roots international No. 2, 2014
Cover
/ Editorial
/ Content
/ Passive micro-volume management of sodium hypochlorite in endodontic treatment
/ Instrument fracture removal revisited
/ BT-Race: Biological and conservative root canal instrumentation with the final restoration in mind
/ Managing coronal destruction A clinical case demonstrating the pre-endodontic reconstruction of a tooth
/ Root canal therapy setting your teeth on edge?
/ Diclofenac - dexamethasone or laser phototherapy? Part I
/ SIROLaser Factbook: Comprehensive information on diode lasers
/ Planmeca and the University of Turku found Nordic Institute of Dental Education
/ “Striving for perfection”— AAE holds 2014 Annual Session in Washington
/ International Events
/ Submission guidelines
/ Imprint
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[1] =>
Vol. 10 • Issue 2/2014
issn 2193-4673
roots
international magazine of
endodontology
2
2014
| CE article
Passive micro-volume
management of sodium hypochlorite
in endodontic treatment
| review
Instrument fracture removal revisited
| industry report
BT-Race: Biological and conservative
root canal instrumentation with the
final restoration in mind
[2] =>
Dental Tribune International
The World’s Largest News and
Educational Network in Dentistry
www.dental-tribune.com
[3] =>
editorial _ roots
I
Dear Reader,
_Mahatma Gandhi once said, “Live as if you were to die tomorrow; learn as if you were to live forever.” Learning, thus, is a never-ending process, more so in dentistry and particularly in endodontics.
In this present era, knowledge is just a click away; however, the authenticity of such information is not
always reliable. Literature plays a vital role in the shaping of a dentist into a concept-driven clinician.
Apart from textbooks and journals, various educational forums where knowledge and clinical skills
are shared without barriers contribute to the field of dentistry. One such online forum is Roots, which
has been passionately educating and motivating young general dentists and endodontists. It has
welcomed all those who have a passion for endodontics into its fold.
Dr Sekar Mahalaxmi
The majority of the advancements in endodontics are technology driven. Complete dependence on
gadgets, however, without application of basic concepts makes us technicians, not endodontists. These
tools can only be useful adjuncts to good theoretical knowledge and clinical skills. What better place
to obtain the best of both, the latest in technological advancements and the training to use them to
enhance your concept-driven clinical acumen, than dental meetings? Roots Summits have been held
in various parts of the world. The last one was held at Foz do Iguaçu in Brazil in 2012. This year’s Roots
Summit will be held in Asia for the first time, in Mahabalipuram, a peaceful beach town near the southern city of Chennai in India. The organising committee has been working tirelessly to make this summit a memorable one. An array of national and international speakers are working on presentations,
including the complexities of the root canal, the management of separated instruments, and regenerative endodontics, which are critical areas in today’s clinical scenario in endodontics. To add to this,
there are more than a dozen pre-summit workshops to choose from for those who wish to gain firsthand experience. This will be a golden opportunity for all dentists from Asian countries and from far to
meet in India to further enhance their knowledge and skills in a positive way. To learn more about the
technological advancements, there is no better place than the summit, where there will be a plethora
of dental companies showcasing the latest in the field of endodontics.
roots magazine has always been known for its superior quality, in its articles, illustrations and print.
This issue too covers topics that will offer insights on instrument retrieval, pre-endodontic restorations, conservative root canal instrumentation and phototherapy, among others.
I wish to sign off with an invitation to every reader and member of the Roots community to attend
Roots Summit 2014 and contribute to its success.
Yours faithfully,
Dr Sekar Mahalaxmi
Head of the Department of Conservative Dentistry and Endodontics
SRM University, College of Dentistry, Chennai, India
roots
2
I 03
_ 2014
[4] =>
I content _ roots
page 6
page 10
I editorial
I research
03
30
Dear Reader
| Dr Sekar Mahalaxmi
Diclofenac, dexamethasone or laser phototherapy? Part I
| Jan Tunér
I CE article
I industry news
06
34
Passive micro-volume management of
sodium hypochlorite in endodontic treatment
| Dr Les Kalman
SIROLaser Factbook: Comprehensive information on
diode lasers
| Sirona Dental
36
I review
10
page 20
Instrument fracture removal revisited
Planmeca and the University of Turku
found Nordic Institute of Dental Education
| Planmeca
| Drs Dominique Martin & Pierre Machtou
I events
I industry report
20
38
BT-Race: Biological and conservative root canal
instrumentation with the final restoration in mind
“Striving for perfection”— AAE holds 2014 Annual
Session in Washington
| AAE
| Drs Gilberto Debelian & Martin Trope
40
I case report
24
Managing coronal destruction
I about the publisher
41
42
| Dr Andreas Schult
International Events
| submission guidelines
| imprint
I feature
28
Root canal therapy setting your teeth on edge?
