Endodontic Practice US July 2012 Vol. 5 No. 4

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July/August 2012 – Vol 5 No 4

Direct or indirect restorations? Drs. Jason Smithson, Philip Newsome, David Reaney, and Siobhan Owen

Fiber post techniques for anatomical root variations Drs. Leendert (Len) Boksman, Alejandro Bertoldi Hepburn, Enrique Kogan, Manny Friedman, and Waldemar de Rijk

Top ten tips: Tip number 2 – Diagnosis Dr. Tony Druttman

Practice profile Dr. Pirooz Zia – A practice filled with canals, culture, compassion, and camaraderie

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PROMOTING EXCELLENCE IN ENDODONTICS

Memo from the Publisher

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

Dear Readers: Summertime is finally here (as the Kenny Chesney song goes)! While school is out, and many of your patients are happily involved with their summer vacations, we know that you are still hard at work, determined to provide them with the best endodontic treatment all year round. As always, Endodontic Practice US is dedicated to helping you reach your treatment goals by providing new information about every aspect of the endodontic experience. In his Endodontics in Focus column, Dr. Druttman offers his second tip on diagnosing endodontic problems. Our CE discusses how to choose between direct and indirect restorations. Dr. Manhart’s clinical article showcases a case study using a core composite and subsequent permanent treatment with glass porcelain restorations. In the Legal Matters column, we are happy to welcome Dr. Eric Ploumis, an attorney/orthodontist, who shows how preparing for the worst can result in the best outcome for the dentist and his family. For practice management, we welcome back Dr. Lou Shuman and Diana Friedman, who illustrate the whys and hows of staying connected to patients on the Internet. Knowing that 97% of dental patients would rather click their mouse than call the practice for information, this article can provide insights to boost your practice’s profitability. Staying connected and building a relationship with patients is becoming increasingly more important. Just as patients want to know that their endodontist cares about them in between appointments, the MedMark team wants to keep you involved in between issues! Please look for us on Facebook, Twitter, LinkedIn, and our website: www.medmarkaz.com/web/. The MedMark editorial team is always interested in endodontist/authors for our clinical and CE articles, practice profiles, practice management and development, or technology columns. Please feel free to contact us for more details or writers’ guidelines for submitting an article. We are all grateful to our authors, peer reviewers, editorial advisory board, advertisers, and columnists, for helping Endodontic Practice US to evolve into the enriching, thought-provoking, engaging publication it is today. As I say on our website: “The success of our business is achieved as a direct result of helping others succeed in their business.” I hope that your business continues to thrive and grow, and while you’re at it, remember to save room for some summer fun! All the best,

Lisa Moler Publisher

Volume 5 Number 4

Endodontic practice 1

Contents 8

14

18

8

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!"#$%&$'()"*+&,' Through the keyhole Dr. Pirooz Zia – A practice filled with canals, culture, compassion and camaraderie

-*")*"#%'()"*+&,' SS White. Bedrock of innovation. Changing the shape of dentistry, again

-,&.&$#, Fiber post techniques for anatomical root variations Drs. Leendert (Len) Boksman, Alejandro Bertoldi Hepburn, Enrique Kogan, Manny Friedman, and Waldemar de Rijk, show that while all fiber posts appear to have commonalities, they are not all the same

26

Anatomy matters–part 2

28

Treating infected roots

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Core buildup using a dual-curing composite and treatment with allporcelain restorations

Dr. John West discusses how anatomy can affect the “finishing” of endodontic treatment

Dr. Jason Bedford shows how a new hydroxyapatite root repair material benefits the apical closure and healing of a large periradicular radiolucency

Dr. Jürgen Manhart discusses a case study using a core composite and subsequent permanent treatment with glass porcelain restorations

36

/.0*0*.%&$1(&.(+*$21 Top ten tips: Tip number 2 – Diagnosis In his second article of the series, Dr. Tony Druttman offers some tips on the often difficult subject of diagnosing endodontic problems

36 2 Endodontic practice

Volume 5 Number 4

Contents July/August 2012 - Volume 5 Number 4

39

MISSION STATEMENT To be a practical journal promoting excellence in endodontics by providing a full range of clinical, continuing education, practice management, and technology articles written by leading specialists.

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PRODUCTION MANAGER/ CLIENT RELATIONS Kim Murphy Email: kmurphy@medmarkaz.com

E-MEDIA MANAGER/GRAPHIC DESIGNER Deidra Cole Email: dcole@medmarkaz.com

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CONTRIBUTORS Julian Webber (Editor-In-Chief/UK Edition) Email: jw@julianwebber.com Richard Mounce Email: RichardMounce@MounceEndo.com

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Cliff Ruddle DDS Email: ruddlec@aol.com Pierre Machtou DDS, FICD

$99 $239

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4 Endodontic practice

10"*&+$(20"3%4) Carestream Dental announces six solutions at Ontario Dental Association Annual Spring Meeting

DiaDent: Dia-Gun & Dia-Pen Warm vertical compaction and cordless obturation

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10,+$%+)(5,#,')5)#$ Stay connected // the engine driving practice efficiency and patient satisfaction

6)',4(5,$$)0/ Coverage groups: don’t be caught dead without one

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Dr. Eric J. Ploumis

Toll-free: (866) 579-9496 Email: kmurphy@medmarkaz.com Web: www.endopracticeus.com © FMC, Ltd 2012. All rights reserved. FMC is part of the specialist publishing group Springer Science+Business Media. 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 or the publisher.

39

Dr. Lou Shuman and Diana P. Friedman

POSTAL ADDRESS MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 Toll-free: (866) 579-9496 Fax: (480) 629-4002 SUBSCRIPTION RATES Individual subscription 1 year (6 issues) 3 years (18 issues)

The latest in endodontic research

New product offerings provide benefits for dental practitioners, streamline workflow, and improve doctor-topatient communication

NATIONAL SALES/MARKETING MANAGER Drew Thornley Email: drew@medmarkaz.com Tel: (619) 459-9595

PRODUCTION ASST./ SUBSCRIPTION COORDINATOR Lauren Peyton Email: lauren@medmarkaz.com

-./$0,+$/ Dr. Kishor Gulabivala

47

ASSISTANT EDITOR Kay Harwell Fernández Email: kay@medmarkaz.com

Direct or indirect restorations? Drs. Jason Smithson, Philip Newsome, David Reaney, and Siobhan Owen

PUBLISHER Lisa Moler Email: lmoler@endopracticeus.com Tel: (480) 403-1505 MANAGING EDITOR Mali Schantz-Feld Email: mali@medmarkaz.com Tel: (727) 515-5118

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Author guidelines Diary Ruddle on the radar A retrospective report on WaveOne

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PAYING SUBSCRIBERS EARN 24 CONTINUING EDUCATION CREDITS PER YEAR!

PROMOTING EXCELLENCE IN ENDODONTICS

Cover image courtesy of Dr. Jürgen Manhart Volume 5 Number 4

Practice profile

Through the keyho e Dr. Pirooz Zia $ SUDFWLFH ÀOOHG ZLWK FDQDOV FXOWXUH FRPSDVVLRQ DQG FDPDUDGHULH

What can you tell us about your background? I was born in Iran, to parents who were both physicians. In 1979, when I was 10 years old, my family and I moved to England after the revolution hit. I spent the next 14 years living and studying in London. While initially the move was a big change, over time, I grew to love all of the positive aspects of the UK. I received my dental degree at University of London (Guy’s Hospital) in 1991. From there, I went to Boston University Goldman School of Dental Medicine Boston (BUGSDM) to become an endodontist, where I was trained by Herb Schilder. Looking back, I feel that I’m really blessed to have lived in three different continents and to have been exposed to three different cultures. As a result, I will encourage my children to get out of their usual environment once in awhile. I want them to learn how to adapt and overcome the feeling of being an outsider. It’s possible to embrace the best elements of each culture. Now, I know a bit about carpets, making a nice cup of tea, and baseball! After finishing the program at Boston, I moved to the Washington DC area, and I’ve lived here for the past 17 years. It is a very cosmopolitan city and a great place to live and raise a family. Is your practice limited to endodontics? Yes. My practice focuses on endodontics only. It does, however, make a great deal of sense for endodontists to get involved in implantology. By nature, endodontists are exacting people. They have a great understanding of the anatomy as well as the skill to perform delicate surgery. Endodontists who wish to expand their services and place implants must invest in serious training first. I hope to see meaningful educational opportunities in the future — perhaps a part-time residency program for practicing endodontists — to get the necessary training. For me, in this area’s competitive environment when so many skilled specialists can place implants, without prolonged training, I wouldn’t be comfortable providing that service. Why did you decide to focus on endodontics? I decided to focus on endodontics because I was attracted to the “micro� and precise nature of the specialty. A millimeter is a long way in our field and is the difference between success and failure. 8 Endodontic practice

Also, in endodontics, we can create and complete outstanding results on a daily basis. The results and the gratification are pretty immediate. In other specialties like prosthodontics or orthodontics, it can take months or even years to get an outcome. Dr. Stephen Buchanan once described himself as an “impatient perfectionist.� I can relate to that! Most importantly, we have the opportunity to meet people in significant pain and distress and provide them with relief and effective care. That is very gratifying. Through our patients, we can make a meaningful difference and a friend for life! How long have you been practicing, and what systems do you use? I have been a dentist for 21 years and an endodontist for 17 years, and use many different systems: 1. For cleaning and shaping—ProtaperŽ (Dentsply Tulsa Dental Specialties). 2. For obturation: Vertical compaction of warm gutta percha. I use the System B for downpacking and the CalamusŽ for backpacking of the canals. 3. Improved visibility: In endodontics, microscopy should be the standard of care. We have microscopes in every operatory — we don’t even have overhead lights! 4. Improved imaging: We use DEXISŽ digital radiography with DEXIS Platinum sensors. Digital radiography is a “no-brainer.� This imaging method gives me instant, clear images, lower radiation, and the opportunity to sit side-by-side with a patient and communicate. The new revolution in endodontics is the ability to see in three dimensions. I have a VeraviewepocsŽ 3De (J. Morita) CBCT. It is a fantastic unit with terrific image quality and relatively low radiation. It has increased the predictability of our treatments and allows us to provide a realistic prognosis prior to commencing treatment. I can see it becoming very prevalent in Volume 5 Number 4

Practice profile

(Top left) This is my amazing team. From the right: my partner Dr. Farshey, my RIĂ€FH PDQDJHU -HQQLIHU 5KHD &ODXGLD 0DULW]D &LQG\ DQG .LUVWHQ 7KH\ DUH DQ exceptional group of people and make me look good every day 7RS ULJKW 2XU - 0RULWD &%&7 XQLW %RWWRP OHIW 7KH RIĂ€FH LV GHVLJQHG WR exude a clean, calm feel %RWWRP ULJKW , KDYH XVHG *OREDO microscopes since 1995

dentistry. 5. ASI carts: It’s important to have a clean, uncluttered, organized, calm ambiance in your office and the operatories. The amalgamation of all the various tools into one unit is very helpful. Technology has made endodontics easier and has leveled the playing field. But, good technology does not make the distinction between who is good and who is great. You also need exceptional patience, intentionality, and awareness to do good work. Dr. Schilder used to create outstanding shapes with just hand-held files and reamers. He filled many portals of exit and lateral canals without fancy gadgets. Even now, I make a concerted effort to slow down and be methodical. +RZ KDV \RXU H[SHULHQFH DQG DIÀOLDWLRQV DIIHFWHG \RXU practice philosophy? I feel that my specific program at BU was very focused on producing good clinicians versus good academicians. I liked that, and it was one of the reasons I chose the program. But, the process of board certification (ABE, which I completed in 2002) completed the circle when I became familiar with the research. I definitely recommend that all young endodontists go through the process. It’s a challenge, but well worth it! My partner, Reza Farshey, also a BU-trained endodontist, is a sharp guy. We took the time to get to know each other as people, and made sure that our philosophies were aligned. That is the most important aspect of making partnerships work in dentistry — whether you have the same core values and outlook in life. We push each other to get better every day. Teaching is the best way to learn. I taught the endodontic residents at University of Maryland for 6 years. I was responsible for teaching vertical compaction of warm gutta percha. There was still a lot of resistance to that technique at the time as most schools taught lateral condensation. I loved it when a student would fill his/her first lateral canal, and suddenly a light bulb would go off! One of the best teachers I ever had was the program director at BU, Carlo Castellucci. I still hear his voice in my head when I’m negotiating a calcified canal. We have some terrific practitioners in our area with a wealth of knowledge. Lecturing locally keeps me up-to-date especially in other specialties, and this is essential. I don’t want to be a oneVolume 5 Number 4

tooth dentist; I want to know a lot about other disciplines and get involved in the treatment planning process. My last, but definitely not least philosophy: stay an eternal student — you are never done learning! Who has inspired you? 1. Dr. Herb Schilder: He had a very clear sense of the realities of the root canal system and what it takes to address them. He then held himself (the clinician) as “cause in the matter.� He proposed that lesions of endodontic origin had a 100% potential for healing (if the tooth was structurally and periodontally sound) and that our ability to deal with the root canal system was the main factor in the success or failure of the case. I loved his clarity, his vision, his passion, and his willingness to take responsibility. 2. Drs. John West and Cliff Ruddle have taken Dr. Schilder’s ideas and have worked hard to make them relevant to today’s practice through creating innovative and efficient systems. They have done this without losing the essence of exceptional endodontics as initially described by Schilder. 3. Marc Cooper (www.masteryofpractice.com), a periodontist by training, is my practice coach. He is all about looking in the mirror and being mindful. I really recommend finding someone who can help you develop the non-clinical skills that we all need to run a successful practice. I feel strongly that even endodontic training programs should include non-clinical skills training in their curriculum. Besides being familiar with the research, it makes sense to educate endodontists in how to lead and manage, especially in this rough economy. 4. My father was a surgeon with exceptional skills, but more importantly, he taught me that people don’t care how much you know until they know how much you care. We need to understand that caring is an indispensable part of health care. What is the most satisfying aspect of your practice? I get to work as part of a team with my referring colleagues, some wonderfully committed professionals, who have over the years become friends. We work on treatment planning and delivering exceptional results. I feel I’m an extension of their practices and really enjoy that. Endodontists are like sculptors, working on the internal anatomy of the tooth. In almost all cases, I can look at Endodontic practice 9

Practice profile

a preoperative image and form a “future memory” of what the postoperative image will look like. Then, with the help of my extraordinary team, I create it! To see a mental image become reality is very fulfilling. I think it’s up to our generation of endodontists to undo the historical negative image of root canals. To exceed a patient’s expectation as far as the totality of their experience is a wonderful interaction.

the waiting room with calming messages and beautiful scenery. Patients arriving from the hubbub and traffic are treated to calm, subliminal messages. The quality of our communication is our “secret sauce.” How many times in your life, when it comes to interactions, do people sit down and listen to you, explain something to you, do what they say they would do in a timely manner? They should be respectful of your time and comfort and follow up long after you have paid the bill. Besides calling right after the procedure, we call our patients a month after the root canal and ask if they got the final restoration done, and if they are comfortable. My imaging methods also help me achieve this goal. I am a very visual person and use PowerPoint presentations and preoperative imaging to educate my patients. This connects me to my patients and makes me accountable.

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Professionally, what are you most proud of? I’m certainly proud of having come to a very “saturated” area in terms of the ratio of endodontists to restorative dentists and creating a practice that is successful, consistent, and stable. We ask every single one of our patients for feedback, and it has been overwhelmingly positive. So, I’m proud of having worked hard to earn the respect and trust of my patients and colleagues. It’s something we have to strive for every day and never take it for granted. I never get comfortable! The essence of life is relationships. Mostly, I’m proud of the phenomenal relationships that have been formed around me, whether it’s with colleagues, my partner, or my wonderful staff. We have each other’s back. I’m surrounded by givers and proud to be “in the trenches” with them. These things mean a lot more to me than any awards or recognition I may have received. What do you think is unique about your practice? We are uncompromising about our commitment to excellence. We define it as the natural result of consistently adhering to the core fundamentals without cutting corners. We have embraced the technology that allows us to deliver great care, such as equipping all rooms with operating microscopes and being among the first practices in the area to acquire the CBCT. The quality of the endodontic care is like the quality of the food at a restaurant. The food needs to be great, but it’s only part of the experience. We are focused on providing exceptional service and are tuned into all aspects of the patient’s senses — what they feel, hear, see, and smell. We have a flat screen TV in 10 Endodontic practice

What has been your biggest challenge? It has taken me a long time to understand that it’s about energy management versus time management. We have to wear many hats concurrently, as leaders, managers, clinicians, and “rainmakers.” I have also had to learn to prioritize effectively, to deliver my best at the office and still have enough energy left in the “tank” for the people who matter most — my wife and kids!

What would you have become if you had not become a dentist? A professional tennis player! I really loved tennis as a kid and definitely dreamt of raising the Wimbledon trophy. I was “gently encouraged” by my folks to pursue “something a bit more sensible,” so here we are. I get to raise several mental trophies a day with each successful result. Great tennis champions are perceptive, proactive, and reactive all at the same time; the same qualities that you need to be a good endodontist — I just use files instead of a racket! I am really grateful for my profession and the opportunities that it has afforded me. What is the future of endodontics and dentistry? Endodontics is more exciting than ever. We have a profound understanding of the elements that are needed for success, and we have fabulous technology and innovative techniques to satisfy them. Endodontics has never been more predictable, efficient, and comfortable for the patient. I know that we are struggling with a deep downturn in the economy that has affected all of us significantly. But, I know that “this too shall pass,” and through it we can learn to become better, provide more value, and be of more service to others. Although it seems like a cliché, out of every adversity comes abundance. There will always remain an appreciation for quality, patient-centered dental care. I see the pendulum swinging back on the issue of teeth being “sacrificed” for implants. I think it is crucial that endodontists make the effort to educate our colleagues about the predictability of a properly performed endodontic procedure. We must know all that we can about the alternatives so that we can provide our patients with intelligent and cost-effective treatment options. We can’t be passive observers. We must be advocates of what serves our patients best. I have joined forces with other endodontists in the Volume 5 Number 4

Practice profile

community to educate our colleagues with a uniform message. I am happy that implants are an option for certain dental conditions, but the public also deserves information on quality endodontics. Endodontists should make a case for our specialty as a whole, not just for their specific practice. What are your top tips for maintaining a successful practice? 1. Have a clear, authentic, patient-centered vision that your team can commit to rather than comply with. This is the main job of a leader, and you must lead! 2. Work hard on learning to listen and being more “relational” vs. “transactional.” People are generally not listened to very well. Listening can be powerful, and you run the risk of actually learning something! 3. Take the time to develop and implement sensible managerial systems. Write the “managerial software” that will make the practice run — that way you can spend more time doing what you are best at — endodontics. 4. Be committed to “Kaizen” (Japanese for continuous improvement). Every day ask yourself: “What did I do to improve the practice?” and “What did I do to grow the practice?” 5. Don’t listen to coaches that tell you to deliver doughnuts to your referrers. You’ll only kill them sooner of a heart attack! And, that’s not good for business. If you are truly committed to the success of your referring colleagues, then you will see the reciprocation. What advice would you give to budding endodontists? 1. Create the time to sit down and form a clear vision of what you want your practice to be like and who you want to be. “Being” is a lot more important than “doing.” So many of us have a to-do list. Only a few people take the time to make a to-be list. This will define your core values. Then stick to them! Don’t let anything/ anyone, not the insurance companies, your referring doctors, or your patients, talk you into compromising your values. 2. Beyond that, it’s about working hard to consistently deliver value to your patients and referral colleagues. The trust placed in you by them is worthy of your absolute best effort, every day! 3. Don’t be afraid of failure. A productive failure is more valuable than an unproductive success. 4. Don’t focus on generating income. Focus on providing value by doing great work. 5. Surround yourself with good mentors and teachers. Then, be coachable! 6. Look for ways of giving back to your profession and your community. 7. Always be grateful and humble. What are your hobbies, and what do you do in your spare time? I follow tennis pretty closely and play as often as I can. It used to be a lot more often before we had kids! (Time is a thief!) Luckily, both my sons are getting into playing tennis now, so they tag along. My 7-year-old loves it. I’m banking on him winning Wimbledon in 15 years (who needs a retirement plan!). I also love skiing. The mountain air clears my head. I don’t do the double-diamond runs anymore. A few blue runs and then a nice cup of hot chocolate! I’m trying to stay fit and take care of my back. I absolutely detest going to the gym, and have a trainer who truly enjoys inflicting pain and suffering. (I can’t believe that we endodontists are the ones with the bad reputation). Beyond that, I love spending time with my family and 12 Endodontic practice

friends. There is a difference between success and significance. Nido Qubein, president of High Point University, once told me that success is about fans, fortune, and fame. Significance is about family, friends and faith. At the end of the day, these are the things that will matter most. EP

Top Ten List: 1. An amazing team of people who understands and is committed to a common vision. 2. The ASI units (Advance Integrated Systems). I hate clutter, and these units are extremely well made. 3. Great educational software to help me communicate effectively with my patients. 4. DEXIS® digital radiography and sensors. The instant images which are produced with less radiation are a “no brainer” for diagnosis and clarity of communication. 5. Veraviewepocs® 3De CBCT (J. Morita). It is fantastic. The ability to remove superimpositions and get multiple perspectives on a tooth has revolutionized our field. We have a much clearer idea of pitfalls and prognoses before we start a case. No pilot should take off without a flight plan! 6. ProTaper® rotary files. 7. The electronic apex locator. 8. Chlor-XTRA™ (Vista Dental Products), 6% sodium hypochlorite with surface modifiers. This is far more effective than regular bleach in dissolving tissue because of the lower surface tension that allows it to really “bathe all the canal irregularities.” 9. System B for vertical compaction of warm gutta percha to seal all portals of exit and Calamus® to “backpack.” 10. A sense of humor! Take what you do seriously without taking yourself too seriously.

Pirooz Zia, BDS, MScD, maintains full-time private practice in Chevy Chase, Maryland, and he presents seminars nationally and internationally on current endodontic techniques. He was an associate clinical professor at the University of Maryland School of Dentistry, and has lectured at Boston University, the University of Michigan and the University of London, England. Dr. Zia is a Diplomate of the American Board of Endodontics and an active member of the American Association of Endodontists, the American Dental Association, and the DC Dental Society. He is the 2001 recipient of the District of Columbia Dental Society’s David Mast Memorial Award for excellence in continuing education. He was voted one of Washington’s “Top Dentists” in a survey of his peers conducted by Washingtonian magazine and was voted among “America’s Top Dentists” in a similar national survey. He is a Fellow of the International College of Dentistry, which is dedicated to advancing the science and art of dentistry worldwide. Volume 5 Number 4

Corporate profile

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Sometimes inspiration can be found in the very tools you’re using. Nobody understands this more than SS White, who for more than 160 years has been changing the shape of dentistry every day. Today, SS White’s innovation and advancements are helping to create the masterpieces that are improving patient satisfaction and the bottom line. Their innovation. Your work of art.

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ew companies can trace a corporate history with a bedrock of innovation that spans over 160 years. Today, SS White Burs, Inc. is a family owned and operated U.S.-based business with more than 250 employees and worldwide distribution. Its corporate roots are found in the history of Samuel Stockton White, who began his career as an apprenticing dentist and ventured into his own business in 1844, manufacturing porcelain teeth, in Philadelphia, Pennsylvania. The company proudly bears the name of its founder and continually maintains its original objective: better products for better dentistry.

Founder: Samuel Stockton White

CEO, Tom Gallop, and Director of Worldwide Marketing Brant Miles, discuss their thoughts on the future of the industry and how their new campaign, Practice Inspiration, is more relevant than ever. !"#$%&'()%*+#,$-,(% ./)0-+#$-'/%1(#/%$'%2'34 5'1%6#77'089:; “Inspiration is the vehicle that moves a team to work together to obtain the greater good. In the dental practice, an inspired team works more effectively together, leading to increased practice success. Inspiration can be discovered in many different forms, but is most heartfelt and motivating to the dental team when coming from a patient, often in the simple form of a thank you; maybe for a painless procedure or the creation of a beautiful smile.”

14 Endodontic practice

!"#$%1#<()%$"-)%,'+0'+#$(%0"-7')'0"2%)'%#007-,#=7(% $'%$"(%-/&3)$+24 “The instruments manufactured by SS White allow clinicians to find the proper balance between three important factors: health, business and art. Patient satisfaction, which leads to increased case acceptance and referrals, is greatly enhanced when functional and beautiful restorations are fabricated and delivered in a timely manner, provide maximum patient comfort during and after the procedure, and enhance their smile. The instruments developed by SS White, when used in conjunction with the latest clinical techniques and procedures, allow clinicians to create more beautiful smiles, which lead to more satisfied patients.” >'?%"#)%2'3+%,'10#/2@)% -//'A#$-A(%"-)$'+2%"(70(&% $'%)"#0(%$"-)%,#10#-B/4 C+#/$%D-7()8E-+(,$'+% !'+7&?-&(%D#+<($-/B “SS White was founded in 1844 by Samuel Stockton White, a practicing dentist who was not satisfied with the quality of care and product offered at the time. Dr. White’s passion of changing dentistry for the better remains a core building block for which the current generation of employees within SS White strives to achieve. SS White has the drive and commitment to work with leading clinicians worldwide to bring better dental care to more people around the world, inspiring them to achieve better patient outcomes.” !"#$%,#/%?(%7''<%F'+?#+&%$'%F+'1%GG%!"-$(4 “Our commitment is to manufacture the highest quality dental products, designed with purpose to bring value to the clinician, technician, dental team, and most importantly, the patient. The core values of SS White revolve around manufacturing more conservative, efficient, and effective dental products. We continue to create and seek innovative products that will advance dentistry; to question, listen, and respond to new ideas and challenges from the dental community. We embrace the astonishing Volume 5 Number 4

Corporate profile

for the doctor; the introduction of Jazz Supreme Polishers has helped to create faster, more beautiful smiles, while Great White Z Diamonds allow dentists to cut zirconia with greater efficiency and time savings. While SS White enjoys a leadership position in the dental industry, we also feel a need to serve the community in which we work. We hunger to help solve bigger problems and strive to act in a manner that offers integrity and humility, knowing that we do not always have all the answers. SS White sincerely appreciates the cooperative effort and relationships with many of the leaders in the dental community over the past few years in new product design, development and introduction.”

developments of the 21st century; advances in dental research; sophisticated restoratives; and the perfection of new technology in instrumentation that will elevate the future of dentistry to a level limited only by the imagination and synergy of engineers and the dental clinicians we serve.” !!"#$%&'"&()*+"%,"-".'*'/(-&'0" 12'(%.-3".425-3+ SS White lays claim to being the sole remaining major America-born manufacturer of carbide burs still in operation, making all of its carbide instruments in Lakewood, New Jersey while outsourcing nothing. SS White manufactures and guarantees 100% customer satisfaction for every carbide bur it sells. SS White is dedicated to the dealer network of sales operations and works closely with its dealers to provide personal service and value to dental professionals across the globe. SS White currently markets and sells its diamond and carbide products in over 100 countries worldwide, and more innovations are yet to come. Today, SS White’s second-generation family leadership and skilled management and manufacturing teams, continue to preserve the tradition of bringing the highest quality dental products to market, providing dentists with precision instruments that maximize clinical efficiency, enhance patient comfort, and increase the opportunity for the ultimate clinical outcome of a beautiful, functional smile for each and every patient. 6$'"'3&$),%-,2"47"8(9"#$%&'"':%,&,"&40-+ Current CEO Tom Gallop states, “We understand that SS White holds an eminent place in dentistry as a great innovator, manufacturer, and charitable sponsor, and we will continue to promote these values. SS White is committed to helping dental dealers and doctors with their bigger challenges. We have seen that in these trying times, it is very important to help doctors increase patient satisfaction and referrals through the use of patient-friendly dental instruments, such as Fissurotomy. This is an example of an instrument that is minimally invasive, promotes the conservation of healthy tooth structure in class 1 lesions and that most often does not require the use of anesthesia. Conversely, doctors that are extremely busy in their practice have been overwhelmingly positive in the time savings allotted to them by using the latest in efficient rotary instrument designs by SS White, such as the Great White Burs. We are passionate about solving problems Volume 5 Number 4

6$'";('-&"#$%&'<"=%3'"47">-(/%0'"-30"8%-2430 ?3,&()2'3&, Great White Gold Series Burs are engineered using a proprietary design that revolutionized the carbide bur market. Proven to cut the hardest and most challenging dental material, such as composite and semi-precious metals, with greater efficiency and less chatter. Great White Gold Burs significantly reduce restoration removal and preparation time, saving clinicians up to 50 hours per year in operatory time. Great White Z Diamonds are engineered for superior cutting of ceramic and zirconia-based crowns during crown removal, endodontic access and lab procedures.

@%,,)(4&42+<A"B-&'3&'0"C%3%2-**+"?3D-,%D'">-(/%0', Developed in collaboration with Temple University, the Fissurotomy instrument head shape allows early diagnosis and conservative preparation of fissure caries, often without the use of anesthesia.

B%(-3$-<"!%3E*'FB-&%'3&FG,'"8%-2430, Piranha single-use burs are specifically designed to increase office efficiency and clinical effectiveness by using a new diamond for each procedure. Piranha diamonds offer greater tactile feel, leading to more consistent performance and more precise results. Over 500 shapes, sizes and grits; cuts as fast as pricier alternatives, at a fraction of the cost. Endodontic practice 15

Corporate profile

It’s time to elevate the art of dentistry. Nobody respects this inspiration more than SS White, a worldwide leader in creating the tools that inspire dental masterpieces every day — works of art that are moving businesses and patients alike.

removal, root canal access, and finishing; gutta percha, paper points; and endodontic motor and handpieces.

!"#$%&'$()*++*,-./"0$*1#$20(*30"-4#.*+5(%$'"05%( Developed in conjunction with Temple University, Smartburs II are the intelligent option for safe, painless caries removal. Smartburs II preserve the existing healthy tooth substance and reduce the risk of unintentional pulp exposures. Offering a more patient-friendly, conservative, treatment option. Smartburs are the instrument of choice to help foster patient referrals.

657-8'270 EndoGuide™ Burs are a unique set of eight burs for nonsurgical root canal treatment. The patented, conical shaped micro-diameter tip acts as a self-centering guide for straightline access to canals, maximizing treatment efficiency and conserving healthy pericervical dentin.

