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ARTICLES
CONGRESSES
Sinus Floor Elevation: an overview of current techniques
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Dr. Ines Zaguia, Dr. Sofien Ben Abdallah, Dr. Nader Tlili, Dr. Mohamed Tlili, Dr. Faten Ben Amor
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Dental News, Volume XXIV, Number III, 2017
12 Implant Dentistry
Sinus Floor Elevation: an overview of current techniques Dr. Ines Zaguia, Outcome Patients Department, University of Monastir, Anatomy Resident, Faculty of Dental Medecine of Monastir - Tunisia
Dr. Sofien Ben Abdallah, University of Monastir, Periodontology specialist, Faculty of Dental Medecine of Monastir - Tunisia
Dr. Nader Tlili, Outcome Patients Department, University of Monastir, Anatomy Resident, Faculty of Dental Medecine of Monastir - Tunisia
Dr. Mohamed Tlili, Outcome Patients Department, University of Monastir, Anatomy Resident, Faculty of Dental Medecine of Monastir - Tunisia
Dr. Faten Ben Amor, Outcome Patient›s Department, University of Monastir, Professor Head of Anatomy department and Outcome Patients Department, Faculty of Dental Medecine of Monastir - Tunisia faten.benamor@yahoo.fr
Abstract Consequently, to the resorption of the alveolar process following tooth loss, vertical bone height in the posterior maxillary region is often insufficient to receive an implant.
Introduction
Following dental extractions, the residual bone crest undergoes a complex resorption process.
The pneumatization of the maxillary sinus causes a resorption in the coronary direction. Besides, the post-extraction alveolar resorption evolves a resorption in the apical direction. So, implant placement in this region requires the use of surgical techniques to increase the sub-sinusal bone volume. 1, 10
Moreover, the loss of teeth may induce expansion of the maxillary sinus, which is probably caused by pneumatization the maxillary sinus (i.e. the positive air pressure created during breathing). Thus, implant-supported prosthetic rehabilitation requires the use of surgical techniques to increase the sub-sinusal bone volume. The surgical approach is done either by the lateral or by the crestal way. The filling of the sinuses can be done by autogenous bone, by allografts or by xenografts. In this article we will describe two clinical cases illustrating two different surgical techniques allowing to raise the sinus floor in order to gain vertical height of the edentulous crest. A 4/10 standard implant was placed following the sinus elevation in both cases. Each of the surgical techniques presents its precise indications and a well-defined protocol.
In the posterior maxillary region, the vertical bone height is often insufficient to receive an implant. Following dental extractions, the residual bone crest undergoes a complex resorption process.
For more than 30 years, sinus elevation has been the gold standard for increasing the vertical height of edentulous ridges in the posterior regions of the maxilla 2. The effectiveness and predictability of this procedure have been determined by numerous studies. The surgical approach may be performed either laterally or from the crest 3. Thus, the elevation of the sinus membrane allows the placement of a filling material which may be autogenous bone, allografts or xenografts. 3 The aim of this work is to describe different sinus floor elevation techniques based on clinical cases, emphasizing the anatomical considerations and the preoperative evaluations to be taken into consideration.
In both cases we can easily obtain satisfactory aesthetic and functional rendering.
Clinical Reports
Key words: Sinus lift, sinus anatomy, crestal approach, lateral approach, osteotomy.
Two surgical techniques are commonly used to treat bone defects in the posterior maxilla: 1. The lateral window approach. 2. The crestal approach.
Dental News, Volume XXIV, Number III, 2017
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14 Implant Dentistry A. PATIENT 1 Clinical examination • Patient’s History: Patient aged 25 years in good general condition consulted for an implantsupported prosthetic rehabilitation of the 26 extracted for some years. • Endobuccal examination: The alveolar crest showed a slight resorption in the vertical direction. It is covered by a well-healed mucosa with sufficient keratinized gingiva. (Figure 1.1) The mesiodistal space was reduced. • Radiological examination: revealed a reduced vertical height of the edentulous ridge, less than 6 mm. The maxillary sinus was free from pathological signs. Retro alveolar radiograph: confirms the observations found in the panoramic radiograph. Scanner: Coronal oblique section showed that the vertical height is reduced, less than 6mm. The vestibulo-lingual width is sufficient for a standard implant 4/10.
Fig 1.1
Fig 1.2
Fig 1.3
Therapeutic decision Sinus floor elevation using lateral approach with simultaneous single implant placement:
Figure 1.1: Clinical photograph taken prior to lateral approach sinus lift with simultaneous implant placement. Figure 1.2: A lateral bone window is prepared and lifted off. Figure 1.3: The sinus membrane has been carefully dissected and elevated and implants have been placed. Figure 1.4: Clinical photographs showing removed lateral sinus floor window and grafting material filled in the sinus cavity Figure 1.5: The flap is repositioned and sutured.
Surgical procedure: (figure 3) After infiltration of a local anesthetic, a supracrestal incision was made along the posterior maxillary edentulous ridge. It was complemented with two vertical release incisions anteriorly and posteriorly. A full-thickness flap with trapezoid base was reclined exposing the lateral wall of the maxilla.
Fig 1.4
A series of specially designed piezosurgery inserts and curettes were used to prepare the area for maxillary sinus grafting. The delimitation of the lateral window, first described by Tatum 4, was performed with a round piezosurgery insert 5. Drilling was only made through the bone, avoiding laceration of the sinus membrane. The osteotomy was done under constant irrigation for cooling at a speed of 800-1200 rpm. The maxillary sinus membrane was identified by bluish hue appearing through the thin bone. An oval shape is given to the lateral window to avoid sharp bone edges (Figure 1.2).
Dental News, Volume XXIV, Number III, 2017
Fig 1.5
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16 Implant Dentistry Fig 1.6
B
A
C
Figure 1.6: (a) Clinical photograph showing the healing of the site; (b) Clinical photograph of the definitive restauration; (c) Periapical radiograph of the final restauration
After the window has been carefully assessed, the lateral bone was gently removed as to prevent trauma to the membrane. At this stage, the bony flap remains bound to the membrane. Horn shaped flat smooth insert with dull edges was used for displacing sinus membrane from the floor of maxillary sinus and the lateral flap connected to the membrane. The sinus membrane was then carefully elevated from the sinus floor using the specially designed curettes. The curettes were used to detach the membrane from the anterior, inferior, and medial walls of the maxillary sinus cavity. The membrane was carefully elevated to be able to create a compartment for the grafting material. Further to the confirmation of an intact sinus membrane and sufficient superior displacement,
the implant site was prepared for a standard 4/10 implant (Figure 1.3). The sinus cavity was then grafted with bone substitute using 250–1000 m particles of Anorganic Bovine Cancellous Bone (DirectOss) mixed with saline. After sinus filling, the lateral window was sealed with a resorbable collagen membrane at 18 weeks (Figure 1.4). The flap was repositioned and sutured. (Figure 1.5) Postoperative medications consisting of 500mg Amoxicillin 2 times per day for 1 week and 500mg of Paracetamol 3 times per day for 5 days were prescribed for the patient. The patient was examined 2 weeks after the surgery for suture removal, and no complications were noted. The patient revealed slight discomfort and swelling after the surgery.
Fig 2.1
A
B
C Figure 2.1.: Radiographic examination: (a) Panoramic radiograph showing the resorption of the crest and the pneumatization of the maxillary sinus prior to sinus lift procedure; (b) Cone beam computed tomography scan measuring <8 mm of residual alveolar ridge height at the site of future implant placement.
Dental News, Volume XXIV, Number III, 2017
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18 Implant Dentistry Fig 2.2
Fig 2.3
Figure 2.2: Clinical photograph taken prior to crestal approach sinus lift and simultaneous implant placement.
Figure 2.3: initial drilling connected with the stopper of 2mm.
Fig 2.4
Fig 2.5
Figure 2.4: Injecting 0.3-mL saline solution after inserting the hydraulic lifter to elevate the maxillary sinus membrane before filling the hole with bone graft material using the bone carrier.
Figure 2.5: Standard standard 4/10 implant placement.
Fig 2.6
Fig 2.7
Figure 2.6: Second intervention and placement of the healing abutement.
Figure 2.7: Clinical photograph showing final restoration.
Dental News, Volume XXIV, Number III, 2017
20 Implant Dentistry B. PATIENT N°2 Clinical examination • Patient’s History: A 35-year-old patient, in good general condition, consulted for an implantsupported prosthetic rehabilitation of the 16 extracted in recent years. • Endobuccal examination: Absence of the 16 (Figure 2.2) • Radiographic examination: the vertical height of the ridge was reduced but the mesiodistal distance was sufficient. (Figure 2.1) Fig 3
Therapeutic decision: Sinus floor elevation using crestal Approach with simultaneous single Implant placement: Surgical procedure: (figure 4) In the following clinical case the crestal approach 7,8 using the CAS-kit (Crestal Approach Sinus using hydraulic pressure) was applied, according to the operating protocol defined by the manufacturer 10. Once the oral cavity was disinfected, local anesthesia was performed. A supra-crestal incision is made along the edentulous ridge. A flap of total thickness was elevated in the vestibular and slightly in the palatal so as to expose the entire width of the crest. The 2.0 mm diameter drill was used to drill up to 2.0 mm in the residual bone. For safe drilling, stops ranging from 2mm to 12mm were set up. The diameter of the drill was then increased gradually in function of the implant diameter which would be put in place later. For safe drilling, stops ranging from 2mm to 12mm were set up 10. A standard 4/10 mm implant was placed in this case. The blunt-ended depth gauge was used to measure the residual height of the bone beneath of the sinus floor and to check the elevation of the membrane after each drilling. It was connected to a stop to prevent the perforation of the Schneider membrane. The hydraulic lift was then inserted into the drilled site and 0.3 ml of saline were injected slowly with the 1.0 ml syringe to raise the maxillary sinus membrane. An aspiration and then a new injection were carried out gradually until complete detachment of the sinus membrane. Implant placement was performed at this stage (Figure 2.5). The filling material consisting of 250–1000 m particles of Anorganic Bovine Cancellous Bone (DirectOss) was carried by the Bone Carrier to the drilling site and condensed by the Bone Condenser 10, 11. Finally, the implant was placed and the site hermetically sealed.
