Endodontic Practice US Summer 2018 Vol 11 No 2

clinical articles • management advice • practice profiles • technology reviews Summer 2018 – Vol 11 No 2 • endopracticeus.com

PROMOTING

EXCELLENCE

IN

ENDODONTICS Surgical extrusion and endodontic treatment following dental trauma Dr. Judy McIntyre

Corporate profile Carestream Dental

Practice profile Dr. Gregori Kurtzman

Root canal obturation: hermetic or biological seal Dr. Josette Camilleri

SEE WHY OVER HALF THE ENDODONTISTS HAVE SWITCHED TO EDGEENDO

Dr. Clovis Monteiro Bramante, et. al

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Micro-computed tomographic analysis of a maxillary central incisor with three roots and three canals

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Learn more at sonendo.com/change. © 2018. All rights reserved. SONENDO, the SONENDO logo, GENTLEWAVE, the GENTLEWAVE logo and SAVING TEETH THROUGH SOUND SCIENCE are trademarks of Sonendo, Inc. Patented: www.sonendo.com/intellectualproperty. MM-0528 Rev 01

* Images courtesy Khang T. Le, DDS 1 Sigurdsson A et al. (2016) J Endod. 42:1040-48 2 Molina B et al. (2015) J Endod. 41:1701-5 3 Vandrangi P et al. (2015) Oral Health 72-86 4 Nair NPR et al. (2014) Int Endod J. 47:1003-1011

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DR. CHARLES J. GOODIS ENDODONTIST, OWNER, CEO CELL 505-414-8122

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ASSOCIATE EDITORS Julian Webber, BDS, MS, DGDP, FICD Pierre Machtou, DDS, FICD Richard Mounce, DDS Clifford J Ruddle, DDS John West, DDS, MSD 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 CE QUALITY ASSURANCE ADVISORY BOARD Dr. Alexandra Day, BDS, VT Julian English, BA (Hons), editorial director FMC Dr. Paul Langmaid, CBE, BDS, ex chief dental officer to the Government for Wales Dr. Ellis Paul, BDS, LDS, FFGDP (UK), FICD, editor-inchief Private Dentistry Dr. Chris Potts, BDS, DGDP (UK), business advisor and ex-head of Boots Dental, BUPA Dentalcover, Virgin Dr. Harry Shiers, BDS, MSc (implant surgery), MGDS, MFDS, Harley St referral implant surgeon © FMC 2018. All rights reserved.

The publisher’s written consent must be obtained before any part of this publication may be reproduced in any form whatsoever, including photocopies and information retrieval systems. While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any consequence arising from it. The views expressed herein are those of the author(s) and not necessarily the opinion of either Endodontic Practice US or the publisher.

Succeed in today’s endodontic market

T

o maintain your practice success, you must be able to control your overhead and cut costs. Overhead can be like cancer — it wants to grow and spread.

We all realize that endodontics is becoming more competitive with root canal reimbursements decreasing and patients finding it harder to pay their part of the cost. Endodontists are struggling and making all-time low profits. In this environment, overhead control clearly becomes a major factor — not only for our success but also for our survival.

With an aging population, the demand for advanced Dr. Charles Goodis endodontic files will increase and result in more overhead cost.

As endodontists, our operating cost is a choice, made by decisions we make or don’t make. Without a proper business plan, high expenses will invade and spread into our profits. Accommodating for more patients could be financially easier when file costs are low; the benefit of being able to save $10,000 to $30,000 per year on endodontic file costs cannot be overstated. If these savings are invested properly, the result could be millions of dollars of extra income over the course of your career.

EdgeEndo’s research, development, and testing show that its endodontic NiTi files manufactured and sold are better than what endodontists are currently using, and the files cost half the price of competing files, saving tens of thousands of dollars per year and reducing overhead cost. Also, with EdgeEndo® files, you don’t need to buy in bulk, tying up thousands of dollars of your money on inventory that sits on your shelves instead of earning you more money.

Technological innovations and advancements in heat treatment have so profoundly increased NiTi file performance that endodontists can now perform procedures that were unimaginable with standard nickel-titanium files. But taking advantage of these advancements doesn’t necessarily come at a cost. In fact, EdgeEndo’s proprietary technology creates manufacturing efficiencies that offer superior NiTi files at a fraction of traditional prices. Also, many of the file systems are designed as direct replacements for your current systems. Since you don’t need to change techniques, the switch is seamless and cost-effective.

Endodontists will see a vast difference in monthly-yearly cost, avoiding unnecessary financial troubles. Together, we can move faster to prevent these issues from happening and succeed in today’s endodontic market.

Dr. Charles Goodis

Dr. Charles Goodis received his DDS from the University of Michigan, his GPR residency at the University of Minnesota, and his Endodontic residency at the University of Connecticut. His undergraduate major at the University of Michigan was Mechanical Engineering. Dr. Goodis has dedicated his career to constantly improving the root canal procedure, making it safer, simpler, and more efficient. His findings led him to create more effective root canal instruments and procedures.

The instruments are marketed to dentists and endodontists around the world, and he conducts national seminars on advanced (safer, simpler, faster, painless) root canal procedures. Dr. Goodis also served as a commissioned officer in the Indian Health Service as Chief Dentist at the Fort Berthold Reservation.

Disclosure: Dr. Goodis is founder and owner of EdgeEndo®.

ISSN number 2372-6245

Volume 11 Number 2

Endodontic practice 1

INTRODUCTION

Summer 2018 - Volume 11 Number 2

TABLE OF CONTENTS

Clinical case

Practice profile

6

Gregori Kurtzman, DDS, MAGD, FPFA, FACD, FADI, DICOI, DADIA Connecting with patients and colleagues

Healing of apical periodontitis in a maxillary second molar with fused roots and complex isthmus using the GentleWave® Procedure Dr. Randy W. Garland discusses a technique to thoroughly debride and disinfect complex anatomy..............12

Clinical research Comparative study of the shaping capacity obtained with the Reciproc® and Reciproc® Blue files in simulated doublecurved root canals Drs. Jorge Alberdi and Fernando Goldberg compare canal transportation in simulated doublecurved root canals...........................18

Micro-computed tomographic analysis of a maxillary central incisor with three roots and three canals

Corporate profile Carestream Dental The newest well-established digital dental company

2 Endodontic practice

10

Drs. Clovis Monteiro Bramante, Murilo Priori Alcalde, Pablo Andrés AmorosoSilva, Alexandre Silva Bramante, Helberth Gonzalis Giraldo, Rodrigo Ricci Vivan, and Marco Antonio Hungaro Duarte discuss possible anatomical variations that can be of consequence even in those teeth considered as less complex.............24

Volume 11 Number 2

OPEN DESIGN? P URE GENIUS. TM

The Genius hybrid files can be used in both reciprocation and rotation, and most procedures can be completed using just two files. The Genius endodontic motor switches between reciprocation and rotation with the touch of a button, and the open design gives you the freedom to provide the best treatment for your patient. www.ultradent.com/genius

800.552.5512 | ultradent.com Š 2018 Ultradent Products, Inc. All Rights Reserved.

TABLE OF CONTENTS

Continuing education Root canal obturation: hermetic or biological seal Dr. Josette Camilleri evaluates what type of seal is possible using classic obturation materials and techniques ..................................................... 28

Continuing education

33

Surgical extrusion and endodontic treatment following dental trauma

Dr. Judy McIntyre describes endodontic treatment for comminuted and complicated crown-root fractures after trauma

Product debut

PUBLISHER | Lisa Moler Email: lmoler@medmarkmedia.com

Brasseler USA®: AAE new product introductions

MANAGING EDITOR | Mali Schantz-Feld, MA Email: mali@medmarkmedia.com | Tel: (727) 515-5118

......................................................40

ASSISTANT EDITOR | Elizabeth Romanek Email: betty@medmarkmedia.com VP, SALES & BUSINESS DEVEL. | Mark Finkelstein Email: mark@medmarkmedia.com NATIONAL ACCOUNT MANAGER | Robert Akert Email: rob@medmarkmedia.com

Practice management Recover, repair, and heal from super stress with BrainTap® Sandra Marlowe discusses how to nurture a relaxation response in everyday life and the dental office ......................................................43

4 Endodontic practice

Small talk

CLIENT SERVICES/SALES SUPPORT | Adrienne Good Email: agood@medmarkmedia.com

Achieve a “personal best” by expanding your comfort zone

CREATIVE DIRECTOR/PROD. MGR. | Amanda Culver Email: amanda@medmarkmedia.com

Joel Small notes, “Each time we achieve a new personal best, we expand the limitations of our being until these limitations no longer exist” ....................................................... 46

Industry news ....................................................... 48

OFFICE MANAGER/EXECUTIVE ASST. | Mystey Helm Email: mystey@medmarkmedia.com OFFICE ASSISTANT | Lauren Drake Email: lauren@medmarkmedia.com MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 Fax: (480) 629-4002 Toll-free: (866) 579-9496 www.endopracticeus.com | www.medmarkmedia.com SUBSCRIPTION RATES 1 year (4 issues) $129 | 3 years (12 issues) $349

Volume 11 Number 2

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PRACTICE PROFILE

Gregori Kurtzman, DDS, MAGD, FPFA, FACD, FADI, DICOI, DADIA Connecting with patients and colleagues What can you tell us about your background?

I attended SUNY Fredonia for undergrad, earning a BS degree in Biology, and was two courses short of a bachelor’s degree in genetics. While in undergrad, I volunteered at a VA hospital dental clinic to test the waters on going into dentistry and enjoyed it, so I applied to dental school. After graduating from Howard University College of Dentistry in 1986, I started a general practice in Silver Spring, Maryland.

Is your practice limited to endodontics?

I am a general practitioner who enjoys many areas of dentistry, including endodontics.

How long have you been practicing, and what systems do you use?

I have been in practice coming up on 32 years and had the benefit of using most endodontic systems on the market over that time. The systems I am predominately using these days are V-Taper™ 2 (SS White), Dia-X (DiaDent®), Aurum Pro™ (Meta® Biomed), and EndoSequence® (Brasseler USA®).

What training have you undertaken?

I have always been an education junkie, taking CE to broaden my knowledge and skills in numerous areas of dentistry and accumulating over 4,800 hours of CE over the past almost 32 years. Additionally, I have published over 585 articles, and in writing those, I have needed to read and absorb lots of research and keep up on the literature.

Who has inspired you?

My inspirations have been Drs. Anne Koch, Dennis Brave, C.J. Munce, and Steve Buchanan in Endodontics; Drs. Carl Misch, Leonard Linkow, Scott Ganz, Lanka Mahesh, Hilt Tatum, Jack Wimmer, and Norman Cranin in Implantology; Drs. Steve Wagner and Burt Melton in Removable Prosthetics; and Drs. Howard Strassler, David Clark, and Gerald Benjamin in Restorative Dentistry, to name a few.

6 Endodontic practice

Christmas cookies from one of my favorite patients to me and my staff

What is the most satisfying aspect of your practice?

When patients tell me they appreciate my treatment, how I have helped improve their lives by giving them a better-looking smile that allows them to eat better.

Professionally, what are you most proud of?

That through my articles and sharing knowledge, how I have been able to touch many dentists’ lives, how at meetings they come up and tell me how a particular article helped them. I can understand how articles connect with people and help them but am always amazed that people remember who wrote an article.

What do you think is unique about your practice?

Most practitioners focus on a narrow area of dentistry as that’s where their interests fall. I have always been multifaceted in my interests, and dentistry is no different. I think my patients benefit from this as I can

provide a wider range of care they may need or when referring them to a specialist, and have a better understanding of what is needed than the average GP may have.

What has been your biggest challenge?

As with most practitioners, dealing with dental insurance companies dictating what treatment they will cover verses what treatment is best for that patient. As in most areas of life, basing health decisions on profit are not usually the best decisions, and insurance companies will always place profit over care.

What would you have become if you had not become a dentist?

Having grown up with dogs, my first choice on career as a young child was to be a veterinarian. But as I got older, I realized that although I love animals, I tended to get emotional with ill and injured animals and felt I wouldn’t be able to handle that on a daily basis. But in the past few years, I was able to combine my love of dentistry and animals Volume 11 Number 2

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PRACTICE PROFILE

Top favorites

Cheering on the Caps in the playoffs, Woo-hoo!

with a friend who is a veterinary dentist. We published some articles on implants in cats and dogs. This allowed me to help those who treat animals to expand the treatment options they can offer their patients.

What is the future of endodontics and dentistry?

Technology continues to expand in dentistry both material-wise and equipmentwise. This also is true in endodontics. We will continue to see materials that are more biocompatible, bond better with tooth structure, and are antibacterial to provide stronger reinforced teeth and roots. When I started dental school 36 years ago, little had changed over the prior 2 decades. As I moved through dental school, materials and technology used in other areas started filtering into dentistry.

Impression materials went from rubber-base

1. The newer NiTi files, with their greater flexibility and the better preservation of tooth structure they provide.

• V-Taper™ 2 rotary files (SS White®) • Dia-X Rotary Files (DiaDent®) • Aurum Pro™ (Meta® Biomed) • EndoSequence® (Brasseler USA®) 2. Digital radiography, as it allows me to see more, diagnose more, and communicate with my patients and colleagues better. I don’t know how I ever practiced using film before; it has been visionary in my practice.

3. Lasers, as they have changed how I practice in all areas of dentistry; they have been a shining light to my treatment.

4. My weekly BNI networking meetings and the friendships I have made in the group, helping each other grow our diverse businesses. It has proven that their motto of “Givers Gain” is a life motto.

5. Facebook and the global communications it has opened for me with friends in the dental field around the world.

6. Helping people, whether it is patients, visitors at the park, park volunteers, or the random stranger who crosses my path trying to make the world a better, kinder place.

7. Spending time with my cats, which contrary to popular belief about cats, are very affectionate and playful.

8. Increasing my culinary foodie experiences, proving there are two types of people in life — those who eat to live, and me, a person who lives to eat.

9. My girlfriend, who somehow puts up with my sense of humor and my outgoing quirky view of life.

10. Sharing my offbeat sense of humor with the voices in my head who think I am hilarious.

to vinyl polysiloxanes (VPS). We started truly bonding resins to teeth. Endodontics went from hand filing with stainless steel files to rotary NiTi. Obturation went from sealers that were irritating if extruded out the apex to biocompatible ceramics. More products and better technology are approaching as more science from outside dentistry filters in to our field.

Showing Paula Deen that a stick of butter per serving isn’t necessary when cooking 8 Endodontic practice

What are your top tips for maintaining a successful practice?

Never stop educating yourself, keep an open mind to incorporating new materials and advances in your practice, but be careful about jumping on things until they have been tested and proven. It’s good to be on the cutting edge, but don’t rush to be on the bleeding edge. If you’re a specialist,

Our youngest cat, Wolfie, showing why we think he’s part werewolf Volume 11 Number 2

PRACTICE PROFILE

remember your practice is referral-based, and the GP is your bread and butter. Build a good relationship with your GPs so they feel comfortable referring to you, and periodically don’t forget to refer new patients back to them. Learn to network as that can build a practice, but ignoring that aspect can kill a practice.

What advice would you give to budding endodontists?

Learn and understand restorative dentistry because endodontics is a restorative treatment with an endodontic component. If you cannot predictably restore the tooth, it doesn’t matter how many canals you can find, instrument, and obturate.

Don’t always assume that a patient referred in for endodontic treatment had the tooth evaluated for restorability. Preserve as much tooth structure as possible especially in the tooth’s cervical area as this is where occlusal load concentrates and is what will make or “break” a tooth in the long term. If you do not think its restorable, or other factors such as cracks or periodontal support issues are present, call the referring doctor and discuss what is present and what’s the best treatment for that patient. Communication helps build specialist-referral relationships.

What are your hobbies, and what do you do in your spare time?

Having never been a sports fan (although my hockey-loving girlfriend does drag me to Washington Capitals hockey games from time to time), writing is my hobby and helps me share my experiences and knowledge as well as increase my own. I do enjoy cooking and watching the Food Channel. I started cooking at age 11, having to have dinner ready most nights when my parents got home from work, and I worked as a cook in high school at an Italian restaurant in New York.

Also, I have always volunteered in one form or another since childhood, and during the past 5 years, I have volunteered with my girlfriend at the Chesapeake & Ohio (C&O) Canal National Historical Park at Great Falls with the bike loaner program. Recently, we got tasked with heading up CPR and First Aid Training for the park rangers and volunteers, and we became certified American Heart Association (AHA) instructors. When not at the park or cooking, we enjoy time with our five very affectionate cats: Bear, Cali, Zippy, April, and Wolfie. EP Volume 11 Number 2

Volunteering at the C&O Canal National Park

Maybe I do have a bacon problem

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CORPORATE PROFILE

Carestream Dental The newest well-established digital dental company

W

ith more than 120 years of oral healthcare experience, Carestream Dental is built on the shoulders of industry giants such as Eastman Kodak, Trophy Radiologie, and PracticeWorks. Recent changes to the company’s structure make it more nimble and even more capable of responding to the unique needs of oral healthcare professionals. As a new freestanding digital company focused solely on oral health, Carestream Dental continues to develop imaging systems and software designed specifically for specialists, such as endodontists, to facilitate treatment planning and improve patient care.

History of Carestream Dental It’s a unique dichotomy: To be more than 120 years old and also be in its first year as a freestanding company. In 1896, Eastman Kodak introduced the first photographic paper designed specifically for dental X-rays. Later, as technology improved and became more digitalized, Trophy Radiologie filed a patent for the world’s first digital intraoral sensor in 1983. The technology earned Trophy the reputation as the world’s leader in dental digital radiography.

“I don’t think anyone then could have predicted the accelerated growth of 2D and 3D imaging once digital radiography entered the field, but even then I remember feeling the digital sensor was a game-changer,” said Ed Shellard, DMD, chief dental officer, Carestream Dental, who had a practice in Rochester, New York.

In 2000, PracticeWorks emerged as a dominant dental software company when it acquired several other software companies, before going on to acquire Trophy Radiologie in 2002. The following year, it was purchased

by Eastman Kodak, which was looking to expand its presence in the dental business.

The company built the industry’s leading portfolio of film, digital imaging systems, and practice management software. Then, in 2007, Kodak’s Health Group was purchased and renamed Carestream Health; at this point in Carestream Dental’s history, the company was known as “PracticeWorks Systems, LLC, the exclusive manufacturer of Kodak Dental Systems.” In 2010, the Carestream Dental brand was born, and 7 10 Endodontic practice

CS 3D Imaging software allows practitioners to view images slice by slice in axial, coronal, sagittal, cross-sectional, and oblique views

years of rapid technological expansion later, Carestream Dental became an independent digital dental business focused specifically on oral healthcare solutions and services.

Transforming dentistry. Simplifying technology. Changing lives.

While Carestream Dental wouldn’t be the company it is today without its proud heritage, it’s more excited about what the future holds. To reflect its status as an independent entity, Carestream Dental adopted a new mission: Transforming Dentistry. Simplifying Technology. Changing Lives. These are concepts that the company has embraced for years, but with more freedom to focus exclusively on the oral healthcare industry, these ideas can be further expanded upon.

Transforming dentistry Just take a look at Carestream Dental’s legacy, and it’s clear how the company has transformed, and is continuing to transform, dentistry. From film and chemicals to the most advanced cone beam computed tomography equipment, Carestream Dental has played a role in some of the most significant transformations in the endodontic industry. Take, for example, the first Trophy sensor patented in the early 1980s. More than 35 years and 200,000 sensors later, the technology has evolved into the sleek, efficient RVG 6200 sensor that many endodontists count on today.

CS 8100 3D

Simplifying technology But it’s not enough to simply supply specialists with flashy equipment; the technology behind it must be user-friendly, easy to integrate, and complemented by intuitive software and modules. By developing imaging solutions that can be quickly utilized by practitioners — and easily integrated with leading third-party endodontic practice management software, such as TDO, PBS, and EndoVision — users can eliminate time that would have been spent troubleshooting problems and instead focus on patients.

Meanwhile, constant improvements to software make clinicians more efficient and help them expand their diagnostic capabilities.

Changing lives Patients are an integral part of every endodontic practice, so last, but not least, Carestream Dental’s ultimate goal is to deliver equipment, software, and services that are going to change the lives of clinicians, their staff, and — ultimately — patients. That means safer exams, more precise diagnoses, and faster treatment.

Volume 11 Number 2

CORPORATE PROFILE

Technology developed specialists in mind

with

Carestream Dental would not be able to fulfill its mission without working closely with specialists. As one of the only oral healthcare companies that develops, manufactures, and supports its own imaging systems and software, Carestream Dental is in the unique position to work closely with technology users and solicit their insight and feedback.

Endodontists play a key role in shaping the future direction of the company’s technology.