90:*,$-7';%*<250=*!!*>?2%0)*1@36A*657-7-5%2;( Clinical collaboration is the fundamental building block of SS White’s new CORE™ Endodontics selection of innovative products developed for root canal procedures. Complementing SS White’s recently launched EndoGuide® product line is the addition of the patented Guidance™ endodontic product group, designed by Dr. Charles Goodis, which now carries the SS White® brand names of V-Glide Path™2 files, V-Taper™2 NiTi rotary files and V-Fill™2 obturation system. The product line is designed to support techniques that emphasize conservation of healthy dentin as well as a systematic approach to efficient and effective root canal procedures. Other products included in the SS White® CORE™ Endodontics line include the patented V-Clean™ endodontic agitator; specially selected rotary instruments for restoration 16 Endodontic practice

!!* >?2%0)* BCD#E0$AF* 92D2* 3-%#$/* 657-7-5%2;*G2.0*!/(%0" This performance-enhanced rotary file system shortens treatment time through use of fewer files per case, allowing for safe, efficient, conservative root canal treatment. Use of V-Taper™2 rotary files allows most molar and premolars to be completed with two to three rotary files and anterior teeth with one to two rotary files. V-Taper™2 is a series of patented, variable-taper NiTi rotary files that permit deeper apical shapes with fewer instruments. The files yield a conservative access path that retains more healthy tooth structure at the heart of the tooth, which is critical to support longer-lasting restorations. V-Taper™2 rotary files feature a parabolic cross-section design that combines high efficiency and flexibility while being safe and resistant to fracture. These desirable features allow the clinician to effectively combine access and shaping into a single integrated process. When establishing canal patency the V-Taper™2 rotary files are ideally preceded with use of V-Glide Path™2 files. Used together, the V-Rotary File System adds precision to root canal procedures, while saving chair time and reducing stress for operator and patient. BC1.0#5A*657-7-5%2;*H82%#%-$ SS White V-Clean is a medical-grade polymer hand instrument, uniquely designed for cleaning the surfaces of a filed root canal. V-Clean™ is constructed of multiple flexible paddles that protrude from its semi-rigid shank. The paddles are oriented in opposing directions along the length of the shank, and facilitate a dualaction scrubbing and scraping process. V-Clean™ will remove the smear layer, dislodge and remove debris from the canal and concurrently provide an agitating action when used with disinfecting or irrigating solutions. In a University study, use of V-Clean™ reduced bacterial contamination within the root canal on average by 90.2% compared to use of irrigation alone. EP This information was provided by SS White. Volume 5 Number 4

Clinical

!"#$%&'()*&*$+,-"./$)&0(%&1-1*(2"+13& %((*&41%"1*"(-) 5%)6&7$$-8$%*&97$-:&;(<)21-=&>3$?1-8%(&;$%*(38"&@$'#/%-=&A-%"./$& B(C1-=&D1--E&!%"$821-=&1-8&F138$21%&8$&G"?<=&),(H&*,1*&H,"3$&133& 0"#$%&'()*)&1''$1%&*(&,14$&+(22(-13"*"$)=&*,$E&1%$&-(*&133&*,$&)12$

T

he purpose of this article is to identify and describe the newer materials and techniques deemed as viable alternatives to metallic post/cores, and to propose a rationale for the selection of one product or restorative technique protocol over others for simple and complex post-endodontic restorations. These are indicated where remaining coronal tooth structure is less than 50% and/or the core strength is compromised by the endodontic access opening. !"#$%&'()* Custom cast posts were first described more than 100 years ago, and utilized the optimal impression techniques, casting, and cementation materials available at that time. In most of the world, cast posts (still taught in some dental schools) have been supplanted in clinical practice by prefabricated posts made either of metallic alloys or from fiber-reinforced composite. In even a cursory review of the literature, the evidence-based support for a trend away from metal posts to fiber posts is abundant and conclusive: Fiber posts, regardless of brand, are anisotropic and have a modulus of elasticity similar to that of dentin (~20 GPa), which allows the post to flex slightly (microscopically) with the tooth and dissipate stress, thereby reducing the likelihood of damage to the root.1-4 Fiber posts are not susceptible to galvanic or corrosion activity; the latter of which is responsible for a high percentage of failures with cast posts5 which, in turn, fail twice as often (clinically) as do prefabricated metal posts.6 Fiber posts are available in translucent and tooth-colored versions (the original black carbon posts are passé), which are esthetically invisible under all ceramic crowns, veneers and resin restorations, and also mitigate the effects of the dark root syndrome (Figure 1).7,8 Fiber posts (excepting a South American post design that has a metal wire running through its long axis) are more easily and safely removed “by hollowing them out from the inside,” should retreatment ever become necessary.9-12 In fact, cemented metal posts may further limit or complicate endodontic treatment options if these become necessary.13 While all brands of fiber posts appear to have these commonalities, they are not all the same; they can vary considerably from brand to brand in terms of composition and microstructure. The difference in the manufacturing process of the posts can significantly influence their mechanical properties,14,15 and thus their clinical performance. Furthermore, a connection can be found between the data obtained with SEM observations of fiber posts and their clinical behavior. SEM photographs (Figures 2-4), taken at the same (700x) magnification, show the variations in size of fiber, orientation, number of fibers, amount of composite, and the relative percentages that vary from fiber post to fiber post. In fact, posts that have more imperfections in the matrix will have a less compact and even structure, and thus are weaker and less resistant to load stress.14 18 Endodontic practice

Figure 1: Typical gingival darkening created by metal post and core technique

Figure 2: Cross section of a good quality post that is highly loaded with fibers with no voids

Figure 3: Cross section of a poor quality post showing lower fiber loading with voids in the matrix

Figure 4: Cross section of a fiber post with low-fiber and high-resin matrix content

Figure 5: Radiograph of various shapes, designs, and tapers of early radio-apparent fiber posts

Figure 6: Radiograph of typical fiber post when prepared for a 1.5 mm taper

Figure 7: The Macro-Lock Illusion X-RO (CLINICIAN’S CHOICE) shows excellent radiopacity at 1.5 mm post space preparation

Figure 8: Same tooth radiographed with a popular radio-apparent fiber post

Increases in the mechanical properties (fracture strength) appear directly proportional to the density of fibers and to their interface/bond to the matrix.16 In addition to influencing flexural strength, the fiber type, density, and uniformity of microstructure also affect the radiopacity and fatigue resistance. Figure 5 shows the relative radiopacity of various fiber posts side by side, and Figures 6 to 8 demonstrate the same variation in an extracted tooth that is prepared for a 1.5 mm tapered fiber post. It is obvious Volume 5 Number 4

Clinical

Figure 9: Scanning electron microscope photograph of intimate adaptation of fiber post, dual-cure resin cement and root dentin

Figure 10: Parallel-sided fiber post of 1.5 mm does not seat in same tooth without more apical removal of dentin structurally weakening the tooth

Figure 11: A 1.5 mm parallel post with lateral serrations and core bulk again requires more apical dentin removal to seat to same length as the tapered Macro-Lock Illusion X-RO (compare to Figure 7)

Figure 12: A conservative nonflared canal is ideal for a conservative flared fiber post preparation

Figure 13A: Clinical presentation of failed post and core crown on upper right central incisor

Figure 13B: A small starter drill is used to initiate removal of the gutta percha

Figure 13C: The appropriate size tapered Macro-Lock drill is used to maximize size while minimizing dentin removal

Figure 13D: The Macro-Lock Illusion X-RO post inserted and checked for fit. Notice the small space between the post and the walls of the post preparation. A diamond is then used to shorten the post to the desired length

Figure 13E: An acid gel (UltraEtch [Ultradent Products]) is injected from the bottom of the post space up to the cavosurface margin by using a 20- or 22-gauge needle to avoid air entrapment

Figure 13F: After water rinsing from the bottom of the canal up, and light drying, the canal is checked for excess moisture with a paper point; the bonding agent is placed in the canal and lightly agitated to increase the bond strength to the dentin

Figure 13G: After air-thinning the bonding agent from the bottom up, the canal is checked for excess bonding agent with a paper point, and the bonding agent is cured with a high output curing light for 20 seconds

Figure 13H: The bonding agent is applied to the post with a microbrush

that the Macro-Lock Illusion X-RO (CLINICIAN’S CHOICE) is the most radiopaque in this sampling of fiber posts (Figure 7). Quartz fibers are among the most radiopaque fibers being used,17,18 and the quartz fiber posts have proven superior in fatigue resistance to glass fiber posts15 and to metal posts.19 Fatigue tests can be considered as the most relevant methodological standard for evaluating and predicting the behavior in an oral environment.18 The in vitro studies that, more than any other, permit the fair prediction of yielding and, therefore, the long-term behavior of the restoration, are the fatigue tests.20,21 Into the 1970s, it was hoped that metal posts could help reinforce weakened endodontically treated teeth. In the 1980s, Sorensen, et al.,20 surmised otherwise. Today there is a growing body of in vitro evidence that if properly placed, low modulus restorations (quartz fiber posts with bonded composite cores) with varying amounts of remaining tooth structure can, in fact, provide some restrengthening of weakened teeth restored with MOD restorations, veneers, or full-coverage techniques.22-26 Figure 9 shows a high-power SEM of the adaptation possible with an appropriately sized bonded fiber post creating a “monoblock.” A ferrule of 2 mm has to be provided for the reconstruction of endodontically treated teeth by post and core techniques. (Studies show that increasing the length of a ferrule from 1 to 1.5 mm in a Volume 5 Number 4

quartz fiber post does not significantly increase fracture loads, but an increase to 2 mm results in higher fracture thresholds.) Now the clinical observation of carbon27-30 or glass and quartz fiber31-34 post restorations offer admirable performances at 7 to 11 years’ conclusion,35 and the difference in failure rates particularly catastrophic failure rates - between fiber posts and cast posts is no less compelling at 4 years’ service.36 The placement of a single fiber post in a relatively “round” and minimally tapered conservative root canal has been described in many articles and is now appearing in textbooks. There is evidence that (unlike metal predecessors) there is no difference in the performance between tapered and parallel fiber posts.37,38 However, it is self-evident to an experienced clinician that parallel posts may often require the removal of additional dentin and the creation of acute internal angles (stress magnets). Therefore, the tapered apical/parallel body shape is preferable39-41 if only for the sake of dentin conservation. Figures 10 and 11 show the same tooth as above, prepared for a tapered 1.5 mm fiber post. It is obvious from the radiographs that more tooth structure at the apical end of the canal would need to be sacrificed to allow the parallel 1.5 mm posts to seat to the same length, needlessly weakening the remaining root structure. So, then, what is the contemporary technology protocol, Endodontic practice 19

Clinical when faced with a flared, ovoid, or figure-8 canal? Circular parallel post systems are only effective in the most apical portion of the post space, because the majority of prepared post spaces demonstrate considerable flare in the coronal half. Similarly, when the root canal is elliptical, a parallel-sided post will not be effective unless the canal is considerably enlarged,42 thereby needlessly removing extra dentin. From a clinical perspective, when assessing posts that have failed, many are, in fact, cemented or bonded to areas in the canal still occupied by gutta percha. One of the causes for the lack of resultant retention is due to this oversight, which is a direct result of preparing a round canal space with a rotary instrument in a canal that is never round. There are two prefabricated posts available (in limited market areas) that are designed with a rounded, tapered apical extremity, and an oval coronal section (PeerlessPost™ [SybronEndo] and ELLIPSON™ [RTD]). The low modulus approach needs to be adaptable to the over-flared canal, while addressing the inherent challenges, which include C-factor stress and S-factor stress,43 polymerization shrinkage and, presumably, microleakage. Most fiber posts on the market come in cylindrical sizes that mimic their metallic ancestors, so that the practitioner may use the drills already purchased. However, as previously discussed, a tapered preparation is the most noninvasive. Unlike fiber posts, as the diameter of metal posts increases, so does the stress transfer to the tooth,44 and so, logically, does the likelihood of root splits. There are some tapered quartz fiber posts that come in extra large sizes that range from 0.8 mm at the apical tip to 2.3 mm at the coronal extreme (DT Light-Post [RTD, BISCO] and MacroLock Post [RTD]). These sizes exceed the diameters available in most brands, and are capable of fitting most root canal treatments without further instrumentation. The authors will now describe and suggest an approach and technique for the inevitable variations presented by prepared and filled root canals, which fall into three proposed treatment categories. !"#$%&'()#$*+,+)$ In a “simple” case, where the canal treatment results in the typical tapered conservative shape (less than 25% larger than the fiber post [Figure 12]), a single fiber post can be inserted and covered with a composite core buildup in preparation for the prosthetic restoration. The clinical protocol for this type of case is as follows: All procedures inside the root canal should focus on the bottom-up approach; the canal is prepared with the matching sized post drills and posts, and all remnants of gutta percha must be removed from the walls of the post space to facilitate bonding. The fiber post is generally shortened to the height of the core with a diamond bur before the bonding procedure is started, but it can also be cut with a diamond bur after the core is cured. If using a self-curing resin cement, the post should always be cut to length first, so as not to vibrate the post while the cement may be setting. Fiber posts can be cut to length after the core is placed, but colorchanging posts are unique. A color-changing post should be cut 1.5 mm short of the anticipated coronal extent of the core, and thus be buried in the core composite. This is done to prevent reappearance of the color under translucent ceramics due to exposure to intraoral temperature changes when the patient ingests cold beverages or food. The clinical presentation and treatment of a case that is typical for the simple canal is shown in Figures 13A to 13N. The tooth is isolated, and gutta percha is removed with a small starter drill (Figure 13B), and the post space is created with the appropriate size taper drill (Figure 13C). Care should be taken to match the post, as close as possible, to the size of the existing canal space rather than over preparing the canal for a large 20 Endodontic practice

post. At this time, all remnants of gutta percha should be removed and verified visually with magnification. (Some practitioners use chloroform to dissolve any remaining gutta percha in the post space area.) The fiber post (Macro-Lock Illusion X-RO is tried in the canal {Figure 13D}). Then, it is trimmed to length with a diamond bur to prevent chatter and possible damage to the post. To decontaminate the post after try-in and length adjustment, it is cleaned with alcohol prior to bonding. The canal is acid etched by placing the acid gel from the bottom up using a 20- or 22-gauge needle tip (Figure 13E). This is done to keep an air lock from forming below the etchant, which would prevent etching of the entire canal space. It has been shown that agitating the acid with a microbrush during this 15-second procedure increases bond strength. The canal is rinsed with water, again from the bottom up, using a 20- or 22-gauge needle adapted to either a Stropko Irrigator™ (CLINICIAN’S CHOICE) or TriAway™ Adaptor (Ultradent Products), to thoroughly wash and remove the acid gel out of the canal space. This cannot be achieved with a typical threeway syringe, which can leave some acid in the canal, interfering with the chemical setting reaction of a dual or self-cure cement. The canal is lightly dried using air from the bottom up and then double checked with a paper point. The adhesive bonding agent is placed with a microbrush and agitated into the opened tubules of the root canal (Figure 13F). Air is delivered from the bottom up, and excess bonding agent and pooling is prevented by inserting a paper point to absorb any excess. The bonding agent is then lightcured with a high-power, broad spectrum LED curing light for at least 30 seconds (Figure 13G). It must be remembered that light intensity for some curing lights falls drastically with distance, so the cure must be adequate. There are only three possible solutions for this: (1) a dual (photo and chemical) activation adhesive, (2) conducting the light through the post and photo-activating it together with the resin cement, or (3) light-curing adequately with a high-power light (such as the VALO® [Ultradent Products]) in its plasma emulation mode, 3 seconds at over 3,000 mW/ cm2. The point here is that if light-cured adhesives are used, undercuring will lead to failure. Next, bonding agent is applied to the post (Figure 13H) and light-cured (Figure 13I). Then, after the dualcure resin cement is placed into the canal with Skini Syringe mated to an Endo-Eze® tip (Ultradent) [Figure 13J], the post is inserted, and the dual-cure resin cement is light-cured for 30 seconds (Figure 13K). It is best to inject the dual-cure resin cement from the bottom up rather than using the lentulo spiral. This prevents any possible air entrapment and prevents the acceleration of set caused by the lentulo-spiral drill. The core material is injected around the post, and then light-cured (Figure 13L). The final preparation of the core for the patient is shown in Figure 13M, and the final Zirconia (ZirkonZahn®) [ceramic] restorations are shown in Figure 13N. There are many recommendations being made for the selection of cementation media and placement technique. Standard bonding tests would support the use of a fourth-or fifthgeneration adhesive system (i.e., All-Bond 2® [BISCO] or OneStep® [BISCO], SealBond Ultima™ [RTD], MPa™ [CLINICIAN’S CHOICE] respectively) in conjunction with dual-cure or chemical-cure resin cement, as being superior to self-etching or self-adhesive cement formulas.45 Clinical success with these also assumes proven chemical compatibility between the adhesive and the resin cement, and meticulous isolation, good access, vision, and technique. This is easy in the in vitro laboratory, but not always so easy in vivo. In cases where access and/or visibility and/or good moisture control are compromised, some post manufacturers and clinicians/ researchers report good results using self-adhesive, self-etching cements46-48 and resin-reinforced glass ionomer cements,49 Volume 5 Number 4

Clinical

Figure 13I: After evaporating the solvent and air thinning, the bonding agent is light-cured

Figure 13J: Using a lentulospiral to insert the dual-cure resin cement will accelerate the set. It is best to inject using a 20- to 22-gauge needle (EndoEze [Ultradent Products]) from the bottom up to eliminate air entrapment

Figure 13M: The clinical preparation of the fiber post and core for full-coverage restoration is shown in this intraoral photograph

Figure 13N: The final ceramic restorations (Zirconia [ZirkonZahn]) on the two upper central incisors

Figure 15A: In this type of canal, the tooth is isolated and prepared to a post size that will fit at the apical end without overly enlarging the prepared canal

Figure 15B: The Macro-Lock Illusion X-RO post is verified for fit — notice how the canal flares and there is excess space at the coronal aspect

Figure 15C: Using a brush, a water soluble separating medium is applied to the post space

Figure 15D: A light-cured composite (such as Grandio [VOCO]) is adapted to the prebonded post

Figure 15E: The post and hybrid composite are seated into the prepared post space creating a custom post

Figure 15F: After light-curing, the custom fiber post and core is removed — this mitigates the S-factor by allowing the resin to shrink toward the post

Figure 15G: The custom fiber post and core, the result of creating a core build-down into the canal

Figure 15H: After a thorough rinsing of the prepared canal space and the custom fiber post and core, the core is reseated in the canal and the labial aspect marked with a pencil

Figure 15I: The canal is etched, and the etchant is agitated with a microbrush, rinsed from the bottom up, and a bonding agent is agitated into the dentin and light-cured

Figure 15J: Labial view of Macro-Lock Illusion X-RO post inserted into the cement

Figure 15K: The post is seated into the canal with the pencil marking placed labially. The custom posts allow for a minimal thickness of luting cement, thus, minimizing the S-factor. Excess cement is removed before light polymerization

Figure 15L: The margins of the tooth preparation are refreshed and etched prior to bonding the core

Volume 5 Number 4

Figure 13K: After insertion of the fiber post into the dualcured resin cement and placed to length, the cement is cured with light down the long axis of the fiber post for 30 seconds

Figure 13L: After injecting and hand sculpting the core material around the remainder of the fiber post, the composite resin is light-cured

Figure 14: A typical cross section of a tooth with a mildly flared canal, which results in some excess space around the proposed fiber post in the coronal area

Endodontic practice 21

Clinical

Figure 15M: Bonding resin is placed on the dentin prior to hand sculpting the composite resin core, then the core buildup is shaped/completed and light-cured

Figure 15N: This photograph shows the hand-sculpted, custom-fabricated fiber post and core after hand sculpting and light-curing

Figure 15O: The core is finalized with a coarse diamond bur to length and depth requirements for the ceramic crown

Figure 15P: The final ceramic restoration e.maxPress (Ivoclar Vivadent) with feldspathic overlay over the custom fiber post and core is shown in this photograph

Figure 16A: Photo of failed cast post and core with widely flared canal — note the thickness of the prior cement used

Figure 16B: With the gutta percha and cement removed, no other dentin was removed, and the largest diameter fiber post that fit at the apex was the starting point

Figure 16C: The existing canal space was acid-etched with phosphoric acid for 15 seconds and rinsed from the bottom up with a 20- to 22-gauge needle tip. The bonding resin was agitated into the dentin, airthinned from the bottom up and verified with a paper point

Figure 16D: The bonding resin is thoroughly cured with a high output light-curing unit

particularly when using macroretentive quartz fiber posts (MacroLock™ Illusion™ X-RO). However, it should also be noted that some of the comparative in vitro bond strength studies (to dentin) show these newer generations of cements to be inferior to the “total-etch/moist-bonding” dual-cure cementation technique. Furthermore, a post inserted like this should also have high flexural strength (minimum 1,500 MPa), since it won’t have the mechanical reinforcement that the adhesive cementation provides. Because larger, tapered, and even double-tapered fiber posts are now offered, and these are mechanically compatible with the remaining tooth structure, good close adaptation of the post to the post space can routinely be achieved, with a minimum of cement thickness,40,41 thus minimizing the S-factor. It is the more flared spaces that are addressed now. !"#$%&%'()*+%,$-(.'$%&/$+(0# Polymerization shrinkage, and the stresses associated with that (the C-factor and S-factor), are a big consideration in all bonding/ restorative procedures, and nowhere is the C-factor higher than it is in post cementation,43 because of the high number of involved surfaces and unbounded surfaces. Even though composite resin core materials generally have more filler and, therefore, higher strength than resin cements, the polymerization shrinkage stress is higher with 70% filler than that with 10% filler.50 This may seem counterintuitive to most dentists, but the objective is to utilize a technique that compensates for the inherent deficiencies of some materials and, in fact, actually capitalizes on them without becoming clinically cumbersome, time consuming, or with the integration of outside laboratory fees. In an earnest attempt to address these factors, Grande, et al,51 and Plotino, et al,52 have described chairside techniques for adapting prefabricated fiber posts to ribbon-like, oval, or ovoid canal spaces by remodeling; in essence, by whittling the post with a diamond bur to match an analog achieved through a separate procedure. The results suggest that the volume of cement is minimized, and the retentive surfaces of the post are not compromised. However, no information is offered regarding the 22 Endodontic practice

effects that whittling a round (tapered or parallel) post brings to the other mechanical properties of the fiber post, such as structural integrity. In the mildly flared space (Figure 14), we can create a composite “core build-down” followed by the core buildup. In the flared canal with a coronal circumference 25% to 50% greater than that of the largest fiber post (by itself) available, the authors suggest the following protocol. In this clinical case, the canal has a moderate flare with the above criteria. The tooth is isolated, and the canal is prepared as previously with a size appropriate drill (Figure 15A). After the canal is thoroughly cleaned, the fiber post is inserted and the fit verified (Figure 15B). A water soluble separating medium is applied to the post space (Figure 15C), a light-curable hybrid composite core material (such as Grandio® [VOCO]) is adapted to the prebonded post (Figure 15D), which is then inserted into the root canal space (Figure 15E). The composite is light-cured through the light-conductive fiber post, and the post is removed from the canal (Figures 15F and 15G). When performing this technique, the clinician must look for undercuts before creating the “core build-down.” It won’t be possible to remove the post if cured in those undercuts, and the procedure will have to be repeated, possibly injuring the post. After verifying the position (Figure 15H) by marking the labial with a pencil for orientation, the canal is thoroughly rinsed and the build-down is rinsed to remove the water soluble separating medium. As in the first clinical protocol, the canal is etched with a microbrush, which is agitated in the canal (Figure 15I), rinsed from the bottom up, dried from the bottom up, and any excess water removed with a paper point. The light-cured bonding agent is applied and fully cured as in the previous protocol. The dual-cure resin cement is placed in the canal, the core build-down is inserted (Figures 15J and 15K), and thoroughly light-cured. After cementation, the dentin is refreshed with a diamond, the surface etched (Figure 15L), rinsed and bonded (Figure 15M); then, the core material is adapted and light-cured. The resultant freehanded core is shown in Figure 15N, which is modified with a tapered coarse round Volume 5 Number 4

Clinical

Figure 16E: The dual-cured resin cement (Rebilda DC [VOCO]) is then injected from the bottom of the preparation to the coronal aspect

Figure 16I: The occlusal view of the “reinforced” fiber post and core with rubber dam still in place

Figure 16F: The “master” prebonded post is inserted to length into the dual-cure resin cement

Figure 16J: The intraoral clinical view of the “reinforced” fiber post as prepared for the full coverage ceramic restoration

Figure 16G: Prebonded Fibercones (RTD) are inserted prior to light-curing to minimize the amount of dualcure resin and to strengthen the post

Figure 16H: The core composite is injected between and around the Fibercones and central “master” fiber post and hand sculpted prior to lightcuring

ended diamond (Figure 15O), and the final ceramic crown (IPS e.max® [Ivoclar Vivadent]) over the custom-fabricated fiber post and core is shown in Figure 15P. This way, any shrinkage in the build-down is now in free space, not between the tooth and the restoration, neutralizing the S-factor effect. And it assures that the cement thickness will be minimal and uniform.48 In most cases, the air-inhibited layer on the build-down can remain intact. If in doubt, the excess cement and remaining tooth structure can be refreshed before the bonding agent and core buildup composite is applied. It is a direct-indirect technique, and has shown optimistic results.53-55 !"#$%&'($)*("$+,,#''&-.$%&'(' Now, in the case where the coronal circumference has a wide flare of more than 50% greater than that of the largest fiber post

Volume 5 Number 4

Endodontic practice 23

Clinical

Figure 17A: The typical triangular shape of anterior root canal space after endodontic preparation

Figure 17B: This anatomic space is ideal for the placement of a Macro-Lock Illusion X-RO fiber post complemented with an auxiliary Fibercone to decrease the amount of dualcure resin used and fortify the restoration

available, or the practitioner is working with a ribbon, ovoid, or triangular canal, the suggested technique is as follows: As can be seen from Figure 16A, the existing canal in which a cast post and core failed, is over prepared and widely tapered at the coronal aspect. By following the previous methodology, the canal is prepared, and the fit of the fiber post is assessed (Figure 16B). The large amount of resin cement will need to be minimized to decrease the shrinkage factor, and the cement and core material will need strengthening. The canal is etched, rinsed, and dried lightly; the compatible bonding agent is agitated into the canal (Figure 16C); and light-cured (Figure 16D). After direct injection of the dual-cured resin cement (Figure 16E), the prebonded fiber post is inserted (Figure 16F), and prebonded Fibercones™ (RTD) are inserted (Figure 16G). Then, core composite is injected between and around the Fibercones and central “master” fiber post and hand sculpted prior to light-curing (Figure 16H). Lastly, the core buildup is shaped, light-cured, and prepared to final shape with diamonds (Figures 16I and 16J). Figure 17A shows the typical triangular shape encountered when restoring anterior teeth. Figure 17B shows a Macro-Lock Illusion X-RO with an accessory Fibercone placed in the lingual slot area. The final clinical photograph is shown in Figure 17C. This we will call the (direct) accessory post technique, in which the “master” fiber post — size-selected for its fit at the apical end of the space — is accompanied by one or more slender, tapered accessory posts (e.g., Fibercone). The clinician may draw an immediate parallel to his/her training with gutta-percha cones. RTD translucent quartz fiber posts (DT Light-Post and Macro-Lock Illusion X-RO) have been shown to have limited but relatively superior transmission of the polymerization light energy56-58 down into the post-restorative space, a property that is an important attribute and would necessarily disqualify the use of many other (less conductive) fiber posts for this technique. In addition, the flexural and compressive strength of the factory-made composite (99.9% cross-linked) are higher than a composite hand-cured by light energy at chairside. In comparison, the cross-linked networks during polymerization and degree of conversion for most direct resin materials ranges from 45% to 70%.59 Published studies demonstrate the other benefits of this accessory post technique: Minimizes shrinkage in flared canals and, therefore, gap formation60 Reduces the need for drilling in order to adapt posts to root cavity61 (minimizes dentin removal) Reduces the thickness of cement and increased fracture resistance.60 Fiber posts, associated with composite resin or with accessory fiber posts, seem to be more indicated as an alternative 24 Endodontic practice

Figure 17C: Postoperative photograph of the Fibercone and auxiliary Fibercone in the triangular-shaped canal

to cast post and core in flared roots, because of the lower risk of catastrophic failures and better stress distribution.62 It is possible to conclude that use of the fiber post, associated with accessory posts, is the method of choice for reinforcing structurally weakened roots, and provides an improvement in the load carrying ability of the restored root is validated, as opposed to the use of one single inadequately fitting post.63,64 !"##$%& In contemporary dental practice, there is no remaining reason to use metallic posts, custom or prefabricated. Many cases that several years ago would have required a retentive post will not require that post today, because of the many improvements in bonding agents and composite resin restoratives. However, in cases where less than 50% of coronal tooth structure remains — or in other cases wherein the judgment of the clinician a post is indicated — there are now esthetic, noncorresive, fracture resistant and radiopaque alternatives for all varieties that save time and money without compromise. Their most compelling advantage, regardless of the geometry or amount of residual tooth structure, is the protection from root fracture that a low modulus restoration provides. In selecting the materials (posts, resins) for these techniques, the dentist is advised not to cut corners, and to seek the strongest and most radiopaque products available. EP This article was reprinted with permission by Dentistry Today.

Leendert Boksman DDS, BSc, is an adjunct clinical professor at the Schulich School of Medicine and Dentistry, and has a private practice in London, Ontario, Canada. He can be reached at lboksman@clinicalresearchdental.ca. Disclosure: Dr. Boksman has a paid part-time consultancy position as the director of clinical affairs for Clinical Research Dental and CLINICIAN’S CHOICE. Alejandro Bertoldi Hepburn, DDS, works as adjunct professor at the operative dentistry department of the University of Buenos Aires Dental School (Buenos Aires, Argentina), and at the Oral Rehabilitation Postgrade Career in the University del Desarrollo Dental School (Concepción, Chile). He has a private practice in Buenos Aires, Argentina. He can be reached at hepburn@speedy.com. ar. Disclosure: Dr. Hepburn is a consultant for VOCO GmbH (Germany). Enrique Kogan, DDS, works as a professor of Restorative Dentistry Universidad Tecnológica de Mexico, visiting professor Nova Southeastern University College of Dental Medicine, Fort Lauderdale, Florida and has a private practice in Mexico City, Mexico. He can be reached at ekoganf@gmail.com. Disclosure: Dr. Kogan is the designer and patent owner of the PeerlessPost (SybronEndo). Manny Friedman BDS, BChD, maintains a private practice limited to endodontics in London, Ontario, Canada, and is assistant adjunct professor in the division of restorative dentistry at the University of Western Ontario, London, Canada. He can be reached via e-mail at ndofriedman@rogers.com. Waldemar de Rijk, PhD, DDS, was formerly in the department of restorative dentistry at the University of Tennessee Health Science Center, Memphis, Tennessee. He is currently an associate professor of restorative dentistry and chief of the biomaterials unit at the School of Dental Medicine East Carolina University. He can be reached at (252) 737-7020 or at derijkw@ecu.edu.

Volume 5 Number 4

Clinical References

posts—a prospective study. J Can Dent Assoc, 66:613-618.

1. Adanir N, Belli S (2007). Stress analysis of a maxillary central incisor restored with different posts. Eur J Dent,1:67-71.

28. Schmitter M, Rammelsberg P, Gabbert O, et al, (2007). Influence of clinical baseline findings on the survival of 2 post systems: a randomized clinical trial. Int J Prosthodont, 20:173-178.

2. Albuquerque Rde C, Polleto LT, Fontana RH, et al, (2003). Stress analysis of an upper central incisor restored with different posts. J Oral Rehabil, 30:936-943.

29. Ferrari M, Vichi A, Mannocci F, et al (2000). Retrospective study of the clinical performance of fiber posts. Am J Dent,13(special issue):9B-13B.

3. Lanza A, Aversa R, Rengo S, et al, (2005). 3D FEA of cemented steel, glass and carbon posts in a maxillary incisor. Dent Mater, 21:709-715.

30. Fazekas A, Menyhárt K, Bódi K, et al, (1998). Restoration of root canal treated teeth using carbon fiber posts [in Hungarian]. Fogorv Sz, 91:163-170.

4. Okamoto K, Ino T, Iwase N, et al, (2008). Three-dimensional finite element analysis of stress distribution in composite resin cores with fiber posts of varying diameters. Dent Mater, 27:49-55.

31. Cagidiaco MC, Radovic I, Simonetti M, et al, (2007). Clinical performance of fiber post restorations in endodontically treated teeth: 2-year results. Int J Prosthodont, 20:293-298.

5. Rosenstiel SF, Land MF, Fujimoto J (2001). Contemporary Fixed Prosthodontics. 3rd ed. St. Louis, MO: Mosby, 295.

32. Ferrari M, Cagidiaco MC, Grandini S, et al, (2007). Post placement affects survival of endodontically treated premolars. J Dent Res, 86:729-734.

6. Torbjörner A, Karlsson S, Odman PA (1995). Survival rate and failure characteristics for two post designs. J Prosthet Dent, 73:439-444.

33. Grandini S, Goracci C, Tay FR, et al, (2005). Clinical evaluation of the use of fiber posts and direct resin restorations for endodontically treated teeth. Int J Prosthodont,18:399-404.

7. Martelli R (2000). Fourth-generation intraradicular posts for the aesthetic restoration of anterior teeth. Pract Periodontics Aesthet Dent, 12:579-588. 8. Milnar FJ (2010). Aesthetic treatment of dark root syndrome. Dent Today, September 29:74-79. 9. Anderson GC, Perdigão J, Hodges JS, et al, (2007). Efficiency and effectiveness of fiber post removal using 3 techniques. Quintessence Int, 38:663-670. 10. Cormier CJ, Burns DR, Moon P (2001). In vitro comparison of the fracture resistance and failure mode of fiber, ceramic, and conventional post systems at various stages of restoration. J Prosthodont, 10:26-36. 11. Frazer RQ, Kovarik RE, Chance KB, et al, (2008). Removal time of fiber posts versus titanium posts. Am J Dent, 21:175-178. 12. Gesi A, Magnolfi S, Goracci C, et al, (2003). Comparison of two techniques for removing fiber posts. J Endod, 29:580-582.

