Endodontic Practice US Summer 2020 Vol 13 No 2 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews

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Summer 2020 – Vol 13 No 2 • endopracticeus.com

PROMOTING

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ENDODONTICS

Minimally invasive endodontics using a new single-file rotary system Drs. Peet J. van der Vyver, Martin Vorster, and Ove A. Peters

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Diastema closure through Z-plasty and ceramic veneers: a case report Drs. Rupali Balpande, Amil Sharma, Sarvesha Bhondwe, and Gayatri Deshmukh

Occurrence of post-endodontic pain after single-visit RCT using balanced force technique and two reciprocating systems... Drs. Jorge Paredes Vieyra, Fabian Ocampo Acosta, Francisco Javier Jiménez Enriquez, and Daniel Jiménez Zaragoza

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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 2020. 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.

From evolution to revolution (while remaining a clinician)

he anatomy of the root canal system has always been fascinating to researchers, academicians, and clinicians. From the early works of Walter Hess in 1925 to the most advanced micro-CT imaging techniques in 2020, one can appreciate the extensive isthmuses, anastomoses, lateral canals, and fins of root canals, making them a challenging environment to exert microbial control — the ultimate goal of any clinician. Thankfully, the discipline of endodontics has witnessed multiple evolutionary advancements in terms of instrumentation, irrigation, and obturation, with the hope of overcoming challenges associated with the anatomy. Clinicians can think of the various NiTi file designs and various motions yielding a multitude of rotary Chafic Safi, DMD, MS systems over the last decade or the advances in irrigation fluid dynamics and agitation, as well as the various sealers and obturation techniques that have become available to us. However, there is an emerging current revolution in endodontics taking place within these evolutionary advancements aimed at setting a new philosophy, one that is more biologically based than just technically based. For instance, root canal instrumentation is shifting from “rotary instrumentation” — a scenario where the file shapes the canal, leaving behind a considerable amount of untouched areas, to “adaptive instrumentation,” a scenario where the file expands and adapts itself to the irregular ovoid shapes of canals, hence respecting root canal anatomy and yielding a cleaner canal. This allows for a more conservative approach and less dentin removal, contributing to long-term strength of the tooth. These new adaptive files, such as the XP-3D Shaper™ (Brasseler USA®), can be used during both primary root canal treatments and retreatments. Their expandable potential helps in grabbing and pulling out the root canal filling materials, especially stubborn gutta-percha tags attached to axial walls, in a fast, clean, and secure manner. Irrigation is also experiencing its share of revolution in terms of delivery and activation systems. From passive ultrasonic irrigation, XP-3D Finisher™ (Brasseler USA), EndoVac™ (Kerr Dental), and GentleWave® (Sonendo) to nanocatalysts, it is clear that it is getting easier and more predictable to chemically disinfect inaccessible areas of the root canal system. Without a doubt, root canal obturation is the aspect of endodontic therapy that has undergone the most important changes over the years — probably because of the insatiable desire to obtain a particular radiographic “look.” Sadly, most of the “evolutionary’’ obturation techniques still rely on gutta percha to overcome the poor performance of traditional sealers in terms of dimensional stability and proper bonding to the dentinal surfaces, not to mention their lack of biocompatibility and mitotic activity. Today the development of bioceramic-based sealers, such as EndoSequence® BC Sealer™ (Brasseler USA) or BioRoot™ RCS (Septodont), offers a safe and predictable way to obtain a long-term seal of the root canal system without excessive preparation in the coronal component of the root canal space to accommodate obturation procedures. It was these paradigm changes in obturation that sparked the chain reaction to revolutionize all other steps of endodontic therapy. Finally, in this fast-paced world we live in, we should not sink into the mindset of mastering techniques. Rather, we should always question the biology behind it, hence challenging the clinician within each one of us. Dr. Chafic Safi

Chafic Safi, DMD, MS, is a Board-certified endodontist practicing in Montreal, Canada. He graduated from University of Montreal Dental School in 2012 and from the University of Pennsylvania Postdoctoral Endodontics Program in 2015, where he also received a Masters in Oral Biology. He divides his time between private practice and teaching. Dr. Safi is also a published researcher and lectures nationally and internationally on various surgical and nonsurgical endodontic topics.

ISSN number 2372-6245

Volume 13 Number 2

Endodontic practice 1

INTRODUCTION

Summer 2020 - Volume 13 Number 2

TABLE OF CONTENTS

Case study

Publisher’s perspective “It’s what you learn after you know it all that counts” Lisa Moler, Founder/CEO, MedMark Media................................ 6

Diagnosing dens invaginatus with Orthophos SL CBCT

Drs. Prashant P. Jaju and Sushma P. Jaju diagnose and treat a difficult condition with the help of smaller volume CBCT

Case study Surgical management of mandibular central incisor with periapical lesion: 6-month follow-up case report Drs. Juliana Larocca de Geus, Abel Barreto Jr., Márcia Fernanda de Rezende Siqueira, Jane Kenya Nogueira da Costa, and Alessandra Reis document their success in the surgical treatment of the periapical lesion............................................... 14

Clinical

Case study

2 Endodontic practice

Volume 13 Number 2

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TABLE OF CONTENTS

Continuing education Occurrence of post-endodontic pain after single-visit RCT using balanced force technique and two reciprocating systems when apical patency (AP) is maintained Drs. Jorge Paredes Vieyra, Fabian Ocampo Acosta, Francisco Javier Jiménez Enriquez, and Daniel Jiménez Zaragoza sample 216 patients to analyze the occurrence of postendodontic pain after single-visit RCT using balanced force technique and two reciprocating file systems..........30

Continuing education Minimally invasive endodontics using a new single-file rotary system

Drs. Peet J. van der Vyver, Martin Vorster, and Ove A. Peters discuss the design features of the TruNatomy™ instruments and present case reports to illustrate the clinical application and benefits of these instruments

Practice management Small talk

Technology

Priorities to drive practice recovery and growth

A millisecond that can change everything

Advancements in endodontic root-end surgeries

Dr. Albert (Ace) Goerig discusses embracing critical change in the overall strategic direction of the practice......36

Drs. Joel Small and Edwin McDonald discuss the power and consequences of words............................................... 38

Dr. Jon Irelan discusses advancements in endodontic apical surgeries, driven in large part by microscopy...............39

www.endopracticeus.com READ the latest industry news and business WATCH DocTalk Dental video interviews with KOLs LISTEN to the Dental Clinical Companion podcast with host Dr. Richard Mounce

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4 Endodontic practice

Volume 13 Number 2

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ASK ABOUT OUR RECOVERY TEAM SUMMIT IN SEPTEMBER! Shake off the slow pandemic summer and get your team focused and motivated with our 2-day live webinar summit on September 18th and 19th.

PUBLISHER’S PERSPECTIVE

“It’s what you learn after you know it all that counts”

e never presume to know everything during any time period, but during this COVID-19 crisis, our learning curves have ramped up to high gear. Over the past few months, we have learned so many things — about business, medicine, dentistry’s evolving needs, resilience, hope, and caring — to name just a valuable few. Forward-looking leadership and a loyal team are attributes that MedMark Media has always cultivated, and all of us have turned our quarantines into positive action during these trying times. We are changing as our world changes, as needs evolve, and as dentists seek answers to difficult questions. We have also sought insight from mentors whose experience can be life-changing and game-changing. “A mentor is someone who allows you to see the hope Lisa Moler Founder/Publisher, MedMark Media inside yourself. A mentor is someone who allows you to know that no matter how dark the night, in the morning joy will come. A mentor is someone who allows you to see the higher part of yourself when sometimes it becomes hidden to your own view.” These words by talk show host, media executive, and actress Oprah Winfrey are meaningful to dentists as well as entrepreneurs. After being a part of the dental world for 20 years, I have had the opportunity to see firsthand the phenomenal benefits of having and being a mentor. Traveling on the journey to building a business can be frustrating and heartbreaking if you don’t have someone to offer advice on the right paths to take and the hazards to avoid. I recently read an article from Inc. magazine that described why mentors are integral to success. John Rampton, entrepreneur and investor, pointed out these top 10 reasons: 1. Provide information and knowledge. 6. Are open to listening to our ideas. 2. Point out where we need to improve. 7. Are trusted advisors. 3. Stimulate our growth. 8. Help with networking. 4. Offer encouragement. 9. Have experience you can learn from. 5. Help us develop self-discipline. 10. Are free, but priceless. With publications that are read by general dentists and specialists alike, MedMark Media brings the expertise of mentors and innovators in the dental community to your houses, offices, and computers. Authors write for us because they believe in sharing their knowledge for better patient care, more efficient workflow, and more lucrative business methods. Over the years, dental mentors have helped our company grow from print magazines to digital formats, webinars, videos, and podcasts. If there is a way to reach you, we will be there! In this issue of Endodontic Practice US, we bring you a CE by Dr. Vieyra, et al., on reduction of post-endodontic pain and a CE by Dr. van der Vyver, et al., on the clinical application of TruNatomy® instruments. Drs. Tavares and Almeida write about nonsurgical endodontic treatment and how bioceramic cements can have an effective action in inducing repair of periapical tissues. And Drs. Joel Small and Edwin McDonald focus on the power and consequences of words. Our issues also bring you product, service, and corporate profiles and practice development and management articles — each full of ideas to help your practices grow clinically, professionally, and financially. Mentors will help keep your protocols and knowledge fresh and exciting. So keep searching for those who can help you to achieve greatness. Of course, we want you to read our publications and listen to our digital offerings. But also at this time, you can take advantage of online speakers who can expand your horizons, no matter where you are on your career journey. It’s never too late to have a mentor or to become one, since learning and sharing knowledge should happen in all stages of life. As President Harry S. Truman said, “It’s what you learn after you know it all that counts.” To all of our readers, authors, and advertisers, we wish you all health, safety, and a speedy resolution to the COVID-19 crisis. 6 Endodontic practice

Published by

PUBLISHER Lisa Moler lmoler@medmarkmedia.com DIRECTOR OF OPERATIONS Don Gardner don@medmarkmedia.com MANAGING EDITOR Mali Schantz-Feld, MA mali@medmarkmedia.com | Tel: (727) 515-5118 ASSISTANT EDITOR Elizabeth Romanek betty@medmarkmedia.com MANAGER - CLIENT SERVICES/SALES Adrienne Good agood@medmarkmedia.com CREATIVE DIRECTOR/PRODUCTION MANAGER Amanda Culver amanda@medmarkmedia.com MARKETING & DIGITAL STRATEGY Amzi Koury amzi@medmarkmedia.com EMEDIA COORDINATOR Michelle Britzius emedia@medmarkmedia.com SOCIAL MEDIA & PR MANAGER April Gutierrez medmarkmedia@medmarkmedia.com FRONT OFFICE ADMINISTRATOR Melissa Minnick melissa@medmarkmedia.com

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Volume 13 Number 2

Courtesy of Allen Ali Nasseh, DDS, MMSc

BY YOUR SIDE

Visit our website at BrasselerUSA.com To order call 800.841.4522 or fax 888.610.1937. In Canada call 800.363.3838. Invoice or statement prices may reflect or be subjected to a bundled discount or rebate pursuant to purchase offer, promotion, or discount program. You must fully and accurately report to Medicare, Medicaid, Tricare and/or any other federal or State program, upon request by such program, the discounted price(s) or net price(s) for each invoiced item, after giving effect to any applicable discounts or rebates, which price(s) may differ from the extended prices set forth on your invoice. Accordingly, you should retain your invoice and all relevant information for your records. It is your responsibility to review any agreements or other documents, including offers or promotions, applicable to the invoiced products/prices to determine if your purchase(s) are subject to a bundled discount or rebate. Any such discounts must be calculated pursuant to the terms of the applicable purchase offer, promotion, or discount program. Participation in a promotional discount program is only permissible in accordance with discount program rules. By participation in such program, you agree that, to your knowledge, your practice complies with the discount program requirements.

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CASE STUDY

Diagnosing dens invaginatus with Orthophos SL CBCT Drs. Prashant P. Jaju and Sushma P. Jaju diagnose and treat a difficult condition with the help of smaller volume CBCT

s a practice specialized in dental radiology, many dentists use our services. We were the first practice in India to use 3D imaging. With the introduction of Dentsply Sirona’s Orthophos SL CBCT, complicated cases are diagnosed and treated efficiently and more successfully with the help of a smaller volume specific for endodontic purposes. Indeed, cone beam computed tomography is a boon for endodontists across the globe. In this article, we are presenting a difficult endodontic case in which an Orthophos SL CBCT 5 x 5.5-volume aided in identifying dens invaginatus and its subsequent treatment planning. A 24-year-old male patient had swelling in the upper right canine region. An intraoral periapical radiograph showed variation in pulpal floor anatomy, but the lack of a third dimension limited its utility. For further evaluation of tooth root canal anatomy, limiting volume CBCT was advised. Orthophos SL CBCT 5 x 5.5 High Definition (HD) volume at 80 microns showed variation in pulpal floor anatomy.

CBCT images revealed invagination extending through the root and communicating laterally with the periodontal ligament space through a pseudo foramen without communicating with the main root canal space. A single major orifice was present surrounded by two radiolucent areas on mesial and distal sides extending approximately 4 mm within the root not associated with the main canal (Figure 1). A single, large, periapical radiolucency was present with the tooth resulting in thinning of labial cortical plates. This was radiographically diagnosed as a case of dens invaginatus Type IIIA, resulting in chronic periapical abscess.1 With threedimensional visualization of the root canal space anatomy variation, the endodontist was able to proceed with a new, improved treatment protocol resulting in successful root canal filling and restoration. Dens invaginatus is a developmental anomaly resulting in a deepening or invagination of the enamel organ into the dental papilla prior to calcification of the dental tissues.

Although dens invaginatus is common, it may be easily overlooked because of the absence of any significant clinical signs of the anomaly. Periapical radiographs are limited in revealing the type, extension, and complex morphology of dens invaginatus as well as the actual bone loss when compared to tomographic techniques. More advanced imaging techniques such as CBCT may aid the diagnosis as well as the management plan and follow-up of teeth with this developmental defect.2 EP

REFERENCES: 1. Alani A, Bishop K. Dens invaginatus. Part 1: Classification, prevalence and aetiology. Int Endod J. 2008;41(12): 1123-1136. 2. Pradeep K, Charlie M, Kuttappa MA, Rao PK. Conservative management of Type III dens in dente using cone beam computed tomography. J Clin Imaging Sci. 2012;2(1): 51.

This article was previously published in the brochure “Orthophos SL – around the world,” 2019 by Dentsply Sirona.

Figure 1: Sagittal, cross-sectional, and axial images of upper right canine on Orthophos SL with a resolution of 80 µm Prashant P. Jaju, BDS, MDS, is a gold medalist in Oral Medicine and Radiology from the reputed Pune University. He is currently serving as professor, head of the department, and guide in Rishiraj College of Dental Sciences and Research Centre, Bhopal, India. He is the director of CBCT imaging centers and also the director at Oral Imaging Solutions — a teleradiology company providing online reporting services. He is author of two books on CBCT, which have been appreciated worldwide. Dr. Jaju has published more than 20 research papers in international journals. He is the recipient of profile of the month and year awards by the Indian Dental association. He is certified CBCT trainer and trains dentists and specialists in CBCT imaging nationally and internationally. Sushma P. Jaju, BDS, MDS, is a specialist in Conservative Dentistry and Endodontics from the reputed Dr. NTR University. She is currently serving as Associate Professor in Rishiraj College of Dental Sciences and Research Centre, Bhopal, India. She is the director of CBCT imaging centers and also the director at Oral Imaging Solutions — a teleradiology company providing online reporting services. She has contributed book chapters on the role of CBCT in endodontics, which have been appreciated worldwide, and has published numerous papers in international journals. Disclosure: Dr. Prashant P. Jaju is a key opinion leader for Dentsply Sirona India for imaging since 2011.

8 Endodontic practice

Volume 13 Number 2

We’re here for you to support healthy practices and healthy smiles

DS Digital Academy Library – Earn CE with Webinars and On-Demand Courses Our online Academy library is here to digitally empower dental professionals with webinars and ondemand videos across all areas of dentistry. We are here to help you create healthy smiles through healthy practices. Register for live courses or watch our on-demand videos at your leisure. Go to dentsplysirona.com and click on ‘Academy’ to learn more.

CASE STUDY

The use of bioceramic sealer in endodontic retreatment Drs. Warley Luciano Fonseca Tavares and Gustavo de Cristofaro Almeida explore the use of bioceramic cements in nonsurgical endodontic retreatment Abstract The success of endodontic treatment is closely related to the complete debridement and disinfection of the root canal system (RCS) associated with its three-dimensional seal. Bioceramics, which are cements composed of silicates (particles similar to those found in the MTA) have characteristics that enable their use in the filling of the RCS. The aim of this article is to present two cases involving the use of a bioceramic root canal sealer. It is clinically notable that bioceramic cements have an effective action in inducing repair of periapical tissues. In view of the observed findings, we conclude that the use of bioceramic cements in cases of nonsurgical endodontic retreatment is well indicated.

