 7. Timpawat S, Sripanaratanakul S. Apical sealing ability of glass ionomer sealer with and without smear layer. J Endod. 1998;24(5):343-345. 8. Timpawat S, Vongsavan N, Messer HH. Effect of removal of the smear layer on apical microleakage. J Endod. 2001;27(5):351-353. 9. Torabinejad M, Handysides R, Khademi AA, Bakland LK. Clinical implications of the smear layer in endodontics: a review. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002;94(6):658-666. 10. McComb D, Smith DC. A preliminary scanning electron microscopic study of root canals after endodontic procedures. J Endod. 1975;1(7):238-242. 11. Goldman LB, Goldman M, Kronman JH, Lin PS. The efficacy of several irrigating solutions for endodontics: a scanning electron microscopic study. Oral Surg Oral Med Oral Pathol. 1981;52(2):197-204.

12. Goldman M, Goldman LB, Cavaleri R, Bogis J, Lin PS. The efficacy of several endodontic irrigating solutions: a scanning electron microscopic study: Part 2. J Endod. 1982;8(11):487492. 13. Yamada RS, Armas A, Goldman M, Lin PS. A scanning electron microscopic comparison of a high volume final flush with several irrigating solutions: Part 3. J Endod. 1983;9(4):137142. 14. Baumgartner JC, Mader CL. A scanning electron microscopic evaluation of four root canal irrigation regimens. J Endod. 1987;13(4):147-157. 15. Baker NA, Eleazer PD, Averbach RE, Seltzer S. Scanning electron microscopic study of the efficacy of various irrigating solutions. J Endod. 1975;1(4):127-135. 16. Grawehr M, Sener B, Waltimo T, Zehnder M. Interactions of ethylenediamine tetraacetic acid with sodium hypochlorite in aqueous solutions. Int Endod J. 2003;36(6):411-415. 17. Teixeira CS, Felippe MC, Felippe WT. The effect of application time of EDTA and NaOCI on intracanal smear layer removal: an SEM analysis. Int Endod J. 2005;38(5):285-290. 18. Al-Hadlaq SM, Al-Turaiki SA, Al-Sulami U, Saad AY. Efficacy of a new brush-covered irrigation needle in removing root canal debris: a scanning electron microscopic study. J Endod. 2006;32(12):1181-1184. 19. Uroz-Torres D, Gonzalez- Rodriquez MP, Ferrer-Luque CM. Effectiveness of the EndoActivator System in removing the smear layer after root canal instrumentation. J Endod. 2010;36(2):308-311. 20. Crumpton BJ, Goodell GG, McClanahan SB. Effects on smear layer and debris removal with varying volumes of 17% REDTA after rotary instrumentation. J Endod. 2005;31(7):536538. 21. Torabinejad M, Khademi AA, Babagoli J, Cho Y, Johnson WB, Bozhilov K, Kim J, Shabahang S. A new solution for the removal of the smear layer. J Endod. 2003;29(3):170-175.

Endodontic practice 17

CASE STUDY

Maxillary molar endodontic case presentation Dr. Rahul Bose presents the case report that won him the acclaimed title of Young Dentist Endodontic Award 2012 “Endodontology is concerned with the form, function and health of, injuries to, and disease of the dental pulp and periradicular region, their prevention and treatment.” —European Society of Endodontology, 2006

Young Dentist Endodontic Award, sponsored by the The Harley Street Centre for Endodontics, invited young dentists from the UK who graduated in the last 3 years to submit a case report of their best endodontic treatment so far.

hen the pulp is subject to continued stimulation from microorganisms, the inevitable result is its irreversible destruction and complete breakdown. Anaerobic bacteria may then exploit the enclosed environment of the pulp chamber and proliferate. Consequently, the inflammatory process may spread beyond the confines of the pulp chamber and into the periapical tissues. The main aim of treatment is the ability to control the intracanal infection. Root canal therapy is performed with the intention of thorough mechanical and chemical debridement of the entire pulp space followed by complete obturation with an inert filling material. Success is measured in terms of clinical signs, symptoms, and radiographic evidence of healing.

Table 1: Using Endo Frost (Coltène®), the following teeth were tested for vitality

Tooth

Result

UR6

Negative

UR5

Positive

UR7

Positive

Case history A 30-year-old medically fit female attended complaining of low grade dull ache localized to the UR6. After a thorough history and examination, a diagnosis of apical periodontitis of the UR6 was made (Table 1). Treatment options were discussed, following which treatment entailing prevention, restorative, and endodontic care was undertaken. The UR6 required a conventional root canal, and using the AAE’s American Endodontic Case Difficulty Assessment Form, it was deemed to be of minimal to moderate difficulty. Informed consent was gained, explaining the benefits, risks, and alternative options for procedure and treatment. The prognosis was assessed to be around 80-85% due to the radiographic evidence of a

Rahul Bose, BDS, is a general dental practitioner, practicing in Oxford and London, England.

18 Endodontic practice

Figure 1: Pre-endodontic treatment radiograph

Figure 2: Prepared access cavity

periradiculuar lesion (Figure 1). Treatment was performed in one visit (Figini, et al., 2007) under rubber dam and anesthesia, which helped in managing the patient’s anxiety. The access cavity was prepared prior to placement of the rubber dam. The aim was to achieve straightline access and to preserve tooth tissue (Qualtrough, et al., 2005). Further refinement was performed using an ultrasonic scaler and a round bur on a long neck to remove dentin overlying the canal orifices. Magnification (2.5% Orascoptic loupes with illumination) and a DG16 probe were used to find the MB2 canal, but in this case, only three canals were located (Figure 2). Disinfection was performed using a small gauge needle (30) and 3% sodium

hypochlorite (NaOCl). Coronal third shaping was then performed with copious irrigation throughout using Gates-Glidden burs. An electronic apex locator (Root ZX®, J Morita Corp.) was used to determine working length (Simon, et al., 2009), and canal patency was obtained using a size 10 stainless steel K-file. Apical preparation was then performed using a size 30, .06 taper ProFile® nickel-titanium rotary instrument (Dentsply Maillefer) lubricated with EDTA (Glyde™, Dentsply). A strict irrigating regime was employed throughout the cleaning and shaping phase of treatment (Table 2). The technique used to obturate the three canals was cold lateral condensation followed by thermo compaction of gutta percha (GP) using a gutta condenser and Sealapex™ Volume 6 Number 3

Figure 5: Postoperative radiograph

Figure 4: Obturation

Figure 6: One-year follow-up radiograph

(SybronEndo) [Figures 3 and 4]. Coronal seal was then obtained using Vitrebond™ (3M) to seal the GP followed by a Fuji IX™ Core (GC) and a hybrid composite (3m Z250). A postoperative periapical of the UR6 showed the final outcome was good (Figure 5), and over a period of 12 months, the periradiculuar lesion had healed (Figure 6), and the patient was symptom free.

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The irrigating probe confirmed

Discussion

THE BEST

The aim of the treatment provided to the patient was based on integrating the best evidence with clinical knowledge and patient preferences. The following areas warrant further discussion regarding the treatment provided: 1. Why was 3% NaOCl used rather than any other irrigant? Evidence available suggests that NaOCl is the “gold standard” irrigant to use in root canal treatment in comparison to chlorhexidine, iodine, and other products (Eliyas, Briggs, Porter, 2010). When used in combination with 15-17% EDTA, both inorganic and organic substances can be removed effectively. The EDTA also enhances the antimicrobial effects of the NaOCl due to removal of the smear layer (Hülsmann, Heckendorff, Lennon, 2003). Concentrations of 0.5%-5.25% NaOCl have been Volume 6 Number 3

2. Are apex locaters more effective than radiographs for working length measurements? Modern apex locators are shown to be more accurate in working length determination than a radiograph (Pagavino, Pace, Baccetti, 1998; McDonald, 1992). They work using different frequencies,

in the Journal of Endodontics.

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Endodontic practice 19

CASE STUDY

Figure 3: Obturation

shown to have the same antibacterial effect (Byström, Sundqvist, 1983). However, NaOCl at greater concentrations dissolves vital and necrotic tissue faster, but in turn carries the potential risk of extrusion from the apical foramen, resulting in rapid, painful, and serious inflammatory response. Three percent is a good compromise, and its use is also recommended by endodontist Tony Hoskinson. There is also evidence to suggest that heating NaOCl to temperatures of 45-60°C significantly increases the effectiveness of the solution (Sirtes, et al., 2005). However, no facility existed within the practice to heat the solution while performing the treatment.

CASE STUDY Table 2: Irrigation regime

Irrigation regime: Irrigate copiously and frequently with room temperature 3% NaOCl during mechanical preparation. Every third irrigation, EDTA used. After shaping complete: Two minutes with NaOCl – GP cones were tried for length with NaOCl in situ. This allows for displacement of NaOCl solution into lateral canals (mechanical activation). One minute EDTA + U/s followed by NaOCl to remove smear layer. Final flush saline. Throughout the procedure, a small gauge needle (30) was placed loosely in the canal, which allowed the correct application of the irrigant and hydrodynamics. For the apical third, the needle was bent 2-3 mm shorter than the working length in order to prevent extrusion of the irrigant through the apex.

determining the ratio between the different electric potentials proportional to each impedance. These devices are not root canal length “calculators,” rather they are apical area locators (foramen or constriction). Radiography is still an important adjunct to the use of a locator. However, it has been confirmed to be less reliable than an apex locator as the foramen may not end at the radiographic apex. Although, it may be seen as good practice to take working length/dry run radiographs, the British Endodontic Society (BES) does not state it to be mandatory. Reducing the amount of additional radiographs taken results in a reduced exposure of ionizing radiation. 3. What are the benefits of using nickeltitanium instruments? The advantages of using rotary instruments include:

References Byström A, Sundqvist G. Bacteriologic evaluation of the effect of 0.5 sodium hypochlorite in endodontic therapy. Oral Surg Oral Med Oral Pathol. 1983;55(3):307-12. Cheung GS, Liu CS. A retrospective study of endodontic treatment outcome between nickel-titanium rotary and stainless steel hand filing techniques. J Endod. 2009;35(7):938-943. Eliyas S, Briggs PF, Porter RW. Antimicrobial irrigants in endodontic therapy: 1. Root canal disinfection. Dent Update. 2010;37(6):390-392,395-397. European Society of Endodontology. Quality guidelines for endodontic treatment: consensus report of the European Society of Endodontology. Int Endod J. 2006;39(12):921-930.

20 Endodontic practice

• More effective debris removal coronally • Centered in canal – much less likely to ledge • Predetermined taper • Predictable shape • Quicker Studies show that there are fewer procedural errors and better shaping ability of the nickel-titanium instruments in comparison to stainless steel K-files. However, there are few reports to show any significant differences between the two instruments (Cheung, Liu, 2009). 4. Why was no extra coronal restoration provided? Firstly, studies have shown that the quality of the coronal seal has a significant effect on the outcome of endodontic treatment (Saunders, Saunders, 1994). Leakage can be reduced by the placement of adhesive restoration placed over the gutta percha

followed by provision of a well-sealed permanent filling (Qualtrough, et al., 2005). In this case, the marginal ridges of the UR6 were intact following treatment. This suggested the tooth was less liable to fracture and more likely to withstand “wedging” forces developed during function (Hansen, 1988). Evidence suggests that root canal therapy does not change the quality of dentin, except some moisture loss (increase in brittleness), and it is thought that weakening of the tooth is more as a result of tooth tissue loss (Ingle, Bakland, Baumgartner, 2008). Therefore an extracoronal restoration was not provided. 5. How is the tooth going to be monitored for success? According to the BES (2006), the RCT should be assessed at least after 1 year. The following findings indicate a favorable outcome: • Absence of pain/swelling/sinus tract • No loss of function • Radiological evidence of normal periodontal ligament space around the tooth.

Conclusion The case demonstrates a predictable new technique (for a newly qualified dentist), integrating best evidence with clinical knowledge and patient preference, demonstrating the ability to efficiently and effectively provide appropriate and adequate care. Upon a yearly review, the tooth had responded favorably to treatment, and the patient had no symptoms or complaints. The periapical radiograph taken to visualize the DB canal and assess healing shows healing of the apical radiolucency, and the DB canal was filled satisfactorily (Figure 6). EP

Figini L, Lodi G, Gorni F, Gagliani M. Single versus multiple visits for endodontic treatment of permanent teeth. Cochrane Database Syst Rev. 2007;17(4).

Pagavino G, Pace R, Baccetti T. A SEM study of in vivo accuracy of the Root ZX electronic apex locator. J Endod. 1998;24(6):438-441.

Hansen EK. In vivo cusp fracture of endodontically treated premolars restored with MOD amalgam or MOD resin fillings. Dent Mater. 1988;4(4):169-173.

Qualtrough AJE, Satterthwaite JD,Morrow LA, Brunton PA. Principles of operative dentistry. Oxford UK: Blackwell Munksgaard; 2005.

Hülsmann M, Heckendorff M, Lennon A. Chelating agents in root canal treatment: mode of action and indications for their use. Int Endod J. 2003;36(12):810830.

Simon S, Machtou P, Adams N, Tomson P, Lumley P. Apical limit and working length in endodontics. Dent Update. 2009;36(3):146-150,153.

Ingle JI, Bakland LK, Baumgartner JC. Ingle’s endodontics. 6th ed. Hamilton, Ontario: BC Decker; 2008. McDonald NJ. The electronic determination of working length. Dent Clin North Am. 1992;36(2):293-307.

Sirtes G, Waltimo T, Schaetzle M, Zehnder M. The effects of temperature on sodium hypochlorite short-term stability, pulp dissolution capacity, and antimicrobial efficacy. J Endod. 2005;31(9):669-671. Saunders WP, Saunders EM. Coronal leakage as a cause of failure in root-canal therapy: a review. Endod Dent Traumatol. 1994;10(3):105-108.

Volume 6 Number 3

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CASE REPORT

Detection and endodontic treatment of a threerooted maxillary second premolar Dr. Imran Cassim presents a case report detailing treatment of a multi-rooted maxillary second premolar

uccessful endodontic therapy is dependent on the quartet of shaping, disinfection, three-dimensional sealing of the root canal system, and a coronal seal, forming an effective barrier between the root canal system and the oral cavity (Schilder, 1974; Cantatore, Berutti, Castellucci, 2009; Kirkevand, HorstedBindslev, 2002). The possibility of finding aberrant canal configurations is always present and higher in premolars and molars (Cantatore, Berutti, Castellucci, 2009). The use of magnification and illumination, an astute assessment of parallel and angled radiographs, as well as the pulp chamber floor map, can help in reducing the risk of missing a canal during endodontic treatment. Clinicians should be careful when treating maxillary premolars because of the extreme variability of their anatomy, and the risk of missing a canal in these teeth is always present. The maxillary second premolar usually has one or two canals, and one or two roots, but the incidence of three root canals is very rare and has been reported to be 0.3% (Pecora, et al., 1992) and 0.66% (Kartal, Özçelik, Çimilli, 1998). Radiographic appearances that would indicate more than one canal are: • The “fast break” rule suggested by Yoshioka, et al. (2004), which is a sudden narrowing of the canal system on a parallel radiograph • When the mesiodistal width of a maxillary premolar tooth at midroot level is equal to or greater than the mesiodistal width of the crown, on a parallel radiograph, then the tooth most likely has three roots suggested by Sieraski, et al., (1989).

Imran Cassim obtained his BDS degree in 1999 from University of Witwatersrand, South Africa. He completed a postgraduate diploma in endodontics with distinction from University of Pretoria in 2009. He is currently completing an MSc in endodontics at University of Pretoria and is in practice in Durban, South Africa. He is a visiting lecturer in the Postgraduate Department of Endodontics at University of Pretoria. He writes, lectures, and conducts workshops on endodontic topics.