34. Cagidiaco MC, Goracci C, García-Godoy F, et al, (2008). Clinical studies of fiber posts: a literature review. Int J Prosthodont, 21:328-336. 35. Ferrari M, Cagidiaco MC, Goracci C, et al, (2007). Long-term retrospective study of the clinical performance of fiber posts. Am J Dent, 20:287-291. 36. Ferrari M, Vichi A, García-Godoy F (2000). Clinical evaluation of fiber-reinforced epoxy resin posts and cast post and cores. Am J Dent,13(special issue):15B-18B. 37. Naumann M, Blankenstein F, Dietrich T (2005). Survival of glass fibre reinforced composite post restorations after 2 years—an observational clinical study. J Dent, 33:305-312. 38. Signore A, Benedicenti S, Kaitsas V, et al, (2009). Long-term survival of endodontically treated, maxillary anterior teeth restored with either tapered or parallel-sided glass-fiber posts and full-ceramic crown coverage. J Dent, 37:115-121.

13. Rosenstiel SF, Land MF, Fujimoto J (2001). Contemporary Fixed Prosthodontics. 3rd ed. St. Louis, MO: Mosby, 275.

39. Dietschi D, Duc O, Krejci I, et al, (2007). Biomechanical considerations for the restoration of endodontically treated teeth: a systematic review of the literature—part 1. Composition and micro- and macrostructure alterations. Quintessence Int, 38:733-743.

14. Ferrari M, Scotti R (2002). Fiber posts: characteristics and clinical applications. Paris, France: Masson Publishing, 26.

40. Baldissara P, Zicari F, Ciocca L, et al, (2007). Effect of fiber post emerging diameter on composite core stabilization. J Dent Res, 86(A, special issue). Abstract 2623.

15. Grandini S, Goracci C, Monticelli F, et al, (2004). An evaluation, using a three-point bending test, of the fatigue resistance of certain fiber posts. Il Dentista Moderno, March; 70-74.

41. Boudrias P, Sakkal S, Petrova Y, et al, (2001). Anatomical post design applied to quartz fiber/epoxy technology: a conservative approach. Oral Health, 91:9-20.

16. Vallittu PK, Lassila VP, Lappalainen R (1994). Acrylic resin-fiber composite—part 1: The effect of fiber concentration on fracture resistance. J Prosthet Dent, 71:607-612. 17. Denny D, Heaven T, Broome JC, et al, (2005). Radiopacity of luting cements and endodontic posts. J Dent Res, 84(A, special issue). Abstract 0675. 18. McClendon K, Ripps A, Fan Y (2010). Comparative study on radiopacity of fiber posts and resin cements. J Dent Res, 84(A, special issue). Abstract 0253. 19. Wiskott HW, Meyer M, Perriard J, et al, (2007). Rotational fatigue-resistance of seven post types anchored on natural teeth. Dent Mater, 23:1412-1419. 20. Sorensen JA, Ahn SG, Berge H-X, Edelhoff D (2001). Selection criteria for post and core materials in the restoration of endodontically treated teeth. Dent Materials, 15:67-84.

42. Rosenstiel SF, Land MF, Fujimoto J (2001). Contemporary Fixed Prosthodontics. 3rd ed. St. Louis, MO: Mosby, 279. 43. Breschi L, Mazzoni A, De Stefano D, et al (2009). Adhesion to intraradicular dentin: a review. Journal of Adhesion Science and Technology, 23:1053-1083. 44. Rodríguez-Cervantes PJ, Sancho-Bru JL, Barjau-Escribano A, et al, (2007). Influence of prefabricated post dimensions on restored maxillary central incisors. J Oral Rehabil, 34:141-152. 45. Mazzoni A, Marchesi G, Cadenaro M., et al, (2009). Push-out stress for fibre posts luted using different adhesive strategies. Eur J Oral Sci, 117:447-453. 46. Kremeier K, Fasen L, Klaiber B, et al, (2008). Influence of endodontic post type (glass fiber, quartz fiber or gold) and luting material on push-out bond strength to dentin in vitro. Dent Mater, 24:660-666.

21. Wiskott WH, Nicholls JI, Belser UC (1995). Stress fatigue: basic principles and prosthodontic implications. Int J Prosthodont, 8:105-116.

47. Akgungor G, Akkayan B (2006). Influence of dentin bonding agents and polymerization modes on the bond strength between translucent fiber posts and three dentin regions within a post space. J Prosthet Dent, 95:368-378.

22. Hajizadeh H, Namazikhah MS, Moghaddas MJ, et al, (2009). Effect of posts on the fracture resistance of load-cycled endodontically-treated premolars restored with direct composite resin. J Contemp Dent Pract, 10:10-17.

48. Radovic I, Monticelli F, Goracci C, et al, (2008). Self-adhesive resin cements: a literature review. J Adhes Dent, 10:251-258.

23. Salameh Z, Sorrentino R, Ounsi HF, et al, (2008). The effect of different full-coverage crown systems on fracture resistance and failure pattern of endodontically treated maxillary incisors restored with and without glass fiber posts. J Endod, 34:842-846. 24. Dikbas I, Tanalp J, Ozel E, et al, (2007). Evaluation of the effect of different ferrule designs on the fracture resistance of endodontically treated maxillary central incisors incorporating fiber posts, composite cores and crown restorations. J Contemp Dent Pract, 8:62-69. 25. D’Arcangelo C, De Angelis F, Vadini M, et al, (2010). Fracture resistance and deflection of pulpless anterior teeth restored with composite or porcelain veneers. J Endod, 36:153-156. 26. Hayashi M, Takahashi Y, Imazato S, et al, (2006). Fracture resistance of pulpless teeth restored with post-cores and crowns. Dent Mater, 22:477-485.

49. Baldissara P, Monaco C, Valandro LF, et al, (2009). Retention of quartz fiber posts using different luting cements. J Dent Res, 88(A, special issue). Abstract 976. 50. Ferrari M, Carvalho CA, Goracci C, et al, (2009). Influence of luting material filler content on post cementation. J Dent Res, 88:951-956. 51. Grande NM, Butti A, Plotino G, et al (2006). Adapting fiber-reinforced composite root canal posts for use in noncircular-shaped canals. Pract Proced Aesthet Dent, 18:593-599. 52. Plotino G. Grande NM, Pameijer CH, et al (2008). Influence of surface remodelling using burs on the macro and micro surface morphology of anatomically formed fibre posts. Int Endod J, 41:345-355. 53. Ferrari M, Scotti R. Fiber Posts: Characteristics and Clinical Applications. Paris, France

27. Glazer B (2000). Restoration of endodontically treated teeth with carbon fibre

Volume 5 Number 4

Endodontic practice 25

Clinical

!"#$%&'(&#$$)*+,-#*$(. /*0(1%2"(3)+$(45+67++)+(2%8(#"#$%&'(6#"(#99)6$($2)(:95"5+25";<(%9( )"4%4%"$56($*)#$&)"$(

I

n the March/April issue of Endodontic Practice US, I published an example of “failure to heal means failure to produce the endodontic seal.” The patient had what most endodontic readers would have considered a “good” radiographic obturation. However, a sinus tract and eventual lateral lesion of endodontic origin manifested. In nonsurgical retreatment, a lateral canal with two portals of exit were discovered after gutta-percha removal, slight reshaping to increase obturation hydraulics, thorough irrigation and agitation using the EndoActivator® (Dentsply Tulsa Dental Specialties) with QMix® (Dentsply) and ChlorXTRA™ (Vista Dental) followed by drying the root canal system with paper points and the Stropko™ Irrigator (Stopko.com). The obturation technique was classic Schilder vertical compaction of warm gutta percha using Sybron Endo’s original Kerr Pulp Canal Sealer™. Subsequent posttreatment digital images demonstrated radiographic healing of the lateral lesion of endodontic origin, and the clinical images revealed closure and healing of the sinus track that had originally traced to the lateral lesion area. So what may the “doubting Thomas” ask? John, you have no control to prove that sealing portals of exit truly matter, especially when they are considered lateral canals. You cannot prove the lateral canal was the cause of the lateral lesion. And, you would be right. There is no control. In fact, sufficient endodontic literature in the last 50 years suggests cleaning and filling the main canal is enough for good healing. Again, if you believe this, you are right. Maybe your experience tells you the same. So here is the dilemma: should I simply “instrument” say a millimeter short, clean thoroughly, obturate, and place an excellent endodontic seal? For everyone reading this, I will bet you a cup of coffee that you want more. You want more because all of us know better. As endodontists, we see the failures to heal, we retreat them successfully, and they heal. To me this is our control: literally millions of patients healing once the endodontic seal has been produced either nonsurgically or surgically. In a recent survey I did for the topic “How Do Masters Do It?” at April’s annual AAE scientific session in Boston, 18% of endodontists surveyed reported most of their practice is retreatment. We better know how to predictably produce the endodontic seal. We especially need to be successful in retreatments, because in a separate survey I sent to Boston, San Francisco, and New York-based endodontists, dentists are tending more and more to remove endodontic failures and place implants. Many dentists consider implants more predictable than endodontic retreatment, which may destroy the existing restorative during the disassembly process, or may cause an esthetic black triangle or leave a scar in surgical retreatment. They believe the tooth already has two strikes against it; they can often treat the patient in house, and so the tooth is removed. Anatomy does matter. We just don’t know when, so we have to finish well every time. The more examples of anatomy matters, such as the patient presented in this issue, that we can share with and teach to our referring dentists, the more value and respect we will earn. For me, it is often to slow down, do it right, and grade my results using a finishing checklist for successful cases such as: 1. Funnel-shaped preparation for hydraulics 2. Appropriate shape for the root, not too big, not too small, but just right for preserving ferrule and coronal tooth structure 3. Smooth walls for equal obturation hydraulics along the entire 26 Endodontic practice

Figure 1: Pretreatment image of mandibular left first molar prior to endodontic treatment

Figure 2: One year posttreatment of original nonsurgical endodontics. Note radiographic furcal radiolucency. Gingival crevice was inflamed and symptomatic but probed precipitous 3 mm wide endodontic sinus tract

internal surface of the root canal system walls 4. Solid obturation 5. Coronal seal. Then, use feedback by following patients for 6 months, 1 year, and 5 years and beyond. Only then will you know if anatomy As the founder and director of the Center for Endodontics, John West, DDS, MSD, continues to be recognized as one of the premier educators in clinical and interdisciplinary endodontics. He received his dental degree from the University of Washington in 1971 where he is an affiliate associate professor. He then received his MSD in endodontics at Boston University Henry M. Goldman School of Dental Medicine in 1975. Dr. West is past president of the American Academy of Esthetic Dentistry and the Academy of Microscope Enhanced Dentistry. He serves as editorial board member for five journals, has authored four textbook chapters while co-authoring several others, and has written a plethora of articles from teaching subjects such as diagnosis, endodontic mechanics, and endodontic predictability, to enhancing endodontic performance. He is a visionary clinician, an inventor, and an interdisciplinary endodontic thinker and teacher and maintains a private practice in Tacoma, Washington. He can be reached at: email: johnwest@ centerforendodontics.com, phone: 800-900-7668 or fax: 253-4736328 or (ROOT). www.centerforendodontics.com.

Volume 5 Number 4

Clinical

Figure 3: Coronal conefit mesial and distal systems

Figure 4: Downpack image and radiographic evidence to furcal lateral portal of exit endodontic seal

matters. It does. This issue’s example of anatomy matters is a dental hygienist who presented with previous endodontics and a developing furcal radiolucency and endodontic precipitous probing of 7 mm in a 3 mm mesial-distal width (Figures 1 and 2). I made an assumption of furcal disease from an unsealed furcal lateral portal of exit. The apical lamina dura appeared intact, so I decided to leave it alone, at least for now. Simply, I removed the coronal half of the gutta percha, thoroughly cleaned and slightly improved the coronal shape and packed (Figures 3-5). A major lateral portal of exit was visibly sealed on the radiographic image with subsequent healing of both the furcal endodontic disease and the gingival crevice (Figures 6 and 7). The dentist then restored the tooth, although I had placed a permanent seal over the gutta percha at the time of obturation in order to prevent coronal microleakage while pausing for permanent access repair by the dentist. For this patient, anatomy matters. EP

Volume 5 Number 4

Figure 5: Backpack complete and posttreatment image

Figure 6: Clinical image of Figure 7: 8 month posttreatment gingival crevice probing within normal limits. The tooth is asymptomatic, and next visit will be at 1 year posttreatment in 5 months. I will submit images of my first two “Anatomy Matters� at that time

Endodontic practice 27

Clinical

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T

raumatic injuries to the upper central incisors are extremely common. By the age of 20, 23% of males and 13% of females have suffered some degree of traumatic injury to their anterior teeth (Andreasen & Andreasen, 2000). These injuries are likely to take place between the ages of 8 and 10. At this age, many of the teeth injured are therefore immature, which complicates their management and long-term prognosis. Contemporary endodontic techniques revolve around maintaining the vitality of the pulp, to encourage it to develop, and the root and pulp space to mature. In one study, more than 50% of patients attending a pediatric dentistry clinic with complex enamel or dentin fractures were successfully treated using simple etch and bonding techniques with no need for root treatment (Cem Gungor, et al., 2007). However, many older patients will not have had the benefit of these contemporary techniques. They will regularly present for treatment decades after the traumatic incident, requesting an esthetic improvement to their aging restorations. Unfortunately, these teeth often have longstanding, commonly asymptomatic endodontic infections, immature root formation and large posts in situ. It is not unusual for patients to find it difficult to relate their presenting complaints with traumatic incidents that may have occurred decades earlier, of which they have very little recollection. Managing these cases is not straightforward, and the results can be unpredictable. Fortunately though, several options are now available to clinicians and their patients.

show their age, and the patient was keen to have replaced. X-rays of the anterior teeth revealed that the upper right central incisor had been root filled some months before and had been asymptomatic since that time. There was some evidence of an apical radiolucency, which it was decided would be reviewed as it had only recently been completed. The upper left central incisor had been restored with a wide, serrated metal post. The root filling material had been placed to the correct apical extent, but appeared to be a single cone that did not completely obturate the canal. The tooth appeared to have an immature, open apex. The upper left lateral incisor had been root filled more recently. It looked well condensed but possibly 1–2 mm short of the radiographic root terminus. A large, well-circumscribed circular radiolucency, approximately 12 mm in diameter, appeared to be associated with the apices of both upper left incisors. Both teeth had lost the normal periodontal ligament space. An initial diagnosis of failing root fillings UL1, UL2 with chronic periapical periodontitis was made. The alternative diagnoses of a root fracture UL1 or periradicular cyst were also considered. The treatment choices were: 1. Orthograde revision of the root fillings 2. Apical surgery 3. Extraction followed by implant placement, a denture, or conventional bridgework

!"#$%#&'() A 42-year-old lady was referred by her GP for the assessment of the prognosis of two endodontically involved failing anterior crowns. The patient was fit and well, with no relevant medical history. Her main complaint was that one of her crowns had recently fractured and was currently replaced with a temporary crown. She was also concerned about discoloration of the tooth and the composite fillings in her other front teeth. The teeth in question had originally been root filled and crowned soon after they were damaged in a bicycle accident when the patient was around 10 years old. The crowns had been replaced several times over the years, and the current crowns had been in place for 15 years. The patient had not experienced any pain recently, but had been aware of a swelling below her upper lip for as long as she could remember. On examination, the dentition was heavily restored but well cared for. There was a palpable swelling over the apices of the upper left incisor teeth. A small sinus was found adjacent to the upper left lateral incisor. The upper left central incisor had been recently restored with a temporary crown. The lateral incisor had an all-ceramic crown, through which an access cavity had been made some years ago. There were several Figure 1: Appearance of composite restorations on the other anterior teeth on first visit to surgery anterior teeth that had begun to

*+&,-.% /0% *1&2-31"($% 1$4 1--&%5,66,.3# Orthograde revision of the root fillings was complicated by several things: the presence of the large metal post in the UL1 – removal of this post was not without risk and Figure 2: Preoperative view could have resulted in a fracture of the root - the extent of the apical lesion, the long duration of the infection, and the immature/open apex present UL1. Additionally, even if successful, the end result for the UL1 would be a replacement post crown, of which 61% will last less than 10 years (Peutzfeld, et al., 2007).

28 Endodontic practice

*+&,-.%70%8+,9"6%#'13$1) One of the key indications for apical surgery is that there should be an adequate root filling in situ. Therefore, apical surgery was not indicated in this case.

Jason Bedford, BDS, MDentSci, MFDS, RCPSG, is a specialist in endodontics, works in specialist endodontic practices in Nottingham, Stoke and Solihull, England, and is also a co-founder of d2dENDO Ltd.

Volume 5 Number 4

Clinical The patient was advised, however, that should the infection not respond to conventional endodontics, then apical surgery may be required. !"#$%&' ()' *+#,-.#$%&' -&/' ,0"1-.020&#' %3' 456' -&/'457 The opinion of an experienced implantologist was sought. After considering the practical difficulties posed by the large bony defect, the possible need for a bone graft and the cost implications, the patient decided against pursuing the implant option. The use of a bridge to replace the UL1 and UL2 was considered a last option by the patient. As implants were not appropriate, and a bridge could always be placed at a later date if the endodontic treatment failed, the patient asked us to attempt to revise the failing root fillings. Conventional re-root filling is then broken down into several stages, all of which are relatively straightforward, but put together can result in a very long appointment. 8,%9&'-&/'"%:#',02%;-1' The temporary crown was removed easily and the post removed using a combination of ET25 (Satelec) and CPR postremoving ultrasonic tips (Dentsply Tulsa Dental Specialties). <02%;-1'%3'%1/',%%#'3$11$&='2-#0,$-1 The original root filling in the UR1 consisted of a single GP cone with sealer. This point was removed using a braiding technique. Three size 15 Hedstroem files are passed down either side of the GP cone. These are then twisted around each other, gripping the GP point. The files are then withdrawn together with the GP point. The root filling material in the UR2 was more densely compacted. This was removed using the gutta percha removal files - GPR files. These are used in a crown down manner removing the GP down to the apical third. Often the GP cones will wrap around these files and are rapidly removed in one piece. If this is not the case, then the apical GP is softened with products such as Orange Solvent and removed manually with Hedstroem files. 8-&-1':>-"$&= The UR1 required very little in the way of further canal preparation. The walls of the canal were debrided of residual filling materials using hand files. The apical diameter was gauged at size 80. 8-&-1'/$:$&30.#$%& Careful irrigation with warmed 4% sodium hypochlorite solution was carried out throughout the shaping procedure. This was followed by a 1-minute rinse with 17% EDTA solution to remove any further debris and to dissolve the smear layer created during canal preparation. The canal was then irrigated with more sodium hypochlorite, activated with Satelec Irrisafe™ ultrasonic tips (Figure 3). These have been shown to heat the irrigant and enhance its chemical and physical action on the bacterial biofilm present within the canal (Haappsalo, et al., 2010). The canals were then dressed with non-setting calcium hydroxide paste for 2 weeks.

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Volume 5 Number 4

800-752-2812

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Clinical

Figures 4A, 4B, and 4C: Managing the open apex

At the second visit, the buccal swelling that had been present for months had resolved, and the area was much healthier looking. The patient reported that the discomfort had settled almost immediately following the first visit. The root canals were re-irrigated and dried using paper points. The apex of the central incisor was gauged to be around a size 80. This is too wide to be predictably obturated using traditional thermoplastic obturation techniques due to the risk of extrusion of the filling material into the apical tissues. In recent years, apical-closure techniques have been described that utilize tricalcium phosphate cements, such as MTA. However, the mixing, manipulation, and placement of these materials can be frustratingly difficult. The use of hydroxyapatite to repair roots has long been established (Alhadainy, et al., 1998). Recently, pre-filled syringes of hydroxyapatite have become available in the form of iRoot BP® (Veriodent®, Canada). The premixed material is relatively viscous and can simply be syringed into the canal. These products are considerably less expensive than MTA preparations. The working length is marked on the syringe using a rubber stop and a small amount of the paste placed at the apex of the tooth. The needle is withdrawn as the paste is extruded, and the canal filled to the required depth. This is usually 4–5 mm. The rest of the canal can be filled with GP, or in this case, a small amount of glass ionomer was place over the iRoot BP and a post space prepared. A temporary post crown was constructed, and the patient referred back to her general dental practitioner for the immediate construction of new anterior crowns.

!"#$$%&'()"*#$+,$-*.)/0$ Although the patient had been asymptomatic, it was considered prudent to take a radiograph in order to assess the healing of the very large apical area at the 3-month stage. A periapical radiograph revealed rapid healing of the apical area. On closer examination, it also appears to show the formation of a hard tissue barrier apical to the hydroxyapatite paste. The use of injectable hydroxyapatite paste such as iRoot BP provides a convenient, cost effective, and predictable method of sealing canals with large apical diameters. This versatile material can also be used as a replacement for MTA Figure 6: Final restorations in perforations, apicectomies and (Image courtesy of Dr. Nigel Hammond) pulp capping. EP

References Alhadainy, HA, Himel, VT, Lee WB, Elbaghdady YM (1998). Use of a hydroxyapatite-based material and calcium sulfate as artificial floors to repair furcal perforations. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. Dec: 86(6): 723–9. Andreasen JO, Andreasen FM (2000). Essentials of traumatic injuries to the teeth. Munksgaard and Mosby; 9–154. Cem Gungor H, Uysal S, Altay N (2007). A retrospective evaluation of crown-fractured permanent teeth treated in a pediatric dentistry clinic. Dent Traumatology Aug: 23 (4) 211–7. Haapasalo M, Shen Y, Oian W, Gao Y (2010). Irrigation in endodontics. Dent Clin North Am. Apr: 54(2): 291–312.

Figure 5: Healing after 3 months

30 Endodontic practice

Peutzfeldt A, Sahafi A, Asmussen E (2008). A survey of failed post-retained restorations. Clin Oral Investig, Mar: 12 (1): 37–44.

Volume 5 Number 4

Clinical

!"#$% &'()*'+% ',(-.% /% *'/)01'#(-.% 1"2+",(3$%/-*%3#$/32$-3%4(35%/))0 +"#1$)/(-%#$,3"#/3("-, 6#7%89#.$-%:/-5/#3%*(,1',,$,%/%1/,$%,3'*;%',(-.%/%1"#$%1"2+",(3$% /-*%,'&,$<'$-3%+$#2/-$-3%3#$/32$-3%4(35%.)/,,%+"#1$)/(-% #$,3"#/3("-, !"#$%&'(#)%" All-porcelain restorations produce esthetically superior anterior and posterior restorations. Excellent esthetics are, however, only one important feature that has led to the ever-increasing popularity of these restorations. As the porcelain materials are highly biocompatible, all-porcelain restorations are also well tolerated by patients. When fabricating crowns or bridges, it is often necessary to use a core material before preparation to reconstruct extensive sections of lost tooth structure caused by large carious lesions or previous dental treatment. Various materials are used for building up the tooth core. While the use of amalgams was common in the past, glass ionomer cements and related materials or composites are now mainly used. Composite adhesive cores in particular are becoming increasingly popular, as an excellent bond can be achieved with the tooth structure when they are used in conjunction with a suitable adhesive system. Parapulpal posts for retaining the core material to vital teeth are no longer required. This method not only saves time, but also provides a safer form of treatment, as drilling preparation for parapulpal posts tends to cause iatrogenic damage to the pulp or perforation of the root surface. The options provided by the adhesive technique mean that, in numerous clinical situations, root canal posts are no longer required when preparing endodontically treated teeth. Further information on this can be found in a joint report published in 2003 by the DGZMK (German Maxillofacial Surgery Association), the DGZPW (German Society for Dental Prosthetics and Materiology) and the DGZ (German Society for Conservative Dentistry) dealing with the buildup of endodontically treated teeth. Composite cores can either be fabricated using conventional light-curing filling composites, but the curing thickness of these composites is limited, and larger defects require a time-consuming, incremental buildup, or using core composites specially developed for larger defects. Core composites are either chemically curing or dual-curing (the use of core composites that are purely light-curing is restricted to small defects). Different types of core composites also have very different rheological properties. High viscosity composites have to be mixed from two pastes by the dental nurse and applied to only partially visible cavities by condensing with manual instruments to ensure all the surfaces are covered, while flowable types can be applied directly intraorally to fill the defect using a handy cartridge system with an integrated spiral mixer. Low viscosity core composites provide excellent coverage for the tooth structure and also root canal posts and screws, if required. Core composites are normally supplied in a dentin shade, used under translucent all-porcelain restorations, as well as in a contrasting shade to the tooth (e.g., blue or white), which facilitates assessment of the gap between the margin of the core material and the preparation margin. Blue contrasting shades are recommended only for use with metal-based restorations: white Volume 5 Number 4

Figure 1: Initial situation: glass ionomer cement fillings in teeth Nos. 24 and 25

Figure 2: The teeth after removal of the old fillings showing the tooth structure affected by caries

JĂźrgen Manhart, DDS, Priv.-Doz., Dr.med. dent., is an associate professor in the Department of Conservative Dentistry and Periodontology University,

Munich,

at

Germany.

Ludwig He

also

Maximilians did

post-

doctoral work at the University of Texas–Houston as an Adjunct Assistant Professor in the Department of Basic Sciences, Biomaterials Research Center. His professional affiliations include the International Association for Dental Research, Continental European Division of the IADR, German Scientific Dental Association (DGZMK), German Association for Operative Dentistry (DGZ), and Work Group for Basic Research (AfG).

Endodontic practice 31

Clinical

Figure 3: After placing the rubber dam

Figure 4: The palatal cusp of tooth No. 25 fractured during excavation

Figure 5: Pinpoint perforation of the pulp at the buccal cusp

Figure 6: After explaining the situation to the patient, the pulp was capped directly. First an aqueous calcium hydroxide suspension was applied to the perforated area

Figure 7: The calcium hydroxide was carefully adapted using a clean cotton pellet

Figure 8: A hardening calcium hydroxide solution (Calcimol, VOCO) was applied over the aqueous suspension. Because of the extent of the caries, the mesial surface of tooth No. 24 was included in the cavity preparation

Figure 9: Placing a steel matrix at tooth No. 25

Figure 10: A 37% phosphoric acid gel was first applied selectively to the enamel of the cavity margins

Figure 11: After approximately 15 seconds, the whole cavity was filled with etching gel, and the enamel and dentin were conditioned for a further 15 seconds (total etch).

opaque core composites provide a contrast to the tooth structure without impairing the esthetics of all-porcelain restorations. The requirements of a core material are summarized as follows: UÊ `iµÕ>ÌiÊL `ÊÜ Ì ÊÌ iÊÌ Ì ÊÃÌÀÕVÌÕÀiÊ­«ÀiÛi ÌÃÊ >À} > ÊÊ gaps, does not require parapulpal posts) UÊ >ÃÞÊ> `ÊµÕ V ÊÌ ÊÕÃiÊ­iÛi ÊÜ Ì Ê >À}iÊ`iviVÌî UÊ `ÊV ÛiÀ>}iÊ­w ÃÊÕ `iÀVÕÌÃÊÜ Ì ÕÌÊLÕLL iî UÊ ÜÊÃiÌÌ }ÊÌi «iÀ>ÌÕÀiÊ­«ÀiÛi ÌÃÊ ÀÀ Ì>Ì Ê vÊÌ iÊ«Õ «® UÊ- ÀÌÊÃiÌÌ }ÊÌ iÊ­V> ÊLiÊ«Ài«>Ài`Êà ÀÌ ÞÊ>vÌiÀÊ>«« V>Ì ® UÊ } Êw > Ê >À` iÃÃ]Êà >ÀÊÌ Ê`i Ì Ê­i>ÃÞÊÌ ÊÌÀ ® UÊ `iµÕ>ÌiÊ iV > V> Ê«À «iÀÌ iÃÊ­i°}°ÊV «ÀiÃà ÛiÊÃÌÀi }Ì ® UÊ,>` «>V ÌÞ UÊ"«>V ÌÞÊ­ >à ÃÊÀ ÌÊ« ÃÌÃÊ> `ÊÃVÀiÜî UÊ Õ À `i Ài i>à }Ê­«À « Þ >Ý ÃÊ>}> ÃÌÊÃiV `>ÀÞÊV>À iî UÊ À >`ÊÀ> }iÊ vÊ>«« V>Ì Ã !"#$#%&"'%&()'*#(+,-. The following case history of a 27-year-old female patient demonstrates the buildup of two premolars step-by-step using a core composite and subsequent permanent treatment with glass porcelain restorations. The initial situation shows the mirror image of teeth Nos. 32 Endodontic practice

24 and 25 with long-term temporary restorations fabricated from glass ionomer cement (Figure 1). Both teeth were sensitive to the cold stimulus of carbon dioxide snow and were not percussion sensitive. Large surface areas with softened carious dentin were evident in both premolars after removal of the fillings (Figure 2). Due to the proximity of the defect to the pulp at tooth No. 25, a rubber dam was placed as a prophylactic measure before excavation of the caries to prevent any infection from the saliva, if the pulp chamber were to be exposed (Figure 3). The palatal cusp of the second premolar, which had a large undercut, fractured during removal of carious tooth structure (Figure 4). Further removal of the caries resulted in a small, pinpoint perforation of the pulp at the buccal cusp (Figure 5). The situation was explained to the patient and, as there was no evidence of tooth pain, the exposed pulp was capped directly. After cleaning and disinfecting the surface with a 3% hydrogen peroxide solution, a permanently soft calcium hydroxide solution was applied to the perforated area (Figure 6), and adapted carefully using a small, clean cotton pellet (Figure 7). The area was completely covered with a hardening calcium hydroxide solution, and because of the extent of the caries, the mesial surface of the first premolar was included in the cavity preparation (Figure 8). After placing a steel matrix around the extensive defect Volume 5 Number 4

Clinical

Figure 12: Rinsing off the etching gel and loosened fragments of tooth structure using the compressed air and water spray Figure 13: The cavity was carefully dried with oil-free compressed air. It is essential to avoid overdrying the dentin

Figure 14: Application of Solobond Plus primer (VOCO) to the enamel and dentin for 30 seconds using a disposable brush

Figure 15: Excess is carefully blown off using oil-free compressed air

Figure 16: Application of Solobond Plus adhesive (VOCO) to the enamel and dentin for 15 seconds using a disposable brush

Figure 17: Excess is carefully blown off using oil-free compressed air

Figure 18: The bonder was light-cured for 20 seconds

Figure 19: Filling the defect with a dualcuring core composite (Rebilda DC, VOCO) from the mini-cartridge using an angled application tip with a 360째 rotation

Figure 20: The cavity was slowly and carefully filled with core material avoiding the inclusion of air bubbles

Figure 21: The defect completely filled with core composite

Figure 22: The surface of the dual-curing core composite was light-cured for 40 seconds using a light-curing lamp

Figure 23: Placing a steel matrix at tooth No. 24

Figure 26: Rinsing off the etching gel and loosened fragments of tooth structure with the compressed air and water spray Figure 24: A 37% phosphoric acid gel is first applied selectively to the enamel of the cavity margins

Volume 5 Number 4

Figure 25: After approximately 15 seconds, the whole cavity was filled with etching gel, and the enamel and dentin were conditioned for a further 15 seconds (total etch) Endodontic practice 33

Clinical

Figure 27: The cavity was carefully dried with oil-free compressed air. It is essential to avoid overdrying the dentin

Figure 28: Application of Solobond Plus primer (VOCO) to the enamel and dentin for 30 seconds using a disposable brush

Figure 29: Excess was carefully blown off using oil-free compressed air

Figure 30: Application of Solobond Plus adhesive (VOCO) to the enamel and dentin for 15 seconds using a disposable brush

Figure 31: Excess was carefully blown off using oil-free compressed air

Figure 32: The bonder was light-cured for 20 seconds

Figure 33: Filling the defect with a dualcuring core composite (Rebilda DC, VOCO)

Figure 34: The cavity was slowly and carefully filled with core material avoiding the inclusion of air bubbles

Figure 35: The defect completely filled with core composite

Figure 36: The surface of the dual-curing core composite was light-cured for 40 seconds using a light-curing lamp