| Dr Peter Southerden
Cover image: first mandibular premolar anatomical variation
by Ronald Ordinola Zapata
page 24
04 I roots
2_ 2014
page 36
page 38
[5] =>
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• rtefact-free images with e cient Planmeca ARA™ algorithm
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CBCT + 3D model scan + 3D face photo
Find more info and your local dealer
www.planmeca.com
Planmeca Oy Asentajankatu 6, 00880 Helsinki, Finland. Tel. +358 20 7795 500, fax +358 20 7795 555, sales@planmeca.com
[6] =>
I CE article _ irrigation
Passive micro-volume management of sodium hypochlorite in
endodontic treatment
Author_ Dr Les Kalman, USA
roots
_ce credit
This article qualifies for CE credit. To take the CE quiz, log on to
www.dtstudyclub.com. Click on ‘CE articles’ and search for this
edition of the magazine. If you are not registered with the site,
you will be asked to do so before taking the quiz. You may also
access the quiz by using the QR code.
_Abstract
_Introduction
Endodontic treatment addresses the removal of
the tooth’s internal pulp and micro-organisms,1
primarily due to infection and necrosis. Once proper
diagnosis and prognosis has been established, the
patient has the option of maintaining the tooth’s
form and function while the vitality becomes lost.
Current endodontic treatment consists of utilizing
rotary files to remove the pulpal tissue and shape
the internal dentin chamber of the tooth. Chemicals,
in the form of gels and liquids, are then implemented
to disinfect the canal(s) and eliminate bacteria.2 The
chemicals are then dried and the canal space filled
with either gutta-percha or resin to create a hermetic seal.
The passive utilization and micro-volume management of sodium hypochlorite as an endodontic
irrigant has been illustrated with a laboratory demonstration and several clinical cases. By limiting the volume and pressure of sodium hypochlorite, the injurious effects can be minimized while still benefiting
from the ideal disinfecting characteristics. Further
studies are required to understand the behaviour
of fluids, especially sodium hypochlorite, within the
context of permeability, fluid mechanics and multiphase fluid flow through porous media.
The chemicals employed to clean and disinfect
the intracanal space are vast and include file lubricants such as Prolube (DENTSPLY) and irrigants such
as QMix (DENTSPLY). During clinical endodontics, the
canal is filled with a cocktail of chemicals, as file lubricants and irrigants become a mixture.
Fig. 1
Fig. 2
Fig. 1_DENTSPLY Vortex rotary file
with sodium hypochlorite.
Fig. 2_ DENTSPLY Profile rotary file
with dyed sodium hypochlorite.
06 I roots
2_ 2014
[7] =>
CE article _ irrigation
I
Fig. 3_Micro-volume delivery of
sodium hypochlorite with rotary file.
Fig. 4_Sodium hypochlorite in block
with rotary file.
Fig. 3
Fig. 4
Chlorhexidine gluconate (CHX) is an uncommonly
used irrigant3 with several desirable properties. It
provides antimicrobial activity against certain aerobic and anaerobic bacteria, exhibits no significant
changes in bacterial resistance in the oral microbial
environment and has no injurious effect to the skin or
mucosa4. In fact, CHX has a role as an oral rinse at the
0.12 per cent concentration.4
Allergy from NaOCl is rare but has been reported
and may result in severe pain, a burning sensation,
edema and transient paraesthesia.6
Sodium hypochlorite (NaOCl) still remains the
most commonly used chemical,2,3 due to its availability, cost and effectiveness.2,5 Sodium hypochlorite
is effective against broad-spectrum bacteria and has
the ability to dissolve both vital and necrotic tissue.6
However, this irrigant is equally damaging to the patient and has a history of injurious effects.5 Typically
the NaOCl is delivered into the canal space with a syringe dose of 2–10ml that is expelled under pressure.
The ability of NaOCl to escape either through poorly
sealed isolation or other means can cause serious
injury to the patient.5
Injury from NaOCl is well established in the literature3,5,6 and has been attributed to three main errors:
poor handling, injection beyond the apical foramen
and allergy.6 Poor handling injury can result in operator and/or patient injury to the eye and/or skin.6 Injection beyond the apical foramen can result in the
following:6
_immediate and severe pain,
_edema to adjacent tissue edema,
_edema to the lip, infraorbital region, and side of face,
_intense bleeding from within the canal space,
_skin and mucosa bleeding,
_intestinal bleeding,
_paraesthesia,
_secondary infection.