Introduction The success of endodontic treatment is closely related to the complete debridement and disinfection of the root canal system (RCS) associated with its three-dimensional seal.1,2 Therefore, it is essential that the filling material used is biocompatible and induces the repair process in the periapical tissues. Over the years, several types of cements have been used to fill the RCS, and those based on zinc oxide and eugenol or resin were the most used.1,2 Although very widespread, these cements have limitations regarding the induction of tissue repair.1 The filling materials, although contained within the RCS, interact directly with the surrounding tissues through the apical foramen and accessory communications.3,4 Thus, its properties and compositions can influence the immunoinflammatory reactions

that occur in the periradicular region after its use.3 Recently, a new class of endodontic cements — the bioceramic cements — has emerged on the market. These materials are an evolution of mineral trioxide aggregate (MTA), which has been used frequently, presenting satisfactory clinical and laboratory results.5,6 MTA is a biocompatible, bioactive, and hydrophilic material5-9 indicated mainly for the treatment of internal and external resorption, sealing of perforations, apexification, and retro-obturations. However, due to its sandy consistency and lack of flow, MTA is not suitable for conventional RCS filling. Bioceramics, which are cements composed of silicates (particles similar to those found in the MTA) have been developed to reverse these limitations, having characteristics that enable their use in the filling of the RCS.10 The aim of this article is to present two cases involving the use of a bioceramic root canal sealer.

Case 1 A 54-year-old man was referred for the endodontic retreatment of his mandibular

left first molar. The patient presented with swelling and pain. At the radiographic evaluation, the presence of a fractured instrument in the mesial root and periapical lesion were observed. At the first appointment, the instrument was retrieved under the use of the operating microscope and the auxilium of ultrasonic tips. After complete removal of gutta percha, patency was reached, and the canals were instrumented with a series of rotary NiTi files (Bassi Logic™ shaping and glidepath files, Bassi Endo) up to size 30/.05 and irrigated with a 2.5% sodium hypochlorite (NaOCl) solution. After a 17% ethylenediaminetetraacetic acid (EDTA) solution was applied for 60 seconds, the canals were filled with calcium hydroxide, and it was left in place for 15 days until the next appointment. During the second session, the root canal dressing was removed, and the canals were irrigated again using the following protocol. First, 3 mL of 2.5% NaOCl solution was introduced and agitated for 60 seconds with a rotary plastic activating file (Bassi Clean™, Bassi Endo) at 20,000 rpm. Next, 1 mL of 17% EDTA was placed and agitated for 60 seconds at 20,000 rpm. And last, another 3 mL of 2.5% NaOCl solution was placed

Warley Luciano Fonseca Tavares, DDS, PhD, is on the faculty at the Department of Restorative Dentistry, School of Dentistry, Federal University of Minas Gerais, Belo Horizonte, Brazil. Gustavo de Cristofaro Almeida, DDS, MS, is on the faculty of the Department of Restorative Dentistry, School of Dentistry, Federal University of Minas Gerais, Belo Horizonte, Brazil. Disclosure: The authors deny any conflict of interest and have nothing to disclose.

10 Endodontic practice

Figures 1A-1F: 1A. Preoperative radiography shows the presence of fractured instrument and periapical lesion. 1B. Removal of fractured instrument. 1C. Immediate postoperative radiography. 1D,1E. Post cementation. 1F. 6-month follow-up radiography Volume 13 Number 2

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CASE STUDY

Figures 2A-2B: 2A. Preoperative radiography and CBCT. Note the absent filling in the second mesiobuccal canal. 2B. Seven-month follow-up radiography and CBCT

and agitated for 60 seconds at 20,000 rpm, followed by a final irrigation with 1 mL of saline solution. After the canals were properly dried with absorbent paper cones, the root canal obturation was performed with a bioceramic root canal sealer (BIO-C® Sealer, Angelus) and gutta percha using the lateral condensation technique. The tooth received a fiberglass post in the distal canal and was restored with composite resin. An onlay ceramic restoration was performed. At the 6-month follow-up visit, the patient was asymptomatic, and complete healing of the periapical tissues was observed (Figure 1).

Case 2 A 59-year-old woman presented with diffuse pain in the left upper jaw and symptoms compatible with sinusitis. At the radiographic and cone beam computed tomography (CBCT) evaluation, the presence of unsatisfactory endodontic treatment of maxillary first molar and associated periapical lesion were observed. The nonsurgical retreatment was performed with a series of rotary NiTi files (Bassi Logic™ shaping and glidepath files, Bassi Endo) up to size 30/.05 in buccal canals and 40/.05 in the palatal canal. During the procedure, the root canal system was irrigated with 5.25% NaOCl solution. After the application of 17% EDTA solution for 90 seconds, the canals were dried with paper points and filled with calcium hydroxide, which was left in place for 15 days until the next appointment. At the second session, the root canal dressing was removed, and the canals were irrigated again using the same protocol described for Case 1. After the canals were properly dried with absorbent paper cones, 12 Endodontic practice

the root canal obturation was performed with a bioceramic root canal sealer (BIO-C® Sealer, Angelus) and gutta percha using the single cone technique. The tooth received a fiberglass post in the palatal canal and was restored with composite resin. A ceramic full-crown was performed. At the 7-month follow-up visit, the patient was asymptomatic, and complete healing of the periapical tissues was observed (Figure 2).

In view of the observed findings, we conclude that the use of bioceramic cements in cases of nonsurgical endodontic retreatment is well indicated. EP

Discussion

3. Bernáth M, Szabó J. Tissue reaction initiated by different sealers. Int Endod J. 2003;36(4):256-261.

The lack of adequate mechanical chemical debridement and sealing of the RCS enabled the establishment and maintenance of an infectious process, which is the cause of the previous failure of the cases presented. It has been shown that infection in cases of lesions refractory to endodontic treatment is more complex than previously imagined.11 For us to be able to reverse the infectious condition, it is essential that all root canals are accessed and instrumented in all its extension. In cases of retreatment with periapical lesion, this task can bring great difficulties for the clinician. The filling material plays an important role in retreatment cases due to the presence of irregularities in the walls caused by wear during the removal of the filling material or resorption. Interestingly, within a short period of time, we observed the repair of periapical tissues in the cases presented. This result corroborates to the findings of a recent article that presented cases of endodontic treatment on teeth with extensive lesions and resorption.12 It is clinically notable that bioceramic cements have an effective action in inducing repair of periapical tissues, in accordance to the findings of in vitro studies with such materials.13,14

4. Chen I, Salhab I, Setzer FC, Kim S, Nah HD. A new calcium silicate-based bioceramic material promotes human osteoand odontogenic stem cell proliferation and survival via the extracellular signal-regulated kinase signaling pathway. J Endod. 2016;42(3):480-486.

REFERENCES 1. de Oliveira Mendes ST, Sobrinho AP, de Carvalho AT, de Souza Côrtes MI, Vieira LQ. In vitro evaluation of the cytotoxicity of two root canal sealers on macrophage activity. J Endod. 2003;29(2):95-99. 2. Murray PE, Garcia-Godoy F, Hargreaves KM. Regenerative endodontics: a review of current status and a call for action. J Endod. 2007;33(4):377-390.

5. Rezende TMB, Vargas DL, Cardoso FP, Sobrinho AP, Vieira LQ. Effect of mineral trioxide aggregate on cytokine production by peritoneal macrophages. Int Endod J. 2005;38(12):896-903. 6. Rezende TMB, Vieira LQ, Cardoso FP, et al. The effect of mineral trioxide aggregate on phagocytic activity and production of reactive oxygen, nitrogen species and arginase activity by M1 and M2 macrophages. Int Endod J. 2007;40(8):603-611. 7. Koch KA, Brave DG. Bioceramics, part I: the clinician’s viewpoint. Dent Today. 2012;31(1):130-135. 8. Liu S, Wang S, Dong Y. Evaluation of a bioceramic as a pulp capping agent in vitro and in vivo. J Endod. 2015;41(5):652-657. 9. Braga JM, Oliveira RR, Martins RC, Ribeiro Sobrinho AP. The effects of a mineral trioxide aggregate-based sealer on the production of reactive oxygen species, nitrogen species and cytokines by two macrophage subtypes. Int Endod J. 2014;47(10):909-919. 10. Borges RP, Sousa-Neto MD, Versiani MA, et al. Changes in the surface of four calcium silicate-containing endodontic materials and an epoxy resin-based sealer after a solubility test. Int Endod J. 2012;45(5):419-428. 11. Henriques LC, de Brito LC, Tavares WL, et al. Microbial Ecosystem Analysis in Root Canal Infections Refractory to Endodontic Treatment. J Endod. 2016;42(18):1239-1245. 12. Tavares WL. Endodontic Obturation Using a Bioceramic Sealer. Inside Dentistry. 2020;16(4). 13. Candeiro GTM, Moura-Netto C, D’Almeida-Couto RS, et al. Cytotoxicity, genotoxicity and antibacterial effectiveness of a bioceramic endodontic sealer. Int Endod J. 2016;49(9):858-864. 14. Zamparini F, Siboni F, Prati C, Taddei P, Gandolfi MG. Properties of calcium silicate-monobasic calcium phosphate materials for endodontics containing tantalum pentoxide and zirconium oxide. Clin Oral Investig. 2019;23(1):445-457.

Volume 13 Number 2

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CASE STUDY

Surgical management of mandibular central incisor with periapical lesion: 6-month follow-up case report Drs. Juliana Larocca de Geus, Abel Barreto Jr., Márcia Fernanda de Rezende Siqueira, Jane Kenya Nogueira da Costa, and Alessandra Reis document their success in the surgical treatment of the periapical lesion Abstract This manuscript presents a case report of the surgical management of a periapical lesion located in a mandibular incisor, showing a 6-month follow-up. The purpose of paraendodontic surgery is to solve problems that could not be solved by conventional endodontic treatment, or when such treatment is impossible to perform. In the present report, there was no possibility of conventional root canal obturation due to the presence of exudate within the root canal, which did not cease even after changes of intracanal medication. Parendodontic surgery was performed through curettage, apicoectomy, and trans-surgical filling. The authors conclude that the case report showed success in the surgical treatment of the periapical lesion, where the apical area already showed a great bone regeneration after 6 months.

Introduction Endodontic treatment should provide complete obliteration of the entire root canal system. The establishment of suitable sealing is intended to prevent microorganisms and/ or endotoxins from reaching apical and periapical tissues.1 Due to evolution in the biological, scientific, and technical areas, root canal Juliana Larocca de Geus, PhD, is from the Department of Dentistry, Paulo Picanço School of Dentistry, Fortaleza, CE, Brazil, and Department of Dentistry, Guairacá Faculty, Guarapuava, PR, Brazil. Abel Barreto Jr, DDS, is from the Department of Dentistry, Federal University of Paraná, PR, Brazil. Márcia Fernanda de Rezende Siqueira, PhD, is from the Department of Dentistry, Paulo Picanço School of Dentistry, Fortaleza, CE, Brazil. Jane Kenya Nogueira da Costa, MS, is a student in the Department of Dentistry, Paulo Picanço School of Dentistry, Fortaleza, CE, Brazil Alessandra Reis, PhD, is from the Department of Dentistry, State University of Ponta Grossa, PR, Brasil. Disclosure: The authors have no financial interest in any of the companies mentioned in this article.

14 Endodontic practice

cleaning and shaping procedures have been increasing success rates ranging from 65% to 90%.2 But despite all the growth, endodontic treatments continue to be performed through technical steps that are liable to fail.3 Paraendodontic surgery is indicated in the cases with the following features: • persistent periapical infections with chronicity and extensive apical radiolucent area • restricted coronal access due to insufficient retrograde sealing • root pins that are impossible to remove/perforate • fracture of the apical third • pulp calcifications in the cervical and middle third4 The most used surgical modalities are periapical curettage, apicectomy, apicectomy with retrograde obturation, apicectomy with instrumentation and root canal obturation via retrograde and root canal obturation simultaneously with the surgical procedure.5 Periapical curettage is a surgical procedure whose purpose is to remove pathological tissue in a lesion at the apical level of a tooth.5 Apicoectomy is the surgical removal of the apical portion of a tooth.6 The canal obturation simultaneous to the surgical procedure consists of periapical curettage with apicoectomy of a tooth, followed by conventional filling of the canal system during the surgical procedure. It is indicated to resolve cases of extensive chronic periapical lesions in which the canal is well instrumented and numerous calcium hydroxide exchanges have already been made; however, there is presence of inflammatory exudate impeding the conclusion of the treatment,5 as occurred in the case report that follows. The objective of this study is to demonstrate the treatment of apical lesion with persistent exudation through a case report.

Case report Patient H.S., a 32-year-old male, attended the endodontic specialization course of the Brazilian Dental Association of Ponta Grossa and was referred by a dental

Figure 1: Initial case — large apical lesion involving tooth No. 31

Figure 2: Access to apical lesion

surgeon who could not fill the mandibular left central incisor (tooth No. 31) due to persistent exudation. The dental surgeon had already undergone some intracanal medication changes with calcium hydroxide with an interval of 30 days, and even then the exudation persisted. After radiography of the tooth (Figure 1), the presence of a circumscribed radiolucent lesion of considerable size indicative of periapical cyst was observed. A pulp sensitivity test was performed through the cold test on the adjacent teeth, and all responded positively, indicating pulp vitality. It was decided to perform the parendodontic surgery of the tooth in Volume 13 Number 2

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CASE STUDY question. For this, access to the apical lesion was performed through an envelope incision with two relaxing incisions in the canine region (Figure 2). The curettage of the periapical region was performed, and the lesion was removed (Figure 3). Then the instrumentation was performed with manual files up to No. 40 K-file (Dentsply Sirona, Ballaigues, Switzerland), and the canal was filled with gutta percha and a calcium hydroxide-based sealer (Sealapex™, SybronEndo — Kerr Endodontics, Orange, California) (Figure 4). After that, an apicoectomy of a tooth was performed (Figure 5) with the high-speed Endo-Z™ FG drill (Dentsply). After these procedures, the suture was performed with several simple stitches (Figure 6). Figure 7 shows the the immediate final radiographic appearance. Immediately after obturation, coronary shielding was performed by means of composite resin restoration. After the surgical procedure, the patient was prescribed amoxicillin 500 mg for 7 days, paracetamol 750 mg for 1 day, in addition to dexamethasone 4 mg for a period of 2 days. After 6 months of surgery, bone regeneration was observed in the apical region (Figure 8), the patient was asymptomatic, and the adjacent teeth had vitality.

Figure 3: Appearance after curettage and lesion were removed

Figure 4: Instrumentation and obturation of the root canal

Discussion Several authors have reported cases of paraendodontic surgery in the literature, showing the diversity of clinical situations and techniques employed. The surgical exposure of the apex facilitates the biomechanics of the root canal, allowing a more efficient filling and a vigorous condensation without the concern of extravasation of the obturator material. By removing the pathological material from the periapical area, a duct absent from exudation is obtained, favoring the complete obturation and regeneration of the supporting tissue.7 Some factors could affect the prognosis of periapical surgery. Examples follow: • systemic conditions of the patient8 • the involved tooth, amount and location of bone resorption, previous quality of treatment or retreatment performed • degree of occlusal microleakage in restorations • surgical restorative materials, involved technique • the surgeon’s skill and experience9 The rates of success and failure in paraendodontic surgeries are quite variable. 16 Endodontic practice

Figure 5: Apicoectomy

Figure 6: Immediate final aspect

Figure 7: Immediate final radiography

Figure 8: Radiography after 6 months Volume 13 Number 2

It is important to emphasize that no paraendodontic surgery will result in success if the canal is not well sealed or if it is not possible, through surgery, to improve its sealing conditions.

Conclusion It can be concluded that the paraendodontic surgery was effective in the removal of the periapical lesion, promoting a good result after 6 months of follow-up. In addition, it was the only way to achieve the root canal filling due to persistent exudate. EP

REFERENCES 1. Chugal N, Mallya SM, Kahler B, Lin LM. Endodontic Treatment Outcomes. Dent Clin North Am. 2017;61(1):59-80. 2. Iqbal MK, Kim S. A review of factors influencing treatment planning decisions of single-tooth implants versus preserving natural teeth with nonsurgical endodontic therapy. J. Endod. 2008;34:519-29. 3. Siqueira JF Jr. Aetiology of root canal treatment failure: why well-treated teeth can fail. Int Endod J. 2001;34(1):1-10.