22 Endodontic practice

Figures 1A and 1B: Parallel preoperative X-ray showing the sudden narrowing of the pulp chamber (white arrow) and the mesiodistal width of the midroot almost equal to the mesiodistal width of the crown

Figure 3: A view of the initial access cavity

Figure 2: Angled preoperative X-ray

Figure 4: The Start-X 1 ultrasonic tip used to refine access and modify to a T-shape

Case report The patient, a healthy 52-year-old male was referred for endodontic treatment of UL5 (upper left second premolar). He experienced severe pain on percussion and with hot and cold thermal tests. A diagnosis of acute apical periodontitis and acute irreversible pulpitis was made (Holland and Walton, 2009). Radiographic examination showed a deep interproximal filling close to the pulp chamber (Figures 1A, 1B and 2). It was also noted that the mesiodistal width of the tooth at midroot level was equal to the mesiodistal width of the crown of the tooth, and that the pulp chamber suddenly decreased in width, indicating the presence of three canals on this upper left second premolar (Figure 1B). Following anesthesia and rubber dam placement, the access cavity was made using a 0.16 tapered diamond crown preparation bur because of the depth and narrow width of the pulp chamber (Figure 3). Though there was no periapical radiolucency discernable on X-ray, pus oozed out the palatal canal, and it was flushed with 3% sodium hypochlorite. The access cavity was then modified

Figure 5: The straightline access to all the canals after troughing with the Start-X 1 and 3 ultrasonic tips

to a T-shape using the Start-X™ 1 (Dentsply) ultrasonic tip (Figure 4). The Start-X 3 tip was then used to refine the straightline access to the two buccal canals (Figure 5). Working lengths were determined using an electronic apex locator, and a working length X-ray was taken (Figure 6). Preparation of the canals was initiated after ensuring a size 10 K-file was loose in all canals. Then glide paths were prepared using Pathfiles™ 1, 2, and 3 (Dentsply). The canals were then shaped using the WaveOne® Primary file (25/08) in the WaveOne motor (Dentsply). A 3% solution of sodium hypochlorite was used for irrigation and agitated with the EndoActivator (Dentsply) [Figure 7]. Once shaping was completed, the canals were irrigated with 17% EDTA to remove the smear layer and agitated with the EndoActivator® (Dentsply). The canals were dried, and there was still exudate present, so a dressing of calcium hydroxide was placed in the canals and the access cavity sealed with DuoTemp™ light cured temporary filling material (Colténe Whaledent®). The patient was scheduled a second appointment 2 weeks later. At the second visit, the patient reported Volume 6 Number 3

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CASE REPORT

Figure 6: Working length X-ray showing three separate canals 9A

Figure 7: EndoActivator (Dentsply) in use for agitation of irrigants

Figure 8: View of pulp chamber after obturation

Figures 9A, 9B and 9C: The different angled postoperative X-rays; note the S-shaped curvature of the DB root and material adaptation to the canal walls

that all symptoms had subsided. Following anesthesia and rubber dam application, the temporary filling was removed. The canals were flooded with 17% EDTA and agitated with the EndoActivator to remove the calcium hydroxide dressing. The canals were gauged with a size 25 K-file (Dentsply Maillefer), and it was snug at the apex of all three canals. The GuttaCore® (Dentsply Tulsa Dental Specialties) size 25 verifier file was placed in each canal to verify easy placement and passage of the GuttaCore obturator. The canals were irrigated with 3% sodium hypochlorite, the irrigant agitated, and then the canals dried. A small amount of AH Plus® sealer (Dentsply) was placed with a paper point in the coronal third of the mesiobuccal canal; a paper point trimmed to orifice level was placed in the distobuccal canal, and then, the GuttaCore obturator was placed in the dedicated heating oven, and the mesiobuccal canal was obturated. The obturator was sectioned off at orifice level using a Thermacut® bur (Dentsply Maillefer) and then a Machtou plugger (Dentsply Maillefer) used to apply condensation pressure to the obturator at orifice level. The excess gutta percha over the distobuccal orifice was removed by engaging the paper point with a size 40 Hedstroem file (Dentsply Maillefer) and removing it from the canal, thereby allowing easy placement of the subsequent GuttaCore obturator in the distobuccal canal. The distobuccal and palatal canals were obturated in the same manner as described for the first canal, but the handle of the carrier was removed by bending it 24 Endodontic practice

to either side of the canal wall. Figure 8 shows the pulp chamber after all canals were obturated. The access cavity was etched and restored with Spectrum® SDR® and TPH® spectrum composite (Dentsply), and the patient was referred back to his dentist for an overlay to protect the cusps. A follow-up X-ray at 1 year revealed radiographically healthy periradicular tissues (Figure 10), and the patient was reminded that a coronal restoration with cuspal coverage would be needed.

Discussion Three rooted premolars are a challenge to identify and treat, and a lack of knowledge of the internal anatomy of maxillary premolars with three root canals may lead to failure of root canal treatment (VierPelisser, et al., 2010). When the two buccal canals arise from a common narrow canal, access is restricted to each canal, and this gives rise to an S-shaped canal curvature (Sieraski, Taylor, Kohn, 1989). Modifying the access to a T-shape and troughing the buccal overhang of dentin allow straightline access to the buccal canals. The Start-X 1 and 3 ultrasonic tips (Dentsply) facilitate this step with conservative removal of dentin in the narrow confines of the premolar pulp chamber, and the non-end cutting tip of the Start-X 1 ultrasonic tip helps to leave the pulp chamber floor map intact and reduces the risk of perforating the pulp floor. The occlusal can also be reduced to facilitate visibility and access, and to the orifices of the canals. The PathFiles series of nickel-titanium

Figure 10: A 1-year follow-up X-ray reveals healthy periapical tissue

files allowed for rapid preparation of a glide path while minimizing hand fatigue. The preparation of a glide path reduces change to the natural curvature of the canal with subsequent mechanical shaping of the canal by reciprocation (Bertutti, et al., 2012). The GuttaCore carrier based obturation technique allows for the movement of warm gutta percha three-dimensionally into all areas of the properly shaped root canal system (Gutmann, 2011). A meticulous assessment of multiple angled radiographs, the use of magnification, illumination, adequate access cavity preparation, and the awareness of possible anatomic variations can aid the clinician in the treatment of multi-rooted maxillary second premolars. EP References Berutti E, Paolino DS, Chiandussi G, et al. Root canal anatomy preservation of WaveOne reciprocating files with or without glide path. J Endod. 2012;38:101-104. Cantatore G, Berutti E, Castellucci A. Missed anatomy: frequency and clinical impact. Endod Topics. 2009;15:3-31. Gutmann JL. The future of root canal obturation. Dent Today. 2011;30(11):128,130-1. Holland GR, Walton RE. Diagnosis and treatment planning. In: Torabinejad M, Walton RE, eds. Endodontics Principles and Practice, 4th ed. St. Louis, MO: Saunders Elsevier; 2009:68-93. Kartal N, Özçelik B, Çimilli H. Root canal morphology of maxillary premolars. J Endod. 1998;24(6):417-419. Kirkevang LL, Horsted-Bindslev P. Technical aspects oftreatment in relation to treatment outcome. Endod Topics. 2002;2:89-102. Pecora JD, Sousa Neto MD, Saquy PC, Woelfel JB. In vitro study of root canal anatomy of maxillary second premolars. Braz Dent J. 1992;3:81-85. Schilder H. Cleaning and shaping the root canal. Dent Clin North Am. 1974;18:269-96. Sieraski SM, Taylor GN, Kohn RA. Identification and endodontic management of three-canalled maxillary premolars. J Endod. 1989;15(1):29-32. Vier-Pelisser FV, Dummer PMH, Bryant S, Marca C, So´ MVR, Figueiredo JAP. The anatomy of the root canal system of three-rooted maxillary premolars analyzed using high-resolution computed tomography. Int Endod J. 2010;43:356-362. Yoshioka T, Villegas JC, Kobayashi C, Suda H. Radiographic evaluation of root canal multiplicity in mandibular first premolar. J Endod. 2004;30:73-74.

Volume 6 Number 3

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ENDODONTICS IN FOCUS

Top ten tips: Tip number 7 â&#x20AC;&#x201C; To determine length Continuing his series on endodontics, Dr. Tony Druttman looks at the best ways to measure the length of a canal

ne of the main reasons endodontically treated teeth fail is because the canals have not been cleaned adequately. All too often, cases are referred for retreatment where the root fillings are short on the radiograph, and on retreating the tooth, the correct working length has been achieved (Figures 1A and 1B). Long root fillings have also been associated with endodontic failures, although this is usually due to inadequate debridement and disinfection, rather than overextension of the root filling through the root apex (Figure 2). Adequate canal preparation does not just involve reaching the apex with a file of a certain size: the canal has to be cleaned thoroughly in all its dimensions, but Iâ&#x20AC;&#x2122;ll discuss this further in later issues. Determining the working length is an evolutionary process starting with the preoperative radiograph. As I have discussed in previous articles, a good quality radiograph has to be taken using the paralleling technique with the aid of an aiming device/image receptor holder. This should give an undistorted image of the crown and the roots. When using film, a reasonably accurate estimate of the working length can be achieved by measuring the length with a hand file against the film. With digital techniques, the software should be available in the program, which can measure the length, irrespective of whether the canal is curved or straight. Some canals are divergent from the long axis of the tooth and will look foreshortened on a radiograph. This is often the case with the palatal roots of upper molars but can affect other teeth as well (Figure 3).

Tony Druttman, MSc, BChD, BSc, is an endodontist working in central London. He is also a part-time teacher at the Eastman Dental Institute, University of London, and lectures in the UK and abroad.

26 Endodontic practice

Figure 1A: Preoperative radiograph of a failed root treatment on tooth 25

It is therefore important to measure the working length accurately and to maintain working length during preparation. There are three methods for determining length: diagnostic length radiographs, electronic apex locators, and the consistent drying point,1 and during canal preparation, either two out of the three or all three methods can be used to give optimal results.

Figure 1B: Postoperative radiograph of the retreated 25 at the correct working length

Figure 2: Lack of correct working length determination has caused overextension of the root filling and left the patient with a parasthesia of the lower lip

The apical extent of preparation There are differing opinions regarding the apical extent of the preparation. The average distance between the apical constriction and the radiographic apex is 0.5 to 1.0 mm, but can be considerably more. The end point of preparation should be the minor apical diameter or apical constriction (Figure 4). The difficulty is that the position of this junction can be quite variable and by preparing the canal to an arbitrary end point, an apical plug of infected material may be left, which could result in failure. Also it is not unusual for the root tip to have multiple apical foramina, which may exacerbate the problem further (Figures 5A and 5B). The alternative approach is to maintain apical patency, and rather than to create an apical stop, a tapered preparation is developed, which relies on the developed geometry to create resistance form for the obturating material. Apical patency is created and maintained by inserting a small file approximately 1 mm through the apical constriction to ensure that an apical plug of dentin/infected material does not

accumulate during preparation. Sometimes this is not possible as the canal appears to have a ledge at the apex, which has been created naturally rather than iatrogenically. This is due to the natural anatomy of the root, and it may be impossible to bypass the ledge. In this situation, the canal has to be prepared as far possible (Figure 6).

Radiographic technique The traditional way of determining working length is by taking radiographs with files in the canals. Where canals overlap, as in the mesial canals of lower molars, the radiograph can be taken with an increased horizontal angulation to separate the canals. If the leading edge of the image receptor is angled away from the mesiodistal axis, the buccal canal is the more distal, and the palatal or lingual canal is the more mesial (Figure 7). A Hedstrom file can be used in one canal and a K-file in the other to distinguish between the canals. The radiographic technique is useful to cross check against an apex locator reading. Volume 6 Number 3

ENDODONTICS IN FOCUS

Top ten tips: Tip number 7 â&#x20AC;&#x201C; To determine length Continuing his series on endodontics, Dr. Tony Druttman looks at the best ways to measure the length of a canal

Tony Druttman, MSc, BChD, BSc, is an endodontist working in central London. He is also a part-time teacher at the Eastman Dental Institute, University of London, and lectures in the UK and abroad.

26 Endodontic practice

Figure 1A: Preoperative radiograph of a failed root treatment on tooth 25

Figure 1B: Postoperative radiograph of the retreated 25 at the correct working length

Figure 2: Lack of correct working length determination has caused overextension of the root filling and left the patient with a parasthesia of the lower lip

Figure 4: Landmarks at the root apex

Figure 5A: Endodontic treatment of tooth No. 30 carried out to an arbitrarily determined working length

Figure 5B: Endodontic retreatment of tooth in Figure 5A demonstrating the presence of an apical delta

Figure 6: Teeth Nos. 28 and 29 with blocked apices and extruded sealer

Figure 7: Diagnostic length radiograph of tooth No. 14. The mb1 canal is to the right; the mb2 is to the left in the mesiobuccal root

Figure 8: Endo Ray

Figure 9: Morita Root ZX

Figure 10: Paper point showing a consistent point of bleeding

Positioning the image receptor can be difficult with the rubber dam in place. Using a positioning device, such as the Endo Ray for use with film, ensures consistently accurate result (Figure 8).

Consistent drying point technique

and recorded, whether by radiograph or electronic apex locator. EP

Electronic apex locators These are some of the most useful instruments that we have in endodontics and produce very reliable and reproducible readings. Recent research quotes 97% reliability.2 We now have sixth-generation units, which are designed to cope with any fluid in the canal. The convention is to take the “zero reading” length and reduce 0.5 mm to get the working length. I find my unit – a Morita Root ZX – gives me such reliable readings that I rarely need to take diagnostic length radiographs (Figure 9). Readings should be taken throughout the process of canal enlargement as the canal length can change especially in curved canals. Volume 6 Number 3

This is a simple technique, which determines the junction between where there is a blood supply, for example, the periodontal membrane, and where there is not, the prepared root canal. It can only work when patency filing is used. The canal is dried and a paper point inserted that will pass beyond this junction. The length of the dry part of the paper point is measured to confirm the working length (Figure 10). The technique is repeated three or four times to ensure that a consistent result is obtained. The canal length should also be confirmed by other means before the root filling is placed.

Dento-legal obligations In our ever more litigious society, endodontics is one of the specialities that attracts the greatest amount of activity from our defense organizations. It is vital that the length of every canal is measured

References 1. Rosenberg DB. The paper point technique, part 1. Dentistry Today. 2003;22:80-86. Rosenberg DB. The paper point technique, part 2. Dentistry Today. 2003;22(2):62-64, 66-67. 2. Plotino G, Grande NM, Brigante L, Lesti B, Somma F. Ex vivo accuracy of three electronic apex locators: Root ZX, Elements Diagnostic Unit and Apex Locator and ProPex. Int Endod J. 2006;39:408–414.

Clarification: In the January/February 2013 issue of Endodontic Practice US, Dr. Druttman’s Endodontics in Focus article titled “Tip number 5 — Access cavities and canal location,” inadvertently omitted the reference for an article written by Drs. Paul Krasner and Henry Rankow from The Journal of Endodontics. On pages 28 and 29, the information in the list of basic rules about canal position, numbered 1-6 should have ended with the following reference: Krasner P, Rankow H. Anatomy of the pulp chamber floor. J Endod. 2004;Jan;30(1):5-16.

Endodontic practice 27

ENDODONTICS IN FOCUS

Figure 3: Lower first molar with two distal roots, with the same working length for each distal canal

CONTINUING EDUCATION

Preserving the natural smile by immediate reattachment of a fractured tooth Drs. Ramesh Bharti, Deeksha Arya, Anil Chandra, Aseem Prakash Tikku, Rakesh Yadav, and Promila Verma present two case reports detailing the reattachment of a fractured tooth fragment for the restoration of function and esthetics Traumatic injury in the form of anterior crown fracture has been estimated to occur in one-quarter of the population under the age of 18 (Murchison, Burke, Worthington, 1999; Petti, Tarsitani, 1996). Ninety-six percent of these traumatic injuries involve maxillary incisors (80% central incisors and 16% lateral incisors) [Andreasen, Ravn, 1972]. These injuries pose a substantial challenge to the dental team because the patient often wants resolution of trauma during an emergency visit. Restoration difficulties depend on: • The type of fracture (according to Dean’s classification) [Trushkowsky, 1998; Dean, Avery, Swartz, 1986] • The extent of fracture (supragingival, subgingival, or may involve root) • The type of occlusion • The involvement of soft tissue (Leroy, et al., 2000; Qulis, Berdouses, 1996).