Figure 37: After removal of the matrix

Figure 38: After removal of the rubber dam

at tooth No. 25 for the subsequent buildup (Figure 9), a 37% phosphoric acid gel was first applied selectively to the enamel margin of the cavity (Figure 10). After allowing a reaction time of approximately 15 seconds, the whole cavity was filled with etching gel, and the enamel and dentin were conditioned for a further 15 seconds according to the total-etch technique (Figure 11). After thoroughly rinsing off the etching gel and loosened fragments of tooth structure using the compressed air and water spray (Figure 12), the cavity was carefully dried using oil-free compressed air (Figure 13). It is essential to avoid overdrying the dentin at this stage, as this would result in the collapse of the three-dimensional woven collagen fibers in the conditioned dentin, making it extremely difficult for the subsequent adhesive application to penetrate, with the risk of 34 Endodontic practice

a poor bond and increased risk of postoperative sensitivity. The primer of the Solobond Plus adhesive system (Voco) was applied to the enamel and dentin with a disposable brush and massaged into the dentin for 30 seconds (Figure 14). After blowing off the excess carefully and evaporating the acetone solvent using oil-free compressed air (Figure 15), adhesive was applied uniformly to all the prepared enamel and dentin surfaces with a new disposable brush and massaged in for 15 seconds (Figure 16). The adhesive was then finely dispersed and thinned to form a uniform film (Figure 17). The adhesive was cured for 20 seconds using a halogen lamp (Figure 18). Ê ÊÜ ÌiÊÃ >`iÊ vÊ,iL `>® DC dual-curing core composite (Voco) was applied directly into the defect from the mixing tip of the cartridge system, to which an angled intraoral tip with a 360° Volume 5 Number 4

Clinical

Figure 39: The core fillings were prepared with finishing diamonds and pre-polished with rubber composite polishers

Figure 40: Checking the static and dynamic occlusion for high spots and interference

Figure 41: The core fillings were polished to a high luster with composite polishing paste to minimize plaque buildup until permanent treatment of the teeth with all-porcelain restorations. The teeth are dehydrated and lightened due to a reversible water loss caused by the use of the rubber dam

Figure 42: After 1 week in situ, the teeth have regained their natural shade

Figure 43: All-porcelain crown and porcelain inlay on the unsectioned plaster model

Figure 44: Close-up view of the porcelain restorations

Figure 45: Preparation for an all-porcelain crown with circumferential shoulder on tooth No. 25 and for a porcelain inlay on tooth No. 24

Figure 46: The restorations after being placed using the adhesive technique

rotation can be attached (Figure 19). Starting at the cavity floor, the cavity was slowly and carefully filled with the core material avoiding the inclusion of air bubbles (Figure 20). Figure 21 shows the defect completely filled with core composite. The dual-curing core composite was lightcured for 40 seconds using a halogen lamp (Figure 22). The first premolar was then built up using the same procedure as described above (Figures 23-36). After removing the matrices, but before removing the rubber dam, the buildup was checked again to ensure that it was not short in any area and that there were no marginal gaps (Figure 37). Figure 38 shows both core buildups before trimming. The cores were trimmed and all excess material carefully removed with finishing diamonds before pre-polishing with rubber composite polishers (Figure 39). The static and dynamic occlusion was checked for high spots and interference using colored foil (Figure 40). As the core buildups were to be used as long-term Volume 5 Number 4

temporaries until permanent treatment of the teeth with allporcelain restorations, the surfaces were polished to a high luster using composite polishing pastes to minimize plaque buildup. The teeth were dehydrated due to reversible water loss caused by the use of the rubber dam, and as a result, the shade of the teeth was definitely lighter (Figure 41). At the follow-up appointment a week later to check for sensitivity of the second premolar, the teeth had regained their normal shade (Figure 42). Figure 43 shows the all-porcelain restorations, which were fabricated almost 3 months later. A glass porcelain crown Ü>ÃÊ v>LÀ V>Ìi`Ê v ÀÊ Ì Ì Ê °Ê Óx]Ê > `Ê > Ê " Ê « ÀVi > Ê >ÞÊ was fabricated for tooth 24 (Figure 44). Figure 45 shows the two prepared teeth immediately prior to the restorations being placed using the adhesive technique. Following adhesive placement, the two restorations restore the function and natural esthetics in the dental arch (Figure 46). EP

Endodontic practice 35

Endodontics in focus

!"#$%&'$%(#)* !(#$'+,-&.$/$0$1(23'")() 4'$5()$)&6"'7$2.%(68&$"9$%5&$)&.(&):$1.;$!"'<$1.+%%,2'$"99&.)$)",&$ %(#)$"'$%5&$"9%&'$7(99(6+8%$)+-=&6%$"9$7(23'")('3$&'7"7"'%(6$ #."-8&,)

T

he diagnosis of an endodontic problem is like everything else in dentistry, sometimes very easy, sometimes impossibly difficult. We have all been in the situation where a patient has presented in pain, and it has been a considerable challenge to locate the cause. Although pain is often the trigger for endodontic treatment, that is not always the case. Sometimes an endodontic lesion is symptomless and is only picked up from a radiograph. In other situations, the culprit may be of periodontal, occlusal, or not even of dental origin. Trying to establish a diagnosis is a bit like being a detective - get a statement and then, look at the evidence. It starts with a dental history, which will give you important clues, followed by a clinical and radiographic examination, and then, the special tests. This article will not be an exhaustive review of diagnosis, but will cover some points that will be helpful in everyday general practice. !"#$%&'(')* Damage to the pulp is cumulative, so that starting from the first restoration to secondary caries to a larger restoration to a crown, the pulp is being repeatedly assaulted. In the early stages, it recovers, but as the physiological pulp space reduces with age and with the assault or insult, so the blood supply to the pulp reduces, and it becomes less able to defend itself against incoming bacteria. Think how often a perfectly symptomless tooth that you have decided to protect with a crown becomes symptomatic after you have prepared the tooth. In the early stages of the demise of the pulp, as it becomes irreversibly inflamed, it will either produce a prolonged response to temperature, produce spontaneous episodes of pain without stimulus, or both. This is sometimes referred to as a stressed pulp. Often the pain radiates, and in a heavily filled dentition, it can be very difficult to work out which is the culprit. The radiograph may not give any indication of a problem, other than perhaps a sclerosed pulp chamber (Figure 1). +,'-.*&%/**/0 Often patients will complain of temperature sensitivity and pain on biting in the early stages of a cracked tooth. The pulp will be vital at this time, although the tooth may be irreversibly damaged. As the crack progresses, more bacteria invade the pulp space, and may become tender to percussion and show periradicular changes on a radiograph. An easy way to diagnose a cracked tooth in the early stages is to use a Tooth Slooth速 (Figure 2) and get the patient to bite on each cusp in turn. The pain is triggered on release, not on biting. 122/%3,'-/",*4 A root may crack or fracture through occlusal stresses that have propagated from the coronal tooth tissue. Conversely, it may fracture from the apical end during lateral condensation. If you use that method of obturation, you may not even be aware of using excessive force with a lateral spreader. A cracked root will cause a 36 Endodontic practice

Figure 1: Tooth No. 26 appears to be moderately heavily filled but has a very sclerosed pulp chamber, indicating long-term insult to the pulp

Figure 2: The Tooth Slooth fracture detector device

Endodontic

specialist

Tony

Druttman,

MSc, BChD, BSc, has extensive expertise in treating dental root canals, resolving difficult endodontic cases, and saving teeth from being extracted. His two London, England practices, one in the West End and the other in the City of London are restricted to endodontic treatment. www.londonendo.co.uk

Volume 5 Number 4

Endodontics in focus

Figure 3A: Tooth No. 47 looks like it has an insignificant crack

Figure 3B: Periapical radiograph of tooth No. 47

Figure 4: Root fracture showing narrow area of bone loss along fracture line

Figure 5: Classic J-shaped lesion of a tooth with vertical root fracture

Figure 6: Apparent J-shaped lesion without a periodontal pocket

Figure 7A: Tooth No. 46 with a 10 mm pocket in the buccal furcation

Figure 7B: Six-month review of tooth No. 46

narrow periodontal pocket (Figure 4), which will often show on a radiograph as a J-shaped lesion (Figure 5). A tooth without a crack can have a similar radiographic appearance, but there is no pocket (Figure 6).

cause is endodontic and not periodontal. Vitality tests should also be carried out. Endodontic treatment will often heal pockets very quickly, particularly if the lesion is not a longstanding one (Figures 7A and 7B).

!"#$%&'()$*+',)$", Endodontic infections can sometimes mimic periodontal disease with the development of deep pockets and considerable bone loss, particularly in furcal areas. A careful clinical examination to look for signs of cracks and a radiographic examination to look for signs of a sclerosed or damaged pulp chamber will often reveal that the

-)./+).0*.',., Electric pulp tests, and hot and cold tests are used to determine the vitality of the tooth. A vital tooth is one that has an intact blood supply, but these tests gauge the reaction of the nerve supply, not the blood supply. The C-fibers in the nerve may give a positive response even when the blood supply has been compromised

Volume 5 Number 4

Endodontic practice 37

Endodontics in focus

Figure 8: Endo-Frost

Figure 9A: Draining sinus above tooth No.15 leading to a misdiagnosis

or lost. The electric pulp test is not always reliable because in a multi-rooted tooth, the pulp may be dead in one canal and alive in another. In sclerosed canals, the electrical stimulus may not get through to the pulp. Cold tests are often more reliable, but the temperature has to be sufficiently low. Ice or ethyl chloride (-4°C) is just not cold enough; far better to use ROEKO Endo-Frost (Coltène WhaledentŽ), which reaches -50°C (Figure 8). When taking a history, always ask if anything triggers the pain. If the answer is either hot or cold, these can be used to help diagnose the source of the symptoms. Often the problem tooth is easy to identify, but when it is not, because of large restorations, crowns, etc., each tooth can be isolated with rubber dam and a syringe full of hot water applied to the tooth.

" -

N

" ĂŠ 1 / "

38 Endodontic practice

N

Figure 9B: Gutta-percha point indicating a chronic apical periodontitis in tooth No.16

!"#$%$%&'($%)(' If you see a draining sinus or fistula adjacent to a tooth, always take a radiograph with a gutta-percha point in the sinus (if it is painful, use a little local anesthetic). The sinus does not always take the shortest route out, and one can easily be caught by surprise. The case in Figures 9A and 9B was misdiagnosed as a problem with tooth No. 15. Extraction and an implant were recommended. *)++#", Hopefully these little tips are useful, and you can incorporate them into your usual diagnostic sieve. The important thing with diagnosis is to think logically. EP Next issue - Radiography

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Volume 5 Number 4

Continuing education

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he majority of clinical decisions regarding the most appropriate choice of restorative material and technique are relatively straightforward and are usually dictated by a variety of factors including: UĂŠ iĂƒÂˆÂœÂ˜ĂŠĂƒÂˆâiĂŠ>˜`ĂŠiĂŒÂˆÂœÂ?Âœ}Ăž UĂŠ ĂƒĂŒÂ…iĂŒÂˆV]ĂŠÂœVVÂ?Ă•Ăƒ>Â?]ĂŠi˜`Âœ`ÂœÂ˜ĂŒÂˆVĂŠ>˜`ĂŠÂŤiĂ€ÂˆÂœ`ÂœÂ˜ĂŒ>Â?ĂŠVÂœÂ˜ĂƒÂˆ`iĂ€>ĂŒÂˆÂœÂ˜ĂƒĂŠ UĂŠ ՓLiĂ€ĂŠÂœvĂŠĂŒiiĂŒÂ…ĂŠ>vviVĂŒi` UĂŠ*>ĂŒÂˆiÂ˜ĂŒĂŠVÂœÂ“ÂŤÂ?ˆ>˜Vi]ĂŠÂ…>LÂˆĂŒĂƒĂŠ>˜`ĂŠÂŤĂ€iviĂ€i˜ViĂƒĂŠ UĂŠ/Â…iĂŠ`iÂ˜ĂŒÂˆĂƒĂŒ½ĂƒĂŠÂœĂœÂ˜ĂŠVÂœÂ“ÂŤiĂŒi˜ViĂŠ>˜`ĂŠĂ•Â˜`iĂ€Â?ĂžÂˆÂ˜}ĂŠLiÂ?ˆivĂƒĂŠ>LÂœĂ•ĂŒĂŠĂŠ restorative treatment. The decision-making process involved when choosing to use either a direct or an indirect approach for any given clinical ĂƒÂˆĂŒĂ•>ĂŒÂˆÂœÂ˜ĂŠV>Â˜ĂŠLiĂŠv>VˆÂ?ÂˆĂŒ>ĂŒi`ĂŠLÞÊVÂœÂ˜ĂƒÂˆ`iĂ€ÂˆÂ˜}ĂŠĂŒÂ…iĂŠvÂœÂ?Â?ÂœĂœÂˆÂ˜}ĂŠVÂœÂ˜ĂŒÂˆÂ˜Ă•Ă•Â“]ĂŠ which has at one end direct restorations and at the other indirect Ă€iĂƒĂŒÂœĂ€>ĂŒÂˆÂœÂ˜Ăƒ]ĂŠ>˜`ĂŠĂœÂ…ÂˆVÂ…ĂŠV>Â˜ĂŠLiĂŠĂƒÂŤÂ?ÂˆĂŒĂŠÂˆÂ˜ĂŒÂœĂŠĂŒÂ…Ă€iiĂŠ`ÂˆĂƒĂŒÂˆÂ˜VĂŒĂŠV>ĂŒi}ÂœĂ€ÂˆiĂƒ° !"#$%&'()*+),-'$.#)'$/#&'"#-&0/).1$"'1()-0,-."#$, Category A is populated by the overwhelming majority of Class ]ĂŠ ]ĂŠ 6ĂŠ>˜`ĂŠ6ĂŠĂ€iĂƒĂŒÂœĂ€>ĂŒÂˆÂœÂ˜Ăƒ]ĂŠ>ĂƒĂŠĂœiÂ?Â?ĂŠ>ĂƒĂŠÂ“ÂœĂƒĂŒĂŠĂƒÂ“>Â?Â?ĂŠ Â?>ĂƒĂƒĂŠ ĂŠ­ "]ĂŠ

"ĂŠ>˜`ĂŠ " ÂŽĂŠĂ€iĂƒĂŒÂœĂ€>ĂŒÂˆÂœÂ˜Ăƒ°ĂŠ 1˜Â?iĂƒĂƒĂŠ ĂŒÂ…iĂ€iĂŠ >Ă€iĂŠ ÂœĂŒÂ…iÀÊVÂœÂ˜ĂŒĂ€ÂˆLĂ•ĂŒÂœĂ€ĂžĂŠ v>VĂŒÂœĂ€ĂƒĂŠ>ĂŒĂŠÂŤÂ?>Ăž]ĂŠĂŒÂ…iĂŠĂ€iĂƒĂŒÂœĂ€>ĂŒÂˆÂœÂ˜ĂŠÂœvĂŠV…œˆViĂŠĂœÂˆÂ?Â?ĂŠLiĂŠ`ÂˆĂ€iVĂŒĂŠ>˜`]ĂŠÂ“ÂœĂƒĂŒĂŠ ÂŤĂ€ÂœL>LÂ?Ăž]ĂŠVÂœÂ“ÂŤÂœĂƒÂˆĂŒi°ĂŠ7…ˆÂ?iʓ>Â˜ĂžĂŠ>“>Â?}>“ÊÀiĂƒĂŒÂœĂ€>ĂŒÂˆÂœÂ˜ĂƒĂŠVÂœÂ˜ĂŒÂˆÂ˜Ă•iĂŠ ĂŒÂœĂŠLiĂŠÂŤÂ?>Vi`]ĂŠ>ĂƒĂŠv>ÀÊ>ĂƒĂŠĂŒÂ…ÂˆĂƒĂŠÂŤ>ÂŤiĂ€ĂŠÂˆĂƒĂŠVœ˜ViĂ€Â˜i`]ĂŠ`ÂˆĂ€iVĂŒĂŠĂ€iĂƒĂŒÂœĂ€>ĂŒÂˆÂœÂ˜ĂƒĂŠ Ă€iviĂ€ĂŠĂŒÂœĂŠĂ€iĂƒÂˆÂ˜Â‡L>Ăƒi`ĂŠVÂœÂ“ÂŤÂœĂƒÂˆĂŒiĂŠĂ•Â˜Â?iĂƒĂƒĂŠÂœĂŒÂ…iĂ€ĂœÂˆĂƒiĂŠĂƒĂŒ>ĂŒi`°ĂŠ Â˜ĂŠĂŒÂ…iĂŠ1°-°]ĂŠ it appears that around two-thirds of direct restorations currently being placed are made of composite and one-third amalgam ­ Â…Ă€ÂˆĂƒĂŒiÂ˜ĂƒiÂ˜ĂŠ ]ĂŠĂ“ä£äŽ°ĂŠ ĂƒĂŠ Â…Ă€ÂˆĂƒĂŒiÂ˜ĂƒiÂ˜ĂŠÂŤÂœÂˆÂ˜ĂŒĂƒĂŠÂœĂ•ĂŒ]ĂŠ>“>Â?}>Â“ĂŠÂˆĂƒÂ˜½ĂŒĂŠ `i>`ĂŠqĂŠÂˆĂŒĂŠÂˆĂƒĂŠĂƒÂˆÂ“ÂŤÂ?ÞÊLiˆ˜}ĂŠĂ•Ăƒi`ĂŠÂ?iĂƒĂƒĂŠÂœvĂŒi˜°ĂŠ Â?>ĂƒĂƒĂŠÂˆÂœÂ˜ÂœÂ“iÀʓ>ÞÊLiĂŠ considered in a limited number of situations where its cariostatic ivviVĂŒĂƒĂŠÂ“Âˆ}Â…ĂŒĂŠLiĂŠVÂœÂ˜ĂƒÂˆ`iĂ€i`ĂŠĂ•ĂƒivĂ•Â?ĂŠ­/>ÞÊ ,]ĂŠiĂŒĂŠ>Â?]ĂŠĂ“ä䣎°ĂŠ !"#$%&'() 2+) 30.$'#"-0#() &4$') 56-.6) -/) #6$) 7&/#) "88'&8'-"#$)"88'&".6 It is in the middle ground of Category B where we find a number of commonly occurring clinical scenarios that can and do cause confusion among many dentists who are unsure which avenue they should pursue – direct or indirect. These are the clinical situations we wish to explore further in this paper. !"#$%&'()!+)-0,-'$.#)'$/#&'"#-&0/).1$"'1()-0,-."#$, ĂŒĂŠ ĂŒÂ…iĂŠ ÂœĂŒÂ…iÀÊ i˜`ĂŠ ÂœvĂŠ ĂŒÂ…iĂŠ ĂƒÂŤiVĂŒĂ€Ă•Â“]ĂŠ >ĂŒi}ÂœĂ€ĂžĂŠ ĂŠ ÂˆĂƒĂŠ >Â?ĂƒÂœĂŠ Ă€iÂ?>ĂŒÂˆĂ›iÂ?ÞÊ straightforward in that here we find large cavities and/or failed direct restorations with multiple missing cusps; anterior teeth with large interproximal cavities along with maybe one or both mesial and distal incisal edges requiring replacement; replacement ÂœvĂŠ v>ˆÂ?i`ĂŠ VĂ€ÂœĂœÂ˜Ăƒ]ĂŠ >˜`ĂŠ Â?>Ă€}iĂŠ Ă€iÂ…>LˆÂ?ÂˆĂŒ>ĂŒÂˆÂœÂ˜ĂŠ V>ĂƒiĂƒĂŠ Ă€iÂľĂ•ÂˆĂ€ÂˆÂ˜}ĂŠ ĂŒÂ…iĂŠ Ă€i‡ creation of multiple occlusal surfaces. There is little contention that the treatment of choice in such situations is some form of ˆ˜`ÂˆĂ€iVĂŒĂŠ Ă€iĂƒĂŒÂœĂ€>ĂŒÂˆÂœÂ˜ĂŠ ­ ˆ}Ă•Ă€iĂŠ £Ž°ĂŠ /Â…iĂŠ V…œˆViĂŠ ÂœvĂŠ “>ĂŒiĂ€Âˆ>Â?ĂŠ ­}ÂœÂ?`]ĂŠ ÂŤÂœĂ€ViÂ?>ÂˆÂ˜ĂŠ vĂ•Ăƒi`ĂŠ ĂŒÂœĂŠ “iĂŒ>Â?ĂŠ Q* RĂŠ ÂœĂ€ĂŠ >Â?Â?ĂŠ ViĂ€>“ˆVÂŽĂŠ `iÂŤi˜`ĂƒĂŠ ÂœÂ˜ĂŠ >Â˜ĂŠ analysis of the various factors listed in the introduction. 9&&#:;-11$,)#$$#6)

ÂœÂ“ÂŤ>Ă€i`ĂŠ ĂŒÂœĂŠ ĂŒiiĂŒÂ…ĂŠ ĂœÂˆĂŒÂ…ĂŠ Â…i>Â?ĂŒÂ…ĂžĂŠ ÂŤĂ•Â?ÂŤĂƒ]ĂŠ Ă€ÂœÂœĂŒÂ‡wÂ?Â?i`ĂŠ ĂŒiiĂŒÂ…ĂŠ >Ă€iĂŠ VÂœÂ˜ĂƒÂˆ`iĂ€i`ĂŠĂŒÂœĂŠLiĂŠÂ“ÂœĂ€iĂŠĂƒĂ•ĂƒViÂŤĂŒÂˆLÂ?iĂŠĂŒÂœĂŠvĂ€>VĂŒĂ•Ă€iĂŠ­ ˆ}Ă•Ă€iĂŠĂ“ÂŽ]ĂŠ>ĂƒĂŠĂŒÂ…iÞÊ ÂŤÂœĂƒĂƒiĂƒĂƒĂŠ Ă€i`Ă•Vi`ĂŠ `iÂ˜ĂŒÂˆÂ˜>Â?ĂŠ iÂ?>ĂƒĂŒÂˆVÂˆĂŒĂžĂŠ ­ ÂœÂ…Â˜ĂƒÂœÂ˜ĂŠ ]ĂŠ iĂŒĂŠ >Â?°]ĂŠ ÂŁÂ™Ă‡ĂˆÂŽ]ĂŠ 6ÂœÂ?ՓiĂŠxĂŠĂŠ ՓLiÀÊ{

Educational aims and objectives

The aim of this article is to educate the reader on the factors that must be considered when choosing between direct and indirect restorations.

Expected outcomes

Correctly answering the 20 questions on page 43, worth 4 hours of CE, will demonstrate that each clinical case is different, and there are many options to choose from, with various advantages and disadvantages.

Figure 1: It is clear that in this case, replacing these failing amalgams and composites with further direct restorations would be inappropriate and that indirect restorations are required

Â?ÂœĂœiÀÊ Ăœ>ĂŒiÀÊ VÂœÂ˜ĂŒiÂ˜ĂŒĂŠ ­,ÂœĂƒiÂ˜ĂŠ ]ĂŠ ÂŁÂ™ĂˆÂŁÂŽ]ĂŠ `iiÂŤiÀÊ V>Ă›ÂˆĂŒÂˆiĂƒĂŠ ­ >`ÂˆĂƒÂœÂ˜ĂŠ -]ĂŠ 7ˆÂ?VÂœĂ?ĂŠ ,]ĂŠ £™nnÂŽĂŠ >˜`ĂŠ ĂƒĂ•LĂƒĂŒ>Â˜ĂŒÂˆ>Â?ĂŠ Â?ÂœĂƒĂƒĂŠ ÂœvĂŠ `iÂ˜ĂŒÂˆÂ˜ĂŠ ˆ˜VÂ?Ă•`ˆ˜}]ĂŠ VĂ€ÂˆĂŒÂˆV>Â?Â?Ăž]ĂŠĂŒÂ…iĂŠĂƒĂŒĂ€i˜}ĂŒÂ…i˜ˆ˜}ĂŠivviVĂŒĂŠÂœvĂŠĂŒÂ…iĂŠÂŤĂ•Â?ÂŤĂŠVÂ…>“LiĂ€ĂŠĂ€ÂœÂœvĂŠ­ ĂƒĂƒÂˆvĂŠ

]ĂŠiĂŒĂŠ>Â?°]ĂŠĂ“ääĂŽŽ°ĂŠ ĂŠ ĂŒĂŠÂ…>Ăƒ]ĂŠĂŒÂ…iĂ€ivÂœĂ€i]ĂŠLiiÂ˜ĂŠ>ĂŠÂ?œ˜}ĂŠ>˜`ĂŠĂœÂˆ`iÂ?ÞʅiÂ?`ĂŠĂ›ÂˆiĂœĂŠ­ ÂœiĂ€Âˆ}ĂŠ ]ĂŠ Ă•i˜ˆ˜}Â…ÂœvvĂŠ ]Ê£™nÎÆÊ,iiÂ…ĂŠ -]ĂŠiĂŒĂŠ>Â?°]Ê£™nÂ™ÂŽĂŠĂŒÂ…>ĂŒĂŠÂŤÂœĂƒĂŒiĂ€ÂˆÂœĂ€ĂŠ root-filled teeth require some form of indirect occlusal coverage ­ÂœÂ˜Â?>ĂžĂŠÂœĂ€ĂŠVĂ€ÂœĂœÂ˜ÂŽĂŠÂˆÂ˜ĂŠÂœĂ€`iĂ€ĂŠĂŒÂœĂŠÂŤĂ€ÂœĂŒiVĂŒĂŠĂŒÂ…iĂŠĂŒÂœÂœĂŒÂ…ĂŠ>}>ÂˆÂ˜ĂƒĂŒĂŠĂƒĂ•LĂƒi¾ÕiÂ˜ĂŒĂŠ Ă€ÂœÂœĂŒĂŠvĂ€>VĂŒĂ•Ă€iĂŠ­ ˆ}Ă•Ă€iĂŠĂŽŽ°ĂŠ ĂŠ ĂŒĂŠ Â…>ĂƒĂŠ >Â?ĂƒÂœĂŠ LiiÂ˜ĂŠ ĂƒĂ•}}iĂƒĂŒi`ĂŠ ­ ĂƒĂƒÂˆvĂŠ ]ĂŠ iĂŒĂŠ >Â?°]ĂŠ Ă“ääÎÆÊ -“>Â?iĂƒĂŠ , ]ĂŠ >ĂœĂŒÂ…ÂœĂ€Â˜iĂŠ7-]ĂŠÂŁÂ™Â™Ă‡ÂŽĂŠĂŒÂ…>ĂŒĂŠĂœÂ…iĂ€iĂŠÂ“ÂœĂ€iĂŠiĂ?ĂŒiÂ˜ĂƒÂˆĂ›iĂŠĂŒÂœÂœĂŒÂ…ĂŠÂ?ÂœĂƒĂƒĂŠ Â…>ĂƒĂŠ ĂŒ>ÂŽiÂ˜ĂŠ ÂŤÂ?>Vi]ĂŠ ÂˆĂŒĂŠ ÂˆĂƒĂŠ ÂŤÂœĂƒĂƒÂˆLÂ?iĂŠ ĂŒÂœĂŠ Ă•ĂƒiĂŠ >ĂŠ `ÂˆĂ€iVĂŒÂ?އÂ?>Vi`ĂŠ >“>Â?}>“Ê œ˜Â?>ĂžĂŠĂŒÂœĂŠÂŤĂ€ÂœĂŒiVĂŒĂŠĂŒÂ…iĂŠĂŒiiĂŒÂ…ĂŠ­>ĂŒĂŠÂ?i>ĂƒĂŒĂŠ>ĂƒĂŠ>ʓi`ÂˆĂ•Â“ĂŠĂŒiÀ“]ĂŠVÂœĂƒĂŒÂ‡ivviVĂŒÂˆĂ›iĂŠ ÂŤĂ€iVĂ•Ă€ĂƒÂœĂ€ĂŠ ĂŒÂœĂŠ >ĂŠ Â?>ĂŒiÀÊ ˆ˜`ÂˆĂ€iVĂŒĂŠ Ă€iĂƒĂŒÂœĂ€>ĂŒÂˆÂœÂ˜ÂŽĂŠ ÂŤĂ€ÂœĂ›Âˆ`i`ĂŠ ĂŒÂ…>ĂŒĂŠ ĂƒĂ•vwVˆiÂ˜ĂŒĂŠ LĂ•Â?ÂŽĂŠ ÂœvĂŠ “>ĂŒiĂ€Âˆ>Â?ĂŠ qĂŠ >ĂŒĂŠ Â?i>ĂƒĂŒĂŠ Ă“ĂŠ ““Ê ­ >ÞÞ>ÀÊ ]ĂŠ iĂŒĂŠ >Â?°]ĂŠ £™näŽĂŠ qĂŠ ÂˆĂƒĂŠ ÂŤĂ€iĂƒiÂ˜ĂŒĂŠ­ ˆ}Ă•Ă€iĂŠ{Ž°ĂŠ This type of extensive restoration is more difficult and VÂ?ˆ˜ˆV>Â?Â?ÞÊ `i“>˜`ˆ˜}ĂŠ ĂŒÂœĂŠ VĂ€i>ĂŒiĂŠ ÂˆÂ˜ĂŠ `ÂˆĂ€iVĂŒĂŠ VÂœÂ“ÂŤÂœĂƒÂˆĂŒiĂŠ ­ĂƒiiĂŠ LiÂ?ÂœĂœÂŽ]ĂŠ and there are concerns whether such a restoration would exhibit sufficient strength to resist occlusal forces. If there is only an ÂœVVÂ?Ă•Ăƒ>Â?ĂŠ >VViĂƒĂƒĂŠ V>Ă›ÂˆĂŒĂžĂŠ Ă€iÂľĂ•ÂˆĂ€ÂˆÂ˜}ĂŠ Ă€iĂƒĂŒÂœĂ€>ĂŒÂˆÂœÂ˜ĂŠ ĂŒÂ…i˜]ĂŠ ˆ˜VĂ€i>ĂƒÂˆÂ˜}Â?Ăž]ĂŠ >ĂŠ ĂƒÂˆÂ“ÂŤÂ?iĂŠ`ÂˆĂ€iVĂŒĂŠĂ€iĂƒĂŒÂœĂ€>ĂŒÂˆÂœÂ˜ĂŠÂˆĂƒĂŠ`ii“i`ĂŠĂŒÂœĂŠLiĂŠĂƒĂ•vwVˆiÂ˜ĂŒĂŠ­ iĂ€Â˜>˜`iâĂŠ,]ĂŠ iĂŒĂŠ>Â?°]Ê£™™{Ž°ĂŠ ÂŤ>Ă€ĂŒĂŠvĂ€ÂœÂ“ĂŠVÂœÂ˜ĂƒiĂ€Ă›ÂˆÂ˜}ĂŠĂŒÂœÂœĂŒÂ…ĂŠĂŒÂˆĂƒĂƒĂ•i]ĂŠĂŒÂ…ÂˆĂƒĂŠĂœÂœĂ•Â?`ĂŠÂ…>Ă›iĂŠ Endodontic practice Ι

Continuing education

Figures 2A and 2B: The combination of endodontic treatment and Figures 3A and 3B: Most posterior root-filled teeth require some extensive tooth loss, especially if this involves loss of one or both form of indirect occlusal coverage to provide protection and prevent marginal ridges, makes a tooth highly susceptible to fracture subsequent tooth fracture