4. Love RM. Persistent endodontic infection—re-treatment or surgery? Ann R Australas Coll Dent Surg. 2012;21:103-105. 5. Gutmann JL, Harrison JW, Posterior endodontic surgery: anatomical considerations and clinical techniques. Int Endod J. 1985;18:8-34. 6. Nasseh AA, Brave D. Apicoectomy: The Misunderstood Surgical Procedure. Dent Today. 2015;34(2):130-136. 7. Chércoles-Ruiz A, Sánchez-Torres A, Gay-Escoda C. Endodontics, Endodontic Retreatment, and Apical Surgery Versus Tooth Extraction and Implant Placement: A Systematic Review. J Endod. 2017;43(5):679-686. 8. Aminoshariae A, Kulild JC, Mickel A, Fouad AF. Association between Systemic Diseases and Endodontic Outcome: A Systematic Review. J Endod. 2017;43(4):514-519. 9. Lustmann J, Friedman S, Shaharabany V. Relation of pre and intra operative factors to prognosis of posterior apical surgery. J Endod. 1991:17:239-241. 10. Öğütlü F, Karac, İ. Clinical and Radiographic Outcomes of Apical Surgery: A Clinical Study. J Oral Maxillofac Surg. 2018;17(1):75-83. 11. Haapasalo M, Shen Y, Wang Z, Gao Y. Irrigation in endodontics. Br Dent J. 2014;216(6):299-303. 12. Rodrigues RCV, Zandi H, Kristoffersen AK, et al. Influence of the Apical Preparation Size and the Irrigant Type on Bacterial Reduction in Root Canal-treated Teeth with Apical Periodontitis. J Endod. 2017;43(7):1058-1063 13. Navabi AA, Khademi AA, Khabiri M, Zarean P, Zarean P. Comparative evaluation of Enterococcus faecalis counts in different tapers of rotary system and irrigation fluids: An ex vivo study. Dent Res J. 2018;15(3):173-179.

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Endodontic practice 17

CASE STUDY

It should be emphasized that surgery should only be performed after conventional endodontic treatment, or when endodontic risk and benefit indexes result in an uncertain prognosis of success.10 The present case is in accordance with this recommendation on performing the parendodontic surgery only after attempts to make the filling of the root canal by conventional endodontics. It has already been shown that a correct instrumentation of the canal accompanied by abundant irrigation11-13 is able to drastically reduce the number of bacteria, allowing the root canal obturation. In the case reported, there was difficulty in clearing the infection, since the area involved was extensive; and even using intracanal medication, there was no expected result. After 6 months, radiographically, periapical repair, and clinically no symptomatology were observed, confirming the success of the procedure.

CLINICAL

Diastema closure through Z-plasty and ceramic veneers: a case report Drs. Rupali Balpande, Amil Sharma, Sarvesha Bhondwe, and Gayatri Deshmukh, along with Satakshi Bartere, discuss an esthetic restorative procedure Abstract Patient demands for esthetic dentistry with minimally invasive procedures and immediate results are increasing. The esthetics of patients’ teeth have taken on a greater importance in today’s day-today life. A midline diastema is an esthetic problem arising in the anterior zone with high esthetic demands by those patients who are dissatisfied with their smile. This case report discusses a patient with a diastema in the anterior region with a high-frenum attachment. The patient was treated with Z-plasty technique of frenectomy to remove the etiological factors causing the midline diastema, followed by porcelain laminate veneers for esthetic closure of the midline diastema.

Introduction Midline diastema refers to any spacing or gaps existing in the midline of the dental arch. A midline spacing can be associated with many etiological factors, including tooth width, arch length discrepancy, abnormal frenum attachment, pressure habits, midline pathology, or an iatrogenic racial predisposition, among other factors. Multiple options are available to treat problems arising in the esthetic zone.1 Each treatment modality offers some advantages and disadvantages. The use of ceramic veneers to resolve esthetic and/or functional problems has been shown to be a valid management option, Rupali Balpande, BDS, MDS, is Senior Lecturer at Vidarbha Youth Welfare Society (VYWS) Dental College and Hospital, Amravati, Maharashtra, India. Amil Sharma, BDS, MDS, is Senior Lecturer at Maharana Pratap College of Dentistry And Research Centre, Gwalior, Madhya Pradesh, India. Sarvesha Bhondwe, BDS,MDS, HOD, and Professor at Yashwantrao Chavan Memorial Medical and Rural Development Foundation’s (YCMM & R.D.F) Dental College, Ahmednagar, India. Gayatri Deshmukh BDS, MDS, Post Graduate student at VYWS Dental College and Hospital, Amravati, Maharashtra, India. Satakshi Bartere is a postgraduate student at VYWS Dental College and Hospital, Amravati, Maharashtra, India.

18 Endodontic practice

especially in the anterior esthetic zone. The techniques and the materials employed to fabricate ceramic veneers offer satisfactory, predictable, and lasting results.2 For patients having a high frenum attachment at or near the center of the crest, frenectomy is advised to remove the etiological factor causing the diastema. Frenectomy is complete removal of the frenum, including its connection to the underlying bone, and may be required in the rectification of an abnormal diastema between the maxillary central incisors. When the frenum and its crestal attachment are not fully removed, relapse of the diastema may result even with restoratively filling the space between the central incisors. In the current case, the frenectomy was performed through a Z-plasty procedure — a plastic surgical technique used to recover the functional and cosmetic appearance of scars. It comprises a central incision and formation of two triangular flaps of equal dimension that are then swapped to prevent or limit scar formation and promote healing.3

Case report A 21-year-old male presented with a primary complaint of spacing between his maxillary central incisors (diastema) and a desire to improve the esthetics of his smile. Examination determined the cause of the diastema related to an abnormal frenum attachment. Periapical radiographs were taken, and no osseous pathology was noted that could be contributory to the diastema. The frenum presented as a wide band attaching to the facial aspect of the crestal midline (Figure 2). The patient was informed that to correct the esthetic issues, excision of the frenum would be required, followed by placement of ceramic veneers to widen the central incisors, thus eliminating the midline gap. Following the patient’s acceptance of the treatment plan, impressions for diagnostic models were

Z-plasty technique A “Z”-shaped incision is made with a scalpel or laser (practitioner preference) with the frenum oriented at the vertical aspect of the incision (Figure 1A). The incisions are extended to the underlying bone through the periosteum and are full thickness. This creates two flaps (flap 1 and flap 2). Any fibrous tissue at the frenum is excised to prevent frenum reattachment following soft tissue healing. Once the flaps have been mobilized, the apex of flap 1 is repositioned inferiorly, and the apex of flap 2 repositioned superiorly (Figure 1B). The repositioning prevents contracture of the soft tissue during healing from frenum re-establishment, defeating the purpose of the intended treatment. Transposition of these triangles redistributes tension on the wound and changes central limb direction. The flaps are then fixed in their new positions using simple interrupted sutures (Figure 1C).

Figure 1: Z-plasty technique: A Z-shaped incision is made in the soft tissue creating two flaps (A), flap 1 is repositioned inferiorly, while flap 2 is repositioned superiorly (B), and the newly repositioned flaps are sutured into position (C)

Figure 2: A surgical marker is used to indicate where the initial Z incision will be made at the frenum Volume 13 Number 2

Volume 13 Number 2

CLINICAL

taken and models fabricated. The models were studied to decide the shape and size of the restorations to be placed with help of a diagnostic wax-up. The patient presented for treatment, and 2% lidocaine with epi (Lignox® 2%, Warren) was administered with infiltration into the labial aspect and palatal aspect of the anterior maxilla. A surgical marker was used to outline the planned Z incision on the labial aspect of the premaxilla at the frenum. An incision was made across the base of the frenum at its attachment to the incisive papilla. The incision was extended to the periosteum with the vertical aspect of the incision down the center of the frenum, and then a superior incision was made at the depth of the vestibule in the opposite direction as the horizontal incision made at the inferior aspect of the frenum. The lateral incisions were made at a 45° angle to the vertical frenum incision, creating two triangular flaps of equal size and shape (Figure 3). The incision was then extended superiorly along with removing the interradicular bone between the teeth at the midline. Following elevation of the full-thickness flaps, removal of fibrous tissue across the alveolar ridge between the teeth at the midline diastema was performed. Adequate undermining of surrounding tissues was performed to achieve proper mobilization of the flaps and minimize distortion of the underlying soft tissue. The two flaps were then transposed to the opposite side of apex of each flap. The newly repositioned flaps were then secured in their new position with simple interrupted sutures. The vertical incision on the attached gingival was also closed by suturing (Figure 4). Antibiotics and analgesics were prescribed (CLAVUM® antibiotic 625 mg, Alkem Laboratories Ltd.; analgesic/NSAID Zerodol® P, Ipca laboratories, Ltd.), and routine wound care instructions were given to the patient. The patient returned at 7 days postsurgically for suture removal. At 1-month postsurgically, the wound was re-examined, and healing without complications was noted. The patient was referred to his restorative dentist for completion of treatment with the planned ceramic veneers. The restorative phase of treatment consisted of preparation of the maxillary central and lateral incisors bilaterally. Local anesthetic was administered and depth orientation grooves were placed with a diamond in a high-speed handpiece on the facial surface of the teeth to be treated to a depth on the gingival half (0.3 mm) and incisal half (0.5 mm), respectively. The tooth

Figures 3 and 4: 3. Z incision is created at the previously made mark with a scalpel to the underlying bone with the vertical aspect of the incision along the frenum, and the fibrous tissue of the frenum is excised. 4. The flaps are repositioned to the opposite apex of each side of the flap and sutured into the new position for stability

Figures 5 and 6: 5. Postoperative image of the patient after 1 month of frenectomy — then showing the healed area followed by Z-plasty frenectomy technique. 6. Preoperative image of the patient showing the midline diastema in relation to teeth Nos. 11, 12, 21, and 22

structure between the depth orientation grooves was removed with a round-end tapered diamond. A chamfer finish line was placed slightly subgingivally. Interproximally, the tooth preparation was extended into the contact area but terminated facial to the contact area. The preparation on the incisal edge was to provide a margin on the lingual aspect that would be less susceptible to chipping during functional use. Additionally, this provides a vertical stop to aid in seating the veneer in the planned position. It is possible without the incisal overlap that the veneer may be luted either too incisally or gingivally, affecting the desired esthetics. The lingual finish line was created with a round-end tapered diamond, approximately one-fourth the distance between the incisal edge and gingival connecting the two proximal finish lines. The finish line should be a minimum of 1 mm away from centric contacts to prevent veneer chipping during occlusion. The preparation design extending onto the lingual surface enhances mechanical retention of the veneer, increasing the bonding surface area. All sharp angles of the preparation were rounded to prevent stress concentrators in the finished veneer.

A coat of dentin bonding agent (Adper™ single bond, 3M ESPE, St. Paul, Minnesota) was applied to the prepared tooth surfaces immediately after preparation and light-cured. After gingival retraction (Ultrapack™ No. 00; Ultradent, South Jordan, Utah), the impression (3M ESPE) was made with polyvinylsiloxane by puttywash technique using an impression tray (GDC® edentulous impression trays). The shade was selected under direct sunlight with VITA 3D-Master®, (Yorba Linda, California) shade guide (Shade A2). Temporary restoration was done with light-cured composite resin. The diagnostic wax-up was used to fabricate a matrix for making provisional restorations. Spot-etching of enamel with phosphoric acid gel for 30 seconds was performed at mid-central locations on facial aspects of teeth. Bonding resin was applied on the etched spots and light-polymerized. The matrix was loaded with provisional veneer material (Luxatemp®, DMG America, Ridgefield Park, New Jersey) and secured in place over the prepared teeth. After 3 minutes, the matrix was then lifted off with a sickle scaler, and trimming of excess material was Endodontic practice 19

CLINICAL carried out with a carbide bur. Occlusion was checked and adjusted accordingly. At the next appointment, the temporary veneers were removed; the teeth were cleaned using pumice in a prophy cup in a slow-speed handpiece and were isolated and air-dried. The IPS e.max® (Ivoclar Vivadent, Amherst, New York) ceramic veneers were tried on to the teeth with a try-in paste (Luxatemp, DMG America) in the selected shade of the veneers requested to verify shade and restoration fit. The esthetics and fit were found to be acceptable, and the veneers were removed from the teeth, rinsed thoroughly, and dried. The interior of the ceramic veneers were etched with 5% hydrofluoric acid (IPS Ceramic etching gel, Ivoclar Vivadent) for 20 seconds and then rinsed under running water and air-dried. A layer of saline coupling agent (Monobond S, Ivoclar Vivadent) was applied to the interior surface of the veneers and gently airdried after 1 minute. The saline coupling agent forms a chemical bond between the ceramic and resin luting materials to be used, reducing marginal leakage potential and resin luting discoloration. The salinized surface was then coated with a thin layer of Adper single bond and then air-thinned with the air syringe. The resin layer was

light-polymerized for 40 seconds. The prepared teeth were then etched with a 37% phosphoric acid gel for 30 seconds, rinsed thoroughly, and air-dried. A layer of bonding agent (Adper single bond) was applied to the tooth surfaces. A dual-cure resin cement (Variolink® II, Ivoclar Vivadent) in the selected shade of base paste and catalyst paste was mixed and applied into each veneer. The veneers were then positioned on to the teeth with slight pressure and excess cement at the margins removed with a brush. The veneers were tack cured at the center of each veneer for 10 seconds. After the initial set, the remaining excess cement was removed with a No. 12 BardParker® blade. Light-curing was continued to complete resin polymerization for 60 seconds per veneer by directing the light initially from lingual side so that the resin cement shrinkage would be toward the tooth. Then each veneer was light-cured for 40 seconds from the labial. Margins were checked with an explorer to verify that all residual resin was removed, and the occlusion checked to ensure that no contact existed on toothceramic margins. The patient was shown a mirror and expressed satisfaction with his new smile.

Figures 7 and 8: 7. Tooth preparations were carried out in relation to teeth Nos. 11, 21, 12, and 22 for porcelain laminates. Depth-orientation grooves were placed on the facial surface of the tooth with a three-diamond depth cutter. The tooth structure remaining between the depth orientation grooves were removed with a round-end tapered diamond. 8. Lingual preparation was done for veneers in relation to teeth Nos. 11, 12, 21, and 22. The veneers extended onto the lingual surface to enhance mechanical retention and increase the surface area for bonding with the tooth surface

Figure 9: Cementation of laminates completed 20 Endodontic practice

Figure 10: Lingual view

Discussion Treatment planning for diastema correction should include consideration of orthodontic closure, restorative therapy, surgical correction, or multidisciplinary approach depending upon the cause of the diastema.2 The restorative closure of diastema can be achieved by using direct composite veneers, indirect composite veneers, ceramic laminate veneers, all ceramic crowns, metal ceramic crowns, or composite crowns.4 Composite resin and ceramics are the most frequently used veneering materials for diastema closure providing a more conservative approach than full-coverage restorations. Smaller diastema may be closed with micro-filled and hybrid composite resins if the diastema is 1.0 mm-1.5 mm in width. One of the greatest advantages of ceramic veneers is that they are extremely conservative in terms of tooth reduction with some cases being able to be performed with no tooth reduction and others with minimal reduction. In the current case, only 0.5 mm reduction on the labial surface was required. This minimal reduction rarely, if ever, leads to pulpal involvement — a major advantage that also preserves enamel for bonding under the veneer, allowing for higher bond strengths and dentin bonding. The highly glazed surface of the porcelain laminates prevents plaque accumulation, considered important to attain a healthy periodontal response. Additionally, ceramic has better luster maintenance over time then composite with less potential for surface staining. Excellent esthetics can also be achieved due to the lifelike appearance of ceramic (better translucency then composites) and lightscattering effect of the luting cement.1,2,4 The high frenum attachment, being the etiological factor of the diastema, was planned for removal via a surgical approach. With the Z-plasty technique, it is possible to redirect a scar into better alignment with

Figure 11: Postoperative image of the patient Volume 13 Number 2

case. Koora K,7 reported a case of spontaneous closure of a midline diastema after 2 months following frenectomy in a 9-year-old girl. The same procedure can also be done through lasers as performed by Olivi G8 using an Er,Cr:YSGG (erbium, chromium: yttrium, scandium, gallium, garnet) laser at a power setting of 1.5 W or less and 20 to 30 pulses per second and by Puthuserry9 using carbon dioxide laser, but it is expensive and still not routinely available in our country. A diode laser may also be used as an alternative to the Er,Cr:YSGG laser.

long-term, and reoccurrence of the diastema does not result. EP

Conclusion

REFERENCES Viswambaran M, Londhe SM, Kumar V. Conservative and esthetic management of diastema closure using porcelain laminate veneers. Med J Armed Forces India. 2015;71(Suppl 2):S581–S585.

Dlugokinski MD, Frazier KB, Goldstein RE. Restorative Treatment of Diastema. In: Goldstein RE, Hoywood VB, eds. Esthetic in Dentistry (Vol. 2). 2nd ed. London: BC Decker Inc.; 2002.

Burke M. Z-plasty. How, when and why. Aust Fam Physician. 1997;26(9):1027–1029.

Dumfahrt H, Schäffer H. Porcelain laminate veneers. A retrospective evaluation after 1 to 10 years of service: Part II-Clinical results. Int J Prosthodont. 2000;13(1):9-18.

Salam OA, Amin JP. Michigan State University College of Human Medicine, East Lansing, Michigan. Am Fam Physician. 2003;67(11):2329-2332.

Koc MN, Orbay H, Uysal AC, Unlü RE, Sensöz O. Z plasty closure of lower lip defects after tumor excision. J Craniofac Surg. 2007;18(5):1120-1124.

Koora K, Muthu MS, Rathna PV. Spontaneous closure of midline diastema following frenectomy. J Indian Soc Pedod Prev Dent. 2007;25(1):23-26.

Olivi G, Chaumanet G, Genovese MD, Beneduce C, Andreana S. Er,Cr:YSGG laser labial frenectomy: a clinical retrospective evaluation of 156 consecutive cases. Gen Dent. 2010;58(3):e126-e133.