Figure 3: Schematic illustrations showing lateral sinus floor elevation. 1. Delimitation of the lateral window using round piezo surgery insert; 2. Displacing sinus membrane using horn shaped flat smooth insert with dull edges and lifting off the lateral window; 3. Careful elevation of sinus membrane from using the specially designed curettes; 4. Implant placement then sinus filling with graft material; 5. Sealing of the lateral window and flap repositioning; 6. Bone formation around the implant after 1 year of healing.
Dental News, Volume XXIV, Number III, 2017
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1. Drill up to 2.0 mm in the residual bone using 2.0 mm diameter drill with a stop of 2 mm; 2-3. Gradually increasing the diameter of the forests; 4. Using the gauge to measure the residual height beneath of the sinus floor and to check the elevation of the membrane after each drilling; 5. Hydraulic lifting of the membrane; 6. Finalisation of the implant site drilling; 7. Carrying the filling material with the Bone Carrier; 8. Condensing the filling material with Bone Condenser; 9. Placing the implant and suturing the site.
Discussion A thorough knowledge of sinus anatomy is mandatory for successful sinus lift surgery. The maxillary sinuses are pyramidal cavities excavated in the maxillary bones. They are located laterally to the nasal cavity, above the maxillary teeth, below the orbits and
24 Implant Dentistry anterior to the infratemporal fossa (Fig. 5). 12 Maxillary sinus has four walls (upper, medial, postero-lateral and antero-lateral), a lower and a top edges. The upper wall corresponds to the floor of the orbit. It is traversed by the infra-orbital nerve. The medial wall is complex. It corresponds to the lateral wall of the nasal cavity. It includes the ostium of the maxillary sinus. It represents a communication between the maxillary sinus and the nasal cavity via the middle nasal meatus. The position of the maxillary ostium represents the upper limit of the sinus elevation. It must not be obstructed in any way to allow drainage of the secretions. The posterolateral wall is located opposite to the 3rd molar and the tuberosity of the maxilla by separating the sinus from the infra-temporal fossa. The anterolateral wall corresponds to the lateral surface of the maxillary bone. This is the first surgical approach to a lateral approach. The evaluation of the thickness of this wall is essential before the Fig 5
Figure 5: Anatomy of the maxillary sinus: 1. Maxillary Sinus; 2. Nasal Cavity; 3. Sinus membrane; 4. Orbital cavity; 5. First superior molar
realization of the lateral flap. The lower edge is narrow it corresponds to the sinus floor. It is formed by the alveolar process of the maxilla with projections corresponding to the dental alveoli. This is the crestal way first. The vertex corresponds to the zygomatic process of the maxillary bone. The vascularization of the maxillary is complex. The blood supply is assured by numerous arterioles from the sphenopalatine artery and an anastomosis between the posterior superior alveolar artery and the infraorbital artery, also known as alveolar antral artery. It guarantees the blood supply to the sinus membrane, to the periosteal tissues, and especially to the anterior lateral wall of the sinus. 12, 14 The sinus cavity can be smooth and regular or it can present bony septa that rise vertically in a random manner leading to the formation of more or less important partitions. They are present in 37% of patients 12, 14. The presence and location of septa influences the therapeutic approach. The maxillary sinuses are lined with a mucous membrane known as Schneiderâ&#x20AC;&#x2122;s membrane, which includes a ciliated cylindrical pseudostratified epithelium (respiratory epithelium). 12 This mucosa is fine, fragile and very adherent to the underlying bone. Its thickness varies between 0.3 and 0.8 mm 13. The pre-surgical assessment must be performed as part of a sinus filling. The panoramic radiograph provides a general view of maxillary and mandibular arches. Cone beam computed tomography (CBCT) provides high-quality images in three dimensions using low doses of irradiation compared with conventional computed tomography. It can reveal information about residual bone volume, thickness of the lateral bone wall, presence of septa or pre-existing sinus pathologies 12. It can also reveal a significant thickening of Sinus membrane. Mucosal thickening may indicate an inflammatory condition, which must be treated before any intervention. 13 Local contraindications to sinus lifting should be noted. These may include: - Maxillary sinus infections such as chronic sinusitis, or allergic rhinitis. - Maxillary sinus aspergillosis of odontogenic origin
Dental News, Volume XXIV, Number III, 2017
26 Implant Dentistry - Sinonasal polyposis. When the polyps are multiple, it may be associated with other conditions and cause bilateral nasal obstruction. - Smoking and alcohol are contraindications to this type of surgery such as any bone graft surgery. The sinus lifting is indicated by the impossibility of placing implants with a minimum length of 8-10 mm 12, 13 in the planned implant sites. The choice of the method is based on Jensenâ&#x20AC;&#x2122;s classification 16. Measuring the height of the residual alveolar bone may help the surgeon to determine the choice of surgical technique and the appropriate filling material. Although other factors, such as marginal bone width, local intra-sinus anatomy, number of teeth to be placed and surgical experience, may have an impact.
The approach remains rather empirical, depending on the satisfactory results usually obtained by the practitioner. The evaluation of the original bone at the recipient site influences the choice of the graft type. The smaller the remaining bone is the more autogenous bone is required to achieve a good graft quality 17. Each of the previously described techniques has its own indication. The lateral approach is mainly indicated for a vertical height of residual bone of less than 6 mm. A thorough clinical and, above all, radiological examination can be carried out to assess the thickness of the sinus membrane or the presence of sinus in relation to the surgical site. However, the successes obtained with the crestal approach are also satisfactory and make it possible to gain up to 3-5 mm of bone height. For the lateral approach, the delimitation of the lateral flap, first described by Tatum 4, is carried out with a tungsten carbide or diamond cutter mounted on a contra-angle 5. This technique is still used when the side wall is thick. However, in the case of a thin lateral wall, the risk of perforating the Schneiderian membrane is high. This is the reason why some opt for the use of a piezo surgery ball insert 6 . This osteotomy is done under constant irrigation. The lateral window, often rectangular or oval in shape, is outlined with a size of approximately 10 mm x20 mm. 1 However, the oval shape may avoid sharp bone edges. The separation of the bone flap is also completed by a flat piezo surgery insert with a diamond base. The bone window can either be infracted with the membrane or removed for replacement after the augmentation. 1 The transcrestal sinus floor elevation technique has some advantages over the lateral sinus floor elevation procedure, such as less trauma 10, shorter operation time and less postoperative morbidity. Moreover, the implants are commonly placed simultaneously with the transcrestal sinus floor elevation procedure. It is indicated when the residual height below the maxillary sinus is around 5-8 mm and a dental implant exceeding that height is to be installed. The technique is particularly suitable for single tooth gaps with sufficient bone width but can be used for multiple implants. 1
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28 Implant Dentistry There are two principally different techniques with regard to the perforation of the sinus floor preparation of the implant site starts according to the traditional drill protocol and is completed either with drills to the level of the sinus floor or by using an osteotome as part of the preparation. As the crestal approach is a ‘blind’ procedure 10, assessment of the condition of the membrane has to be performed through the osteotomy site. 1 After preparation of the site is complete, together with lifting of the sinus membrane, with or without additional bone material, the implant is installed. The long-term clinical outcome for the procedure is good (a 97.2% survival rate of the implants followed up to 6 years compared with 93.7% for the lateral window approach) and complications are few. The clinician should, however, bear in mind that for a predictable outcome, namely a flat sinus floor without bone septa, an intact Sinus membrane is essential and membrane elevation must be performed with great care.
Bibliography 1. Lundgren, Stefan,
and clinical outcomes.”
120.
Sinus floor elevation has become a technique of choice for the treatment of insufficient bone height in the posterior maxillary region. And there is a wide range of techniques available for maxillary sinus augmentation. The choice of technique will largely depend on the characteristics of the edentulous site, which will either allow or prevent placement of implants simultaneous to the augmentation procedure. Other therapeutic alternatives have been proposed such as short implants. These have proved to be effective in the short term, but there is a lack of studies on their longevity. So Although there are some contraindications to the procedure, there are almost no absolute contraindications. With experience, maxillary sinus floor elevation is a procedure that greatly benefits the patient, with a predictable outcome.
“Sinus
floor elevation procedures to en-
Periodontology 2000 73.1 (2017): 103-
2. Boyne PJ, James RA. Grafting of the maxillary sinus floor with autogenous marrow and bone. J Oral Surg 1980;38(8):613–6. 3. Kaufman E. Maxillary sinus elevation surgery: an overview. Journal of Esthetic and Restorative Dentistry. 2003 Sep 1;15(5):27283. 4. Tatum H Jr. Maxillary and sinus implant Clin North Am 1986 ; 30 (2): 207-29.
reconstructions.
Dent
5. Garg Arun K. Augmentation grafting of the maxillary sinus for placement of dental implants: Anatomy, physiology and procedures. Implant Dentistry 1999 ; 8 (1) : 36-45. 6. Vercelotti T, DE Paoli S, Nevins M. The
piezoelectric bony win-
dow osteotomy and sinus membrane elevation introduction of a new technique for simplification of the sinus augmentation procedure. Int
Periodontics Restorative Dent 2001; 21 (6) : 561-7.
J
7. Summers RB. The osteotome technique: Part 2 the ridge expansion osteotomy (R.E.O). Compend Contin Educ Dent 1994 ; 14 (4) : 422-35. 8. LI TF. Sinus
Conclusion
et al.
able implant placement and integration: techniques, biological aspects
floor elevation
its biological concept.
Com-
: 619-24.
:
a revised osteotome technique and
pend
Contin Educ Dent 2005 ; 26 (9)
9. Kaufmaun E. Maxillary sinus elevation surgery : Esthet Restor Dent 2003 ; 15 (5) : 272-83.
an overview.
J
10. Kim, Young-Kyun, Yong-Seok Cho, and Pil-Young Yun. “Assessment of dentists’ subjective satisfaction with a newly developed device for maxillary sinus membrane elevation by the crestal approach.” Journal of periodontal & implant science 43.6 (2013): 308-314. 11. Lundgren, Stefan,
et al.