Innovative products to facilitate endodontic treatment planning Endodontists require high-resolution images to evaluate the morphology of the dental pulp and view the most intricate details of canals — something that Carestream Dental consistently delivers. The following is just a sample of the imaging products Carestream Dental has designed to meet the specific needs of endodontic practices: CS 8100 3D System The CS 8100 3D was designed with the specific needs of endodontists in mind. For diagnostic and treatment planning, HD mode (5 cm x 5 cm) captures the finest details of root and canal morphology with no additional dose to the patient above the standard 5 cm x 5 cm exam. The CS 8100 3D is compact enough to fit in any space; as more and more endodontists embrace CBCT, it’s easy to incorporate the system into their practice and workflow. Today, there have been more than 15,000 systems from the CS 8100 family installed all over the world.

CS 3D Imaging Software Included with Carestream Dental’s CBCT imaging units, CS 3D Imaging Software allows practitioners to view images slice by slice in axial, coronal, sagittal, cross-sectional, and oblique views to support diagnostic efficiency and interpretation. Constant enhancements to the software keep endodontists practicing at their best and deliver timely and efficient workflows. For example, 3D initial reconstruction times are now faster. Also, a new fullfunction “preview” mode lets clinicians open scans in a few seconds while the full data set is being loaded. A recent update to the preset exposure parameters for 3D programs has also enhanced image quality.

RVG 6200 Sensor The RVG 6200 continues the legacy of innovative digital sensors by shaping technology around endodontists and their preferred workflow. With a simple three-step acquisition process — position, expose, and Volume 11 Number 2

RVG 6200

view — digital images are available faster, so doctors go from capturing radiographs to diagnosing more efficiently. Additionally, the RVG 6200’s tough, durable cord has been reinforced to withstand the wear and tear of a busy endodontic office. Also, the CS Adapt module allows doctors to adapt images to their preferred look and feel. The module includes many filter presets, but 12 are specifically dedicated to endodontics. Of course, the clinicians still have the freedom and range to fine-tune images to meet their exacting clinical requirements.

Comprehensive education With the rapid expansion of technology in the field of endodontics, it’s vital that specialists keep up with the latest techniques and equipment. Learning the ins and outs of a CBCT system’s capabilities or imaging software’s functionality aids in advanced diagnoses while giving doctors a competitive edge over other practices that don’t embrace the same technology. Plus, when doctors extend training to their entire team, from the operatory to the front office, they encourage more cohesive teamwork. Finally, for endodontists looking to take on more advanced cases, offer additional treatment options, work closer with referrals, or even partner with other specialists in a multi-disciplinary practice, educating themselves on all the capabilities of their advanced technology is a tremendous benefit.

With that in mind, Carestream Dental makes it a priority to offer doctors comprehensive educational opportunities across a variety of media. In addition to the in-depth training options available to its customers, Carestream Dental also offers free training

videos available at any time (for both clients and referring offices) at carestreamdental. com/learn3d, in addition to multiple free monthly webinars. Hands-on training is provided throughout the year at different locations around the country, and Carestream Dental also partners with endodontic training programs, leading endodontic specialists and the AAE to sponsor in-depth interactive courses and workshops.

What’s next?

These are exciting times for Carestream Dental, especially when it comes to the pace at which technology is advancing. The company has just evolved into a new dental digital technology business, but it’s hardly “new” to the industry. Carestream Dental is continuing to provide the service and innovation that endodontists have come to expect, while simultaneously pushing the envelope of innovation.

“Our years of experience mean we understand and acknowledge what modern endodontics is all about,” said Jordan Reiss, endodontic and 3D imaging sales director, Carestream Dental. “As we focus on the nottoo-distant future, we’ll pull from that experience as well as rely in the insight of doctors so we can provide endodontists with what they’re asking for today, in addition to new innovations in the future that they never knew they needed.”

To learn more about Carestream Dental’s portfolio of imaging products and software for endodontic practices, please call 800-944-6365, or visit carestream dental.com today. EP This information was provided by Carestream Dental.

Endodontic practice 11

CLINICAL CASE STUDY

Healing of apical periodontitis in a maxillary second molar with fused roots and complex isthmus using the GentleWave® Procedure Dr. Randy W. Garland discusses a technique to thoroughly debride and disinfect complex anatomy Abstract Thorough debridement and disinfection are essential for long-term endodontic success. Molars are more likely to have complex and uncommon canal configurations, accessory canals, and isthmi, which increase the likelihood of missing anatomy during the root canal treatment. This case report details a 57-year-old male smoker that presented with moderate pain in the upper right quadrant. Based upon clinical and radiographic findings, a diagnosis of pulpal necrosis with symptomatic apical periodontitis was made for the right maxillary second molar. Preoperative cone beam computed tomographic images indicated fusion of the mesiobuccal and palatal roots.

A complex isthmus between a mesiobuccal and palatal canal that would not be accessible by standard methods was also visualized. Although calcification was present throughout all canals, minimal instrumentation to an apical diameter of size No. 20 was completed. Because the mesiobuccal and palatal isthmus was inaccessible with standard methods, the GentleWave® Procedure was used to debride and disinfect the root canal system and allow a path for obturation. Postoperative radiography demonstrated complete obturation throughout the complex root canal system. Radiographs at 9 and 15 months’ follow-up revealed a clinically asymptomatic tooth and a healed periapical lesion at 15 months. In conclusion, this

Randy W. Garland, DDS, received his Bachelor’s degree in Biology from San Diego State University. He then attended University of Southern California where he earned a Doctorate of Dental Surgery (DDS) in 1988. After practicing general dentistry for 7 years, he decided to go back to school to specialize in endodontics. He was accepted into the postdoctoral residency program at Loma Linda University where he received a Certificate in Endodontics in 1997. Since that time, he has operated a private practice in Encinitas, California.

Disclosure: Dr. Randy Garland is a consultant for Sonendo, Inc.

12 Endodontic practice

case report demonstrates the ability of the GentleWave Procedure to thoroughly debride and disinfect complex anatomy.

Introduction Successful long-term root canal treatment requires thorough debridement, disinfection, and obturation of the entire root canal system to eliminate bacteria and prevent reinfection.1-3 A seemingly simple or ordinary case may present with an anomalous root or root canal morphology; such complex internal anatomy and the inability to identify and treat all canals are common reasons for failure of endodontic treatment.4-6 Previous studies on resected roots with failed root canal therapy have linked persistent apical periodontitis with anatomy that was not prepared or filled adequately.7 Thus, thorough knowledge of both root and root canal morphology is needed to ensure optimal outcomes.8 While all types of teeth may have extra roots and/or canals, molars are more likely to have complex and aberrant canal configurations, accessory canals, and isthmi that increase the risk of untreated anatomy following root canal treatment.5 Maxillary second molars were shown to have more variations in root morphology than maxillary first molars.9 Maxillary second molars also have a higher prevalence of fused roots when compared to maxillary first molars and mandibular second molars. The prevalence of fused roots varies by geographic region, ranging from 7.94% in Brazil to 43% in Ireland.10-14 Yang, et al., described five types of root fusion in maxillary molars. Fusion between the mesiobuccal root and palatal root occurred most commonly in maxillary second molars in 18.1% (56 of 309) of the teeth studied.13 Other studies have reported the frequency of this type of fusion to be approximately 6%-8%.10,13,15-17 Not only do fused roots have wide variability in the number and type of canals, they also may contain isthmi or additional canals

that connect some or all of the roots. This anatomy creates a challenge for cleaning and shaping, which may increase the failure rate of root canal therapy. The percentage of isthmi seen in fused roots ranges from 9% to 43%, depending on the type of root fusion. For the mesiobuccal-palatal root fusion, isthmi were seen up to 40% of the time in these teeth.7 Small isthmi have been shown to be inaccessible to standard hand and rotary instrumentation and may even be too thin to be radiographically evident.18-19 Thus, it is likely that proper recognition and treatment of isthmi will reduce the failure rate of some endodontic procedures.

The following case report depicts the successful endodontic treatment of a maxillary second molar with fused mesiobuccal and palatal roots with an isthmus connecting the two canals using a novel endodontic device.

Materials and methods A 57-year-old male presented with moderate pain in the upper right quadrant.

Review of the patient’s clinical history indicated that he was a current smoker. After clinical examination, the right maxillary second molar (tooth No. 2) elicited a mild pain response to percussion. The tooth did not respond to vitality testing with EndoIce® (Coltene/Whaledent, Cuyahoga Falls, Ohio). After periodontal probing, an abnormal distolingual periodontal pocket depth was measured at 7 mm. A perceptible mobility <1 mm in the buccolingual direction was documented (Class I mobility). No soft tissue lesions were noted, but preoperative radiographs and intraoral examination with tactile exploration revealed a Class II furcation involvement. Radiographic examination showed tooth No. 2 with a periapical radiolucency (Figure 1). Based upon the clinical and radiographic findings, a periradicular diagnosis of symptomatic apical periodontitis with necrotic pulp was made. Preoperative cone beam computed tomography Volume 11 Number 2

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CLINICAL CASE STUDY (CBCT) indicated fusion of the mesiobuccal and palatal roots with a possible isthmus connecting a mesiobuccal and palatal canal (data not shown). It was determined that this complex intercanal anatomy would be difficult to access by standard endodontic methods. Therefore, the GentleWaveÂŽ Procedure (SonendoÂŽ Inc., Laguna Hills, California) which uses advanced fluid dynamics, acoustics, and tissue dissolution chemistry was employed to simultaneously debride and disinfect the entire root canal system.20-21,34 The treatment plan was reviewed with the patient, who agreed and consented to receiving the GentleWave Procedure.

The patient received local anesthesia per standard techniques, and a dental dam was applied to isolate the tooth for endodontic treatment. A conservative straight-line access was prepared, including removal of all pulp horns, overhangs, and ledges. Three distinct canals were noted: the mesiobuccal, distobuccal, and palatal. No isthmi were visible in the pulp chamber. Each of the three canals exhibited calcification throughout its length.

A minimally invasive endodontic protocol was utilized that included the use of K-type hand files and rotary file instrumentation to an apical diameter of size No. 20. The isthmus between the fused mesiobuccal and palatal roots could not be accessed with instrumentation, so the GentleWave Procedure was used to debride and disinfect the area.

Canals were dried with absorbent paper points and then obturated using a warm vertical compaction technique with guttapercha and AH PlusÂŽ sealer (Dentsply Sirona, York, Pennsylvania). The pulp chamber floor was sealed with flowable glass ionomer.

There was no patient discomfort during or after the procedure, and the procedure was completed without complication. A postoperative radiograph was obtained, revealing complete obturation of the root canal system with obturation material evident throughout the mesiobuccal-palatal complex anatomy (Figures 1B and Figure 2).

The patient returned for follow-up 4, 9, and 15 months postoperatively. No pain or discomfort was reported by the patient at any of the follow-up timepoints. Clinical assessment revealed improvement with normal responses to percussion and mobility testing.

Upon periodontal assessment, furcation involvement was noted to improve to Class I, and mobility was restored after 4 months. The patient continued to exhibit general periodontal issues and had only minor improvement of the abnormal pocket depth to 6 mm at 15 months; however, the treated tooth had 14 Endodontic practice

Figure 1: Periapical radiographs of the second maxillary molar (tooth No. 2) 1A. Preoperative. 1B. Postoperative. 1C. 9 months.

1D. 15 month recall. Healing of the periapical lesion is evident at 15 months

Figure 2: CBCT images of the second maxillary molar (tooth No. 2). 2A, 2C are postoperative and 2B, 2D are at the 15-month recall. Cross-sectional slices detailing the isthmus are seen in the upper panel of each image. In the bottom panels, the isthmus is seen as a thin line connecting the palatal and mesiobuccal roots

healed within normal limits and was clinically asymptomatic (Figures 1 and 2).

Results and discussion Even with the advent of improved imaging such as CBCT, limitations of current instrumentation, including the inability to access canals or isthmi, may result in inadequate debridement and disinfection of the entire root canal system in such complex anatomy. In fact, the frequency and risk of missed anatomy are strongly linked to

the complexity of the root canal system.5,18 Such difficulties may lead to eventual failure, necessitating retreatment.22 In a study of 493 teeth with failed root canal treatments, missed canals and anatomical complexity were the cause of 19.7% and 8.7% of failed cases, respectively.23 A prospective in vivo study by Hoen and Pink demonstrated that 42% of 1,100 endodontically treated teeth that were failing had an untreated canal space, while 85% had periradicular radiolucencies.24 Volume 11 Number 2

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CLINICAL CASE STUDY While maxillary molars are the secondmost frequently treated group of teeth endodontically, they are also the most complex.4 Maxillary second molars are even more challenging as they have been shown to have more variation in the number of roots, canals, and 4 times greater prevalence of root fusion than maxillary first molars.10,15-16,25 An ex vivo study by Ordinola-Zapata, et al., examined 100 maxillary second molars with fused roots and found that mesiobuccalpalatal fusion, similar to the current case report, occurred in 15% of the fused teeth studied.7 Isthmi were seen 40% of the time in mesiobuccal-palatal fused teeth, thus making this type of maxillary second molar challenging to treat.

Cleaning of the isthmus can thus be quite difficult and problematic. Whereas wider isthmi are more readily accessible to instruments and irrigants, small isthmi are often inaccessible to standard hand and rotary instrumentation.18 Complications such as strip perforations are possible if too large of a file is used.19 Despite continuous irrigation during and after rotary instrumentation, up to 35.2% of the isthmus volume can be filled with apparent hard dentin debris, which can prevent adequate debridement and obturation.26 Debris removal is much more difficult in a small isthmus versus an instrumented canal.

Several studies have examined the debridement efficacy of hand/rotary instrumentation and ultrasonics in small isthmi.

One study compared the manual hand file/ rotary instrumentation cleaning and shaping technique with or without the addition of ultrasonic irrigation. Isthmus cleanliness values were significantly different between the two groups, with 33% cleanliness observed with the use of hand/rotary instrumentation.

The addition of ultrasonic irrigation improved the cleanliness value to 83%.27 Similar results were noted by Gutarts, et al., where isthmus cleanliness ranged from 15%-38% for hand/rotary instrumentation compared to 73%-96% with the addition of ultrasonic activation.18 Another study demonstrated

Successful long-term root canal treatment requires thorough debridement, disinfection, and obturation of the entire root canal system to eliminate bacteria and prevent reinfection. that continuous ultrasonic irrigation removed significantly more debris in noninstrumented isthmi than side-vented needle irrigation (87.53%-99.93% versus 52.14%99.32%).28 Susin, et al., compared manual dynamic irrigation and apical negative pressure techniques in mandibular molars with narrow isthmi. Neither technique completely removed debris from isthmi, though considerably less debris was found in the apical negative pressure group.29 However, none of these approaches completely cleaned the isthmi. Since microorganisms have been shown to exist for more than a decade in extremely harsh and nutrient-deficient environments such as an isthmus area, the need for alternate approaches to enhance cleaning and disinfection are needed.30 The GentleWave Procedure is designed to enhance cleaning and disinfection throughout the entire root canal system using Multisonic Ultracleaning.20-21 The system is comprised of a console and a sterile, singleuse GentleWave Procedure Instrument, which delivers distilled water, sodium hypocholorite, and ethylenediaminetetraacetic acid (EDTA) throughout the entire root canal system using advanced fluid dynamics, tissue dissolution chemistry, and acoustic technology to debride and disinfect the entire root canal system, even areas untouched or undetected by standard techniques.20-21,31 As detailed by Haapasalo, et al., the GentleWave Procedure provides 7 times faster tissue dissolution than standard root canal therapy devices, including ultrasonic-based

Clinical implications • Complex anatomy may be difficult to clean or inaccessible using standard instrumentation techniques.

• The GentleWave Procedure was able to clean and disinfect complex anatomy that was otherwise inaccessible; the 15-month recall indicated the patient was clinically and radiographically healing.

• This technique may be a useful approach to clean and disinfect challenging cases involving complex anatomy, which may improve patient outcomes.

16 Endodontic practice

irrigation devices, and creates negative pressure at the apex as compared to the positive apical pressure generated by syringe irrigation devices.32-33 When the cleaning efficiency of the GentleWave Procedure was compared with a passive ultrasonic system and standard needle irrigation configuration, the GentleWave Procedure was the only technique that removed all calcium hydroxide from mesial and distal canals of 30 mandibular molars, even in the apical third.31 Similar conclusions were drawn by Molina, et al., in 45 freshly extracted molars when root canal debridement of the GentleWave Procedure was compared to standard rotary instrumentation with needle irrigation; cleaning effectiveness was 97.2% versus 67.8%, respectively, for the mesial canals.21 As healing is a focus in this case report, a long-term, prospective, multicenter clinical study of 75 molars treated with the GentleWave Procedure showed a 97% healing rate at 12 months with 96.2% of patients being free from severe and moderate posttreatment pain in the first 2 postoperative days and no incidence of pain reported by day 14.34 Calcification was also noted in all three canals; excessive calcification can impede successful navigation of the canals and may even reduce long-term success for teeth with pre-existing apical disease.23 The probability of long-term endodontic success was further complicated since the patient was a smoker. Smoking has been shown to impair the body’s response to infection, which could delay periapical healing and promote a higher incidence of apical periodontitis in smokers.35-36 Smokers are also ~1.7 times more likely to require root canal treatment.37 The fact that the periapical lesion shows extensive healing for the maxillary second molar in this patient over the 15 month followup period, despite the patient’s generalized periodontal issues and lifestyle choices, indicates that the GentleWave Procedure was able to debride and disinfect the root canal system, including the isthmus, sufficiently to eradicate the periradicular infection and allow obturation materials to enter the space.

Volume 11 Number 2

Some patients often have complex anatomy that is not easily accessible by standard endodontic methods. It is well-known that endodontic therapy cannot succeed without adequate debridement and disinfection and that untreated canals are a major cause of endodontic failure. The GentleWave Procedure was able to debride and disinfect the entire root canal system in a difficult case with complex and inaccessible anatomy. This report demonstrates that the GentleWave Procedure may be a useful approach for treating teeth with complex anatomy. EP

REFERENCES 1. Ford MW. Complex Apical Anatomy Revealed Following Endodontic Treatment of a Maxillary Molar Using the GentleWave System: A Case Report. Dentistry. 2017;7:446.

2. Holderrieth S, Gernhardt C. Maxillary molars with morphologic variations of the palatal root canals: a report of four cases. J Endod. 2009;35(7):1060-1065.

3. Siqueira J Jr, Rôças IN. Clinical implications and microbiology of bacterial persistence after treatment procedures.

J Endod. 2008;34(11):1291-1301.

instrumentation in human mandibular molars. J Endod.

2005;31(3):166-170.

irrigant delivery techniques in a closed system. J Endod.

2011;37(4):544-548.

19. Jafarzadeh H, Wu YN. The C-shaped root canal configuration: a review. J Endod. 2007;33(5):517-523.

29. Susin L, Liu Y, Yoon J, et al. Canal and Isthmus debridement efficacies of two irrigant agitation techniques in a closed system. Intl Endod J. 2010;43(7):1077-1090.

20. Wohlgemuth P, Cuocolo D, Vandrangi P, Sigurdsson A. Effectiveness of the GentleWave System in Removing Separated Instruments. J Endod. 2015;41(11):1895-1898.

21. Molina B, Glickman G, Vandrangi P, Khakpour M. Evaluation of Root Canal Debridement of Human Molars Using the GentleWave System. J Endod. 2015;41(10):1701-1705.

22. von Arx T. Frequency and type of canal isthmuses in first molars detected by endoscopic inspection during periradicular surgery. Intl Endod J. 2005;38(3):160-168.

23. Song M, Kim H, Lee W, Kim E. Analysis of the cause of failure in nonsurgical endodontic treatment by microscopic inspection during endodontic microsurgery. J Endod.

2011;37(11):1516-1519.

30. Fan B, Pan Y, Gao Y, Fang F, Wu Q, Gutmann JL. Three-dimensional morphologic analysis of isthmuses in the mesial roots of mandibular molars. J Endod.

2010;36(11):1866-1869.

31. Ma J, Shen Y, Yang Y, et al. In vitro study of calcium hydroxide removal from mandibular molar root canals. J Endod. 2015;41(4):553-558.

32. Haapasalo M, Wang Z, Shen Y, Curtis A, Patel P, Khakpour M. Tissue dissolution by a novel multisonic ultracleaning system and sodium hypochlorite. J Endod.

2014;40:1178-1181.

24. Hoen MM, Pink FE. Contemporary endodontic retreatments: an analysis based on clinical treatment findings. J Endod. 2002;28(12):834-836.

33. Haapasalo M, Shen Y, Wang Z, et al. Apical pressure created during irrigation with the GentleWave system compared to conventional syringe irrigation. Clin Oral Investig. 2016;20(7):1525-1534.

25. Ratanajirasut R, Panichuttra A, Panmekiate S. A Conebeam Computed Tomography Study of Root and Canal Morphology of Maxillary First and Second Permanent Molars in a Thai Population. J Endod. 2018;44(1):56-61.