Puthussery FJ, Shekar K, Gulati A, Downie IP. Use of carbon dioxide laser in lingual frenectomy. Br J Oral Maxillofac Surg. 2010;49(7):580-581.

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The predictability of any restorative process will rest on the precise evaluation of oral and occlusal conditions. The veneers are technique- and material-sensitive, but if used with proper knowledge and skill, these restorations provide the best esthetic and functional outcome. The key in diastema closure is proper evaluation of the frenum involvement and management of this so that the resulting restorative treatment is stable

Endodontic Practice US

CLINICAL

natural skin folds or the lines of least skin tension. Basic Z-plasty flaps are created using an angle of 60° on each side.5 Classic 60° Z-plasty lengthens scars by 75%, while 45° and 30° designs lengthen scars by 50% and 25%, respectively. The Z pattern is effective as it promotes redistribution of tension on the soft tissue and the wound, which helps in healing along the soft tissue lines. This helps in minimizing scar formation and has a camouflaging effect to the incision upon healing. A curvilinear form of Z-plasty (referred to as S-plasty) may be used when straight lines may be particularly obvious, such as in the cheek. Design of the Z-plasty with unequal angles and limbs creates a situation in which the smaller triangle moves significantly less than the larger triangle. This may be useful in areas where small amounts of tissue need to be moved with as little distortion as possible (e.g., near eyes, lips).6 Labial frenectomy can be performed before, during, or even after the orthodontic closure of the maxillary midline diastema depending on the individual

CONTINUING EDUCATION

Minimally invasive endodontics using a new singlefile rotary system Drs. Peet J. van der Vyver, Martin Vorster, and Ove A. Peters discuss the design features of the TruNatomy™ instruments and present case reports to illustrate the clinical application and benefits of these instruments Introduction The long-term retention of root canaltreated teeth depends on many factors, but it has become evident that the most common reasons for extraction of these teeth are “large carious lesion” or “unrestorable tooth,” followed by “tooth fracture,” “periodontal disease” and last of all, “endodontically related disease” (Ng, Mann, and Gulabivala, 2010). Moreover, it is apparent that remaining structural integrity and the preservation of especially peri-cervical dentin are key factors that determine the long-term prognosis (relating to fracture resistance) in these teeth (Tang, Wu, and Smales, 2010). The term pericervical dentin was first described by Clark and Khademi (2010) and refers to an area roughly 4 mm coronal to the crestal bone and 6 mm apical to the crestal bone (Figure 1). According to Herbranson (2014), it appears to be critical dentin for tooth strength, and that should be conserved as much as possible to ensure long-term retention of the tooth. It is also the area of the tooth that is often destructed with access burs, Gates Glidden burs, and orifice shapers used for coronal enlargement of root canal systems. The fact that endodontically treated teeth are more prone to fracture is largely due to the structural loss during the shaping phase of endodontic treatment and not to dehydration. Studies show minimal dehydration effects from pulpal removal with Professor Peet J. van der Vyver, BChD, MSc, PhD — Studio for Endodontics, Restorative Dentistry and Dental Education (www.studio4endo.com) — is a part-time Lecturer at the University of Pretoria, Department of Odontology, School of Dentistry, University of Pretoria, Pretoria, South Africa. Martin Vorster, BChD, MSc, is a Lecturer/Dentist at the University of Pretoria’s School of Dentistry, Pretoria, Gauteng, South Africa (martin.vorster@up.ac.za) Department of Odontology, School of Dentistry, University of Pretoria, Pretoria, South Africa. Professor Ove A. Peters, DMD, MS, PhD, is Professor and Chair, Department of Endodontics, University of the Pacific Arthur A. Dugoni School of Dentistry, San Francisco, California, and University of Queensland Oral Heath Centre, Herston Qld, Australia.

22 Endodontic practice

Educational aims and objectives

This clinical article aims to discuss the design features of the TruNatomy™ instruments and present case reports to illustrate the clinical application and benefits of these instruments.

Expected outcomes

Endodontic Practice US subscribers can answer the CE questions on page 29 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Realize that respecting original canal anatomy, preserving dentin, and therefore maintaining the structural integrity of teeth should form an integral part of root canal shaping and preparation.

•

Define peri-cervical dentin.

•

Realize why peri-cervical dentin appears to be critical dentin for tooth strength.

•

Identify a way to preserve structural integrity and preservation especially of peri-cervical dentin.

•

Recognize some characteristics of TruNatomy instruments that can result in superior debridement while respecting original canal anatomy.

similar strength test results between vital and nonvital dentin (Sedgley and Messer, 1992, Papa, Cain, and Messer, 1994). Structural loss alone is, however, not the only cause for increased fracture incidence in teeth. The impact of irrigants, medicaments, as well as restorative procedures, and even physiological age changes should also be taken in account. Root canal therapy requires effective shaping in order to facilitate irrigation and disinfection of the canals. This should be done in such a conservative manner that the structural integrity of the tooth is respected, and dentin is preserved where possible. Peri-cervical dentin preservation has been reported as critical in the long-term survival, especially in molars with optimum function (Clark and Khademi, 2010). More advanced treatment options in endodontics (for example, magnification and more flexible nickel-titanium instrumentation) have therefore also shifted paradigms to a minimally invasive approach in both access cavity preparation as well as shaping of root canals in order to preserve dentin (Gluskin, Peters, and Peters, 2014). Recently, TruNatomy™ (Dentsply Sirona), a new generation of rotary files, was launched. TruNatomy files are prepackaged, presterilized rotary instruments designed to shape root canal systems to a continuously tapering

Figure 1: Peri-cervical dentin

preparation with maximum preservation of peri-cervical dentin. This new file system offers the clinician more simplicity, safety, improved cutting efficiency, and mechanical properties compared to previous generations of rotating instruments. In this article, the authors will discuss the design features of the TruNatomy instruments and present case reports to illustrate the clinical application and benefits of these instruments. Volume 13 Number 2

Figure 2: TruNatomy Orifice Modifier (Dentsply Sirona)

Figure 3: TruNatomy Glider (Dentsply Sirona)

Figure 4: TruNatomy Prime shaping file (Dentsply Sirona)

Figure 5: TruNatomy Medium shaping file (Dentsply Sirona)

Figure 6: TruNatomy Small shaping file (Dentsply Sirona)

The manufacturing of the instruments begins with a smaller initial wire blank (0.8 mm diameter) compared to the 1.1 mm diameter of other conventional rotary instruments. The post-grind thermal treatments have been further refined to produce more flexibility. This level of flexibility has been selected to complement the inherent flexibility of the fluting design and smaller maximum flute diameters. TruNatomy instruments are manufactured using a post-manufacturing thermal process that produces a file with superelastic nickel-titanium metal properties. Due to the superelastic properties of the new wire, the files might appear slightly curved when removed from a curved root

Figures 7A-7E: 7A. Preoperative periapical radiograph of maxillary left first premolar and orifice modification with the TruNatomy Orifice Modifier. 7B. Glide path expansion with the TruNatomy Glider after negotiation with stainless steel K-Files. 7C. Root canal preparation with the TruNatomy Prime instrument. 7D. Conefit periapical radiograph. 7E. Postoperative result after obturation Volume 13 Number 2

canal because the metal demonstrates less memory compared to conventional nickeltitanium or M-Wire. The file can be straightened out; if it is placed back in the root canal, it will follow the natural shape of the canal. Another advantage of this reduced memory of the files is that in cases with difficult straight-line access, it is possible to slightly precurve the files to allow easy placement into the canal orifices. All the instruments in the system have a shortened handle of 9.5 mm to further improve the straight-line access and placement of the instruments into the root canal systems. In the case of the TruNatomy Glider and TruNatomy preparation instruments, the largest taper is at the apical extent of the shaping instruments. The instruments are designed to provide approximately the same apical sizing as the most commonly used instruments. However, they have a reduction or regressive taper as the instrument progresses coronally, allowing each instrument to maintain the 0.8 mm maximum flute diameter. The TruNatomy system is comprised of an Orifice Modifier, a Glider, and three shaping files for different clinical applications. Regardless of the motor selected, all of the TruNatomy instruments are designed to run in continuous rotation at 500 rpm with a torque setting of 1.5 Ncm. The TruNatomy Orifice Modifier is characterized with a modified triangular cross section, 7.5 mm of active cutting flutes on the 16-mm shank, and an ISO tip size of 20 with a fixed 0.08 taper. The Orifice Modifierâ&#x20AC;&#x2122;s main function is to modify the canal orifice conservatively while still retaining coronal anatomy and to create an ideal receptacle for the introduction, scouting, and canal preparation instruments. Compared to the ProTaper SXâ&#x201E;˘ (Dentsply Sirona) or ProTaper Nextâ&#x201E;˘ XA Opener (Dentsply Sirona) instrument, the TruNatomy Orifice Modifier has several advantages: 1. Smaller coronal maximum flute diameter of 0.8 mm compared to the 1.2 mm of the SX instrument 2. Shorter active cutting flutes distance of 7 mm compared to 14.5 mm of the SX instrument 3. Shorter handle of 9.5 mm compared to the 11 mm handle for the SX instrument. Another difference is in that the Orifice Modifier is used with two-to-three gentle, smooth, apical movements (amplitudes) of 2 mm-5 mm into the root canal instead of backstroke brushing motions that are used Endodontic practice 23

CONTINUING EDUCATION

Metallurgy and design features

CONTINUING EDUCATION

Figures 8A-8C: 8A. Preoperative periapical radiograph of maxillary right first molar. 8B. Conefit periapical radiograph. 8C. Postoperative result after obturation, fiber post placement, and composite core

for the SX instrument. This protocol results in a more conservative orifice relocation compared to the SX instruments, which are more aggressive with an increased risk of over-preparation of the coronal aspect. TruNatomy Glider is available in 21 mm, 25 mm, and 31 mm lengths. The cross section is a cantered parallelogram. The instrument has a tip size of ISO 17 with an average taper of 0.02 and 14 mm of active cutting flutes. The glider is designed with a regressive variable taper ensuring that the shank ends up again with a maximum flute diameter of 0.8 mm. For the preparation instruments, there are three different tip-size instruments for development of a final root canal shape. The Prime instrument (red stopper and color band) is the workhorse of the group and is called for in nearly every case. It has a tip size of ISO 26 with an overall decreasing taper that averages at 0.04. The Medium (green stopper and color band) is used for larger cases and situations where more apical shape is desired. It has a tip size of ISO 36 and a similarly decreasing taper of about 0.03. Each of these shaping instruments have 16 mm of cutting blades and are available in 21 mm, 25 mm, and 31 mm lengths with off-centered parallelogram cross sections. The Small (yellow stopper and color band) is used for extremely curved canals where the Prime is not able to reach working length with ease or in cases where glide path preparation was very difficult. This instrument has a tip size of ISO 20 and a taper of 0.04. 24 Endodontic practice

Clinical guidelines for the use of TruNatomy instruments 1. Create adequate access. It is always important to prepare a cavity that will ensure adequate access into each root canal system after removal of all the pulp chamber contents. Because TruNatomy files have less memory compared to conventional nickel-titanium or M-Wire instruments, it is possible to slightly prebend the tip of the file to allow easy insertion into a secured canal orifice that fails to have complete straight-line access or in cases where patients present with limited mouth opening. Their highfatigue resistance, specifically high on the shaft, allows their use in a restricted access. The TruNatomy Orifice Modifier is used to create and refine the coronal opening as it transitions into the root canals. The Orifice Modifier is used with two-to-three gentle, smooth apical movements (amplitudes) of 2 mm-5 mm into the root canal. Regardless of the preparation, the TruNatomy Orifice Modifier is recommended to be used in all canal systems. 2. Negotiate canals to patency, create a reproducible micro glide path (RMG), and enlarge glide path. With an estimated working length obtained from a preoperative radiograph, a size 08 or 10 K-File is negotiated to patency in the presence of a viscous chelator. After the establishment of patency (Figure 9), a working length is determined (Figure 10), and the canal is ready for the preparation of an RMG, using manual stainless

For the preparation instruments, there are three different tip-size instruments for development of a final root canal shape. steel instruments (Van der Vyver, 2011). It is recommended to use size 08 or 10 K-Files in a vertical in-and-out motion with an amplitude of 1 mm from working length and gradually increasing the amplitude to approximately 4 mm, as the irregularities are removed from the dentin wall (Van der Vyver, 2011). A â&#x20AC;&#x153;super looseâ&#x20AC;? size 10 K-File is the minimum requirement (BĂźrklein, et al., 2012; Van der Vyver, 2011). To confirm that a reproducible glide path is present, a size 10 K-File is taken to full working length. The file is withdrawn 1 mm and should be able to slide back to working length by using only light finger pressure. Thereafter, the file is withdrawn 2 mm and should be able to progress to working length, using the same protocol. When the file can be withdrawn 4 mm-5 mm and slid back to working length, an RMG is confirmed. After establishment of an RMG, it is recommended to enlarge the glide path further to create as macro glide path. The micro glide path can be expanded by using the TruNatomy Glider using three Volume 13 Number 2

3. Select the correct TruNatomy file The following guidelines can be used for TruNatomy file selection. a. TruNatomy Prime file (26/04)(Figure 4) Any canal where a size 08 and 10 K-File have to be negotiated to working length, followed by preparation of a glide path or where a size 15 K-File fits loose in the canal to working length. This will probably be the case in the majority of root canal systems with an average length and moderate curvatures in the midroot and apical regions.

pass until working length is reached. If the selected preparation does not reach length, remove and clean the instrument, re-irrigate the canal space, and then reinsert the instrument for another three-amplitude pass. Repeat this until working length is reached, and remember to take enough time for the shaping instruments to expand and contract to promote conforming shaping. In addition, sonic activation of irrigating fluids are recommended to enhance cleaning efforts. The authors recommend using the EDDY® Endo Irrigation Tip (VDW) driven by an airscaler (SONICflex™ Lux 2000L, KaVo).

Case report 1 The patient, a 25-year-old female, presented with irreversible pulpitis on her

maxillary left first premolar that had a history of a previous pulp cap procedure and a large Class II composite restoration. (Figure 7A shows the preoperative periapical radiograph and orifice modification with the TruNatomy Orifice Modifier). After glide path preparation with stainless-steel K-Files and the TruNatomy Glider (Figure 7B), both root canal systems were prepared with a single TruNatomy Prime instrument (Figure 7C). Two TruNatomy Prime Conform Fit™ gutta-percha cones were placed, and the fit confirmed radiographically (Figure 7D). Figure 7E shows the postoperative result after root canal obturation using the continuous wave of condensation technique (Calamus® Dual Obturation Unit, Dentsply Sirona) with AH Plus® Root Canal

b. TruNatomy Medium file (36/03) (Figure 5) Any canal where a size 20 or 25 K-File fits loose in the canal and is not necessary to negotiate and prepare a glide path with smaller instruments. This will usually include larger diameter, relatively straight root canals. This file can also be used after the Prime file if more shape is desired or if it is felt that not enough infected dentin was removed from the canal. c. TruNatomy Small file (20/04)(Figure 6) The Small file is mainly used when the Prime 26/04 file does not passively progress apically or when the operator feels unsecure with the Prime file after the canal was negotiated to patency and a glide path prepared. When this Small file reaches working length, the clinician may accept the canal preparation or, alternatively, if more shape is required, to further enlarge the canal with the Prime file. However, in canals with severe apical curvatures and very long root canals or in canals where the glide path preparation was very challenging, the TruNatomy Small file can be used to start root canal preparation with more safety. When this file reaches working length, the clinician may again accept the canal preparation or alternatively, if more shape is required, further enlarge the canal with the Prime file. 4. Canal preparation with the TruNatomy preparation files. The selected preparation file in the presence of an irrigation solution (typically sodium hypochlorite) is allowed to passively advance inward and to progress down the canal upon activation, using three easy amplitudes in a Volume 13 Number 2

Figures 9A-9D: Preoperative periapical radiograph of maxillary left lateral incisor. 9B. Length determination periapical radiograph. 9C. Conefit periapical radiograph. 9D. Postoperative result after obturation Endodontic practice 25

CONTINUING EDUCATION

easy amplitudes in a pass. If the Glider instrument does not reach length, remove and clean the instrument, re-irrigate the canal space, and then re-insert the instrument for another three-amplitude pass. Repeat this until working length is reached.

CONTINUING EDUCATION Sealer (Dentsply Sirona) and two TruNatomy Prime Conform Fit gutta-percha points.

Case report 2 The patient, a 58-year-old male, presented with a nonvital maxillary right second molar. A preoperative periapical radiograph revealed a very deep, previously placed composite restoration (Figure 8A). After access cavity preparation, four root canal systems were detected (two mesiobuccal, distobuccal, and palatal). After orifice modification with the TruNatomy Orifice Modifier and glide path preparation with K-Files and the TruNatomy Glider, the four root canals systems were prepared with a single TruNatomy Prime instrument. The fit of four Prime TruNatomy Conform Fit gutta-percha cones were confirmed radiographically before the root canal systems were obturated (Figure 8B). Figure 8C depicts the postoperative result after obturation of the root canal systems and placement of fiber post and composite core. The clinical procedure of this case can be viewed on the following link: https://you tu.be/OplAENoh3b8.