Dr. Ramesh Bharti, MDS, is assistant professor at the Department of Conservative Dentistry and Endodontics, Faculty of Dental Sciences, CSM Medical University (formerly King George’s Medical College), Lucknow, India. Dr. Deeksha Arya, MDS, is assistant professor at the Department of Prosthodontics and Dental Material Sciences, Faculty of Dental Sciences, CSM Medical University (formerly King George’s Medical College), Lucknow, India. Dr. Anil Chandra, MDS, is professor at the Department of Conservative Dentistry and Endodontics, Faculty of Dental Sciences, CSM Medical University (formerly King George’s Medical College), Lucknow, India. Dr. Aseem Prakash Tikku, MDS, FICD, is professor of the Department of Conservative Dentistry and Endodontics, Faculty of Dental Sciences, CSM Medical University (formerly King George’s Medical College), Lucknow, India. Dr. Rakesh Yadav, MDS, is Assistant Professor at the Department of Conservative Dentistry and Endodontics, Faculty of Dental Sciences, CSM Medical University (formerly King George’s Medical College), Lucknow, India. Dr. Promila Verma, MDS, is associate professor at the Department of Conservative Dentistry and Endodontics, Faculty of Dental Sciences, CSM Medical University (formerly King George’s Medical College), Lucknow, India.

28 Endodontic practice

Educational aims and objectives This clinical article aims to describe the immediate reattachment of a fractured tooth fragment for the resoration of function and esthetics at the emergency visit. Expected outcomes • Correctly answering the questions on page 31, worth 2 hours of CE, will demonstrate that the reader can: • Recognize successful pain management with immediate restoration of function, esthetics, and phonetics as the prime objective in treating these cases.

Oblique fractures (type B, according to Dean’s classification) are more difficult to treat than horizontal fractures. The conventional treatment of fractured anterior teeth includes post and core and composite restoration followed by prosthetic restoration. However, reattaching the fractured segment has several advantages over other treatment. The patient’s own incisal enamel appears more natural than any other restoration (Busato, et al., 1998), so preserving it will maintain the contour, color, texture, and translucency of the original tooth.

Figure 1: Case report one – fractured maxillary lateral incisor

Case report one A 21-year-old female consulted at the postgraduate clinic of the Department of Conservative Dentistry and Endodontics of CSM Medical University, Lucknow (King George’s Medical College). She arrived at the clinic 13 hours after an outdoor activity accident that had fractured her maxillary right lateral incisor. The patient history revealed no systemic disease, and there was no hemorrhaging or swelling in the related area. The clinical and radiographic maxillofacial examination revealed that there was no fracture of the maxilla, mandible, or any other facial bones. Intraorally, the right maxillary lateral incisor tooth showed an oblique crown fracture. The fractured line was located 2 mm supragingivally on the buccal aspect and at the level of the alveolar crest on the palatal aspect (Figures 1 and 2). The fragment was extremely mobile, and only periodontal fibers on the palatal aspect retained it.

Figure 2: Case report one – radiograph showing fracture line in maxillary lateral incisor

After removal of the coronal fragment, it was kept in physiological saline solution to prevent dehydration of the segment (Figure 3). Root canal therapy was performed with rubber dam. After cleaning and shaping, the root canal was filled with AH Plus® sealer (Dentsply) and gutta percha using a warm vertical compaction technique. Throughout the procedure, homeostasis was achieved by locally placing adrenalineVolume 6 Number 3

Figure 4: Case report one – post positioning to accommodate the fracture fragment

Figure 5: Case report one – fractured crown after removal and preparation

Figure 6: Case report one – labial view after sealing

Figure 7: Case report one – radiograph after sealing the fractured fragment

Figure 8: Case report one – photograph after 1 month of the treatment

Figure 9: Case report two – clinical view of fractured mandibular left central incisor

Figure 10: Case report two – radiograph showing fracture line, and tooth was root canal treated

embedded cotton pellets. A ParaPost® XP™ (Coltène Whaledent) was inserted into the first third section of the root canal for retention (Figure 4). A hole was drilled in the middle part of crown fragment (Figure 5). RelyX™ U100 selfadhesive resin cement (3M™ ESPE™) was then applied to the adherent surfaces. The crown fragment was reattached to the root surface, light-cured for 40 seconds, and allowed to self-cure. The remnants of the resin were removed from the interdental space and the tooth surfaces. Finishing and polishing of the restoration was carried out, and the occlusion was checked to make sure that there was no contact (Figures 6 and 7). One month later, the clinical and radiographical examination revealed a stable reattachment of the crown fragment with no color change (Figure 8). At this

time, periodontal probing revealed a depth of 2 mm on the mesial side, 2 mm on the buccal side, 2.5 mm on the distal side, and 1 mm on the palatal side. The patient was then scheduled 6-month recall visits, and the periodontal measurements were repeated at each visit. After 1 year, the clinical and radiographic findings presented no color change, no mobility, no periapical pathosis, and the tooth had a healthy periodontium with no pocket formation or gingival recession.

Volume 6 Number 3

Case report two A 28-year-old female patient reported to the Department of Conservative Dentistry and Endodontics of CSM Medical University, Lucknow (King George’s Medical College) following trauma to the mandibular left central incisor. The day before her visit, she was eating corn, resulting in a fracture of

the mandibular left central incisor. The fragment was mobile, but still in place (Figure 9). Clinical examination revealed an oblique fracture. The fracture line was present on the coronal portion, extending from lingual to labial aspect subgingivally. The margin on the labial surface was located 2 mm below the free gingival margin and could be probed easily with a periodontal probe. Clinical and radiographic examination revealed that the tooth was endodontically treated (Figure 10). The patient was very apprehensive about her fractured tooth. However, after the condition was explained to her, she felt reassured. Of the various treatment options explained, she preferred to retain the fractured fragment. The fractured fragment of the mandibular left central incisor was removed and stored in physiological saline, to be used at a later stage. Isolation was achieved using cheek retractors, cotton rolls, and saliva ejector. A gelatin sponge (AbGel®, Sri Gopal Krishna Labs, India) was packed on the labial surface of the subgingival area to control any bleeding. To prepare the post space, ParaPost XP (Coltène Whaledent) was tried in the canal and cut to the desired length. The fractured fragment was removed from the physiological saline and tried on the cut end of the fiber post. A groove was made on the Endodontic practice 29

CONTINUING EDUCATION

Figure 3: Case report one – clinical view after the removal of the fractured fragment

CONTINUING EDUCATION

Figure 11: Case report two – clinical view after completion of treatment

Figure 12: Case report two – radiograph after sealing the crown fragment

fractured fragment until it fitted comfortably on the post. Care was taken not to remove excess dentin, as it would have altered the final esthetic appearance of the tooth. Once the desired fit was confirmed, it was again stored in physiological saline. The post was cemented with the help of RelyX U100 self-adhesive resin cement (3M ESPE). Any excess cement was removed so as to not compromise the fit of the coronal fragment. The gelatin sponge was then removed, and the exposed root surface and fractured fragment were acidetched simultaneously. The groove in the fractured fragment was filled with resin cement, and the exposed post was also luted with the same resin. The fragment was repositioned. Because the fracture line was visible on the lingual surface, a groove was made along the fracture line. It was then restored with nanocomposite (Filtek™ Z 350 universal restorative, 3M ESPE). Finishing and polishing were performed using SofLex™ polishing system (Sof-Lex extra thin contouring and polishing discs, 3M ESPE), and a radiograph was taken (Figures 11 and 12). After 8 weeks, none of the fragments were mobile, and the periodontal status in relation to both central and lateral incisors was satisfactory (no periodontal pockets, normally contoured palatal gingiva). Radiographic examination revealed satisfactory healing of both central and

lateral incisors, and no discoloration was evident on clinical examination.

Discussion With the advances in dental bonding technology, it is now possible to achieve excellent results with reattachment of fractured tooth fragments. The use of natural tooth substance clearly eliminates the problems of differential wear of restorative material, unmatched shades, and difficulty of contour and texture reproduction associated with other techniques. The treatment plan can be made after evaluation of the periodontal, endodontic, coronal, and occlusal status (Chu, Yim, Wei, 2000). Other factors that might influence the choice of technique include the need for endodontic therapy, extension of fracture line, and the fracture pattern. Resin cements applied in this technique have added advantages over other cements because of decreased chance of microleakage (Andreasen, 2001). Resin luting cements have good bond strength to the tooth, are predictable, and easy to use. Resin-based root canal sealers are used to obturate such teeth, which are planned to seal posts with resin cement, as the eugenol-based root canal sealers inhibit the setting of resin cements (Demarco, et al., 2004). An additional chamfer was also prepared on the labial surface along

References

Int. 2000;31(6): 385-391.

Andreasen JO. Buonocore memorial lecture. Adhesive dentistry applied to the treatment of traumatic dental injuries. Oper Dent. 2001;26(4):328-335.

Dean JA, Avery DR, Swartz ML. Attachment of anterior fragments. Pediatric Dentistry. 1986;8(3):139-143.

Andreasen JO, Ravn JJ. Epidemiology of traumatic dental injury to primary and permanent teeth in a Danish population sample. Int J Oral Surg. 1972;1(5):235-239. Baratieri LN, Monteiro Júnior S, Cardoso AC, de Melo Filho JC. Coronal fracture with invasion of biologic width: a case report. Quintessence Int. 1993;24(2):85-91. Busato AL, Loguercio AD, Barbosa AN, Sanseverino Mdo C, Macedo RP, Baldissera RA. Biological restorations using tooth fragments. Am J Dent. 1998;11(1):46-49. Chu FC, Yim TM, Wei SH. Clinical considerations for reattachment of fractured tooth fragments. Quintessence

30 Endodontic practice

Demarco FF, Fay RM, Pinzon LM, Powers JM. Fracture resistance of re-attached coronal fragments – influence of different adhesive materials and bevel preparation. Dent Traumatol. 2004;20(3):157-163. Leroy RL, Aps JK, Raes FM, Martens LC, De Boever JA. A multidisciplinary treatment approach to a complicated maxillary dental trauma: a case report. Endod Dent Traumatol. 2000;16(3):138-142. Murchison DF, Burke FJ, Worthington RB. Incisal edge reattachment: indications for use and clinical technique. Br Dent J. 1999;186(12):614-619. Oulis CJ, Berdouses ED. Dental injuries of permanent teeth

the fracture line, which was filled with microhybrid composite, in case report one, after reattachment to increase the fracture resistance (Reis, et al., 2002). If the fracture line is supragingival, the procedure for reattachment will be straightforward. However, when the fracture line is subgingival or intraosseous, orthodontic extrusion with a post-retained crown may be necessary. Alternatively, surgical techniques, such as electrosurgery, elevation of tissue flap, clinical crown lengthening surgery with removal of alveolar bone, and removal of gingival overgrowth for access to the fractured site, are viable methods for bonding fractured components. It has been suggested that whenever the fracture site invades the biological width, surgery should be performed with minimum osteotomy and osteoplasty (Baratieri, et al., 1993). However, in cases with minimal biological width invasion, the operator is able to restore the biological width by providing adequate plaque control, and satisfactory esthetics and function, without conventional flap surgery but requiring long-term follow-up. The success rate of reattached fragments has been seen to be 90%, depending upon the periodontal and pulpal condition (Yilmaz, et al., 2008). The prognosis of the reattached teeth would also depend on the health, contour, and surface finishing of the subgingival restoration.

Conclusion Reattachment of fractured tooth segment is a conservative, effective, and immediate treatment approach for the maintenance of esthetics and function as compared to ceramic crown fabrication. However, long-term follow-up is very important for such cases. Periodontal status should be checked during follow-up appointments. EP treated in private practice in Athens. Endod Dent Traumatol. 1996;12(2):60-65. Petti S, Tarsitani G. Traumatic injuries to anterior teeth in Italian schoolchildren: prevalence and risk factors. Endod Dent Traumatol. 1996;12(6):294-297. Reis A, Kraul A, Francci C, de Assis TG, Crivelli DD, Oda M, Loguercio AD. Re-attachment of anterior fractured teeth: fracture strength using different materials. Oper Dent. 2002;27(6):621-627. Trushkowsky RD. Esthetic, biologic and restorative considerations in coronal segment reattachment for a fractured tooth: a clinical report. J Prosthet Dent. 1998;79(2):115-119. Yilmaz Y, Zehir C, Eyuboglu O, Belduz N. Evaluation of success in the reattachment of coronal fractures. Dent Traumatol. 2008;24(2):151-158.

Volume 6 Number 3

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Preserving the natural smile by immediate reattachment of a fractured tooth 1. Traumatic injury in the form of anterior crown fracture has been estimated to occur in _____ of the population under the age of 18. a. one-quarter b. one-third c. one-half d. three-quarters 2. Oblique fractures (type B, according to Deanâ&#x20AC;&#x2122;s classification) are ________to treat than horizontal fractures. a. easier b. more difficult c. the same amount of work d. more natural 3. The ________ of fractured anterior teeth includes post and core and composite restoration followed by prosthetic restoration. a. unconventional b. recently developed c. conventional treatment d. off-label 4. The patientâ&#x20AC;&#x2122;s own incisal enamel appears more natural than any other restoration, so preserving it will maintain the ______and translucency of the original tooth.

Volume 6 Number 3

a. contour b. color c. texture d. all of the above 5. In case report one, after removal of the coronal fragment, it was kept in ________ to prevent dehydration of the segment. a. calcium hydroxide b. chlorhexidine c. physiological saline solution d. ethylenediaminotetraacetic acid (EDTA) 6. The treatment plan can be made after evaluation of the ______and occlusal status. a. periodontal b. endodontic c. coronal d. all of the above 7. a. b. c. d.

the periodontal and pulpal condition. a. 60% b. 70% c. 80% d. 90% 9. The prognosis of the reattached teeth would also depend on the _______of the subgingival restoration. a. health b. contour c. surface finishing d. all of the above 10. _______ should be checked during followup appointments. a. Biological width b. Periodontal status c. The fracture line d. The interdental space

Resin luting cements __________. have good bond strength to the tooth are predictable are easy to use all of the above

8. The success rate of reattached fragments has been seen to be _____depending upon

Endodontic practice 31

CE CREDITS

ENDODONTIC PRACTICE CE

CONTINUING EDUCATION

Direct pulp capping with a bioactive dentin substitute Dr. Markus Firla discusses various solutions for pulp exposure Introduction Direct exposure of the pulp as a result of preparation work during caries excavation or possibly due to trauma is something that repeatedly occurs in everyday clinical practice. Restorative measures that preserve the long-term vitality of an affected – essentially healthy – pulp are dependent on a number of crucial factors. The one most important for the therapeutic outcome is the bioactive potency of the capping material directly covering the pulp wound.

Educational aims and objectives The purpose of this article is to look at the uses and benefits of calcium silicate-based products for direct pulp capping. Expected outcomes Correctly answering the questions on page 35, worth 2 hours of CE, will demonstrate that you can: • Recognize how some dental materials work in conjunction with endodontic measures to preserve the vitality of the pulp. • Realize the advantages of mineral trioxide aggregate (MTA). • See the positive effect of calcium silicate-based products.

High biocompatibility and bioactivity The dental material mineral trioxide aggregate (MTA) was introduced into restorative dentistry as long ago as the 1990s. Further refinement of the process of preparing a fine-grained mixture of up to 95% hydrophilic tricalcium silicate, tricalcium aluminate, tricalcium oxide, and silicon oxide in an aqueous solution of calcium chloride and polycarboxylate, with the addition of zirconium dioxide as contrast medium, has made MTA an important material for endodontic treatments. This is based on studies that showed that the biocompatibility – i.e. biological tolerability – of MTA is extremely good, since no signs of any threat of cytotoxicity, genotoxicity, or mutagenicity on body tissue, particularly the pulp tissue, were found. MTA is also safe in regards to the absence of negative influences on cell differentiation or specific cell functions.

Dr. Markus Firla graduated from Münster Dental Faculty at Wilhelms University, Germany, in 1986. While practicing dentistry, he has been a consultant for international dental manufacturers, a dental journalist for German and English dental publications, and advisor to many a dental colleague over the past 20 years. In 1998 he founded WeCoMeD GmbH – Consulting & Services to provide a basis for his lecturing on practice management and general dentistry. In 2003, his own practice has attained certification in ISO 9001:2000 (Requirements for Quality Management Systems), and in 2005 it complied with EPA-Dent (European Practice Assessment for Dentistry) standards. In 2006, he became involved in post-graduate education with the Dental Board of Lower Saxony in Hanover, Germany.