34. Sigurdsson A, Garland R, Le KT, Woo SM. 12-month Healing Rates after Endodontic Therapy Using the Novel GentleWave System: A Prospective Multicenter Clinical Study. J Endod. 2016;42(7):1040-1048.

26. Endal U, Shen Y, Knut A, Gao Y, Haapasalo M. A highresolution computed tomographic study of changes in root canal isthmus area by instrumentation and root filling. J Endod. 2011;37(2):223-227.

35. Krall EA, Abreu Sosa C, Garcia C, Nunn ME, Caplan DJ, Garcia RI. Cigarette smoking increases the risk of root canal treatment. J Dent Res. 2006;85(4):313-317.

27. Burleson A, Nusstein J, Reader A, Beck M. The in vivo evaluation of hand/rotary/ultrasound instrumentation in necrotic, human mandibular molars. J Endod.

2007;33(7):782-787.

28. Adcock J, Sidow S, Looney S, et al.. Histologic evaluation of canal and isthmus debridement efficacies of two different

36. Kirkevang LL, Vaeth M, Hörsted-Bindslev P, Bahrami G, Wenzel A. Risk factors for developing apical periodontitis in a general population. Intl Endod J. 2007;40:290-299.

37. Ghattas Ayoub C, Aminoshariae A, Bakkar M, et al.

Comparison of IL-1β, TNF-α, hBD-2, and hBD-3 Expression in the Dental Pulp of Smokers Versus Nonsmokers. J Endod. 2017;43(12):2009-2013

4. Nosrat A, Verma P, Hicks ML, Schneider SC, Behnia A, Azim A. Variations of Palatal Canal Morphology in Maxillary Molars: A Case Series and Literature Review. J Endod.

2017;43(11):1888-1896.

5.

Cantatore G, Berutti E, Castellucci A. Missed Anatomy: frequency and clinical impact. Endod Topics.

2009;15(1):3-31.

6. Vertucci F. Root canal morphology and its relationship to endodontic procedures. Endod Topics. 2005;10(1):3-29.

s e l i F hing

7. Ordinola-Zapata R, Martins JNR, Bramante CM, VillasBoas MH, Duarte MH, Versiani MA. Morphological evaluation of maxillary second molars with fused roots: a microCT study. Int Endod J. 2017;50(12):1192-1200.

Finis

8. Ahmed H, Abbott P. Accessory roots in maxillary molar teeth: a review and endodontic considerations. Aust Dent J. 2012;57(2):123-131.

9. Kim Y, Lee SJ, Woo J. Morphology of maxillary first and second molars analyzed by cone-beam computed tomography in a Korean population: variations in the number of roots and canals and the incidence of fusion. J Endod.

2012;38(8):1063-1068.

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10. Rwenyonyi CM, Kutesa AM, Muwazi LM, Buwembo W. Root and canal morphology of maxillary first and second permanent molar teeth in a Ugandan population. Int Endod J. 2007;40(9):679-683.

11. Neelakantan P, Subbarao C, Ahuja R, Subbarao C, Gutmann J. Cone-beam computed tomography study of root and canal morphology of maxillary first and second molars in an Indian population. J Endod. 2010;36(10):1622-1627.

es remov ore g n i h t is m No l debr rally a u d i res ite ghly, l t of u o r o h t ou ing it pump al! † n the ca

12. Silva EJ, Najaim Y, Silva AI, Haiter-Neto F, Zaia AA, Cohenca N. Evaluation of root canal configuration of maxillary molars in a Brazilian population using cone-beam computed tomographic imaging: an in vivo study. J Endod.

2014;40(2):173-176.

13. Yang ZP, Yang SF, Lee G. The root and root canal anatomy of maxillary molars in a Chinese population. Endod Dent Traumatol. 1988;4(5):215-218.

14. Al Shalabi R. Omer O, Gle Yang Z-P, Yang S-F, Lee G. The root and root canal anatomy of maxillary molars in a Chinese Population. Endod Dent Traumatol. 1988;4:215-218.

15. Martins J, Mata A, Marques D, Carames J. Prevalence of Root Fusions and Main Root Canal Merging in Human Upper and Lower Molars: A Cone-beam Computed Tomography In Vivo Study. J Endod. 2016;42(16):900-908.

16. Tian X, Yang X, Qian L, Wei B, Gong Y. Analysis of the Root and Canal Morphologies in Maxillary First and Second Molars in a Chinese Population Using Cone-beam Computed Tomography. J Endod. 2016;42(5):696-701 17. Ghobashy A, Nagy MM, Bayoumi AA. Evaluation of Root and Canal Morphology of Maxillary Permanent Molars in an Egyptian Population by Cone-beam Computed Tomography. J Endod. 2017;43(7):1089-1092.

way to ll the Goes ag length. ost workin than m s s le s Cost isposable d other ents. m d, attach equire eries r ive t t a b No ns o expe and n ent to buy. equipm

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18. Gutarts R, Nusstein J, Reader A, Beck M. In vivo debridement efficacy of ultrasonic irrigation following hand-rotary

Volume 11 Number 2

Endodontic practice 17

CLINICAL CASE STUDY

Conclusion

CLINICAL RESEARCH

Comparative study of the shaping capacity obtained with the Reciproc® and Reciproc® Blue files in simulated double-curved root canals Drs. Jorge Alberdi and Fernando Goldberg compare canal transportation in simulated double-curved root canals Summary Objective To compare canal transportation in simulated double-curved root canals after instrumentation with the Reciproc® R25 and Reciproc® Blue R25 files.

Materials and methods Thirty Endo Training Block-S models were dyed with black India ink and photographed.

The resin blocks were randomly divided into two groups: A and B (n = 15). The canals were instrumented with the Reciproc R25 (Group A) and Reciproc Blue R25 (Group B) systems. After instrumentation, the canals were dyed again and photographed under the same conditions. The pre-instrumentation images were superimposed on the post-instrumentation images. A measurement template, divided into 16 equal cells of 1 mm, was placed on each instrumentation in each canal of the 30 blocks. The visual evaluation was conducted in cells 1 to 10 according to the following categorization: 0 = centered and 1 = transported. Apical transportation was evaluated for each group.

The position of the foramen after instrumentation was classified into three categories: 0 = centered, 1 = transported, and 2 = perforated. Groups were compared for the variable “modification” within each cell by the chi-squared test or Fisher’s exact test, as

appropriate, and for the variable “foramen” by the chi-squared test. In all cases, the level of significance was P < 0.05.

Results The differences between groups were significant at 1 mm, 5 mm, and 6 mm but not significant at 2 mm, 3 mm, 4 mm, 7 mm, 8 mm, 9 mm, or 10 mm. With regard to apical transportation, the difference between groups was significant (P < 0.001).

Conclusion Compared with the Reciproc R25 file, the Reciproc Blue R25 file produced a more centered canal that more accurately represented the original anatomy of the simulated double-curved root canal.

Objective The objective of this study was to compare, through the superposition of photographic images, canal transportation in simulated double-curved root canals (Endo Training Block-S) after instrumentation with Reciproc R25 and Reciproc Blue R25 files.

Introduction Nickel-titanium (NiTi) instruments have been and continue to be widely used for the preparation of root canals. The great advantage of these instruments is their flexibility,

Jorge Alberdi, DDS, is a specialist in endodontics, and auxiliary professor at the Endodontic Department of the Dental School at Universidad del Salvador/Asociación Odontológica Argentina (USAL/AOA) in Buenos Aires, Argentina. He is Director of the Postgraduate Endodontic Course at Círculo Odontológico de Rosario (COR), Rosario, Argentina, and is in private practice in endodontics and restorative post-endodontics in Las Rosas, Santa Fe, Argentina. Dr. Alberdi is also director of the Operative Microscope in Endodontics postgraduate course at the Institute Troiano Dentistry, Rosario, Argentina.

Fernando Goldberg, DDS, PhD, is Professor Emeritus of the Endodontic Department of the Dental School at the Universidad del Salvador- Asociación Odontológica Argentina. He is also a professor at the Department of Endodontics at the Dental School, Universidad de Buenos Aires, Argentina. Dr. Goldberg is a Life Member of the American Association of Endodontists. He is author of the book Materiales y Técnicas de Obturación Endodóntica.

Ed. Mundi. 1982 and editor of Endodoncia Técnica y Fundamentos, Ed. Med. Panamericana, Buenos Aires, Argentina, 2002 and 2nd edition 2012. He has also had numerous papers published in local and international journals.

Disclsoure: The authors declare that there are no conflicts of interest related to this study.

18 Endodontic practice

which allows the technique for preparing curved canals to become more predictable.

However, in these situations, there is a risk of torsional fracture and/or cyclical fatigue, which compromises the prognosis of the endodontic treatment. Different alloys and instrument sections have been proposed to increase flexibility and resistance to fatigue.1 The thermal treatment of NiTi alloys has been an important advance in improving the mechanical properties of the instrument, resulting in a better centered and safer preparation of the root canal.2-3 Manufacturers have introduced several heat-treated NiTi alloys, such as control memory wire (Coltène Whaledent, Cuyahoga Falls, Ohio), M-Wire™ (Dentsply Tulsa Dental Specialties, Tulsa, Oklahoma), and R-phase wire (SybronEndo, Orange, California).

A new generation of instruments (Vortex Blue® and ProTaper Gold® rotary files (Dentsply Sirona Endodontics, Tulsa, Oklahoma) are subjected to a complex heating-cooling treatment that results in a visible layer of titanium oxide on the surface of the instrument. This treatment controls the transition temperatures, creating a shape-memory alloy that the manufacturer claims improves the mechanical and performance properties of NiTi instruments.

Also on the market is the HyFlex™ rotary system (Coltène Whaledent), with an alloy of similar characteristics and other control memory products.4 In addition to thermal treatment, a new kinematics, the reciprocating motion, extends the useful life of NiTi instruments and their resistance to fatigue compared with continuous rotation. Reciprocating instruments travel a shorter angular distance than rotary instruments, so they are subject to lower tension values and prolonged fatigue life.5 Reciproc (VDW, Munich, Germany) and WaveOne® (Dentsply Sirona, Baillagues, Switzerland) are the main examples of systems available for the preparation of the root canals using reciprocating motion; both instruments are currently manufactured with Volume 11 Number 2

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CLINICAL RESEARCH NiTi M-wire, a heat-treated alloy marketed as Blue and Gold versions, respectively. Thermal treatment when NiTi is in the crystalline phase enables very good flexibility and little elastic memory, which prevents the instrument from recovering its shape inside the root canal, conforming better to the anatomy of the canal. In addition to thermal treatment, the WaveOne Gold® (Dentsply Sirona) has an updated cross-sectional instrument shape: a parallelogram.6 The design of the Reciproc Blue (VDW) remains exactly the same as its M-wire version; the only difference between the two Reciproc versions is the heat treatment used during their manufacture.

Numerous authors have used resin models with double-curved simulated canals (DCSCs) with the purpose of evaluating the conformations generated by different mechanized instrumentation systems.1-6 These models are marketed with different curvatures that resemble root canals with difficult anatomies. DCSC models are manufactured with similar morphology, working length, caliber, and angle of curvature to real canal anatomy, which allows the performance of different endodontic preparation systems to be compared without having to manage the anatomical variables of human teeth.

In the present study, the conformations produced by the Reciproc R25 and Reciproc Blue R25 files in simulated doublecurved root canals were compared to determine whether the alloy treatment modifies their performance in keeping the root canal centered.

Materials and methods Simulated canals In the present study, 30 Endo Training Block-S resin models (Dentsply Sirona) with these features were used: • simulated canals of double curvature (S-shaped) • a conicity of 0.02 • an apical diameter of 0.15 mm • a length of 16 mm The respective angles and radii were 30 mm and 5 mm for the coronal curvature and 20 and 4.5 mm for the apical curvature. The permeability of the canals was confirmed by passing a K No.10 file (Dentsply Sirona) beyond the foramen. Next, all the DCSCs were dyed with black India ink (Pelikan, Argentina) and injected with a Max-i-Probe 30-G needle (Dentsply-Rinn, Elgin, Illinois).

The stained DCSCs were photographed using a cell phone digital camera (iPhone® 6S plus, 12 megapixels) on a fixed support and under the same image output parameters. Subsequently, the resin blocks were 20 Endodontic practice

Figure 1 Table 1: Canal score Group 1

Group 2

Reciproc

Reciproc Blue

Centered

2

14

16

Transported

13

1

14

Total

15

15

30

Centered

0

1

1

Transported

15

14

29

Total

15

15

30

Centered

1

3

4

Transported

14

12

26

Total

15

15

30

Centered

3

9

12

Transported

12

6

18

Total

15

15

30

Centered

0

5

5

Transported

15

10

25

Total

15

15

30

Centered

0

6

6

Transported

15

9

24

Total

15

15

30

Centered

5

11

16

Transported

10

4

14

Total

15

15

30

Centered

14

15

29

Transported

1

0

1

Total

15

15

30

Centered

15

15

30

Transported

0

0

0

Total

15

15

30

Centered

15

15

30

Transported

0

0

0

Total

15

15

30

Conformation

1 mm

2 mm

3 mm

4 mm

5 mm

6 mm

7 mm

8 mm

9 mm

10 mm

Total

Results Fisher’s exact or Chi-squared test Chi-squared = P < 0.001 Significant difference

Chi-squared = P > 0.05 No significant difference

Chi-squared = P > 0.05 No significant difference

Fisher’s exact: P = 0.06 No significant difference

Fisher’s exact: P = 0.04 Significant difference

Fisher’s exact: P = 0.02 Significant difference

Fisher’s exact: P = 0.06 No significant difference

Fisher’s exact: P = 1.0 No significant difference

No difference between groups

No difference between groups

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CLINICAL RESEARCH randomly divided into two groups, A and B (n = 15 canals/group), and numbered 1 to 15 in each group.

S-shaped canal instrumentation The DCSCs were instrumented using the Reciproc R25 and Reciproc Blue R25 systems according to the manufacturer’s instructions and irrigated with 2 ml of distilled water using a Max-i-Probe® 30G needle (Dentsply-Rinn, Elgin, USA) before, during, and after DCSC instrumentation.

Groups Group A: Fifteen DCSCs were instrumented with the Reciproc R25 file (VDW), apical caliber No. 25 and conicity 0.08, operated in the “RECIPROC” mode of the X-Smart Plus motor (Dentsply Sirona). The instruments were used with a pecking motion, advancing approximately 3 mm, according to the manufacturer’s instructions. The whorls of the instrument were cleaned with alcoholmoistened gauze before each new entry.

Group B: Fifteen DCSCs were instrumented with the Reciproc Blue R25 file (VDW), apical caliber No. 25 and conicity 0.08. The instrumentation was performed with the same motor and procedure as group A. Once the instrumentation was finished, the DCSCs were stained again following the same procedure, and the resin blocks were photographed again under the same conditions.

Image analysis and evaluation of the preparation of the canal The pre- and post-instrumentation images of each sample were copied and pasted into a presentation slide of Keynote software (Apple Inc., Cupertino, California).

The preoperative black image of the DCSC was converted into a pink image using Keynote®. Then the pre-instrumentation image was superimposed with the postinstrumentation image. A measurement template, prepared with the same software and divided into 16 equal cells representing 1 mm each, was placed from the apical region to the coronal portion of the canal on each of the DCSCs of the 30 resin blocks.

Visual evaluations were conducted in cells 1 to 10 according to the following categorization: 0 = centered, 1 = transported. Cells 1 to 3 corresponded to 3 mm of the apical curve, 3 to 6 to 3 mm of the coronal curve, and 7 to 10 to 3 mm of the straight portion of the DCSC (Figure 1). The results were entered in a score table for each sample. The apical transportation for groups A and B was evaluated according to tables 22 Endodontic practice

prepared for that purpose. The position of the foramen after instrumentation was classified into three categories: 0 = centered, 1 = transported, and 2 = perforated. These data were entered into the table. The variable “modification” within each cell was compared using the chi-squared test or Fisher’s exact test, as appropriate. The variable “foramen” was compared between groups using the chi-squared test. In all cases, the level of significance was P < 0.05.

Results The differences between groups were significant at 1 mm, 5 mm, and 6 mm and not significant at 2 mm, 3 mm, 4 mm, 7 mm, 8 mm, 9 mm, or 10 mm (Table 1). With regard to apical transportation, the significant difference between groups was significant (P < 0.001) (Table 2).

Discussion In this study, resin blocks with simulated double-curved root canals were used to reproduce clinical situations with complicated anatomies. The use of the Endo Training Blocks (Dentsply Sirona) enables a more realistic comparison of the conformation produced by the different instrumentation systems. Their use makes standardization of the experimental conditions possible.8,9 The resin blocks can be photographed, measured, and evaluated before and after the canal-shaping procedure.4 Care must be taken when extrapolating the experimental results of simulated canals to clinical applications because there is a difference in hardness between resin and dentin.7 In addition, the dental elements of actual root canals have numerous infractuosities and varying cross sections along their anatomy from coronary to apical, while the canals of the resin blocks have a circular cross-section throughout the entire length of the path, without irregularities.

De Deus, et al.,10 found that the instruments manufactured with the NiTi Blue alloy were more flexible than those manufactured with NiTi M-wire. Gao, et al.,11 obtained similar results when comparing Vortex rotary files (Dentsply Tulsa Dental Specialties) manufactured with both alloys. Gagliardi, et al.,12 compared ProTaper Universal® (Dentsply Maillefer), ProTaper Next® (Dentsply Maillefer), and ProTaper Gold (Dentsply Maillefer) and found that both ProTaper Gold and ProTaper Next showed less transportation of the root canal. ProTaper Universal and ProTaper Gold have the same geometric design but are made from different alloys. The greater flexibility of the ProTaper Gold alloy, combined

Table 2: Foramen score Foramen

Group

Total

Reciproc

Reciproc Blue

Centered

4

15

19

Transported

9

0

9

Perforated

2

0

2

Total

15

15

30

Chi-squared = 17.4; P < 0.001 (significant differences between systems).

with the decreased recovery strength of the instrument, could explain why the root canals remained better centered during instrumentation.12,13 Özyürek, et al.,6 highlighted that files made with alloys of greater flexibility were better centered in simulated S-shaped canal preparations. Similar results were obtained in the present study when comparing two identically designed files of different alloys.

The NiTi Blue showed, as did the NiTi Gold alloy, a loss of elasticity resulting in a weaker recovery force. Along these lines, Pongione, et al.,14 noted the benefit of using more flexible instruments in curved canals to reduce the tendency for iatrogenic errors and to facilitate apical preparations while maintaining the original morphology of the root canal.

Yared15 proposed the possibility of using a single file for root canals in 2008, for which he used a reciprocating-motion Universal ProTaper F2 file (Dentsply Maillefer). Subsequently, the Reciproc file was introduced into the market and has been widely studied.

Zuolo, et al.,16 found in vivo that the Reciproc R25 file (VDW) was 32% more effective than the C-Pilot manual instruments No. 06, No. 08, and No. 10 (VDW) in permeabilizing and negotiating the MB2 canal of upper molars.

Plotino, et al.,17 reported the high cutting efficiency of the Reciproc instrument (VDW) compared with the WaveOne file and emphasized that its cross-sectional design appeared to be the determining factor of its cutting capacity. Recently, Topcuoglu and Topcuoglu18 revealed that the Reciproc Blue R25 and R40 (VDW) files had greater resistance to cyclic fatigue than their predecessors Reciproc R25 and R40 (VDW), manufactured with NiTi M-wire, when they instrumented S-shaped artificial canals. Keskin, et al.,19 described similar results, observing that the Reciproc Blue R25 files (VDW) had higher cyclic fatigue resistance than the WaveOne Gold Primary and Reciproc R25 files.

In the present study, the Reciproc R25 and Reciproc Blue R25 files were used, taking into account that the S-shaped curvature of the simulated canals required using instruments of smaller caliber and conicity.20 Volume 11 Number 2

Under the conditions of this study, the Reciproc Blue R25 file produced a more centered canal that more accurately represented the original anatomy of the doublecurvature simulated canal than did the Reciproc R25 file.

Acknowledgments Appreciation to Dr. Ricardo L. Macchi for his collaboration in the statistical evaluation. EP

REFERENCES 1. Zmener O, Pameijer CH, Álvarez Serrano S. Análisis histométrico de la capacidad de dos sistemas mecanizados para la instrumentación y conformación de conductos curvos simulados. Rev Asoc Odontol Argent. 2011;99:325-33.

CLINICAL RESEARCH

Conclusion

Ref.8469

2. Berutti E, Cantatore G, Castellucci A, et al. Use of nickeltitanium rotary Pathfile to create the glide path: comparison with manual preflaring in simulated root canals. J Endod.

2009;35:408-412.

3. Berutti E, Paolino DS, et al. Root canal anatomy preservation of WaveOne reciprocating files with or without glide path. J Endod. 2012;38:101-104.