Case report 3 The patient, a 30-year-old, presented with a nonvital maxillary left lateral incisor previously restored with a zirconia crown (Figure 9A). After access cavity preparation, the canal was located, and a size 20 K-File was used for length determination (Figure 9B) using an electronic apex locator. The size 20 K-File was loose in the canal; it was decided to complete canal preparation

Figures 10A-10F: 10A. Preoperative periapical radiograph of maxillary right second premolar after a previous emergency root canal treatment. 10B. Length determination periapical radiograph. 10C. S-curvature root canal shape of the buccal root canal imprinted on a size 10 K-File. 10D. Conefit periapical radiograph. 10E. TruNatomy Conform Fit Small gutta-percha cone showing that the S-curvature was maintained during root canal preparation. 10F. Postoperative result after obturation

Figures 11A-11C: 11A. Preoperative periapical radiograph of mandibular right first molar. 11B. Parallel postoperative periapical radiograph after obturation. Note the conservative coronal root canal preparation shape in the peri-cervical area. 10C. Mesio-angulated view showing the four obturated root canal systems 26 Endodontic practice

Volume 13 Number 2

CONTINUING EDUCATION

with a single TruNatomy Medium instrument. A size Medium TruNatomy Conform Fit gutta-percha cone was placed, and the fit confirmed radiographically (Figure 9C). Figure 9D illustrates the postoperative radiograph after the canal was obturated using the continuous wave of condensation technique (Calamus Dual Obturation Unit) with Pulp Canal Sealer (Kerr) and a Medium TruNatomy Conform Fit gutta-percha point. The clinical procedure of this case can be viewed on the following link: https://you tu.be/sG5paE_2FN4.

Case report 4 The patient, a 65-year-old male, presented with a nonvital maxillary right second premolar with a history of a previous emergency root canal treatment and placement of calcium hydroxide as an intracanal medicament. The temporary restoration and calcium hydroxide paste were removed before length determination was done using an electronic apex locator, and the working length was confirmed radiographically. The canals were extremely difficult to negotiate, and when the size 08 K-Files that were used for length determination were removed, it was noted that the buccal root canal system presented with an S-curvature. A size 08 and 10 K-File were used to secure a reproducible micro glide path before the glide path was expanded using the TruNatomy Glider. It took several passes with the glider before working length was reached in both root canals. Taking into account the fact that glide path preparation

Figures 12A-12G: 12A. Preoperative periapical radiograph of mandibular right first molar. 12B. An axial slice of a high resolution CBCT scan revealed four root canal systems (arrows). Three root canals in the mesial root and one large oval root canal in the distal root. 12C. Periapical radiograph taken with a mesio-angulated view to confirm the length determination for the three mesial root canals. 12D. Periapical radiograph to confirm the length determination for the distal root canal. 12E. Magnified view of the pulp chamber floor. Note the large amount of tooth structure that was still intact after root canal preparation with the TruNatomy Small file. 12F. Parallel view of the obturation result. Note the maximum preservation of the root structure in the peri-cervical region of the mesial and distal root canal systems. 12G. Mesio-angulated view shows the full extent of the lateral anatomy that was cleaned and obturated Volume 13 Number 2

Endodontic practice 27

CONTINUING EDUCATION was extremely difficult and the fact that the buccal root canal presents with an S-curve (not visible on periapical radiographs), it was decided to complete canal preparation with the TruNatomy Small instrument. After canal preparation, two TruNatomy Conform Fit Small gutta-percha cones were placed and the fit confirmed radiographically. Again, upon removal of the cone from the buccal root canal, the S-curvature was imprinted on the gutta-percha cone. This confirmed that the TruNatomy file maintained the original root canal anatomy. The canals were obturated using the continuous wave of condensation technique (Calamus Dual Obturation Unit) with Pulp Canal Sealer and two Small TruNatomy Conform Fit gutta-percha points. The clinical procedure of this case can be viewed on the following link: https://you tu.be/FaK0tXqULM8

Case report 5 The patient, a 71-year-old male, presented with irreversible pulpitis on his mandibular maxillary right first molar previously restored with a zirconia crown (Figure 11A). An access cavity was prepared, and four root canal systems were located followed by length determination using and electronic apex locator. After orifice relocation using the TruNatomy Orifice Modifier, a glide path was prepared using stainless-steel K-Files and a TruNatomy Glider. Root canal preparation was done with a single TruNatomy Prime instrument. Figure 11B illustrates postoperative radiograph after the canal was obturated using the continuous wave of condensation technique (Calamus Dual Obturation Unit) with Pulp Canal Sealer and four Prime TruNatomy Conform Fit gutta-percha points. Note the conservative coronal root canal preparations in the peri-cervical area. Figure 11C depicts a mesio-angulated view showing the four obturated root canal systems.

Case report 6 The patient, a 45-year-old female, presented with irreversible pulpitis on her mandibular right first molar (Figure 12A). A preoperative CBCT scan revealed the presence of a mid-mesial root canal system in the mesial root (Figure 12B). After access cavity preparation, and removal of pulp calcifications in the pulp chamber, the three main root canal systems were located (mesiolingual, mesiobuccal, and distal). The groove between the mesiolingual and mesiobuccal canals was roughed with a Start-X® No. 3 tip (Dentsply Sirona) to remove an overlapping dentin ledge, exposing the internal anatomy 28 Endodontic practice

With a renewed focus on dentin preservation and benefits like improved performance and efficacy, the Trunatomy instruments offer the clinician superior debridement while respecting original canal anatomy. of the groove. A micro-debrider (Dentsply Sirona) was used to locate the orifice of the mid-mesial canal. A size 08 C+ file (Dentsply Sirona) was used to negotiate the initial few millimeters of the constricted canal. Canal orifices were relocated and opened coronally with the TruNatomy Orifice Modifier before the three mesial root canal systems were negotiated to full working length and apical patency. It was noted clinically and on CBCT that the distal root canal system was very wide in a buccal-lingual direction (Figure 12B), and it was possible to place a size 20 K-File to full working length. Working lengths were determined by using an electronic apex locator and confirmed radiographically (Figures 12C and 12D). It was noted that the mid-mesial canal joins the mesio-lingual canal and the mesiolingual joins within the mesio-buccal canal in the apical 2 mm of the root canal system. A reproducible micro glide path was established in all five root canal systems using a size 08 and 10 K-File before the glide paths were expanded with the TruNatomy Glider. Taking into account that there were three root canal systems in the mesial root, the authors decided to use the TruNatomy Small file for root canal preparation and maximum preservation of root structure. Figure 12E shows a magnified view of the pulp chamber floor. Note the large amount of tooth structure that was still intact after root canal preparation with the TruNatomy Small file. The distal root canal was prepared with a TruNatomy Medium file. Root canal irrigation was achieved by using 17% EDTA and heated 3.5 % sodium hypochlorite activated with the EDDY Endo Irrigation Tip (VDW) driven by an airscaler. Obturation of the canals was achieved by using TruNatomy Conform Fit gutta-percha cones and TotalFill® BC Sealer Highflow (FKG) using the continuous condensation technique. Figure 12F shows a parallel view of the obturation result. Note the maximum preservation of the root structure in the pericervical region of the mesial and distal root

canal systems. However, the mesio-angulated view (Figure 12G) shows that the full extent of the lateral anatomy that was cleaned and obturated. The clinical procedure of this case can be viewed on the following link: https://youtu.be/MxVKMc-E2VM.

Conclusion Respecting original canal anatomy, preserving dentin and therefore maintaining the structural integrity of teeth should form an integral part of root canal shaping and preparation. In this paper, the authors illustrate the clinical guidelines, applications, and advantages of the recently launched TruNatomy system. With a renewed focus on dentin preservation and benefits like improved performance and efficacy, the TruNatomy instruments offer the clinician superior debridement while respecting original canal anatomy. EP

Reprinted with permission by International Dentistry African Edition. van der Vyver PJ, Vorster M, Peters OA. Minimally invasive endodontics using a new single-file rotary system. Int Dent Afr Ed. 2019;9(4):6-20.

REFERENCES 1. Bürklein S, Hinschitza K, Dammaschke T, Schäfer E. Shaping ability and cleaning effectiveness of two singlefile systems in severely curved root canals of extracted teeth: Reciproc and WaveOne versus Mtwo and ProTaper. Int Endod J. 2012;45(5):449-461. 2. Clark D, Khademi J. Case studies in modern molar endodontic access and directed dentin conservation. Dent Clin North Am. 2010;54(2):249-273. 3. Gluskin AH, Peters CI & Peters OA. Minimally invasive endodontics: challenging prevailing paradigms. Br Dent J. 2014;216:347-353. 4. Herbranson E. Microendodontics? Roots, North America Edition. 2014;8(3) 5. Ng YL, Mann V, Gulabivala K. Tooth survival following nonsurgical root canal treatment: a systematic review of the literature. Int Endod J. 2010;43(3):171-189. 6. Papa J, Cain C, Messer H. Moisture content of vital vs endodontically treated teeth. Endod Dent Traumatol. 1994;10(2):91-93. 7. Sedgley CM, Messer HH. Are endodontically treated teeth more brittle? J Endod. 1992;18(7):332-335. 8. Tang W, Wu Y, Smales RJ. Identifying and reducing risks for potential fractures in endodontically treated teeth. J Endod. 2010;36(4):609-617. 9. van der Vyver P. WaveOne® Instruments: Clinical application guidelines. Endodontic Practice US. 2011;11:45-54

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Minimally invasive endodontics using a new single-file rotary system VAN DER VYVER, ET AL.

1. The term pericervical dentin was first described by Clark and Khademi (2010) and refers to an area roughly _______ coronal to the crestal bone and 6 mm apical to the crestal bone. a. 3 mm b. 4 mm c. 5 mm d. 6 mm 2. The fact that endodontically treated teeth _______ is largely due to the structural loss during the shaping phase of endodontic treatment and not to dehydration. a. are more prone to fracture b. are less prone to fracture c. are never expected to fracture d. will always fracture 3. Structural loss alone is, however, not the only cause for increased fracture incidence in teeth. _______ and even physiological age changes should also be taken in account. a. The impact of irrigants b. Medicaments c. Restorative procedures d. all of the above 4. This (effective shaping) should be done in such a conservative manner that _______.

Volume 13 Number 2

a. b. c. d.

magnification is not needed the structural integrity of the tooth is respected dentin is preserved where possible both b and c

5. Peri-cervical dentin preservation has been reported as _______ in the long-term survival, especially in molars with optimum function. a. overrated b. noncritical c. critical d. fairly important, but not critical 6. More advanced treatment options in endodontics (for example, magnification and more flexible nickeltitanium instrumentation) have therefore also shifted paradigms to a _______ approach in both access cavity preparation as well as shaping of root canals in order to preserve dentin. a. less conservative b. more aggressive c. minimally invasive d. more complex 7. The manufacturing of the (TruNatomy) instruments begins with a smaller initial wire blank (0.8 mm diameter) compared to the ______ diameter of other conventional rotary instruments. a. 1.1 mm b. 1.8 mm

c. 2.1 mm d. 2.8 mm 8. Due to the superelastic properties of the new (TruNatomy) wire, the files might appear _______ when removed from a curved root canal because the metal demonstrates less memory compared to conventional nickel-titanium or M-Wire. a. slightly curved b. very straight c. thicker than usual d. more tapered 9. All the instruments in the (TruNatomy) system have a shortened handle of _______ to further improve the straight-line access and placement of the instruments into the root canal systems. a. 7.5 mm b. 8.5 mm c. 9.5 mm d. 10.5 mm 10. It is always important to prepare a cavity that will ensure adequate access into each root canal system _______ of all the pulp chamber contents. a. before removal b. after removal c. instead of removal d. during removal

Endodontic practice 29

CE CREDITS

ENDODONTIC PRACTICE CE

CONTINUING EDUCATION

Occurrence of post-endodontic pain after singlevisit RCT using balanced force technique and two reciprocating systems when apical patency (AP) is maintained Drs. Jorge Paredes Vieyra, Fabian Ocampo Acosta, Francisco Javier Jiménez Enriquez, and Daniel Jiménez Zaragoza sample 216 patients to analyze the occurrence of post-endodontic pain after single-visit RCT using balanced force technique and two reciprocating file systems

ost-endodontic pain is an ache after root canal treatment (RCT) and is described by more than 35% of patients regardless of periapical condition. Management of it is essential in endodontic practice (Ince, Ercan, Dalli, et al., 2009). Pain of endodontic origin is widely feared by the patients. Accurate information of pain occurrence and strictness related with pulpal or periradicular illness and its decrease by RCT has the possibility to change the attitudes of the patients, general dentists, endodontists, and other healthcare professionals (Watkins, Logan, Kirchner, 2002). Debris, organic tissue, microbes, and irrigant solutions can be sent beyond the apex through RCT and can lead to postoperative problems such as intensive pain or flare-ups. Therefore, acceptable care of the working length (WL) may diminish the expulsion of remains through the apical foramen (AF) but may not avoid this entirely (Torabinejad, Kettering, McGraw, et al., 1988). Accumulation of soft material remnant in the apex is a usual occurrence that can produce obstruction of the root canal (RC). This condition can be prevented if patency of the AF is maintained (Souza, 2006). Presently, maintaining apical patency

Jorge Paredes Vieyra DDS, MSc, PhD, is a full-time professor of endodontics, at Autonomous University of Baja California, School of Dentistry, Tijuana campus. Fabian Ocampo Acosta DDS, MSc, is a full-time professor in the histopathology department, at Autonomous University of Baja California, School of Dentistry, Tijuana campus. Francisco Javier Jiménez Enriquez DDS, MSc, PhD, is a fulltime professor of oral surgery, at Autonomous University of Baja California, School of Dentistry, Tijuana campus. Daniel Jiménez Zaragoza MD is of the Facultad de Medicina, Autonomous University of Baja California, Tijuana campus.

30 Endodontic practice

Educational aims and objectives

This clinical article aims to discuss research that related to the occurrence of postendodontic pain after single-visit RCT using balanced force technique and two reciprocating system when AP is conserved.

Expected outcomes

Endodontic Practice US subscribers can answer the CE questions on page 35 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Observe that the incidence of post-endodontic pain is lower when apical patency (AP) is maintained and presence/absence of preoperative pain has to be considered.

•

Identify possible causes of post-endodontic treatment pain.

•

Identify possible techniques to clean and shape the root canal.

•

Identify the concept and benefits of balanced forces.

(AP) is suggested through RCT (Monsef, Hamedzadeh, Soluti, 1997). Apical patency is the action of using a tiny hand file to maintain the apical constriction (AC) open. It is a method that keeps the apex free of remains (Monsef, Hamedzadeh, Soluti, 1998). A patency instrument is described as a tiny bendable K-File, which is used through the AC (Fava, 1998; Buchanan, 1989). The instruments employed to gain AP are often the same instruments primarily used to negotiate RC (Izu, Thomas, Zhang, Izu, Michalek, 2004). To improve cleaning and shaping of the canal, a technique such as the concept of balanced forces has been proposed (Roane, Sabala, Duncanson, 1985). The benefits of balanced forces (BF) are that these reduce the chance of change of WL, decrease canal alterations and formation of apical ledges (Monsef, Hamedzadeh, Soluti, 1997), permit maintenance of the integrity of the AC (Flanders, 2002), and increase the palpable appreciation of the professional through RCT (Buchanan, 1989). Main improvements in mechanical shaping and metallic properties have led to the improvement of plentiful methods with

novel designs in modern years. However, all methods and tools existing to this time are related with some level of expulsion of remains (Ferraz, Gomes, Gomes, et al., 2001; Bürklein and Schëafer, 2012). The model of one-file for canal shaping was presented in endodontics (Yared, 2008) with the promotion of RECIPROC® (VDW®) tools (VDW, Munich, Germany). These metallic tools are made up of a nickel-titanium alloy named M-Wire by means of a novel thermal management procedure (Gutmann and Gao, 2012). The watch-winding motion comprises an initial turning of the device in a counterclockwise way during which the file enters and cuts the dentin and after that a sequence in the clockwise direction. Meanwhile, the file is liberated. All root canal preparation techniques cause apical extrusion to some degree; however, the amount of extrusion may vary (Reddy and Hicks, 1998; Al-Omari and Dummer, 1995). Some other factors may disturb the occurrence of post-endodontic pain when AP was conserved in concordance to when it was not (Arias, Azabal, Hidalgo, de la Macorra, 2009). Volume 13 Number 2

CONTINUING EDUCATION

One of the unproven details for not operating AP is the probable passage of remains throughout the AF, a clinical situation associated with post-endodontic pain (Ferraz, Gomes, Gomes, et al, 2001; Kirchhoff, Fariniuk, Mello, 2015). Some other authors have indicated that maintaining AP would not produce more postoperative complications, requiring it is reasonably made (Arias, Azabal, Hidalgo, de la Macorra, 2009). The goal of this research was to relate the occurrence of post-endodontic pain after single-visit RCT using two reciprocating system and balanced force as control group when AP is conserved.