“Sinus
floor elevation procedures to
enable implant placement and integration: techniques, biological aspects and clinical outcomes.”
103-120.
Periodontology 2000 73.1 (2017):
12. Stern A, Green J. Sinus lift rent techniques. Dental Clinics 31;56(1):219-33. 13. Seban A. Greffes 2008.
procedures: an overview of curof
North America. 2012 Jan
osseuses et implants.
Elsevier Health Sciences;
14. Van Den Bergh JP, TEN Bruggenkate CM., Disch FJ, Tuinzing DB. Anatomical aspects of sinus floor elevations. Clin Oral Implants Res 2000 ; 11 (3) : 256-65. 15. Pommer, Bernhard, et al. “Prevalence, location and morphology of maxillary sinus septa: systematic review and meta-analysis.” Journal of clinical periodontology 39.8 (2012): 769-773. 16. Jensen OT. The sinus bone graft. Quintessence books edit ; 1999: 52-67. 17. Zijderveld SA, Zerbo IR, Van Den Berg JF, Schulten EA, Ten Bruggenkate CM. Maxillary sinus floor augmentation using a betatricalcium phosphate alone compared to autogenous bone grafts. Int J. Oral Maxillofacial Implants 2005;20(3):432-40.
Dental News, Volume XXIV, Number III, 2017
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30 Endodontics
Rare occurrence of c‑shaped root canal configuration in mandibular first molar Dr Ahmed Abdulrahman Almalaq, Hail Dental Center, Hail City, Saudi Arabia. Dr_ahmed933@yahoo.com
Dr Saad Al‑Nazhan, Department of Restorative Dental Science, Division of Endodontics, College of Dentistry, King Saud University, Riyadh, Saudi Arabia
Abstract The occurrence of C-shaped root canal configuration in mandibular first molar is rare. The present case has an unusual C-shaped root canal configuration for both the appearances of the canal orifices and the configuration along the roots. Use of cone-beam computed tomography, rotary and hand instrumentation assisted with sonic and ultrasonic activation of irrigation solution is very important for effective management of this anomalous canal configuration. Modifications in the obturation techniques will ensure a three-dimensional fill of the canal system. Clinician should expect to encounter unusual features when performing endodontic treatment. Key words: Cone-beam computed tomography, C-shaped canal, mandibular first molar, root canal configuration, root canal treatment
Introduction
Republished from the Saudi Endodontic Journal Volume 7 / Issue 3 September - December 2017
The knowledge of root canal anatomy plays a major role on the influence of the outcome of endodontic treatment. A thorough biomechanical cleaning and shaping of the root canal system, followed by hermetic seal of entire root canal space should be achieved for successful treatment. However, unexpected complex canal anatomy presents clinical challenges and difficulties that might jeopardized the main goal of such therapy. 1 Therefore, clinician should recognize the variations in the root canal systems and its characteristic features in different races when performing endodontic treatment. The mandibular first molars erupt at the age of 6–7 years and apical closure is usually completed by 8–9 years. The completion of canal differentiation commences about 3–6 years after root completion. 2 Any disturbances in this differ-
Dental News, Volume XXIV, Number III, 2017
entiation can result in variations in canal anatomy. One such variation of the root canal system is the C-shaped canal configuration. 3 It is termed so because of the C-shaped cross-sectional anatomical configuration of the root and root canal. This condition was described for the first time in literature by Cooke and Cox. 4 C-shape root canal configuration in molars is an anatomical variation that make diagnosis and treatment more difficult. The occurrence of C-shaped root canal configuration is very rare in mandibular first molars. 5 Out of 125 samples of mandibular first molars from an Indian population; only one sample had C-shaped canal. Demirbuga et al., 6 reported an incidence of 0.85% of C-shaped canals in mandibular first molars of the Turkish population. The aim of this paper was to report a management of an unusual and rare case of C-shaped canal in mandibular first molar.
Case report A 48-year-old Saudi female was complaining from pain with cold and biting about 3 weeks ago on the right mandibular first molar (#46). She went to primary health care center where root canal treatment was initiated for the tooth then referred to Hail Dental Center, Hail, Saudi Arabia to continue the treatment. The patient is a hypothyroidism “controlled” and according to American Society of Anesthesiologists (ASA) classification, she is class ASA II. 7 The patient chief complaint was “I have pain with biting on lower right side.” Clinical examination revealed no extra or intraoral soft tissue abnormalities; the probing depth was within normal measures, and the affected tooth has responded to percussion test. Preoperative radiographs revealed widening of the periodontal ligament of the distal root [Figure 1a]. The case was diagnosed as previously initiated and symptomatic apical periodontitis.
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32 Endodontics The tooth was isolated with rubber dam, and after proper deroofing, the pulp chamber, a Cshaped canal configuration with 4 orifices was noticed [Figure 1b]. Working length was determined, and the radiograph shows two distal canals, distobuccal (DB) and distolingual (DL), were joined at apical third. The mesial canals, mesiobuccal (MB) and mesiolingual (ML) were separate. The MB canal with mesial shift in the working length file radiograph shows that the file looks outside the canal [Figure 1c] and with distal shift the file looks inside the canal. Paper point was placed to observe if there is bleeding due to perforation. No bleeding was observed. Apex locater (Root ZX II J. Morita, Tokyo, Japan) was used to check the working length of the MB canal. It gives reading at a level close to that of ML canal which indicates that the file is inside the canal, but there was catch at the middle third with file. The decision was taken to finish the root canal treatment except the MB canal which was kept for another visit for further investigations. All canals were cleaned and shaped using ProFile. 04 Files Rotary System (Dentsply, Maillefer, Ballaigues, Switzerland) up to size 45 for MB canal, 50 for ML and 55 for DB and DL canals. K-files passively introduced into the canal, and filing directed towards the isthmus areas to obtain better debridement in clinical practice. Sodium hypochlorite (5.25%) was used in a larger
quantity, alternately with passive ultrasonic activation (Irrisafe tips, Acteon, Merignac, France). This helped to remove tissues from the narrow canal isthmus. The master cone was checked, and obturation was completed with careful warm vertical compaction of gutta-percha (GP) and AH-Plus sealer (Dentsply Maillefer, Ballaigues, Switzerland). In the second visit, a decision was taken to view the area with cone-beam computed tomography (CBCT). GP was placed inside the MB canal before taking CBCT to evaluate the path of canal. The GP was cut, and the coronal access was filled with temporary filling then CBCT was taken. There was deviation toward the furcation in axial view which may suggest strip perforation also because the danger zone in C-shaped root canal configuration is very thin and could be easily perforated [Figure 2]. Final decision was taken to fill the whole MB canal with mineral trioxide aggregate (ProRoot MTA, Dentsply Tulsa Dental, Tulsa, OK, USA) to assure proper sealing of the MB canal [Figure 3]. Wet pellet was placed over MTA to provide better environment for MTA setting then temporary filling was placed. The patient was given another appointment to check MTA setting. The cotton pellet was removed, and the access cavity was sealed with temporary filling then the patient was referred for final restoration. The patient was asymptomatic on follow-up visit after 10 months, and periapical radiograph shows no abnormalities [Figure 4].
Fig 1
Figure 1: Preoperative radiograph (a). Access cavity showing the location of the orifices of the canals in C‑shaped (b). Working length radiograph “Notice file in mesiobuccal canal looks perforating the furcation area” (c) Dental News, Volume XXIV, Number III, 2017
26 Restorative Dentistry Discussion
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Numerous classifications were proposed to facilitate a better understanding of the root canal anatomy of C-shaped canals. The earliest classification was proposed by Manning 8 and Melton et al. 9 Various other classifications were then proposed. 10, 14 Melton et al., classification of C-shaped canals was based on their crosssectional shape. 9 It was modified by Fan et al., 11 into the following categories: • Category I (C1): The shape was an interrupted “C” with no separation or division • Category II (C2): The canal shape resembled a semicolon resulting from a discontinuation of the “C” outline • Category III (C3): Two or three separate canals (highest incidence) • Category IV (C4): Only one round or oval canal in that cross‑section • Category V (C5): No canal lumen could be observed (which is usually seen near the apex only). In present case report, the tooth does not belong to any of the previously mentioned classifications. It has 4 orifices, two separate mesial canals, and two joined distal canals. The incidence of C-shaped mandibular second molar in Saudi Arabian population was 10.6% where eight cases were classified as having Category III, with Subdivision I, II, and III. 10 According to the classification of Al-Fouzan, 10 the mesial root fall into Category III Subdivision III “C-shaped orifice that divided into two or more discrete and separate canals in the coronal third to the apex.” The distal root falls in Type II of Manning 8 classification “a Type 2 canal system has two canals that combine and exit as one at the apex.” In general, the majority of permanent mandibular first molars of Saudi population (57.76%) typically present with two well-defined roots, mesial and a distal root with two canals in each root. 15 Cshaped of mandibular first molar has not been reported in Saudi. The working length radiographs that were taken during negotiating the root-canal show the file in the furcation area as if it is perforating it. This confusion was reported by Melton et al. 9 and Chai and Thong. 16 The present case was checked with CBCT to role out root perforation. The CBCT provides comprehensive information about the root canal from different directions that could not be detected using conventional radiographs or clinical techniques. 17, 18 CBCT technology uses isotropic voxels, which are equal dimensions in all three planes of space, enabling accurate linear geometric and three-dimensional measurements of the data acquired. 19, 20 Sabala et al., 21 have stated that the rarer the aberration is, the greater the probability of C-shaped being bilateral. In this case, the contralateral mandibular first molar was different and did not show a C-shaped root canal configuration in CBCT [Figure 5].