Figures 4A and 4B: In cases where, for whatever reason, indirect Figures 5A and 5B: Large, durable, esthetic direct placement occlusal coverage restorations are not able to be placed, amalgam restorations are now possible thanks to modern composite/bonding can be used, provided that there is sufficient occlusal reduction technology. It is imperative, though, that the operator has an excellent understanding of the sensitive nature of the clinical techniques required

the added benefit of reducing the length of restoration margin and ĂŒÂ…iĂ€ivÂœĂ€iĂŠĂŒÂ…iĂŠÂŤÂœĂŒiÂ˜ĂŒÂˆ>Â?ĂŠvÂœĂ€ĂŠÂ“ÂˆVĂ€ÂœÂ?i>ÂŽ>}i]ĂŠ>ĂŠÂ…Âˆ}Â…Â?ĂžĂŠĂƒÂˆ}˜ˆwV>Â˜ĂŒĂŠv>VĂŒÂœĂ€ĂŠ ÂˆÂ˜ĂŠÂ?œ˜}Â‡ĂŒiÀ“Êi˜`Âœ`ÂœÂ˜ĂŒÂˆVĂŠĂƒĂ•VViĂƒĂƒĂŠ­/ˆVÂŽÂ?iĂŠ ]ĂŠiĂŒĂŠ>Â?°]ĂŠĂ“äänŽ°ĂŠ ĂŠ /Â…iĂ€iĂŠ>Ă€iĂŠV>Ă›i>ĂŒĂƒĂŠĂŒÂœĂŠĂŒÂ…ÂˆĂƒĂŠ>ÂŤÂŤĂ€Âœ>VÂ…]ĂŠÂ…ÂœĂœiĂ›iĂ€°ĂŠ ÂœĂ€ĂŠiĂ?>“Â?i]ĂŠ ĂŒÂ…iĂŠÂŤĂ€iĂƒi˜ViĂŠÂœvĂŠĂƒĂ•ĂƒÂŤÂˆVÂˆÂœĂ•ĂƒĂŠVĂ€>VÂŽĂŠÂ?ˆ˜iĂƒĂŠ>˜`ĂŠÂ…i>Ă›ĂžĂŠÂœVVÂ?Ă•Ăƒ>Â?ĂŠÂ?Âœ>`ˆ˜}]ĂŠ Vœ“Lˆ˜i`ĂŠ ĂœÂˆĂŒÂ…ĂŠ ÂŤ>Ă€>vĂ•Â˜VĂŒÂˆÂœÂ˜>Â?ĂŠ Â…>LÂˆĂŒĂƒ]ĂŠ ĂœÂœĂ•Â?`ĂŠ ĂƒĂŒiiÀÊ œ˜iĂŠ ĂŒÂœĂœ>Ă€`ĂƒĂŠ Ă•ĂƒÂˆÂ˜}ĂŠÂˆÂ˜`ÂˆĂ€iVĂŒĂŠÂœVVÂ?Ă•Ăƒ>Â?ĂŠVÂœĂ›iĂ€>}i°ĂŠ ``ÂˆĂŒÂˆÂœÂ˜>Â?Â?Ăž]ĂŠÂŤĂ€i“œÂ?>Ă€ĂŠĂŒiiĂŒÂ…ĂŠ>Ă€iĂŠ thought to be more likely to fracture when a direct intracoronal Ă€iĂƒĂŒÂœĂ€>ĂŒÂˆÂœÂ˜ĂŠÂˆĂƒĂŠÂŤÂ?>Vi`]ĂŠĂƒÂˆÂ“ÂŤÂ?ÞÊLiV>Ă•ĂƒiĂŠĂŒÂ…iĂŠĂŒÂœÂœĂŒÂ…ĂŠĂŒÂˆĂƒĂƒĂ•iĂŠÂ?ÂœĂƒĂƒĂŠV>Ă•Ăƒi`ĂŠ by the access preparation is proportionally larger than in a molar ĂŒÂœÂœĂŒÂ…°ĂŠ >ĂƒĂŒÂ?Ăž]ĂŠ ĂŒÂ…iĂ€iĂŠ ÂˆĂƒĂŠ >ĂŠ ĂŒÂ…iÂœĂ€iĂŒÂˆV>Â?ĂŠ ÂŤÂœĂƒĂƒÂˆLˆÂ?ÂˆĂŒĂžĂŠ ĂŒÂ…>ĂŒĂŠ ĂŒÂ…iĂŠ ivviVĂŒĂŠ ÂœvĂŠ VÂœÂ˜ĂŒĂ€>VĂŒÂˆÂœÂ˜ĂŠ ĂƒĂŒĂ€iĂƒĂƒĂŠ }i˜iĂ€>ĂŒi`ĂŠ ĂŒÂ…Ă€ÂœĂ•}Â…ĂŠ ÂŤÂœÂ?ޓiĂ€Âˆâ>ĂŒÂˆÂœÂ˜ĂŠ ĂƒÂ…Ă€ÂˆÂ˜ÂŽ>}iĂŠ ­ iˆÂ?âiÀÊ ]ĂŠiĂŒĂŠ>Â?°]Ê£™nǎʓ>ÞÊLiʓ>}˜ˆwi`ĂŠÂœÂ˜ĂŠĂŒiiĂŒÂ…ĂŠĂŒÂ…>ĂŒĂŠ>Ă€iĂŠ>Â?Ă€i>`ÞÊ more susceptible to fracture. ĂŠ Â˜ĂŠ>Â˜ĂŒiĂ€ÂˆÂœĂ€ĂŠĂŒiiĂŒÂ…ĂŠĂœÂ…iĂ€iĂŠĂŒÂ…iĂŠÂœVVÂ?Ă•Ăƒ>Â?ĂŠÂ?Âœ>`ˆ˜}ĂŠÂˆĂƒĂŠÂ“Ă•VÂ…ĂŠÂ?iĂƒĂƒ]ĂŠ it is common practice now to use direct composite in cases with simple cingulum access cavities. The greater the extent of any ÂŤĂ€iĂ›ÂˆÂœĂ•ĂƒĂŠV>Ă€ÂˆiĂƒ]ĂŠĂ€iĂƒĂŒÂœĂ€>ĂŒÂˆÂœÂ˜ĂŠÂœĂ€ĂŠĂŒĂ€>Փ>]ĂŠĂŒÂ…iĂŠÂ“ÂœĂ€iĂŠÂ?ˆŽiÂ?ĂžĂŠĂƒÂœÂ“iĂŠvÂœĂ€Â“ĂŠ ÂœvĂŠiĂ?ĂŒĂ€>‡VÂœĂ€ÂœÂ˜>Â?ĂŠĂ€iĂƒĂŒÂœĂ€>ĂŒÂˆÂœÂ˜ĂŠĂœÂˆÂ?Â?ĂŠLiĂŠĂ€iÂľĂ•ÂˆĂ€i`°ĂŠ ÂœĂ€ĂŠiĂ?>“Â?i]ĂŠ>ĂŠĂŒÂœÂœĂŒÂ…ĂŠ ĂœÂˆĂŒÂ…ĂŠ “iĂƒÂˆ>Â?ĂŠ >˜`ĂŠ `ÂˆĂƒĂŒ>Â?ĂŠ V>Ă›ÂˆĂŒÂˆiĂƒ]ĂŠ Vœ˜˜iVĂŒi`ĂŠ LÞÊ >Â˜ĂŠ ÂœVVÂ?Ă•Ăƒ>Â?ĂŠ >VViĂƒĂƒĂŠ V>Ă›ÂˆĂŒĂž]ĂŠĂœÂˆÂ?Â?ĂŠÂ…>Ă›iĂŠÂ?ÂœĂƒĂŒĂŠÂ“Ă•VÂ…ĂŠÂœvĂŠÂˆĂŒĂƒĂŠÂˆÂ˜ĂŒi}Ă€>Â?ĂŠĂƒĂŒĂ€i˜}ĂŒÂ…ĂŠ>˜`ĂŠĂœÂœĂ•Â?`ĂŠLiĂŠ much more prone to fracture if restored simply by means of a `ÂˆĂ€iVĂŒĂŠVÂœÂ“ÂŤÂœĂƒÂˆĂŒi°ĂŠ"˜ViĂŠ>}>ˆ˜]ĂŠV>Ă•ĂŒÂˆÂœÂ˜ĂŠÂ“Ă•ĂƒĂŒĂŠLiĂŠiĂ?iĂ€VÂˆĂƒi`ĂŠĂœÂ…i˜iĂ›iÀÊ there is evidence of crack lines and heavy occlusal loading. !"#$%&'$()*'+',In cases where a single cusp of a posterior tooth has been lost vÂœĂ€ĂŠ ĂœÂ…>ĂŒiĂ›iÀÊ Ă€i>ĂƒÂœÂ˜ĂŠ ­VĂ€>VÂŽĂŠ Â?ˆ˜i]ĂŠ V>Ă€ÂˆiĂƒ]ĂŠ ĂŒĂ€>Փ>]ĂŠ iĂŒV°Ž]ĂŠ ÂˆĂŒĂŠ ÂˆĂƒĂŠ Â˜ÂœĂœĂŠ considered acceptable to restore the tooth using direct composite ­ ˆ}Ă•Ă€iĂŠ xŽ°ĂŠ iÞÊ ĂŒÂœĂŠ ĂŒÂ…ÂˆĂƒĂŠ ÂˆĂƒĂŠ ĂŒÂ…iĂŠ `iÂ˜ĂŒÂˆĂƒĂŒ½ĂƒĂŠ ÂœĂœÂ˜ĂŠ VÂ?ˆ˜ˆV>Â?ĂŠ >LˆÂ?ÂˆĂŒĂž]ĂŠ ÂˆÂ˜ĂŠ particular the skill and knowledge of dental anatomy to re-create correctly a replacement cusp directly in the mouth. These skills are far removed from those required to carve a large amalgam. 7…ˆÂ?iĂŠ ÂˆĂŒĂŠ “>ÞÊ LiĂŠ ÂŤÂœĂƒĂƒÂˆLÂ?iĂŠ ĂŒÂœĂŠ Ă€i‡VĂ€i>ĂŒiĂŠ Â“ÂœĂ€iĂŠ ĂŒÂ…>Â˜ĂŠ œ˜iĂŠ VĂ•ĂƒÂŤĂŠ `ÂˆĂ€iVĂŒÂ?ĂžĂŠÂˆÂ˜ĂƒÂˆ`iĂŠĂŒÂ…iĂŠÂ“ÂœĂ•ĂŒÂ…]ĂŠVœ˜ViĂ€Â˜ĂƒĂŠÂœĂ›iĂ€ĂŠĂŒÂ…iĂŠĂƒĂŒĂ€i˜}ĂŒÂ…ĂŠÂœvĂŠĂŒÂ…iĂŠw˜>Â?ĂŠ Ă€iĂƒĂŒÂœĂ€>ĂŒÂˆÂœÂ˜]ĂŠ>ĂƒĂŠĂœiÂ?Â?ĂŠ>ĂƒĂŠĂŒÂ…iĂŠVÂœÂ˜ĂƒÂˆ`iĂ€>LÂ?iĂŠVÂ…>ÂˆĂ€ĂƒÂˆ`iĂŠĂŒÂˆÂ“iĂŠĂ€iÂľĂ•ÂˆĂ€i`ĂŠĂŒÂœĂŠ VÂœÂ“ÂŤÂ?iĂŒiĂŠ ĂƒĂ•VÂ…ĂŠ >ĂŠ Ă€iĂƒĂŒÂœĂ€>ĂŒÂˆÂœÂ˜]ĂŠ “i>Â˜ĂŠ ĂŒÂ…>ĂŒĂŠ “>Â˜ĂžĂŠ >Ă•ĂŒÂ…ÂœĂ€ÂˆĂŒÂˆiĂƒĂŠ ÂœÂ˜ĂŠ ĂŒÂ…iĂŠ use of direct composite would often draw the line at replacing Â?Ă•ĂƒĂŒĂŠ œ˜iĂŠ VĂ•Ăƒ°ĂŠ Â˜ĂƒĂŒi>`]ĂŠ ĂŒÂ…iÞÊ ĂœÂœĂ•Â?`ĂŠ Ă€iVœ““i˜`ĂŠ Ă•ĂƒÂˆÂ˜}ĂŠ iÂˆĂŒÂ…iÀÊ >Â˜ĂŠ {äĂŠĂŠEndodontic practice

indirect restoration or a so-called “semi-directâ€? or “direct-indirectâ€? >ÂŤÂŤĂ€Âœ>VÂ…ĂŠ­-ÂŤĂ€i>wVÂœĂŠ,]ĂŠÂŁÂ™Â™ĂˆÂŽĂŠvÂœĂ€ĂŠĂŒÂ…iĂƒiĂŠÂ“ÂœĂ€iĂŠiĂ?ĂŒiÂ˜ĂƒÂˆĂ›iĂŠV>Ă›ÂˆĂŒÂˆiĂƒ°ĂŠ .''$%$&/01+)(%2/0'#

ÂˆĂ€iVĂŒĂŠ VÂœÂ“ÂŤÂœĂƒÂˆĂŒiĂƒĂŠ >Ă€iĂŠ Â“ÂœĂ€iĂŠ Â?ˆŽiÂ?ÞÊ ĂŒÂœĂŠ LiĂŠ iĂƒĂŒÂ…iĂŒÂˆV]ĂŠ vĂ•Â˜VĂŒÂˆÂœÂ˜>Â?ĂŠ >˜`ĂŠ `Ă•Ă€>LÂ?iĂŠĂœÂ…iÂ˜ĂŠV>Ă›ÂˆĂŒĂžĂŠÂ“>Ă€}ÂˆÂ˜ĂƒĂŠ>Ă€iĂŠĂƒÂˆĂŒĂ•>ĂŒi`ĂŠĂœÂˆĂŒÂ…ÂˆÂ˜ĂŠi˜>“iÂ?]ĂŠvĂ€iiĂŠvĂ€ÂœÂ“ĂŠ Â…i>Ă›ĂžĂŠÂœVVÂ?Ă•Ăƒ>Â?ĂŠVÂœÂ˜ĂŒ>VĂŒ]ĂŠ>˜`ĂŠi>ĂƒÂˆÂ?ÞÊ>VViĂƒĂƒÂˆLÂ?iĂŠÂˆÂ˜ĂŠĂŒiĂ€Â“ĂƒĂŠÂœvĂŠĂ›ÂˆĂƒÂˆLˆÂ?ÂˆĂŒĂž]ĂŠ i>ĂƒiĂŠ ÂœvĂŠ ÂˆĂƒÂœÂ?>ĂŒÂˆÂœÂ˜]ĂŠ >˜`ĂŠ Ă€iÂ?>ĂŒÂˆÂœÂ˜ĂƒÂ…ÂˆÂŤĂŠ ĂŒÂœĂŠ >`Â?>ViÂ˜ĂŒĂŠ }ˆ˜}ÂˆĂ›>Â?ĂŠ ĂŒÂˆĂƒĂƒĂ•iĂƒ°ĂŠ /Â…iĂŠÂ“ÂœĂ€iĂŠ>ĂŠV>Ă›ÂˆĂŒĂžĂŠv>ˆÂ?ĂƒĂŠĂŒÂœĂŠvĂ•Â?wÂ?Â?ĂŠĂŒÂ…iĂƒiĂŠVĂ€ÂˆĂŒiĂ€Âˆ>]ĂŠĂŒÂ…iĂŠÂ“ÂœĂ€iĂŠ`ˆvwVĂ•Â?ĂŒĂŠ ÂˆĂŒĂŠ LiVœ“iĂƒĂŠ ĂŒÂœĂŠ ÂŤĂ€i`ˆVĂŒĂŠ ĂƒĂ•VViĂƒĂƒ°ĂŠ /Â…iĂ€ivÂœĂ€i]ĂŠ VÂœÂ˜ĂƒÂˆ`iĂ€>ĂŒÂˆÂœÂ˜ĂŠ ĂƒÂ…ÂœĂ•Â?`ĂŠ LiĂŠ}ÂˆĂ›iÂ˜ĂŠĂŒÂœĂŠ>Â˜ĂŠ>Â?ĂŒiĂ€Â˜>ĂŒÂˆĂ›iʓi>Â˜ĂƒĂŠÂœvĂŠĂ€iĂƒĂŒÂœĂ€ÂˆÂ˜}ĂŠĂŒÂ…iĂŠĂŒÂœÂœĂŒÂ…°ĂŠ"˜iĂŠĂ›iÀÞÊ common example of this is when the box of a Class II cavity extends beyond enamel. Apart from the likelihood of a significant loss of ĂŒÂœÂœĂŒÂ…ĂŠĂƒĂ•LĂƒĂŒ>˜Vi]ĂŠĂŒÂ…iʓ>ÂˆÂ˜ĂŠÂŤĂ€ÂœLÂ?i“Ê>Ă€ÂˆĂƒÂˆÂ˜}ĂŠÂˆÂ˜ĂŠĂƒĂ•VÂ…ĂŠ>ĂŠĂƒÂˆĂŒĂ•>ĂŒÂˆÂœÂ˜ĂŠÂˆĂƒĂŠ the difficulty inherent in trying to seal subgingival cervical margins located within dentin and/or cementum. .',-1,%2/,31,4 7…ˆÂ?iĂŠ Lœ˜`ˆ˜}ĂŠ ĂŒÂœĂŠ i˜>“iÂ?ĂŠ ÂˆĂƒĂŠ Â˜ÂœĂœĂŠ …ˆ}Â…Â?ÞÊ ÂŤĂ€i`ˆVĂŒ>LÂ?i]ĂŠ `œˆ˜}ĂŠ ĂƒÂœĂŠ iÂˆĂŒÂ…iĂ€ĂŠĂŒÂœĂŠ`iÂ˜ĂŒÂˆÂ˜ĂŠÂœĂ€ĂŠVi“iÂ˜ĂŒĂ•Â“ĂŠÂˆĂƒĂŠv>Ă€ĂŠÂ“ÂœĂ€iĂŠÂŤĂ€ÂœLÂ?i“>ĂŒÂˆV]ĂŠÂŤĂ€ÂˆÂ“>Ă€ÂˆÂ?ÞÊ because of the difficulty forming an effective hybrid layer. This is dependent on the successful execution of a series of crucial VÂ?ˆ˜ˆV>Â?ĂŠ ĂƒĂŒiÂŤĂƒĂŠ qĂŠ iĂŒV…ˆ˜}]ĂŠ Ăœ>ĂƒÂ…ÂˆÂ˜}ĂŠ >˜`ĂŠ `Ă€ĂžÂˆÂ˜}]ĂŠ ÂŤĂ€ÂˆÂ“iÀÊ >˜`ĂŠ Lœ˜`ĂŠ >ÂŤÂŤÂ?ˆV>ĂŒÂˆÂœÂ˜]ĂŠ >˜`]ĂŠ w˜>Â?Â?Ăž]ĂŠ ĂŒÂ…iĂŠ ÂŤÂœÂ?ޓiĂ€Âˆâ>ĂŒÂˆÂœÂ˜ĂŠ ÂœvĂŠ >`Â…iĂƒÂˆĂ›iĂŠ Ă€iĂƒÂˆÂ˜ĂŠ ÂˆÂ˜ĂŠ ÂœĂ€`iĂ€ĂŠĂŒÂœĂŠĂƒĂŒ>LˆÂ?ˆâiĂŠĂŒÂ…iĂŠvĂ€>}ˆÂ?iĂŠĂƒĂŒĂ€Ă•VĂŒĂ•Ă€iĂŠÂœvĂŠĂŒÂ…iĂŠÂ…ĂžLĂ€Âˆ`ĂŠÂ?>ĂžiĂ€ĂŠÂˆĂŒĂƒiÂ?v°ĂŠ Â˜ĂŠ Â?ˆ}Â…ĂŒĂŠÂœvĂŠĂŒÂ…ÂˆĂƒĂŠ}Ă€i>ĂŒĂŠVÂœÂ“ÂŤÂ?iĂ?ÂˆĂŒĂž]ĂŠĂŒÂ…iĂ€iĂŠ>Ă€iĂŠĂœiÂ?Â?‡`ÂœVՓiÂ˜ĂŒi`ĂŠVœ˜ViĂ€Â˜ĂƒĂŠ >LÂœĂ•ĂŒĂŠ ĂŒÂ…iĂŠ Â?>ĂƒĂŒÂˆÂ˜}ĂŠ ĂƒĂŒ>LˆÂ?ÂˆĂŒĂžĂŠ ÂœvĂŠ `iÂ˜ĂŒÂˆÂ˜ĂŠ Lœ˜`ˆ˜}ĂŠ ­ ˆiĂŒĂƒVÂ…ÂˆĂŠ ]ĂŠ iĂŒĂŠ >Â?°]ĂŠ £™™xÆÊ 6>Â˜ĂŠ iiĂ€LiiÂŽĂŠ ]ĂŠ *iĂ€`ˆ}>ÂœĂŠ ]ĂŠ £™™nÆÊ >ĂƒÂ…ÂˆÂ“ÂœĂŒÂœĂŠ ]ĂŠ iĂŒĂŠ >Â?°]ĂŠ Ă“ää䎰ĂŠ/Â…iʓ>Â?ÂœĂ€ÂˆĂŒĂžĂŠÂœvĂŠV>Ă›ÂˆĂŒÂˆiĂƒĂŠ>Ă€iĂŠiÂ˜ĂŒÂˆĂ€iÂ?ÞÊLÂœĂ•Â˜`i`ĂŠLÞÊi˜>“iÂ?]ĂŠ >˜`ĂŠÂˆĂŒĂŠÂˆĂƒĂŠĂŒÂ…ÂœĂ•}Â…ĂŒĂŠĂŒÂ…>ĂŒĂŠĂŒÂ…iĂŠĂƒi>Â?ĂŠ>V…ˆiĂ›i`ĂŠ>ĂŒĂŠĂŒÂ…iʓ>Ă€}ÂˆÂ˜ĂŠ­Âˆ°i°]ĂŠLiĂŒĂœiiÂ˜ĂŠ Ă€iĂƒÂˆÂ˜ĂŠ>˜`ĂŠi˜>“iÂ?ÂŽĂŠÂŤĂ€ÂœĂŒiVĂŒĂƒĂŠ>Â˜ĂžĂŠÂşÂˆÂ˜ĂŒiĂ€Â˜>Â?ÊÀiĂƒÂˆÂ˜Â‡`iÂ˜ĂŒÂˆÂ˜ĂŠLœ˜`ĂŠ>ĂŒĂŠĂŒÂ…iĂŠ yÂœÂœĂ€ĂŠÂœvĂŠĂŒÂ…iĂŠV>Ă›ÂˆĂŒĂž°ĂŠ ÂœĂœiĂ›iĂ€]ĂŠĂœÂ…>ĂŒĂŠÂ…>ÂŤÂŤiÂ˜ĂƒĂŠĂœÂ…iÂ˜ĂŠÂŤ>Ă€ĂŒĂŠÂœvĂŠĂŒÂ…iĂŠV>Ă›ÂˆĂŒĂžĂŠ “>Ă€}ÂˆÂ˜ĂŠÂˆĂƒĂŠLÂœĂ•Â˜`i`ĂŠLÞÊ`iÂ˜ĂŒÂˆÂ˜ÂśĂŠ ÂœĂœĂŠĂƒÂ…ÂœĂ•Â?`ĂŠÂœÂ˜iĂŠÂŤĂ€ÂœVii`œÊ If the decision has been taken to place a direct composite Ă€iĂƒĂŒÂœĂ€>ĂŒÂˆÂœÂ˜]ĂŠ ˆiLi˜LiĂ€}ĂŠ ­Ă“ääxÂŽĂŠ >`Ă›ÂœV>ĂŒiĂƒĂŠ >ĂŠ Ă€iĂƒÂˆÂ˜Â‡Â“Âœ`ˆwi`ĂŠ }Â?>ĂƒĂƒĂŠ ˆœ˜œ“iÀÊVi“iÂ˜ĂŒĂŠĂƒ>˜`ĂœÂˆVÂ…ĂŠĂŒiVÂ…Â˜ÂˆÂľĂ•i°ĂŠ/Â…ÂˆĂƒĂŠÂˆĂƒ]ĂŠÂœvĂŠVÂœĂ•Ă€Ăƒi]ĂŠÂ˜ÂœĂŒĂŠ>ĂŠÂ˜iĂœĂŠ ĂŒiVÂ…Â˜ÂˆÂľĂ•iĂŠ­-Ă•âĂ•ÂŽÂˆĂŠ ]ĂŠ ÂœĂ€`>Â˜ĂŠ, ]Ê£™™äŽ]ĂŠ>˜`ĂŠĂŒĂ€>`ÂˆĂŒÂˆÂœÂ˜>Â?Â?ĂžĂŠĂŒÂ…iĂŠwÂ?Â?iÀÊ ÂœvĂŠ ĂŒÂ…iĂŠ ÂşĂƒ>˜`ĂœÂˆV…Ê Ăœ>ĂƒĂŠ >ĂŠ }Â?>ĂƒĂƒÂ‡ÂˆÂœÂ˜ÂœÂ“iÀÊ Vi“iÂ˜ĂŒ°ĂŠ ÂœĂœiĂ›iĂ€]ĂŠ Ă€iĂƒÂˆÂ˜Â‡ “œ`ˆwi`ĂŠ }Â?>ĂƒĂƒĂŠ ˆœ˜œ“iÀÊ Vi“iÂ˜ĂŒĂƒĂŠ ­, ÂŽĂŠ Â…>Ă›iĂŠ LiiÂ˜ĂŠ ĂƒÂ…ÂœĂœÂ˜ĂŠ ĂŒÂœĂŠ 6ÂœÂ?ՓiĂŠxĂŠĂŠ ՓLiÀÊ{

Continuing education

Figure 6: Simple at-home tooth whitening can produce dramatic results and, as in this case, is a useful precursor to restorative treatment. The upper arch has been whitened to give the patient an initial indication of the level of improvement achieved

Figures 7A and 7B: Non-vital tooth whitening is an extremely efficient, conservative way of dealing with minimally restored, darkened, non-vital teeth

Figures 8A and 8B: It was initially thought that this discoloration would be impossible to treat, and further options were discussed with the patient. The whitening occurred within 3 months and was very rapid using 10% carbamide peroxide. The patient was very happy with this result. After a period of 2 weeks, further composite bonding was undertaken to improve the shape of the upper left central incisor (Photographs courtesy of Dr. Linda Greenwall)

possess superior mechanical properties and bonding strength to `i Ì Ê ­*iÀi À>Ê ]Ê iÌÊ > °]Ê ÓääÓ®°Ê `iÀÃà 7i V iÀÌÊ ­Óää{®Ê examined the durability and cariostatic effect of a modified open Ã> `Ü V ÊÀiÃÌ À>Ì ÊÕà }Ê, Ê> `ÊV V Õ`i`ÊÌ >ÌÊ ÌÊiÝ L Ìi`Ê acceptable durability for the extensive restorations evaluated. Another approach is to use indirect porcelain or composite >ÞÉ >ÞÃ]Ê Ì iÀiLÞÊ â }Ê « Ìi Ì > Ê ÀiÃ Ê Ã À >}iÊ Ì Ê that exhibited by the thin layer of luting resin. These restorations ÀiµÕ ÀiÊ>ÊV>Û ÌÞÊÜ Ì Ê>Ê V>Ì Ê>L ÛiÊÌ iÊ} } Û> Ê >À} Ê­ iÌÃV Ê

]Ê iÌÊ > °]Ê £ {®Ê > `Ê i Ì iÀÊ >Ê LiÛi vÀiiÊ LÕÌÌÊ >À} Ê ÀÊ >Ê ÜÊ V > viÀÊ ­ > }Ê ]Ê iÌÊ > °]Ê £ £®°Ê 7 iÀiÊ Ì iÊ >À} Ê ÃÊ Ã } Ì ÞÊ ÃÕL} } Û> ]Ê iÌÃV Ê ­£ n®Ê >`Û V>ÌiÃÊ ºÀi V>Ì }»Ê Ì iÊ ViÀÛ V> Ê «Ài«>À>Ì Ê >L ÛiÊ Ì iÊ } } Û> Ê >À} ]Ê > Ã Ê Ü Ê >ÃÊ º >À} Ê i iÛ>Ì ]»ÊLÞÊ>«« Þ }Ê> Ê VÀi i ÌÊ vÊy Ü>L iÊV « à ÌiÊÀiÃ Ê at the margin. This represents a noninvasive alternative to surgical crown lengthening. !""#$%&'()"*"+,#'"Tooth discoloration has a number of different possible etiologies > `Ê >ÞÊLiÊi Ì iÀÊ ÌÀ à VÊ ÀÊiÝÌÀ à VÊ Ê >ÌÕÀi°Ê ÃÌÊiÝÌÀ à VÊ ` ÃV À>Ì ÊV> ÊLiÊÀi Ûi`Êi>à Þ]Ê> `Ê ÌÊ ÃÊÌ iÊ ÃÌÀ à VÊÛ>À iÌÞÊ Ì >ÌÊ ÃÊ ÀiÊ` vwVÕ ÌÊÌ ÊÌÀi>Ì]Ê`i«i ` }Ê ÊÌ iÊÃiÛiÀ ÌÞÊ> `Ê`i«Ì Ê of discoloration. Dentists are often unsure which is the best strategy to adopt and much depends on the etiology of the discoloration. A correct diagnosis is important and allows the dental practitioner to explain to the patient the exact nature of the condition. In à iÊ ÃÌ> ViÃ]ÊÌ iÊ iV > Ã Ê vÊÃÌ> }Ê >ÞÊ >ÛiÊ> ÊivviVÌÊ Ê Ì iÊ ÕÌV iÊ vÊ ÌÀi>Ì i ÌÊ > `]Ê Ê ÌÕÀ ]Ê yÕi ViÊ Ì iÊ ÌÀi>Ì i ÌÊ «Ì ÃÊ Ì iÊ `i Ì ÃÌÊ Ü Ê LiÊ >L iÊ Ì Ê vviÀÊ Ì Ê «>Ì i ÌÃÊ ­7>ÌÌÃÊ ]Ê ``ÞÊ ]ÊÓä䣮°Ê Ê >À}iÊ Õ LiÀÊ vÊ` ÃV Ài`ÊÌiiÌ Ê>ÀiÊ Ü>`>ÞÃÊ ÌÀi>Ìi`Êi Ì iÀÊV ÃiÀÛ>Ì Ûi ÞÊLÞÊÌ Ì ÊÜ Ìi }Ê­ }ÕÀiÊÈ®Ê ÀÊ iÃÃÊ conservatively by means of ceramic laminate veneers or even full coverage crowns. Dentists will often restrict the use of bleaching to mild forms vÊ` ÃV À>Ì ÊqÊ Ê Ì iÀÊÜ À`Ã]ÊÌ iÊ`>À i }Ê vÊÌiiÌ ÊÌ À Õ} Ê 6 Õ iÊxÊÊ Õ LiÀÊ{

normal wear and tear of daily life – while ceramic solutions are reserved for more severe situations such as tetracycline ` ÃV À>Ì °Ê i> Ü i]Ê Û Ì> Ê L i>V }Ê ÃÊ ÛiÀÞÊ ivviVÌ ÛiÊ Ê ÃÌÊ V>ÃiÃÊ ­ }ÕÀiÊ Ç®]Ê > `Ê ÃÊ > Ê iÝVi i ÌÊ >` Õ VÌÊ Ì Ê L `i`Ê composite when the only tooth tissue loss is a result of the access «Ài«>À>Ì Ê­ i «iÀ Ê-]Ê >À`Üi Ê ]ÊÓääx®°Ê Tetracycline-discolored teeth present their own specific «À L i Ã°Ê 6i iiÀÃÊ >ÀiÊ vÌi Ê «ÀiÃVÀ Li`Ê v ÀÊ ÃÕV Ê ÌiiÌ °Ê / iÊ ` vwVÕ ÌÞ]Ê ÜiÛiÀ]Ê Ü Ì Ê Õà }Ê Ûi iiÀÃÊ Ì Ê ÌÀi>ÌÊ ÌiÌÀ>VÞV iÊ discoloration is that the staining usually extends deep within the ÃÌÀÕVÌÕÀiÊ vÊÌ iÊÌ Ì °Ê ÃÊÌ iÊi > i Ê ÃÊÀi Ûi`]ÊÌ iÊ` ÃV À>Ì Ê Ìi `ÃÊÌ Ê}iÌÊÜ ÀÃi]Ê> `Ê Ã Ê ÀiÊ `i Ì Ê ÃÊÀi Ûi`Ê Ì Ê > ÜÊ v ÀÊ a greater thickness of ceramic. As the preparation inevitably ÛiÃÊ vÕÀÌ iÀÊ Ì Ê `i Ì ]Ê Ì iÊ ÀiÌi Ì Ê vÊ Ì iÊ Ûi iiÀÊ LiV iÃÊ increasingly dependent on dentin bonding rather than enamel bonding with all the attendant difficulties described earlier in this paper. A further problem is that removal of enamel in this way for veneer restorations is an attempt to match up high elastic modulus porcelain with lower elastic modulus dentin. It is predictable that functional loading of the veneered tooth will transfer this energy to Ì iÊ ÌiÀv>Vi]ÊÀiÃÕ Ì }Ê Ê`iL ` }Ê ÀÊVÀ>V }Ê ÊÌ iÊ« ÀVi > °Ê / iÊÕ«Ã ÌÊ vÊ> ÊÌ ÃÊ ÃÊÌ >ÌÊÌ iÊ}Ài>ÌiÀÊÌ iÊ`i«Ì Ê vÊÌ iÊÛi iiÀ]Ê Ì iÊ }Ài>ÌiÀÊ Ì iÊ ii`Ê v ÀÊ >`` Ì > Ê ­ °i°]Ê V Ûi Ì > ®Ê i> ÃÊ vÊ retention and this means the use of full coverage restorations. Ê ÀiÊÌ iÀiÊ Ì iÀ]Ê ÀiÊV ÃiÀÛ>Ì ÛiÊ i> ÃÊ vÊ`i> }ÊÜ Ì Ê Ì iÊ ÌÞ«iÊ vÊ `ii«Ê ` ÃV À>Ì Ê V>ÕÃi`Ê LÞÊ ÌiÌÀ>VÞV i¶Ê iÀÌ> Þ]Ê } ÌiÀ Ê Ì Ì Ê Ü Ìi }Ê V> Ê Þ i `Ê >VVi«Ì>L iÊ ÀiÃÕ ÌÃÊ ­ }ÕÀiÊ n®]ÊÜ Ì ÊÃÕVViÃÃÊ`i«i ` }Ê ÊÌ iÊ`i«Ì ]ÊÃiÛiÀ ÌÞÊ> `Ê`i}ÀiiÊ vÊ Ì iÊ` ÃV À>Ì Ê­ Àii Ü> Ê ]ÊÓä䣮]Ê>ÃÊÜi Ê>ÃÊ ÊÌ iÊ«>Ì i ̽ÃÊ «>ÀÌ VÕ >ÀÊ iÝ«iVÌ>Ì ÃÊ vÊ ÌÀi>Ì i Ì°Ê 7 Ì Ê Ì iÊ `iÛi « i ÌÊ vÊ ÀiÊivwV i ÌÊ «>µÕ }ÊÃÞÃÌi Ã]ÊÌ iÊÕÃiÊ vÊ` ÀiVÌÊV « à ÌiÃÊ ÃÊ i ÞÊÌ Ê VÀi>ÃiÊ ÊÌ iÊvÕÌÕÀi]Ê«À L>L ÞÊ ÊV Õ VÌ ÊÜ Ì Ê«À ÀÊ tooth whitening. !""#$%(.+/,)0%*"(( / Ì ÊÃÕÀv>ViÊ ÃÃÊ­/- ®Ê ÃÊ`iw i`Ê>ÃÊ ÃÃÊ vÊÌ Ì ÊÃÕLÃÌ> ViÊ Ê Endodontic practice {£

Continuing education

Figures 9A and 9B: Indirect composite onlays are more durable than many believe, are extremely conservative of tooth structure and are unlikely to damage the opposing dentition. In any case, does it really matter that they may occasionally require replacement if the underlying tooth is preserved and tooth vitality maintained with minimal effect on the periodontal tissues?