32 Endodontic practice

Figure 1: Lower first molar of a 42-year-old man. Despite the complex damage, the tooth showed a normal positive reaction to cold stimulus testing using a cotton wool pellet cooled with ice spray and was on the whole otherwise clinically normal

A material can be described as bioactive if it has a beneficial effect on living cells and interacts with them in a biologically compatible manner. The bioactivity of a material is of interest and importance for dental practice, particularly in regards to its effect on the promotion of hard tissue formation in the pulp. This is particularly useful when covering extremely thin pulpfacing layers of dentin, but especially on the direct capping of opened pulp cavities, since the success of these endodontic measures to preserve the vitality of the pulp depends crucially on whether the dental materials used: • Cause no postoperative sensitivity • Support remineralization of the dentin • Initiate the formation of new hard tissue (dentin bridges, tertiary, or repair dentin) • Help to restore the general integrity of the dental pulp or, if already present, to guarantee its preservation The strikingly positive effect of such calcium silicate-based products, like the dentin substitute Biodentine manufactured by Septodont described as an example here, is based – in simplified terms – on the release of calcium hydroxide ions in the

Figure 2: The targeted removal of the insufficient amalgam filling and careful clearance of all softened areas of dentin meant that opening of the pulp cavity was unavoidable despite using the least invasive approach possible with an excavator

Figure 3: The obviously healthy and asymptomatic pulp makes possible the use of direct pulp capping as sole endodontic measure. The first step here is disinfection of the entire cavity for 2 minutes with polyhexanide/betaine

setting reaction. This reaction is associated with the presence of an extremely alkaline environment with a pH of about 12.5, which stimulates the pulp tissue to form reactive dentin.

Antibacterial properties Because of the manifest alkalization of the environment, this high pH also exerts a clear inhibitory effect on microorganisms. In addition, the alkaline change demonstrably leads to the disinfection of adjacent Volume 6 Number 3

MTA – the material of choice A manifestly healthy pulp can be treated clinically using a number of materials. Calcium hydroxide preparations are still the gold standard, since the antibacterial and dentin-inducing action of calcium hydroxide is undeniable. However, the chemical stability and mechanical strength of pure calcium hydroxide and all preparations based on calcium hydroxide are major drawbacks. Methods in which adhesives and composites are used for the direct capping of exposed pulp can be regarded as having comparable disadvantages. These drawbacks are, however, due mainly to the possible irritation of the exposed pulp by the unavoidable acid etching of the adhesives and the toxicity of the monomers, which trigger what ultimately becomes manifest inflammation of the pulp. If glass ionomer cements are used for direct capping, their chemical stability, mechanical strength, adhesive anchoring to the dentin, and the threat of toxicity should not be regarded as weaknesses, but they lack the required and particularly necessary dentin-forming effect that is to be expected. As already emphasized, MTA preparations give off — during the setting and for a relatively long time thereafter — particularly large quantities of calcium hydroxide ions, so that they are extremely suitable for treatment of the exposed pulp. They also have physical properties comparable to those of dentin. The specific properties of the Biodentine presented as an example here are: • The elastic modulus, at 22.0 Gpa, is very similar to that of dentin at 18.5. • The compressive strength of about 220 MPa is equivalent to the average figure for dentin of 290 MPa and is much greater than that of glass ionomer cements. • The microhardness of this dentin Volume 6 Number 3

substitute, at about 60 HVN is virtually the same as that of natural dentin. • Acid resistance in acid erosion tests showed that the tricalcium silicate material presented here has less surface disintegration than glass ionomer cements. There was no abrasion at all in artificial saliva. There was, however, deposition of apatite-like calcium phosphate crystals on the surface. This phenomenon allows conclusions to be drawn about a progressively improving interface between the dentin substitute Biodentine and the adjacent phosphate-rich hard tooth substance.

Biodentine can be described as a hard

the text above). The extremely high pH causes organic tissue to dissolve out of the dentin tubuli — unlike on the breakup and dissolution of the inorganic constituents of natural hard tooth substance in classic “conditioning” of tooth enamel and dentin with acids. The alkaline environment at the boundary area of contact between this tricalcium silicate material and the hard tooth substance thus opens a path, via which the dentin substitute mass can enter the exposed openings of the dentin canaliculi. This enables Biodentine to be keyed to the dentin by means of innumerable microscopic cones, creating a stable anchorage with a sealing, bacteriatight effect, without the need for prior treatment with irritants that compromise the pulp.

Figure 4: The cavity after disinfection. The surface of the exposed area can be seen clearly. Now it is necessary to close the dentin wound in a pulp-sparing, absolutely germ-proof manner that induces tertiary or repair dentin

Figure 5: The material of choice for this is – in the author’s view and experience – Biodentine. A bioactive material based on mineral trioxide aggregate (MTA), which has all these positive properties

Figure 6: The material that can be used as a dentin substitute can be deployed in a wide range of restorative endodontic procedures and can even, according to the manufacturer, be used for “complete closure” of a cavity for up to 6 months

Figure 7: With a working time of about 12 minutes and its smooth, pasty consistency, Biodentine is to be preferred to all previously known materials for MTA-based endodontic uses

tooth substance-adhesive restoration material. According to the investigations of the Chair in Biomaterials and Restorative Dentistry at Guy’s Hospital Dental Institute at King’s College in London, England, Professor Timothy Watson, the micromechanical adhesion of this tricalcium silicate material is, in particular, caused by the alkaline effect during the setting reaction (already described in

Summary

“Alkaline etching” produces reliable density

Mechanically stable capping of the exposed pulp to preserve the health of the pulp or, in cases of reversible disease, to decisively promote complete recovery, can, on the basis of the emerging knowledge about clinical use and materials, best be done using MTA-based materials. The handling difficulties and relatively long setting time of such refined Portland cements have been Endodontic practice 33

CONTINUING EDUCATION

hard- and soft-tissue structures. These two effects are — according to relevant scientific investigations with calcium silicate materials such as Biodentine — very pronounced and have a demonstrable impact. Dentin wounds to teeth with varying areas of exposed pulp with noncarious causes — such as accidental pulp opening or direct abrasive trauma — can be treated, and extensive carious defects caused by bacteria can also be properly excavated and given specific treatment.

CONTINUING EDUCATION

Figure 8: The X-ray taken immediately after completion of the cavity treatment. The addition of zirconium dioxide gives good radiopacity. The tightness of the seal and the cap on the oblique pulp chamber opening are clearly visible

Figure 9: The molar with its complete Biodentine treatment 6 weeks after direct pulp capping. The border seal and integrity of the dentin substitute are clinically impeccable

Figure 10: Since the molar continued to be completely symptom-free during this period, and the cold stimulus test again produced a normal, positive result, it was decided, in agreement with the patient, to now give the tooth a permanent composite filling

Figure 11: Since the pulp-facing portion of the dentin substitute could, according to manufacturer’s information, be left in place as “foundation,” an adhesive cover filling with N’Durance® (Septodont) was inserted

markedly improved for successful routine use in dental practice of the latest materials available as capsule systems, such as the calcium silicate dentin substitute Biodentine, which has been available on the dental market for some time. EP Figure 12: Distal view of the filled tooth (in a mirror). The sound bond of Biodentine and N’Durance both with one another and with the hard tooth substance itself is clearly visible

References 1. About I. Bioactivity of Biodentine™: A Ca3SiO5based dentin substitute. Oral session presented at: IADR Congress; 2010; Barcelona. 2. Accorinte ML, Loguercio AD, Reis A, Costa CA. Response of human pulps capped with different self-etch adhesive systems. Clin Oral Investig. 2008;12(2)119-127. 3. Boinon C, Bottero-Cornillac MJ, Koubi G, Dejou J. Evaluation of adhesion between composite resins and an experimental restorative material [abstract]. Eur Cell Mater. 2007;13(suppl 1):17. 4. Biodentine™ - Publications and Communications 2005-2010. Research & Development, Septodont, Paris 2010. 5. Biodentine™ - Produktinformation. Septodont GmbH, Niederkassel 2010. 6. Biodentine™ - Active Biosilicate Technology. Scientific File. Septodont, Paris 2010.

34 Endodontic practice

7. Biodentine Symposium 2011 – TricalciumsilicatTechnologie: Die neuesten Entwicklungen und Perspektiven - von der restaurativen Zahnheilkunde und Kinderzahnheilkunde bis hin zur Endodontie. Wissenschaftliche Leitung Prof. Dr. G. Schmalz, Franfurt 2011. 8. Dammaschke T. Dentinersatz. Dent Mag. 2011;28(2):30-34. 9. Dammaschke T. Biodentine–eine Übersicht. ZMK. 2011;27(9):546-550. 10. Firla M. Dentin-Ersatzmaterial auf der Basis der Active Biosilicate Technology. DZW Kompakt. 2011;14(1):11-14. 11. Firla M. Neue möglichkeiten zur endodontischen versorgung. DZW Kompakt. 2011;14(2):16-20. 12. Franquin JC, Marie O, Bottero MJ, Koubi G, About I. Physical properties of a new Ca3Sio5-based dentin substitute. Poster session presented at: IADR Congress; 2010; Barcelona.

13. Krämer N. MTA in der milchzahnendodontie – anwendung und klinische bewertung. Niedersächs Zahnärteblatt. 2011;46(7-8)18-21. 14. Koubi G, Colon P, Franquin JC. A clinical study of a new Ca3SiO5-based material indicated as a dentine substitute [abstract]. Clin Oral Invest. Poster Conseuro presented; 2009; Sevillia. 15. Panagidis D. Wurzelperforationsverschluss per MTA. Dent Mag. 2011;28(2):52-56. 16. Shayegan A, Petein M, Vanden Abbeele A. Biodentine: A new biomaterial used as pulp-capping agent in primary pig teeth. Poster presented at: IADT 16th World Congress Dental Traumatology; 2010; Verona. 17. Tran V, Pradelle N, Colon P. Microleakage of a new restorative calcium based cement (Biodentine®). Oral presentation: PEF IADR; 2008; London. 18. Valyi E, Plasse-Pradelle N, Decore D, Colon P, Grosgogeat B. Antibacterial activity of a new Ca-based cement compared to other cements. Oral session presented at: IADR Congress; 2010; Barcelona.

Volume 6 Number 3

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Direct pulp capping with a bioactive dentin substitute 1. The dental material _______ was introduced into restorative dentistry as long ago as the 1990s. a. composite b. mineral trioxide aggregate (MTA) c. glass ionomer d. bisphenol A-glycidyl methacrylate (Bis-GMA) 2. Further refinement of the process of preparing a fine-grained mixture of up to _____ hydrophilic tricalcium silicate, tricalcium aluminate, tricalcium oxide, and silicon oxide in an aqueous solution of calcium chloride and polycarboxylate, with the addition of zirconium dioxide as contrast medium, has made MTA an important material for endodontic treatments. a. 35% b. 55% c. 80% d. 95% 3. A material can be described as bioactive if it ______. a. has a beneficial effect on living cells b. interacts with cells in a biologically compatible manner c. endures acid erosion tests d. both a and b 4. Because of the manifest alkalization of the environment, this high pH also exerts a clear inhibitory effect on microorganisms. In addition, the alkaline change demonstrably leads to the _______ of adjacent hard and soft-tissue structures.

Volume 6 Number 3

a. destruction b. color change c. disinfection d. growth 5. Calcium hydroxide preparations are still the gold standard, since the ________of calcium hydroxide are undeniable. a. antibacterial action b. dentin-inducing action c. elastic properties d. both a and b 6. If glass ionomer cements are used for_______, their chemical stability, mechanical strength, adhesive anchoring to the dentin, and the threat of toxicity should not be regarded as weaknesses, but they lack the required and particularly necessary dentin-forming effect that is to be expected. a. micromechanical adhesion b. direct capping c. inhibitory effects d. caries prevention 7. As already emphasized, MTA preparations ______– during the setting and for a relatively long time thereafter – particularly large quantities of calcium hydroxide ions, so that they are extremely suitable for treatment of the exposed pulp. a. give off b. absorb c. retain d. accumulate

8. According to the investigations of the Chair in Biomaterials and Restorative Dentistry at Guy’s Hospital Dental Institute at King’s College in London, England, Professor Timothy Watson, the micromechanical adhesion of this tricalcium silicate material is, in particular, caused by the ________ during the setting reaction. a. dentin-inducing action b. non-exposed pulp c. soft tissue structures d. alkaline effect 9. The extremely high pH causes organic tissue to _______the dentin tubuli – unlike on the breakup and dissolution of the inorganic constituents of natural hard tooth substance in classic “conditioning” of tooth enamel and dentin with acids. a. accumulate in b. dissolve out of c. grow rapidly in d. stabilize 10. The alkaline environment at the boundary area of contact between this tricalcium silicate material and the hard tooth substance thus opens a path, via which the dentin substitute mass can enter the exposed openings of the _____. a. interface b. soft tissue c. enamel d. dentin canaliculi

Endodontic practice 35

CE CREDITS

ENDODONTIC PRACTICE CE

TECHNOLOGY

3D Apical Cork – Part 2 In the second article of this series, Dr. Wyatt Simons discusses the technologic breakthroughs that the Cork delivery device brings to obturation Introduction Our goal as practitioners of endodontic therapy is to diagnose, heal, and prevent endodontic disease. This final objective of providing long-term success for our patients is influenced by our ability to provide the elusive endodontic seal. Creating this dense, three-dimensional filling of all internal caverns and portals of exit eliminates potential space that may harbor future endodontic disease.1-3 The observation that our ability to threedimensionally seal pulpal systems greatly influences our ability to provide sustained endodontic success is not trivial. The significance of obtaining the endodontic seal is only foreshadowed by the challenge of creating it. The technique of warming and compacting gutta percha to help facilitate this objective has been outlined and advocated for almost 50 years.1 An early example of our potential to threedimensionally fill complex pulpal anatomy by warming and plugging gutta percha is shown in Figure 1. These teeth were treated by Dr. Herb Schilder in the 1960s and are highlighted as outstanding examples of filling accessory and severely curved canals in Dr. John Ingle’s endodontic textbook.4 Although the benefits of warming and compacting gutta percha for three-dimensional molding are self-evident, there has been a disconnect in its broad clinical acceptance. Still today, the main

Wyatt Simons, DDS, is a Diplomate of the American Board of Endodontics who lives and practices in San Clemente, California. He received his doctorate in dental surgery from the University of the Pacific, Arthur A. Dugoni School of Dentistry in 1999. He then completed his postdoctoral Specialty Training in Endodontics at Boston University in 2001. Dr. Simons is an Adjunct Faculty at the University of the Pacific, Arthur A. Dugoni School of Dentistry. He lectures nationally and has published several articles in national and international journals. In 2004, Dr. Simons founded Signature Specialists in San Clemente, California, where he practices and presents live patient demonstrations. Dr. Simons is passionately committed to the advancement of the profession of endodontics. He is the innovator of the CORK system of obturation and three-dimensional plugger. He can be reached at: email: wdsimons@ corkendo.com, phone: 888–905–7668, fax: 949-4982473. www.corkendo.com and www.signaturendo.com.

36 Endodontic practice

Figure 1: Cases filled by warming and compaction gutta percha done by the legendary Dr. Herbert Schilder over 50 years ago

obturation technique taught to U.S. dental students is cold lateral condensation. This carries over into clinical practice as more than 40% of U.S. dentists utilize cold lateral condensation as their main technique of obturation.5 For dental schools, there are concerns with accuracy and safety of warm vertical techniques for the novice practitioner. This perceived complexity tends to carry over into practice for many dentists, inhibiting them from obtaining the training that may otherwise allow them to reach their potential in warming and compacting gutta percha. For many of us that utilize warm vertical techniques, apical molding can be limited by gutta percha’s inability to transfer heat more than a few millimeters. The Cork technique evolved in an effort to improve our potential in warming and compacting gutta percha, as well as teach the next generation of clinicians to experience the thrill of the fill. Many technologic advances are aimed at building controls around critical procedures, thereby empowering clinicians to work within parameters that promote safe, reproducible outcomes. These technological breakthroughs increase the scope of our capabilities. In many instances, they allow us to provide services outside human capacity. For example, when rotary systems emerged in our profession, it became apparent that there

Figure 2: Package of .25 06 Cork delivery devices

are parameters by which desired results are obtained. Randomly running a motor and file through a complex root canal system without knowledge of speed or forces encountered would not yield safe, predictable results. However, sensing and controlling the forces encountered by the motorized file would contribute to higher levels of success. This ability to perceive and control such levels is humanly impossible. Fortunately, we are uniquely capable of building tools, and this technology is standard in most rotary systems today. This advancement allows us to utilize our rotary instruments within safe levels of torque, thereby limiting complications when unsafe levels are inadvertently exceeded. Just as torque control refers to controlling Volume 6 Number 3

TECHNOLOGY

Figure 3A

Figure 3D Figure 3B Figure 3C Figures 3A-3D: This graphic of the Cork technique illustrates the levels of three-dimensional apical compaction. Once temperature is delivered to the entire apical gutta, an initial wave of compaction occurs (3A-3B). The Cork delivery device is removed (3C), apical compaction is completed, and the apical CORK is held as the gutta percha cools (3D)

the torque of our rotary systems, Cork control refers to controlling parameters that affect obturation. The Cork system of obturation was designed to increase the clinician’s ability to consistently provide a dense, homogeneous obturation of root canal systems through regulating parameters that influence compaction of warm gutta percha. This second article in the series focuses on the technologic breakthroughs that the design of the Cork delivery device provides; the ability to establish a calibrated heat to apical gutta percha; the ability to control length with conventional apex locators; and the ability to compact and mold simultaneously as apical temperatures are confirmed.