Dental News, Volume XXIV, Number III, 2017
36 Endodontics Fig 2
Figure 2: Cone‑beam computed tomography “axial view” which shows deviation of the mesiobuccal canal toward the furcation which may suggest a strip perforation Fig 3
C-shaped canals are difficult to clean and fill due to high percentage of canal irregularities 8, 22 Therefore and to successfully treat a C-shaped canal, the canals should be located and negotiated carefully then the biomechanical debridement of the pulp tissue should be carried out. 23 Care should be taken during cleaning and shaping to avoid perforating the thinner lingual walls of Cshaped canals. The anticurvature filing technique proposed by Abou-Rass et al. have been recommended to avoid danger zones that are frequently present at ML walls. 24 In addition, using rotary instruments to clean the C-shaped canal system assisted by ultrasonic irrigation was recommended due to large area of canal space that is difficult to touch using endodontic instruments alone. 25, 26 This was followed in the present case. Filling of a C-shaped canal is another problem. Using a cold lateral condensation technique might leave unfilled spaces due to the various canal intricacies that jeopardized the outcome of the treatment. To assure good filling, the thermoplasticized GP technique may prove to be more beneficial. 27 The canals of the present case were carefully filled with warm vertical compaction of GP. Light force was used during compaction to avoid root fracture due to thin remaining dentin thickness as a result of canal instrumentation. 12, 28 The MB canal of the current case was filled with MTA to assure proper sealing of the canal.{Weine, 1998 #21}. The use of MTA to fill the root canals has been recommended in different complicated clinical cases because of its superior physiochemi-
Figure 3: Obturation radiographs showing the mesiobuccal canal “yellow arrow” at different angles (a and b). Clinical photo of the pulp chamber showing MTA filling the mesiobuccal canal orifice “yellow arrow” (c)
Fig 5
Fig 4
Figure 4: Follow‑up radiographs after 10 months of different angles showing no abnormalities (a and b) Dental News, Volume XXIV, Number III, 2017
Figure 5: Cone‑beam computed tomography “axial view” shows that the contralateral mandibular first molar with two mesial and one distal canals
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38 Endodontics cal and bioactive properties when compacted against dentin. 29,30
Conclusion This case report presents the uncommon C-shaped anatomy of mandibular first molar. Careful inspection of the tooth, the use of CBCT and the correct choice of cleaning, shaping and obturation techniques suitable for such case helps achieve good outcome.
References 1. de Pablo OV, Estevez R, Péix Sánchez M, Heilborn C, Cohenca N. Root anatomy and canal configuration of the permanent mandibular first molar: A systematic review. J Endod 2010;36:1919‑31. 2. Kottoor J, Velmurugan N, Sudha R, Hemamalathi S. Maxillary first molar with seven root canals diagnosed with cone‑beam computed tomography scanning: A case report. J Endod 2010;36:915‑21. 3. Rahimi S, Shahi S, Lotfi M, Zand V, Abdolrahimi M, Es’haghi R. Root canal configuration and the prevalence of C‑shaped canals in mandibular second molars in an Iranian population. J Oral Sci 2008;50:9‑13. 4. Cooke HG 3rd, Cox FL. C‑shaped canal configurations dibular molars. J Am Dent Assoc 1979;99:836‑9.
7.– 9. February Stand: 7E07
in man-
5. Reuben J, Velmurugan N, Kandaswamy D. The evaluation of root canal morphology of the mandibular first molar in an Indian population using spiral computed tomography scan: An in vitro study. J Endod 2008;34:212‑5. 6. Demirbuga S, Sekerci AE, Dinçer AN, Cayabatmaz M, Zorba YO. Use of cone‑beam computed tomography to evaluate root and canal morphology of mandibular first and second molars in Turkish individuals. Med Oral Patol Oral Cir Bucal 2013;18:e737‑44. 7. American Society of Anesthesiologists. ASA Physical Status Classification System. Available from: https://www.asahq.org/ resources/clinical‑information/asa‑physical‑status‑classification‑system. [Last accessed on 2016 Sep 14]. 8. Manning SA. Root canal anatomy of mandibular second molars. Part II. C‑shaped canals. Int Endod J 1990;23:40‑5. 9. Melton DC, Krell KV, Fuller MW. Anatomical and histological features of C‑shaped canals in mandibular second molars. J Endod 1991;17:384‑8. 10. Al‑Fouzan KS. C‑shaped root canals in mandibular second molars in a Saudi Arabian population. Int Endod J 2002;35:499‑504. 11. Fan B, Chen WX, Fan MW. Configuration of C‑shaped canals in mandibular molars in Chinese population. J Dent Res 2001;80:704. 12. Gao Y, Fan B, Cheung GS, Gutmann JL, Fan M. C‑shaped canal system in mandibular second molars part IV: 3‑D morphological analysis and transverse measurement. J Endod 2006;32:1062‑5.
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13. Min Y, Fan B, Cheung GS, Gutmann JL, Fan M. C‑shaped canal system in mandibular second molars part III: The morphology of the pulp chamber floor. J Endod 2006;32:1155‑9. 14. Fernandes M, de Ataide I, Wagle R. C‑shaped root canal configuration: A review of literature. J Conserv Dent 2014;17:312‑9. 15. Al-Nazhan S. Incidence of four canals in root‑canal‑treated mandibular first molars in a Saudi Arabian sub‑population. Int Endod J 1999;32:49‑52. 16. Chai WL, Thong YL. Cross‑sectional morphology and minimum canal wall widths in C‑shaped roots of mandibular molars. J Endod 2004;30:509‑12. 17. Cotton TP, Geisler TM, Holden DT, Schwartz SA, Schindler WG. Endodontic applications of cone‑beam volumetric tomography. J Endod 2007;33:1121‑32. 18. Patel S. New
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dimensions in endodontic imaging:
beam computed tomography. Int
Part 2. Cone Endod J 2009;42:463‑75.
19. Damstra J, Fourie Z, Huddleston Slater JJ, Ren Y. Accuracy of linear measurements from cone‑beam computed tomogra-
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phy‑derived surface models of different voxel sizes.
2010;137:16.e1‑6.
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20. Pinsky HM, Dyda S, Pinsky RW, Misch KA, Sarment DP. Accuracy of three‑dimensional measurements using cone‑beam CT. Dentomaxillofac Radiol 2006;35:410‑6. 21. Sabala CL, Benenati FW, Neas BR. Bilateral root or root dental school patient population. J Endod 1994;20:38‑42.
canal aberrations in a
22. Cheung GS, Yang J, Fan B. Morphometric study of the apical anatomy of C‑shaped root canal systems in mandibular second molars. Int Endod J 2007;40:239‑46. 23. Jin GC, Lee SJ, Roh BD. Anatomical study of C‑shaped canals in mandibular second molars by analysis of computed tomography. J Endod 2006;32:10‑3. 24. Abou‑Rass M, Frank AL, Glick DH. The anticurvature filing method to prepare the curved root canal. J Am Dent Assoc 1980;101:792‑4. 25. Weine FS. The C‑shaped mandibular second molar: Incidence and other considerations. Members of the Arizona Endodontic Association. J Endod 1998;24:372‑5. 26. Ruddle CJ. Endodontic disinfection: Tsunami irrigation. Saudi Endod J 2015;5:1‑12. 27. Schilder H. Filling 1967:723‑44.
root canals in three dimensions.
28. Walid N. The use of two pluggers canal. J Endod 2000;26:422‑4.
Dent Clin North Am
for the obturation of an uncommon
C‑shaped
29. Torabinejad M, Chivian N. Clinical applications of mineral trioxide aggregate. J Endod 1999;25:197‑205. 30. Kanfar M, Al‑Nazhan S. MTA root canal Case report. Saudi Endod J 2013;3:144‑7.
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42 Prosthodontics
A convincing duo: zirconium oxide and fluorapatite glass-ceramic Dr Torsten Seidenstricker, MSc Allaman/Switzerland
Dominique Vinci Petit-Lancy/Switzerland
In many ways, the symbiosis of different procedures and materials allows simplified and safe work. The individual advantages are intelligently combined.
This patient case demonstrates on the one hand how a monolithic zirconium oxide framework can ensure stability and function in a complex prosthetic restoration. On the other hand, the ceramic veneering of the vestibular surfaces gives the restoration natural light-optical properties. This contributed towards the very pleasing final results.
Starting situation A 60-year old patient came to the dental practice as an emergency case. In addition to esthetic and functional problems, there was also severe periodontal damage. The treatment began with an in-depth diagnosis and an informative consultation. First, the teeth 25, 26, 14, 16, 11 and 12 were extracted. Then, the periodontitis was targeted. Treatment of the periodontitis was successfully completed approximately 13 months later. Implants needed to be placed in the regions 11, 12, 14, 16, 25 and 26. The clinical situation meant that all teeth in the maxilla and some teeth in the mandible had to be restored.
Planning and temporization Before starting such an extensive prosthetic reconstruction, photo documentation of the oral Fig 1
Figure 1: The situation after the implants in the maxilla had healed. All-ceramic restorations were planned. Dental News, Volume XXIV, Number III, 2017
situation and the patientâ&#x20AC;&#x2122;s face is essential. Primarily, the photos help in assessing the axes and planes in terms of optimum esthetics and function. We work with a 3D design software (Digital Smile System, DSS). This tool enables us to simulate the possible results virtually. Another advantage of this software is that the photos can be used in the CAD software whilst the restoration is being produced. The teeth to be extracted were removed from the situation model and the remaining teeth were prepared using the information provided by the dentist. On this foundation, we designed a wax-up with the CAD software (3Shape) and then transferred it into wax. This was the basis for a matrix made from transparent silicone, which was sent to the practice. After the dental preparation was complete (implant placement, preparation, etc.), the matrix was ďŹ lled with an auto-polymerizing temporary composite (e.g. Telio C&B) and a temporary restoration was produced and then inserted into the mouth. The temporary restoration served as a dental prosthesis during the implant healing phase and it also allowed us to determine whether the Fig 2
Figure 2: Diagnosis according to photos in a design software
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44 Prosthodontics situation, which was planned in the laboratory, harmonized in a functional and esthetic manner in the patient’s mouth. The patient wore the adapted temporary restoration for approximately six months up to the osseointegration of the implants.