ĂŒÂ…iĂŠ>LĂƒi˜ViĂŠÂœvĂŠV>Ă€ÂˆiĂƒĂŠÂœĂ€ĂŠĂŒĂ€>Փ>°ĂŠ/Ă€>`ÂˆĂŒÂˆÂœÂ˜>Â?Â?Ăž]ĂŠÂˆÂ˜`ÂˆĂ€iVĂŒĂŠĂ€iĂƒĂŒÂœĂ€>ĂŒÂˆÂœÂ˜ĂƒĂŠ have been used as the treatment of choice in such cases as they confer greater strength than direct restorations. Improvements in composite mechanical properties and bonding chemistry over the Ăži>Ă€ĂƒĂŠÂ…>Ă›i]ĂŠÂ…ÂœĂœiĂ›iĂ€]ʓ>`iĂŠÂˆĂŒĂŠÂŤÂœĂƒĂƒÂˆLÂ?iĂŠĂŒÂœĂŠĂ€iĂƒĂŒÂœĂ€iĂŠĂƒĂ•Ă€v>ViĂƒĂŠÂœvĂŠĂœÂœĂ€Â˜ĂŠ ĂŒiiĂŒÂ…ĂŠ`ÂˆĂ€iVĂŒÂ?ĂžĂŠĂœÂˆĂŒÂ…ÂœĂ•ĂŒĂŠĂ€iVÂœĂ•Ă€ĂƒiĂŠĂŒÂœĂŠÂˆÂ˜`ÂˆĂ€iVĂŒĂŠĂ€iĂƒĂŒÂœĂ€>ĂŒÂˆÂœÂ˜Ăƒ]ĂŠ>Â?ĂŒÂ…ÂœĂ•}Â…ĂŠ this option remains if the need arises in the future. Dentists often focus on the survival of their restoration ĂœÂ…i˜]ĂŠ ÂˆÂ˜ĂŠ v>VĂŒ]ĂŠ ĂŒÂ…iĂŠ vÂœVĂ•ĂƒĂŠ ĂƒÂ…ÂœĂ•Â?`ĂŠ LiĂŠ ÂœÂ˜ĂŠ ĂƒĂ•Ă€Ă›ÂˆĂ›>Â?ĂŠ ÂœvĂŠ ĂŒÂ…iĂŠ ĂŒÂœÂœĂŒÂ…ĂŠ ÂœÂ˜ĂŠ ĂœÂ…ÂˆVÂ…ĂŠÂˆĂŒĂŠÂ…>ĂƒĂŠLiiÂ˜ĂŠÂŤÂ?>Vi`ĂŠ­ ˆ}Ă•Ă€iʙŽ°ĂŠ ĂŒĂŠÂˆĂƒĂŠĂ€iÂ?>ĂŒÂˆĂ›iÂ?ĂžĂŠĂ•Â˜ÂˆÂ“ÂŤÂœĂ€ĂŒ>Â˜ĂŒĂŠÂˆvĂŠ ĂŒÂ…iĂŠĂ€iĂƒĂŒÂœĂ€>ĂŒÂˆÂœÂ˜ĂŠv>ˆÂ?Ăƒ]ĂŠÂŤĂ€ÂœĂ›Âˆ`i`ĂŠĂŒÂ…iĂŠĂŒÂœÂœĂŒÂ…ĂŠĂƒĂŒÂˆÂ?Â?ĂŠÂ…>ĂƒĂŠ>ĂŠ}œœ`ĂŠÂŤĂ€Âœ}Â˜ÂœĂƒÂˆĂƒ°ĂŠ ˜`ii`]ĂŠ >Â˜ĂŠ ˆ˜VĂ€i>ĂƒÂˆÂ˜}ĂŠ Â˜Ă•Â“LiÀÊ ÂœvĂŠ ĂƒĂŒĂ•`ˆiĂƒĂŠ Â…>Ă›iĂŠ ˆÂ?Â?Ă•ĂƒĂŒĂ€>ĂŒi`ĂŠ ĂŒÂ…iĂŠ vi>ĂƒÂˆLˆÂ?ÂˆĂŒĂžĂŠÂœvĂŠĂŒÂ…ÂˆĂƒĂŠ>ÂŤÂŤĂ€Âœ>VÂ…ĂŠĂŒÂœĂŠĂŒÂ…iĂŠĂŒĂ€i>ĂŒÂ“iÂ˜ĂŒĂŠÂœvĂŠ/- ĂŠV>ĂƒiĂƒ°ĂŠ ĂŠ

Â?ˆ˜ˆV>Â?ĂŠĂŒĂ€Âˆ>Â?ĂƒĂŠVœ˜`Ă•VĂŒi`ĂŠLÞÊ i““ˆ˜}Ăƒ]ĂŠiĂŒĂŠ>Â?°]ĂŠ­Ă“äääŽĂŠ>˜`ĂŠ Jason Smithson BDS, DipRestDentRCS, (Eng) qualified at the Royal London Hospital in 1995, achieving a number of awards including The Constance Klein Memorial, The Stafford Millar, and The Malcolm Jenkins Scholarships, The American Association of Endodontics Prize, and the Overall Award for Clinical Dentistry. After spending 3 years in oral surgery residency in London, he relocated to Cornwall in the extreme southwest of England, and is in general practice with a special interest in esthetic and restorative dentistry. His specific interest is composite resin artistry and he has presented to dentists in the U.S., Canada and Europe on this topic. Philip Newsome PhD, MBA, BChD, FDS RCS, (Ed) MRD RCS, (Ed) is currently Associate Professor at the Faculty of Dentistry, University of Hong Kong and is on the Specialist Prosthodontist Registers of both Hong Kong and the UK. His main area of academic interest is in the factors that lay behind success in dental practice, and he has published and lectured widely on this subject. He has written four dental textbooks and is on the Editorial Board of Aesthetic Dentistry Today. He is particularly interested in the current ethical debate over the use of ceramic restorations to “transformâ€? smiles.

References ˜`iĂ€ĂƒĂƒÂœÂ˜Â‡7i˜VÂŽiĂ€ĂŒĂŠ ]ĂŠĂ›>Â˜ĂŠ ˆÂ?ÂŽiÂ˜ĂŠ 7]ĂŠ ˆiĂ€ÂˆĂŠ ĂŠ­Ă“ää{Ž°ĂŠ Durability of extensive class II open-sandwich restorations ĂœÂˆĂŒÂ…ĂŠ>ĂŠĂ€iĂƒÂˆÂ˜Â‡Â“Âœ`ˆwi`ĂŠ}Â?>ĂƒĂƒĂŠÂˆÂœÂ˜ÂœÂ“iÀÊVi“iÂ˜ĂŒĂŠ>vĂŒiĂ€ĂŠĂˆĂŠĂži>Ă€Ăƒ°ĂŠAm J Dent棂\ĂŠ{ĂŽqxä° ĂƒĂƒÂˆvĂŠ ]ĂŠ ÂˆĂƒĂƒ>Â˜ĂŠ ]ĂŠ >v˜ˆ]ĂŠiĂŒĂŠ>Â?°]ĂŠ­Ă“ääĂŽŽ°ĂŠ ĂƒĂƒiĂƒĂƒÂ“iÂ˜ĂŒĂŠÂœvĂŠĂŒÂ…iĂŠ resistance to fracture of endodontically treated molars restored with amalgam. J Prosthet DentÊÇ£\ĂŠxĂˆx‡Ç°

Â…Ă€ÂˆĂƒĂŒiÂ˜ĂƒiÂ˜ĂŠ ĂŠ­Ă“ä£äŽ°ĂŠ-Â…ÂœĂ•Â?`ĂŠĂ€iĂƒÂˆÂ˜Â‡L>Ăƒi`ĂŠVÂœÂ“ÂŤÂœĂƒÂˆĂŒiĂŠ dominate restorative dentistry today? J Am Dent AssocĂŠÂŁ{ÂŁ\ĂŠ ÂŁ{™ä‡Î°

iÂ?ÂˆÂŤiĂ€ÂˆĂŠ-]ĂŠ >Ă€`ĂœiÂ?Â?ĂŠ ĂŠ­Ă“ääxŽ°ĂŠ/ĂœÂœÂ‡Ăži>ÀÊVÂ?ˆ˜ˆV>Â?ĂŠiĂ›>Â?Ă•>ĂŒÂˆÂœÂ˜ĂŠ of non-vital tooth whitening and resin composite restorations. J Esthet Restor Dent棂\ĂŠĂŽĂˆÂ™Â‡Ă‡Â™°

ˆiĂŒĂƒVÂ…ÂˆĂŠ ]ĂŠ >}˜iĂŠ*]ĂŠ ÂœÂ?ĂŒâĂŠ ĂŠ­£Â™Â™{Ž°ĂŠ,iViÂ˜ĂŒĂŠĂŒĂ€i˜`ĂƒĂŠÂˆÂ˜ĂŠiĂƒĂŒÂ…iĂŒÂˆVĂŠ restorations for posterior teeth. Quintessence IntĂŠĂ“x\ĂŠĂˆx™‡ÇÇ°

ˆiĂŒĂƒVÂ…ÂˆĂŠ ]ĂŠ-V>“>ĂŠ1ĂŠ­£Â™Â™xŽ°ĂŠ >Ă€}ˆ˜>Â?ĂŠ>`>ÂŤĂŒ>ĂŒÂˆÂœÂ˜ĂŠ>˜`ĂŠĂƒi>Â?ĂŠ of direct and indirect class II composite restorations: an in vitro evaluation. Quintessence IntĂŠĂ“Ăˆ\Ê£ÓLJÎn°

ˆiĂŒĂƒVÂ…ÂˆĂŠ ]ĂŠ-ÂŤĂ€i>wVÂœĂŠ,ĂŠ­£Â™Â™nŽ°ĂŠ ÕÀÀiÂ˜ĂŒĂŠVÂ?ˆ˜ˆV>Â?ĂŠVœ˜ViÂŤĂŒĂƒĂŠvÂœĂ€ĂŠ adhesive cementation of tooth-colored posterior restorations. Pract Periodontics Aesthet DentĂŠ£ä\ĂŠ{Çx{° iˆÂ?âiÀÊ ]ĂŠ iĂŠ iiĂŠ ]ĂŠ >Ă›Âˆ`ĂƒÂœÂ˜ĂŠ ĂŠ­£Â™nÇŽ°ĂŠ-iĂŒĂŒÂˆÂ˜}ĂŠĂƒĂŒĂ€iĂƒĂƒĂŠÂˆÂ˜ĂŠ composite resin in relation to configuration of the restoration. J Dent ResĂŠĂˆĂˆ\ĂŠÂŁĂˆĂŽĂˆÂ‡Â™° ÂœiĂ€Âˆ}ĂŠ ]ĂŠ Ă•i˜ˆ˜}Â…ÂœvvĂŠ ĂŠ­£Â™nĂŽŽ°ĂŠ >˜>}i“iÂ˜ĂŒĂŠÂœvĂŠĂŒÂ…iĂŠ i˜`Âœ`ÂœÂ˜ĂŒÂˆV>Â?Â?ĂžĂŠĂŒĂ€i>ĂŒi`ĂŠĂŒÂœÂœĂŒÂ…°ĂŠ*>Ă€ĂŒĂŠ \ĂŠĂŒiVÂ…Â˜ÂˆÂľĂ•iĂŠJ Prosthet Dent xx\ĂŠÂŁn{‡x° >˜˜ˆ}ĂŠ ]ĂŠ,>Â…Â?vĂŠ ]ĂŠ-VÂ…Â?ˆVÂ…ĂŒÂˆÂ˜}ĂŠ ĂŠ­£Â™Â™£Ž°ĂŠ >Ă€}ˆ˜>Â?ĂŠLiÂ…>Ă›ÂˆÂœĂ€ĂŠ ÂœvĂŠÂş Ă•Â?âiÀÊVÂœÂ“ÂŤÂœĂƒÂˆĂŒiĂŠÂˆÂ˜Â?>ĂžĂƒĂŠĂ•Â˜`iĂ€ĂŠĂƒÂˆÂ“Ă•Â?ĂŒ>˜iÂœĂ•ĂƒĂŠÂ“iVÂ…>˜ˆV>Â?ĂŠ and thermal loading. Dtsch Zahnarztl Z°ĂŠ{Ăˆ\ĂŠĂˆÂŁnÂ‡Ă“ä° >ĂƒÂ…ÂˆÂ“ÂœĂŒÂœĂŠ ]ĂŠ"Â…Â˜ÂœĂŠ ]ĂŠ >}>ĂŠ ]ĂŠiĂŒĂŠ>Â?ĂŠ­Ă“ää䎰ĂŠ Â˜ĂŠĂ›ÂˆĂ›ÂœĂŠ `i}Ă€>`>ĂŒÂˆÂœÂ˜ĂŠÂœvĂŠĂ€iĂƒÂˆÂ˜Â‡`iÂ˜ĂŒÂˆÂ˜ĂŠLœ˜`ĂƒĂŠÂˆÂ˜ĂŠÂ…Ă•Â“>Â˜ĂƒĂŠÂœĂ›iĂ€ĂŠÂŁĂŠĂŒÂœĂŠĂŽĂŠ years. J Dent ResÊǙ\ĂŠÂŁĂŽnx‡™£°

{Ă“ĂŠĂŠEndodontic practice

,i`“>˜]ĂŠ iĂŒĂŠ >Â?°]ĂŠ ­Ă“ääĂŽÂŽĂŠ iĂ?>“ˆ˜i`ĂŠ ĂŒÂ…iĂŠ Ă•ĂƒiĂŠ ÂœvĂŠ `ÂˆĂ€iVĂŒĂŠ VÂœÂ“ÂŤÂœĂƒÂˆĂŒiĂŠ Ă€iĂƒĂŒÂœĂ€>ĂŒÂˆÂœÂ˜ĂƒĂŠ vÂœĂ€ĂŠ ĂŒÂ…iĂŠ ĂŒĂ€i>ĂŒÂ“iÂ˜ĂŒĂŠ ÂœvĂŠ Â?ÂœV>Â?ˆâi`ĂŠ >Â˜ĂŒiĂ€ÂˆÂœĂ€ĂŠ ĂŒÂœÂœĂŒÂ…ĂŠ Ăœi>Ă€]ĂŠ >˜`ĂŠĂ€iĂ›i>Â?i`ĂŠĂ€iÂ?>ĂŒÂˆĂ›iÂ?ÞÊÂ?ÂœĂœĂŠv>ˆÂ?Ă•Ă€iĂŠĂ€>ĂŒiĂƒĂŠÂœvĂŠĂŒÂ…iĂŠVÂœÂ“ÂŤÂœĂƒÂˆĂŒiĂƒ]ĂŠĂœÂˆĂŒÂ…ĂŠ>ĂŠ “i`ˆ>Â˜ĂŠĂƒĂ•Ă€Ă›ÂˆĂ›>Â?ĂŠĂ€>ĂŒiĂŠÂœvĂŠxĂŠĂži>Ă€Ăƒ°ĂŠ/Â…ÂœĂƒiĂŠv>ˆÂ?Ă•Ă€iĂƒĂŠĂŒÂ…>ĂŒĂŠ`ˆ`ĂŠ>Ă€ÂˆĂƒiĂŠĂœiĂ€iĂŠ “>ˆ˜Â?ĂžĂŠĂŒÂ…iĂŠĂ€iĂƒĂ•Â?ĂŒĂŠÂœvĂŠ}i˜iĂ€>Â?ˆâi`ʓ>Ă€}ˆ˜>Â?ĂŠv>ˆÂ?Ă•Ă€iĂŠ>˜`ĂŠ`ÂˆĂƒVÂœÂ?ÂœĂ€>ĂŒÂˆÂœÂ˜°ĂŠ -ˆ“ˆÂ?>Ă€Â?Ăž]ĂŠ *ÂœĂžĂƒiĂ€]ĂŠ iĂŒĂŠ >Â?°]ĂŠ ­Ă“ääǎÊ iĂ›>Â?Ă•>ĂŒi`ĂŠ VÂ?ˆ˜ˆV>Â?ĂŠ ÂŤiĂ€vÂœĂ€Â“>˜ViĂŠ and related patient satisfaction of direct composite restorations used to restore worn mandibular anterior dentitions. The authors concluded that direct composite restorations placed at an increased occlusal vertical dimension are a simple and time-efficient method of managing the worn mandibular anterior dentition. They also found that patient acceptance and adaptation to the technique is good and is maintained for the medium term. !"#$%&'("# Â˜ĂŠ Ă›ÂˆĂ€ĂŒĂ•>Â?Â?ÞÊ iĂ›iÀÞÊ VÂ?ˆ˜ˆV>Â?ĂŠ V>Ăƒi]ĂŠ ĂŒÂ…iĂ€iĂŠ ĂœÂˆÂ?Â?ĂŠ LiĂŠ Â“ÂœĂ€iĂŠ ĂŒÂ…>Â˜ĂŠ œ˜iĂŠ Ăœ>ÞÊ ĂŒÂœĂŠ >V…ˆiĂ›iĂŠ >ĂŠ Ă€iĂƒĂ•Â?ĂŒ°ĂŠ >Â˜ĂžĂŠ `iVÂˆĂƒÂˆÂœÂ˜ĂƒĂŠ Ă€i}>Ă€`ˆ˜}ĂŠ ĂŒĂ€i>ĂŒÂ“iÂ˜ĂŒĂŠ >Ă€iĂŠ ĂƒĂŒĂ€>ˆ}Â…ĂŒvÂœĂ€Ăœ>Ă€`]ĂŠ >ĂƒĂŠ ĂŒÂ…iĂŠ >`Ă›>Â˜ĂŒ>}iĂƒĂŠ ÂœvĂŠ œ˜iĂŠ ÂŤ>Ă€ĂŒÂˆVĂ•Â?>ÀÊ ÂŤĂ€ÂœVi`Ă•Ă€iĂŠ outweigh its own disadvantages and the relative advantages of ÂœĂŒÂ…iÀÊ>Ă›>ˆÂ?>LÂ?iĂŠÂœÂŤĂŒÂˆÂœÂ˜Ăƒ°ĂŠ/Â…iĂ€iĂŠ>Ă€i]ĂŠÂ…ÂœĂœiĂ›iĂ€]ĂŠ>ĂŠĂ›>Ă€ÂˆiĂŒĂžĂŠÂœvĂŠĂƒÂˆĂŒĂ•>ĂŒÂˆÂœÂ˜ĂƒĂŠ ĂœÂ…iĂ€iĂŠĂŒÂ…iĂŠV…œˆViĂŠÂˆĂƒĂŠÂ?iĂƒĂƒĂŠVÂ?i>ÀÊVĂ•ĂŒ]ĂŠ>˜`ĂŠÂˆÂ˜ĂŠĂŒÂ…ÂˆĂƒĂŠÂŤ>ÂŤiĂ€ĂŠĂœiĂŠÂ…>Ă›iĂŠĂŒĂ€Âˆi`ĂŠ to highlight some of these in relation to the selection of an indirect or a direct restorative approach. There will never be a completely black and white guide ĂŒÂœĂŠ `iÂ˜ĂŒ>Â?ĂŠ ĂŒĂ€i>ĂŒÂ“iÂ˜ĂŒ]ĂŠ >˜`ĂŠ }Ă€>ÞÊ >Ă€i>ĂƒĂŠ ĂœÂˆÂ?Â?ĂŠ >Â?Ăœ>ĂžĂƒĂŠ iĂ?ÂˆĂƒĂŒ°ĂŠ ĂƒĂŠ Â?œ˜}ĂŠ >ĂƒĂŠ ĂŒĂ€i>ĂŒÂ“iÂ˜ĂŒĂŠÂˆĂƒĂŠÂŤiĂ€vÂœĂ€Â“i`ĂŠĂœÂˆĂŒÂ…ĂŠV>Ă€i]ĂŠĂŒÂœĂŠ>ĂŠÂ…Âˆ}Â…ĂŠĂƒĂŒ>˜`>Ă€`ĂŠ>˜`ĂŠĂœÂˆĂŒÂ…ĂŠ>ĂŠÂ˜Âœ`ĂŠ ĂŒÂœĂŠĂŒÂ…iĂŠĂ•Â˜`iĂ€Â?ĂžÂˆÂ˜}ĂŠĂƒVˆi˜Vi]ĂŠÂˆĂŒĂŠĂœÂˆÂ?Â?ĂŠÂ“ÂœĂ€iĂŠĂŒÂ…>Â˜ĂŠÂ?ˆŽiÂ?ÞÊLiĂŠĂƒĂ•VViĂƒĂƒvĂ•Â?° EP Siobhan Owen, BDS, graduated from Dundee Dental School in 1990. Since gaining her BDS she has worked in NHS and private practices. She is currently practice principle of a very successful six surgery private practice in the southwest of England. She is Managing Director of Southern Cross Dental Laboratories UK Ltd., and has a particular interest in modern crown and bridge design, especially in relation to the new generation of esthetic all porcelain restorative systems. David Reaney BDS, DGDP, (UK) M Clin Dent, (Pros) graduated from the Faculty of Medicine, The University of Edinburgh with a Bachelor of Dental Surgery degree with distinction in Prosthetics and Conservative Dentistry in 1985. In 1993, he received his Diploma in General Dental Practice from the Royal College of Surgeons, England, and in 2003 his Master of Clinical Dentistry in Fixed and Removable Prosthodontics, Kings College, University of London. Dr. Reaney dedicates a significant amount of his clinical time to complex prosthodontic cases requiring crown and bridgework and implant dentistry.

i““ˆ˜}ĂƒĂŠĂŠ 7]ĂŠ >Ă€L>ÀÊ1,]ĂŠ6>Ă•}Â…>Â˜ĂŠ-ĂŠ­Ă“ää䎰ĂŠ/ÂœÂœĂŒÂ…Ăœi>ÀÊ treated with direct composite restorations at an increased Ă›iĂ€ĂŒÂˆV>Â?ĂŠ`ˆ“iÂ˜ĂƒÂˆÂœÂ˜\ĂŠĂ€iĂƒĂ•Â?ĂŒĂƒĂŠ>ĂŒĂŠĂŽäĂŠÂ“ÂœÂ˜ĂŒÂ…Ăƒ°ĂŠJ Prosthet DentĂŠnĂŽ\ĂŠ Ă“nLJ™Î° iĂ€Â˜>˜`iâĂŠ,]ĂŠ >`iÀÊ-]ĂŠ ÂœĂƒĂŒÂœÂ˜ĂŠ ĂŠiĂŒĂŠ>Â?ĂŠ­£Â™Â™{Ž°ĂŠ,iĂƒÂˆĂƒĂŒ>˜ViĂŠĂŒÂœĂŠ fracture of endodontically treated premolars restored with new generation dentin bonding systems. Int Endod J ÓÇ\ĂŠ Ă“n£‡{° ÂœÂ…Â˜ĂƒÂœÂ˜ĂŠ ]ĂŠ-VÂ…Ăœ>Ă€ĂŒâĂŠ ]ĂŠ Â?>VÂŽĂœiÂ?Â?ĂŠ,/ĂŠ­£Â™Ă‡ĂˆŽ°ĂŠ Ă›>Â?Ă•>ĂŒÂˆÂœÂ˜ĂŠ and restoration of endodontically treated posterior teeth. J Am Dent AssocʙÎ\ĂŠxÂ™Ă‡Â‡Ăˆäx° ˆiLi˜LiĂ€}ĂŠ7ĂŠ­Ă“ääxŽ°ĂŠ,iĂŒĂ•Ă€Â˜ĂŠĂŒÂœĂŠĂŒÂ…iĂŠĂ€iĂƒÂˆÂ˜Â‡Â“Âœ`ˆwi`ĂŠ glass-ionomer cement sandwich technique. J Calif Dent Assoc Ç£\ÊÇ{·Ç° Âœ}Ă•iĂ€VÂˆÂœĂŠ ]ĂŠ Â?iĂƒĂƒ>˜`Ă€>ĂŠ,]ĂŠ >ââÂœVVÂœĂŠ ]ĂŠiĂŒĂŠ>Â?ĂŠ­Ă“ääĂ“Ž°ĂŠ ˆVĂ€ÂœÂ?i>ÂŽ>}iĂŠÂˆÂ˜ĂŠVÂ?>ĂƒĂƒĂŠ ĂŠVÂœÂ“ÂŤÂœĂƒÂˆĂŒiĂŠĂ€iĂƒÂˆÂ˜ĂŠĂ€iĂƒĂŒÂœĂ€>ĂŒÂˆÂœÂ˜Ăƒ\ĂŠĂŒÂœĂŒ>Â?ĂŠ bonding and open sandwich technique. J Adhes DentĂŠ{\ĂŠ £ÎÇq{{° >`ÂˆĂƒÂœÂ˜ĂŠ-]ĂŠ7ˆÂ?VÂœĂ?ĂŠ ,ĂŠ­£Â™nnŽ°ĂŠ Â˜ĂŠiĂ›>Â?Ă•>ĂŒÂˆÂœÂ˜ĂŠÂœvĂŠVÂœĂ€ÂœÂ˜>Â?ĂŠ “ˆVĂ€ÂœÂ?i>ÂŽ>}iĂŠÂœvĂŠi˜`Âœ`ÂœÂ˜ĂŒÂˆV>Â?Â?ĂžĂŠĂŒĂ€i>ĂŒi`ĂŠĂŒiiĂŒÂ…°ĂŠ*>Ă€ĂŒĂŠ ĂŠ Â˜ĂŠĂ›ÂˆĂ›ÂœĂŠ study. J EndodĂŠÂŁ{\ʙ™‡£ä{° >ÞÞ>ÀÊ ]ĂŠ7>Â?ĂŒÂœÂ˜ĂŠ, ]ĂŠ iœ˜>Ă€`ĂŠ °ĂŠ­£Â™n䎰ĂŠ Â˜ĂŠ>“>Â?}>“Ê coronal-radicular dowel and core technique for endodontically treated posterior teeth J Prosthet DentĂŠ{ĂŽ\ĂŠ x££‡x£° iĂœĂƒÂœÂ“iĂŠ*, ]ĂŠ Ă€iiÂ˜Ăœ>Â?Â?ĂŠ ĂŠ­Ă“äänŽ°ĂŠ >˜>}i“iÂ˜ĂŒĂŠÂœvĂŠ tetracycline discolored teeth. Aesthetic Dentistry TodayĂŠĂŠĂ“\ĂŠ ÂŁxÂ‡Ă“ä° i“‡-VÂ…ÂœÂ?ĂŒiĂŠ ]ĂŠ >Ă›Âˆ`ĂƒÂœÂ˜ĂŠ ĂŠ­£Â™Â™䎰ĂŠ ÂœÂ“ÂŤÂ?iĂŒiʓ>Ă€}ˆ˜>Â?ĂŠ Ăƒi>Â?ĂŠÂœvĂŠVÂ?>ĂƒĂƒĂŠ6ĂŠĂ€iĂƒÂˆÂ˜ĂŠVÂœÂ“ÂŤÂœĂƒÂˆĂŒiĂŠĂ€iĂƒĂŒÂœĂ€>ĂŒÂˆÂœÂ˜ĂƒĂŠivviVĂŒi`ĂŠLÞÊ increased flexibility. J Dent Res ĂˆÂ™\ĂŠÂŁĂ“{ä‡Î° *iĂ€iÂˆĂ€>ĂŠ ]ĂŠ Ă•Â˜iĂƒĂŠ ]ĂŠ ˆLLĂŠ, ]ĂŠiĂŒĂŠ>Â?ĂŠ­Ă“ääĂ“Ž°ĂŠ iVÂ…>˜ˆV>Â?ĂŠ properties and bond strength of glass-ionomer cements. J Adhes DentĂŠĂŠ{\ÊÇÎqnä° *ÂœĂžĂƒiÀÊ ]ĂŠ Ă€Âˆ}}ĂƒĂŠ* ]ĂŠ Â…>˜>ĂŠ -ĂŠiĂŒĂŠ>Â?ĂŠ­Ă“ääÇŽ°ĂŠ/Â…iĂŠiĂ›>Â?Ă•>ĂŒÂˆÂœÂ˜ĂŠ

of direct composite restorations for the worn mandibular anterior dentition – clinical performance and patient satisfaction. J Oral RehabĂŠĂŽ{\ĂŠĂŽĂˆÂŁqĂŽĂ‡Ăˆ° ,i`“>Â˜ĂŠ

]ĂŠ i““ˆ˜}ĂƒĂŠ 7]ĂŠ œœ`ĂŠ ĂŠ­Ă“ääĂŽŽ°ĂŠ/Â…iĂŠĂƒĂ•Ă€Ă›ÂˆĂ›>Â?ĂŠ and clinical performance of resin-based composite Ă€iĂƒĂŒÂœĂ€>ĂŒÂˆÂœÂ˜ĂƒĂŠĂ•Ăƒi`ĂŠĂŒÂœĂŠĂŒĂ€i>ĂŒĂŠÂ?ÂœV>Â?ˆâi`ĂŠ>Â˜ĂŒiĂ€ÂˆÂœĂ€ĂŠĂŒÂœÂœĂŒÂ…ĂŠĂœi>Ă€°ĂŠBr Dent JÊ£™{\ĂŠxĂˆĂˆÂ‡Ă‡Ă“° ,iiÂ…ĂŠ -]ĂŠ ÂœĂ•}Â?>ĂƒĂƒĂŠ7 ]ĂŠ iĂƒĂƒiÀÊ ĂŠ­£Â™n™Ž°ĂŠ-ĂŒÂˆvv˜iĂƒĂƒĂŠÂœvĂŠ endodontically treated teeth related to restoration technique. J Dent ResĂŠĂˆn\ĂŠÂŁx{ä‡{° ,ÂœĂƒiÂ˜ĂŠ ĂŠ­£Â™Ăˆ£Ž°ĂŠ"ÂŤiĂ€>ĂŒÂˆĂ›iĂŠÂŤĂ€ÂœVi`Ă•Ă€iĂƒĂŠÂœÂ˜ĂŠÂ“Ă•ĂŒÂˆÂ?>ĂŒi`ĂŠ endodontically treated teeth. J Prosthet DentĂŠÂŁÂŁ\ʙÇӇnĂˆ° -“>Â?iĂƒĂŠ, ]ĂŠ >ĂœĂŒÂ…ÂœĂ€Â˜iĂŠ7-ĂŠ­£Â™Â™Ă‡Ž°ĂŠ œ˜}Â‡ĂŒiĂ€Â“ĂŠĂƒĂ•Ă€Ă›ÂˆĂ›>Â?ĂŠÂœvĂŠ extensive amalgams and posterior crowns. J DentĂŠĂ“x\ĂŠĂ“Ă“x‡Ç° -ÂŤĂ€i>wVÂœĂŠ,ĂŠ­£Â™Â™ĂˆŽ°ĂŠ ÂˆĂ€iVĂŒĂŠ>˜`ĂŠĂƒi“ˆ‡`ÂˆĂ€iVĂŒĂŠÂŤÂœĂƒĂŒiĂ€ÂˆÂœĂ€ĂŠ composite restorations. Pract Periodontics Aesthet DentĂŠn\ĂŠ Çä·£Ó° -Ă•âĂ•ÂŽÂˆĂŠ ]ĂŠ ÂœĂ€`>Â˜ĂŠ, ĂŠ­£Â™Â™䎰ĂŠ Â?>ĂƒĂƒĂŠÂˆÂœÂ˜ÂœÂ“iÀÊVÂœÂ“ÂŤÂœĂƒÂˆĂŒiĂŠ sandwich technique. J Am Dent AssocĂŠÂŁĂ“ä\ĂŠxxqÇ° />ÞÊ ,]ĂŠ*>ĂƒÂ…Â?iÞÊ ]ĂŠ Ă•>˜}ĂŠ ]ĂŠiĂŒĂŠ>Â?ĂŠ­Ă“ä䣎°ĂŠ/Â…iĂŠ}Â?>ĂƒĂƒÂ‡ÂˆÂœÂ˜ÂœÂ“iÀÊ phase in resin-based restorative material. J Dent Res nä\ĂŠ ÂŁnän‡£Ó° /ˆVÂŽÂ?iĂŠ ]ĂŠ ˆÂ?ĂƒÂœÂ“ĂŠ ]ĂŠ+Ă•>Â?ĂŒĂ€ÂœĂ•}Â…]ĂŠiĂŒĂŠ>Â?ĂŠ­Ă“äänŽ°ĂŠ/Â…iĂŠv>ˆÂ?Ă•Ă€iĂŠ Ă€>ĂŒiĂŠÂœvĂŠ -ĂŠvĂ•Â˜`i`ĂŠÂ“ÂœÂ?>ÀÊi˜`Âœ`ÂœÂ˜ĂŒÂˆVĂŠĂŒĂ€i>ĂŒÂ“iÂ˜ĂŒĂŠ`iÂ?ÂˆĂ›iĂ€i`ĂŠÂˆÂ˜ĂŠ general dental practice. Br Dent JĂŠĂ“ä{\ĂŠ nĂ†ĂŠÂŁÂ‡Ăˆ° 7>ĂŒĂŒĂƒĂŠ ]ĂŠ ``ÞÊ ĂŠ­Ă“ä䣎°ĂŠ/ÂœÂœĂŒÂ…ĂŠ`ÂˆĂƒVÂœÂ?ÂœĂ€>ĂŒÂˆÂœÂ˜ĂŠ>˜`ĂŠĂƒĂŒ>ˆ˜ˆ˜}\ĂŠ>ĂŠ review of the literature. Br Dent J £™ä\ĂŠĂŽäÂ™Â‡ÂŁĂˆ° 6>Â˜ĂŠ iiĂ€LiiÂŽĂŠ ]ĂŠ*iĂ€`ˆ}>ÂœĂŠ ĂŠ­£Â™Â™nŽ°ĂŠ/Â…iĂŠVÂ?ˆ˜ˆV>Â?ĂŠÂŤiĂ€vÂœĂ€Â“>˜ViĂŠ of adhesives. J DentĂŠĂ“Ăˆ\ĂŠÂŁÂ‡Ă“ä° 6i˜iâˆ>Â˜ÂˆĂŠ ĂŠ­Ă“ä£äŽ°ĂŠ `Â…iĂƒÂˆĂ›iĂŠĂ€iĂƒĂŒÂœĂ€>ĂŒÂˆÂœÂ˜ĂƒĂŠÂˆÂ˜ĂŠĂŒÂ…iĂŠÂŤÂœĂƒĂŒiĂ€ÂˆÂœĂ€ĂŠ area with subgingival cervical margins: new classification and differentiated treatment approach. Eur J Esthet DentĂŠx\ĂŠxäÂ‡Ă‡Ăˆ°

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Endodontic Practice CE Certificate details Approved PACE Program Provider FAGD/MAGD Credit Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement 12/1/2010 to 11/30/2012 Provider ID# 325231

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Direct or indirect restorations?