_Methodology
Although there is no universally accepted irrigation protocol regarding endodontic treatment,3 it is
the duty of the clinician to apply evidence-based dentistry within clinical parameters to provide their patients with the highest standard of care with minimal
morbidity. The use of NaOCl has numerous beneficial
factors that maximize treatment success; however,
it is the application of the liquid that can cause injury.
Micro-volume management of NaOCl has been
proposed. The concept is based on the premise that
endodontic instruments have irregular surfaces, crucial for dentinal preparation, and that liquids exhibit
surface tension characteristics.7 By placing an instrument into a suitable container, the NaOCl will be
carried within the surface texture of the instrument
(Figs. 1 & 2). As the operator inserts the instrument
into the canal (Fig. 3), the NaOCl is carried with it.
Upon instrument movement, the NaOCl is released
into the canal space (Fig. 4). Surface tension and permeability of porous media (dentin) will also increase
the ability of the liquid to percolate into the canal.7
This approach is radically different than current
philosophies, as the NaOCl is introduced into the
canal space in a micro-volume amount without any
pressure. The operator has control of the minimized
liquid while benefitting from its effectiveness.
The micro-volume management of sodium hypochlorite has been applied to numerous clinical cases.
Post-operative obturation radiographs of completed
clinical cases have been presented (Figs. 5–9).
roots
I 07
2
_ 2014
[8] =>
I CE article _ irrigation
Fig. 5
Fig. 6
Fig. 5_Radiograph of endodontic
treatment on tooth #47.
Fig. 6_Radiograph of endodontic
treatment on tooth #26.
Fig. 7_Radiograph of endodontic
treatment on tooth #16.
Fig. 8_Radiograph of endodontic
treatment on tooth #36.
Fig. 7
_Discussion
The canal system inside a tooth is very complex.
Although there is the presence of one or more canals,
there also exist numerous micro tunnels, ribbons and
sheets throughout the canal network.8 The canals are
also housed within a porous dentinal structure, for
which the permeability has been distinguished.9 Although the elimination of the pulp is a relatively predictable clinical procedure, the introduction of liquids
into this complex micro-network porous development further complicates matters. If the clinician introduces liquids, then the successful removal of those
liquids is key to clinical success. Concepts of multiphase fluid flow through porous media and capillaries,10 permeability of porous media11 and surface tension fluid mechanics7 must be recognized to validate
and further advance canal irrigation.
Micro-volume management of NaOCl has been
suggested as a delivery modality to maximize its bactericidal effects yet minimizing its injurious effects.
Fig. 8
08 I roots
2_ 2014
Surface tension fluid mechanics and permeability7,10,11
suggest that the NaOCl can be carried within the
surface irregularities of endodontic instrumentation
and deposited into the canal space and percolate
within the complex network of the canal. The passive
management of the irrigant in micro-volume would
greatly reduce complications due to poor handling.
CHX has been suggested as the larger volume, positive pressure irrigant that may be delivered into the
canal space. CHX has favourable antibacterial characteristics but minimal injurious effects, if mismanagement of the irrigant has occurred. If positive pressure delivery of CHX is required, the operator should
regulate the pressure and avoid the risk of injection
beyond the apex. The use of EDTA (ethylenediaminetetraacetic acid) could be employed after NaOCl, to
minimize the formation of precipitates.2
The application of micro-volume management of
NaOCl suggests that the canal space can be effectively
cleaned in a conservative manner. Application of this
principle has been applied to clinical cases with little
[9] =>
CE article _ irrigation
I
to no post-endodontic sensitivity. Obturation has
been completed with ThermaSeal and Thermafil
(DENTSPLY). Even though there is evidence of sealer
extrusion, the absence of post-operative symptoms
and pathology suggests adequate volume for sufficient disinfection.
Further laboratory studies are required to understand permeability, fluid mechanics and multiphase
fluid flow through porous media and their relation to
the micro-management of NaOCl. Additional clinical
investigations should be implemented to assess and
validate the efficiency and efficacy of micro-volume
management of sodium hypochlorite on endodontic
therapy.
Fig. 9
_Conclusions
Introduction of lubricants and irrigants into the
canal complex is crucial for endodontic success. The
action of fluids in the canal complex must be understood within the context of permeability, fluid mechanics and multiphase fluid flow through porous
media.
NaOCl has several advantages for its role as an
endodontic irrigant, but its use must be exercised
with caution in order to prevent injury. Application
of NaOCl as a passive, micro-volume liquid has been
illustrated.
Further consideration is required to validate the
theory. The potential to minimize morbidity while
maximizing clinical endodontic success seems promising for both clinician and patient._
_References
1. Dang E. Comparison of sodium hypochlorite and chlorhexidine
gluconate: quality of current evidence. The Journal of Young
Investigators: An Undergraduate, Peer-Reviewed Science
Journal 2008:23(1):1–9.