4. Shen Y, Coli JM, Zhou H, et al. HyFlex nickel-titanium rotary instruments after clinical use: metallurgical properties. Int Endod J. 2013; 46: 720–729.

5. Saleh AM, Gilani PV, Tavanafar S, Shäfer E. Shaping ability of 4 different single-file systems in simulated S-shaped canals. J Endod. 2015;41:548-552.

6. Özyürek T, Yilmaz K, Uslu G. Shaping ability of Reciproc, WaveOne Gold, and Hyflex EDM single-file systems in simulated S-shaped canals. J Endod. 2017; 43:805-809.

7. Schafer E, Diez C, Hoppe W, Tepel J. Roentgenographic investigation of frequency and degree of canal curvatures in human permanent teeth. J Endod. 2002; 28:211-216.

8. Dummer PM, Alodeh MH, al-Omari MA. A method for the construction of simulated root canals in clear resin blocks.

Int Endod J. 1991;24:63-66.

9. Bonaccorso A, Cantatore G, Condorelli GG, et al. Shaping ability of four nickel-titanium rotary instruments in simulated S-shaped canals. J Endod. 2009;35:883–886.

10. De-Deus G, Nogueira Leal Silva EJ, Leal Vieira VT, et al. Blue thermomechanical treatment optimizes fatigue resistance and flexibility of the Reciproc Files. J Endod.

2017;43:462–466.

11. Gao Y, Gutmann JL, Wilkinson K, et al. Evaluation of the impact of raw materials on the fatigue and mechanical properties of ProFile Vortex rotary instruments. J Endod.

2012;38:398–401.

12. Gagliardi J, Versiani MA, de Souza –Neto MD et al. Evaluation of the shaping characteristics of ProTaper Gold, ProTaper NEXT, and ProTaper Universal in curved canals.

J Endod. 2015;41:1718–1724.

13. Hieawy A, Haapasalo M, Zhou H, et al. Phase transformation behavior and resistance to bending and cyclic fatigue of ProTaper Gold and ProTaper Universal instruments. J Endod. 2015;41:1134–1138.

14. Pongione G, Pompa G, Milana V, et al. Flexibility and resistance to cyclic fatigue of endodontic instruments made with different nickel-titanium alloys: a comparative test.

Ann Stomatol (Roma). 2012;3:119–122.

15. Yared G. Canal preparation using only one Ni-Ti rotary instrument: preliminary observation. Int Endod J. 2008;41:339–344.

16. Zuolo ML, Carvalho MC, De-Deus G. Negotiability of second mesiobuccal canals in maxillary molars using a reciprocating system. J Endod. 2015;41:1913–1917.

17. Plotino G, Giansiracusa Rubini A, Grande NM, et al. Cutting efficiency of Reciproc and WaveOne reciprocating instruments. J Endod. 2014;40:1228–1230.

18. Topçuoğlu HS y Topçuoğlu G. Cyclic fatigue resistance of Reciproc Blue and Reciproc Files in an S-shaped canal. J Endod. 2017;43:1679–1682.

19. Keskin C, Inan U, Demiral M, Keleş A. Cyclic fatigue resistance of Reciproc Blue,Reciproc, and WaveOne Gold reciprocating instruments. J Endod. 2017;43:1360-1363.

20. Bürklein S, Poschmann T, Schäfer E. Shaping ability of different nickel-titanium systems in simulated S-shaped canals with and without glide path. J Endod.

2014;40:1231-1234.

Volume 11 Number 2

Endodontic practice 23

CLINICAL RESEARCH

Micro-computed tomographic analysis of a maxillary central incisor with three roots and three canals Drs. Clovis Monteiro Bramante, Murilo Priori Alcalde, Pablo Andrés Amoroso-Silva, Alexandre Silva Bramante, Helberth Gonzalis Giraldo, Rodrigo Ricci Vivan, and Marco Antonio Hungaro Duarte discuss possible anatomical variations that can be of consequence even in those teeth considered as less complex Abstract Introduction and objective To describe a detailed analysis of the internal anatomy of an extracted maxillary central incisor with a rare anatomical variation, containing three roots and three canals using micro-computed tomography (CT).

Methods The tooth was scanned using a micro-CT device and analyzed at 1 mm, 2 mm, and 3 mm from the apex, and cervical and middlethird of the root were selected. A quantitative analysis of the canal, roundness, and major and minor diameters was performed.

Results The tooth’s crown had normal morphological characteristics but with grooves in the buccal aspects and in both the proximal aspects that started from the cementoenamel junction and advanced towards the apical direction. At the cervical portion, a single wide canal was observed. In the

middle-third of the root, the main canal bifurcated into a mesial and distal canal. The distal canal was oval shaped with a large major diameter, and the mesial canal presented lower values of major and minor diameters and a more rounded canal then the distal canal. At the apical region, a new bifurcation of the distal canal occurred giving rise to a palatal root, which was approximately 2 mm longer than the distobuccal root with similar morphometric measurements.

Conclusions It is important that clinicians be aware of possible anatomical variations even in those teeth considered as less complex such as the one presented in this report. Furthermore, the radiographic examination did not provide anatomical details, which could be improved using other imaging diagnostic tools, such as cone beam CT.

Introduction Knowledge regarding dental anatomy

is an important prerequisite for successful endodontic treatment,1 which includes understanding the normal morphology of the root canal along with its anatomical variations that are encountered in clinical practice,2,3 thereby minimizing operative procedure errors, which can interfere with the success rate of endodontic treatments.1 Moreover, the internal root canal anatomy of anterior teeth is currently well established in the literature with numerous studies reporting the incidence of the number of roots and root canals of each dental group.4-9 Regarding the maxillary incisors, these teeth almost always possess a single root canal and a less complex internal anatomy. However, the presence of the two canals has been reported with a low variation percentage between 2% and 4% and may include the presence of two root canals in a single root or two root canals in two separate roots.5,6,10,11,12,13 Although the incidence of maxillary central incisors with two root canals is considered low, the literature contains many

Clovis Monteiro Bramante, PhD, is a Senior Professor of the Department of Operative Dentistry, Endodontics and Dental Materials at Bauru School of Dentistry.

Murilo Priori Alcalde, PhD, is a Professor of Endodontics at the University of Sagrado Coração.

Pablo Andrés Amoroso-Silva, PhD, is a Professor in the Department of Endodontics at Londrina State University.

Alexandre Silva Bramante, PhD, is a Surgeon Dentist in private practice in Bauru, São Paulo, Brazil.

Helberth Gonzalis Giraldo, DDS, is Surgeon Dentist in private practice in Arequipa, Peru.

Rodrigo Ricci Vivan, PhD, is a Professor of the Department of Operative Dentistry, Endodontics and Dental Materials at Bauru School of Dentistry.

Marco Antonio Hungaro Duarte, PhD, is a Professor of the Department of Operative Dentistry, Endodontics and Dental Materials at Bauru School of Dentistry.

Disclosure: Authors deny any conflict of interest or financial disclosure.

24 Endodontic practice

Figure 1: Maxillary central incisor images. 1A. The buccal surface of the central incisor where it is possible to observe a pronounced groove that begins in the middle of the tooth crown, extending to the root in the apical direction where the bifurcation occurs. 1B. Proximal view, that shows a severe curvature towards the buccal direction of the palatal root. 1C. Palatal view Volume 11 Number 2

Methods A maxillary central incisor was donated by a student from the Dental School of the Santa Maria Catholic University located in Arequipa, Peru. There was no possibility of obtaining an accurate case history because the student was unaware of the origin of the tooth.

Macroscopically, the tooth showed a crown with normal morphological characteristics in the buccal, palatal, and proximal aspects and within the average patterns of measurement for this tooth group. On the buccal aspect of the crown, a discreet groove was observed in the cervical region extending toward the buccal aspect of the root, thereby becoming more pronounced in the apical region where the bifurcation of the buccal roots occurred. Two roots in the buccal aspect and one in the palatal were observed. Both buccal roots exhibited a slight apical curvature toward the mesial side.

The palatal root was approximately 2 mm longer than the buccal roots and exhibited a severe curvature to the distobuccal direction in the apical portion of the root.

Furthermore, in both, the proximal sides two radicular grooves were observed that started from the cementoenamel junction (Figure 1).

During the radiographic examination, it was possible to observe a wide and single canal in the mesiodistal direction and flattened in the buccal-palatal direction until the middlethird where three root canals were observed (Figure 2).

Micro-CT examination For a more precise examination of the internal anatomy of this tooth, a micro-CT device Skyscan 1174 (Bruker-microCT, Kontich, Belgium) with the following parameters: 50 kV, 800 mA, 3600 of rotation, and an isotropic resolution of 19.6 mm was used to analyze the tooth. The image of the specimen was reconstructed using the NRecon v.1.6.3 software (Bruker-microCT) that provided axial cross sections of the inner Volume 11 Number 2

Figure 2: 1A. Radiographic image of the buccal aspect (left) and axial micro-CT image (right) of the maxillary central incisor, showing the internal anatomy with two buccal canals. 2B. Proximal view of the radiographic image (left) and sagittal view of the micro-CT showing the internal anatomy of the palatal canal

Figure 3: Micro-CT reconstruction of the internal and external anatomy of the MCI: 3A. buccal, 3B. proximal, and 3C. palatal view

structures of the roots in the bitmap format.

The three-dimensional model was reconstructed using the automatic segmentation and surface modeling CTAn v.1.12 software (Bruker-microCT; Figure 3).

Furthermore, two-dimensional cross sections that were taken at 1 mm, 2 mm, and 3 mm from the apex, and from the cervical and middle-third of the root were selected. Using the CTAn and data viewing software (Bruker-microCT), quantitative analysis of the canal, roundness, and major and minor diameters were performed. Figure 4 shows the morphometric data obtained in the micro-CT analysis. At the cervical portion, a single wide canal was observed.

In the middle-third of the root, the main canal bifurcated into a mesial and distal canal. The distal canal was oval shaped with a large major diameter (1.72 mm), and the mesial canal presented with lower values of major and minor diameters and was more rounded than the distal canal. At the 3-mm and 2-mm sections, morphological canal characteristics

similar to the ones of the middle-third section were observed.

At the apical region, a new bifurcation of the distal canal occurred giving origin to a palatal root, which was approximately 2 mm longer than the distobuccal root. In the cross section at 1 mm from the apex, the distobuccal and palatal canals had similar measurements. Contrary, the mesiobuccal canal had lower values of major and minor diameters and an oval-shaped canal.

Discussion The anatomy of the maxillary central incisor is considered simple, containing a single root with a single canal in most cases. Anatomical variations of these teeth with more than one canal or root have been reported.16,17 However, the majority of these case reports are usually associated with some morphological abnormalities such as macrodontia, fusion, or germination, and dens in dens.23-26 Godim, et al., 27 published a case report of a central incisor with normal Endodontic practice 25

CLINICAL RESEARCH

case reports.14-18 Furthermore, there are reports of maxillary central incisors with three root canals and one root,19,20 two roots and three canals,21 and four canals in one root.22 To date, there are no reports in the literature regarding maxillary central incisors presenting with three roots and three canals. This report aimed to provide a detailed analysis of the internal anatomy of an extracted maxillary central incisor containing three roots and three canals using microcomputed tomography (CT).

CLINICAL RESEARCH morphology containing three canals but only two roots. In our case, the three-rooted maxillary central incisor with three separate canals was not associated with any morphological abnormalities, which probably makes this case a very rare occurrence.

On observation of the extracted tooth, the crown was intact without any signs of decay or trauma and contained various radicular grooves, one on the vestibular portion and two at the proximal portions of the root. These may indicate that the cause of extraction originated from a periodontal problem, leading to a periodontal pocket and the loss of its supporting tissue.

The maxillary incisors may be affected by the presence of a palatogingival groove with major occurrence in lateral incisors, which can lead to periodontal problems and an association with endodontic problems.28,29 Although it is rare, radicular grooves can occur in the buccal root region 27,30 as was observed in this case. Such cases often require a multidisciplinary approach for restoring the periodontal tissue through periodontal and endodontic treatment.29 Micro-CT analysis revealed larger apical diameters in the palatal (0.67 mm) and distobuccal (0.60 mm) canals at 1 mm from the apex and lower values for the mesiobuccal canals (Figure 4). However, a previous study reported that the largest diameter at 1 mm from the apex in a maxillary central incisor was 0.3 mm–0.45-mm31 lower than the ones encountered in this report. Furthermore, because it occurs in a three-rooted tooth, the palatal canal presented the larger apical diameters.

The use of micro-CT technology enabled a precise evaluation of the internal tooth anatomy, in which it was possible to observe with more precision the anatomical variation of this maxillary central incisor with three roots and the exact point of bifurcation and trifurcation of the canals. These characteristics are important because in a conventional radiographic image, it would be difficult to observe the anatomical variations in such a detailed manner (Figure 2). In cases with a complex anatomy, the use of cone beam computed tomography (CBCT) could be used for a more precise evaluation of teeth with anatomical variations before endodontic treatment.32

Conclusions It is important that clinicians be aware of possible anatomical variations even in those teeth considered as less complex such as the one presented in this report. Therefore, 26 Endodontic practice

Figure 4: Morphometric values of roundness (R), major diameter (>D) and minor diameter (<D) of the different cross sections analyzed in the apical third from the buccal and palatal roots

it is essential to implement radiographic or other imaging methods, such as CBCT, for an accurate diagnosis and a more predictable treatment of such cases. EP

15. Lambruschini GM, Camps J. A two-rooted maxillary central incisor with a normal clinical crown. J Endod.

1993;19(2):95-96.

16. González-Plata-R R, González-Plata-E W. Conventional and surgical treatment of a two-rooted maxillary central incisor. J Endod. 2003;29(6):422-424.

17. Rao Genovese F, Marsico EM. Maxillary central incisor with two roots: a case report. J Endod. 2003;29(3):220-221.

18. Lin WC, Yang SF, Pai SF. Nonsurgical endodontic treatment of a two-rooted maxillary central incisor. J Endod.

2006;32(5):478-481.

REFERENCES 1. Vertucci FJ. Root canal morphology and its relationship to endodontic procedures. Endod Topics. 2005;10(1):3-29.

19. Zaitoun H, Mackie IC. Management of a non-vital central incisor tooth with three root canals. Dent Update.

2004;31(3):142-144.

2. Cantatore G, Berutti E, Castellucci A. Missed anatomy: frequency and clinical impact. Endod Topics. 2006; 5(1):3-31.

20. Sheikh-Nezami M, Mokhber N. Endodontic treatment of a maxillary central incisor with three root canals. J Oral Sci. 2007;49(3):245-247.

3. Ahmed HM, Abbott PV. Accessory roots in maxillary molar teeth: a review and endodontic considerations. Aust Dent J. 2012;57(2):123-131.

21. Mangani F, Ruddle CJ. Endodontic treatment of a “very particular” maxillary central incisor. J Endod.

1994;20(11):560-561.

4. Vertucci FJ. Root canal anatomy of the mandibular anterior teeth. J Am Dent Assoc. 1974;89(2):369-371.

22. Aznar Portoles C, Moinzadeh AT, Shemesh H. A Central Incisor with 4 Independent Root Canals: A Case Report. J Endod. 2015;41(11):1903-1906.

5. Vertucci FJ. Root canal anatomy of the human permanent teeth. Oral Surg Oral Med Oral Pathol. 1984;58(5):589-599.

6. Pineda F, Kuttler Y. Mesiodistal and buccolingual roentgenographic investigation of 7,275 root canals. Oral Surg Oral Med Oral Pathol. 1972;33(1):101-110.

7. Han T, Ma Y, Yang L, Chen X, Zhang X, Wang Y. A study of the root canal morphology of mandibular anterior teeth using cone-beam computed tomography in a Chinese subpopulation. J Endod. 2014;40(9):1309-1314.

8. Milanezi de Almeida M, Bernardineli N, Ordinola-Zapata R, et al. Micro-computed tomography analysis of the root canal anatomy and prevalence of oval canals in mandibular incisors. J Endod. 2013;39(12):1529-1533.

9. de Silva EJ, de Castro RW, Nejaim Y, et al. Evaluation of root canal configuration of maxillary and mandibular anterior teeth using cone beam computed tomography: An in-vivo study. Quintessence Int. 2016;47(1):19-24.

10. Caliskan MK, Pehlivan Y, Sepetçioğlu F, Türkün M, Tuncer SS. Root canal morphology of human permanent teeth in a Turkish population. J Endod. 1995;21(4):200-204.

11. Sert S, Bayirli GS. Evaluation of the root canal configurations of the mandibular and maxillary permanent teeth by gender in the Turkish population. J Endod.

2004;30(6):391-398.

12. Rahimi S, Shahi S, Yavari HR, Reyhani MF, Ebrahimi ME, Rajabi E. A stereomicroscopy study of root apices of human maxillary central incisors and mandibular second premolars in an Iranian population. J Oral Sci. 2009;51(3):411-415.

13. Calvert G. Maxillary central incisor with type V canal morphology: case report and literature review. J Endod.

2014;40(10):1684-1687.

14. Michanowicz AE, Michanowicz JP, Ardila J, Posada A. Apical surgery on a two-rooted maxillary central incisor.

J Endod. 1990;16(9):454-455.

23. Oehlers FA. Dens invaginatus (dilated composite odontome). I. Variations of the invagination process and associated anterior crown forms. Oral Surg Oral Med Oral Pathol.

1957;10(12):1302-1316.

24. Pereira AJ, Fidel RA, Fidel SR. Maxillary lateral incisor with two root canals: fusion, gemination or dens invaginatus?

Braz Dent J . 2000;11(2):141-146.

25. Alani A, Bishop K. Dens invaginatus. Part 1: classification, prevalence and aetiology. Int Endod J. 2008;41(12):1123-1136.

26. Steinbock N, Wigler R, Kaufman AY, Lin S, Abu-El Naaj I, Aizenbud D. Fusion of central incisors with supernumerary teeth: A 10-year follow-up of multidisciplinary treatment. J Endod. 2014;40(7):1020-1024.

27. Gondim E, Setzer F, Zingg P, Karabucak B. A maxillary central incisor with three root canals: a case report. J Endod. 2004; 35(10):1445-1447.

28. Lara VS, Consolaro A, Bruce RS. Macroscopic and microscopic analysis of the palato-gingival groove. J Endod.

2000;26(6):345-350.

29. Schwartz SA, Koch MA, Deas DE, Powell CA. Combined endodontic-periodontic treatment of a palatal groove: a case report. J Endod. 2006;32(6):573-578.

30. Kerezoudis NP, Siskos GJ, Tsatsas V. Bilateral buccal radicular groove in maxillary incisors: case report. Int Endod J. 2007;36(12):898-906.

31. Kerekes K, Tronstad L. Morphometric observations on root canals of human anterior teeth. J Endod. 1977;3(1):24-29.

32. Levin A, Shemesh A, Katzenell V, Gottlieb A, Ben Itzhak J, Solomonov M. Use of Cone-beam Computed Tomography during Retreatment of a 2-rooted Maxillary Central Incisor: Case Report of a Complex Diagnosis and Treatment. J Endod. 2015;41(12):2064-2067.

Volume 11 Number 2

AUTHOR GUIDELINES Endodontic Practice US is a peer-reviewed, quarterly publication containing articles by leading authors from around the world.

Endodontic Practice US is designed to be read by specialists in Endodontics, Periodontics, Oral Surgery, and Prosthodontics.

Submitting articles Endodontic Practice US requires original, unpublished article submissions on endodontic topics, multidisciplinary dentistry, clinical cases, practice management, technology, clinical updates, literature reviews, and continuing education.

Typically, clinical articles and case studies range between 1,500 and 3,000 words. Authors can include up to 15 illustrations. Manuscripts should be double-spaced, and all pages should be numbered. Endodontic Practice US reserves the right to edit articles for clarity and style as well as for the limitations of space available.

Articles are classified as either clinical, continuing education, technology, or research reports. Clinical articles and continuing education articles typically include case presentations, technique reports, or literature reviews on a clinical topic. Research reports state the problem and the objective, describe the materials and methods (so they can be duplicated and their validity judged), report the results accurately and concisely, provide discussion of the findings, and offer conclusions that can be drawn from the research.

Under a separate heading, research reports provide a statement of the research’s clinical implications and relevance to endodontics.

Clinical and continuing education articles include an abstract of up to 250 words.

Continuing education articles also include three to four educational aims and objectives, a short “expected outcomes” paragraph, and a 10-question, multiple-choice quiz with the correct answers indicated. Questions and answers should be in the order of appearance in the text, and verbatim. Product trade names cited in the text must be accompanied by a generic term and include the manufacturer, city, and country in parentheses.

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Number tables consecutively and provide a brief title and caption (if appropriate) for each.

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Aesthetic & Implant Dentistry. 2000;1(1):92-96.