!"#$%&'($)#%'*+,-$).(/,#'.0$12,(%'".($3435$'($6"%,.%')++7$/"#%&$8$*#,9'%($).9 ).(/,#'.0$12,(%'".($33485$'($6"%,.%')++7$/"#%&$8$*#,9'%(-$:"#$)$%"%)+$":$;$*#,9'%(< =2,(%'".($3435 1. In the U.S., it appears that around _____ of direct restorations currently being placed are made of composite and one-third amalgam. a. one-third b. two-thirds c. about half d. three-quarters 2. (In category A,) Glass ionomer may be considered in a limited number of situations where its ______effects might be considered useful. a. cariostatic b. rehabilitative c. esthetic d. fracture-resistant 3. At the other end of the spectrum, Category C is also relatively straightforward in that here we find _______. a. large cavities and/or failed direct restorations with multiple missing cusps b. anterior teeth with large interproximal cavities along with maybe one or both mesial and distal incisal edges requiring replacement c. replacement of failed crowns, and large rehabilitation cases requiring the re-creation of multiple occlusal surfaces d. any of the above 4. There is little contention that the _______in such situations is some form of indirect restoration. a. least recommended treatment b. last resort c. treatment of choice d. none of the above 5. Compared to teeth with healthy pulps, root-filled teeth are considered to be more susceptible to fracture as they possess ______ including, critically, the strengthening effect of the pulp chamber roof. a. reduced dentinal elasticity b. lower water content c. deeper cavities and substantial loss of dentin d. all of the above

=2,(%'".($33485 6. It has, therefore, been a long and widely held view that posterior root-filled teeth require some form of indirect occlusal coverage (onlay or crown) in order to _______. a. protect the tooth against subsequent root fracture b. maintain esthetics c. discourage caries d. none of the above 7. It has also been suggested that where more extensive tooth loss has taken place, it is possible to use a directly-placed amalgam onlay to protect the teeth (at least as a medium term, cost-effective precursor to a later indirect restoration) provided that sufficient bulk of material –______ – is present. a. about 1 mm b. at least 2 mm c. 3 mm d. 4 mm 8. If there is only an occlusal access cavity requiring restoration then, increasingly, a simple direct restoration is _______. a. not strong enough b. probably not the most effective choice c. deemed to be sufficient d. susceptible to microleakage 9. Additionally, premolar teeth are thought to be ______when a direct intracoronal restoration is placed, simply because the tooth tissue loss caused by the access preparation is proportionally larger than in a molar tooth. a. less likely to fracture b. more likely to fracture c. susceptible to caries d. unesthetic 10. Lastly, there is a theoretical possibility that the effect of contraction stress generated through polymerization shrinkage (Feilzer AJ, et al., 1987) may be _____on teeth that are already more susceptible to fracture. a. acceptable b. minimized c. diagnosed d. magnified

11. In cases where a single cusp of a posterior tooth has been lost for whatever reason (crack line, caries, trauma, etc.), it is now considered _____to restore the tooth using direct composite. a. unacceptable b. acceptable c. uncautious d. both a and c 12. While it may be possible to re-create more than one cusp directly inside the mouth, concerns over ____________, mean that many authorities on the use of direct composite would often draw the line at replacing just one cusp. a. the strength of the final restoration b. the considerable chairside time required to complete such a restoration c. amalgam d. both a and b 13. Direct composites are more likely to be _____when cavity margins are situated within enamel, free from heavy occlusal contact, and easily accessible in terms of visibility, ease of isolation, and relationship to adjacent gingival tissues. a. esthetic b. functional c. durable d. all of the above 14. While bonding to enamel is now ______, doing so either to dentin or cementum is far more problematic, primarily because of the difficulty forming an effective hybrid layer. a. unpredictable b. obsolete c. highly predictable d. unstable 15. However, resin-modified glass ionomer cements (RMGIC) have been shown to possess _____mechanical properties and bonding strength to dentin. a. superior b. inferior c. unstable d. both b and c

16. Tooth discoloration has a number of different possible etiologies and may be _____in nature. a. intrinsic b. extrinsic c. mutable d. either a or b 17. The difficulty, however, with using veneers to treat ______is that the staining usually extends deep within the structure of the tooth. a. tetracycline discoloration b. anterior tooth darkening c. resin stains d. normal wear and tear 18. With the development of more efficient opaquing systems, the use of direct composites is likely to _____in the future, probably in conjunction with prior tooth whitening. a. remain unchanged b. decrease c. increase d. become more costly 19. Clinical trials conducted by Hemmings, et al., (2000) and Redman, et al., (2003) examined the use of direct composite restorations for the treatment of localized anterior tooth wear, and revealed relatively low failure rates of the composites, with a median survival rate of ___ years. a. 4 b. 5 c. 6 d. 7 20. The authors concluded that direct composite restorations placed at an increased occlusal vertical dimension are a/an _______of managing the worn mandibular anterior dentition. a. outdated method b. simple method c. time-efficient method d. both b and c

To provide feedback on this article and CE, please contact Endodontic Practice US 15720 N Greenway Hayden Lp. #9, Scottsdale, AZ 85260 | fax: (480) 629-4002 | email: education@endopracticeus.com Volume 5 Number 4

Endodontic practice 43

Abstracts

!"#$%&'#('$)*$#*+,+,*')-$.#(#&.-" /.0$1)(",.$23%&4)5&%&$6.#(#*'($'"#$%&'#('$%)'#.&'3.#7$8##6)*9$:,3$ 36;',;+&'#$<)'"$'"#$=,('$.#%#5&*'$.#(#&.-" !"#$%&#'()*+'"(%,%$)"&)-./"%0"'1.%.%1)*(")$'2)3'1)&" %0"45678"$%%)"(2129&:"$'&-9)&"20)'$";"/'2$&<" Ricucci D, Russo J, Rutberg M, Burleson JA, Spangberg LS. Oral Surgery Oral Medicine Oral Pathology Oral Radiology & Endodontics. 112(6):825-42, 2011 Dec. Abstract Aim: The purpose of this prospective study was: 1) to follow up a large number of endodontic treatments performed by a single operator, periodically checked over a 5-year period; and 2) to correlate outcome to a number of clinical variables. Methodology: This prospective study included all consecutive cases during the selected time period. All cases were followed regularly for a 5-year period. At the 5-year end point of the study, 470 patients with 816 treated teeth and with 1,369 treated root canals were available for evaluation. Results: The overall rate of success among the 816 teeth/1,369 root canals available for evaluation was 88.6%/90.3%. The success rate for 435 teeth/793 root canals undergoing vital pulp therapy was 91.5%/93.1%. Teeth/root canals with necrotic pulp, but without detectable periapical bone lesion, were successfully treated in 89.5%/92.3%. If the pulp necrosis was complicated by apical periodontitis, the success rate fell to 82.7% for the teeth and 84.1% for the root canals (P = .037). Teeth with periapical lesion <5 mm had a success rate of 86.6%, and in cases where the lesion was >= 5 mm, the rate of success was 78.2%. Conclusions: More severe disease conditions negatively affect outcome. An optimal working length was identified. Excess of root canal filling material decreases success. Infected pulp space should be treated with an effective intra-canal dressing. The quality of the coronal restoration or the placement of intracanal post retentions do not affect treatment outcome. Copyright 2011 Mosby, Inc. All rights reserved. =00'()&" %0" ),$''" %$29" 2129>'&*(&" %1" #%&)%#'$2)*+'" #2*1"0%99%?*1>"$%%)"(2129"#$'#2$2)*%1:"2"(%1)$%99'." (9*1*(29")$*29<" Mehrvarzfar P, Abbott PV, Saghiri MA, Delvarani A, Asgar K, Lotfi M, Karamifar K, Kharazifard MJ, Khabazi H. International Endodontic Journal. 45(1):76-82, 2012 Jan. Abstract Aim: To compare the effects of single doses of three oral medications on postoperative pain following instrumentation of root canals in teeth with irreversible pulpitis. Methodology: In this double-blind clinical trial, 100 patients who had anterior or premolar teeth with irreversible pulpitis without any signs and symptoms of acute or chronic apical periodontitis and moderate to severe pain were divided by balanced block random allocation into four groups of 25 each: a control group receiving a placebo medication, and three experimental groups receiving a single dose of either Tramadol (100 mg), Novafen (325mg of paracetamol, 200 mg ibuprofen and 40 mg caffeine anhydrous) or Naproxen (500 mg) immediately after the first appointment where the pulp was removed, and the canals were fully prepared. The intensity of pain was scored based on 10-point VAS before and after treatment for up to 24 hours postoperatively. Data were submitted to repeated analysis of variance. Results: At the 6-, 12- and 24-hour postoperative intervals after 44 Endodontic practice

drug administration, the intensity of pain was significantly lower in the experimental groups than in the placebo group (P < 0.01). Tramadol was significantly less effective (P < 0.05) than Naproxen and Novafen that were similar to each other (P > 0.05). Conclusion: A single oral dose of Naproxen, Novafen and Tramadol taken immediately after treatment reduced postoperative pain following pulpectomy and root canal preparation of teeth with irreversible pulpitis. Copyright 2011 International Endodontic Journal. =00*(2(/" (%3#2$*&%1" %0" #'$*2#*(29" *10*9)$2)*%1" *1@'()*%1"%0".'A23'),2&%1'5"3%$#,*1'"21."#92('B%" 0%$"#%&)%#'$2)*+'"'1.%.%1)*("#2*1<" Shantiaee Y, Mahjour F, Dianat O. International Dental Journal. 62(2):74-8, 2012 Apr. Abstract Aim: To evaluate the efficacy of periapical infiltration injection of dexamethasone and morphine in reducing postoperative endodontic pain. Methodology: Ninety patients participated in this double-blind randomized controlled clinical trial. They were referred to the dental school of Shahid Beheshti Medical University, Tehran, Iran for conventional endodontic treatment of molar teeth. The canals of each tooth were completely prepared with cleansing and shaping. The patients were randomly divided into three experimental groups to receive dexamethasone, morphine or normal saline (1 mL). Patients were then instructed to complete a pain diary 4, 8, 24 and 48 hours after the appointment. Statistical analysis consisted of chi-squared test, analysis of variance and Kruskal-Wallis test. Results: There was a statistically significant correlation between dexamethasone or morphine treatment and decreased levels and incidence of endodontic pain at 4, 8 and 24 hours, but not at 48 hours (P < 0.05). It was also observed that dexamethasone was significantly more effective (56.7% no pain) than morphine (43.3% no pain). Conclusions: Periapical infiltration of dexamethasone and morphine led to a considerable decrease in postoperative endodontic pain during the first 24 hours after operation. Dexamethasone was more effective than morphine in pain reduction. Copyright 2012 FDI World Dental Federation. C,2$2()'$*&)*(&"21.".*3'1&*%1&"%0"),'"D(,1'*.'$*21" 3'3B$21'" 21." 2#*(29" B%1'" *1" 32A*992$/" 3%92$&" $'0'$$'." 0%$" 2#*(29" &-$>'$/:" 2" (%3#2$2)*+'" $2.*%>$2#,*(" 2129/&*&" -&*1>" 9*3*)'." (%1'EB'23" (%3#-)'.")%3%>$2#,/<" Bornstein MM, Wasmer J, Sendi P, Janner SF, Buser D, von Arx T. Journal of Endodontics. 38(1):51-7, 2012 Jan.

Kishor

Gulabivala

BDS,

MSc,

FDSRCS,

PhD, FHEA, is professor and Chairman of Endodontology, and Head of Department of Restorative Dentistry at Eastman Dental Institute, University College London. Volume 5 Number 4

Abstracts Abstract Aim: To evaluate the thickness and the anatomic characteristics of the Schneiderian membrane and cortical bone using limited conebeam computed tomography (CBCT) scanning in patients referred for planning of apical surgery of maxillary molars. Methodology: This controlled study included two cohorts of patients (n = 50 for each group). For patients in group 1 (with apical pathology), three measurements in millimeters were performed using coronal and sagittal CBCT slices: the dimension of the apical lesion in the axis of the root, the width of the cortical bone in the axis of the root, and the thickness of the Schneiderian membrane perpendicular to the underlying cortical bone. For the analysis of CBCT scans of group 2 (without apical pathologies), two measurements were performed using coronal and sagittal CBCT slices: the width of the cortical bone in the axis of the root and the thickness of the Schneiderian membrane perpendicular to the underlying cortical bone. Results: For group 1, the periapical lesions evaluated measured between 0.27 and 7.41 mm in diameter, the apical bone separating the apical lesions from the maxillary sinus ranged from 0.13 to 7.83 mm, and the dimensions of the Schneiderian membrane ranged from 0.25 to 13.98 mm. The apical bone was generally thicker in patients with periapical lesions. Regarding the dimensions of the Schneiderian membrane, the values were statistically significantly higher for the patients in group 1 compared with group 2. Conclusions: The study showed that the Schneiderian membrane in the vicinity of roots with apical lesions tends to be significantly thicker when compared with the roots of teeth without apical pathoses. Copyright 2012 American Association of Endodontists. Published by Elsevier Inc. All rights reserved. !"#$%&'(%)('*+%+%*#,$(-"./'.01(2(&'#232*240-,-(%)( #5'( 4,#'.2#".'672.#( 81( $%&72.,-%*( %)( '*+%+%*#,$( &,$.%-"./,$24(#'$5*,9"'-(:,#5(2*+(:,#5%"#(#5'("-'( %)(5,/5'.(&2/*,),$2#,%*;(<='>,':?( Setzer FC, Kohli MR, Shah SB, Karabucak B, Kim S. Journal of Endodontics. 38(1):1-10, 2012 Jan. Abstract Aim: To investigate the outcome of root-end surgery. The study identifies the effect of the surgical operating microscope or the endoscope on the prognosis of endodontic surgery. The specific outcomes of contemporary root-end surgery techniques with micro instruments, but only loupes or no visualization aids (contemporary root-end surgery [CRS]), were compared with endodontic microsurgery using the same instruments and materials but with high-power magnification as provided by the surgical operating microscope or the endoscope (endodontic microsurgery [EMS]). The probabilities of success for a comparison of the two techniques were determined by means of a meta-analysis and systematic review of the literature. The influence of the tooth type on the outcome was investigated. Methodology: A comprehensive literature search for longitudinal studies on the outcome of root-end surgery was conducted. Three electronic databases (i.e., Medline, Embase, and PubMed) were searched to identify human studies from 1966 up to October 2009 in five different languages (i.e., English, French, German, Italian, and Spanish). Review articles and relevant articles were searched for cross-references. In addition, five dental and medical journals (i.e., Journal of Endodontics, International Endodontic Journal, Oral Surgery Oral Medicine Oral Pathology Oral Radiology and Endodontics, Journal of Oral and Maxillofacial Surgery, and International Journal of Oral and Maxillofacial Surgery) dating back to 1975 were hand searched. Following predefined inclusion and exclusion criteria, all articles were screened by three independent reviewers (S.B.S., Volume 5 Number 4

M.R.K., and F.C.S.). Relevant articles were obtained in fulltext form, and raw data were extracted independently by each reviewer. After agreement among the reviewers, articles that qualified were assigned to group CRS. Articles belonging to group EMS had already been obtained for part 1 of this meta-analysis. Weighted pooled success rates and a relative risk assessment between CRS and EMS overall, as well as for molars, premolars, and anteriors, were calculated. A random-effects model was used for a comparison between the groups. Results: One hundred and one articles were identified and obtained for final analysis. In total, 14 studies qualified according to the inclusion and exclusion criteria, two being represented in both groups (7 for CRS [n = 610] and 9 for EMS [n = 699]). Weighted pooled success rates calculated from extracted raw data showed an 88% positive outcome for CRS (95% confidence interval, 0.8455-0.9164) and 94% for EMS (95% confidence interval, 0.8889-0.9816). This difference was statistically significant (P < .0005). Relative risk ratio analysis showed that the probability of success for EMS was 1.07 times the probability of success for CRS. Seven studies provided information on the individual tooth type (4 for CRS [n = 457] and 3 for EMS [n = 222]). The difference in probability of success between the groups was statistically significant for molars (n = 193, P = .011). No significant difference was found for the premolar or anterior group (premolar [n = 169], P = .404; anterior [n = 277], P = .715). Conclusions: The probability for success for EMS proved to be significantly greater than the probability for success for CRS, providing best available evidence on the influence of high-power magnification rendered by the dental operating microscope or the endoscope. Large-scale randomized clinical trials for statistically valid conclusions for current endodontic questions are needed to make informed decisions for clinical practice. Copyright 2012 American Association of Endodontists. Published by Elsevier Inc. All rights reserved. @( *%>'4( >'*+,*/( &2$5,*'( )%.( -"7740,*/( .%%#( $2*24( #%%4-(+".,*/(-"./'.0;( Nelson C, Hossain SG, Al-Okaily A, Ong J. Journal of Medical Engineering & Technology. 36(2):102-16, 2012 Feb. Abstract Aim: Root canal treatment involves the successive use of several tools one after another. Typically dozens of tools are laid out for possible use, and the process of tool selection is done manually. This is a rather inefficient process and uses up a large area on the mobile cart or cabinet of the dental chair due to the large number of tools. In this article, a novel “tool vending machine� is introduced, which will be capable of solving those problems, and at the same time, move a step closer to robot-assisted dental surgery. Methodology: The tool vending machine was designed considering the needs of the dentists and also from the perspective of the entire product life cycle. For these reasons the design process was implemented using a rigorous analysis of effective manufacturing processes and product quality. To show the feasibility of using such a machine in improving work efficiency during operations, a study of the associated motion patterns and the required time increments were assessed. Results: The study showed the potential for time reduction in dispensing and cleaning. Conclusions: The dispensing machine was shown to reduce setup and preparation time for root canal treatment. The designed product was deemed to be marketable. EP

Endodontic practice 45

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arestream Dental introduced six of the newest additions to its extraoral imaging system, intraoral imaging system, intraoral camera, and software suites – all geared towards streamlining workflow and improving doctor-to-patient communication. The products debuted at the 2012 Ontario Dental Association (ODA) Annual Spring Meeting at the Metro Toronto Convention Centre. During the ODA Annual Spring Meeting, the Carestream Dental team showcased new solutions, which included: UÊ / iÊ -Ê ÎääÊ vi>ÌÕÀiÃÊ Õ Ì « iÊ wi `ÃÊ vÊ Û iÜÊ v ÀÊ Î Ê >}iÃ]Ê À> } }ÊvÀ ÊxÊV ÊÝÊxÊV ÊÌ Ê£ÇÊV ÊÝʣΰxÊV °Ê/ iÃiÊ Õ Ì « iÊ wi `ÃÊ vÊ Û iÜÊ i >L iÊ «À>VÌ Ì iÀÃÊ Ì Ê v VÕÃÊ Ê >Ê Ã«iV wVÊ Ài} Ê vÊ ÌiÀiÃÌÊ LÞÊ V >Ì }Ê Ì iÊ wi `Ê vÊ Û iÜ]Ê } Û }Ê V V > ÃÊ Ì iÊ ability to limit radiation exposure to patients. Additionally, the

-Ê ÎääÊ vviÀÃÊ «À>VÌ Ì iÀÃÊ Ó Ê ` } Ì> Ê «> À> VÊ >} }Ê Ü Ì Ê Û>À >L iÊ v V> Ê ÌÀ Õ} Ê ÌiV }Þ°Ê / iÊ -Ê ÎääÊ ÃÊ > Ã Ê >Û> >L iÊ with a cephalometric option. UÊÊ i ÛiÀ }ÊÌ iÊ } iÃÌÊÀià ÕÌ Ê >}iÃÊ vÊ> ÞÊ ÌÀ> À> ÊÃi à ÀÊ in the industry (> 20 line pairs/mm), the RVG 6500 System uses Wi-Fi technology to completely eliminate the need for a wired connection to a computer. In 5 seconds, images can be transferred to an operatory’s computer with no workflow interruptions. Available in three sizes, these waterproof and shock-resistant sensors are perfectly sized for any examination, including a size 0 sensor that is ideal for pediatric applications. UÊ } V Ê >À iÃÊ iÌiVÌ À™ Software, the only FDA-approved caries detection software, is now available in an automatic version. This software serves as a computer-aided detection tool that is clinically proven1ÊÌ Ê i «Ê`i Ì ÃÌÃÊw `Ê ÀiÊ ÌiÀ«À Ý > ÊV>À iÃÊ Ê ÌÀ> À> Ê À>` }À>« Ã°Ê / ÃÊ iÜÊ ÛiÀÃ Ê vÊ } V Ê - vÌÜ>ÀiÊ «À ÛiÃÊ«À>VÌ ViÊivwV i VÞÊÜ Ì ÊÌ iÊ>L ÌÞÊÌ Ê>ÕÌ >Ì V> ÞÊÀÕ Ê the detection algorithm on all applicable tooth surfaces within a bitewing radiograph and immediately display the results with a single click. UÊ / iÊ V «>VÌÊ -Ê ÇÈääÊ ` } Ì> Ê ÌÀ> À> Ê À>` }À>« ÞÊ ÃÞÃÌi Ê reinvents imaging plate technology by improving usability, productivity, and security. This cost-effective system’s patented intelligent workflow technology prevents plate mix-up and reduces operation time. The CS 7600 is fully automated and is as i>ÃÞÊÌ ÊÕÃiÊ>ÃÊw ÊqÊÜ Ì Ê> ÊÌ iÊLi iwÌÃÊ vÊ` } Ì> Ê >} }° UÊ / iÊ -Ê £ÈääÊ ÃÊ >Ê Õ Ì ÕÃiÊ ÌÀ> À> Ê V> iÀ>Ê Ì >ÌÊ V L iÃÊ exclusive, patented caries detection technology with Carestream Dental’s industry-leading image quality. With the widest focus À> }iÊ ÊÌ iÊ >À iÌÊ­£Ê ÊÌ Ê w ÌÞ®]ÊÌ ÃÊi>ÃÞ Ì ÕÃiÊV> iÀ>Ê marks a leap forward in dental care, as dentists typically must rely upon traditional, more subjective methods of caries detection. This camera features the same unique liquid-lens autofocus technology as Carestream Dental’s 1500 Intraoral Camera as well >ÃÊ >Ê Ã « ÃÌ V>Ìi`Ê £n Ê Õ >Ì Ê ÃÞÃÌi Ê > `Ê > Ê «Ì > Ê « >À âiÀÊw ÌiÀÊÌ ÊÀi`ÕViÊ} >Ài° UÊ Ê>`` Ì > Ê iÜÊ ÌÀ> À> ÊV> iÀ>]ÊÌ iÊ -Ê£Óää]Ê ÃÊi>ÃÞÊÌ ÊÕÃiÊ 6 Õ iÊxÊÊ Õ LiÀÊ{

and provides practitioners with an affordable entry point into digital imaging. The CS 1200 captures crisp, clear images. The camera’s wide focus range captures a variety of images including macro, single teeth, arches and smiles, and it has the ability to ÃÌ ÀiÊÕ«ÊÌ ÊÎääÊ >}iÃÊÜ Ì ÊÌ iÊV> iÀ>Ê ÌÃi v° “Carestream is dedicated to developing and producing solutions that help, not hinder, workflows and optimize patient V>Ài]»Ê Ã> `Ê `Ü>À`Ê - i >À`]Ê ]Ê V ivÊ >À iÌ }Ê vwViÀÊ > `Ê director of business development for Carestream Dental. “We’re excited for practitioners to experience our new solutions and the time savings they provide.” For more information or to contact a Carestream Dental Ài«ÀiÃi Ì>Ì Ûi]ÊV> Ê£ nää {{ ÈÎÈxÊ­ ÊÌ iÊ1°-°®]Ê ÀÊ£ nää ÎÎ näΣʭ Ê > >`>®]Ê ÀÊÛ Ã ÌÊÜÜÜ°V>ÀiÃÌÀi> `i Ì> °V ° EP This information was provided by Carestream Dental.

Reference £°Ê > i i iÀ]Ê >Û `Ê °Êº/ iÊ vwV>VÞÊ vÊ>Ê «ÕÌiÀ âi`Ê >À iÃÊ Detector in Intraoral Digital Radiography.” Journal of the American Dental AssociationÊ£ÎÎÊ­ÓääÓ®\ÊnnÎ n ä°

Endodontic practice {Ç

Product profile

DiaDent: Dia-Gun & Dia-Pen warm vertical compaction and cordless obturation

T

he purpose of obturating a root canal is to fill the space three-dimensionally to eliminate any gateways through which bacteria might enter. Thanks to DiaDent, doctors can now have a bulletproof way to seal root canals that will help ensure treatment success. Studies indicate that using the warm compaction technique increases the chances that no voids will be left behind in the obturation process. Introducing Dia-Pen Cordless Warm Vertical Compaction Device and Dia-Gun Cordless Backfill System. Together, these two devices will enable you to obturate with confidence and precision. While countless methods and techniques are available for root canals, perhaps none is as easy and time-saving as DiaDent’s complete obturation system. Dia-Pen is a cordless warm vertical compaction device. It effectively and tightly compacts and seals all canals including lateral canals. After a canal has been shaped and cleaned, a master cone is selected for a snug fit and tug back. Dia-Pen is then used to soften, spread, cut and compact root canal filling material. Color-coded pen tips are available in five different sizes including XF, F, FM, M, and ML. DiaPen is ergonomic and one of the lightest compaction devices on the market, weighing only 65 grams. Its quick heating tip reaches 220˚C, its highest level of temperature, within 1 second to save treatment time. Three temperature settings of low, medium, and high let you have full control of any procedure. Dia-Gun then follows. Dia-Gun is a cordless obturation system that extrudes warm gutta percha to backfill the yet unfilled portion of the canal. Dia-Gun comes with two types of disposable tips (23G or 25G). The tips can be bent to the desired shape and angle using the multi-purpose wrench provided. Using the guttapercha pellet included in the kit, load one into the loading slot, and push it into the heat chamber with the hand plunger. Dia-Gun has three variable temperature settings (160˚C, 180˚C, 200˚C) to allow precise control of obturation flow. Temperature reaches 200˚C in just 25 seconds. The ergonomically designed 360-degree swivel tip allows improved access, while the thin tip eases narrow canal filling. Other benefits include a lid for the heat chamber that offers protection from dirt and debris. Dia-Gun is designed to provide reliability and precision while delivering a fast, continuous flow of canal-sealing gutta percha. Both Dia-Pen and Dia-Gun are easy to clean and easy to use. Ergonomically designed features reduce hand fatigue while offering excellent tactile feedback. Instructional and introductory videos can be viewed on DiaDent’s website at www.diadent.com. Purchase Dia-Gun and Dia-Pen from your trusted dental dealers such as Henry Schein, Patterson, Benco Dental, Ultimate Dental, etc. DiaDent will be exhibiting at the ADA show in San Francisco. Visit booth #5607 for a detailed Dia-Gun and Dia-Pen product demonstration. For more product information, please call 1-877-342-3368. EP This information was provided by DiaDent.