2. Basrani BR, Manek S, Rana SNS, Fillery E. and Manzur A.
Interaction between sodium hypochlorite and chlorhexidine
gluconate. J Endod 2007;33: 966–969.
3. Dutner J, Mines P, and Anderson A. Irrigation trends among
American Association of Endodontists members: a web-based
survey. J Endod: 2011: 1–4.
4. 3M ESPE: Peridex™ Chlorhexidine Gluconate (0.12%) Oral
Rinse Fact Sheet: 2009.
5. Clarkson RM, and Moule AJ. Sodium hypochlorite and its
use as an endodontic irrigant. Australian Dental Journal
1998;43:(4):250–6.
6. Hülsmann H. & Hahn W. Complications during root canal
irrigation-literature review and case reports. International
Endodontic Journal: 2000;33:186–193.
7. Trefethen L. Surface tension in fluid mechanics. Encyclopaedia Britannica. (12ed.) Wiley:Chicago,1969;1–7.
8. West JD, Roane JB and Goering AC. Cleaning & shaping of the
root canal system. In Cohen S. and Burns RC. Pathways of the
Pulp. (6th ed.) Mosby: St. Louis,1994;179–218.
9. Trowbridge HO. and Kim S. Pulp development, structure &
function. In Cohen S. and Burns RC. Pathways of the Pulp. (6th
ed.) Mosby:St. Louis,1994;296–336.
10. Templeton CC. and Rushing SS. Jr. Oil-water displacements in
microscopic capillaries. Journal of Petroleum Technology.
1956;8:(9):211–214.
11. Crotti MA. Motion of Fluids in Oil and Gas Reservoirs.
Mosby:New York,1978;8–14.
Fig. 9_Radiograph of endodontic
treatment on tooth #16.
_about the author
roots
Dr Les Kalman, B.Sc. (Hon), DDS, graduated from the
University of Western Ontario with a doctor of dental surgery
degree in 1999. He then completed a GPR at the London
Health Sciences Centre. He has been involved in general
dentistry within private practice since 2000. He has served
as the chief of dentistry at the Strathroy-Middlesex General
hospital. In 2011, he transitioned to full-time academics as
an assistant professor at the Schulich School of Medicine and
Dentistry. Kalman’s research focuses on clinical innovations,
including the Virtual Facebow app. Kalman is also the director of the Dental Outreach
Community Services (DOCS) program, which provides free dentistry within the community. Kalman has authored articles ranging from paediatric impression to immediate implant surgery in both Canadian and American journals. He has been a product
evaluator for several companies, including GC America and Clinician’s Choice.
Kalman is the co-owner of Research Driven, a company that deals with intellectual
property development. Kalman is a member of the American Society for Forensic
Odontology, International Team for Implantology, Academy of Osseointegration,
American Academy of Implant Dentistry and the International Congress of Oral
Implantology. He has been recognized as an Academic Associate Fellow (AAID)
and Diplomate (ICOI). In his spare time, Kalman enjoys photography as an accredited
MotoGP photojournalist. He can be contacted at lkalman@uwo.ca
roots
I 09
2
_ 2014
[10] =>
I review _ instrument fracture removal
Instrument fracture
removal revisited
Authors_ Drs Dominique Martin & Pierre Machtou, France
_Introduction
The fracture of a root canal instrument during
endodontic treatment is quite a common occurrence.
The estimated risk of instrument fracture is between
0.5 and 5per cent.1–6 It has been shown that the number of instrument fractures has notably increased
with the growing use of rotary instruments made of
nickel titanium (NiTi).2,4
Fig. 1
Fig. 1_The Endo Rescue Kit (Komet).
10 I roots
2_ 2014
Procedures to remove instrument fragments have
been used for many years, but the introduction of operatory microscopes to clinical practice has led to a
completely new approach. The possibility of actually
seeing the instrument allows a far more effective procedure, which is further helped by the development of
instruments specially designed for this purpose. These
techniques are now well documented, and studies
evaluating the possibilities of removing instrument
fragments have shown encouraging results.7–10 The
most common technique entails preparing straightline access to the coronal part of the fragment using
Gates Glidden drills, creating a staging platform with
a modified Gates Glidden drill, and then using thin
ultrasonic tips to retrieve the fragment from the canal
walls through ultrasonic vibration.11
Although this technique is very effective, it has
some disadvantages:
_It requires great skill from the operator, since the
procedure is done under high magnification. In addition, it is difficult to trough around the fragment
without touching it. Especially in the case of an NiTi
broken instrument, the fragment may fracture during the course of treatment if the ultrasonic tip
contacts the instrument too early or if not enough
space is available around it.12
_Often, too much radicular dentine structure is removed, which is likely to weaken the root.13
_In order to improve visual control, the treatment
is carried out without irrigation, potentially leading
to an increase in temperature of the periodontal
tissue.14, 15 Work therefore must be interrupted regularly to control heating and provide cooling.