Materials and methods This clinical research took place at the University Autonomous of Baja California, School of Dentistry, Tijuana, Mexico. The subjects review committee accepted the research, and the study was conducted in accordance with ethical principles (including the World Medical Association Declaration of Helsinki). Three certified endodontists trained in the procedures, devices, and systems investigated took part in the research. All experts tracked a pre-established procedure for the balanced force technique, ProTaper Next™ (Dentsply Sirona), and RECIPROC® (VDW®) instrument systems. The principal inclusion parameters were absence of radiographic sign of apical periodontitis and a diagnosis of irreversible pulpitis (IP) established by affirmative response to hot and cold examinations. Thermal pulp examination was achieved by the corresponding author, and radiographic analysis was established by three certified endodontists. Clinical requirements were established on the following conditions: 1. The purposes and necessities of the research were spontaneously accepted. 2. Clinical management was pointed to patients in physical and mental well-being. 3. All teeth had vital pulps and absence of apical periodontitis. 4. Positive thermal stimulation with Endo-Ice® (Hygenic Corp., Akron, Ohio). 5. Teeth with enough coronal structure for rubber dam isolation. 6. No RCT done before the research. 7. No painkillers or antibiotics used 7 days prior the clinical events started. Exclusion parameters were the necessity for retreatment, gravidity, impossibility to obtain patient’s approval, patients who Volume 13 Number 2

Figure 1: Flow diagram of the progress of phases of the study

didn’t complete inclusion necessities, a history of medication for chronic pain or those compromising the immune response, patients younger than 18 years old, and the existence of mishaps or difficulties during RCT (calcified canals, impracticality of achieving AP in any canal). The subsequent records were collected in clinical archives. The judgment of vital tissue was established by accumulating dental records and doing digital radiography, periodontal assessment, percussion, and cold test. The diagnostic results were evaluated by relating the tooth’s reaction versus a contiguous tooth with the same vital condition. This condition was rechecked by the presence of bleeding through the access. If the thermal test was positive and there was bleeding during endodontic access, the tooth was established as vital. The occurrence or nonexistence of preoperative pain (yes/no) was noticed. We requested whether the patients had pain or discomfort 7 days prior to the event. Teeth (posterior/ anterior) and location (superior/inferior) were also added.

Patient selection Two hundred and sixteen of 245 patients (119 women and 97 men) aged 18 to 65 years were incorporated in this research (Figure 1). Sample size estimate was achieved in accordance with a method for this specific purpose (Cochran’s method, 1986). Therefore, the 72 teeth allocated to each group were adequate to confirm an essential sample. All patients had upper or lower molar, premolar, or anterior teeth selected for conventional RCT for prosthetic reasons detected with vital pulps. Clinical cases with nonvital teeth and apical periodontitis, endodontic retreatment, root resorption, undeveloped apex, or a root canal with severe curvature (>35º) or a radiographically untraceable canal path were all rejected from the study (shown in Figure 1). Patients opting to reject the research, those with issues with single-visit RCT, those consuming a specific kind of medicine such as painkillers or NSAIDs, and participants with some unrestrained systemic ailment were excluded as well. All participants were knowledgeable of the goals and strategy of the study, and written permissions were gained prior to their addition. Endodontic practice 31

CONTINUING EDUCATION Random selection of instrumentation groups Of the sample of 216 teeth, 72 were selected to the three instrumentation methods. The study strategy included three experts, and each expert prepared 72 teeth, 24 per technique.

Treatment protocol All patients were anesthetized with two carpules of articaine 2% with epinephrine 1:200,000 (Septodont, Saint-Maur des-Fosses, France). In cases in which supplemental anesthesia was needed, intraligamental articaine 2% was injected. After absolute isolation, the tooth was sanitized with 5.25% NaOCl. Cavity access was performed by using No. 331 bur (Dentsply International, York, Pennsylvania), with high speed and water cooling during the procedure. 5.25% NaOCl was used to clean the coronal cavity. The canals were evaluated with No. 10 K-type hand files (Flex-R® files, Moyco Union Broach, York, Pennsylvania). The standard method involved the following steps: Access was achieved, and REDTA (Roth International, Chicago, Illinois) lubricant was placed at the entry of the canals. Determination of WL was first determined with a No. 15 K-File and the Root ZX electronic device (J. Morita, Irvine, California), followed by subtracting 0.5 mm from the measurement, which was calculated with the assistance of a metallic ruler and digital radiographic confirmation (Schick Technologies, New York). A glide path to the WL was then established. The pulpal cavity was dried with a sterilized cotton pellet. Lubricant was positioned at the entry of canals (i.e., measurements were made along humid canals). A No. 15 file attached to Root ZX apex locator was used to calculate WL, which was calculated with No. 20 and No. 25 files, respectively. If there was no arrangement among measures obtained by using the three files, the data that was dissimilar was reevaluated. If the discrepancy continued, the measure conveyed with the thicker file was designated. WL was confirmed with a digital radiograph. In the event of dissimilarity between radiographic and electronic quantities, the last was designated. For hand instrumentation, balanced force was used. All canals were cleaned and shaped with hand Flex-R files (Moyco Union Broach, York, Pennsylvania). Gates Glidden burs (Dentsply Maillefer) sizes No. 2 and No. 3 were used at the entry of the 32 Endodontic practice

Table 1: Distribution by group of teeth Clinical Features

Balanced Force (BF) (n=72)(%)

ProTaper Next (PTN) (n=72)(%)

RECIPROC (R) (n=72)(%)

Total

Female

38 (52.78)

40 (55.56)

41 (56.94)

119 (55.09)

Male

34 (47.22

32 (44.44)

31 (43.06)

97 (44.91)

Maxillary Teeth

37 (17.3)

111 (51.39)

Incisors and Canines

2 (2.78)

3 (4.17)

2 (2.78)

22 (30.56)

Bicuspids

12 (16.67)

11 (15.28)

18 (25.00)

Molars

23 (31.94)

24 (33.33)

11 (15.28)

Mandibular Teeth

35 (16.20)

105 (48.60)

Incisors and Canines

3 (4.17)

2 (2.78)

1 (1.39)

6 (1.00)

Bicuspids

11 (15.28)

12 (16.67)

11 (15.28)

34 (47.22)

Molars

21 (29.17)

23 (31.94)

65 (90.28)

Table 2: Mann-Whitney, U Test in analysis of duration of postendodontic pain Clinical Factor

Condition N

Pupal Diagnosis

Vital

216

Preoperative Pain

Yes No

70 146

.005 .44

Group of Teeth

Anterior Posterior

13 203

Position of Teeth

Maxillary Mandibular

111 105

P Value

Table 3: Kruskal/Wallis test applied to the post-endodontic pain results for the groups Balanced Force, ProTaper Next and RECIPROC Instrumentation N Technique

Mean

Standard Deviation

Pain after 24 h Balanced force

.58

.82

.41 .11

ProTaper Next

.65

.81

RECIPROC

.87

.96

.021 .019

Pain after 48 h Balanced force

.24

.43

ProTaper Next

.23

.42

RECIPROC

.21

.59

Balanced force

.00

.82

ProTaper Next

.03

.81

RECIPROC

.04

.96

canals. For mechanical shaping, all instruments were used with a micro motor (VDW Silver RECIPROC motor). Torque and rotation were established independently for each instrument method used. ProTaper Next and RECIPROC instruments were used in continuous brushing rotary motion and reciprocating mode, respectively. Dentinal remains were eliminated from the file by means of a gauze, simultaneously to the next instrument change (ProTaper Next system) or after two or three in-and-out (pecking) movements (RECIPROC systems) according to the manufacturer’s commendations. Each root canal was irrigated with 2.5mL 2.6% NaOCl. Irrigation was achieved using a 24-gauge needle (Max-i-Probe®; Tulsa Dental, York, Pennsylvania) through access and a 31-gauge NaviTip™ needle (Ultradent Products Inc., South Jordan, Utah) when getting the WL after each instrument insertion. Group BF. For the balanced force group, the root canals were cleaned and shaped using a No. 40 instrument for thin or curved canals and a No. 55 file for widespread canals.

Pain after 72 h

Group PTN. For the ProTaper Next group, SX files, X1 and X2 (ProTaper Universal System; Dentsply, Ballaigues, Switzerland) were used for preflaring and preparation of thin and curved canals and X3 and X4 (40.06) for preparation of wide canals up to the WL. The instruments were operated using a continuous rotary brushing motion at a speed of 300 rpm and a torque of 2 Ncm. Group R. R25 (25.08) instrument was used in thin and curved RC, and R40 files (40.06) were used in wide canals. Three in-and-out motions were used with lengths not beyond 3 mm in the three thirds of the canal until reaching the estimated WL. Hand and rotary files were employed in just one tooth (single use) and then excluded. AP was conserved through all the procedures used by using a No. 10 K-type file at WL. Volume 13 Number 2

Assessment of post-endodontic pain and statistical analysis Patients were informed of the probable incidence of pain for days following RCT and received a survey form to be finished and returned 3 days after. In it, they provided proof of the occurrence or nonappearance of post-endodontic pain, its period and level of distress rated as follows: mild pain — any discomfort of any duration that does not require treatment; moderate pain — pain that requires and is relieved with analgesics; and severe pain — any pain that is not calmed with treatment (analgesics). Some 210 of the 216 surveys were returned correctly with responses and on the

date requested. Of these, 69 belonged to BF group, 70 to PTN group, and 71 to R group. The rest of the 216 were received 1 day after and were included in the data analysis. Outcomes of groups BF, PTN, and R associated with occurrence (yes/no), level (mild, moderate, severe), and interval (days) of post-endodontic ache were evaluated, focusing to diagnostic factors: condition of tooth (all vital), occurrence or nonappearance of preoperative pain, group of teeth (molar/ premolar or anterior), or location (maxillary, mandibular). Outcomes were examined with the Chi-Square for the occurrence of postendodontic pain and Mann-Whitney U test.

Results The clinical structure of the participants is shown in Table 1. The average age of the 216 participants registered in this research was 54 years. No statistically significant difference (p > .05) among the groups was found regarding degree or duration of pain. The post-endodontic pain marks were seen 24 hours later in the three groups with an important decline subsequently. No statistically important difference was seen between the three groups evaluated in the research in terms of level and amount of analgesic medicine consumption (p > .05, Tables 2 and 3). In general, analgesic consumption was limited to the next 24 hours after RCT in all the groups evaluated. None of the 216 patients stated acute pain or flare-ups during the phase of the research (Table 4). In situations with informed occurrence of preoperative pain, periods of postendodontic pain were considerably more. There was no statistically significant difference (p> .05) among the Balanced Force technique, PTN, and R techniques in relation to the occurrence of post/endodontic ache at any of the three time points measured (Tables 3 and 4).

Group of teeth No statistically significant differences were encountered between groups about occurrence, grade, or length of post-endodontic pain among anterior and posterior teeth.

Table 4: Distribution of teeth by randomized factors 24 hrs after Quantity

Balanced Force (BF) ProTaper Next (PTN) RECIPROC (R) (n=72)(%) (n=72)(%) (n=72)(%)

None

51 (70.83)

54 (75)

One tablet

12 (16.66)

13 (18.05)

11(15.27)

Two tablets

9 (12.5)

7 (9.72)

Three tablets

1 (1.38)

Volume 13 Number 2

Post-endodontic pain associated to the arch In maxillary teeth, differences among groups were not statistically relevant concerning occurrence, level, or length of post-endodontic pain. In mandibular teeth, post-endodontic pain was significantly lengthier (P .016; Table 3) than maxillary teeth.

Discussion Pain by itself is difficult to understand and measure, especially when it happens suddenly in patients. The principal difficulties in learning aching and discomfort are the participants’ idiosyncratic assessment and its dimension. For this purpose, planning the evaluation form has to be completely comprehended by participants. In our research, a simple spoken classification was followed in the feedback procedure with three classes: minor, modest, and acute. These classes were clearly comprehended by participants and were described by the occurrence or nonappearance of the necessity for pain-relieving treatment. Preoperative pain is one of the highest predictors of post-endodontic pain (Glennon, Ng, Setchell, et al., 2004). Thus, only teeth with IP indicated for RCT because of prosthodontic purposes were chosen for this research. All treatments were performed in one visit to avoid any the possible influence of intracanal medication or other issues generating pain, and all the teeth in the three groups were released of any early occlusal points after endodontic procedures so that unsuitable traumatic occlusion would not disturb the outcomes. In this research, correct measure of WL during RCT was furthermore crucial. WL was estimated with an EAL and confirmed with a radiograph. Root ZX EAL was employed because its exactitude has been established in two clinical environments (Luiz, et al., 2006; Tselnik, et al., 2006; Welk, et al., 2003; Dunlap, et al., 1998). As suggested by Herrera, et al. (2007), electronic WL measurement was repetitive after cervical and middle thirds shaping. When clinicians combine radiographic interpretation and digital RC dimensions, occasionally, outcomes do not match. In the occasion of inconsistency among both magnitudes, the electronic assessment would be chosen (Lucena-Martín, et al., 2004; Kim-Park, et al., 2003; Williams, et al., 2006), as in this study. A recent study (Caillateau and Mullaney, 1997) demonstrated that the dimension Endodontic practice 33

CONTINUING EDUCATION

After the instrumentation phase, the pulp chamber was rinsed with 1 mL 2.6% NaOCl, agitated ultrasonically. Ultrasonic activation was performed using an Irrisafe™ ultrasonic 20.00 tip (Satelec, Merignac, France) at 50% power of the MiniEndo™ ultrasonic unit (Kerr Endo) to place the tip 3 mm from the WL for 30 seconds per canal. Then each experimental group received a final irrigation with cold (8ºC) 17% EDTA gently delivered to the WL using a cold (8ºC) sterile metallic microcannula attached to the EndoVac™ negative pressure irrigation system (Kerr Endo) for 3 minutes to eliminate the smear layer and reduce post-endodontic pain. Caution was taken to ensure that the microcannula would suction correctly by detecting the system’s transparent evacuation tube. In case of any obstruction, the microcannula was instantly substituted. Repeat of WL was established again by using EAL as described previously, using No. 35, No. 40, and No. 45 files. The root canals were then desiccated with disinfected paper cones and filled at the same visit. Guttapercha cones (Dentsply Maillefer) were laterally compacted with No. 20 nickel-titanium spreaders (Dentsply Maillefer) and AH Plus sealer (Dentsply Maillefer). Entrance openings of anterior teeth were etched and repaired with Fuji IX (GC Corp., Tokyo, Japan). For posterior teeth, a rebuilding was placed with the same method.

CONTINUING EDUCATION of the file employed to preserve AF open varied. We methodically used a No. 10 width file to maintain AP in this study. Operating major widths to maintain AP can produce damage of surrounding tissues, hard control in complete RCT. All of these situations predispose the occurrence of postendodontic pain. It is well-known that forcing of endodontic files outside the AF can send a diversity of toxic materials to the surrounding tissues, which can generate pain (Nobuhara, et al., 1993). Georgepoulou, et al. (1986), showed a significantly major occurrence of pain if through the modeling procedure, instruments or material were involuntary placed outside the AF instead of maintaining them inside the canal (Georgepoulou, et al., 1986). In our protocol, there is no over-instrumentation; AP was maintained in all cases. Nevertheless, AP does not appear to be related to post-endodontic pain in vital condition because of its control during RCT (Fox, et al., 1970). Furthermore, Torabinejad, et al. (1988), stated that if inadvertent over-passage of the instrument occurs while determining WL, this doesn’t interfere with the incidence of post-endodontic pain. Our methodology was similar to them because likely we employed

REFERENCES 1. Al-Nahlawi T, Hatab TA, Alrazak MA, Al-Abdullah A. Effect of intracanal cryotherapy and negative irrigation technique on post endodontic pain. J Contemp Dent Pract. 2016;17(12):990-996. 2. Al-Omari MAO, Dummer PMH. Canal blockage and debris extrusion with eight preparation techniques. J Endod. 1995;21(3):154-158. 3. Arias A, Azabal M, Hidalgo JJ, de la Macorra JC. Relationship between post endodontic pain, tooth diagnostic factors, and apical patency. J Endod. 2009;35(2):189-192. 4. Bleakley CM, McDonough SM, MacAuley DC, Bjordal J. Cryotherapy for acute ankle sprains: a randomized controlled study of two different icing protocols. Br J Sports Med. 2006;40(8):700-705. 5. Buchanan LS. Management of the curved root canal. J Calif Dent Assoc. 1989;17(4):18-27. 6. Bürklein S, Schëafer E. Apically extruded debris with reciprocating single-file and full-sequence rotary instrumentation systems. J Endod. 2012;38(6):850-852. 7. Caillateau J, Mullaney T. Prevalence of teaching apical patency and various instrumentation and obturation techniques in United States dental schools. J Endod. 1997;23(6):394-396. 8. Dunlap CA, Remeikis NA, BeGole EA, Rauschenberger CR. An in vivo evaluation of an electronic apex locator that uses the ratio method in vital and necrotic canals. J Endod. 1998;24(1):48-50. 9. Fox J, Atkinson J, Dinin A, et al. Incidence of pain following one-visit endodontic treatment. Oral Surg. 1970;30(1):123-30. 10. Fava L. Acute apical periodontitis: incidence of postoperative pain using two different root canal dressings. Int Endod J. 1998;31(5):343-347. 11. Ferraz CC, Gomes NV, Gomes BP, et al. Apical extrusion of debris and irrigants using two hands and three engine-driven instrumentation techniques. Int Endod J. 2001;34(5):354-358. 12. Flanders D. Endodontic patency: how to get it, how to keep it, why it is so important. N Y State Dent J. 2002;68(3):30-32.