The production of the final dental restoration The implant abutments The wax-up was positioned on the master model and adapted based on the patient’s and dentist’s feedback. A double scan followed. We digitized both the model and the wax-up using the laboratory scanner. Subsequently, the implant abutments were produced via CAD/CAM. The implant abutments were milled from a new translucent zirconium oxide (IPS e. max® ZirFig 3
A
CAD). Before sintering, we stained the cervical areas of the frameworks. We used a liquid with a warm yellow tone for the infiltration. After sintering, the implant abutments were adhesively bonded to the titanium bases (TiBase, Straumann) with a luting composite (Multilink® Hybrid Abutment, shade HO), specifically designed for this indication. The self-curing composite provides excellent adhesion qualities. After adhesive bonding, the abutments could be integrated. Note: During the CAD design of the abutments, amongst other aspects, the parallelism of the surfaces was taken into consideration. The fit of the milled objects is very accurate; our experience has shown that an angle of 7° to 10° is ideal. Fig 4
B
Figure 3a, 3b: The master model with the gingival mask in the articulator
Figure 4: The upper wax-up in the planned final situation
Fig 5
A
Fig 6
B
Figure 5a, 5b: CAD construction of the abutments Fig 7
Figure 6: The CAD/CAM-fabricated abutments (hybrid abutments) are screwed onto the implants. A Figure 7a, 7b: The CAD framework construction after the buccal areas had been cut back. Dental News, Volume XXIV, Number III, 2017
B
46 Prosthodontics Figure 8a, 8b: Colouration of the zirconium oxide before sintering
Fig 8
A
B
Note: The adhesive bonding of the titanium base must be prepared very carefully in order to avoid errors or incorrect placement. Producing the framework The following restorations were planned for the final prosthetic restoration: 1. a bridge in the region 11 to 13, 2. a bridge in the region 14 to 16, 3. a crown on tooth 17, Figure 9: The zirconium oxide frameworks prepared for veneering in the buccal area
Fig 9
4. seven single crowns on the teeth 21 to 24 and 27 as well as in the region 25 and 26. We designed the tooth shape and the occlusal morphology in full anatomical contour in the CAD software. The buccal surfaces should be built-up in ceramic in order to achieve optimum esthetics. In preparation for this, the software performed a cutback. After the framework design, the individual elements were milled from zirconium oxide (IPS e.max ZirCAD). The material used has interesting mechanical properties which, amongst other qualities, guarantee the long-term stability of the restorations. The selected shade â&#x20AC;&#x153;LT sunâ&#x20AC;? offers a light chroma, which matches perfectly the envisaged A-shade restorations. After milling the frameworks, we corrected the morphology slightly and paid particular attention to the interdental areas. For top esthetic results, we infiltrated the frameworks with the special IPS e.max ZirCAD LT colouring liquids before sintering. In the incisal and occlusal areas, the chroma was increased and the translucency was adapted in the appropriate areas. As only the buccal surfaces are veneered in this case, the framework volume is relatively solid. We always carry out a slow sintering procedure (nine hours) in our laboratory with complex restorations, such as the reconstruction presented here. Subsequently, the surfaces of The ceramic materials (IPS e.max Ceram) for veneering the buccal areas:
Figure 10: The ceramic buildup in the anterior region (IPS e.max Ceram)
Fig 10
Cervical Transpa orange-pink with Special Incisal yellow 50 % & Transpa Neutral 50 % Power Dentin A2
Power Dentin A2 Power Incisal I for more brightness on the transition lines
Transpa blue 50 % and Opal Effect 1 50 %
Transpa orange-grey to create a contrast in the incisal area
Figure 11: Prepared for the second firing. Finely detailed adjustments in the shape and morphology
Fig 11
Transpa orange-grey with Special Incisal yellow on the incisal edges
Transpa neutral
Transpa clear 50 % and Opal Effect 1 50 %
Power Incisal 2
Dental News, Volume XXIV, Number III, 2017
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48 Prosthodontics Fig 12
A Figure 12a, 12b: The finished restorations. The vestibular areas were layered individually. In the occlusal and palatal areas, the framework was designed in full anatomi cal contour.
Fig 14
B Fig 13
Figure 14: The all-ceramic restorations look very natural and vital in the mouth.
Figure 13: Natural looking translucency with internal shade effects
the monolithic zirconium oxide parts were polished and special attention was paid to the occlusal areas. For polishing, we used polishing cones from Shofu or Anaxdent. These cones guarantee thorough polishing, so that the surface can subsequently be easily polished to a high lustre. We do not use silicone cones or discs as they leave residues on the surface, which makes the application of glazing materials difficult. The areas which are difficult to access during polishing are covered with a thin glaze layer. This was followed by a restoration try-in in the patient’s mouth. The dentist checked the occlusion and function.
advantage of the IPS e.max Ceram material is its excellent stability. The individual areas do not merge during the buildup of the ceramic veneer, so that the exact desired effects can be achieved. In order to achieve the correct shape, morphology and liveliness, a second firing was necessary. The restorations were then glazed and finished. We like to use the glaze material (IPS Ivocolor® fluo) in a creamy consistency.
Veneering
Conclusion
After conditioning of the framework parts to be veneered, a fluorescent liner (IPS e.max Ceram ZirLiner) was applied; this gave the restoration fluorescence from the depths in order to achieve light effects resembling that of the natural dentition. Non-fluorescent materials (e.g. pure zirconium oxide) appear dull and dark. Since the framework was already coloured, we opted for a clear liner. This additionally enhanced the light transmission and contributed to the adhesion of the ceramic veneer to the zirconium oxide. A classic ceramic veneering build-up was then carried out. We used a special indicator (SmileLine, Switzerland) to mix the ceramic powder in order to differentiate the individual materials better. The IPS e.max Ceram range includes Power materials, which provide an increased level of brightness, in particular for translucent framework materials. In this case, we decided to use the Power materials. A further great
In the design illustrated above, only the buccal surfaces of the otherwise monolithic zirconium framework are veneered. An esthetic and durably stable result is achieved with relatively minimal effort. The qualities of the materials are used to their full advantage. These include:
Dental News, Volume XXIV, Number III, 2017
• the excellent light-optical properties of IPS e.max Ceram, in this case especially the Power materials, • the high strength of zirconium oxide, • possibility of colouring the zirconium oxide (to achieve a warmer colour effect. White zirconium oxide is far too bright for this type of restoration. Reducing the degree of brightness would have been difficult in view of the low thickness of the veneering ceramic), • the low amount of ceramic material (this allows minimal controlled shrinkage and ensures easy handling).
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50 Endodontics
Root canal morphology of mandibular first molars in a North Indian subpopulation: An in vitro clearing study Dr. Osama Adeel Khan Sherwani, Department of Conservative Dentistry and Endodontics, ITS Dental College, India. oaksherwani@gmail.com
Ashok Kumar1
Rajendra Kumar Tewari1
Surendra Kumar Mishra1
Sartaj Tabassum2
Surendra Kumar Mishra1
1
Department of Conservative Dentistry and Endodontics, Dr. Z. A. Dental College, AMU 2
Department of Chemistry, Faculty of Sciences, AMU, Aligarh, Uttar Pradesh, India
Republished from the Saudi Endodontic Journal Volume 7 / Issue 3 September - December 2017
Abstract Introduction Limited information is available about the canal morphology of mandibular first molars in North Indian population. The purpose of this study was to evaluate the root canal morphology of North Indian mandibular first molars by clearing and staining technique. Materials and Methods A total of 863 mandibular first molars collected from various places in North India were subjected to canal staining and decalcification procedures. Access cavities were prepared, and pulp tissue dissolved with sodium hypochlorite. Indian ink was injected into the root canals aided by negative pressure applied at the root tips. The stained teeth were decalcified with 7% hydrochloric acid. Instead of ascending concentrations of alcohol, a nonalcohol‑based drying agent (anhydrous calcium chloride) was used to remove traces of acid and water from the specimens. The dried specimens were immersed in methyl salicylate to render them transparent. The following features were observed under operating microscope at ×6 magnification: (i) Number of root canals per tooth, (ii) number of root canals per root, (iii) root canal configuration in each root (Vertucci’s classification), and (iv) lateral canals, intercanal communications, and their location. Results Majority had two roots (85%) with three (61%) and four (30%) canals. Three roots were present in 15% of the specimens. Type IV (49%) and type I (48%) were the most common configurations in mesial and distal roots, respectively.
Dental News, Volume XXIV, Number III, 2017
Conclusion First molars with two roots and three canals are a common feature in North Indian patients. Both roots showed wide variations in canal anatomy with type IV and type I configurations predominating in mesial and distal roots, respectively. Key Words: Canal staining, decalcification, mandibular first molar, North Indian population, root canal morphology
Introduction Endodontic treatment is aimed at the removal of microorganisms and necrotic tissue from the root canal spaces. This requires thorough cleaning and shaping followed by three-dimensional obturation of the entire root canal system. A clinician can achieve proper disinfection only when he has appropriate knowledge about the canal morphology and the aberrancies associated with it. The study of root canal anatomy has anthropological significance.1 It is well accepted that genetics influences the root canal morphology with some features being more common in certain races while absent in others. The root and canal anatomy of mandibular first molars has been extensively studied with wide variations reported among different populations.2 This can be attributed not only to the racial divergence but also to the differences in study designs. Diaphonization or clearing is an established technique to study the internal anatomy of human teeth. It allows for three-dimensional evaluation of the intricacies of the root canal system.3, 7 However, the traditional clearing technique uses alcohol as a drying agent 8 which is time-con-
52 Endodontics suming requiring 5–10 days in achieving proper results. This makes the procedure lengthy, especially when the specimen number is large. In the current study, a nonalcohol-based drying agent (anhydrous calcium chloride [CaCl2]) was used in place of ascending concentrations of alcohol that made the procedure simple and yielded transparent specimens in a relatively short period of time.
suming requiring 5–10 days in achieving proper results. This makes the procedure lengthy, especially when the specimen number is large. In the current study, a nonalcohol-based drying agent (anhydrous calcium chloride [CaCl2]) was used in place of ascending concentrations of alcohol that made the procedure simple and yielded transparent specimens in a relatively short period of time.
Limited information is available regarding the canal morphology of mandibular first molars in North Indian population.[9,10] Hence, there was a need to study the peculiarities in the canal morphology of North Indian mandibular molars. Thus, the aim of the current study was to evaluate the root canal anatomy of two- and three-rooted mandibular first molars in North Indian subpopulation by clearing and staining technique.