_The procedure is fairly time consuming. The estimated time required for the treatment was shown to
be between 40 and 55 minutes.16
An alternative method is to remove the fragment
with the micro-tube technique. Several variations
of this technique have been described, including
the Masserann Micro Kit (MICRO-MEGA),17 the IRS
(DENTSPLY Maillefer),18 and a micro-tube coupled
with a Hedstroem file.9 The use of tubes and cyanoacrylate glue (Cancellier Kit, SybronEndo) or composite self-curing resin19 are other methods to retrieve the fragment.
The present technique is a combination of the
trephine drill technique using a new device, the Endo
Rescue Kit (Komet Dental), and the micro-tube technique using dedicated needles and composite selfcuring resin. The main goal of this technique is to be
the least destructive as possible for the tooth structure. The aim of the present study was to assess the
success rate of this micro-endodontic removal technique and compare the results with those of published studies.
[11] =>
review _ instrument fracture removal
I
Fig. 2
Fig. 3
_Materials and methods
This clinical endodontic study
was conducted in a specialist endodontic practice by one operator. The
inclusion criterion was a fractured instrument located in a tooth referred
for endodontic retreatment. The case
was either specifically referred for instrument removal or a fracture occurred during endodontic treatment
in the operator’s practice. The exclusion criterion related to the possibility
of safely accessing the fragment. When it
was not possible to create straight-line access to the coronal part of the fragment or when
such access would have been too destructive to the
tooth structure, the case was excluded from the study
and removal of the fragment not attempted. All cases
were treated according to the same procedure using
the Endo Rescue Kit following the Masserann’s basic
approach, which involves removal of dentine around
the fragment with trephine drills. However, this new
kit differs from the Masserann Micro Kit.20 The first instrument is a special centring drill featuring a concave
active surface (Fig. 1) whose diameter matches precisely the size of the corresponding trephine (Fig. 2).
The centring drill prepares the site for the subsequent
use of the trephine. Three trephine sizes are available.
The smallest trephine has an external diameter of
0.7mm (corresponding to a #2 Gates Glidden drill), the
size of the next one is 0.9mm (corresponding to a
#3 Gates Glidden drill) and the last one is 1.1mm (corresponding to a #4 Gates Glidden drill).
The following steps were followed in a strict sequence:
1. Similar to the currently used techniques, straightline access to the coronal portion of the fractured
instrument has to be created. The goal of this step is
to visualise the fractured instrument under the op-
Fig. 4
erating microscope. A cylindro-conical
bur with a non-cutting tip (Komet
Dental) was used to refine the access
cavity walls, followed by the use of a
short #4 Gates Glidden drill (Komet
Dental) to relocate the canal orifice
away from the furcation. Direct access to the fragment was then created
with a #2, 3 or 4 Gates Glidden drill, depending on the diameter of the coronal part of the
fragment and its location within the canal.
2. The centring drill, whose external diameter
matches precisely the size of the previously used
Gates Glidden drill, removes dentine around the
fragment. Its concave active surface, when coming into contact with the fragment, allowed good
centring of the preparation around the coronal
part of the fragment.
Fig. 2_Centring drill.
Fig. 3_Trephine.
Teeth
n
Removed
Not removed
Success (%)
Incisors
1
1
0
100
Upper premolar
6
6
0
100
Lower premolar
0
0
0
0
Upper molar buccal root
8
7
3
70
Upper molar palatal root
1
1
0
100
Lower molar mesial root
13
11
4
73
Lower molar distal root
3
3
0
100
3. The corresponding trephine was placed in the area
previously prepared with the centring drill to free
the fragment by removing the surrounding dentine. The trephine was used in a handpiece at a low
speed (300rpm) in an anti-clockwise rotation or by
hand (Figs. 1 & 3).
4. When the fragment could not be removed with the
trephine alone, the Endo Rescue Kit was used in
combination with a needle filled with a self-curing
composite. A needle (Ultradent) with the same external diameter as the trephine was filled with a selfcuring composite core material and placed on to the
free portion of the fragment. Once the composite
had set, the needle was removed with an anti-clockwise motion (Fig. 2). A radiograph was taken to confirm that the instrument had been successfully removed. Complete removal of the fragment without
creating a perforation was defined as a success.