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Checklist for article submissions: 3 A copy of the manuscript and figures, captions, including all pictures (low res) necessary for reviewers 3 Manuscript: double-spaced including separate references, figure legends, and tables 3 Abstract, educational objectives, expected outcomes paragraph 3 References: double-spaced, alphabetical, American Medical Association style 3 Tables: titled and cited in the text 3 Mandatory submission form, signed by all authors Please contact managing editor Mali SchantzFeld with any questions via email: Mali@medmarkmedia.com

Endodontic practice 27

CONTINUING EDUCATION

Root canal obturation: hermetic or biological seal Dr. Josette Camilleri evaluates what type of seal is possible using classic obturation materials and techniques Abstract Root canal obturation is necessary when the pulp tissue is removed from the root canal system leaving a dead space that can be recolonized by microorganisms.

After pulp removal, the root canal is cleaned, shaped, and irrigated after which it is obturated. For successful root canal obturation, the materials need to have specific properties, and the clinical procedures undertaken are complementary to the materials used.

Root canal obturation has been undertaken with a combination of a solid cone/sealer technique. Gutta percha has been the most frequently used material in conjunction with various sealer types with different chemical compositions. The gutta-percha sealer combination can be compacted laterally and left unmodified or compacted vertically and heated. The appropriate irrigation protocol results in reduction of bacterial load and removal of smear layer. The ensuing obturation materials can thus bind to the root canal wall by sealer interlock in the dentinal tubules leading to a hermetic seal.

The hydraulic dental sealer cements have two basic properties, which are mainly their hydraulic nature; thus, their properties improve in the presence of moisture and the formation of calcium hydroxide as a byproduct of hydration, which makes the materials inherently antimicrobial. Furthermore, the sellers bind chemically to dentin.

This leads to the query whether a paradigm shift is necessary for the use of these sealer cements and the whether the current clinical protocol needs to be reviewed to complement these materials.

Introduction Pulp vitality is lost due to dental caries, trauma, tooth wear, and iatrogenic damage, which is extensive and thus involving the

Educational aims and objectives

The aim of this article is to review the classical obturation techniques and evaluate whether a paradigm shift is necessary for the clinical use of the hydraulic tricalcium silicate-based sealers.

Expected outcomes

Endodontic Practice US subscribers can answer the CE questions on page 32 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Realize that whichever technique and material selected to obturate a root canal, the objectives are always achieving a seal that is impervious to microbial recolonization.

•

Realize that with conservative materials and techniques, a hermetic seal is achievable by compaction of gutta percha, and inherent sealer properties lead to chemical bonding to the dentinal wall.

•

Discuss classical obturation techniques and evaluate whether a paradigm shift is necessary for the clinical use of the hydraulic tricalcium silicate-based sealers.

•

Identify the three primary functions of a root filling.

dental pulp. Dental materials in close proximity to the pulp can also lead to pulp damage.

Occasionally, the dental pulp will have to be removed electively when the root canal space is needed to retain a dental restoration.

Whatever the cause, the pulp chamber and the root canal space need to be filled to prevent reinfection. The root canal space is cleaned mechanically and also by the use of chemical agents to eliminate microorganisms and also to remove the smear layer.

The root canal is then obturated using a combination of solid cones and sealers. The aim of root canal obturation is to provide a hermetic seal and thus prevent reinfection of the root canal space, which will lead to treatment failure. The tricalcium silicatebased sealer cements were introduced due to their hydraulic nature. There is no specific protocol for their use, and currently, they are being used as any other sealer in conjunction with gutta percha. The aim of this article is to review the classical obturation techniques and evaluate whether a paradigm shift is necessary for the clinical use of the hydraulic tricalcium silicate-based sealers.

Professor Josette Camilleri, BCHD, MPHIL, PHD, FICD, FIMMM, FADM, is a dental surgeon specializing in dental and construction cements and is currently associate professor at the Faculty of Dental Surgery, University of Malta. She completed her doctoral degree, supervised by the late professor Tom Pitt Ford, at Guy’s Hospital, King’s College London. Dr. Camilleri has published over 90 papers in peer-reviewed international journals, and her work is cited over 3,800 times.

Declaration: The author declares no conflict of interest.

28 Endodontic practice

Classical obturation techniques Root canal treatment methodologies are very old and have changed very little over the years. The obturation techniques mostly involved a solid cone and sealer combination. Initially, a single cone was used together with root canal sealer; then the techniques evolved to lateral condensation and warm vertical compaction to enhance the threedimensional quality of the root canal filling (Schilder, 1967). The core acts as a piston on the flowable sealer, causing it to spread, fill voids, and to wet and attach to the instrumented dentin wall. It is the sealer that comes into contact with the dentin and periodontal tissues. It is thus important that the sealer possesses the ideal material properties as outlined by Grossman (Grossman, 1978).

The three primary functions of a root filling are the sealing against ingrowth of bacteria from the oral cavity, entombment of remaining microorganisms, and complete obturation at a microscopic level to prevent stagnant fluid from accumulating and serving as nutrients for bacteria from any source (Sundqvist and Figdor, 1998). To achieve a good obturation, the root canal needs to be chemo-mechanically cleaned. This is performed by a combination of mechanical root canal cleaning and shaping techniques and various irrigation protocols. The irrigation serves to eliminate the microorganisms and also remove the smear layer, thus leaving Volume 11 Number 2

Company

Material

Cement type

Radiopacifier

Additives

Vehicle

Presentation

Mixing

silicon oxide

salycilate resin

two tubes, double barrel syringe

manual, syringe

bismuth oxide, barium sulfate

calcium carbonate, propylene glycol alginate, propylene glycol, sodium citrate, calcium chloride

water

powder/liquid

manual

bismuth oxide, zirconium oxide

calcium phosphate

/

syringe

premixed

zirconium oxide

calcium phosphate

/

syringe

premixed

zirconium oxide

calcium phosphate

/

syringe

premixed

zirconium oxide

calcium chloride, polymer

water

powder/liquid

manual

bismuth oxide Angelus

MTA Filapex

calcium tungstate Portland cement

Egeo

CPM

Maruchi

Endoseal MTA

Innovative Bioceramix Inc.

IRoot SP

Brasseler / FKG

EndoSequence BC / Totalfill

Septodont

BioRoot

Dicalcium silicate

Tricalcium silicate

patent dentinal tubules. The canal is left clean and dry ready for obturation.

The choice of materials lies in the choice of the solid cone and the sealer type. It gives an indication of the type of obturation technique that can be employed. There are different types of solid cones that can be used. These include silver cones, gutta percha, gutta-percha-coated plastic/metal carriers, and resin cones. The silver cones were popular as they fitted the canal based on the master apical file size used in the canal in a standardized preparation (Kojima, et al., 1974). They can be used as a whole point filling the entire root canal or as sectioned points obturating the apical part of the canal (Eguren, 1966). The technique fell in disuse due to the corrosion of the silver points and questionable seal the technique provided (Gutmann, 1979).

The first gutta percha available for clinical use was manufactured by SS White in 1887. The dental gutta percha is mainly composed of zinc oxide, which accounts for its inherent antimicrobial properties. The gutta percha can be used unmodified or modified by heat (Markin and Schiller, 1973; Schilder, et al., 1974) or organic solvents (Magalhães, et al., 2007). Gutta percha can also be used to coat carriers for Thermafil® obturation technique (Lares and elDeeb 1990). This gutta percha is chemically modified and is found in the alpha-phase rather than in the standard beta-phase, which is found in all the gutta percha for dental use (Maniglia-Ferreira, et al., 2013). Alternatively, a resin core can be used as is available in the Resilon™ system (Shipper, et al., 2004).

The choice of sealer depends on the type of core material in use. The silver cones and all types of gutta percha use various sealers with a range of compositions. The Resilon Volume 11 Number 2

system comes complete with its own sealer and primer system.

The obturation technique varies on the type of core material chosen. The silver points and the gutta-percha-coated carriers in the ThermaFill system are used in a single cone technique. The gutta-percha can be used unmodified in the lateral condensed gutta percha obturation technique. The technique was first published by Bramante in 1972. This technique depends on the sealer’s ability of holding the individual cones together for its success. The technique is popular as it is easy and does not need any specific equipment. Over the years, the lateral condensation obturation technique became considered as the gold standard. The techniques using modified gutta percha are also popular. The solvent techniques result in shrinkage of the obturation in the long term due to the evaporation of the solvent. The application of heat also results in shrinkage as the gutta percha changes phase, but this can be counteracted by application of pressure. The gutta percha can be warmed outside the canal in the warm thermoplasticized injection molding techniques (Yee, et al., 1977), and the carrier based systems like ThermaFill (Lares and elDeeb, 1990; Chohayeb, 1992). Alternatively, intracanal warming using the warm vertical compaction technique can be undertaken (Wong, et al., 1981; Grossman, 1987). Warm vertical compaction of the master cone in the down-packing stage while using thermoplasticized injection molding technique for the back-packing stage would give the best outcome as it avoids gutta percha extrusion apically since the temperature of the master cone is quite stable in the apical third (Yared, et al., 1992). The types of techniques and new paradigms for filling the root canal are discussed by Ingle in 1995 (Ingle, 1995).

The heat profiles of gutta-percha are well researched (Marlin and Schilder, 1973; Schilder, et al., 1974). The heat carriers currently available on the market are set to deliver heat to 200ºC (Silver, et al., 1999) regardless the phase transformation of gutta percha occurring at 65ºC. The heat generated on the external surface of the root was within acceptable limits, thus caused no damage to the periodontal ligament and no bone necrosis (Lee, et al., 1998; Floren, et al., 1999). The dissipation of heat was dependent on the eternal media; thus, data procured in air like in in vitro studies may not be clinically relevant (Viapiana, et al., 2014). The temperature on the heat carrier was lower than that set on the machine dial (Venturi, et al., 2002, Viapiana, et al., 2014, 2015). Maximum temperatures recorded were 100ºC, and the temperature varied depending on the carrier size (Viapiana, et al., 2014). The temperatures generated did not affect the chemistry and properties of the gutta percha (Roberts, et al., 2017).

However, root canal sealers were negatively affected by the rise in temperature generated during warm vertical compaction with AH Plus® (Dentsply), an epoxy resin-based sealer showing deterioration in both physical and chemical properties (Viapiana, et al., 2014, 2015, Camilleri 2015). Salicylate resin-based sealers (Camilleri, 2015) and zinc oxide eugenol-based sealers (Viapiana, et al., 2014) were more state to heat application and exhibited no changes in properties.

The synthetic resin core used with a resin-based sealer of the Resilon/Epiphany system promised to create a mono-block obturation (Raina, et al., 2007). The Resilon/ Epiphany system was not very successful as the synthetic resin was easily degraded by bacteria and their enzymes (Tay, et al., 2005, Endodontic practice 29

CONTINUING EDUCATION

Table 1: Selection of hydraulic sealers available clinically

CONTINUING EDUCATION Hiraishi, et al., 2007). Thus, gutta percha was shown to be the best core material to date.

Root canal obturation with hydraulic sealers A number of hydraulic sealer cements based on tricalcium and dicalcium silicate are available clinically (Table 1). These sealers are primarily composed of tricalcium and dicalcium silicate thus produce calcium hydroxide once in contact with water. The chemistry and presentation of these sealers varies considerably. The Portland cement-based sealers contain traces of heavy elements and an aluminum-based phase, and these features have been shown to be of concern as aluminum has been shown to accumulate in plasma, liver, and brain of test animals (Demirkaya, et al., 2015, 2016). The acid extractable levels of arsenic and chromium are high (Monteiro Bramante, et al., 2008, Schembri, et al., 2010, Matsunaga, et al., 2010; Chang, et al., 2011), and although there is no standard level of chromium for dental cements, the arsenic levels were higher than that set by ISO 6876 (2012) for sealer cements. The leached trace elements were low (Duarte, et al., 2005, Camilleri, et al., 2012), but no standard levels are set in international standards. Due to these concerns, the BioRoot™ RCS, iRoot SP and TotalFill®/EndoSequence® BC materials use pure tricalcium silicate. Interestingly, Endoseal MTA is composed of dicalcium silicate. This is slower to react than tricalcium silicate, but a deca-calcium aluminate is added to enhance the reactivity. Thus, the problem of aluminum incorporation is also present with Endoseal MTA. All sealers contain a radiopacifier to be able to comply with ISO 6876 (2012). Most of the hydraulic sealers are bismuth oxide free unlike the original MTA formulation as bismuth oxide was shown to lead to material and tooth discoloration when in contact with sodium hypochlorite solution (Camilleri, 2014; Marciano, et al., 2015). The MTA Fillapex® excludes the bismuth oxide in the new generation and replaces it with calcium tungstate. CPM sealer and Endoseal MTA both contain the bismuth oxide added to another radiopacifier. All sealers also contain additives. These are present to enhance the material properties. The Endoseal MTA and TotalFill/EndoSequence and iRoot® SP are biphasic, thus contain another cementitious phase. The deca-calcium aluminate in the Endoseal MTA allegedly accelerates the hydration since the dicalcium silicate which is the main phase is a slow reaction. The calcium phosphate in TotalFill/ 30 Endodontic practice

EndoSequence and iRoot SP changes the material hydration with a reduction in pH and calcium ion release in the leachate. No crystalline calcium hydroxide was formed. A reduction in cell growth and proliferation was observed (Schembri-Wismayer and Camilleri, 2017).Other additives include fillers like silicon oxide and pozzolanic ash. These are added to enhance the long-term material physical properties since the silicon oxide races with the calcium hydroxide formed during hydration, and it is converted to calcium silicate hydrate. The depletion of calcium hydroxide may result in a deterioration of antimicrobial properties. The calcium chloride and watersoluble polymer present in the BioRoot RCS control the setting time and material flow.

As shown in Table 1, the sealers also use different vehicles and also vary in their presentation and delivery method. The CPM sealer and BioRoot RCS use a simple water/ powder formulation; thus, the sealers are water based. MTA Fillapex uses a salicylate resin vehicle similar to that used in the calcium hydroxide based conventional sealers. In fact, the calcium ion release of MTA Fillapex is much lower than that of the other water-based sealers (Xuereb, et al., 2015). The iRoot SP, EndoSequence BC/ TotalFill, and Endoseal MTA sealers are premixed. These sealers need moisture present in the root canal to set. A recent study where a low-pressure fluid column filled with simulated body fluid was applied to a root stump showed complete setting of EndoSequence BC sealer (Xuereb, et al., 2015). Thus, the back pressure of the tissue fluids in the root canal is enough to allow the setting of the premixed hydraulic sealers.

The obturation protocol for conventional root canal obturation includes irrigation with sodium hypochlorite to eliminate the microorganisms, followed by irrigation with a calcium chelator to remove the smear layer; thus, the seared can penetrate the dental tubules and enhance the bonding by producing resin tags. The irrigation with sodium hypochlorite is contraindicated in bismuth oxide-containing sealers due to the risk of sealer and tooth discoloration (Camilleri 2014, Marciano, et al.. 2015).

Calcium chelators like ethylene diamine tetracetic aside (EDTA) effect the chemistry of these materials which are calcium containing. The EDTA reduces the interaction of calcium ions with dentin and the deposit of beta calcium phosphate in both BioRoot and EndoSequence BC sealers. The calcium ion depletion was more evident in BioRoot RCS (Harik, et al., 2016). So, the choice of irrigation protocol is important when using

hydraulic tricalcium silicate-based sealers.

The use of phosphate-buffered saline has been suggested as a final irrigant prior to root canal obturation. The push out bond strength of the obturation material is increased as the biomineralizing ability of the sealer is enhanced (Reyes Carmona, et al., 2010a, b). The use of phosphate-buffered saline final wash reduces the antimicrobial activity of the sealers. Even BioRoot which registers the highest pH compared to EndoSequence and double the calcium ion release (Xuereb, et al., 2015) still lost its antimicrobial activity when phosphate buffered saline was used as a final irrigant (Arias Moliz and Camilleri, 2016).

The hydraulic sealers can be used with either gutta-percha solid cones or with the bioceramic coated cones. These cones are only available from Brasseler USA® (Savannah,Georgia) and FKG (La ChauxdeFonds, Switzerland). The bioceramic coating of gutta percha is meant to enhance the bond strength of the sealer to the cone.

There is still no definite data whether this is true. Hygroscopic points (CPoints) have also been suggested for use with biocermaic sealers. The pressure derived from hygroscopic expansion of CPoint or warm vertical condensation did not enhance penetration depths of the calcium silicate-based sealer.

Sealer penetration into the dentinal tubules occurred independent of the obturation technique (Jeong, et al., 2017).

The single cone obturation technique has been suggested for use with hydraulic tricalcium silicate-based sealers. A comparison of single cone obturation with warm vertical compaction showed that the percentage volume of voids was similar in the two groups and was influenced by the obturation technique only in the cervical third (Iglecias, et al., 2017). A higher percentage of voids was shown in the cervical third when BioRoot was used in conjunction with gutta percha compared to AH Plus sealer (Viapiana, et al., 2016). Both techniques produced similar tubule penetration at both the 1 mm and the 5 mm level using tricalcium silicate-based sealers (McMichael, et al., 2016). Conversely, significantly less porosity was observed in root canals filled with the single-cone technique with porosity near the crown of the tooth reduced sixfold, whereas in the midroot region porosity was reduced to less than 10% of values found in the lateral compaction filled teeth (Moinzadeh, et al., 2015). Single cone obturation resulted in better bond strength than warm vertical compaction with EndoSequence BC giving better results than an MTA based sealer (De Long, et al., 2015).

Excessive heat in warm vertical compaction Volume 11 Number 2

Conclusions Whichever technique and material selected to obturate a root canal the objectives are always achieving a seal which is impervious to microbial recolonization.

While conservative materials and techniques achieved a hermetic seal by compaction of gutta percha and sealer tags inside the dentinal tubules, the hydraulic cements based on tricalcium silicates aim at antimicrobial activity which is an inherent sealer property and chemical bonding to the dentinal wall. Therefore, the seal can be considered to be more biological. These materials have specific properties, and a proper clinical protocol is necessary to use the sealers with optimized properties. EP

5. Camilleri J. Sealers and warm gutta-percha obturation techniques. J Endod. 2015;41(1):72-78.

Tubule Penetration of Tricalcium Silicate Sealers. J Endod.

2016;42(4):632-636.

6. Camilleri J, Kralj P, Veber M, Sinagra E. Characterization and analyses of acid-extractable and leached trace elements in dental cements. Int Endod J. 2012;45(8):737-743.

34. Moinzadeh AT, Zerbst W, Boutsioukis C, Shemesh H, Zaslansky P.2015; Porosity distribution in root canals filled with gutta percha and calcium silicate cement. Dent Mater.

31(9):1100-1108.

7. Chang SW, Baek SH, Yang HC, et al. Heavy metal analysis of ortho MTA and ProRoot MTA. J Endod.

2011;37(12):1673-1676.

8. Chohayeb AA. Comparison of conventional root canal obturation techniques with Thermafil obturators. J Endod.

1992;18(1):10-12.

9. DeLong C, He J, Woodmansey KF. The effect of obturation technique on the push-out bond strength of calcium silicate sealers. J Endod. 2015;41(3):385-388.

10. Demirkaya K, Can Demirdöğen B, Öncel Torun Z, Erdem O, Çetinkaya S, Akay C. In vivo evaluation of the effects of hydraulic calcium silicate dental cements on plasma and liver aluminum levels in rats. Eur J Oral Sci. 2016;124(1):75-81.

11. Demirkaya K, Demirdöğen BC, Torun ZÖ, Erdem O, Çırak E, Tunca YM. Brain aluminum accumulation and oxidative stress in the presence of calcium silicate dental cements.

Hum Exp Toxicol. 2017;36(10)1071-1080.

12. Duarte MA, De Oliveira Demarchi AC, Yamashita JC, Kuga MC, De Campos Fraga S. Arsenic release provided by MTA and Portland cement. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005;99(5):648-650.

13. Eguren AE. Technique for root canal obturation with sectioned silver points. Rev Fr Odontostomatol.

1966;13(7):1258-1268.

14. Floren JW, Weller RN, Pashley DH, Kimbrough WF. Changes in root surface temperatures with in vitro use of the system B HeatSource. J Endod. 1999;25(9):593-595.

15. Grossman JJ. Endodontics. Part III: Vertical compaction of warm gutta percha. Hawaii Dent J. 1987;18(7):12, 33.

16. Grossman LI. Endodontic practice. 6th ed. Philadelphia, PA: Lea & Febiger; 1978.

1. Arias-Moliz MT, Camilleri J. The effect of the final irrigant on the antimicrobial activity of root canal sealers. J Dent.

2016;52:30-36.

2. Atmeh AR, Chong EZ, Richard G, Festy F, Watson TF. Dentin-cement interfacial interaction: calcium silicates and polyalkenoates. J Dent Res. 2012;91(5):454-459. The first mention of the mineral infiltration zone 3. Bramante CM, Berbert A, Piccino AC. A technique of lateral condensation for filling root canals with gutta-percha points. Estomatol Cult. 1972;6(1):70-72.