Calibrated apical heat delivery Our potential to constantly provide a dense, three-dimensional filling to shaped root canal systems lies in our ability to mold into the infinite array of anatomic possibilities present from tooth to tooth. Controlling heat delivery to gutta percha is synonymous with controlling moldability of gutta percha. Conventional warm vertical techniques can have limitations in delivering heat to apical gutta percha in many clinical situations. This thermomechanical limitation of gutta percha to transfer heat more than a few millimeters is well documented.6-8 The Cork system of obturation was designed to produce and control known temperatures ideal for molding, particularly in the apical third. The Cork delivery device shown in Figure 2 was designed to transfer a relatively Volume 6 Number 3

uniform heat directly to gutta percha along its entire length as opposed to attempting to transfer a vast heat gradient through gutta percha from top to bottom.8 Uniform heat delivery promotes uniform softening, thereby establishing conditions that promote reproducible molding. Gutta percha’s capacity to accept heat, but its limited ability to transfer heat, results in a gradient in heat delivery in conventional warm vertical techniques. Although skilled and experienced clinicians can yield good results in warming and molding gutta percha, there is potential for us to improve in delivering warmth to apical regions of many pulpal systems. Said differently, the art and science of molding gutta percha can be mastered using conventional techniques and equipment, but the Cork delivery device decreases some of the sophistication needed to establish conditions that promote reproducible three-dimensional molding. The Cork delivery device is made of silver because silver has a high heat transfer coefficient. The design allows heat to transfer to the gutta percha along its entire length directly. In addition to facilitating apical heat delivery, the Cork delivery device can be calibrated to evenly warm gutta percha to 40–42º C along the entire length of gutta percha.8 This has been shown to be a desirable range to mold softened gutta percha.6 In addition, this type of control eliminates potential shrinkage by staying under phase transition temperatures.9

A Cork delivery device is ready for this heat delivery when confirmed to be fit well and correctly positioned in relation to the periodontal ligament (PDL). A conventional heat source is connected to the top of the Cork delivery device, and a calibrated heat wave is supplied down the shaft to the thin sheath that encases the entire apical gutta-percha plug. When the desired conditions are met, an initial phase of compaction occurs. Once this initial phase of compaction produces the majority of apical molding, the Cork delivery device is removed, and a final wave of compaction completes three-dimensional molding of homogenous gutta percha. Figures 3A-3D illustrate this sequence of placement, heat delivery, initial compaction, Cork delivery device removal, and final three-dimensional compaction. Figures 4A-4E illustrate endodontic retreatment in which the Cork delivery device was utilized to enhance apical heat delivery for three-dimensional molding into complex, apical microanatomy. This case also illustrates the capacity to fill lateral anatomy on the opposite side of the retrieved Cork delivery device during the second phase of compaction. At the 1-year recall, cone beam computed tomography (CBCT) was used to confirm good periradicular repair. The threedimensional rendering also illustrates the gutta-percha adaptation within the actual ribbon-shaped anatomy better than the circular appearance seen on the twodimensional digital radiographs. Endodontic practice 37

TECHNOLOGY

Figures 4A-4F: 4A-4D. The use of the Cork delivery device during the retreatment of a long maxillary lateral incisor. Figure 4E. One-year digital periapical radiograph reveals favorable periradiclular attachment. Figure 4F. CBCT taken at the 1-year recall also reveals the obturated three-dimensional ribbon-shaped anatomy Figure 4A

Figure 4D

Figure 5A

Figure 4B

Figure 4E

Figure 5B

Figure 4C

Figure 4F

Figure 5C

Figures 5A-5C: 5A. Cork-fit radiograph confirmed the initial, incomplete navigation of the sharp apical turn of this mandibular second molarâ&#x20AC;&#x2122;s distal root. 5B. Cork delivery device retrieved, and pre-bent prior renegotiation. 5C. Postoperative off-angle radiograph reveals three-dimensional obturation of this apical anatomy after confirmation of final placement was confirmed with use of apex locator opposed to an additional radiograph

38 Endodontic practice

Volume 6 Number 3

TECHNOLOGY

Figure 6: Prototype Cork unit that has the capacity to better control the parameter of the Cork technique. Although this type of unit is beneficial, conventional heat sources, apex locators, and pluggers can be used with the Cork delivery device

Figure 7: Clinical image of a positioned Cork delivery device illustrating the operator’s view of the molding surface

Apex locator confirmation of final position The Cork delivery device was designed to facilitate the delivery of thorough heat to apical gutta percha. An additional benefit of having silver extend the full length of the gutta percha and wrap the apical gutta percha is the ability to utilize apex locator

Figure 8: Clinical image of a conventional heat source heating a Cork delivery device while compaction occurs

technology when fitting for obturation. The Cork delivery device has been shown to have a high capacity to function with conventional apex locators. When endodontic residents at the University of Washington examined this functionality, they found that the Cork delivery device produced statistically similar accuracy to a No. 15 file when determining position to a

simulated periodontal ligament.10 Incorporating apex locator technology to the conefit may do more than give the clinician additional feedback of the final position of the Cork delivery device to the PDL. It may be possible to eliminate the conefit radiograph in many clinical situations. For example, Figure 5A shows a radiograph taken of a the Cork delivery

The first all-in-one, biocompatible and bioactive material to use wherever dentin is damaged Pre-operative radiograph

Completed endodontic treatment

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“ I find Biodentine particularly useful for perforation repair since it is relatively easy to apply in these situations. Upon setting, Biodentine has a very high pH which is anti-microbial and a neutral pH when set so that it does not initiate an inflammatory response and has the added property of stimulating the formation of hydroxy-apatite to promote bonding.” 3 month review

Dr. Godfrey Cutts, Private Practice, UK Photos Courtesy Dr. Godfrey Cutts

From the manufacturers of Septocaine® anesthetics • materials • endodontics • infection control Volume 6 Number 3

800-872-8305 septodontusa.com Endodontic practice 39

TECHNOLOGY

Figure 9A

Figure 9B Figures 9A-9B: 9A.Rendering of the first generation Cork 3D plugger in the fully open position. 9B. Illustration of the functionality of the Cork 3D plugger. In this sequence, the 3D plugger starts in a fully expanded position; it conforms to an oval shape in the body of the canal, and it condenses further as it progresses to match the apical shape

device fit to the elbow of the sharp apical turn present in the distal canal of this mandibular second molar. Knowledge of the canal morphology prompted the Cork delivery device to be removed and pre-bent to facilitate better placement, as shown in Figure 5B. The design of the Cork delivery device facilitates this unique ability to pre-bend the “master cone.” After tactually sensing placement around the apical turn, apex locator confirmation allowed for activation without the need to radiographically reconfirm final placement. The postoperative result is shown in Figure 5C. Another advantage of bringing apex locator technology to obturation is the potential to control safe heat delivery. Figure 6 displays a prototype Cork unit that is programmed to better control the Cork technique. The apex locator confirmation of the delivery device’s accurate placement allows for the initial wave of heat delivery to commence. Apical heat is then calibrated in each case by a feedback loop between thermosensors on the face of the plugger and the heat source. This feedback system promotes safe, accurate, and consistent heat delivery.

Simultaneously apical molding as temperature is delivered When studying the variables that influence three-dimensional molding, timing and type of compaction forces were found to influence predictable molding as much as the ability to uniformly soften gutta percha. 40 Endodontic practice

Just as inadequate heat does not soften gutta percha for three-dimensional molding, transferring heat without transferring corresponding compaction forces does not produce three-dimensional molding. If heat delivery and molding are separate, as in the multiple wave technique, then quick exchange is needed. Good conditions for molding are fleeting because softened gutta percha loses heat quickly. The ability to simultaneously transfer compaction forces while gutta percha is in its softened state is advantageous for reproducible molding. The design of the Cork delivery device allows for simultaneous molding as precise temperatures are being produced. This initial wave of compaction occurs as heat delivery is achieved, followed by removal of the Cork delivery device and a final phase of compaction before and as the softened gutta percha cools. Figure 7 is a clinical photo of what the Cork delivery device looks like when placed in position. This photo illustrates the clinician’s view of the molding surface. Figure 8 illustrates a conventional heat source in place at the top of the Cork delivery device while a plugger is in position to mold the softened gutta percha during the initial phase of compaction. This design allows for seamless retrieval of the Cork delivery device as the final wave of compaction continues to complete threedimensional molding.

Closing comments

are daunting. Adding a tool does not remove the obstacle, but at times, tools can empower us to reach the objectives we try so hard to obtain. Our objective to provide a dense, three-dimensional seal of all anatomic variations that we face after we shape and disinfect individual root canal systems is a supreme challenge. The benefits of warming and compacting gutta percha in the pursuit of this objective need not be an elusive technique for the clinically superior. If a safe and accurate Cork of root canal systems can be achieved by emerging practitioners, they may feel more empowered to embrace the self-evident advantages of warming gutta percha for three-dimensional molding. For the advanced user, establishing apical heat delivery, applying apex locator technology to the conefit, and improving compaction may bring increased apical molding potentials. In turn, these additional tools may bring additional enjoyment to our craft. In the final article of this series, the progressive advances of the Cork technique will be highlighted through clinical cases, and the revolutionary Cork 3D plugger will be introduced. A rendering of this new plugger is shown in Figure 9A. This plugger has the capacity to conform to individual canal anatomy as it progresses apically during compaction. Figure 9B demonstrates the Cork 3D plugger’s functionality to conform to the typical oval shape of root canal systems. EP

Providing long-term endodontic success is not easy. The anatomic and microbiologic obstacles that we face on a daily basis

References 1. Schilder H. Filling root canals in three dimensions. Dent Clin North Am. 1967;723-744. 2. West JD. The Relationship Between ThreeDimensional Endodontic Seal and Endodontic Failure [master’s thesis]. Boston, MA: Boston University; 1975. 3. Simons W. Revolutionary advances, Part 3: Pursuit of the 3-D Cork. Dent Today. 2011;30(12):52, 54-57. 4. Ingle J. Endodontics. Philadelphia, PA: Lea & Febiger; 1795:223. 5. Gordon J. Endodontic survey results. Christensen’s Clinicians Report. 2011;4(5):3 6. Goodman A, Schilder H, Aldrich W. The thermomechanical properties of gutta-percha. Part IV. A thermal profile of the warm gutta-percha

packing procedure. Oral Surg Oral Med Oral Pathol. 1981;51(5):544-551. 7. Miner MR, Berzins DW, Bahcall JK. A comparison of thermal properties between guttapercha and a synthetic polymer based root canal filling material (Resilon). J Endod. 2006;32(7):683686. 8. Simons WD. 3D Apical cork- Part 1. Endodontic Practice US. 2013;6(1):42-45. 9. Schilder H, Goodman A, Aldrich W. The thermomechanical properties of gutta-percha. Part V. Volume changes in bulk gutta-percha as a function of temperature and its relationship to molecular phase transformation. Oral Surg Oral Med Oral Pathol. 1985;59(3):285-296. 10. West JC. A novel approach to apical gutta percha control and sealing of the root canal systems. MSD Presentation: University of Washington; 2012; Seattle WA.

Volume 6 Number 3

Drs. Ane Poly, Juliana Brasil, Paula Marroig, Fabiola Ormiga, Patrícia de Andrade Risso, Marcos Cesar Araújo, and Heloísa Gusman evaluate the ability of solvents used in endodontics to disintegrate different root canal sealers Summary The aim of this study was to evaluate the ability of solvents used in endodontics to disintegrate different root canal sealers. Samples of four sealers were prepared and immersed into the solvents xylene, orange oil, eucalyptol, and alcohol 90% for 5, 10, and 30 minutes. Mass loss was determined and statistically analyzed. Endofill (Dentsply) and Pulp Canal Sealer™ SybronEndo presented a significant mass loss after all times of immersion into all solvents. Xylene promoted a significantly higher mass loss of Endofill than orange oil, followed by eucalyptol and alcohol 90%. Xylene and alcohol promoted a significantly higher mass loss of Pulp Canal Sealer than orange oil, followed by eucalyptol (ANOVA, P<.05). The sealers AH Plus® (Dentsply) and Sealer 26 (Dentsply) did not present significant mass loss in any solvent (ANOVA, P>.05). All solvents used promoted a significant disintegration of Endofill and Pulp Canal Sealer, except AH Plus and Sealer 26.

Introduction Root canal system retreatment is necessary when the endodontic therapy results in failure. The main goal of the endodontic retreatment is the total removal of the filling material, the cleaning and shaping of the root canal system, and its threedimensional filling.1 During the removal of the filling material, it is often easier to remove the gutta percha than to remove the endodontic sealer.2 Consequently, the permanence of this material inside the root canals may also prevent the removal of necrotic tissues and bacteria, which may cause retreatment failure.3

There are several techniques to remove root canal filling materials, including thermal, mechanical, and chemical methods, or the combination of these methods.4-7 The use of the mechanical methods can cause perforations, internal transportation of the foramen, and can change the original shape of the canal.3,5,7 Consequently, the mechanical methods are used in association with the chemical ones. This method uses solvents such as chloroform, xylene, orange oil, and eucalyptol to dissolve the gutta percha and the endodontic sealer present in the root canal system.4,8-10 Several studies evaluated the effect of chemical agents on the dissolution of different sealers. A significant dissolution of zinc oxide-based and glass ionomerbased sealers was observed as a consequence of water immersion.11-14 Studies that tested zinc oxide-based, polydimethylsiloxane-based, epoxy resinbased, and calcium hydroxide-based sealers immersed into eucalyptol solvent found their best dissolution action on the calcium hydroxide-based and zinc oxide-based sealers.4-6 When assessed in immersion tests of epoxy resin-based sealers, eucalyptol showed to be similar to chloroform.15 Immersion tests of these same sealers demonstrated that Citrol® and xylene presented a best action on zinc oxide-based sealers.4,5 In this context, the aim of the present study is to evaluate the ability of the solvents used in endodontics to disintegrate the root canal sealers Endofill, Pulp Canal Sealer EWT, AH Plus, and Sealer 26. The mass loss of the sealers was calculated after their immersion into different solvents for different periods of time.

Materials and methods Drs. Ane Poly, Juliana Brasil, and Paula Marroig are Specialists in Endodontics, and Drs. Fabiola Ormiga, Patrícia de Andrade Risso, Marcos Cesar Araújo, and Heloísa Gusman, are DDS, Professors of Endodontics at the Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.

Volume 6 Number 3

Four different sealers were used in this study: Endofill, Pulp Canal Sealer EWT, AH Plus, and Sealer 26. All sealers were mixed in accordance with manufacturers’ instructions, and compositions and

manufacturers are in Table 1. After manipulation, the sealers were placed in silicon molds in order to prepare circular samples with 6.2 mm of diameter and 2.3 mm of thickness. A total of 60 samples of Endofill, 36 samples of Pulp Canal Sealer EWT, 48 samples of AH Plus, and 36 samples of Sealer 26 were obtained. The samples were kept at room temperature for 48 hours, and were then placed in a kiln at 37ºC for 1 week. After this period, the samples were weighed using an analytical balance (M.S. Mistura, Rio de Janeiro, Brazil) for their initial mass. According to the solvents used, the samples of each sealer were then divided into four groups: Citrol (Biodinâmica, Ibiporã, Brazil), Eucalyptol (Biodinâmica, Ibiporã, Brazil), Xylene PA, (Proquimios, Rio de Janeiro, Brazil) and Alcohol 90% (Ilha do Comércio de Álcool Ltda., Curitiba, Brazil). Each sample was immersed into 0.5 ml of solvent in Eppendorf tubes at room temperature without agitation. Both surfaces of the samples were accessible to the solvent. Three different times of immersion were selected: 5, 10, and 30 minutes. After the immersion test, the samples were placed again in the kiln at 37ºC for 24 hours. The final weighing was then measured to obtain the final mass of the sample. Analysis of variance (ANOVA, P< .05) was used to compare the mass values between the different times of immersion in each condition.