The distribution of fractured instruments among
different root types (i.e. anterior teeth, premolars,
buccal roots of maxillary molars, mesial roots of
mandibular molars, distal roots of mandibular molars,
and palatal roots of maxillary molars) was recorded,
as well as the anatomical location of the fractured instruments (i.e. coronal part of the fragment in the
coronal third, middle third or apical third).
Table 1_Success rate depending on
the type of tooth.
Fig. 4_Different sizes of centring
drill and trephine: the smallest has
an external diameter of 0.7mm
(corresponding to a #2 Gates Glidden
drill), the size of the next one is
0.9mm (corresponding to a #3 Gates
Glidden drill) and the last one is
1.1mm (corresponding to a #4 Gates
Glidden drill).
roots
I 11
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_ 2014
[12] =>
I review _ instrument fracture removal
Position
n
Removed
Not removed
Success (%)
Coronal third
5
5
0
100
Middle third
18
16
2
89
Apical third
8
8
5
61
Table 2_Success rate depending on
the level of the fragment.
Type of tooth and root
There were 24 instrument fragments found in 21
molar teeth (75% of the sample). There were six premolars with six fragments (accounting for 21.4% of
the teeth) and one incisor with one fragment (accounting for 3.6% of the teeth).
_Results
The two failures occurred in a mesial root of a molar, one in a mesial root of a mandibular molar and one
in a mesiobuccal root of a maxillary molar (Table 2).
Success or failure rate
Case 1: Fragment removal with the
ø 90 Endo Rescue Kit.
Fig. 5a_Pre-operative X-ray of tooth
#26 showing a fractured instrument
located in the middle part of a MB
curved root canal.
Fig. 5b_Trephine size 90
surrounding the fragment.
Figs. 5c–d_Fragment locked
inside the trephine and removed
from the canal.
Fig. 5e_Final X-ray.
According to the inclusion criterion, 36 fragments
were recorded within the 18-month period, involving
32 teeth in 30 patients. Five instruments were excluded because straight-line access to the fragment
was deemed impossible. Therefore, no attempt was
made to use the described technique. Thus, the technique was used for 31 instruments, 29 of which were
removed successfully. Of those, 19 were removed with
the trephine alone and ten with a needle filled with
composite resin (Table 1). This resulted in a success rate
of 93.5%. Two instruments (6.5%) further fractured
on attempted removal, leaving the most apical part in
the canal. No perforation of the root walls was noted.
Fig. 5a
Fig. 5c
12 I roots
2_ 2014
Location of fragments in root canal
It is important to note that it was the location of
the coronal part of the fragment that was recorded.
All instruments that had fractured in the coronal
third (n = 5) were removed from the root canal. All
removal failures (n = 2) occurred in situations in
which only the head of the fragment was visible but
the main portion of the fragment was located beyond a sharp curvature. In these two cases, the instrument fractured again, leaving the most apical
part in the canal.
Fig. 5b
Fig. 5d
Fig. 5e
[13] =>
review _ instrument fracture removal
Fig. 6a
Fig. 6b
Fig. 6c
Fig. 6d
_Discussion
Decision-making
Success rate
The general principle for removing a fractured instrument is based on the fundamental principles and
objectives of root canal treatment. A fractured instrument may be an obstacle to mechanical and
chemical treatment of an infected root canal system.
Bacteria and pulp tissue remaining in the root canal
because of insufficient cleaning may have a negative
impact on the treatment outcome.21 Moreover, the
prognosis is likely to depend on the stage and degree
of canal preparation and disinfection at the time of
instrument fracture and, therefore, on the extent to
which microbial control has been achieved.1, 2 The risk
factors associated with the presence of a fragment
are not clear. Recently, a systematic review and metaanalysis were performed to determine the outcome
difference between retained fractured instrument
cases and matched conventionally treated cases. Two
case–control studies were identified, covering 199
cases. The risk difference of the combined data indicated that a retained fragment did not significantly
influence healing.22 The presence or absence of a preoperative periradicular disease has been reported to
be the main predictive factor for outcome in such
cases.2,23 The risk–benefit ratio of the two therapeutic
options, that is, either leaving the fragmentin situ and
completing the treatment by filling the accessible
parts of the canal, or trying to remove the fragment
so that the entire canal can be treated, should be carefully assessed for each case.
The present study is a prospective evaluation of
cases referred to a specialist practice and treated
under a dental operating microscope. The success rate
of removal of the fractured instruments with the
described technique was 93.5%.