4. Camilleri J. Color stability of white mineral trioxide aggregate in contact with hypochlorite solution. J Endod.

2014;40(3):436-440.

Volume 11 Number 2

36. Raina R, Loushine RJ, Weller RN, Tay FR, Pashley DH. Evaluation of the quality of the apical seal in Resilon/Epiphany and Gutta-Percha/AH Plus-filled root canals by using a fluid filtration approach. J Endod. 2007;33(8):944-947.

37. Reyes-Carmona JF, Felippe MS, Felippe WT. A phosphatebuffered saline intracanal dressing improves the biomineralization ability of mineral trioxide aggregate apical plugs.

J Endod. 2010;36(10):1648-1652.

38. Reyes-Carmona JF, Felippe MS, Felippe WT. The biomineralization ability of mineral trioxide aggregate and Portland cement on dentin enhances the push-out strength. J Endod. 2010;36(2):286-291.

39. Roberts HW, Kirkpatrick TC, Bergeron BE. Thermal analysis and stability of commercially available endodontic obturation materials. Clin Oral Investig. 2017;21(8):2589-2602.

40. Sawyer AN, Nikonov SY, Pancio AK, et al. Effects of calcium silicate-based materials on the flexural properties of dentin.

J Endod. 2012;38(5):680-683.

41. Schembri M, Peplow G, Camilleri J. Analyses of heavy metals in mineral trioxide aggregate and Portland cement.

J Endod. 2010;36:1210-1215.

42. Schembri-Wismayer P, Camilleri J. Why Biphasic? Assessment of the Effect on Cell Proliferation and Expression. J Endod. 2017;43(5):751-759.

43. Schilder H. Filling root canals in three dimensions. Dent Clin North Am. 1967;723-744.

17. Gutmann JL. Can root canal filling with silver points provide an effective root canal seal? A perspective. J Dist Columbia Dent Soc. 1979;54(3):35-36.

44. Schilder H, Goodman A, Aldrich W. The thermomechanical properties of gutta-percha. 3. Determination of phase transition temperatures for gutta-percha. Oral Surg Oral Med Oral Pathol. 1974;38(1):109-114

18. Harik R, Salameh Z, Habchi R, Camilleri J. The effect of irrigation with EDTA on calcium-based root canal sealers: a SEM-EDS and XRD study. J Leb Dent Assoc.

2016;49:12-23

45. Shipper G, Ørstavik D, Teixeira FB, Trope M. An evaluation of microbial leakage in roots filled with a thermoplastic synthetic polymer-based root canal filling material (Resilon).

J Endod. 2004; 30(5):342-347.

19. Hiraishi N, Yau JY, Loushine RJ, et al. Susceptibility of a polycaprolactone-based root canal-filling material to degradation. III. Turbidimetric evaluation of enzymatic hydrolysis.

J Endod. 2007;33(8):952-956.

46. Silver GK, Love RM, Purton DG. Comparison of two vertical condensation obturation techniques: Touch ‘n Heat modified and System B. Int Endod J. 1999; 32(4):287-295.

20. Iglecias EF, Freire LG, de Miranda Candeiro GT, Dos Santos M, Antoniazzi JH, Gavini G. Presence of Voids after Continuous Wave of Condensation and Single-Cone Obturation in Mandibular Molars: A Micro-Computed Tomography Analysis. J Endod. 2017;43(4):638-642.

21. Ingle JI. A new paradigm for filling and sealing root canals.

Compend Contin Educ Dent. 1995;16(3):306, 308, 310.

22. Jeong JW, DeGraft-Johnson A, Dorn SO, Di Fiore PM. Dentinal Tubule Penetration of a Calcium Silicate-based Root Canal Sealer with Different Obturation Methods. J Endod. 2017;43(4):633-63.

47. Sundqvist G, Figdor D. Endodontic treatment of apical periodontitis. In: Ørstavik D, Pitt Ford TR, eds. Essential Endodontology. Prevention and Treatment of Apical Periodontitis. Oxford: Blackwell; 1998.

48. Tay FR, Loushine RJ, Weller RN, Kimbrough WF, Pashley DH, Mak YF, Lai CN, Raina R, Williams MC. Ultrastructural evaluation of the apical seal in roots filled with a polycaprolactone-based root canal filling material. J Endod.

2005;31(7):514-519.

49. Tay FR, Pashley DH, Williams MC, et al. Susceptibility of a polycaprolactone-based root canal filling material to degradation. I. Alkaline hydrolysis. J Endod. 2005;31(8):593-598.

23. Kojima K, Fujii K, Suzuki S. Conditions of root canal obturation with various silver points. Effectiveness of standardized reamers, files, and silver points. Aichi Gakuin Daigaku Shigakkai Shi. 1974;12(2):69-84.

50. Tay FR, Pashley DH, Yiu CK, et al. Susceptibility of a polycaprolactone-based root canal filling material to degradation. II. Gravimetric evaluation of enzymatic hydrolysis. J Endod. 2005;31(10):737-741.

24. Lares C, elDeeb ME. The sealing ability of the Thermafil obturation technique. J Endod. 1990;16(10):474-479.

51. Venturi M, Pasquantonio G, Falconi M, Breschi L. Temperature change within gutta-percha induced by the System-B Heat Source. Int Endod J. 2002;35(9):740-746.

25. Lee FS, Van Cura JE, BeGole E. A comparison of root surface temperatures using different obturation heat sources. J Endod. 1998;24(9):617-620.

26. Leiendecker AP, Qi YP, Sawyer AN, et al. Effects of calcium silicate-based materials on collagen matrix integrity of mineralized dentin. J Endod. 2012;38(6):829-833.

27. Li X, Pongprueksa P, Van Landuyt K, et al. Correlative micro-Raman/EPMA analysis of the hydraulic calcium silicate cement interface with dentin. Clin Oral Investig.

2016;20(7):1663-1673.

28. Magalhães BS, Johann JE, Lund RG, Martos J, Del Pino FA. Dissolving efficacy of some organic solvents on guttapercha. Braz Oral Res. 2007;21(4):303-307.

REFERENCES

35. Monteiro Bramante C, Demarchi AC, de Moraes IG, et al.

Presence of arsenic in different types of MTA and white and gray Portland cement. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008;106:909-913.

29. Maniglia-Ferreira C, Gurgel-Filho ED, de Araújo Silva JB Jr, et al. Chemical composition and thermal behavior of five brands of thermoplasticized gutta-percha. Eur J Dent.

2013;7(2):201-206.

30. Marciano MA, Duarte MA, Camilleri J. Dental discoloration caused by bismuth oxide in MTA in the presence of sodium hypochlorite. Clin Oral Investig. 2015;19(9):2201-2209.

31. Marlin J, Schilder H. Physical properties of gutta-percha when subjected to heat and vertical condensation. Oral Surg Oral Med Oral Pathol. 1973;36(6):872-879.

32. Matsunaga T, Tsujimoto M, Kawashima T, et al. Analysis of arsenic in gray and white mineral trioxide aggregates by using atomic absorption spectrometry. J Endod.

2010;36:1988-1990.

33. McMichael GE, Primus CM, Opperman LA. Dentinal

52. Viapiana R, Guerreiro-Tanomaru JM, Hungaro-Duarte MA, Tanomaru-Filho M, Camilleri J. Chemical characterization and bioactivity of epoxy resin and Portland cement-based sealers with niobium and zirconium oxide radiopacifiers.

Dent Mater. 2014;30(9):1005-1020.

53. Viapiana R, Baluci CA, Tanomaru-Filho M, Camilleri J. Investigation of chemical changes in sealers during application of the warm vertical compaction technique. Int Endod J. 2015;48(1):16-27.

54. Viapiana R, Moinzadeh AT, Camilleri L, Wesselink PR, Tanomaru Filho M, Camilleri J.Porosity and sealing ability of root fillings with gutta-percha and BioRoot RCS or AH Plus sealers. Evaluation by three ex vivo methods.Int Endod J. 2016;49(8):774-82.

55. Wong M, Peters DD, Lorton L. Comparison of gutta-percha filling techniques, compaction (mechanical), vertical (warm), and lateral condensation techniques, Part 1. J Endod.

1981;7(12),551-558.

56. Xuereb M, Vella P, Damidot D, Sammut CV, Camilleri J. In situ assessment of the setting of tricalcium silicatebased sealers using a dentin pressure model. J Endod.

2015;41(1):111-124.

57. Yared GM, Bou Dagher FE, Machtou P. Cyclic fatigue of Profile rotary instruments after simulated clinical use. Int Endod J. 1999;32(2):115-119.

58. Yee FS, Marlin J, Gron P, Krakow, AA. Three-dimensional obturation of the root canal using injection-molded, thermoplasticized dental gutta-percha. J Endod. 1977;3(5):168-174.

Endodontic practice 31

CONTINUING EDUCATION

should be avoided as it tends to evaporate the water in the water-based sealers such as BioRoot RCS (Camilleri, 2015) and thus lead to changes in the physical properties, which may be detrimental to long-term success of the obturation. MTA Fillapex was shown to be very stable and resisted degradation when heated during the warm vertical compaction procedure (Viapiana, et al., 2014; Camilleri, et al., 2015).

The interaction of the tricalcium silicatebased sealers with the root canal wall is postulated to be a chemical bond. The sealers bond to dentin by a process known as alkaline etching, and a mineral infiltration zone develops at the interface of the dentin in contact with the material (Atmeh, et al., 2012). The presence of mineral infiltration zone and sealer tags was shown by confocal microscopy using fluorescent dyes to tag the sealer (Atmeh, et al., 2012; Viapiana, et al., 2016). The alkaline etching is caused by the sealer alkalinity. The development of the mineral infiltration zone has been discredited by other authors using micro-Raman and electron probe micro-analyses (Li, et al., 2016). The use of tricalcium silicatebased materials has been shown to cause softening of collagen in dentin (Leiendecker, et al., 2012) and a deterioration in flexural strength of the tooth (Sawyer, et al., 2012).

REF: EP V11.2 CAMILLERI

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Root canal obturation: hermetic or biological seal CAMILLERI

1. After pulp removal, the root canal is _______ after which it is obturated. a. cleaned b. shaped c. irrigated d. all of the above

hydration, which makes the materials inherently antimicrobial. a. silicon oxide b. bismuth oxide c. calcium hydroxide d. zirconium oxide

2. The gutta-percha sealer combination can be compacted laterally and left unmodified or compacted vertically and ________. a. heated b. cooled c. left modified d. frozen

5. The aim of root canal obturation is to provide a _______ and thus prevent reinfection of the root canal space which will lead to treatment failure. a smear layer b. hermetic seal c. biological seal d. dicalcium silicate-based seal

3. The appropriate irrigation protocol results in __________. a. dehydration b. reduction of bacterial load c. removal of smear layer d. both b and c 4. The hydraulic dental sealer cements have two basic properties, which are mainly their hydraulic nature; thus, their properties improve in the presence of moisture and the formation of __________ as a byproduct of

32 Endodontic practice

6. (In classical obturation techniques) The core acts as a piston on the flowable sealer, causing it to _________. a. spread b. fill voids c. wet and attach to the instrumented dentin wall d. all of the above 7. Over the years, the ________ became considered as the gold standard.

a. lateral condensation obturation technique b. silver point technique c. warm vertical compaction technique d. resin cone technique 8. All sealers contain ________ to be able to comply with ISO 6876 (2012). a. bismuth oxide b. sodium hypochlorite c. a radiopacifier d. calcium tungstate 9. The push-out bond strength of the obturation material is _______ as the biomineralizing ability of the sealer is enhanced. a. decreased b. increased c. not affected d. eliminated 10. The single cone obturation technique has been suggested for use with _______ sealers. a. bismuth oxide-based sealers b. calcium hydroxide-based c. hydraulic tricalcium silicate-based d. water-based sealers

Volume 11 Number 2

CE CREDITS

ENDODONTIC PRACTICE CE

Dr. Judy McIntyre describes endodontic treatment for comminuted and complicated crown-root fractures after trauma

A

n 11-year-old female patient presented to a pediatric dental clinic having reported a bike injury the day prior. The pediatric dental examination concluded that both UR1 and UL1 were in need of endodontic treatment, and as a result, I was contacted. Clinical examination revealed an over-the-counter dental temporary material over both UR1 and UL1, which had been placed by a resourceful neighbor (Figure 1).

Radiographs of UR1 and UL1, as well as the lower anterior incisors, were also taken (Figures 2A-2F) (DiAngelis, et al., 2012; American Association of Endodontists, 2013; Andreasen, Andreasen, Andersson, 2007).

The patient was in good spirits and denied any loss of consciousness. She did have a contusion on her forehead consistent with that of a bike injury. Clinically, there was very little coronal tooth structure remaining on either UR1 or UL1. Her lateral incisors (UR2 and UL2) were completely intact and fully erupted. Her canines had not yet erupted; however, she did have premolars present.

Treatment this first day consisted of removing the dental temporary and visualizing the extent of the traumatic dental injury, as well as ruling out any other dental injuries that could have possibly been sustained on adjacent or opposing teeth (DiAngelis, et al., 2012; American Association of Endodontists, 2013; Andreasen, Andreasen, Andersson, 2007). Many clinicians in this emergency

Educational aims and objectives

The aim of this article is to describe the surgical extrusion and endodontic treatment for comminuted and complicated crown-root fractures following a young patient’s bike injury.

Expected outcomes

Endodontic Practice US subscribers can answer the CE questions on page 39 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Realize the endodontic treatment required for comminuted crown-root fractures following dental trauma in a child, including the precautions and sensitivities.

•

Realize some clinical characteristics of an injury of this type.

•

Realize some treatments options for treatment for an injury of this type.

scenario might possibly forget to consider any injury to the opposing arch. It is an important reminder that traumatic dental injuries are rarely a focal point of contact but rather a larger area of impact, thereby clinically affecting multiple teeth to varying extents — even ones in the opposing arch. Clinical examination and pulp vitality testing at that time is shown in Table 1.

Diagnosis and treatment As such, the diagnosis for UR1 was irreversible pulpitis and pulp exposure, and for UL1, irreversible pulpitis secondary to traumatic dental injury; the periodontal diagnosis for both teeth was acute apical periodontitis. Traumatic diagnosis for both UR1 and UL1 were comminuted and complicated (involving the pulp) coronal and root

fractures. UR2 and UL2 exhibited possible dental subluxations as they were slightly percussion positive. For documentation and future treatment, it is highly recommended to document a trauma diagnosis to the best of one’s ability as well as the pulpal and periodontal diagnosis (DiAngelis, et al., 2012; American Association of Endodontists, 2013; Andreasen, Andreasen, Andersson, 2007). A clinician can always revise the trauma diagnosis later (if more involved than originally suspected), but this baseline diagnosis will serve everyone well for treatment planning as well as prognosis.

Risks, benefits, and options were discussed with the parents (Andreasen, et al., 1995; Kinirons, et al., 2000). It was agreed that root canal therapy would commence this first treatment day. Without incident, the

Table 1: Clinical examination and pulp vitality testing on first day of treatment

Figure 1: Patient at time of presentation. No treatment yet performed

Tests

UR2

UR1

UL1

UL2

LL2-LR2

Cold

Wnl

-

-

Wnl

Wnl

Perc

+

++

++

+

Wnl

Palp

Wnl

Wnl

Wnl

Wnl

Wnl

ppds

NT

NT

NT

NT

NT

Wnl = within normal limits

NT = not taken

Judy D. McIntyre, DMD, MS, graduated from the Harvard School of Dental Medicine and completed her endodontics residency at the University of North Carolina at Chapel Hill under the direction of Dr. Martin Trope. She is currently in private practice in the Boston suburbs.

Volume 11 Number 2

Endodontic practice 33

CONTINUING EDUCATION

Surgical extrusion and endodontic treatment following dental trauma

CONTINUING EDUCATION

Figure 3: Treatment postoperatively at first visit. Patient temporized with glass ionomer cement and cleaned up; pulpal debridements performed. Note the mixed dentition and no apparent trauma to lower mandibular anterior teeth Figures 2A-2C: Preoperative radiographs; 1-day post-traumatic injury. Several angled films were indicated; the extent of coronal and coronal/root fractures revealed. Pulpally and periodontally, these would be considered our “baseline” radiographs, unless the patient could provide very recent photographs showing these same teeth

Figures 2D-2F: “Baseline” angled radiographs of the patient’s mandibular anteriors. As the injury was on the opposing arch, it is recommended to take images on the opposing teeth (of injury site) to rule out any other incidental and concomitant dental injuries. Angled images of the mandibular anterior teeth were repeated throughout the follow-up period; all of those images were within normal limits and showed no changes pulpally or periodontally. We would suspect and be looking for visual changes along or within the root surfaces to be able to trace the periodontal ligament, and for any changes in the pulpal space getting smaller, indicating pulp canal obliteration

patient was extremely cooperative, and the pulps of both UR1 and UL1 were extirpated — without rubber dam isolation, but instead with cotton roll isolation. This is the only case ever in which I have not used rubber dam isolation, and it was solely because I did not want the shards of tooth structure to embed themselves further into the gingival tissue since the severity of the tooth and root fractures could be clearly visualized. There were many tooth fragments — like shards of glass; this was unlike any trauma I had seen before (Figures 5D-5F).

The patient was fully anesthetized, and the pulpal debridement went smoothly. An intracanal medicament made of calcium hydroxide powder mixed on a glass slab with 2% chlorhexidine gluconate was then placed 34 Endodontic practice

with a lentulo spiral filler into both canal spaces. This is a very common technique as a treatment modality in traumatic dental injury cases; it is called for when there is a potential need for a long-term intracanal medicament, so as to aid in periodontal healing (Panzarini, et al., 2012). I temporized with Fuji IX® glass ionomer cement (GC America) and reappointed her (Figures 3 and 4).

At the next visit, we explored the extent of her injuries further after an orthodontic consultation to determine if orthodontic extrusion would be an option — as there was no remaining coronal tooth structure (DiAngelis, et al., 2012; American Association of Endodontists, 2013; Andreasen, Andreasen, Andersson, 2007; Andreasen, et al., 1995; Kinirons, et al., 2000). We decided

Figure 4: Radiograph of the maxillary anteriors after pulpal debridement with calcium hydroxide slurry as intracanal medicament

instead upon surgical extrusion of both UR1 and UL1 after completion of root canal treatments (all after a minimum of 2 weeks of calcium hydroxide intracanal medicament) (Panzarini, et al., 2012) primarily due to the shattered state of the tooth.

Approximately 1 month after the traumatic dental injury, the patient returned with her parents for definitive treatment: Surgical extrusion of both UR1 and UL1 was planned, as it was suspected that additional subgingival tooth and root fragments, as well as root fractures, remained on both, despite previous pulp extirpation and pulpal medicament. Pulp vitality tests were repeated prior to any treatment or anesthesia, as the patient reported that her lower teeth had been “hurting” at this visit.

After much discussion and reviewing the risks, benefits, and options, both the parents and the patient consented to continue root canal therapy completion on both UR1 and UL1 — as well as surgical extrusion to Volume 11 Number 2

remove any possible remaining fragments from the trauma site and to make the crowns and root fractures become, essentially, solely crown fractures (with the coronal surgical repositioning), so that both teeth could be restored. Extensive education and possible complications were discussed. The family was informed that the teeth would likely not be perfect esthetically, but that her teeth could hopefully be saved until she was old enough to seek other options: crowns, implants, veneers, etc.

Treatment that day consisted of topical followed by four carpules (1.8ml) of 2% lidocaine (1:100k epinephrine) given as buccal and palatal infiltrations; two carpules preoperatively and two carpules postoperatively for pain. A No. 15 blade was used to reflect a palatal full-thickness mucoperiosteal envelope flap (UR2 to UL2). UR1 was elevated, and the fragments were visualized and removed (Figures 5A-5F). A bigger fragment (running obliquely and more subgingival/ cervical) was visualized, and it was decided to extract UR1 with forceps after elevation (Figure 5A). UR1 was immediately placed in Hank’s Balanced Salt Solution (HBSS) for 3 minutes.

Fragments remained in some granulation tissue that had grown around the gingival cuff; all visible fragments were removed, and other fractures were checked subgingivally.

The tooth was reinserted back after the latter was curetted and irrigated with sterile saline. The total extraoral time for UR1 was 4 minutes; the tooth was soaking in HBSS for 3 (of the 4) minutes.

UL1 was then elevated and the visible fragments removed. Again, a bigger fragment, which ran oblique and more subgingival/cervical, was seen (Figures 5D-5F).

As such, it was decided to also extract UL1 with forceps after elevation. It was placed immediately in HBSS for 2 minutes.