34 Endodontic practice

Siqueira, et al. (2002) discovered little frequency of flare-ups following RCT in teeth with necrotic tissue or teeth with previous RCT if AP was maintained. only thin files to establish the WL. This study supports our results in that apical over-extension does not generate post-endodontic pain, though it varies from our research in that they didn’t maintain AP during all the RCT. Siqueira, et al. (2002), discovered little frequency of flare-ups following RCT in teeth with necrotic tissue or teeth with previous RCT if AP was maintained. They identified that maintenance of AP does not affect postendodontic pain. This was not measured in our research. In our report, we did not treat clinical cases for retreatment procedures, and flare-ups were not evaluated. In our research, we reduced the variation in the procedures following protocols based on recommendations by authors and manufacturers. Clean and shape procedures were performed on root thirds using brushing

and reciprocating movements, respectively, followed a final irrigation with cold (8ºC) 17% EDTA gently delivered to the WL using a cold (8ºC) sterile metallic microcannula attached to the EndoVac™ supported in an early scientific report (Modabber, et al., 2013; Bleakley, et al., 2006; Al-Nahlawi, et al., 2016).

13. Georgepoulou M, Anastassiadis P, Sykaras S. Pain after chemomechanical preparation. Int End J. 1986;19(6): 309-314.

25. Monsef M, Hamedzadeh K, Soluti A. Effect of apical patency on the apical seal of obturated canals. J Endod. 1998;24:284.

14. Glennon JP, Ng YL, Setchell DJ, Gulabivala K. Prevalence of and factors affecting post preparation pain in patients undergoing two-visit root canal treatment. Int Endod J. 2004;37(1):29-37.

26. Nobuhara W, Carnes D, Gilles J. Anti-inflammatory effects of dexamethasone on periapical tissues following endodontic overinstrumentation. J Endod. 1993;19(10):501-507.

15. Gutmann JL, Gao Y. Alteration in the inherent metallic and surface properties of nickel-titanium root canal instruments to enhance performance, durability and safety: a focused review. Int Endod J. 2012;45(2):113-128. 16. Herrera MC, Abalos A, Planas J, Llamas R. Influence of apical constriction diameter on Root ZX apex locator precision. J Endod. 2007;33(8):995-998. 17. Ince B, Ercan E, Dalli M, et al. Incidence of postoperative pain after single- and multi-visit endodontic treatment in teeth with vital and nonvital pulp. Eur J Dent. 2009;3(4):273-279. 18. Izu KH, Thomas SJ, Zhang P, Izu AE, Michalek S. Effectiveness of sodium hypochlorite in preventing inoculation of periapical tissues with contaminated patency files. J Endod. 2004;30(2):92-94.

Conclusion The incidence of post-endodontic pain is lower when AP is maintained, and presence/absence of preoperative pain has to be considered. When previous symptoms are present, occurrence and period of pain is longer in teeth with this condition that when AP is maintained. It can be established that conserving AP with a thin K-File can help to prevent post-endodontic pain in some specific cases. EP

27. Reddy SA, Hicks ML. Apical extrusion of debris using two hands and two rotary instrumentation techniques. J Endod. 1998;24(3):180-183. 28. Roane JB, Sabala CL, Duncanson MG Jr. The “balanced force” concept for instrumentation of curved canals. J Endod. 1985;5(11):203-211. 29. Siqueira J, Rôças I, Favieri A, et al. Incidence of postoperative pain after intracanal procedures based on an antimicrobial strategy. J Endod. 2002;28(6):457-460. 30. Souza RA. The importance of apical patency and cleaning of the apical foramen on root canal preparation. Braz Dent J. 2006;17(1):6-9. 31. Torabinejad M, Kettering J, McGraw J, et. al. Factors associated with endodontic interappointment emergencies of teeth with necrotic pulps. J Endod. 1988;14(5):261-266.

19. Kim-Park MA, Baughan LW, Hatwell GR. Working length determination in palatal roots of maxillary molars. J Endod. 2003;29(1):58-61.

32. Torabinejad M, Kettering JD, McGraw JC, et al. Factors associated with endodontic interappointment emergencies of teeth with necrotic pulps. J Endod. 1998;14:261-6.

20. Kirchhoff AL, Fariniuk LF, Mello I. Apical extrusion of debris in flat-oval root canals after using different instrumentation systems. J Endod. 2015;41(2):237-241.

33. Tselnik M, Baumgartner J, Gordon Marshall J. An evaluation of Root ZX and Elements Diagnostic apex locators. J Endod. 2006;31(7):507-509.

21. Lucena-Martín C, Robles-Gijón V, Ferrer-Luque CM, de Mondelo JM. In vitro evaluation of the accuracy of three electronic apex locators. J Endod. 2004;30(4):231-3. 22. D’Assunção FL, de Albuquerque DS, de Queiroz Ferreira LC. The ability of two apex locators to locate the apical foramen: an in vitro study. J Endod. 2006;32(6):560-562. 23. Modabber A, Rana M, Ghassemi A, et al. Three-dimensional evaluation of postoperative swelling in treatment of zygomatic bone fractures using two different cooling therapy methods: a randomized, observer-blind, prospective study. Trials. 2013;14:1-10. 24. Monsef M, Hamedzadeh K, Soluti A. Effect of apical patency on the apical seal of obturated canals. J Endod. 1997;23(4):253.

34. Watkins CA, Logan HL, Kirchner HL. Anticipated and experienced pain associated with endodontic therapy. J Am Dent Assoc. 2002;133(1):45-54. 35. Welk A, Baumgartner J, Gordon Marshall J.2003; An in vivo comparison of two frequency- based electronic apex locators. J Endod. 2003;29(8):497-500. 36. Williams CB, Joyce AP, Roberts S. A comparison between in vivo radiographic working length determination and measurement after extraction. J Endod. 2006;32(7):624-627. 37. Yared G. Canal preparation using only one Ni-Ti rotary instrument: preliminary observations. Int Endod J. 2008; 41(4):339-344.

Volume 13 Number 2

REF: EP V13.2 VIEYRA, ET AL.

FULL NAME

AGD REGISTRATION NUMBER

LICENSE NUMBER

ADDRESS

CITY, STATE, AND ZIP CODE

TELEPHONE/FAX

Please allow 28 days for the issue of the certificates to be posted.

Occurrence of post-endodontic pain after single-visit RCT using balanced force technique and two reciprocating systems when apical patency (AP) is maintained VIEYRA, ET AL.

1. Post-endodontic pain is an ache after root canal treatment (RCT) and is described by more than ______ of patients regardless of periapical condition. a. 35% b. 45% c. 55% d. 65% 2. _______ and irrigant solutions can be sent beyond the apex through RCT and can lead to postoperative problems such as intensive pain or flare-ups. a. Debris b. Organic tissue c. Microbes d. all of the above 3. _______ is the action of using a tiny hand file to maintain the apical constriction (AC) open. a. Apical gauging b. Apical patency c. Apical curretage d. Apexogenesis 4. To improve cleaning and shaping of the canal, a technique such as the concept of _______ has been proposed. a. mechanical shaping

Volume 13 Number 2

b. soft material remnant c. balanced forces d. periradicular illness 5. These metallic tools (RECIPROC tools) are made up of a _______ alloy named M-Wire by means of a novel thermal management procedure. a. nickel-titanium b. stainless-steel c. copper d. balanced 6. (For the study) The judgment of vital tissue was established by accumulating dental records and doing _______ and cold test. a. digital radiography b. periodontal assessment c. percussion d. all of the above 7. Preoperative pain is one of ________ of postendodontic pain. a. the least effective predictors b. the highest predictors c. the most nonessential predictors d. the least detectible 8. (For the study) All treatments were performed

in ________ to avoid any possible influence of intracanal medication or other issues generating pain, and all the teeth in the three groups were released of any early occlusal points after endodontic procedures so that unsuitable traumatic occlusion would not disturb the outcomes. a. one visit b two visits c. three visits d. four visits 9. (For this study) WL was _______. a. estimated with an intraoral photograph and confirmed with a radiograph b. estimated with a radiograph and confirmed with an EAL c. estimated with an EAL and confirmed with a radiograph d. determined by a CBCT scan 10. The incidence of post-endodontic pain _______ when AP is maintained, and presence/ absence of preoperative pain has to be considered. a. is higher b. is lower c. is the same d. does not change

Endodontic practice 35

CE CREDITS

ENDODONTIC PRACTICE CE

PRACTICE MANAGEMENT

Priorities to drive practice recovery and growth Dr. Albert (Ace) Goerig discusses embracing critical change in the overall strategic direction of the practice

t the start of the year, no one could have predicted what was coming and how dramatically our lives and practices would be affected. Now, as everyone strives to get the economy back to some kind of normalcy, you are faced with the challenge of navigating your individual recovery. There are a couple of factors working against you: • First, general dentistry has been hit harder by the pandemic than endodontic practices. Most endodontic practices stayed to take care of emergencies, while most general dentists were shut down completely. They will be tempted to hold on to whatever patient care they can deliver themselves rather than referring out. There will likely be a bump up in referrals initially due to pent-up demand, but that will subside to a Albert (Ace) Goerig, DDS, MS, is a Diplomate of the American Board of Endodontics and a sought-after speaker who has lectured extensively in the field of endodontics and practice success throughout the United States, Canada, and abroad. He is the author of more than 60 published articles and a contributing author to numerous endodontic textbooks. Dr. Goerig has a private endodontic practice in Olympia, Washington in the top 1% nationwide for practice profitability. He has almost 25 years of experience as an educator and practice coach to nearly 1,000 endodontists. Disclosure: Dr. Goerig is owner and co-founder of Endo Mastery.

36 Endodontic practice

level lower than what you were doing prior to the pandemic. • Second, the economy may be on a slow ramp back up, but many people remain unemployed or underemployed during this time. People have a recession mindset; many have exhausted their available credit and lost their dental insurance. For those still with insurance, some employers are going to be reducing benefits as part of their own financial survival strategies. • Third, many people are still nervous and avoiding situations where they perceive an increased health risk, such as invasive dental procedures. That’s going to result in a suppression of patient flow in referring offices for some time, and GPs have to rebuild patient trust and acceptance for hygiene and non-urgent dental procedures. For endodontists, this means we may have escaped the pandemic with less initial impact than other dental practitioners, but we will potentially have a more extended recovery period. How quickly you will recover will depend on the strategic interventions you take starting now. It’s no longer “business as usual” by any measure, and this means you have to get yourself and your team focused on what matters right now.

Six crucial recovery priorities In my view, there are six key priorities that you need to address in your recovery strategy. Obviously, practices that had strong systems in place and were growing prior to the pandemic are going to have an easier time. However, those who went into the pandemic with underlying weaknesses in some areas (for example: scheduling, marketing, team alignment, stagnation or lack of growth, etc.) will have to embrace a more forceful shift in the overall strategic direction of the practice. Here are the key areas of priority: Team and patient recovery planning The first priority is getting your own house in order. The coronavirus is going to be with us on an ongoing basis, possibly becoming endemic and seasonal like the flu, even if a vaccine becomes available. It is best to assume our “pandemic” infection control adaptions are permanent until we know otherwise. That means settling on what your infection-control regimen is going to be going forward. Finalize your PPE list and suppliers. Right-size and cross-train your staff to the latest CDC, ADA, OSHA, OSAP, and state guidelines. (It’s a lot to review to educate them.) Absolutely master your team’s communication skills with patients and the steps you are taking to protect them. Update your Volume 13 Number 2

Referral recovery planning The next area of priority is optimizing referrals to the current environment. You need to take steps to reduce the number of nontreatment patients. This not only is a benefit for the patient to avoid an unnecessary visit, but also is vital for your economics since changes in how we can schedule mean every treatment slot is vital to your economic recovery. If ever there was great time to train your referrers, once and for all, to send X-rays for all referred patients, this is the time. You also need to carefully consider how you are going to manage your sidebook. For example, routinely recalling patients for follow-up might be better handled through a combination of post-visit care calls and more effective post-op patient education with instructions to call if they develop any concerns. Consults, however, are going to remain a priority, and you have to figure out how those fit in your new schedule template. You may need to adjust the number of days per week and hours per day you work to hit your goals. One area that you should consider is teledentistry. It has the potential to simplify some consults and follow-ups and avoid a patient visit until a treatment need is confirmed (plus it is billable). This may require team training, as well as communicating with referring practices about how teledentistry with better records from the GP is the preferred choice for patient consults at this time. Practice economics recovery planning The goal with recovery is to get back up to your pre-pandemic levels of productivity as soon as possible. The first thing you should do is map out a new framework for goals on a week-by-week basis that take you from where you’re at right now until you are back to normal. I think a reasonable time frame should be 3-to-4 months because it will be happening in parallel with referring practices as they ramp up. In recovery, teams need to be focused and agile on restoring practice productivity and hitting goals. That means, if necessary, staying late on a day if you can complete another case. The reliable patient flow of the Volume 13 Number 2

past will not return without earning it back one day and one case at a time. You also need to consider that your income took a nosedive during the pandemic restrictions, while experiencing new higher costs on PPE. You may also have invested in new technologies to make your practice safer such as air purification, UV sterilization, extraoral suction evacuators, etc.. That deficit has to be made up as well, so your plan must extend past “return to normal” to eliminate the deficit from the books. That means (despite all the forces resisting it) that recovery must continue into growth. Marketing recovery planning Most endodontists do not do enough strategic marketing to drive true growth. Effective marketing is a planned sequence of ongoing activities that is designed to establish you as the preferred endodontist for as many referring doctors as possible. That means developing closer doctor-to-doctor relationships and team-to-team relationships for existing referrers, as well as outreach to connect with new referrers. You should be meeting with your marketing coordinator on a weekly basis to plan a communication activity to all your referring doctors. It does not have to be complicated. What matters is that it is regular and positive. For example, you can email every doctor with useful links or something funny or uplifting. In addition, you should have a list of doctors selected each week for individual marketing activities. Researching and preparing these activities should be part of your marketing coordinator’s duties. Personal economics recovery planning Endodontics is a incredible path to a life of financial freedom. In fact, when I started Endo Mastery 25 years ago, my goal was to help every endodontist achieve that level of success. It is still our primary goal as endodontic coaches to help doctors grow their practices and incomes, so they have a life of abundance. Whether you have that level of abundance or not though, the loss of practice revenue due to the pandemic has a ripple effect into your personal economics (and don’t forget the turmoil in the capital markets too). As part of your practice recovery strategy, you also need to create a parallel personal economic strategy, especially if you’ve taken a shortterm hiatus from saving due to the loss of income. You need a month-by-month plan on getting your personal economics back into alignment with your long-term goals. That should include developing a recovery savings strategy, a family income strategy,

and ensuring you have enough of an economic buffer in reserve for the reinvestments and contingencies you may need to stimulate practice growth and smooth out any future bumps in the road. Productivity recovery and growth planning Growth is possible in any market when you are intentional and engaged with the opportunities that exist. As I mentioned, your practice economics plan should have a week-by-week strategy to recover your former productivity levels, and then continue growing to recover your income deficit. This is absolutely possible even in this market because many endodontists have a routine that is far from optimized for growth. The average Endo Mastery client, prior to beginning practice coaching, had over 2 hours a day of lost clinical time. That’s the equivalent of 2½ months of lost time every year for a practice working 4 days per week and 48 weeks per year. It’s as though they are self-imposing the effects of a pandemic on themselves every year. Ultimately, closing the gaps on these opportunities is what will drive you from recovery into growth. Being prepared to question what you are doing now, to look at your existing systems and processes objectively, and leading your team to adopt an innovation mindset is essential.

Moving forward with new choices Many of your colleagues are working on these same issues, and there are plenty of resources available from many sources to assist you. The trick is pulling it all together in the right combination. At Endo Mastery, we’re available to support you too. In September, we have a Recovery Team Summit to get the team back in focus with new goals and leadership for recovery growth. In addition, we’ve also launched a streamlined and prioritized Recovery Coaching solution that gives you customized professional guidance and implementation from an Endo Mastery coach to achieve the objectives discussed in this article. We’re happy to talk to you about any of these options. In the meantime, this is not the time to sit and wait for the slow tide of recovery to lift you passively. It’s the active strategies you implement now that will determine whether recovery is a 6-month success story for you, or 2-plus years in a drawn-out battle for every inch of ground you regain. I believe, with the right strategies and support, every endodontic practice can emerge from this crisis quickly, stronger, and more profitable than they ever were before. For more information, visit www.endo mastery.com, email info@endomastery.com, or call 1-800-482-7563. EP Endodontic practice 37

PRACTICE MANAGEMENT

website, so patients can check you out in advance and feel confident in you. Get your registration forms online. Rehearse and standardize the protocol for a patient visit from arrival at the door to dismissal at the door. Look at everything from the patient’s perspective, and ensure every member of your team is completely comfortable and natural so patients don’t sense any unease.