A variety of different techniques and devices
for removal of fractured instruments have been described in the endodontic literature.15 The majority of
these publications involve descriptions of techniques
and case reports. To date, there have been only two
detailed investigations on the influence of different
factors regarding success or failure of removal attempts using micro-endodontic techniques and a
dental operating microscope. In these two studies, the
success rate for the removal of fractured instruments
was reported to be 87%9 and 95%,10 respectively. In
Suter’s study, various techniques were used to remove
the fragments. In Cujé’s study, the same procedure
was applied using ultrasonic files in all cases. The loss
of dentine was not mentioned in either study. In the
present study, taking into account the cases for which
no attempt at removal was made, the overall success
rate was 80.5% and compared favourably with
Suter’s study. For the 31 cases treated, the success rate
was similar to Cujé’s study. In the current protocol, the
focus was on the preservation of the tooth structure.
I
Case 2: Fragment removal with the
ø 70 Endo Rescue Kit trephine.
Fig. 6a_Pre-operative X-ray of tooth
#25, featuring a long and narrow root
with a very thin fragment fractured at
the junction between the middle and
the apical third of the root.
Fig. 6b_Trephine size 70 surrounding
the fragment.
Fig. 6c_The fragment is removed
with the trephine, shaping and filling
are achieved.
Fig. 6d_Final X-ray showing a
minimally invasive procedure.
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[14] =>
I review _ instrument fracture removal
NiTi fractured instruments
Fig. 7a
Fig. 7b
Fig. 7c
Fig. 7d
Case 3: Fragment removal with
a needle and composite resin.
Fig. 7a_Pre-operative X-ray of tooth
#16. A fractured instrument is
located in the middle part of the
MB2 canal.
Figs. 7b & c_Relocation of the canal
orifice and centring of the preparation
after the pointer drill use.
Fig. 7d_The coronal portion of the
fragment is freed after the work of
the trephine.
The fracture of rotary NiTi instruments is characterised by certain distinctive features. The first characteristic is that, owing to the rotary movement of
the instrument and penetration of the flutes into
the walls, the fragment is most frequently blocked
in the dentine.23 The second characteristic of these
fractures is related to the instrument design. Most
rotary NiTi instruments have a taper greater than
2%. Owing to this increased taper, the coronal part
of the fragment is likely to be blocked in the canal,
whereas the apical portion remains free. This particular feature of NiTi instruments complicates the primary procedure of removing the fragment, which
normally entails passing an endodontic hand instrument between the fragment and the canal walls,
and guiding it along the fragment to regain patency
of the canal. In this case, a more invasive solution is
required. This involves straightening the coronal
curve to gain access to the fragment at the expense
of the dentinal walls. Such techniques are still very
controversial.
Instrument removal itself represents a risk and
the decision to remove, or not to remove, a fragment
is a difficult one. Depending on the technique used,
perforation of the root, ledge formation and transportation of the original canal may occur, as well as
weakening of the affected root in case of excessive
removal of dentine13 or fracture of an additional instrument.8,9,23–25 Therefore, when no lesion is present,
current knowledge leads us not to attempt a risky procedure to remove the fragment. In this study, five
fragments were deeply fractured and not accessible
with straight-line access. According to the previous
rationale, no attempt was made to remove these fragments, since no apical lesion was present (Fig. 4). Two
of these fragments were bypassed and the endodontic treatment completed.
A frequent counter-argument is the fact that
the root canal is weakened by the removal of dentine
during the procedure.26,27 This loss of tissue reduces
the fracture resistance of the root13,28,29 and may lead
to complications, such as inadvertent perforation of
the root.8 Ideally, the dentine should be preserved as
much as possible and the extent of the root canal
preparation after the removal of the fragment should
not exceed that of a conventional preparation. The
tested technique is intended to overcome this limitation. Although the use of the Endo Rescue Kit involves
the removal of an additional amount of dentine, the
small diameter of the instruments keeps the damage
to the root structure to a minimum, while creating
access to the fragment.
Figs. 7e–h_The needle technique
with composite resin inside the lumen
is used to remove the fragment.
Figs. 7i_Final view of the
completed case.
Fig. 7e
14 I roots
2_ 2014
Fig. 7f
Fig. 7g
[15] =>
review _ instrument fracture removal
Fig. 7h
Fig. 7i
As with all the techniques described, the decisive
factor for success was to gain direct access to the
fragment. Given that the fragment is usually located
beyond the curve of the canal, it is essential to
straighten the coronal curve in order to create direct
access to the fragment and ensure an unobstructed
view of it through the operative microscope. It is
equally necessary to expose at least 1.5mm of the
fragment with a trephine in order to be able to catch
the fragment with a needle filled with composite
resin. A dilemma exists in such situations because
it has not been clearly shown that a retained fragment has any impact on the prognosis,2 but there
is some evidence that removing tooth structure
weakens the tooth. It must be carefully evaluated
and critically analysed to determine whether a removal attempt is necessary or indicated in each clinical case.23 In this study, after the preparation of the
coronal access and when no periapical lesion was
present, it was decided not to attempt to remove the
fragment, as it was not visible under the operating
microscope.