48 Endodontic practice

Volume 5 Number 4

Practice management

Stay connected the engine GULYLQJ SUDFWLFH HIÀFLHQF\ and patient satisfaction !"#$%&'$()'*+,$+,-$!.+,+$/#$0".1-*+,2$342$3542$6)&7$)&7$ 8+9.1,96$:+,$;118$9&':)$7.9)$<&'"$8"+:9.:1$=>?@

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he Internet affords us, as consumers, incredible benefits such as making it easy to research information quickly and seamlessly transact with service providers online. From online banking to ordering books through Amazon, increasingly the Internet plays a bigger role in our lives. In fact, 98% of those with a household income of $75,000 or above use the Internet. Put yourself in a patient’s shoes for a minute. What would the impact be if you had access to your account and records, whenever you want, wherever you want it? Download an appointment reminder to your calendar; fill out health history forms from the privacy of your home, with clear access to your medication cabinet; print an insurance form without having to request the practice generate this form for you; look up and confirm your upcoming appointments at your convenience, and/or pay your balance using a credit card, all from the comfort of your home. Sounds perfect and convenient, right? There is something to be said when your patients can perform tasks such as filling out forms, accessing dental records and insurance balances, paying their bill, and sending you communications online, any time of day. In fact, 97% of dental patients would rather click than call the practice for information. Simply put, it is a huge convenience factor. More than 90 percent of dental patients surveyed report that online access is “much more convenient” than calling the office. The fact is, with our modern fast-paced, activity-packed lifestyle, your patients are extremely busy and appreciate service providers that facilitate their interactions. When you can make their experience with your practice hassle-free and accommodate their preferences and convenience, they are going to respond by increasing their loyalty and commitment to the practice. Just as important is the fact that automating certain administrative functions like past due accounts/receivable collections and appointment reminders gives your team the opportunity to leverage their time more efficiently. Their time can be focused on more important tasks such as establishing great relationships with your patients, tracking treatment acceptance and completion, reactivating patients, and other tasks critical to ensure your office runs like a well-oiled machine. In this article, we will examine specific benefits of portals associated with automated patient reminders, email financial reminders, and patient-engagement tools. !"#$%&#'() &**$+,#%',#) -'%+,('-.) /) 0''*) 1$"-) .23'("4')5"44 How much time would your staff save every day if they weren’t making calls to remind patients about upcoming appointments? What could they be accomplishing if they had that valuable time back in their day? According to Medical Group Management Association data, 50 Endodontic practice

in dental practices the average missed appointment rate is between 18 and 22 percent, which translates into an average loss in revenue of $138,000 per practice, annually, due to missed appointments alone. With appointment reminders, you are not just reminding your patients of their appointments, you are reminding them of how crucial dentistry is to their overall health. In fact, 100% of surveyed practices agree that patients perceive their doctors as high-tech with superior customer service when appointment reminders are customized. An effective, automated appointment reminder system decreases your no-show rate, helps staff be more efficient, and strengthens patient commitment. The most significant patient benefit of an automated communication system is the patient’s ability to customize communications to their preferences, specifically email, text, or voicemail appointment reminders. In a 2010 survey, it was found that 79.5% of Sesame Members’ patients preferred text and email reminders over phone reminders. What’s more, 85% of surveyed Sesame Members agreed that using reminders reduced outbound calls from their team. Unlike manual systems, which require daily scheduling, an effective online patient portal requires that your staff only set up the reminder once – the system takes care of the rest. Appointment reminders are automatically sent when you want, including 1-hour pre-appointment text messages to gently remind patients about their appointments. By using an automated process, doctors have the peace of mind in knowing all reminders were executed properly and on time, every time. The result? Fewer patients telling you, “I got so busy I forgot,” not to mention more productive days with filled chairs. Without an online portal to communicate with your patients about their upcoming appointments, remaining insurance benefits, treatment images, and financial data, your office staff must spend time manually responding to each and every request for information. 6+,&,2+&4)-'%+,('-.)/)+%*-$7')2$44'2#+$,. What would you be more likely to do on time – go to the post office to mail a check to a business, or pay online with a credit card from the comfort of your home or office? Online bill pay is becoming more of an expectation in today’s digital world, with the total number of households transacting online growing by 53% in the past 10 years, and check payment volume dropping by 57%. The convenience of being able to pay online not only means a quicker turnaround for payments, but the ability to collect payment outside of office hours. Sesame Members receive more than 46% of payments outside of normal business hours, meaning the money is in their account and waiting for them by morning. More significantly, 90.5% of Sesame Member patients surveyed stated they are comfortable paying their dental bill online. Clearly, emailed financial reminders and the ability to discreetly pay Volume 5 Number 4

Practice management balances via credit card 24/7 is a convenience patients both expect and endorse. Automated past-due financial reminders also present an opportunity for increased effectiveness and efficiency on the part of the practice. In 2010, a comprehensive study by TransFirst found that 32% of online payments to practices were made the day the patient received their past-due financial reminder. An impressive 50% of payments were made by the end of the second day (within 48 hours). Past-due balances dramatically impact the practice cash flow and profitability. Implementing a system that seamlessly and effortlessly collects half of those outstanding balances without administrative time required to manage collection calls is an important benefit. More significantly, collection calls are not only time-consuming, but can damage the relationship between the practice and the patient. Automated effective online collection systems reduce the need for that activity and minimize such a risk. !"#$%&#'($)$#"*'+,--.&$+"#$,&/'0'1.$*('12"&('#2./# Regular communication with your patients not only builds a sense of familiarity with your practice, but over time it builds brand trust as well. E-newsletters, customized personal emails, e-birthday cards, and holiday greetings are an effective way to deliver practice information, engage with your patients, or share news and promotions relevant to your patients’ treatment plans. The average dentist has 1,871 active patients, making the ability to have one-to-many conversations crucial to patient retention and the success of their practice. It’s difficult to make a personal connection with each one of your patients on a regular basis, but by reaching them electronically, you can close the time gap between conversations and increase patient recognition and awareness of your practice’s brand. Furthermore, consistent communication not only saves administrative time and cost, but further affords your practice the opportunity to educate patients about new services they may be interested in. !"#$%&#' 3,2#"*/' 0' )"$&' &%4' 3"#$%&#/' #52,.)5' 2%6%22"*/'"&('-%"/.2%'#,'%&/.2%'/"#$/6"+#$,& Practices are hectic and busy environments, and you may fail to ask your most valued patients for feedback and guidance on how you may better serve them. It is imperative to regularly keep tabs on your patients’ level of satisfaction. A complete online patient portal functionality needs to include post-appointment feedback surveys that can easily be filled out online after every appointment while the patients’ visit is still fresh in their minds. In addition, it should include a survey form any visitor may complete to provide feedback to the practice. Use this valuable information to continually improve the experience of patients in your practice and keep them returning. Take it one step further and post positive testimonials and reviews to your practice blog, Facebook™, Twitter™ and Google+pages™ to attract new patients. Lastly, the continued success of your practice requires happy patients who refer their friends and family. Allowing your patients to conveniently input this information online and send your practice information directly to their referral, means you will have the contact data on hand to reach out directly to prospective patients right away, and that referral will have already received a positive evaluation of your practice. 7,&+*./$,& With the right online patient portal, your practice can elevate the patient experience and quality of care while effectively staying in touch with them at all the crucial moments in their lifecycle with the practice. From ensuring they remember to show up to Volume 5 Number 4

an appointment, to reminding them to pay their bill, automated systems drive consistent, reliable execution of otherwise timeconsuming administrative duties. In an economy where limited budgets and resources have become the norm, it’s imperative to make the most of what you have, and to discover ways to consistently achieve your practice’s production and collection goals through more efficient methods. EP Lou Shuman, DMD, CAGS in Orthodontics, is the president of Pride Institute. He is a member of the Key Opinion Leader Board at DENTSPLY GAC, and is a personal consultant to DENTSPLY GAC, as well as to SomnoMed Inc., the country’s leading sleep apnea company. He currently serves as chairman of the Sesame Communications Technology Advisory Board, is a member of the Clinical Advisory Board at Dentistry Today, as well as the Advisory Boards of The Progressive Orthodontist and The Progressive Dentist. He is also the only dentist who has been selected both as a Top CE Leader and a Leader in Dental Consulting by Dentistry Today magazine. Diana P. Friedman, MA, MBA, is president and chief executive officer of Sesame Communications. She has a 20-year success track record in marketing innovative technologies and fortifying brand positioning for dental companies in the professional and consumer markets. Throughout her career, Ms. Friedman has served as a recognized practice management consultant, speaker, and author. She holds an MBA in Management and Marketing as well as an MA in Sociology from Arizona State University.

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Endodontic practice 51

Legal matters

!"#$%&'$('%")*+,(-"./0(1$(2&)'30( -$&-(4503")0(".$ 6%7(8%52(97(:;")<5+(")0;5.$+(03$(+0$*+(0"(=$$*5.'(&(*%&2052$(03%5#5.'( $#$.(5.(03$(>&2$(">(&-#$%+50?(

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s an attorney who specializes in practice transitions, I have seen a number of instances where the death or disability of a sole practitioner has resulted in a significant decrease in the value of his/her practice. The dramatic drop-off in productivity and income rapidly erodes the attractiveness of the practice to a potential buyer. Even if the doctor is able to return to work, the disruption the practice endured can have a long-lasting impact on growth and profitability. An often overlooked “insurance” is the cross-coverage group – an agreement among like-minded practitioners to fill-in for one another in the event a member is disabled or dies. If the doctor had a cross-coverage agreement in place, he/she could have helped preserve the ongoing value of the practice, made it more appealing to a potential buyer, and maintained the new patient flow essential to every practice. The cross-coverage agreement is a contract among willing participants. Unlike many contracts, its enforceability rests more on the moral compact the parties bring to the agreement rather than something they can bring before a judge to enforce. One of the key elements in an enforceable contract, consideration, is not present in a tangible form. Asking a judge to compel a member to cover for another member or to award monetary damages for a failure to cover is an argument grounded more in theory than in fact. The lesson, then, is to choose your coverage group colleagues wisely and make sure they are professionals you can count on to come to your aid in the event you need them. When you are lying in your hospital bed, the last thing you want to find out is that a member of your coverage group does not plan to fulfill the solemn obligation. Let’s look at what a typical cross-coverage agreement in the event of disability or death should consist of: 1. Parties: The agreement should list the members of the cross-coverage group. No member can substitute or assign his/ her obligation to the group to anyone else. You don’t want casual or oral commitments; you want willing participants who will solemnly agree, in writing, to step up if and when needed. This is not a loose collection of dentists you happen to see on occasion at a meeting. This is an essential part of your practice security, as important as any other insurance coverage you have. It is usually advisable to have at least six members in the group but no more than 12. No member should have to assist more than once a week. With six members, every day of the week is covered; with 12, a member only has to cover once every two weeks. Covering for another member means a day you cannot be in your office. You want to minimize the impact on your practice while being able to 52 Endodontic practice

assist your coverage group member to retain the value of his/her own. Another option to consider is for the group to keep a file of recently-retired local endodontists. Having one doctor covering the practice will provide greater continuity of care for the patients. The local dental society or endo program often has data on recently-retired practioners who might want to help out on a short-term basis. 2. Purpose: An introductory section that defines the mission of the group and its stated purpose, concluding with words like, “The parties seek to provide for the orderly functioning or transition of their practices in the event of a member’s disability or death.” 3. Definitions: In this section, you clearly define when members are obligated to step up and assist the member in need. Death is easy to define; disability is a little trickier. As a member of the group, you want to make sure that if you suffer a disability, the group is obligated to come to your aid. However, there are a number of events that may technically constitute a disability that you might want to consider excluding from the definition of disability, such as: UÊ iVÌ ÛiÊ i` V> Ê«À Vi`ÕÀià UÊ -i v y VÌi`Ê` Ã>L Ì ià UÊ Ã>L Ì iÃÊ>ÃÊ>ÊÀiÃÕ ÌÊ vÊ >â>À` ÕÃÊ>VÌ Û Ì ià UÊ ÀiÃii>L iÊ` Ã>L Ì iÃÊÌ >ÌÊ> ÜÊÌ iÊv ÀÊÌ iÊÊ Ê Ê procurement of a substitute Ê > }Ê Ì Ê >VVÕÀ>Ìi ÞÊ > `Ê «ÀiV Ãi ÞÊ `iw iÊ Ü >ÌÊ ÌÀ }}iÀÃÊ >Ê disability is often the source of friction and resentment within the coverage group. The decision should rest with objective facts, not on the subjective opinion of the majority of the members. 4. Triggering mechanism: The agreement should clearly state how the cross-coverage is put into play. One member should be appointed chair of the coverage group. This should be done on a rotating basis with the subsequent chair already established, either by seniority or alphabetically, in the event the presiding chair is the one in need of assistance. If coverage is required, the member or representative of the member in need of assistance will know immediately who to call to arrange for coverage. There needs to Volume 5 Number 4

Legal matters be a clear chain of command and a specific way members should need to be maintained for the required statutory period. The communicate with each other in the event they are needed to agreement should clearly state that in the event the practice is sold assist. or otherwise disposed of, these provisions shall be binding on any Members should not automatically assume that if they subsequent buyer. hear of another member’s illness or death, they will be required 9. Office records: Each member of the coverage group to serve. The practice may have a buy-sell agreement already in should be required to keep a “transition file” in an accessible place that obviates the need for coverage. It is even possible that but secure location, ideally with a trusted accountant or lawyer. the representative of the practice prefers not to have the coverage Much like a will, this file will be opened only upon a triggering group spring into action, opting to make other arrangements with event. The file should contain vital practice documents such as someone not in the coverage group. financial information, payroll reports, staff roster, passwords 5. Schedule: Each member should know what day he/she is for office accounting and data information, and the names of expected to be available. When the call comes in from a member trusted advisors including the doctor’s accountant, attorney, and in need that is not the time for everyone to decide the day he/she investment advisor. In an urgent situation, it is imperative not to can give. Each member should state a specific day of the week he/ lose time locating these records and advisors. she will be available. Members should also discuss the hours their 10. Transition letter: Members of the group should prepare office is open. If a member likes to work three 12-hour days each several different template letters, to be sent as the appropriate week, that may not be acceptable to a covering doctor who prefers situation arises. One letter should be in the event a member suffers a shorter day. a short-term disability, another is the 6. Duration: The group needs to disability appears to be of a more !"#$%&&'$$(%)#&*+',-.'# agree on how long they will cover permanent nature, and a third in for a doctor in need. The customary the event of a member’s death. The .,*%/#0-$#)12'34156'6# time is no more than 6 months. letter should be directed at both 4'47',$#80*#25*8#'-&0# referring dentists and patients and Most of the time, group members are very happy to step in and assist a seek to assure recipients *90',#-56#.'9#-)*5.#8190# should colleague in need, but the obligation that it is “business-as-usual” in the '-&0#*90',:; must have an end. The rationale office. Agreeing on and composing behind the coverage group is to buy a letter under the stress of an urgent time for the doctor in need to make appropriate arrangements for situation leads either to a costly delay or a poorly-drafted letter. A a more permanent solution. This means that if a doctor is disabled, letter for each scenario should be attached to the cross-coverage the group’s obligation is to fill in while the disabled member agreement as an exhibit. actively looks for a substitute doctor to keep things going until 11. Non-solicitation: The parties to the agreement should he/she can recover. In the event of the death of a member, the promise not to solicit any of the patients or staff of the doctor in group’s obligation is to maintain the value of the practice while the need. Concern by the disabled doctor or the family of the deceased designated representative actively seeks to transition the practice. doctor that the covering doctors will poach patients or staff is the Especially in the event of the death of a doctor, there is often primary reason coverage groups are not utilized. Without this a grieving period that prevents the immediate ability to put a peace of mind, the coverage group will be of little value. transition in play. The group is there to keep things going. What 12. Term and termination: The agreement should self-renew on the coverage group is not obligated to do is provide perpetual an annual basis unless a member withdraws or the group decides coverage while the representative shops the practice around to disband. The agreement should have a mechanism to allow a looking for the perfect buyer. member to withdraw from the coverage group. Members should 7. Compensation: The group must decide whether the covering agree on how much advance notice is required to withdraw. members are entitled to any compensation. The customary way Ninety days is the suggested notice. A method of delivery for the this is handled is that for a period of a few months, usually no notice of withdrawal should be stated, usually a certified letter to more than 3, the members fulfill their obligation to the member the group’s chair with an obligation by the chair to immediately in need with no compensation. In most cases, this will mean notify all other members so that a replacement member can be the covering doctor is out of his/her office for no more than 12 brought into the group. The agreement should have a provision days over a 3-month period, helping out a colleague in need. If that no member may withdraw if an active coverage situation is coverage is needed after 3 months, members should receive per in effect or if there is deficiency in the number of members in the diem compensation. Taking time out of one’s own office is a costly group. Coverage groups work best if there is a critical mass of commitment. Even when the covering doctor is compensated, the doctors who are available to cover. The untimely withdrawal of a compensation rarely exceeds the lost income the covering doctor member in an active coverage situation can negatively impact the experiences. entire dynamic of the group. 8. Patient records: The covering doctor must make concise and 13. Transition plan: In the event of a catastrophic illness or the accurate records of all procedures and income generated. Ideally, death of the practice owner, it is imperative that a transition occur a trusted staff member will be there to assist. In addition, the rapidly. The coverage group should form a relationship with a member must agree that none of those records can be duplicated reputable practice broker and name that broker in the agreement. or removed from the office under normal circumstances. The The broker can advise the coverage group before there is an disabled doctor or the spouse of the deceased doctor does not emergency and be ready to spring into action in the event one want to worry that the confidential records of the office are leaving occurs. the premises. 14. Indemnification: Under the heading of “no good deed goes It also needs to be clearly stated that in the event any of the unpunished,” the last thing any member of the coverage group covering doctors require any of the records to defend against a wants is to be liable for the actions of another. The cross-coverage judicial or administrative action, he/she is entitled to any access agreement must have a clause that states that each of the parties necessary to assist in the defense of such action. There should promises to indemnify and hold harmless all others from their also be a clause in the cross-coverage agreement that all records independent acts, errors and omissions. Volume 5 Number 4

Endodontic practice 53

Legal matters 15. Relationship of parties: Your cross-coverage agreement should unequivocally state that there is no “privity” or business relationship between the members of the coverage group. No member, by virtue of being part of the group, has any claim on or responsibility for any of the assets or liabilities of the other members. 16. Dispute resolution: The agreement should address where and how any dispute between the members will be resolved. The logical venue for any dispute resolution is the state and county where most of the members have their offices. The best dispute resolution mechanism is arbitration rather than litigation in the court system. !"#"$%&'())*") The composition of the group should be age-balanced. As members age, younger members should be asked to join. Although death and disability can strike anyone at any time, older members are actuarially more likely to require the group’s services. Younger members must acknowledge that the old guard has provided coverage for others for years and appreciate that fact if asked to come to the aid of a senior member. Coverage groups don’t work as well if all members are the same age. Members must be clear about what constitutes a disability. A source of friction within a group, and occasionally the cause of a group’s collapse, is when some members feel that a disability is one that could have been foreseen and provided for. The purpose of a coverage group is to provide short-term support for unexpected illness or death. A member who expects the group to cover for him while he/she is out for a month recovering from a hair transplant or maternity leave creates resentment among the other group members. Expecting group members to take time out of their offices when there was ample time to procure a substitute dentist is not within the spirit of the agreement. When forming a coverage group or asking new members to join, vet each potential member to be sure everyone shares similar treatment philosophies. If you have a member who is adamantly opposed, say, to premolar extractions, he/she might not be a good fit in a group that believes in the virtues of Tweed incisor position. In addition to similar philosophy and techniques, all members of the group must be licensed in the same state. It makes no sense to have someone in your coverage group who cannot legally practice in your office. In the case of doctors with multiple offices, the group should determine which of the offices members are obligated to cover. By establishing a pre-existing relationship with a reputable practice broker, the group can use its leverage to negotiate a discounted brokerage fee in the event a practice needs to be sold due to the death or disability of a member. Using those same economies of scale, a coverage group can also negotiate a lower fee with a practice appraiser and get annual or biennial appraisals of their practices to insure that there is a current valuation in the event a rapid sale is required. The broker should be invited to speak to the group on a periodic basis to update the group on the current valuation methods for endodontic practices and the current “state-of-the-market” for transitioning practices. Having a broker in place who knows the practice and the prevailing market will improve the transition value of the practice. In addition, a knowledgeable broker can also provide a “reality check” on the presumed value of the members’ practices and help a disabled doctor realize that the time to sell is before the practice starts to decline significantly. In many jurisdictions, a nonprofessional cannot own a dental practice. Most state boards provide only a brief window where the spouse of a deceased dentist can own and run the practice as it is transitioned. If a coverage group is not in place, and the practice 54 Endodontic practice

has not had a recent valuation, critical time is wasted putting together the necessary transition team. Often, the grieving spouse is too distracted to focus on the importance of acting decisively to transition the practice. Grief, coupled with lack of preparation, can cause a delay that severely impacts the ability of the practice to be effectively transitioned. The delay creates a significant drop in the value of the practice at a time when the surviving spouse may most need the income the sale would produce. A successful coverage group has like-minded members who know each other and get along with each other. As a practical matter, when advising coverage groups I always suggest that they meet twice a year to reaffirm their legal, moral and ethical bond to each other. One of the meetings is a business meeting where the agreement is reviewed, and each member is made aware of his/ her solemn obligation to the other members of the group. The group roster is updated with the names of each of the member’s office manager, accountant, and lawyer. On occasion, a speaker can be invited in to discuss issues that might arise in the event of a doctor’s death or disability such as taxation or estate planning. The second meeting is more of a social gathering where spouses are invited. It is important that spouses meet the members of the group and each other. In the event of the death or disability of the dentists, the surviving spouse will need to rely upon the members of the group to step in and assist in preserving the practice value while it is transitioned. Meeting with each other, even if it is once a year, serves to allay any fears the surviving spouse may have that members of the group would “poach” patients and staff from the deceased doctor’s practice. In the past year, I have worked with six dental-practice transitions that were the result of the death or disability of the selling doctor. In four of the transactions, I represented the seller. Regrettably, not one of the deceased or disabled doctors had a coverage group in place. The spouses all had similar stories: we talked about it, but he never got around to joining one; she was in great health and never thought she’d get sick; he thought it would never happen to him; she knew she was sick but was in denial. Had the practice owners been part of a cross-coverage group, the practice value would have been preserved. The absence of a coverage group and lack of advance planning resulted in a significant reduction in the selling price of the practice. Even where I represented the buyer, and we were able to pick up the practice at a significant discount, neither party benefited. The seller got a lower price, the buyer a lesser practice. Besides life insurance, disability insurance, office overhead insurance and malpractice insurance, add one more thing to your list of insurances: membership in a cross-coverage group. EP This information is not intended as a substitute for legal advice. You should familiarize yourself with the laws of your local jurisdiction and seek legal advice from a local attorney who specializes in such matters.

Eric Ploumis, DMD, JD, is an attorney, an orthodontist, and Associate Clinical Professor

of

Orthodontics

and

Risk

Management at New York University. He limits his legal practice to issues surrounding the practice of dentistry with an emphasis on practice transitions, employment issues, leases, and defense of allegations of professional misconduct before the Office of Professional Discipline. He can be reached at EricPloumis@aol.com or www.dentalpracticelawyers. com. Volume 5 Number 4

Diary 3,16'14'12$574+06',1$>$R4(<$#SO%&.6&FT&)$#UV$!"#! !"#!$%&'(&)$*'+),-+,.&$ /)0'1'12$3,4)-& Drs. Craig & Jennifer Barrington July 14, 2012 Dallas, TX 800-489-2282 nrasch@seilerinst.com

Dr. Jorge Vera September 7, 2012 Miami, FL Dr. Garry Bey September 7, 2012 Moorhead, MN 800-346-3636 x4122- Javier Gutierrez www.sybronendo.com

5--&16'0($517, Dr. Garry L. Bey July 20, 2012 Cleveland, OH Dr. Gary Glassman July 20, 2012 Lancaster, PA Dr. John Olmstead July 20, 2012 Boise, ID Dr. Gary Glassman July 27, 2012 Teaneck, NJ Dr. Joseph Maggio July 27, 2012 Vancouver, WA Dr. Thomas Jovicich July 27, 2012 Tulsa, OK Dr. Garry Bey August 3, 2012 San Diego, CA Dr. Fred Barnett August 3, 2012 Jackson, MS Dr. Joseph Maggio August 3, 2012 Grand Rapids, MI Dr. John Olmstead August 10, 2012 El Paso, TX Dr. Thomas Jovicich August 10, 2012 Tinley Park, IL Dr. Brett Gilbert August 17, 2012 Oklahoma City, OK Dr. Gary Glassman August 17, 2012 North Los Angeles, CA Dr. Thomas Jovicich August 23, 2012 Phoenix, AZ Dr. Gary Glassman August 24, 2012 Jacksonville, FL Dr. John Olmstead August 24, 2012 Denver, CO Volume 5 Number 4

8&9$:,);$3,416<$=&160($ %,+'&6<>$517,7,16'+-$?,)$6@&$ A&1&)0($B)0+6'6',1&) Stephen Niemczyk July 25, 2012 New York, NY 215-573-8500 www.nycdentalsociety.org

/&+@1,(,2'+0($C&-,4)+&-$D$ E',(,2'+0($3,1+&.6-$'1$ *'1'F0((<$G1H0-'H&$=&16'-6)< Dr. Renato Leonardo July 27, 2012 Akron, OH 800-520-6640 www.ultradent.com

34))&16$%+'&16'?'+$5H'7&1+&$ '1$517,7,16'+$/@&)0.< Ryan Facer July 27, 2012 Boise, ID Frank Cervone July 27, 2012 Tampa, FL Joe Camp August 10, 2012 Little Rock, AR Sergio Kuttler September 8, 2012 Honolulu, HI George Bruder September 14, 2012 Long Island, NY 800-662-1202 www.register.tulsadentalspecialties.com

/@&$L(6)07&16$%4FF'6 Dr. Dan Fischer, Neil Jessop & Dr. Renato Leonardo August 16-18, 2012 Salt Lake City, UT 800-520-6640 www.ultradent.com

*,(0)-$M1(<$N017-OM1$ P(4F1'$3,4)-& Stephen Buchanan August 16-17, 2012 Santa Barbara, CA 800-528-1590 – Pamela Vogel

C&0('Q'12$%4++&--$'1$ 517,7,16'+-J$P$%+'&16'?'+$ P..),0+@ William Nudera September 13, 2012 Bloomington, MN 800-622-1202 www.register.tulsadentalspecialties.com

B06@90<-$6,$%4++&--J$ 517,7,16'+$M46+,F&-$E0-&7$ ,1$%+'&16'?'+$5H'7&1+& Sergio Kuttler September 14-15, 2012 Detroit, MI Donnie Luper September 14-15, 2012 Naperville, IL 800-622-1202 www.register.tulsadentalspecialties.com

I&--,1-$,?$6@&$=,9164)1J$ B,-'6',1'12$?,)$6@&$K464)& Dr. Dan Fischer August 10, 2012 Bellevue, WA August 24, 2012 Palm Beach, FL 800-520-6640 www.ultradent.com Endodontic practice 55

Ruddle on the radar !"#$%#&'($)%*+$ #$(&#%"&,"-.+$/,$ !"#$%&'()*+#,*-,./011,2%$3'%$4,5'+'6#

R

ecently, my travels have taken me to the Middle East. In January, I participated in the Pan Arab Endodontic Conference in Dubai, United Arab Emirates. From Dubai, my wife, Phyllis, and I traveled to Amman, Jordan, where the Jordanian Endodontic Society held their annual meeting. Then, in March, Phyllis and I again returned to the Middle East. On this endodontic tour, we visited Dammam and Jeddah, Saudi Arabia, and Kuwait City, Kuwait. In these cities, we gave 13 workshops to more than 400 enthusiastic and eager-to-learn dentists. These dentists shaped a minimum of 1,200 simulated S-curved canals in plastic blocks. Plastic blocks are readily available, allow full visualization of each procedural step, and provide instant feedback as to the effectiveness of me, as a teacher. All the shaping results were evaluated and judged in accordance with Schilder’s five mechanical objectives for shaping canals. 1. Create a funnel-shaped form. 2. The corollary to this funnel-shaped form is that each crosssectional diameter, moving apically, is progressively smaller, with the smallest diameter of the preparation at the terminus of the canal. 3. Maintain the original pathway of the canal. 4. Preserve the anatomical position of the foramen. 5. Keep the prepared foramen as small as practical. These mechanical objectives provide a method to evaluate, grade, and compare each shaping result. In this manner, colleagues can more objectively assess their work, and if necessary, make the mechanical adjustments required for improvement. Importantly, sometimes it is the teacher who needs to make the educational adjustments required for students to move ever closer to their full potential. As a teacher, it is dangerous to make assumptions. For example, it is easy to assume that small details within any given procedural step are already understood, when in fact, this may not be the case. Yet, a successful result is a summation of properly executing all these details. More than a decade ago, I learned something that helped me become a better teacher. In 2001, the ProTaper NiTi rotary file system came to market, and during the subsequent years, became the No. 1 file system in the world. However, this file system did not launch with enormous success. Even though the ProTaper system has remarkable design features, many early adopters did not use these active instruments correctly. Regrettably, the advantages of well-designed files and their potential performance can be sabotaged when dentists do not follow the recommended directions for use. To maximize performance during any given ProTaper workshop, I have been known to have audiences yell in unison, “Float, follow, brush.” My theatrical antics are to emphasize that ProTaper performance improves measurably when the files are used correctly within a canal that has a confirmed, smooth, and reproducible glide path. As an example, the ProTaper Shapers are employed using a brushing motion. Brushing maximizes contact between the file and dentin and allows more complete instrumentation, especially in canals that have an irregular crosssection or exhibit fins off their rounder portions. Importantly, 56 Endodontic practice

brushing creates lateral space and encourages a ProTaper Shaper to more readily advance toward the working length. These earlier teaching experiences helped me better appreciate that it takes more than a well-designed file to produce predictably successful shaping results. Let’s go back to my Middle East tour where I conducted 13 WaveOne workshops to 400 doctors who shaped 1,200 S-shaped canals. After the first and second workshops, it became apparent that I needed to produce teaching language that more effectively emphasized how to use a single WaveOne file. Borrowing from my ProTaper teaching experience, I identified three clinical guidelines that I noticed measurably helped dentists better perform the WaveOne singlefile technique. Brush: Emphasis is on brushing before the file first engages dentin and experiences torque. Brushing creates lateral space, enhances contact between the file and dentin, promotes disinfection in canals that exhibit an irregular cross-section, and enables the file to more readily advance along the glide path. Run: Brushing enables the file to run, advance, or progress apically along the glide path. Many new WaveOne users can be seen in workshops erroneously pecking, pumping, and pushing to encourage the Primary 25/08 WaveOne file to move toward length. Brushing on the outstroke creates lateral space, allowing the file to more passively advance along the glide path. Bites: The Primary 25/08 WaveOne file should work no more than in 3-4 mm bites along the overall length of a canal per pass. After 3-4 mm, or if the file ceases to readily move inward, remove the file, clean and inspect its cutting blades, then irrigate, recapitulate with a 10 file, and re-irrigate. In a single-file technique, recognize that considerable debris is generated when transitioning the canal from a confirmed glide path to a finished preparation resembling the dimensions of the 25/08 file. All instruments tend to bog down when debris builds up internally. Therefore, it is normal to require three to five passes over about 60-90 seconds to fully prepare virtually any canal that, first, has a confirmed glide path. Trying to push, or forcibly advance, the file through the glide path invites blocks, ledges, transportations, or broken instruments. Following a workshop, most colleagues recognize that much of the time expended performing endodontic treatment is not spent shaping canals, but rather identifying orifices and creating a smooth, reproducible glide path to the terminus of the canal. Certainly, mastering anything new requires practice. Keep it on your radar that perfect practice makes for perfect play! EP

Clifford J. Ruddle, DDS, FACD, FICD, is founder and director of Advanced Endodontics (www.endoruddle.com), an international educational source, in Santa Barbara, California. Additionally, he maintains teaching positions at various dental schools. Dr. Ruddle can be reached at info@endoruddle.com. Volume 5 Number 4

TDO IS COMMITTED TO EDUCATION We believe educators will determine the future of our specialty. TDO University gives your endodontic residents the edge they need to be their best. A state-of-the-art endodontic educational system, TDO University provides sophisticated educational tools that are easy to use. With TDO University you can perform complex clinical, management, and accreditation queries with a click of your mouse. TDO University’s EHR certified module is the perfect complement to axiUm Academic software™. TDO University is only a one-time fee of $1,000 plus annual technical support. Set your program apart. Raise the bar with TDO University. Call 858-248-7757, email sales@tdo4endo. com, or visit www.tdo4endo.com/TDOPostgrads. aspx for more information.

At TDO, we believe mentoring is the best way we can give back to the endodontic community. For a one-time fee of $50, postgraduate residents can join TDO Clinical, an online forum where they can see and participate in inspiring cases and join in discussions between top clinicians, educators, and residents from around the world.

This EHR Module is 2011 compliant and has been certified by an ONCÐATCB in accordance with the applicable certification criteria adopted by the Secretary of Health and Human Services. This certification does not represent an endorsement by the U.S. Department of Health and Human Services or guarantee the receipt of incentive payments.

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