SMALL TALK

A millisecond that can change everything Drs. Joel Small and Edwin McDonald discuss the power and consequences of words

here is an old saying that our success is determined by the “three A’s” — ability, availability, and affability. There is no question that ability and availability are key components for success of any clinical healthcare practice. Affability is a curious quality, however. In recent years, the “softer skills” of affability have been well researched and have now risen in stature among the critical three A’s. Daniel Goldman refers to these softer skills as “emotional intelligence” in his seminal book of the same name. Becoming emotionally intelligent is a process through which we become acutely aware of our responses and how we show up in any given situation. It is defined as the capacity to be aware of, control, and express one’s emotions, and to handle interpersonal relationships judiciously and empathetically. Critical to this acquired skill is our degree of self-awareness and the ability to self-regulate. Emotional intelligence has become so highly regarded as a leadership competency that there are now widely used assessments to gauge a person’s level of emotional intelligence. The EQ2 assessment is one of these assessments that is widely used by executive coaching professionals. It is often used in conjunction with other leadership profiles such as the Leadership Circle Profile 360 (LCP 360). In combination, these two assessments are commonly used in developing personalized leadership development plans for many of U.S. best corporate leaders. Viktor Frankl in his groundbreaking book, Man’s Search for Meaning, offers this poignant thought: Drs. Joel Small and Edwin (Mac) McDonald have a total of over 75 years of dental practice experience. Both doctors are trained and certified Executive Leadership Coaches. They have joined forces to create Line of Sight Coaching, a business dedicated to helping their fellow dentists discover a better and more enjoyable way to create and lead a highly productive clinical dental practice. Through their work, clients experience a better work/ life balance, find more joy in their work, and develop a strong practice culture and brand that positively impact their bottom line. To receive their free ebook, 7 Surprising Steps to Grow Your Practice Through Leadership, go to www.lineofsightcoaching.com.

38 Endodontic practice

“Between stimulus and response, there is a space. In that space is our power to choose our response. In our response lies our growth and our freedom.” — Viktor Frankl, Man’s Search for Meaning

“Between stimulus and response, there is a space. In that space is our power to choose our response. In our response lies our growth and our freedom.” Often this space between the stimulus and response is a brief, yet critical, millisecond. Each of us faces pivotal moments in our personal and professional lives when a given response in a critical situation could have a profound and enduring future impact with significant consequences. Emotional intelligence is dictated by the responses we choose and can make the difference between success and failure, a committed or compliant staff, or a transformational versus a transactional organizational culture. In our personal lives, the responses we choose may determine the quality of interpersonal relationships or even our family dynamics. Unfortunately, we often choose the wrong response because we unconsciously default to spontaneous knee-jerk reactions rather than making a thoughtful appropriate choice. These thoughtless knee-jerk responses are blind spots that occur at an unconscious level. Many believe that these spontaneous reactions are caused by deeply engrained responses that have become habitual and originate from beliefs and assumptions that we have brought forth from past experiences. Because we are unaware of these blind spots, making a conscious choice to respond differently is difficult. So how do we go from autopilot to making a thoughtful response in these critical milliseconds? Self-awareness is the answer. Understanding the critical nature of our responses and acknowledging that we have a habitual blind spot when choosing an appropriate response is the key. Only then can we short-circuit the reactive knee-jerk

response in favor of an emotionally intelligent response. Carl Jung, the noted psychologist, is quoted as saying: “Until we make the unconscious conscious, it will direct our lives, and we will call it fate.” Bringing the unconscious to a conscious level is a critical step in substituting a mindful, constructive response for a mindless, reactive one. Having this conscious awareness of our habitual default response is also vital to our ability to self-regulate: a mental process through which we control our emotions in favor of making the appropriate response in any situation. Self-regulation allows us to stop, if even for the briefest moment, and even when emotions run high, to consider our best possible response. There would seem to be some truth that our fate, good or bad, is determined by our choice between responding purposefully or defaulting to an inappropriate spontaneous reaction. As the world in which we practice becomes more volatile, uncertain, and complex, our day-to-day stress level increases. The same is true for our staff. When their stress levels peak, they look to us for reassurance and guidance. We must be the calm in their storm by offering support and reassurance. It is during these times of crisis that our responses become magnified and most impactful. These are the moments when the appropriate response is critical. These are the moments when a millisecond can change everything. Emotional intelligence requires an ongoing awareness of how we are impacting those around us. Carefully choosing our responses and the words we use are part of becoming emotionally intelligent. Words are powerful, and responses have consequences. Choose them wisely. EP Volume 13 Number 2

Dr. Jon Irelan discusses advancements in endodontic apical surgeries, driven in large part by microscopy Stepping into the future Similar to other procedures in medicine and dentistry, rapid advancements have been made in endodontic root-end surgery over the past few decades. Micro-CT has furthered our understanding of root canal anatomy and its complexity, while electron microscopy has shined light on the organization of tooth structure. An understanding of the histopathology of periapical disease and biofilms and the means by which they can be addressed have brought clarity to treatment planning and execution of care like never before. Apical surgery has traditionally been geared toward addressing aberrant apical anatomy, including isthmuses and accessory canals, or in situations where apical canal anatomy has been obstructed. It is now understood that several etiological factors can lead to persistent apical periodontitis, which cannot be addressed with traditional orthograde endodontic treatment, including extraradicular infection, foreign body reactions, apical cysts, cholesterol crystals, and apical scarring.1 In addition to becoming more knowledgeable about disease etiology, innovation has provided clinicians with the tools to improve the quality of care delivered. CBCT imagery allows for precise evaluation of each clinical situation and drives minimally invasive treatment planning. Marked enhancement in visualization with the aid of surgical microscopes and the ability to better perform the root-end preparation with ultrasonics have elevated success rates. While studies show traditional surgery without microscopy and Jon Irelan, DDS, MS, MS, received his BS and DDS at Marquette University in Milwaukee, Wisconsin, where he was the recipient of the American College of Prosthodontists Outstanding Undergraduate Achievement Award, as well as Hanau™ Best of the Best: Excellence in Prosthodontic award from Whip Mix®. He continued on to earn an MS in Prosthodontics from Marquette University, after which he practiced as the sole prosthodontist for a 60-practice dental group. Dr. Irelan later earned a second MS in Endodontics from Marquette University where he continues as an Adjunct Assistant Professor. Dr. Irelan lectures nationally and internationally on topics, including complex treatment planning and advanced restorative procedures, and has been published in multiple endodontic and prosthodontic journals. Additionally, Dr. Irelan maintains a private practice in Mount Pleasant, Wisconsin. Disclosure: Dr. Irelan is a consultant for Carl Zeiss Meditec.

Volume 13 Number 2

ultrasonics garnered success rates ranging from roughly 19%-69%,2-6 endodontists now enjoy success rates of roughly 87%-97%.6-17 Despite root-end microsurgery now demonstrating a success rate that rivals most any dental or medical procedure, the perception among lay people and many dental professionals alike is that apical surgeries are reserved as a last-ditch effort.

A brief history Early attempts to address periapical disease surgically can be dated back to the latter part of the 19th century, when dentists were offered an opportunity to ablate the periapical lesion in lieu of attempting to negotiate the tortuosity of the root canal system. As time progressed, root-end surgery was used as an adjunct for traditional orthograde endodontic treatment in situations where periapical healing was unsuccessful, and where perceived etiology could not be improved upon with orthograde retreatment. In addition to resecting a portion of the rootend, a root-end preparation and filling were later introduced. Using a dental handpiece and bur, a key slot prep was placed in the root-end followed by an amalgam or intermediate restorative material (IRM) restoration. As the procedure evolved, success rates continued to improve. While the clinical situation could typically be improved upon by the surgeon, a large component of the procedure centered on providing the surgeon visual and physical access to the site. As a result, osteotomy sites remained sizable, and the root-end resection was performed at roughly 45 degrees to the long axis of the tooth to allow for visualization. The resultant bevel increased potential for unaddressed canal anatomy and the exaggerated exposure of dentinal tubules, which could allow for the transmission of bacteria. In the 1990s and early 2000s, rootend surgery transformed from a traditional surgery into a microsurgical approach as the implementation of microscopy became more common place in endodontics. With microscopy, the armamentarium evolved to suit the newfound visual capabilities of the clinician, and with it, the procedure could be performed with a significant reduction to both the osteotomy size and taper of the root-end resection. These advancements, in

Figure 1: ZEISS EXTARO 300 Mora Interface

addition to improved root-end filling materials like MTA® and bioceramics, have allowed root-end microsurgery outcomes to become highly predictable.

Personal experiences My practice is largely focused on endodontic retreatment and microsurgery, with roughly 50% of cases falling under either orthograde retreatment or apical microsurgery. With the majority of microsurgeries involving the treatment of molar teeth, ideal visualization of the surgical site is my main concern. This requires not only proper positioning of the patient, which allows him/her to remain comfortable throughout the procedure, but also the ability to maintain an ideal posture as the clinician throughout the surgery. My own surgical technique is centered around features offered by the ZEISS EXTARO® 300. Mechanical features I appreciate in particular are the Mora Interface (Figure 1), the Foldable Tubes (Figure 2), and the strong emphasis on single-handed operation. With the Mora Interface, eyepieces are kept level, while the lens can be angled sharply to accommodate the patient’s position. While the Foldable Tubes are a lesser-known feature of the EXTARO, they allow the clinician to remain a greater distance from the scope in instances where the lens is angled back toward the clinician. During surgery, I regularly employ methylene blue dye (Figure 3) for evaluation of root structure and apical anatomy, but I have also found fluorescence mode on the EXTARO 300 invaluable. While the fluorescence mode allows for the detection of cariogenic Endodontic practice 39

TECHNOLOGY

Advancements in endodontic root-end surgeries

TECHNOLOGY

Figure 3: Tooth No. 2 root-end inspection methylene blue

Figures 2A and 2B: ZEISS EXTARO 300 Foldable Tubes

Figure 5: Tooth No. 13 root-end inspection fluorescence mode

Figure 6: Tooth No. 19 preoperative CBCT (axial view)

bacteria by exciting fluorophores that give off an orange-red light, I have personally found it to act as an excellent contrasting tool during microsurgery. Using this augmented visualization mode, dentin and cementum fluoresce brilliantly relative to osseous and soft tissue, allowing for ready identification and evaluation of the root structure (Figures 4 and 5).

Clinical case While apical microsurgery has evolved from a standalone procedure into one that acts as an adjunct to satisfactory orthograde treatment, it can also offer a solution in challenging clinical situations where initial orthograde treatment is less than ideal. In one such case, a 48-year-old female presented with a previously treated tooth No. 19. At the time of initial treatment by an endodontist, physical access to the MB canal was limited by a congenital jaw abnormality that greatly restricted opening and range of motion (Figure 6). Years later, the patient’s range of motion has been further limited by two invasive jaw surgeries. While tooth No. 19 had presented decoronated during initial treatment, it had since been restored with multiple fiber posts and a large zirconia crown. Now experiencing pain and swelling from an acute infection, the patient’s CBCT demonstrated a large radiolucency associated with the apices of tooth No. 19 in addition to vertical bone loss (Figure 7). More definitive treatment options available included extraction or orthograde retreatment (both of which would have 40 Endodontic practice

Figure 7: Tooth No. 19 preoperative CBCT (midsagittal view)

necessitated significant trauma to the temporomandibular joints) or apical microsurgery. With an understanding that orthograde retreatment or extraction might still be required if infection persisted, apical microsurgery was decided upon and rendered. The patient enjoyed immediate postoperative relief and continued to return periodically for postoperative evaluation during the first year. Radiographs showed a progressive resolution of periapical and vertical bone loss noted in the preoperative CBCT, with the 1-year postoperative CBCT demonstrating a reorganization of the periodontal ligament structure of the root surface of tooth No. 19 (Figure 8).

Conclusion The peer-reviewed literature strongly supports the viability of root-end microsurgery. While clinicians often have the opportunity to consider both orthograde and microsurgical retrograde treatments as options, many situations exist where rootend microsurgery offers the only means of maintaining the patient’s natural dentition. As such, it is vitally important that as stewards of endodontic treatment, we educate our patients and colleagues about the significant advancements made in endodontic microsurgery. EP REFERENCES 1. Nair PN. Pathogenesis of apical periodontitis and the causes of endodontic failures. Crit Rev Oral Biol Med. 2004;15(6):348-381. 2. Kim S, Kratchman S, Guess G. Contemporary endodontic microsurgery: procedural advancements and treatment

Figure 4: Tooth No. 2 root-end inspection fluorescence mode

Figure 8: Tooth No. 19; 1-year postoperative CBCT (midsagittal view)

planning considerations. ENDODONTICS: Colleagues for Excellence. 2010: 1-7. 3. Wesson CM, Gale TM. Molar apicoectomy with amalgam root-end filling: results of a prospective study in two district general hospitals. Br Dent J. 2003;195(12):707-714. 4. Rahbaran S, Gilthrope MS, Harrison SD, Gulabivala K. Comparison of clinical outcome of periapical surgery in endodontics and oral surgery units of a teaching dental hospital: a retrospective study. Oral Surg Oral Med Oral Pathol. 2001;91(6):700-709. 5. Halse A, Molven O, Grung B. Follow-up after periapical surgery: the value of the one-year control. Endod Dent Traumatol. 1991;7(6):246-250. 6. Tsesis I, Rosen E, Schwartz-Arad D, Fuss Z. Retrospective evaluation of surgical endodontic treatment: traditional versus modern technique. J Endod. 2006;32(5):412-416. 7. Chong BS, Pitt Ford TR, Hudson, MB. A prospective clinical study of Mineral Trioxide Aggregate and IRM when used as root-end filling materials in endodontic surgery. Int Endod J. 2003;36(8):520-526. 8. Rubinstein RA, Kim S. Long-term follow-up of cases considered healed 1 year after apical microsurgery. J Endod. 2002;28(5):378-383. 9. de Chevigny C, Dao T, Basrani B, et al. Treatment Outcome in Endodontics: The Toronto Study — Phase 4: Initial Treatment. J Endod. 2008;34(3):258-263. 10. Kim S, Kratchman S. Modern endodontic surgery concepts and practice: a review. J Endod. 2006;32(7):601-623. 11. Rubinstein R, Kim S. Short-term observation of the results of endodontic surgery with the use of a surgical operation microscope and Super-EBA as root-end filling material. J Endod. 1999;25:43-48. 12. Christiansen R, Kirkevang LL, Hørsted-Bindslev P, Wenzel A. Randomized clinical trial of root-end resection followed by root-end filling with mineral trioxide aggregate or smoothing of the orthograde gutta-percha root filling–1-year follow-up. Int Endod J. 2009;42(2):105-114. 13. Taschieri S, Del Fabbro M, Testori T, Weinstein R. Microscope versus endoscope in root-end management: a randomized controlled study. Int J Oral Maxillofac Surg. 2008;37(11):1022-1026. 14. Taschieri S, Del Fabbro M, Testori T, Weinstein R. Endoscopic periradicular surgery: a prospective clinical study. Br J Oral Maxillofac Surg. 2007;45(3):242-244. 15. Kim E, Song JS, Jung IY, Lee SJ, Kim S. Prospective clinical study evaluating endodontic microsurgery outcomes for cases with lesions of endodontic origin compared with cases with lesions of combined periodontal-endodontic origin. J Endod. 2008;34(5):546-551. 16. Song M, Nam T, Shin SJ, Kim E. Comparison of clinical outcomes of endodontic microsurgery: 1-year versus longterm follow-up. J Endod. 2014;40(4):490-494. 17. Kang M, Jung HI, Song M, et al. Outcome of nonsurgical retreatment and endodontic microsurgery: a meta-analysis. Clin Oral Investig. 2015;19(3):569-582.

Volume 13 Number 2

Experiencing the power of digital communication. ZEISS EXTARO 300 in y a t S ! h c u to

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.12496 ©2020 Carl Zeiss Meditec, Inc. All rights reserved.

We’re huge fans of underground art. We know it’s the delicate art you create under the surface that allows the restoration above the surface to last a lifetime. When we crafted our EndoGuide® Access Burs and DCtaper™ NiTi Rotary Files, we were inspired by you, the artisans who use them. SS White’s® intelligently designed endodontic system preserves that which matters most vital dentin at the heart of the tooth. We’ll help you craft your masterpieces with healthier roots that sustain beautiful, longer-life restorations, more satisﬁed patients, and a practice that continues to grow.

“All dentin is not created equally, DCtaper™ ﬁles and EndoGuide® burs foster conservation at the heart of the tooth, peri-cervical dentin. The preservation of healthy dentin leads to longer lasting restorations.” – Dr. Eric Herbranson, Endodontist

Visit sswhitedental.com/manta To Pre-Order the NEW Manta Cordless Handpiece and Receive a FREE Endo Starter Bundle Valued at Over $1000.* *Offer valid through August 31, 2020

©2020 SS White All Rights Reserved. SS White® and DCtaper™and Manta™ are registered trademarks of SS White Dental. End-user doctor promotion must be redeemed by the qualifying practice. Please allow 10-12 weeks for free delivery.