Limited information is available regarding the canal morphology of mandibular first molars in North Indian population.9, 10 Hence, there was a need to study the peculiarities in the canal morphology of North Indian mandibular molars. Thus, the aim of the current study was to evaluate the root canal anatomy of two- and three-rooted mandibular first molars in North Indian subpopulation by clearing and staining technique.
Figure 1: Cleared roots with different canal configurations: (a) Type I,(b) Type II, (c) Type III, (d) Type IV, (e) Type V, (f) Type VI, (g) Type VIII,(h) Type 3‑2, (i) Type 4‑2‑3‑2, (j) Type 2‑3‑2‑1, (k) Type 4‑3‑1
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54 Endodontics Materials and methods The study was conducted in the Department of Conservative Dentistry and Endodontics, Dr. Z. A. Dental College, AMU, Aligarh, over a period of 9 months starting from February 2015 to October 2015. A total of 863 mandibular first molars were collected from different places in North India and stored in 4% sodium hypochlorite (Fischer Scientific, Mumbai, India) until collection was complete. It was ensured that the teeth belonged to indigenous North Indians. The age, gender, and cause of extraction were not recorded. Access opening was done, and the pulp tissues removed by immersing in 4% sodium hypochlorite (Fischer Scientific, Mumbai, India) for 1 h. The teeth were rinsed under running water and allowed to dry for 8–10 h. A 30-gauge endodontic irrigation needle (BU Kwang Medical Inc., Seoul, Korea) was used to inject Indian ink (Sigma-Aldrich, Mumbai, India) into the root canal system with the root apex attached to the central suction system. The injection and evacuation of the ink were repeated thrice at 1-min interval until all the ink exited through apical foramina. The ink was allowed to dry for 4–5 h. Green inlay wax (GC Corporation, Tokyo, Japan) was used to seal the access cavity to prevent or minimize ink dissolution during decalcification. The specimens were demineralized in 7% hydrochloric acid (Merck Limited, Mumbai, India) for 30–36 h. The acid was stirred after every 5–6 h. The point of optimal decalcification was confirmed by periodic radiographic assessment at 6 h interval and insertion of a needle in the crown portions. The teeth were washed in running water to remove acid residues and dried overnight at room temperature. The decalcified specimens were placed in methyl salicylate (Fischer Scientific, Mumbai, India) for 1 min and then subjected
Dental News, Volume XXIV, Number III, 2017
to dehydration in anhydrous CaCl2 (RFCL Limited, New Delhi, India) for 2 h. The dehydrated samples were then placed in methyl salicylate for 6–8 h to render them transparent. The samples were monitored every 3–4 h for transparency and were removed from the oil when they were considered cleared enough to obtain relevant information about their root canal morphology. The transparent specimens were examined under operating microscope (Seiler IQ, Chicago, IL, USA) at ×6 magnification for the following features: (i) Number of root canals per tooth, (ii) number of root canals per root (defined as highest number of canals visualized in one root of a transparent specimen), (iii) root canal configuration in each root, and (iv) lateral canals, intercanal communications, and their location. The canal configurations were classified according to Vertucci’s classification.4 All additional configurations were noted and categorized [Figure 1].
Results Tables 1 and 2 represent the root and canal morphologies of 863 specimens. Number of roots and root canals Two and three separate roots were found in 85% and 15% of the first molars, respectively. The third root was exclusively found on the lingual aspect of distal roots. The majority had three (61%) and four (30%) canals while the rest had two (1.5%) and five (7.5%) canals. Root canal configuration Most of the mesial roots had two canals (86%) with type IV (49%) and type II (24%) being the most common configuration. Nearly half of the distal (48%) and all the distolingual (100%) roots had one canal. Type I (48%) followed by type II (28%) and type IV (15%) was the most common configurations found in distal roots.
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56 Endodontics root canal anatomy was published in 1842 in the form of drawings of sectioned teeth.11 A wide variety of techniques have been employed in understanding the canal morphology including radiographic examination,12, 13 sectioning of roots,14, 15 staining and clearing techniques, 3, 8 computed tomography, 14 spiral computed tomography, 16 cone‑beam computed tomography (CBCT),[17] and micro‑computed tomography (micro‑CT). 18 Although contemporary studies have reported an increased use of three-dimensional imaging systems such as CT, CBCT, and micro-CT, 14, 18 canal staining and clearing has been the most commonly used technique evaluating the canal morphology. 2
Lateral canals and intercanal communications Lateral canals and intercanal communications were more common in mesial roots. In the mesial roots, intercanal communications were more common in cervical (14%) and middle thirds (12%). In the distal roots, cervical third (6%) had more intercanal communications compared to middle (3%) and apical thirds (4%). Lateral canals were more common in the apical third of mesial (6%) and distal roots (10%).
Discussion The root canal anatomy is a widely studied subject right from the 19th century. The first detailed and comprehensive description of the Dental News, Volume XXIV, Number III, 2017
These newer radiographic techniques help in proper visualizing the canal anatomy in an easy and noninvasive manner. Nevertheless, the staining technique has always stood the test of the times in providing valuable results. The traditional technique uses ascending concentrations of alcohol to remove acid and water from the specimens. 8 This step requires at least 24–36 h to achieve optimal drying of specimens. In our study, alcohol was replaced by anhydrous CaCl2 which is hygroscopic in nature and tends to absorb moisture. However, care must be exercised in preventing CaCl2 from coming in contact with the air as it rapidly absorbs water from the air. It must always be kept in an airtight container. It is worth mentioning that the specimens were immersed in methyl salicylate for 1 min before the dehydration step to prevent over-desiccation that may distort the original anatomy of the tooth and yield false results. The mandibular first molar frequently requires endodontic treatment with the success rate lower (81.48%) than that for other teeth (87.79%).19 This may be attributed to a high incidence of variations including additional canals,[10,20] the presence of isthumi, 18 C-shaped roots, 21 and separate distolingual roots. 22 Ethnicity plays an important role in determining the number of roots in mandibular molars with Mongoloid, Native American, Eskimo, and Chinese populations having a higher prevalence of three roots compared to others. 2 In the current study, the prevalence of three roots was found to be 15%, which was in agreement with some of the previously published
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58 Endodontics studies. 5, 23 However, it was higher than a similar study done in an Indian population. 9 This could be attributed to some extent to a large number of teeth included in this study. The majority of first molars had three (61%) and four (30%) canals. In the mesial roots, type IV (49%) and type II (24%) configurations were more commonly found. These findings were consistent with those of Gulabivala et al. in a Thai population 5 and Skidmore and Bjorndal in Caucasians. 24 Type III, type VI, and type VIII configurations were found in approximately 09%, 05%, and 07% of the specimens. Cleaning and shaping of type II and IV canals is relatively simple owing to their separate orifices and course up to the apical third or apical foramen. However, cases in which canals branch in middle and apical thirds (type III, type V, type VI, and type VII) require a more aggressive approach in terms of locating, negotiating, cleaning, and shaping of the entire root canal system. Such canal morphologies could probably be responsible for some of the unexplained treatment failures despite radiographically esthetic root canal obturation. Nearly half of the distal roots had type I (48%) followed by type II (28%) and type IV (15%) configurations. These findings were consistent with those of Al-Qudah and Awawdeh
in a Jordanian population 7 and Pattanshetti et al. in a Kuwaiti population. 25 Two canals were present in approximately 49% of the specimens; however, only 17% exited through separate apical foramina. The distal root is rounder than the mesial one which could partially account for the low percentage of two foramina found in distal roots. Intercanal communications were noted in 35% of mesial and 14% of the distal roots similar to the findings of Al-Qudah and Awawdeh 7 and Gulabivala et al. 5 The lateral canals were more frequently found in the apical thirds of both the roots. The lateral canals and intercanal communications harbor necrotic tissues and microbial products that must be effectively cleaned for the success of root canal therapy. However, it is not always possible to debride and fill these ramifications adequately. In such cases, irrigation plays an important role in the removal of microbes from the uninstrumented areas.26 Moreover, thermoplasticized gutta-percha can be used to seal such communications satisfactorily. 27
Conclusion Fifteen percent of the specimens had three roots which can be
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considered as a mongoloid trait. In the mesial and distal roots, type IV and type I configurations were more commonly found, respectively. The changes in the traditional clearing technique yielded better results in a relatively small period of time.