Another large fragment was removed as well as others. UL1 was reinserted after the Volume 11 Number 2

Figures 5D-5F: Images of the tooth fragments removed during the surgical procedure, measured against the ruler in millimeters. Each tooth had one large fragment (UR1 fragment was about 6 mm long and UL1’s was about 7 mm) and several tiny fragments

Figure 5G: Angled radiographs of the teeth after surgical repositioning with the splint in place were taken; one radiograph shown here. Note the change of new space in between the teeth and the periodontal ligament due to the more coronal “new” position of both teeth

Figures 6A and 6B: One week after surgical repositioning and immediately after suture removal; splint still remains

socket was curetted and irrigated with sterile saline. The total extraoral time for UL1 was 3 minutes; it was in HBSS for 2 of the 3 minutes. The optimal replantation time for the best prognosis has been declared as 5 minutes in clinical studies (Andreasen, et al., 1995; Kinirons, et al., 2000). All fragments were saved and clinical photos taken.

A cotton pellet and Fuji IX glass ionomer cement were placed to close the access.

A sulcular gingivectomy was performed on UR2 to UL2 on both the buccal and palatal

mucosa with a No. 12 blade; 4x4-0 Monocryl® (Ethicon) sutures were placed intrapapillary.

Ultimately, UR1 was extruded approximately 4 mm-5 mm and repositioned at this point coronally; UL1 was extruded approximately 3 mm and repositioned at this point. UR2 to UL2 were prepared for a functional (nonrigid) splint with an orthodontic steel ligature with flowable resin (Figures 5B-5G) (DiAngelis, et al., 2012; American Association of Endodontists, 2013; Andreasen, et al., 2004; Andreasen, et al., 2006; Andreasen, et al., Endodontic practice 35

CONTINUING EDUCATION

Figures 5A-5C: A. Surgical extrusion of UR1 and UL1. Extraction of UR1; only the crown portion of the tooth is held. Great precaution is taken to avoid any contact with the tooth root and its periodontal ligament cells. After this photo, the tooth was immediately placed into HBSS. B. UR1 and UL1surgically extruded and secured in their newly coronally placed positions with the functional (wire-resin) splint. C. Palatal photograph of the surgically extruded teeth with splint secured; glass ionomer access cavities shown

CONTINUING EDUCATION 2004; Robertson, et al., 2000; Andreasen, Andreasen, Bayer, 1989; Humphrey, Kenny, Barrett, 2003; Welbury, et al., 2002; Ebeleseder, et al., 2000).

Occlusion was checked and adjusted.

Verbal and written postoperative instructions were given to the patient and parents, and the patient was informed to return if pain persisted or swelling developed. She tolerated the treatment very well, and a fairto-guarded prognosis on both UR1 and UL1 was given at this time with the understanding that the patient was to return for root canal treatment completions and final restorations on both. Ibuprofen 400 mg was given immediately postoperatively as well as written prescriptions for doxycycline 100 mg bid, ibuprofen 400 mg qid, PRN pain x 28 tablets, and twice daily swish of 0.1% chlorhexidine (alcohol-free) oral rinse (bottle) for 1 to 2 weeks (DiAngelis, et al., 2012; American Association of Endodontists, 2013; Andreasen, Andreasen, Andersson, 2007; Andreasen et al, 2004; Andreasen, Bakland, Andreasen, 2006). An appointment was made for a 1-week checkup for a likely suture removal, with splint removal to follow in 2 to 6 weeks, as suggested by the American Academy of Pediatric Dentistry (AAPD) and American Association of Endodontists (AAE) guidelines for follow-up of traumatic dental injuries.

Follow-up

taken again to follow-up with our baseline radiographs of the adjacent teeth in case any radiographic changes, such as root resorption (Andreasen, Bakland, Andreasen, 2006; Andreasen, et al., 2004; Robertson, et al., 2000; Andreasen, Andreasen, Bayer, 1989), were to begin — it would be advantageous to see this and treat as soon as possible.

That day, the distal root of UR1 appeared to be suspect: It was nonsolid like the other root surfaces. The intracanal medicament was replaced with a fresh slurry of calcium hydroxide and chlorhexidine and condensed incrementally as it was spun into the canal (Figure 7). Inverted coarse paper points were used to “dry” out the medicament some, and then condense some more. This “dry pack” method of calcium hydroxide is a very common technique when any type of root resorption is suspected (Panzarini, et al., 2012).

One week later, the patient returned, and periapical films of UR1 and UL1 were taken; structures appeared within normal limits. The splint was intact, and three sutures were removed (one had fallen out on its own). We discussed the need for better oral hygiene. At this stage, healing was seen, and an appointment was made for her to return in 2 weeks (Figures 6A and 6B).

After 2 weeks, the patient returned, and clinical tests were taken (Table 2). Periodontal measurements were performed, and a few gingival defects were noted palatally on UR1 and UL1 (Table 2: “ppds”). At this early stage, the patient and parents were informed that it could still be healing (the PDL attachment reforming) — however, I did caution that the patient may need gum surgery. At this time, periapical radiographs of UR2 to UL2 were

Table 2: Pulp vitality testing approximately 7 weeks post-injury (approximately 3 weeks after surgical extrusion/repositioning, and 2 weeks post-suture removal) Tests

UR3

UR2

UR1

UL1

UL2

UL3

LL3-LR3

Cold

Wnl

Wnl

-

-

Wnl

Wnl

Wnl

Perc

Wnl

Wnl

++

++

Wnl

Wnl

Wnl

Palp

Wnl

Wnl

Wnl

Wnl

Wnl

Wnl

Wnl

ppds

Wnl

Wnl

333434

555754

Wnl

Wnl

Wnl

EPT

+

+

-

-

+

+

+

Mobility

Wnl

Wnl

+

+

Wnl

Wnl

Wnl

Wnl = within normal limits

Figure 7: “Dry-pack” radiograph of UR1 and UL1 — canal space is completely occluded and of the same radiopacity of the tooth root. In a slurry of intracanal medicament, the canal space will appear radiolucent (as in the prior radiographs).

However, in a “dry-pack,” the density makes the canal space less radiolucent and more radiopaque.

36 Endodontic practice

Figures 8A and 8B: Radiographs taken on the last treatment to build up UR1 and UL1 esthetically with composites. Both teeth were stable at this visit. Root canal treatments on UR1 and UL1 were completed about 2 months prior to this visit Volume 11 Number 2

Periodic radiographic chronicling of the dentition in question is the treatment standard and encouraged with traumatic dental injuries. The American Academy of Pediatric Dentistry and American Association of Endodontists have published extensive guidelines regarding traumatic dental injuries and detailed their follow-up care at 4 weeks, 6 to 8 weeks, 4 months, 6 months and then annually for 5 years (DiAngelis, et al., 2012; American Association of Endodontists, 2013). Furthermore, it is always prudent to rule out any concomitant trauma to the opposing arch/ teeth by taking a baseline radiograph of the opposing teeth at the first or second appointment. In this case, the radiograph of the lower anterior incisors was taken at the first visit for this very reason; this baseline radiograph could then be subsequently referred to if resorption or pulpal calcification were to commence and compared to at a later date.

While the patient did not attend for some of her appointments, she ultimately returned approximately 3 months later to complete the root canal treatments (Figures 8A and 8B).

She reported no pain, discomfort, or symptoms. After topical anesthesia and 2.7ml of 2% lidocaine (1:100k epinephrine) given as buccal and palatal infiltrations, treatment under rubber dam isolation with premolar clamps on the buccal and palatal maxillary bone (not on the teeth), and betadine cleanse on the rubber dam access sites commenced.

The GIC temporary access restorations were removed on both teeth, and the remaining calcium hydroxide medicament was irrigated out with sodium hypochlorite. Both canals were instrumented with nickel-titanium hand files and RC-Prep® (Premier Dental Products Company) (flushing with periodic sodium hypochlorite) to ISO 80.04. Working lengths were confirmed with PA films.

Volume 11 Number 2

After final copious sodium hypochlorite irrigation and an EDTA final rinse, the canals were dried with coarse paper points, and 80.04 master apical cones were placed with sealer. A periapical “trial obturation” film was taken, and the obturation process was completed. The pulp chamber was cleaned very well with ethanol pellets. The access cavities were prepared and flowable white composite placed, followed by incremental Z250 A1 and cured. Occlusion was checked in static and excursive function and adjusted appropriately, and then the composites were polished (Olsburgh, Jacoby, Krejci, 2001).

Again, verbal and written postoperative instructions were given, and the patient tolerated treatment well. Once again, a fairto-guarded prognosis was given (DiAngelis, et al., 2012; American Association of Endodontists, 2013; Andreasen, Andreasen, Andersson, 2007; Kahler, Heithersay, 2008; Andreasen et al, 2004; Olsburgh, Jacoby, Krejci, 2001; Andreasen, Bakland, Andreasen, 2006; Andreasen, et al., 2004; Robertson, et al., 2000; Andreasen, Andreasen, Bayer, 1989; Humphrey, Kenny, Barrett, 2003; Welbury, et al., 2002; Ebeleseder, et al., 2000; Hinckfuss, Messer, 2009; Oikarinen, 1990; Berthold, Thaler, Petschelt, 2009; Cvek, Andreasen, Borum, 2001; Cvek, Tsilingaridis, Andreasen, 2008; Ferrazzini, Von Arx, 2008; Jackson, Waterhouse, Maguire, 2006). The patient returned 1 month later for splint removal (DiAngelis, et al., 2012; American Association of Endodontists, 2013; Andreasen, Andreasen, Andersson, 2007; Hinckfuss, Messer, 2009; Oikarinen, 1990; Berthold, Thaler, Petschelt, 2009), and periapical images were taken of the anterior teeth in both arches. All periodontal ligaments were visible and intact on all the images. The splint was removed with 169L bur and polished with white stone (Figures 9A and 9B).

Periodontal measurements were performed for the first time, and a few gingival defects were noted palatally on UR1 and UL1. At this early stage, the patient and parents were informed that it could still be healing (the PDL attachment reforming) – however, I did caution that the patient may need gum surgery.

A few months later, the patient returned and again reported no discomfort, pain, or symptoms since the last visit. UR1 and UL1 were built-up with composite slightly further to the patient’s satisfaction (Figures 9A and 9B). Periapical films of UR1, UL1 and LL2 to LR2 were taken, and the tests were repeated on UR2 to UL2. All of these teeth were within normal limits to percussion, palpation, mobility, and periodontal probing (less than 4 mm).

Another follow-up in 6 months with X-rays was recommended, as well as the need for annual assessments with X-rays for 5 years. The prognosis of both of these teeth was again reiterated, with the goal of ensuring their survival for as long as possible; hopefully until age 18, if not longer (at least until the patient had matured as an adult).

Discussion Ultimately, despite great efforts, the patient never returned. Although the last set of radiographs seemed cautiously optimistic, a few scenarios (DiAngelis, et al., 2012; American Association of Endodontists, 2013; Andreasen, Andreasen, Andersson, 2007; Andreasen, et al., 1995; Kinirons, et al., 2000; Andreasen, et al., 2004; Andreasen, Bakland, Andreasen, 2006; Andreasen, et al., 2004; Robertson, et al., 2000; Andreasen, Andreasen, Bayer, 1989; Humphrey, Kenny, Barrett, 2003; Welbury, et al., 2002; Ebeleseder, et al., 2000; Cvek, Andreasen, Borum, 2001; Cvek, Tsilingaridis, Andreasen, 2008; Ferrazzini, Von Arx, 2008; Endodontic practice 37

CONTINUING EDUCATION

Figures 9A and 9B: Clinical and palatal view photographs of UR1 and UL1 after composites. The patient and her parents were extremely satisfied with the result

CONTINUING EDUCATION Jackson, Waterhouse, Maguire, 2006) predictably occurred: 1. The patient’s UR1 and UL1 healed without any further sequelae, and she still has them both present and functioning well.

2. One or both of her maxillary incisors might have undergone some inflammatory root resorption and, therefore, might have had needed extracting at some point down the road, hopefully after her growth spurt, or a good amount of growth having lapsed.

3. Replacement root resorption (also known as ankylosis) of one or both teeth.

While ankylosis is usually seen as negative sequelae, in this case, it would actually be quite beneficial. In a growing patient, extraction of either of these teeth would have resulted in a collapsed site deficient of cortical and cancellous bone. Maintaining bony width would be beneficial for later implant placement. When ankylosis occurs, bone replaces the tooth. This bone is beneficial, especially in a pediatric patient who is still relying on alveolar bone growth for jaw/ tooth development.

When a permanent tooth is prematurely extracted on a child who is not yet fully grown, the teeth adjacent to the extraction site can also suffer negative periodontal sequelae due to the collapsed site. This is not optimal for esthetics if a fixed bridge were to be placed, or for an implant in the future.

REFERENCES 1. American Association of Endodontists (2013). The Recommended Guidelines of the American Association of Endodontists for the Treatment of Traumatic Dental Injuries. [online] Available at: <http://www.nxtbook. com/nxtbooks/ aae/traumaguidelines/#/0> [Accessed 30/06/16] 2. Andreasen FM, Andreasen JO, Bayer T. Prognosis of rootfractured permanent incisors--prediction of healing modalities. Endod Dent Traumatol. 1989;5(1):11-22.

3. Andreasen JO, Andreasen FM, Andersson L. 2007 Textbook and Color Atlas of Traumatic Injuries to the Teeth, 4th ed.

Oxford, UK: Wiley-Blackwell; 2007.

4. Andreasen JO, Andreasen FM, Mejàre I, Cvek M. Healing of 400 intra-alveolar root fractures. 2. Effect of treatment factors such as treatment delay, repositioning, splinting type and period and antibiotics. Dent Traumatol.

2004;20(4):203-211.

5. Andreasen JO, Andreasen FM, Mejàre I, Cvek M. Healing of 400 intra-alveolar root fractures. 1. Effect of pre-injury and injury factors such as sex, age, stage of root development, fracture type, location of fracture and severity of dislocation. Dent Traumatol. 2004;20(4): 192-202.

6. Andreasen JO, Bakland LK, Andreasen FM. Traumatic intrusion of permanent teeth. Part 3. A clinical study of the effect of treatment variables such as treatment delay, method of repositioning, type of splint, length of splinting and antibiotics on 140 teeth. Dent Traumatol. 2006;22(2):99-111.

7. Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM. Replantation of 400 avulsed permanent incisors. 4. Factors related to periodontal ligament healing. Endod Dent Traumatol. 1995;11(2):76-89.

8. Berthold C, Thaler A, Petschelt A. Rigidity of commonly used dental trauma splints. Dent Traumatol. 2009;25(3):248-255.

38 Endodontic practice

It is an important reminder that traumatic dental injuries are rarely a focal point of contact but rather a larger area of impact, thereby clinically affecting multiple teeth to varying extents — even ones in the opposing arch.

As this was a traumatic dental injury on a pediatric patient, loss of these teeth would have been catastrophic and would have left psychosocial effects as well as functional, developmental, and esthetic challenges for her and her family to deal with lifelong. In this scenario, ankylosis is a welcomed and successful outcome as it can be predictably managed. Hence, our definition of success must change when traumatic dental injuries occur.

When ankylosis and growth of the jaw bone (either maxilla or mandible) occurs, the replacement resorption must be followed closely. The moment that the tooth becomes infraoccluded (below the adjacent teeth), further treatment must be done to intervene. In such a scenario, decoronation (Malmgren, 2000; Cohenca, Stabholz, 2007; Filippi, Pohl, Von Arx, 2001; Malmgren, 2013) would be indicated.

Much has been written on decoronation, and it is a fascinating and effective procedure that can be easily performed by a clinician with training; historically, endodontists, periodontists, and oral surgeons might have experience with such a treatment modality.

Once decoronation has been performed after extensive replacement resorption has occurred, the bone will eventually be ready for an implant when growth is complete and a very minimal, if any, alveolar defect might exist. Again, this is taking a negative sequelae and turning it into the best possible outcome.

In conclusion, the patient (and her parents) never returned. In these scenarios, it is very likely that all her teeth are still in position. Overall, I believe the best treatment was performed with the given pejorative circumstance, and the young patient was allowed to continue with maxillary alveolar growth and a semblance of dentition in her smile. EP

9. Cohenca N, Stabholz A. Decoronation – a conservative method to treat ankylosed teeth for preservation of alveolar ridge prior to permanent prosthetic reconstruction: literature review and case presentation. Dent Traumatol.

2007;23(2):87-94.

18. Jackson NG, Waterhouse PJ, Maguire A. Factors affecting treatment outcomes following complicated crown fractures managed in primary and secondary care. Dent Traumatol.

2006;22(4):179-185.

10. Cvek M, Andreasen JO, Borum MK. Healing of 208 intraalveolar root fractures in patients aged 7-17 years. Dent Traumatol. 2001;17(2):53-62.

11. Cvek M, Tsilingaridis G, Andreasen JO. Survival of 534 incisors after intra-alveolar root fracture in patients aged 7-17 years. Dent Traumatol. 2008;24(4):379-387.

12. DiAngelis AJ, Andreasen JO, Ebeleseder KA, et al.; International Association of Dental Traumatology. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 1. Fractures and luxations of permanent teeth. Dent Traumatol.

2012;28(1):2-12.

13. Ebeleseder KA, Santler G, Glockner K, Hulla H, Pertl C, Quehenberger F. An analysis of 58 traumatically intruded and surgically extruded permanent teeth. Endod Dent Traumatol. 2000;16(1):34-39.

14. Ferrazzini Pozzi EC, von Arx T. Pulp and periodontal healing of laterally luxated permanent teeth: results after 4 years.

Dent Traumatol. 2008;24(6):658-662.

15. Filippi A, Pohl Y, von Arx T. Decoronation of an ankylosed tooth for preservation of alveolar bone prior to implant placement. Dent Traumatol. 2001;17(2):93-95.

19. Kahler B, Heithersay GS. An evidence-based appraisal of splinting luxated, avulsed and root-fractured teeth. Dent Traumatol. 2008;24(1):2-10.

20. Kinirons MJ, Gregg TA, Welbury RR, Cole BO. Variations in the presenting and treatment features in reimplanted permanent incisors in children and their effect on the prevalence of root resorption. Br Dent J. 2000;189(5):263-266.

21. Malmgren B. Decoronation: how, why, and when? J Calif Dent Assoc. 2000;28(11): 846-854.

22. Malmgren B. Ridge preservation/decoronation. Pediatr Dent. 2013;35(2):164-169.

23. Oikarinen K. Tooth splinting: a review of the literature and consideration of the versatility of a wire-composite splint.

Endod Dent Traumatol. 1990;6(6):237-250.

24. Olsburgh S, Jacoby T, Krejci I. Crown fractures in the permanent dentition: pulpal and restorative considerations.

Dent Traumatol. 2001;18(3):103-115.

25. Panzarini SR, Trevisan CL, Brandini DA, et al. Intracanal dressing and root canal filling materials in tooth replantation: a literature review. Dent Traumatol. 2012;28(1):42-48.

16. Hinckfuss SE, Messer LB. Splinting duration and periodontal outcomes for replanted avulsed teeth: a systematic review. Dent Traumatol. 2009;25(2):50-57.

26. Robertson A, Andreasen FM, Andreasen JO, Norén JG. Long-term prognosis of crown-fractured permanent incisors. The effect of stage of root development and associated luxation injury. Int J Paediatr Dent. 2000;10(3):191-199.

17. Humphrey JM, Kenny DJ, Barrett EJ. Clinical outcomes for permanent incisor luxations in a pediatric population.

I. Intrusions. Dent Traumatol. 2003;19(5):266-273.

27. Welbury R, Kinirons MJ, Day P, Humphreys K, Gregg TA. Outcomes for root-fractured permanent incisors: a retrospective study. Pediatr Dent. 2002;24(2):98-102.