Results Table 2 summarizes the mass loss values as a result of the different immersion tests. The Endofill sealer presented a significant mass loss after immersion into Citrol, where the immersion of 30 minutes caused a higher loss in relation to the immersions of 5 and 10 minutes. The same was observed with the solvent eucalyptol. On the other hand, xylene and alcohol 90% promoted a significant mass loss of Endofill, with no significant influence of the immersion time (ANOVA, P< .05). After all times of Endodontic practice 41

RESEARCH

The effect of different solvents on root canal sealers

RESEARCH immersion, xylene promoted a significantly higher mass loss of Endofill than Citrol did, followed by eucalyptol. There was no significant difference between the effects of eucalyptol and alcohol 90% on the Endofill disintegration after 5 minutes and 30 minutes. However, eucalyptol promoted a significantly higher mass loss of this sealer than that alcohol did after 10 minutes (ANOVA, P< .05). Pulp Canal Sealer showed a significant mass loss after immersion into the solvent Citrol, and a progressive loss (as a function of the immersion time) was observed. Eucalyptol, xylene and alcohol 90% promoted a significant mass loss of this sealer, with no significant influence of the immersion time (ANOVA, P< .05). After all times of immersion, xylene and alcohol promoted a significantly higher mass loss of the Pulp Canal Sealer than Citrol, with no significant difference between those solvents. Citrol promoted a significantly higher mass loss of Pulp Canal Sealer

Table 1: Tested materials, composition and manufacturers Composition

Manufacturer

Endofill

Power: Dexamethasone Acetate; Hydrocortisone Acetate; Polyoxymethylene; Thymol Iodide. Liquid: Eugenol.

Dentsply, Brazil

Pulp Canal Sealer

Power: Zinc oxide; Silver powder; Thymol iodide; Dimeric acid resin. Liquid: Balsam resin; Water; Eugenol.

SybronEndo, USA

AH Plus

Epoxide paste; Diepoxide; Calcium tungstate; Zirconium oxide; Aerosil; Pigment. Amine paste: 1-adamantane amine; N,N’-dibenzyl5-oxanonandiamine-1,9; TCD-Diamine; Calcium tungstate; Zirconium oxide; Aerosil; Silicone oil.

Dentsply, Brazil

Sealer 26

Power: Bismuth trioxide; Calcium hydroxide; Hexamethylenetetramine; Titanium dioxide. Paste: Bisphenol epoxy resin.

Dentsply, Brazil

Table 2: Mass loss (mg) after immersion tests

Oil of orange

Eucalyptol

Xylene

Alcohol

Endofill

Pulp Canal Sealer

AH Plus

Sealer 26

5 min

5.18 (±0.75)

2.43 (± 0.45)

0.00 (±0.00)

10 min

5.60 (±0.57)

3.70 (±0.17)

0.00 (±0.00)

0.13 (±0.00)

30 min

9.22 (±1.74)

5.20 (±0.40)

0.00 (±0.00)

5 min

2.86 (±0.99)

1.90 (±0.26)

0.00 (±0.00)

10 min

3.96 (±0.72)

2.17 (±0.31)

0.00 (±0.00)

30 min

7.34 (±0.93)

2.37 (±0.36)

0.28 (±0.01)

0.17 (±0.00)

5 min

15.14 (±1.26)

9.57 (±1.48)

0.00 (±0.00)

10 min

11.54 (±1.13)

11.20 (±1.99)

0.00 (±0.00)

30 min

13.78 (±2.17)

13.23 (±0.83)

0.00 (±0.00)

5 min

1.04 (±0.40)

4.27 (±0.42)

0.00 (±0.00)

10 min

2.56 (±0.65)

4.67 (±0.76)

0.00 (±0.00)

30 min

1.80 (±0.54)

5.57 (±0.57)

0.00 (±0.00)

0.00 (±0.01)

42 Endodontic practice

Volume 6 Number 3

Discussion A test that measures weight differences of the specimens evaluates disintegration processes that may not be the result of dissolution.11 In cases of solubility tests, there are no particles in suspension, and the solvent remains thus clear. In disintegration tests, there is release and suspension of the sample particles, and the solvent becomes turbid.12 In the present study, the sealers were disintegrated because the solvents were turbid at the end of the tests. The silicon molds used to prepare the samples were similar to those used by Tanomaru Filho, et al.,6 who followed the ANSI/ADA16 specification No. 57, but

Zandbiglari7 who observed that the oxidezinc based sealer used by those authors demonstrated a significant disintegration after immersion into eucalyptol. Our results are in agreement with those obtained by Martos, et al.,5 who observed that xylene, Citrol, and eucalyptol presented a decreasing order of solubility of the Endofill sealer. Also, the present data are in agreement with Tanomaru Filho, et al.,6 who observed that xylene promotes a higher disintegration of an oxide-zinc based sealer than eucalyptol does. However, different results were shown by Pécora, et al.,19 who observed that Citrol promoted a faster cleaning of the root canals filled with oxide-zinc based sealer than the solvents xylene and eucalyptol did. It is noteworthy that the sealers AH Plus and Sealer 26 did not present a significant mass loss in any solvent, regardless of immersion time (ANOVA p > 0.05). Similar findings were presented by TanomaruFilho, et al.,4 who concluded that Citrol and xylene did not promote a significant

with some changes. Such changes were made by those authors because of the low cohesive force of the zinc oxide-eugenolbased sealers, which causes cracks in the sample during its removal from the mold.6,14 All the sealers used here were mixed in accordance with manufacturers’ instructions. This method is different from those used by Tagger, et al.,17 Martos, et al.,5 Schäfer and Zandbiglari,7 and Whitworth and Boursin,2 who mixed the calcium-hydroxide-based sealers with a spatula moistened with tap water. Our method is also different from those used by Carvalho-Júnior, et al.12 and CarvalhoJúnior et al.,14 who mixed the Endofill sealer according to the power/liquid ratio and the mixing time described by Sousa-Neto, et al.18 The results presented herein showed that the solvent eucalyptol resulted in a significant disintegration of the sealers Endofill and Pulp Canal Sealer in all immersion times. These results are compatible with those of Schäfer and

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Volume 6 Number 3

Endodontic practice 43

RESEARCH

than eucalyptol after 5 minutes and 30 minutes. However, there was no significant difference between the effects of these solvents after 10 minutes (ANOVA, P< .05). The sealers AH Plus and Sealer 26 did not present a significant mass loss in any solvent, regardless of immersion time (ANOVA, P> .05).

RESEARCH

disintegration of AH Plus, and that xylene did not promote a significant disintegration of Sealer 26. However, those authors observed that the solvent eucalyptol promoted a significant disintegration of AH Plus and Sealer 26, and that the solvent Citrol promoted a significant disintegration of Sealer 26. This discrepancy with the present study may be related to the different dimensions of the samples used by those authors. It should be noted that the epoxy resin based sealers tends to present less disintegration than the other sealers do because of the epoxy resin property of absorbing liquids.12,14 According to Versiani, et al.,13 this absorption consists in a controlled diffusion process which

occurs predominantly in the resin matrix. The solvents used during the endodontic retreatment must present effectiveness in the chemical dissolution of the material to be dissolved and must still be safe for clinical use.5 Consequently, these solvents are selected considering two basic criteria: dissolution effectiveness and toxicity level.4 Although the present study has shown that xylene gives the best results in the disintegration of zinc oxide based sealers, this solvent is considered potentially carcinogenic, and its local and systemic toxicity has been related.20-23 The present study assessed the ability of the solvents used in endodontics to disintegrate four root canal sealers. All

the solvents used promoted a significant disintegration of Endofill and Pulp Canal Sealer. However, the sealers AH Plus and Sealer 26 did not present a significant mass loss in any solvent. The tests used did not consider clinical aspects, such as the surface contact between filling material and solvent, the temperature, the possible interaction of the solvent with other solutions, and the volatility of the solvents. Consequently, future research is necessary to evaluate the ability of the solvents used in endodontics to disintegrate root canal sealers in conditions more compatible with the clinical practice. EP

References 1. Ruddle CJ. Nonsurgical Retreatment. J Endod. 2004;30(12):827-845. 2. Whitworth JM, Boursin EM. Dissolution of root canal sealer cements in volatile solvents. Int Endod J. 2000;33(1):19-24. 3. Erdemir A, Adanir N, Belli S. In vitro evaluation of the dissolving effect of solvents on root canal sealers. J Oral Sci. 2003;45(3):123-126. 4. Tanomaru Filho M, Silva APO, Silva GF, Guerreiro-Tonomaru JM. Effectiveness of four solvents on different root canal sealers. Ciênc Odontol Bras. 2009;12(2):41-48. 5. Martos J, Gastal MT, Sommer L, Lund RG, Del Pino FA, Osinaga PW. Dissolving efficacy of organic solvents on root canal sealers. Clin Oral Investig. 2006;10(1):50-54. 6. Tanomaru Filho M, Jorge EG, Tanomaru JMG. Ability to solvent action of eucalyptol and xylene on different endodontic sealers. Ciênc Odontol Bras. 2006;9(3):60-65. 7. Schäfer E, Zandbiglari T. A comparison of the effectiveness of chloroform and eucalyptus oil in dissolving root canal sealers. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002;93(5):611-616. 8. Ezzie E, Fleury A, Solomon E, Spears R, He J. Efficacy of retreatment techniques for a resinbased root canal obturation material. J Endod. 2006;32(4):341-344. 9. Gilbert BO Jr, Rice RT. Re-treatment in endodontics. Oral Surg Oral Med Oral Pathol. 1987;64(3):333-338. 10. Schäfer E, Zandbiglari T. Solubility of root-canal sealers in water and artificial saliva. Int Endod J. 2003;36(10):660-669. 11. Orstavik D. Weight loss of endodontic sealers, cements and pastes in water. Scand J Dent Res. 1983;91:316-319.

44 Endodontic practice

12. Carvalho-Júnior JR, Guimarães LF, CorrerSobrinho L, Pécora JD, Sousa-Neto MD. Evaluation of solubility, disintegration, and dimensional alterations of a glass ionomer root canal sealer. Braz Dent J. 2003;14(2):114-118. 13. Versiani MA, Carvalho-Júnior JR, Padilha MIAF, Lacey S, Pascon EA, Sousa-Neto MD . A comparative study of physicochemical properties of AH Plus and Epiphany root canal sealants. Int Endod J. 2006;39(6):464-471. 14. Carvalho-Junior JR, Correr-Sobrinho L, Correr AB, Sinhoreti MA, Consani S, SousaNeto MD. Solubility and dimensional change after setting of root canal sealers: a proposal for smaller dimensions of test samples. J Endod. 2007;33(9):1110-1116.

20. Horvath SD, Altenburger MJ, Naumann M, Wolkewitz M, Schirrmeister JF. Cleanliness of dentinal tubules following gutta-percha removal with and without solvents: a scanning electron microscopic study. Int Endod J. 2009;42(11):10321038. 21. Wourms DJ, Campbell AD, Hicks ML, Pelleu GB Jr. Alternative solvents to chloroform for guttapercha removal. J Endod. 1990;16(5):224-226. 22. Lynge E, Anttila A, Hemminki K. Organic solvents and cancer. Cancer Causes Control. 1997;8:406-419. 23. McMichael AJ. Carcinogenicity of benzene, toluene and xylene: epidemiological and experimental evidence. IARC Sci Publ. 1998;85:318.

15. Bodrumlu E, Er O, Kayaoglu G. Solubility of root canal sealers with different organic solvents. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008;106(3):e67-e69. 16. American Dental Association, American National Standards Institute. ADA/ANSI Specification n°57: endodontic sealing material; 2000; Chicago. 17. Tagger M, Tagger E, Kfir A. Release of calcium and hydroxyl ions from set endodontic sealers containing calcium hydroxide. J Endod. 1988;14(12): 588-591. 18. Sousa-Neto MD, Guimarães LF, Saquy PC, Pécora JD. Effect of different grades of gum rosins and hydrogenated resins on the solubility, disintegration, and dimensional alterations of Grossman cement. J Endod. 1999;25(7):477-480. 19. Pécora JD, Costa WF, Filho DS, Sarti SJ. Introduction of an essential oil, obtained from Citrus aurantium, effective in disintegration of the oxidezinc based sealer inside the root canal. Odonto 1992;1(5):130-132.

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FILLING A NEED

Endodontics in Jamaica: a fulfilling and challenging experience Dr. Gary Glassman takes his endodontic experience on the road to help aspiring dentists The journey begins February 2012 For many years now, I have been providing volunteer dentistry in Jamaica, in addition to teaching the local dentists there how to provide proper endodontic care to their patients. Recently, a new dental school was constructed at the University of Technology in Jamaica, and I was appointed Adjunct Professor of Dentistry, a non-paying position. I strongly believe in paying it forward and that doing hands-on charitable work can often be more effective than just writing a check. The School of Oral Health Sciences is a new institution that was established in September 2010 in a response to the overwhelming burden of oral and dental diseases in Jamaica. The current dental workforce is approximately one dentist to 17,000 of the population. There are only 45 dental surgeons in the public health sector to a population of over 2 million people. The circumstances are dire. Jamaica still has a high prevalence of oral and pharyngeal cancers with a 5-year survival rate of less that 20%. Jamaica is experiencing severe challenges in terms of reducing the overall burden of diseases due to dental conditions. The University of Technology, Jamaica is a very young school with low resources. The dental school approached me about putting together the University’s undergrad Endodontic

Gary D. Glassman, DDS, FRCD(C), graduated from the University of Toronto, Faculty of Dentistry in 1984 and was awarded the James B. Willmott Scholarship, the Mosby Scholarship, and the George Hare Endodontic Scholarship for proficiency in endodontics. A graduate of the Endodontology Program at Temple University in 1987, he received the Louis I. Grossman Study Club Award for academic and clinical proficiency in endodontics. The author of numerous publications, Dr. Glassman is on staff at the University of Toronto, Faculty of Dentistry, is in the graduate department of endodontics, and is adjunct professor of dentistry and director of endodontic programming at UTech in KIngston, Jamaica. The endodonic editor for Oral Health dental journal, Dr. Glassman maintains a private practice, Endodontic Specialists in Toronto, Ontario.

46 Endodontic practice

Class of 2016

Program. After giving it some considerable thought, I decided to move forward and commit my time to this cause. I feel that it is very important. I invite you to follow my continuous journey as I share some stories and attempt to make a difference in endodontics among the Jamaican population. I hope you will also spread the word, and help me bring awareness to what is going on with the local people in one of the top vacation spots.

First steps My plan was to meet with second-year dental students and teach endodontics from the ground floor up. Lessons included the basics grounded in science, pulp biology, diagnosis, and a step-by-step approach. It is a great way to start the students off so they will not be overwhelmed. Both they and I were excited and eager to get started. When I got to the school the first day, there were 30 second-year dental students anxiously awaiting my arrival. They were jammed into the small portable classroom

that had been made available for us. There were even a couple of first-year students who managed to sneak into the classroom. They explained that they wanted to learn new things from the Canadian endodontist! I started off by giving an entertaining introductory lecture, followed by a pulp biology lecture, and finally wrapped the day up with an intense diagnosis lecture, and case presentation. The students were friendly, keen, and ready to learn. Day one turned out to be a big success. They left with homework for the week — they were to gather extracted teeth, and mount them to get ready for the practical session next weekend, to review my manual, to brush up on my videos, and to psyche themselves up to learn how to save teeth — one root at a time! After a quick trip back home to work for a few days, I arrived back in Jamaica to continue teaching the endodontics course. The students were prepared and once again anxiously awaiting my return. We started at 8 a.m., which on island Volume 6 Number 3

Volume 6 Number 3

disguise, as it allowed me to get down to bare bone basics with regards to teaching how to internally sculpt the root canal system. Each student not only understood the concepts taught, but was reinforced by actually watching how the root canal automatically was shaped by employing the techniques discussed. By pushing up our sleeves and actually using the basics, it has created a foundation for more advanced techniques to be used as the year goes on. A special thanks goes out to Steve

me all the technological equipment that customs had not let through before. It was such a relief that it went smoothly this time around so that we could complete the laboratory section of this course. The first day, Sunday, I spent the majority of the time doing a review of cleaning and shaping the root canal system, as well as obturation using warm vertical condensation of gutta percha. The students were not able to afford to purchase nickel-titanium files that are necessary to create the necessary shapes of the root canals, so customs allowed me

Dr. Fenton Ferguson, Minister of Health, Dr. Glassman, and Dr. Irving MacKenzie, Jamaica’s Chief Dental Officer and Dean of Health Sciences

Dr. Glassman demonstrating endodontic techniques to the class of 2015

Dr. Glassman performing a live patient presentation Dr. Glassman with Professor Errol Morrison, President of the UTech

Jones from SybronEndo for the generous donation of equipment and supplies, which has saved the University of Technology, Jamaica in excess of $50,000! Steven Newfield from Global Microscopes facilitated the donation of Dental Operating Microscope. Also thanks goes out to Alba Campusano from Denca iDental Supply in the Dominican Republic for facilitating the delivery of the Endo Kits for the students.