References 1. Walker RT. Root form and canal anatomy of mandibular second molars in a southChinese population. J Endod 1988;14:325‑9. 2. de Pablo OV, Estevez R, Péix Sánchez M, Heilborn C, Cohenca N. Root anatomy and canal configuration of the permanent mandibular first molar: A systematic review. J Endod 2010;36:1919‑31. 3. Weng XL, Yu SB, Zhao SL, Wang HG, Mu T, Tang RY, et al. Root canal morphology of permanent maxillary teeth in the Han nationality in Chinese Guanzhong area: A new modified root canal staining technique. J Endod 2009;35:651‑6. 4. Vertucci FJ. Root canal anatomy of the human permanent teeth. Oral Surg Oral Med Oral Pathol 1984;58:589‑99. 5. Gulabivala K, Opasanon A, Ng YL, Alavi A. Root and canal morphology of Thai mandibular molars. Int Endod J 2002;35:56‑62. 6. Sert S, Bayirli GS. Evaluation of the root canal configurations of the mandibular and maxillary permanent teeth by gender in the Turkish population. J Endod 2004;30:391‑8. 7. Al‑Qudah AA, Awawdeh LA. Root and canal morphology of mandibular first and second molar teeth in a Jordanian population. Int Endod J 2009;42:775‑84. 8. Robertson D, Leeb IJ, McKee M, Brewer E. A clearing technique for the study of root canal systems. J Endod 1980;6:421‑4. 9. Reuben J, Velmurugan N, Kandaswamy D. The evaluation of root canal morphology of the mandibular first molar in an Indian population using spiral computed tomography scan: An in vitro study. J Endod 2008;34:212‑5. 10. Kottoor J, Sudha R, Velmurugan N. Middle distal canal of the mandibular first molar: A case report and literature review. Int Endod J 2010;43:714‑22. 11. Carabelli G, von Lunkaszprie E. Anatomie des Mundes: Braumüller und Seidel; 1842. 12. Pineda F, Kuttler Y. Mesiodistal and buccolingual roentgenographic investigation of 7,275 root canals. Oral Surg Oral Med Oral Pathol 1972;33:101‑10. 13. Badanelli Marcano P, Martinez‑Berna A. Surgical preparation of root canals. Rev Esp Endodoncia 1983;1:61‑77. 14. Navarro LF, Luzi A, García AA, García AH. Third canal in the mesial root of permanent mandibular first molars: Review of the literature and presentation of 3 clinical reports and 2 in vitro studies. Med Oral Patol Oral Cir Bucal 2007;12:E605‑9. 15. Sperber GH, Moreau JL. Study of the number of roots and canals in Senegalese first permanent mandibular molars. Int Endod J 1998;31:117‑22. 16. Sachdeva GS, Ballal S, Gopikrishna V, Kandaswamy D. Endodontic management ern
of a mandibular second premolar with four roots and four root canals with the aid of spiral computed tomography:
A case report. J Endod 2008;34:104‑7. 17. Matherne RP, Angelopoulos C, Kulild JC, Tira D. Use of cone‑beam computed tomography to identify root canal systems in vitro. J Endod 2008;34:87‑9. 18. Gu L, Wei X, Ling J, Huang X. A microcomputed tomographic study of canal isthmuses in the mesial root of mandibular first molars in a Chinese population. J Endod 2009;35:353‑6. 19. Swartz DB, Skidmore AE, Griffin JA Jr. Twenty years of endodontic success and failure. J Endod 1983;9:198‑202. 20. Alenezi MA. Endodontic management of a permanent mandibular first molar with six canals. Saudi Endod J 2016;6:36‑9. 21. Zhang R, Wang H, Tian YY, Yu X, Hu T, Dummer PM. Use of cone‑beam computed tomography to evaluate root and canal morphology of mandibular molars in Chinese individuals. Int Endod J 2011;44:990‑9. 22. Vivekananda Pai AR, Jain R, Colaco AS. Detection and endodontic management of radix entomolaris: Report of case series. Saudi Endod J 2014;4:77‑82. 23. Chen YC, Lee YY, Pai SF, Yang SF. The morphologic characteristics of the distolingual roots of mandibular first molars in a Taiwanese population. J Endod 2009;35:643‑5. 24. Skidmore AE, Bjorndal AM. Root canal morphology of the human mandibular first molar. Oral Surg Oral Med Oral Pathol 1971;32:778‑84. 25. Pattanshetti N, Gaidhane M, Al Kandari AM. Root and canal morphology of the mesiobuccal and distal roots of permanent first molars in a Kuwait population – A clinical study. Int Endod J 2008;41:755‑62. 26. Gulabivala K, Patel B, Evans G, Ng YL. Effects of mechanical and chemical procedures on root canal surfaces. Endod Topics 2005;10:103‑22. 27. Walid N. The use of two pluggers for the obturation of an uncommon C‑shaped canal. J Endod 2000;26:422‑4.
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Dentsply Sirona is aware, that great results are a combination of the right tools and the right skills. This is why their new office includes brand new training facilities â&#x20AC;&#x201C; the goal is to equip dental professionals with everything they need: from the best available products to expert-led clinical education to support the use of these products and services to improve patient care and treatment outcomes.
Dentsply Sirona new facilities feature a large open plan showroom to showcase their equipment offering, and a CEREC suite to offer potential customers hands-on experience and existing users ongoing training. Dentsply Sirona Academy boasts a training centre which can accommodate twenty participants at any one time. It is fully equipped for both product presentations and hands-on trainings, in order to stimulate learning and improve customersâ&#x20AC;&#x2122; knowledge about Dentsply Sirona products and solutions. Dentsply Sirona opened their doors to visitors on the 12th July 2017 with a CEREC Discovery Evening, which educated dental professionals on the CEREC system and was supported by knowledge on the digitisation of dentistry, single-visit dentistry and integrated solutions for more efficient workflows. Dentsply Sirona looks forward to welcoming you to their new facilities and providing you with the products and skills for better, safer and faster dental care.
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LU 2017 64
Lebanese University Faculty of Dental Medicine 15th International Convention May 11 - 13, 2017
Lebanese University, Rafic Hariri Campus Hadath - Lebanon
Pr. Toni Zeinoun, Dean of the Faculty of Dentistry
Pr. Mohamed Rifai Chairman organizing committee
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Pr. Toni Zeinoun, Pr. Fouad Ayoub, MP Ali Bazzi handing the trophy to the president of the Lebanese University
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DeanNews, Essam Osman , Dean Nada Dental Volume XXIV, Number III, 2017
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Prof. Franck Diemer explaining about steps towards perfection in endodontics
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EXPODENTAL MEETING 2017 With a 20% increase over 2016 and 18.000 total visitors, Expodental Meeting proves to be a reflection of a more than ever vital sector Expodental Meeting 2017 confirmed and exceeded the success of the first edition in 2016: 281 exhibiting Companies and more than 18.000 visitors with an overall 20% increase compared to the 2016 statistics. The exhibition and the comprehensive cultural and scientific program â&#x20AC;&#x201C; more than 35 clinical and non-clinical events and workshops - has attracted a huge number of dental professionals and buyers, which resulted more business opportunities and returns for the Exhibitors. Expodental Meeting is the showcase of the Italian dental industry, which has confirmed its position in the forefront of international markets on the strength of products that are appreciated throughout the world for the reliability of their components, their avant-garde technological solutions and pleasing design. Expodental Meeting is growing together with the Italian dental sector, which has proved to be as vital as ever, with growing investments by Italian dental practices and dental techniciansâ&#x20AC;&#x2122; laboratories. Expodental Meeting represents the most important hub for the Italian dental world, even from a more political point of view: in fact, thanks to UNIDI, the Italian Dental Industries Association, the fair hosted a Conference organized and promoted by the Italian Ministry of Health, concerning sustainability and access to oral health prevention and treatment, especially during childhood. What really made the difference at this yearâ&#x20AC;&#x2122;s edition was the new pavilion called EXPO3D: an entire area totally dedicated to the digital workflow from dental practice to dental lab. Besides the display of materials, equipment and technologies used within the digital workflow, a comprehensive scientific program entirely focused on digital technologies took place, including events by dental associations and scientific lectures by academic experts. Expodental Meeting is becoming more and more international, thanks to the intense cooperation with ICE/ITA (Italian Trade Agency): more than 80 foreign delegates from 26 Countries and met the Italian Companies in 1.250 b2b meetings. Dental News, Volume XXIV, Number III, 2017
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ALLIANCE BETWEEN CLINICIAN AND PATIENTS, THE X-FACTOR FOR A SUCCESSFUL PREVENTION On June 15, in the amazing setting of Chia on the beautiful island of Sardegna, the Sardinian branch of the Italian Dental Association, Associazione Italiana Odontoiatri, inaugurated its 3rd international edition entitled Focus on Quality in Dental Practice. Moderating the opening ceremony that hosted many leading international representatives as well as top representatives from Italian institutions were FDI Speaker Gerhard Seeberger and AIO journalist Mauro Miserendino.
demonstrating the correlation between oral pathology and general health diseases.
Called on by Seeberger, president of the AIO, Fausto Fiorile, underlined that we know the cause of many of the most common pathologies found in the oral cavity and their consequences on the patients overall health. What we need to look at now are what preventive measures can be taken collectively to reduce or eradicate them. He went onto add that almost all preventive programs in Europe are not A prestigious panel made up of top international leaders in den- promoted by governments but by the private sector. tistry that included Patrick Hescot (President FDI World Dental Federation), Marco Landi (President Council of European Den- Three proposals were then made to the attending crowd of dental tists), Gary Roberts (President American Dental Association), professionals to create an effective international program in prevenPhillip Fijal (President Chicago Dental Society) and Fausto Fio- tion: rile (President AIO Italian Dental Association) discussed regional 1. Clinician training with continued updating. measures, programs and initiatives aimed at the prevention and 2. Clinician awareness of the importance of prevention for those prothe eventual elimination of many of the problems affecting the fessionals who are so immersed in treating patient problems that they oral cavity throughout the world today. tend to overlook itâ&#x20AC;&#x2122;s significance. 3. Vast campaigns of communication aimed at teaching the society about common oral pathology and how to prevent it. The general consensus of the leaders of the AIO, FDI, CED, ADA and the CDS, was that these programs must involve and have the collaboration of schools, governmental and non governmental institutions, dentists, auxiliary health professionals, family physicians, pediatricians, parents and of course the patients themselves. An effective program of prevention cannot be successful without the participation of all of them.
Enrico Lai, thanking who help most for this congress: Carlotta Casano (AIO Secretary) Mauro Miserendino ( AIO Press Office) and Giancarlo Couch (Translator of all documents and promotions) In an enthusiastic introduction Gerhard Seeberger appealed to dentists visiting from around the world to remind them of the enormous responsibility they have towards providing access to patient care. The current worldwide social-economic change unfortunately has created a barrier in access to care for many patients. The funds that many countries allocated in the past for prevention have been drastically reduced even in the light of increasing evidence Dental News, Volume XXIV, Number III, 2017
Patrick Hescot, president of the FDI, then went on to summarize the federations objectives in prevention and access to care and their projects and initiatives aimed at reaching these goals especially in underserved areas such as in the African continent. In Italy there have been many roundtable discussions on preventive programs. All agree that patient collaboration is essential and that poor lifestyles including alcohol abuse and smoking can never be allies in a program of prevention. On this theme Phil Fijal, CDS President, went on to elaborate that much like alcoholism that is prevalent throughout much of the western world, these problems must be attacked from the cause and not only the effects.