Volume 11 Number 2

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Surgical extrusion and endodontic treatment following dental trauma MCINTYRE

1. It is an important reminder that traumatic dental injuries are rarely a focal point of contact but rather a larger area of impact, thereby clinically affecting ________. a. multiple teeth to varying extents b. teeth in the opposing arch c. only those teeth in the focal point of contact d. both a and b 2. For documentation and future treatment, it is highly recommended to document ________. a. a trauma diagnosis to the best of one’s ability b. the pulpal diagnosis c. periodontal diagnosis d. all of the above 3. An intracanal medicament made of calcium hydroxide powder mixed on a glass slab with 2% chlorhexidine gluconate was then placed with a lentulo spiral filler into both canal spaces. This is a very common technique as a treatment modality in traumatic dental injury cases; it is called for when there is a potential need for ________, so as to aid in periodontal healing. a. waiting a few days before treatment b. a short-term intracanal medicament c. a long-term intracanal medicament d. a short-term extracanal medicament 4. Approximately ________ after the traumatic dental injury, the patient returned with her parents for definitive treatment: Surgical extrusion of both

Volume 11 Number 2

UR1 and UL1 was planned, as it was suspected that additional subgingival tooth and root fragments, as well as root fractures, remained on both, despite previous pulp extirpation and pulpal medicament. a. 1 day b. 1 week c. 1 month d. 2 months 5. _______ were repeated prior to any treatment or anesthesia, as the patient reported that her lower teeth had been “hurting” at this visit. a. Pulp vitality tests b. Pulpal debridement c. Temporization d. 3D radiographs 6. A bigger fragment (running obliquely and more subgingival/cervical) was visualized, and it was decided to extract UR1 with forceps after elevation. UR1 was immediately placed in ________ for 3 minutes. a. milk b. Hank’s Balanced Salt Solution (HBSS) c. sterile water d. tap water 7. The optimal replantation time for the best prognosis has been declared as _______ in clinical studies. a. 5 minutes b. 10 minutes

c. 15 minutes d. 20 minutes 8. The American Academy of Pediatric Dentistry and American Association of Endodontists have published extensive guidelines regarding traumatic dental injuries and detailed their follow-up care at 4 weeks, 6 to 8 weeks, 4 months, 6 months, and then _______. a. biannually for 2 years b. annually for 3 years c. annually for 5 years d. annually for 7 years 9. Furthermore, it is always prudent to rule out any concomitant trauma to the opposing arch/teeth by taking a _______ of the opposing teeth at the first or second appointment. a. baseline radiograph b. intraoral photograph c. pulp test d. periodontal measurement 10. As this was a traumatic dental injury on a pediatric patient, loss of these teeth would have been catastrophic and would have left psychosocial effects as well as _______ challenges for her and her family to deal with lifelong. a. functional b. developmental c. esthetic d. all of the above

Endodontic practice 39

CE CREDITS

ENDODONTIC PRACTICE CE

PRODUCT DEBUT

Brasseler USA®: AAE new product introductions

B

rasseler USA® introduced two new exciting products at this year’s AAE in Denver. Contact Brasseler for more information or to request a sample.

EndoSequence® Scout Files Working with multiple endodontists from different backgrounds, the EndoSequence Scout Files were designed specifically to address the challenges associated with severely curved and calcified canals.

Features and benefits • Shortened cutting length (12 mm) reduces maximum flute diameter and facilitates better scouting of the apical third • Exclusive NiTi allows for optimal prebending and flexibility • Tighter flute structure and robust cross section provides higher resistance to fatigue and deformation • Precision safety tip facilitates navigation of curved and calcified canals • Premium, uncompromised quality • Compression-fit handle (allows for apex locator readings) • Clear calibration markings • Sharp cutting flutes • Consistent sizing • Precision safety tip (not blunt or pointed, which can lead to ledging) • Sterile blister packaging • Premium, uncompromised Brasseler quality

40 Endodontic practice

Volume 11 Number 2

BY YOUR SIDE

ENDOSEQUENCE® BC SEALER™ HIFLOW™ Optimized for warm obturation techniques Higher heat resistance allows for better flow Won’t get chalky during down pack Higher radiopacity

For optimal results and fully bonded obturation, use HiFlow with BC Points 150 Series & BC Pellets at or below 200ºC. ™

"With over 10 years of evidence, I am now convinced that BC Sealer is the best sealer on the market. I have been working with Brasseler to develop a new version of BC Sealer that is optimized for warm obturation. BC Sealer HiFlow will allow clinicians who prefer thermoplastic techniques to fully embrace the biological benefits of BC Sealer."

— STEVE BUCHANAN, DDS

Visit our website at BrasselerUSA.com To order call 800.841.4522 or fax 888.610.1937. In Canada call 800.363.3838

B-5045-EP-06.18

PRODUCT DEBUT EndoSequence BC Sealer™ HiFlow™ The “state-of-the-art” in endodontic obturation is now available for warm techniques!

Clinicians now have two distinct formulations of the same proven pre-mixed bioceramic sealer to choose from. Compared to standard BC Sealer™, BC Sealer HiFlow exhibits a lower viscosity when heated and is more radiopaque, making it optimized for warm obturation techniques.

Features and benefits • Condensation-based technique • Optimal for warm obturation • Lower viscosity when heated • Higher radiopacity Standard gutta percha can be used with BC Sealer, but for a true, gap-free seal, BC Points™ are recommended. BC Points are impregnated and coated with bioceramic particles to allow for bonding with BC Sealer.

For warm techniques, it is recommended to use BC Sealer HiFlow with BC Points™ 150 Series™ along with BC Pellets at 150ºC – 220ºC. EP

“With over 10 years of evidence, I am now convinced that BC Sealer is the best sealer on the market. I have been working with Brasseler to develop a new version of BC Sealer that is optimized for warm obturation. BC Sealer HiFlow will allow clinicians who prefer thermoplastic techniques to fully embrace the biological benefits of BC Sealer.” — Steve Buchanan, DDS This information was provided by Brasseler USA®.

42 Endodontic practice

Volume 11 Number 2

Sandra Marlowe discusses how to nurture a relaxation response in everyday life and the dental office

N

ighttime sleeplessness may be a result of our minds and our bodies combined response to stress. A study in International Journal of Psychophysiology pointed out Chinese researchers’ discovery that our bodies are primed to stay awake when we perceive threats, and nighttime stress may amplify this response. Our bodies are responding to stress much like our ancestors did when they faced nighttime threats from predators — our brain thinks we’re in danger and keeps us on high alert, diminishing the possibility of a good night’s sleep.

Most people experience “super stress,” in their everyday lives, so the brain has to cope by generating high-intensity brain waves, which overpower calming brain waves, especially at night. Once your brain becomes used to this hyper alert state, it can become very difficult to wind down again.

Super stress often manifests in disorders such as ADHD, obesity, diabetes, insomnia, headaches, and high blood pressure, to name but a few.

To obtain a state of homeostasis (balance) for recovery, repair, and healing to take place, try the following five simple steps to optimal health.

Tip No. 1: Breathe deeply Deep breathing sends a message to your brain to calm the body. Detrimental stress responses — such as increased heart rate, increased hormone production, and high blood pressure — all decrease as you breathe deeply to relax. Just a few minutes of deep breathing can calm you and put the body back into recovery mode.

For this reason, every audio session in our BrainTap® Library includes deep, relaxing, guided breathing designed to bring your body to ultimate relaxation.

To obtain a state of homeostasis (balance) for recovery, repair, and healing to take place, try the following five simple steps to optimal health.

1. Breathe deeply.

2. Focus on the moment.

3. Reframe the situation.

4. Keep your problems in perspective.

5. Practice mindful meditation and visualization.

Sandra Marlowe has authored, co-written, or ghostwritten eight self-improvement books, including an award-winning bestseller.

She has earned a Pushcart Prize nomination in literature. She regularly writes and speaks on topics related to brain health and self-development.

Volume 11 Number 2

Endodontic practice 43

PRACTICE MANAGEMENT

Recover, repair, and heal from super stress with BrainTap®

PRACTICE MANAGEMENT

Once you enter this “relaxation response,” the brain sends out neurochemicals that neutralize the effects of stress on the body, allowing you to change your reactions to the stressful events going on around you. The sessions offered in the BrainTap Library are designed to help you reach the relaxation response.

BrainTap’s sessions for optimal health For Breathing deeply — Recommended BrainTap session: SR01 — Create Your Enchanted Forest for Stress Reduction For Focusing on the moment — Recommended BrainTap session: SR04 Putting Future Events into Perspective For Reframing the Situation — Recommended BrainTap session: SR05 Reducing Uncertainty and Doubt

Tip No. 5: Practice mindful meditation and visualization

state of deep rest that changes the physical and emotional responses to stress. Once you enter this “relaxation response,” the brain sends out neurochemicals that neutralize the effects of stress on the body, allowing you to change your reactions to the stressful events going on around you. The sessions offered in the BrainTap Library are designed to help you reach the relaxation response. In 20 relaxing minutes a day, you can reduce or eliminate brain fog and negative mind chatter, have more energy, relax and develop positive sleep habits, rid yourself of unwanted habits and behaviors, gain memory and focus, and improve the quality of your life.

Fortunately, your BrainTap headset produces the relaxation response, which can help your brain relax and feel safe — giving your body precisely what it needs to get back in balance and reverse the effects of stress on the body. The BrainTap headset will help dental patients before, during, and after dental procedures as well. Regular use of BrainTap Technology will help rebalance your brain wave activity, allowing your brain to relax, rejuvenate and reboot itself — helping you to sleep more deeply and awaken refreshed. So, the next time you’re wide awake and feeling the stress, take comfort in knowing that your brain is doing exactly what evolution taught it to do, but you can take back control and ease into a great night’s sleep by using the BrainTap headset. EP

By practicing mindful meditation and visualization, you can achieve a physical

This information was provided by BrainTap®.

For Keeping Your Problems in Perspective — Recommended BrainTap session: SR 06 Eliminate Negative Thinking For Practicing Mindful Meditation and Visualization — Recommended BrainTap session: SR 10 Developing Spontaneous Relaxation

Tip No. 2: Focus on the moment When you are stressed and anxious, you may be worried about the future or regretting a past action. This can cause immense amounts of stress from which our bodies need recovery time.

One way to lessen this type of stress is to bring yourself back to the moment. If you’re walking, feel the sensation of your legs moving your body. If you’re eating, focus on the taste, the smell, the sensation of the food you’re consuming. If you’re relaxing, be mindful of the heaviness of your limbs and the deep, rhythmic sound of your breathing.

Rather than seeing only the negatives, focusing on the moment offers you a space to think differently about stress and respond in a more appropriate manner without past regrets or future worries.

Tip No. 3: Reframe the situation When you are stressed or overwhelmed, focus on a positive thought. (This is called “reframing” the situation.) It’s not as hard as you think. Look at the same situation in a new way that highlights the possibilities.

Viewing our stressors as opportunities can help us stop feeling trapped and reduce 44 Endodontic practice

the physical effects of stress on our bodies almost immediately.

Ways to reframe the situation 1. Look at what is actually stressing you.

2. Consider what you can change, if anything, about the situation.

3. Look for the positives.

4. Find the humor.

Tip No. 4: Keep your problems in perspective Don’t stress too much on a specific problem. It’s important to remind ourselves of the positives in our lives — we woke up this morning; we can see; we can walk; we have family and friends to support us. It might seem a little silly at first, but the next time you’re feeling stressed, consciously make the effort to think about the things you’re grateful for. This can be a surprisingly easy way to reduce the stress in your life.

Volume 11 Number 2

SMALL TALK

Achieve a “personal best” by expanding your comfort zone Joel Small notes, “Each time we achieve a new personal best, we expand the limitations of our being until these limitations no longer exist”

A

chieving a “personal best” is a milestone for an athlete. It validates the exceptional effort required to achieve the desired reward. Most athletes will admit that achieving a personal best doesn’t come easily and requires more than physical training. Yes, the physical element is important, but until athletes embrace the belief that the goal is attainable, they remain hindered by their own mentally imposed self-limitation.

The same is true for us non-athletes. We too must believe that we can grow beyond our current limitations to achieve our own personal best — whatever that may be.

Again, our athletic friends will tell us that developing this mental edge is as much a challenge as developing their physical attributes. For us mere mortals, we develop our professional and personal mental edge by continually expanding our comfort zone beyond its current limit.

For our discussion’s purpose, a comfort zone can be defined as an area of great psychological safety and comfort, free of uncertainty in which we can exist anxiety-free and without challenge to our vulnerability.

All of us have unknowingly created our own personal comfort zones.

Comfort zones have both beneficial and negative effects on our well-being and personal self-actualization. They do provide a positive “safe haven” for us when the demands of the world become overwhelming, and yet they can also represent the siren song that lulls us into a state of complacency. Consider, for example, the difference between listening to a presentation and delivering the presentation. Listening to

the presentation falls well within our comfort zone, but delivering the presentation moves us beyond our comfort zone by creating uncertainty and anxiety. Intuitively, we know that a well-delivered presentation can jump-start our career, yet the fear of failing and exposing our vulnerability becomes a powerful limiting factor that often drives us back to our safe haven. Even worse, by allowing fear to dictate these choices, we diminish our self-confidence and strengthen our self-limiting belief that we are incapable of moving beyond these limiting factors.

We can overcome self-limiting beliefs by employing techniques designed to expand our comfort zone. First, we must accept

Joel C. Small, DDS,MBA, ACC, FICD, is an endodontist, author, and certified executive coach. He received his MBA, with an emphasis in healthcare management, from Texas Tech University. He is a graduate of the University of Texas at Dallas postgraduate program in executive coaching and limits his coaching practice to motivated healthcare professionals. He is a nationally recognized speaker on the subjects of leadership and professional development. Dr. Small is available for speaking engagements and for coaching healthcare professionals who wish to experience personal and professional growth while taking their practices to a higher level of productivity. **To receive a free copy of Dr. Small’s “Core Values Exercise,” please contact the author at joel@joelsmall.com.

He is also available for a complimentary coaching session to discuss your practice-related issues.

46 Endodontic practice

that our growth is restricted by certain beliefs. We must then create a vivid mental picture of a better future in which these beliefs and limitations no longer exist. This vision becomes an implicit validation of the benefits we will derive by expanding our comfort zone and eliminating the many detractors that currently hold us hostage.

Next, we design small excursions beyond or comfort zone boundaries. Each of these excursions, or “experiments,” has a purpose and is designed to move slightly beyond the comfort zone while remaining well below the “panic” level. Each successful experiment builds upon itself by creating within us a growing sense of accomplishment and self-confidence. Setbacks are a natural and inevitable part of the process, but a coach or trusted friend should be there to reframe these setbacks as learning opportunities and turn them into teachable moments.

With each success, we gain the confidence to take bigger steps toward making the vision of our limitless future a reality. Our excitement with each success will become palpable. Each achievement becomes a Volume 11 Number 2

his concept of leadership was distorted with images of history’s greatest, largerthan-life leaders — people like Winston Churchill, Ronald Reagan, and John Kennedy, to name a few. Being an avid student of leadership, I shared with him the stories of other great leaders that changed our world in a quieter and less obtrusive manner. I helped him see that great leaders come in many forms and with very different personalities.

Once I was able to convince him that everyone has leadership capabilities, our work progressed. With guidance, he was able to create and embrace a mental picture of a better and more fulfilling future as a leader. It was then that we began the process of developing a logical and actionable game plan for making his vision a reality. Like many self-improvement initiatives, the first step is always the hardest, and he struggled with how to go about introducing this new leadership initiative to his staff.

From previous assessments and our work together, I knew that one of his

signature strengths was humility, and by aligning our initial action plan (experiment) with this identifiable strength, we were able to move forward. Being humble, he connected with the concept of “servant leadership” — one of many leadership styles and one that matched his personal strength. Using the principles of servant leadership, he felt more comfortable facilitating a staff meeting and sharing his intention of becoming a better leader and boss. He shared the vision of his desired future with his team. He proclaimed his commitment to being accountable for achieving this goal. Finally, and most importantly, he asked for their help in making his vision a reality.

This and subsequent staff meetings served as pivotal points in the transformation of his practice. As a professional coach, I was not surprised to see his practice flourish.

I found great reward in his practice’s transformation, but what fulfilled me the most was the ease and comfort he found in becoming the leader that he was always meant to be.

This transformation will change his life. EP

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SMALL TALK

personal best that serves as a milestone to be broken by subsequent efforts. Those around us will notice a demonstrable improvement in our demeanor as we gain the confidence to overcome previous barriers that we once viewed as being unconquerable. As our belief in our abilities increases, limitations in other areas of our life begin to disappear spontaneously or diminish in significance. Eventually, our vision becomes reality as we view our world as having limitless possibilities.

Recently, one of my coaching clients was struggling with his leadership role within his dental practice. He saw himself as a poor leader and someone who feared moving beyond his current comfort zone. He admitted that staff meetings were seldom held and that he rarely gave feedback to his staff. Even though he understood the value of making necessary changes to become a better leader, previous attempts with practice consultants had failed.

Initially, we visited about what being a leader meant to him, and like most of us,

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Edge

INDUSTRY NEWS Brasseler USA® introduces C-Series carbide burs

CS 8100SC 3D wins 2018 Edison Award™ for its innovative design The CS 8100SC 3D extraoral imaging system by Carestream Dental has been awarded a Bronze 2018 Edison Award™ in the category of Dental/Medical Digital Imaging by the internationally renowned Edison Awards™. The distinguished award, inspired

by Thomas Edison’s persistence and inventiveness, recognizes innovation, creativity, and ingenuity in the global economy. To earn a Bronze 2018 Edison Award, the CS 8100SC 3D was judged on its concept and development, value, and impact on the industry.

The CS 8100SC 3D offers two-dimensional panoramic imaging, cephalometric imaging, cone beam computed tomography (CBCT) imaging, and model/impression scanning all in one compact system.

That means doctors can go from diagnosis to treatment faster, without having to send patients to an imaging center. Not only is the system more convenient, but it’s also faster — featuring the fastest scanning cephalometric module on the market — and safer. The CS 8100SC 3D’s low dose program can deliver 3D imaging at a dose equal to or lower than panoramic imaging.

For more information, visit carestreamdental.com, or call 800-944-6365.

Ultradent introduces ChlorCid® surf canal preparation solution Ultradent Products, Inc., has introduced the newest addition to its award-winning line of endodontics products, ChlorCid® Surf sodium hypochlorite solution with surfactant. ChlorCid Surf solution, a root canal preparation solution, features the added cleansing power of surfactant to break the surface tension and allow for better sodium hypochlorite penetration into difficult-toreach places like isthmuses and lateral canals. The 3% sodium hypochlorite solution and surfactant allows for better wall contact, thanks to its unique formulation. ChlorCid Surf solution comes in two types of delivery, IndiSpense syringes and 480 ml bottles, to cater to every clinician’s needs.

For more information, call 800-552-5512, or visit ultradent.com.

Brasseler USA® has expanded upon its extensive family of operative carbide burs with its new C-Series Carbides. The latest addition to the classic Peter Brasseler Series, C-Series Carbides, are designed to address the No.1 problem clinicians experience while using carbide burs — breakage. The unique and durable singlepiece construction of the C-Series Carbides can enhance patient care and minimizes unforeseen handpiece repairs, improving clinicians’ daily practice flow. In addition to its innovative single-piece solid carbide construction, C-Series Carbides feature improved blade geometry for extremely rapid and precise cutting, consistent with the superior performance and quality that dental professionals have come to expect from the Peter Brasseler Series.

For more information, visit www.BrasselerUSA.com, or call 800-841-4522.

Foundation pilots outreach program offering helping hands and smiles in the United States The American Association of Endodontists’ philanthropic arm, the Foundation for Endodontics, has opened a new endodontics operatory at the Stephen Klein Wellness Center in Philadelphia.

The North Philadelphia center is operated by Project Home and will be staffed on a part-time basis by an endodontic resident and faculty member from Einstein’s I.B. Bender Division of Endodontics, Department of Dental Medicine. It serves low-income patients who would otherwise likely face tooth extraction. Philadelphia endodontist and Past President of the Foundation for Endodontics, Dr. Louis Rossman, who endorsed a domestic mission when he was head of the Foundation, will be volunteering his time as a faculty member at the clinic.

The Foundation would like to thank Carl Zeiss Meditec Inc. for providing one OPMI® pico microscope on a long-term loan basis for use in the operatory, as well as Brasseler USA® and Henry Schein® Inc., for the discounted sale of all other endodontic equipment that will be used in the operatory.

For more information, visit foundation.aae.org.

Share your good (endodontic) news!

Submit your press release for consideration to managing editor Mali Schantz-Feld via email at Mali@medmarkmedia.com.

48 Endodontic practice

Volume 11 Number 2

Experiencing the power of digital communication.

ZEISS EXTARO 300

// INNOVATION MADE BY ZEISS

The integrated HD camera of the EXTARO® 300 from ZEISS records wirelessly to the ZEISS Connect App — empowering patient interaction and informed decisions with images and videos directly transferred to your local network.

• Benefit from a digital workflow • Easily educate your patients • Demonstrate the value of your work

SUR.9424 ©2018 Carl Zeiss Meditec, Inc. www.zeiss.com/med All copyrights reserved.

DRIVING DIAGNOSTIC EXCELLENCE IS MORE THAN WHAT WE DO IT´S IN OUR DNA 2014: CS 8100 3D Carestream Dental

1960s: Dental X-ray Unit Trophy Radiologie

WORKFLOW INTEGRATION I HUMANIZED TECHNOLOGY I DIAGNOSTIC EXCELLENCE

Carestream Dental. Now 100% Digital.

Carestream Dental may be a new dental digital company, it has a long history of defining imaging and practice management technology. Strong legacy brands—which include Eastman Kodak, Trophy and PracticeWorks—have paved the way to bring dental workflows into the new realm of digitalization. And, as an independent company solely focused on the oral healthcare market, Carestream Dental will continue to drive innovation and deliver new solutions for practices.

From consultation to final treatment, we have the solution that’s right for you.

© 2018 Carestream Dental LLC. 17150 EN CS 8100 3D Family AD 0518 Trophy and PracticeWorks are trademarks of Carestream Dental Technology Topco Limited.

Kodak is a trademark of Eastman Kodak Company.

For more information, call 800.944.6365 or visit carestreamdental.com