May 2012 I returned to Jamaica at the beginning of April to continue with the didactic portion of the course that I had started in February. Luckily, this time I was able to bring with

to bring down a generous, personal supply of the files from my own office in Toronto. The students spent the day doing the laboratory exercises and becoming familiar with all the various techniques that were taught. Everyone passed the laboratory component with flying colors. On Tuesday morning, I administered the final exam to the second-year dental students. I am happy and proud to report that they all passed with flying colors. I am looking forward to maintaining ongoing communication with the students and faculty to make sure the learning continues in the most efficient way. In the fall, the students enter their third year of dentistry, Endodontic practice 47

FILLING A NEED

time, translates to 8:45 a.m. — this is something that I’m learning to adapt to. We immediately started going through rubber dam and its application; then followed it up with tooth morphology and access opening. From there, we went straight to clinic. Unfortunately, not all the students had their own rubber dams, clamps, punches, or forceps. So as they say, we “made lemonade out of lemons” by improvising and using what was available for us. A quick show of hands let me know only two students had a full complement of supplies, so based on that, we split off into two groups where each of the students had an opportunity to apply rubber dam on their mannequin heads under my supervision. As the morning progressed, it was incredible for me to observe how the students actually became the teachers! They were able to help each other out with appropriate guidance, and they had a great time doing it! In the afternoon, we went on a hunt for burs, and the next day, we started accessing the teeth that they collected over the last week. Once again, they were helpful to each other, and the camaraderie was contagious. The microscope was generously donated by Global Microscopes and facilitated by Steve Newfield from Toronto. Halfway through the morning, I was joined by Dr. Robert Wallace and Dr. Winston Gray who took parts of the class for me as it was difficult for me to give all 30 students the personal attention they deserved. Lectures were intensive sessions, including discussions on instrumentation, irrigation, and obturation. There was a lot of information to absorb, and Dr. Garth Officer, a medical doctor, and now a dental student, gave me a tip. He told me, “Repetition deepens the impression!” From then on, I made sure to constantly repeat and review the material in order for the students to retain the information. This was helpful for the hands-on workshop. Mnemonics also often help with the retention of material, so the students “rapped” to remember. The students had a great time as they rapped to obturation! On the last day of class, due to a technical customs issue, the main supplies that we needed for treatment did not arrive from Miami. However, we were able to use the only supplies we did have available for us to do the root canal treatment in the morning, which were the hand files. In fact, this turned out to be a blessing in

FILLING A NEED and they start working with live patients. I will be able to supervise them along with the other faculty members.

May 2013 This February, I returned to Jamaica to teach endodontics to the second-year class at UTech in Kingston. This will be the graduating class of 2016. It was great to temporarily escape this year’s harsh winter in Toronto and be back in Kingston where I was greeted by both new and familiar faces. I was also pleased that there were no technical issues this year, and everything was smooth sailing. The class is comprised of a warm, energetic, and highly motivated group of students. Their eagerness and good nature justify why this is all worthwhile for me. On my last day in Kingston, I was fortunate enough to attend a conference for the launch of the Diabetes and Oral Health program. This is organized by the University Diabetes Outreach Programme (UDOP) in collaboration with The University of West Indies and University of Technology, Jamaica. At the last minute, I was also asked to speak at the conference and give my insights on this topic. Since I did not have a lot of time to prepare, I quickly gathered any background knowledge I already had, mixed with some Internet research. I ended up speaking briefly on the relationship between diabetes and oral care and vice versa. During my talk, I also made reference to the incredible things Dr. Irving McKenzie has done, and how the UTech dental school has set their sights on adopting the best standards for dental education in the world. I made it clear that it is also my own personal goal to contribute to that same objective. At the time of this writing, I look forward to returning to Jamaica in May, to not only continue with the second-year program, but also to attend and speak at the Jamaica Dental Association Annual Meeting in Montego Bay. I am touched by how grateful the students were as the final class ended. For me, as I make my way back home to Toronto, I realize how much of an incredible learning and rewarding experience this was. I am so grateful for the opportunity to be a part of this, and I am looking forward to returning to Kingston to see the students’ progress and to continue to empower the future dental students of Jamaica! EP

Steve Jones, Vice President SybronEndo, with students from the Class of 2015

The class is comprised of a warm, energetic, and highly motivated group of students. Their eagerness and good nature justify why this is all worthwhile for me. Class of 2015 “rapping to obturation”

Class of 2015 writing the final endodontic exam 48 Endodontic practice

Volume 6 Number 3

Dr. Rich Mounce explains the significance of a good relationship with referring doctors

ptimizing GP-specialist relationships is vital for all parties, because ultimately improved patient care results. Among other positives, the benefit for the GP is the trust earned with the patient by a constructive referral. Aside from economics and a happy patient, the benefit for the specialist is a stronger relationship with the GP. Ideally, the GP, the specialist, and the patient should all be cooperative partners with delivering optimal and efficient care as the end goal. It is difficult to generalize about specialists (in this case endodontists) and GP relationships because circumstances vary. In some cases, due to personal and family friendships, compatible personalities, proximity, attendance at the same dental school, etc., relationship and communication levels are optimal, obviously to the benefit of all parties. In other situations, representing some segment of the specialist and GP interactions, there are obviously challenges. Among many issues, these include referrals sent with inadequate information about either the tooth or the patient and/or inadequate communication back to the GP along with perceived or real criticism of the GP while in the hands of the specialist. Strategies for optimal working relationships include many things, but here are a few suggestions: 1) While not high tech, a phone call when indicated about any cases that are other than routine is always helpful in either direction. 2) A written referral that includes previous dental history, current treatment status, possibly chart notes, all relevant radiographic images, and the medical history where indicated are the gold

Dr. Rich Mounce is in full-time endodontic practice in Rapid City, South Dakota. He has lectured and written globally in the specialty. He owns MounceEndo, LLC, marketing the rotary nickel-titanium MounceFile in Controlled Memory and Standard NiTi. Dr. Mounce can be reached at: RichardMounce@MounceEndo.com MounceEndo.com Twitter: @MounceEndo

Volume 6 Number 3

standard for referral. 3) GPs should treat patients within their comfort level and skill set. The mentality that a GP can start every case and refer if difficulties arise is rarely productive for all parties in the mix. When technically challenging, cases are difficult for one of three reasons: the patient is difficult, the tooth is difficult, or the patient and tooth are both difficult. Identifying which of these three entities the general practitioner is up against is critical to making a good decision if the GP must decide when to treat, when to refer, and when itâ&#x20AC;&#x2122;s time for titanium. Admittedly, at times, these decisions are not straightforward. Once referred though, the highest level

easier than doing so with strangers. 6) Specialists should show their appreciation as often and sincerely as possible for the referrals they receive. In my view, we can never say thank you enough for the trust placed in us by our general dental colleagues. This thank you can take many forms, but ultimately, it is manifested by communications and gestures that reinforce the relationship at every level. I recognize we are all busy professionals with practice obligations, family, social and church activities, and hobbies. We are busy at home, busy at work, and often busy in our cars between home and work. And we are bombarded with intrusions (advertisements and

Aside from economics and a happy patient, the benefit for the specialist is a stronger relationship with the GP. Ideally, the GP, the specialist, and the patient should all be cooperative partners with delivering optimal and efficient care as the end goal.

of communication possible between the GP and specialist is always beneficial. 4) Specialist post-treatment communication should include a written summary of the treatment, radiographs, anything out of the ordinary documented in writing in the post-treatment report, treatment status, and confirmation of the next step for the patient. Ideally, this will also include calling the referring office to verbally update him/her as treatment progresses. 5) A meal between the doctors every 3 to 6 months, at a minimum a sit down to speak in person without distractions, is invaluable. Especially when something is potentially a problem, working issues out with partners and friends is much

messages on radio, Internet, billboards, mail, etc.) into our day. The volume of information we are encountering is unprecedented. A column (or more like a book) could be written about how to minimize and/or manage such intrusions to give us the personal and professional time and breathing space we need. The above not withstanding, regardless of the reason, not building relationships in both directions between GP and specialist, and a lack of communication is ultimately counterproductive to all parties. Taking the time to develop the strongest relationship possible is priceless. I welcome your feedback. EP

Endodontic practice 49

ENDOSPECTIVE

Optimizing GP-specialist relationships

PRODUCT INSIGHT

Barbed sutures Dr. Michael Norton discusses the barbed suture and its use in oral surgery

n occasion, a new product or material becomes available that simplifies or expands the scope of one’s clinical practice. The Piezosurgery concept certainly revolutionized bone cutting and the harvesting of block grafts, and today the introduction of the barbed knotless suture has the potential to do the same for the closure of long span incisions. This new class of suture takes advantage of 21st century technology to deliver a unique product that has already found favor in other spheres of surgery, notably in obstetrics and gynecology1 where surgeons are also working with mucosa. To date, I have restricted my use to the V-Loc™ 90 (Covidien™) brand, 15 cm length, both dyed (VLOCM1203) and undyed (VLOCM0003), with both a tapered and cutting needle. Certainly the latter is much more efficient at cutting through the often dense and fibrous palatal mucosa. The 15cm length seems well suited to the type of wound sizes we deal with in oral surgery, and the speed of resorption of the V-Loc 90 is certainly not too rapid, still typically being present 2 weeks post-op, while V-Loc 180 would provide too slow a resorption time that is not required, given the relatively rapid healing of oral mucosa.

Figure 1

Figure 2

Figure 3A

Figure 3B

Figure 4

Figure 5

Figure 6

Figure 7

Favorable In general, I have found the use of V-Loc most favorable in longer span wounds typically for sinus lifts (Figures 4 and 5), block bone grafting (Figures 6 and 7), and of course, implant placement (Figures 8 and 9). Its ease of use makes it particularly well suited to closure of wounds at the very back of the mouth where access and visual detail is often limited, and as such, this would also make an ideal suture for closure after the surgical extraction of wisdom teeth, too. Michael R. Norton, BDS, FDS, RCS(Ed), runs a private practice in Harley Street, London, dedicated to implant and reconstructive dentistry as well as the Centre for Treatment of Peri-implant Disease. He is fellow and board director of the Academy of Osseointegration and associate editor of the International Journal of Oral & Maxillofacial Implants. www.nortonimplants.com.

50 Endodontic practice

Volume 6 Number 3

PRODUCT INSIGHT

Figure 8

Figure 9

Figure 10

Figure 12

Figure 13A

Figure 13B

In general, patients have not reported any negative effects from the suture, and certainly they do not seem to be aware of the barbs, which, while a little rough, are certainly not sharp. The only comments have been that the loop feels rigid and when placed in a relieving incision within the sulcus, and it does seem to be irritating, especially against the cheek. I must admit that on four occasions, the loop or suture at the opposite end did appear to have loosened (Figure 10) with associated inflammation, perhaps as a result of resorption and concomitant loss of tension, and I have resorted to removing the loop and parts of the suture at followup.

Indeed, migrating or extruding barbed sutures have been reported elsewhere2, and my early impression is that this may prove to be a common problem; nonetheless, in general at 1 week followup, the closure and tissue appearance have been excellent (Figures 11 and 12).

is needed before one can say that this suture predictably lives up to its potential for oral surgery, but my first impressions are good, and certainly it is a product that demands you give it a try. One thing is for certain: the lack of a need for tying knots is a blessing when struggling at the back of the mouth in patients who are bleeding, salivating, coughing, and tiring of keeping their mouths open. It’s rather unsettling simply cutting off the needle without tying off the suture first, as one expects the whole thing to unravel before one’s eyes, but take it from me, it doesn’t! EP

Figure 11

Worry knot! In a split mouth comparison, it certainly compared well with the healing seen when using interrupted Vicryl™ (Ethicon, Inc.) sutures where much deeper furrowing of the incision line was typically seen (Figures 13A and 13B). No doubt much more documentation

References 1. Greenberg JA. The use of barbed sutures in obstetrics and gynecology. Rev Obstet Gynecol. 2010;3(3):82-91. 2. Villa MT, White LE, Alam M, Yoo SS, Walton RL. Barbed sutures: a review of the literature. Plast Reconstr Surg. 2008;121(3):102e-108e.

Volume 6 Number 3

Endodontic practice 51

ANATOMY MATTERS

Do lateral canals really matter? Part 6 Dr. John West explores the significance of the lateral canal

his question has been asked of endodontists as long as I can remember. Many of us remember spirited 1970s debates between Dr. Herbert Schilder and Dr. Frank Weine. When I went to dental school, we were taught that if we “instrument and fill the mother canal” we could expect a 95% success rate. Dr. Schilder, however, taught his students “all foramina are potentially significant.” Which thinking is right? Do lateral canals matter? And what is a lateral canal anyway?

Is it biology or just “the look?” First, in order to determine the biologic determinants of endodontic predictability, there is the biologic question. Am I willing to leave that answer to our scientists and academicians? Second, I do not distinguish “lateral canal.” Nature doesn’t either. Nature simply creates root canal “systems” with portals of exit (POEs). What if a canal divides into two apical POEs of equal length in the last 2 to 4 mm? Which one is the lateral canal? Which one don’t you want if lateral canals do not matter? As endodontic clinicians, we want them both. We want them all. In my experience the “lateralness” of a lateral canal does not matter since even furcal “lateral” canals can cause and/or prevent lesions of endodontic origin.4 Even if clinicians do not think lateral canals matter, they are always excited and proud if they pack one. I remember

a colleague showing me a radiograph of a central incisor with his filled lateral canal using lateral condensation. It was the first demonstrable lateral canal he filled in over 15 years! Really, that’s what it’s all about. Demonstrating multiple radiographic POEs is a signature outcome. We know from studying all the teeth in the ToothAtlas. com that there are approximately 2.5 POEs on average for every canal.1 Getting them means the clinician has usually accomplished most, if not all, of the following: 1. Unrestricted access, dentin triangles removed while safeguarding precious restorative ferrule dentin Appropriately shaped canals with 2. smooth walls and a continuously tapering funnel design where the clinician has preserved the original position and size of the shaped canal, i.e., FLOW 3. The root canal system has been cleaned of necrotic debris, detached pulpal tissue, dentin shavings and mud, biofilm, and smear layer 4. Proper conefit 5. Vertical compaction of warm gutta percha or carrier-based obturation, thereby delivering heat and pressure at the foraminal sites. It means you have created the possibility to seal multiple POEs where they exist. The clinical does not find the “lateral” canal; the obturation hydraulics system finds the lateral canal, which could be in any position along the tunnel

Figure 1: Pretreatment. 1988 pretreatment radiograph of previous nonsurgical endodontic treatment followed by surgical retreatment. Arrow points to apparent lateral lesion of endodontic origin

geometry of the shaped canal itself. As a clinician and educator for over 35 years, I am often asked by students if I have a patient where I could demonstrate that a lateral canal matters. Actually, all endodontists can produce these examples if the patients are carefully followed.