Opening ceremony with Gary Roberts ( president ADA), Phil Fijal (President Chicago Dental Society), Fausto Fiorile (President AIO), Marco Landi ( President CED) and Patrick Hescot ( President FDI) FDI President, Patrick Hescot reaffirmed the professional and social responsibility that dentists and physicians have in reinforcing a healthy patient lifestyle. AIO President Fausto Fiorile quickly added that often the dentist is one of the few healthcare professionals that regularly sees patients during the course of their lives placing him or her in a position to detect and prevent pathology as well as positively reinforcing good habits and lifestyles. This in turn establishes a rapport of patient loyalty and trust. He ended by stating that prevention must include alliances with other health professionals. CED President Marco Landi moved on to share a brief insight into a current debate going on within the European Union for and against corporate dentistry. He then pointed out that prevention programs throughout Europe today are not only aimed at European born citizens but also include a huge population who have immigrated to Europe over the last decades, many from third world countries and who often suffer from severe oral health problems. He his feelings regarding calls within the European Union for the elimination of the use of amalgam expressing that amalgam can be an excellent choice to use as an inexpensive and effective means of treating the underserved and most vulnerable members of the society. A huge result has already been attained raising the awareness of the European Commissioner regarding the importance of oral health and access to care. He then went on to state that European legislation must not go in the direction of imposing a rigid treatment protocol but instead must leave the independence of treatment choice in the hands of the dentist. Invited to the podium were then Giampiero Malagnino, vice president of Enpam, the Italian Dental and Medical Pension Administration, who in turned called on all to remember the ancient “Oath of Hippocrates” that refers to the upholding high professional ethical standards. Following him Giuseppe Renzo, national president of the Italian Dental Board, pointed out that prevention is a topic that unites the entire dental profession regardless of opinions or views, reminding the audience that in unity within the profession there is strength.
3 great names of the congress: Renato Cocconi, Giovanni Zucchelli and Marco Veneziani In a closing statement Fiorile expressed his sense of immense satisfaction success of the congress in Chia and for the atmosphere of great enthusiasm where multidisciplinary experts and high-level practitioners came from around the world to exchange knowledge, ideas and experiences in a such a spectacular location. He continued by saying that as a leader of dentistry in Italy AIO’s primary mission is to represent and protect the interests of the dental profession but nonetheless AIO will continue to give it’s full to support this congress that has become an important meeting and reference point for the international dental community. In the end a grand round of applause was given to Enrico Lai for his lead role in organizing such an important and successful international congress. Mark your calendar for the next appointment in Sardegna from June 13 - 15, 2019 for an all new edition of the international Dental Meeting in Sardinia, Focus on New Visions in Dentistry. See you there!
AIO SARDEGNA Fax: 0039 070 674561 Email: aiosardegna@aio.it
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MICRO-MEGA® is pleased to announce the launch of a cordless handheld endo device dedicated to the passive ultrasonic activation of the irrigating solutions in only a few sequences of 30 seconds. Due to complex anatomy (isthmuses, lateral canals), a proportion of the root canal surface remains untouched by hand or rotary instruments during the mechanical preparation. Additionally, instrumentation generates smear layer which coats the dentinal tubules’ openings. This means that the root canal’s surface and peripheral areas have not been properly cleaned or disinfected, increasing the probability of retreatment. Final rinse has then a dual key role: a flushing action to re-open tubules and complete debridement, as well as a chemical disinfectant effect.
EndoUltraTM is an endo handpiece which has been specifically designed for intracanal activation of the irrigant during the final rinse, prior to the filling of the root canal system. EndoUltraTM uses the ultrasonic technology at a preset frequency of 40kHz to disrupt biofilm, remove clogs in tubules, improve penetration of the irrigating solution and reduce bacteria level through sonochemistry. Advantages • A cordless activator without pre-settings for user convenience • A dedicated ultrasonic unit to enhance cleansing of difficult root canal anatomy • The essential contribution to the success of any endo procedure website: www.micro-mega.com
NEW PIEZOSURGERY® INSERTS FOR SINUS LIFT BY CRESTAL APPROACH Mectron introduces a new piezoelectric technique for sinus lift by crestal approach, launching on the market 3 new PIEZOSURGERY® inserts developed in collaboration with Professor Tomaso Vercellotti, Italy. Thanks to the new inserts shapes, the new Piezo-lift technique facilitates the sinus lift by crestal approach making the technique even safer, minimizing the risk of membrane perforation, guaranteeing a safe membrane detachment and fewer post-operative complications for the patient. This new protocol allows the membrane elevation by utilizing the cavitation effect (Piezo Lift) and the bone grafting into the sinus cavity , which is the least invasive technique for elevating the maxillary sinus floor prior to implant placement. Particularly: • the new PL1 insert allows the sinus floor reaching and a safe bony ring removal • the new PL2 insert permits to execute the sinus floor consumption and the initial membrane elevation • the new PL3 insert allows the removal of the sinus basal cortex and the elevation of the sinus membrane using the cavitation effect. Thanks to its shape, PL3 insert works like a piston inside a cylinder. Dental News, Volume XXIV, Number III, 2017
This safe and predictable technique (at times no longer blind) allows to overcome the limitations of current methodology that highly depend on the individual operator’s skill. The application of Piezo-Lift protocol allows treating even the most difficult cases, which present severe reduction of residual crest bone volume. The inserts will be available separately as well as in a Kit with all three inserts dedicated to sinus lift by crestal approach. website: www.mectron.com
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RooterTM S
Compact, Cordless Endodontic Motor FKG Dentaire SA presents its new RooterTM S endodontic motor. The outstanding feature of this new instrument is its ability to be used both on its own and in combination with the new apex locator from FKG, the S-ApexTM. Rooter S also has completely functions which guarantee greater safety for the user.
Convincing functions in practice With its modular capabilities, the new endodontic motor from FKG provides users with maximum possible flexibility during treatment. The elegant endodontic motor only weighs 103 grams and guarantees application without any signs of
fatigue. In addition, the angle piece can be turned through 290° to ensure optimum visibility in all quadrants. This is assisted above all in the molar sector by the extremely small head, which has an integrated electrode file. With speeds from 50 to 1,000 rpm, users have the choice of eleven different speed settings to suit their individual needs. The easy-to-read colour display shows all the relevant information and settings and can be turned through 180° for left-handed users. Acoustic signals further assist root canal preparation as the user does not have to keep looking at the instrument’s display.
The Rooter S and S-Apex combination Rooter S combines with S-Apex offers an additional safety function: “Auto Apical Slow Down” reduces the rotational speed automatically as soon as the file tip approaches the reference point. This means that the instrument can guarantee the highest possible safety for both user and patient because it prevents the critical point in the apical area from being exceeded. S-Apex carries out an exact length measurement during treatment so that the user can prepare the root canal safely. This is particularly important in order to prevent any later complications.
website: www.fkg.com
BioSonic® UC150
Ultrasonic Cleaning Systems BioSonic® Coltene’s new BioSonic® UC150 ultrasonic cleaner offers great quality you have come to expect from all BioSonic® products while paving the way for some of the latest technological enhancements in ultrasonic cleaning. The sleek, Swiss design of BioSonic® UC150 is –
and user selectable cycle time and temperature • Can be used as a countertop or recessed unit
Designed for EFFICIENCY • Data logging capability and download usage information
experience • Quick and easy draining with externally accessible drain
via USB • Heater function – Optional built-in controlled heating to aid cleaning process, saving time - feature can be separately activated via code • Degas function - Eliminate air pockets and easily prepare your solution for maximum effective cleaning Fits multiple cassettes at once
Designed for VERSATILITY • Offers customizable operation with multiple cleaning modes Dental News, Volume XXIV, Number III, 2017
Designed for CONVENIENCE • Quiet operation for a safe and comfortable working environment • Glove-friendly, multilingual touch screen for a seamless user
website: www.coltene.com
Aesthetics brought back to the essentials with Essentia and G-Premio Bond Selecting the appropriate bonding for a given indication and making sure to follow precisely the different procedure steps is not always easy. This is why GC developed G-Premio BOND - a one-bottle universal bonding compatible with all etching modes and which can be used not only for direct restorations, but also for repair cases & hypersensitivity treatment. The result is a universal bonding combining versatility & ease of use with an equally good performance in all situations. The high quality of adhesion we have achieved with G-Premio BOND is the result of years of research and development based on the experience gained with GC’s previous adhesives such as G-Bond and G ænial Bond. The performance of G-Premio BOND convinced the jury of the prestigious The Dental Advisor Award. The universal adhesive was awarded with the Editor›s Choice five stars rating. Following the bonding step, the Essentia composite system achieves top-notch results with only those seven shades. Developed over four years together with GC Europe’s Restorative Advisory Board, the product and its new approach to layering has now been proven over two years in clinical practice. The natural aging process of human teeth is the foundation for this innovative shade system: while younger teeth are whiter and more opaque, older teeth are more translucent and chromatic. This is where Essentia comes in with its unique combination of three dentin and two enamel shades. Depending on the combination chosen, young, adult or senior teeth can be easily replicated. Four modifiers ensure that even special cases are covered. website: www.gceurope.com
IPS Empress Direct Natural-looking restorations can now be created even more effortlessly IPS Empress Direct now features optimized handling characteristics that facilitate the contouring of the composite. IPS Empress Direct contains especially small filler particles whose surface characteristics facilitate the handling of the material in several ways. The material can be easily and evenly distributed with the Cavifil Injector. It can be effortlessly and precisely contoured to the desired shape due its exceptionally low stickiness. Excellent adaptation to the cavity walls results in clinical reliability.
popular basic enamel and dentin shades. It also contains the IPS Empress Direct Effect Trans Opal shade for creating special characteristics in anterior teeth in particular. The Trans Opal shade contains special micro-opal fillers that are capable of closely reproducing the subtle play of colour and light typically seen in the natural opalescence of teeth. Furthermore, the kit contains the translucent shade Trans 30, recommended for emphasizing special effects in the incisal edge. With IPS Empress Direct Opaque, the kit offers an opaque material if severe stains need to be covered first. Charts containing indication-related material recommendations complement the offering.
Esthetic design with method The new IPS Empress Direct System Kit provides dentists with all the essential materials required to produce esthetically demanding restorations. The System Kit comprises the most
website: www.ivoclarvivadent.com
Dental News, Volume XXIV, Number III, 2017
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