Lateral canal matters: case report John West, DDS, MSD, the founder and director of the Center for Endodontics, continues to be recognized as one of the premier educators in clinical and interdisciplinary endodontics. Dr. West received his DDS from the University of Washington in 1971 where he is an affiliate associate professor. He then received his MSD in endodontics at Boston University Henry M. Goldman School of Dental Medicine in 1975 where he is a clinical instructor and has been awarded the Distinguished Alumni Award. Dr. West has presented more than 400 days of continuing education in North America, South America, and Europe while maintaining a private practice in Tacoma, Washington. He co-authored “Obturation of the Radicular Space” with Dr. John Ingle in Ingle’s 1994 and 2002 editions of Endodontics and was senior author of “Cleaning and Shaping the Root Canal System” in Cohen and Burns 1994 and 1998 Pathways of the Pulp. He has authored “Endodontic Predictability” in Dr. Michael Cohen’s 2008 Quintessence text Interdisciplinary Treatment Planning: Principles, Design, Implementation, as well as Dr. Michael Cohen’s soon to be published Quintessence text Interdisciplinary Treatment Planning Volume II: Comprehensive Case Studies. Dr. West’s memberships include: 2009 president and fellow of the American Academy of Esthetic Dentistry, and 2010 president of the Academy of Microscope Enhanced Dentistry, the Northwest Network for Dental Excellence, and the International College of Dentists. He is a 2010 consultant for the ADA’s prestigious ADA Board of Trustees where he serves as a consultant to the ADA Council on Dental Practice. Dr. West further serves on the Henry M. Goldman School of Dental Medicine’s Boston University Alumni Board. He is a Thought Leader for Kodak Digital Dental Systems, and serves on the editorial advisory boards for: The Journal of Esthetic and Restorative Dentistry, Practical Procedures and Aesthetic Dentistry, and The Journal of Microscope Enhanced Dentistry. Visit www.centerforendodontics.com, or email: johnwest@ centerforendodontics.com, phone 1-800-900-7668 (ROOT), fax 253-473-6328.

52 Endodontic practice

In this issue of Anatomy Matters, I report on a 25-year posttreatment where a “lateral” canal matters. In 1988, the patient presented with soreness over facial of the maxillary left central incisor (Figure 1). A radiograph demonstrated the patient had experienced previous nonsurgical endodontics followed by a surgical endodontic retreatment. In addition, a lateral radiolucency incisal to the apparent lateral canal surgical seal was observed. After reviewing treatment options, the patient, referring restorative dentist, and I choose to nonsurgically attempt to seal the root canal system with the anticipation of an underfilled or unfilled lateral canal. After gutta-percha removal with heat and Volume 6 Number 3

ANATOMY MATTERS

Figure 2: Nonsurgical retreatment. Note No. 6 manual file sliding into lateral canal approximately 2 mm incisal to lateral canal surgical seal attempt

Figure 3: Posttreatment. Note lateral canal obturated at site of cleaned lateral canal seen in Figure 2

Figure 6: Twenty-five-year posttreatment. Note continued health of lateral lamina dura adjacent to sealed lateral canal and robust post placement, foundation, and new crown

Figure 7: Clinical. Image reveals favorable esthetic match with adjacent central incisor and long-term contribution to an attractive smile

Volume 6 Number 3

Figure 4: Twenty-year posttreatment. Lamina dura and attachment apparatus show sustained healing of lateral lesion of endodontic origin (LEO)

solvents, I was able to slide into a lateral POE with a No. 6 manual file, which can be seen approximately 2 mm incisal to the amalgam retrofilled apparent lateral canal (Figure 2). The root canal system was cleaned and shaped incisal to the apical amalgam, which tested solid and sealed. Vertical compaction of warm gutta-percha was performed with clear obturation of lateral canal that had been cleaned to size 10 manual file (Figure 3). Twentyyear posttreatment validates radiographic healing of the lesion of endodontic origin with reconstitution of the attachment apparatus and the lamina dura (Figure 4). In 2010, the patient returned with a fractured crown but without endodontic symptoms (Figure 5). Dr. John Kois, a superb clinician and educator in Seattle, Washington, restored the crown with a robust post/foundation, and 3 years later, in 2013, the tooth continues to “feel good,” is asymptomatic, and “looks good” to the patient (Figures 6 and 7). For me, endodontics has a golf metaphor. The golf pro tells me that in order to finish the golf swing properly, I need to be “scratching my back” with the club and facing the ball path. That finish position means all the right things had to happen properly: position to desired path and stance relative to the ball, proper grip, back swing and nice flat plane, the swinging club forward through the same plane, proper body position of swing from beginning to end, and then the finish or follow-through. Endodontics is the same way. If you consistently visibly obturate multiple POEs, you have disciplined yourself, just like the golf pro, to do all the

Figure 5: 2010 posttreatment. While continued endodontic healing of lateral LEO continues at the lateral canal seal site (arrow), the patient had fractured the crown (arrow)

right things that increase your Endodontic Seal probability and performance. And remember, some clinicians that may be a little heavy-handed discover that their first lateral canal may actually be their first canal! So, do lateral canals matter? For this patient it did. And while we do not have scientific control to prove the importance the lateral canal plays in endodontic predictability, there are most certainly cause and effect documentations. The cause for the patient in this report was an undersealed root canal system causing a symptomatic tooth with a lateral radiolucency. The root canal system was treated and 25 years later shows that sustained healing has occurred by all biologic and radiographic standards. The only difference in the before and after: a sealed lateral canal. Anatomy Matters once more. EP

References 1. West J. How do masters do it. Presented at: American Association of Endodontists; 2012; Boston, MA. 2. West J. Anatomy matters. Endodontic Practice US. 2012;5(2):14-16. 3. West J. Anatomy matters — part 2. Endodontic Practice US. 2012;5(4):26-27. 4. West J. Anatomy matters — part 3. Furcal endodontic seal heals furcal lesion of endodontic origin. Endodontic Practice US. 2012;5(6):22-24. 5. West J. Anatomy matters. Long-term case report. Endodontic Practice US. 2013;6(1):50-51. 6. West J. Anatomy matters. Root canal system anatomy only matters when it matters. Endodontic Practice US. 2013;6(2):56-58.

Endodontic practice 53

DIARY

lllllllllllllllllllllll OF EVENTS llllllllllllllllllllllllllllllllllllllllllllllllllll

A Walk through the Cycle of Infection Prevention Dr. Fiona M. Collins May 15, 2013 San Diego, CA www.essentialseminars.org

Current Scientific Evidence in Endodontic Therapy Dr. Michael Nimmich May 31, 2013 Tampa, FL www.tulsadentalspecialties.com

Current Scientific Evidence in Endodontic Therapy Dr. Joe Camp May 17, 2013 Birmingham, AL www.tulsadentalspecialties.com

The Attachment-Retained Overdenture Dr. George Bambara June 5, 2013 S. Hackensack, NJ www.essentialseminars.org

Endodontic Techniques for Safe and Predictable Results Dr. Barry Lee Musikant and Dr. Allan S. Deutsch May 17-18, 2013 S. Hackensack, NJ www.essentialseminars.org

Current Scientific Evidence in Endodontic Success Dr. Shawn Velez May 31, 2013 Jacksonville, FL www.tulsadentalspecialties.com

54 Endodontic practice

Current Scientific Evidence in Endodontic Therapy Dr. Michael Ribera June 7, 2013 Raleigh, NC www.tulsadentalspecialties.com

Everything Endo: A Live Clinical Experience Dr. Brett Gilbert June 7-8, 2013 Niles, IL www.sybronendo.com

Pacific Northwest Dental Conference 2013 June 13-14, 2013 Bellevue, WA www.wsda.org/pndc-future-dates

Florida National Dental Convention June 13-15, 2013 Orlando, FL events.floridadental.org/?do=reg. content&event_id=35

Current Scientific Evidence in Endodontic Therapy Dr. Michael Ribera June 21, 2013 Austin, TX www.tulsadentalspecialties.com

Letâ&#x20AC;&#x2122;s Talk Endodontics in 2013 Dr. Tom Jovicich June 21, 2013 Houston, TX www.sybronendo.com

Volume 6 Number 3

MATERIALS lllllllllllll & lllllllllllll EQUIPMENT J. Morita announces TwinPower Turbine Basic The new TwinPower Turbine® Basic handpiece comes with a limited time, 30-day money back guarantee*. This handpiece offers several of the unique features of the original TwinPower product line. Cutting efficiency remains equal to the standard head with the same double-impeller rotor design that produces high power and torque, up to 22 watts. A pressurized air system prevents suck back in the air line resulting in superior infection control. The body of the handpiece is chrome with a convenient push-button chuck. Other features include: ceramic bearings, rapid braking within 2 seconds, and a four-hole connection. For more information, visit www.morita.com/usa/twinpower or call 1-888-JMORITA (566-7482).

Zfx Dental CAD design software: designed by technicians, for technicians Once the scan data is imported, Zimmer Dental’s Zfx software guides you step-by-step through the process — beginning with the crown and working down to the coping or abutment, as needed. This design flow gives you the option to control each detail and tailor the system to suit your needs. The complete software package includes: • Zfx CAD design software for crown and bridge restorations • Abutment Design Module • Virtual Articulator • TruSmile With the Zfx system, there’s a wide range of restorative options at your fingertips for designing abutments, crowns, and bridges. Zfx software allows you to design restorations from the crown down, resulting in an ideal restoration. The Zfx Scan III offers precision, reliability, and processing speed through a userfriendly interface. The system, designed with an open architecture, allows you to output a standard .stl file for flexibility in computeraided manufacturing and restoration. You add the finishing touches. For more information, visit www.zimmerdental.com, or call 800-854-7019.

Brasseler USA®’s most popular procedure kits now available in bonus packs Brasseler USA®, a leading manufacturer of quality instrumentation, innovation, and superior service to the dental industry, recently redesigned and repackaged its most popular procedure kits to include detailed usage and technique information and additional bonus product. Brasseler’s Ultra Denture Kit and All Purpose Dentist Lab Kit now include a bonus pack of 12 medium ET® ProviPro™s, 12 fine ET® ProviPro™s, and six mandrels, allowing dental professionals to polish both composite and acrylic based appliances, and provisional and removable restorations to a high gloss shine chairside without the need for messy pumice. The easy-to-use technique guides include detailed information related to each specific procedure, kit contents, and reorder information, as well as technical tips and easy how-to instructions. The guides are laminated for convenient posting and durability. For more information about Brasseler’s new Bonus Pack Procedure Kits and all Brasseler products and services, please visit www.BrasselerUSA.com or call 800-841-4522.

Septodont introduces the Biodentine™ operatory 5-pack Septodont is introducing the new Biodentine™ 5-pack. This operatory 5-pack provides the convenience of having a smaller package to store Biodentine in each operatory. Biodentine is a proven all-in-one adhesive dentin replacement material that is bioactive, biocompatible, leakage free, and can be used for the restoration of both the crown and root wherever dentin is compromised. Successful clinical indications include restoring deep cavities with both direct and indirect pulp capping, pulpotomies, perforation repair, and internal/external resorptions. The key properties of Biodentine include: higher compressive strength than dentin, equivalent flexural modulus as dentin, microleakage-free, cuts like dentin, no need for special surface preparation, sets in 10-12 minutes – restoration can be placed within 5 minutes, medical grade purity, and stain-resistance. Biodentine has successfully saved hundreds of teeth from the need for root canal therapy (RCT). Studies are available upon request. Biodentine is available through the dental supply dealer. For more information, call 1-800872-8305 or visit the website at www.septodontusa.com.

Air Techniques presents All-New Monarch™ infection control products The Monarch™ line of infection control products for surfaces, instruments, skin and hands, and equipment is designed to exceed practitioners’ expectations in terms of staff and patient safety, effectiveness and efficiency. Stronger. Safer. Smarter. For more information on Air Techniques, please visit: www.airtechniques.com. Become a fan of Air Techniques on Facebook and follow the company on Twitter.

Volume 6 Number 3

Endodontic practice 55

THE NITI SHAPING MOVEMENT FIFTH GENERATION TECHNOLOGY

ince the beginning of modern day endodontics, there has been an evolution of concepts, instruments, and techniques for preparing canals. Over the decades, a staggering array of files has emerged for negotiating and shaping canals. In spite of the design of the file, the number of instruments required, and the surprising multitude of techniques advocated, endodontic treatment is typically approached with optimism for success. This editorial will briefly review the NiTi shaping movement, focusing on the new fifth generation technology. To appreciate the evolution of NiTi mechanical files, it is useful to know that the first generation of NiTi rotary files has passive cutting radial lands. Each file in any given brand line has a fixed-tapered design over the length of its active blades. As such, it is important to note that all first generation files only have a variablytapered design between files within any given series. This generation of technology generally requires a series of files to safely achieve the preparation objectives. The second generation of NiTi rotary files has active cutting edges and requires fewer instruments to fully prepare a canal. The clinical breakthrough occurred when the ProTaper NiTi rotary file system (Dentsply Tulsa Dental Specialties, or DTDS) came to market in 2001 utilizing an increasing or decreasing variably-tapered design over the active portion of any given file. The critical distinction between first and second generation technologies is that ProTaper has a variably-tapered design on a single file. Improvements in NiTi metallurgy became the hallmark of what may be identified as the third generation of mechanical shaping files. In 2007, utilizing heat treatment technology, certain file brands were shown to have significantly greater flexibility and resistance to cyclic

Clifford J. Ruddle, DDS, FACD, FICD, is founder and director of Advanced Endodontics (www.endoruddle.com), an international educational source, in Santa Barbara, California. Additionally, he maintains teaching positions at various dental schools. Dr. Ruddle can be reached at info@endoruddle.com.

56 Endodontic practice

fatigue, which improve safety when shaping more curved canals. For example, DTDS utilized heat treatment technology to create the metallurgical super metal, M-wire. The fourth generation of instruments and related motor technology has largely fulfilled the long hoped-for single-file technique. WaveOne (DTDS) utilizes a reciprocating motor to drive any given file in innovative unequal bidirectional angles. The critical distinction is all other reciprocating files utilize equal bidirectional angles. Strategically, after 3 CCW and CW cutting cycles, the WaveOne file will have rotated 360º. This novel reciprocating movement allows a file to more readily progress, efficiently cut, and effectively auger debris out of the canal. The latest fifth generation of shaping files has been designed with an offset mass of rotation. This design serves to produce a unique mechanical wave of motion that travels along the active length of the file. For example, the recently launched Protaper NEXT (PTN) rotary file system (DTDS) is the convergence of the most successful generational design features from the past, coupled with the fifth generation of continuous improvement, the offset design. PTN is a fifth generation system with three unique design features that greatly influence performance. One strategic feature of PTN is the utilization of the second generation variablytapered design on a single file. This unique design serves to limit each file’s cutting action to a specific region within a canal, which decreases dangerous taper lock and the screw effect. Of clinical significance, a file with a decreasing variably-tapered design strategically improves flexibility, limits shaping in the body of the canal, and conserves coronal two-thirds dentin compared to a similarly-sized, fixedtapered file. Another critical PTN design feature utilizes third generation heat treatment technology. Heat treatment significantly improves safety when shaping canals that exhibit curvature or recurvature. Research has shown that M-wire, a metallurgically improved version of NiTi, reduces cyclic fatigue by 400% when comparing files of

the same D0 diameter, cross-section, and taper. The third critical design feature of PTN is related to utilizing fifth generation technology, where shaping files have an offset mass of rotation. There are three major advantages of utilizing shaping files that rotate with an offset mass of rotation. 1. An offset design generates a repetitive mechanical wave of motion along the active portion of a file. This “swaggering effect” serves to minimize the engagement between the file and dentin compared to the action of a fixed-tapered file with a centered mass of rotation. Synergistically, a variably-tapered file with an offset mass of rotation reduces engagement, undesirable taper lock, and the screw effect. 2. An offset design affords more crosssectional space for enhanced cutting, loading, and augering debris out of a canal compared to a file with a centered mass of rotation. Many instruments break as a result of excessive intrablade debris packed between the file and dentin. Importantly, an offset file design decreases the probability for laterally compacting debris and blocking root canal system anatomy. 3. A PTN file with an offset mass of rotation will generate a mechanical wave of motion analogous to the oscillation noted along a sinusoidal wave. The resulting envelope of motion will more safely and efficiently develop the samesized preparation as would be required from a larger, stiffer, and fixed-tapered file with a centered mass of rotation. Each new generation of shaping files has had something to offer, has been described in different ways, and has been intended to improve shaping results. PTN has emerged as a fifth generation system designed to bring the most proven and successful generational design features from the past, coupled with the most recent technological advancements. The ProTaper NEXT system promises to set a new standard for safety, efficiency, and simplicity for shaping canals. Keep this on your radar! EP

Volume 6 Number 3

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*Ruddle CJ, Machtou P, West JD, The Shaping movement: fifth-generation technology. Dent Today. 2013;32(4):94-99.

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Images Courtesy Dr. Cliff Ruddle