Access to the fragment
I
AD
Biological &
Conservative
FKG Dentaire SA
www.fkg.ch
[16] =>
I review _ instrument fracture removal
Fig. 8a
Fig. 8b
Case 4: No removal attempt.
Figs. 8a & b_Fragment located
apically beyond the canal curvature
of tooth # 26 without radiographic
signs.
The second step was to prepare a staging platform around the fragment. By investigating different
techniques for preparation of a staging platform,
Iqbal et al. found it was increasingly difficult to prepare a platform with a centred fragment owing to the
increasing distance between the fractured instrument and the maximum curvature of the root canal.4
The modified Gates Glidden drill described in Ruddle’s
technique is a helpful instrument for preparing the
staging platform but it does not allow centring of
the fragment.
The design of the centring drill in the Endo Rescue
Kit follows the same concept but was modified to
have a tapered concave active portion. The outer
blades cut into the dentine surrounding the fragment,
and the concave tapered area that encounters the
coronal part of the fragment allows centring of the
preparation by advancing the drill apically. This can be
carried out by removing a minimum amount of dentine according to the size of the drill, while working in
the centre of the canal (Fig. 8).
The micro-tube technique
The first device to use micro-tubes was the
Masserann Micro Kit. This well-known kit is designed
to remove all metallic objects from the root canal and
consists of a variety of trephines of different sizes and
an extractor to grasp the fragment and remove it.17
The extraction method is easier to use than the ultrasonic technique, but it has some disadvantages as
well. The trephines are too large compared with the
size of the fragments that are usually found in the
root canal. The smallest available diameter is 1.1mm,
whereas the diameter of the extractor is 1.2mm, which
means that it has to be used with a trephine of the
same diameter. Depending on the position of the fragment in the root, a large quantity of dentine might
have to be removed, which is likely to weaken the root.
16 I roots
2_ 2014
Some improvement to the Masserann’s extractor
was made with the introduction of the IRS. However,
in the described technique,18 access to the fragment
was accomplished with ultrasonic tips. The use of
ultrasonic tips to disengage the fragment results in
an over-enlarged access compared with the size of
the IRS extractor. This reduces the interest to use
smaller extractors, which are fragile and may deform.
Compared with the Masserann Micro Kit, the
Endo Rescue Kit has a number of special features.
The first feature is a centring drill with the same diameter as the trephine. Owing to its active concave
tip, the outer blades trough around the fragment,
and allow centring of the preparation. The second
feature is the miniaturisation of the trephines. Three
trephines are available: the smallest trephine has
an external diameter of 0.7mm (internal diameter
of 0.4mm), the size of the next one is 0.9 mm (internal diameter of 0.5mm), and the last one is 1.1mm
(internal diameter of 0.7mm). Compared with the
Masserann’s trephines, the sizes are considerably
smaller. The largest size trephine drill in the Endo
Rescue Kit corresponds to the smallest size in the
Masserann Micro Kit. The trephines are designed to
be used with an anti-clockwise motion in order to
have an unscrewing effect on the fragment. This feature is particularly useful for NiTi rotary fragments,
which are usually screwed into the dentine. When
the fragment is short (less than 3mm), it is often
pulled out of the canal with the trephine drill. In this
instance, it is trapped by the dentinal chips inside the
lumen of the trephine. When the fragment is longer
than 3mm or when the tip is located beyond the curvature, the action of the trephine should be stopped
before grinding the fragment with the active part
of the trephine. The direction of rotation must be
considered too, depending on the type of fractured
instrument. Rotary instruments used for obturation,
such as Lentulo spirals or McSpadden compactors,
[17] =>
P R O F E S S I O N A L
M E D I C A L
C O U T U R E
EXPERIENCE OUR ENTIRE COLLECTION ONLINE
WWW.CROIXTURE.COM
[18] =>
I review _ instrument fracture removal
Fig. 8c
Fig. 8d
Fig. 8c_Cleaning, shaping and filling
of the root canal system.
Fig. 8d_One year recall: tooth is
symptomless.
or shaping instruments that work in a reciprocating
motion, should be disengaged with a clockwise motion because their helix angle is reversed.
The micro-tube coupled with the Hedstroem file
technique9 is another way to create an extractor that
is more adaptable to the clinical situation using different size tubes and files.
Using tubes and glue is also advocated to grasp
the fragment with cyanoacrylate glue (Cancellier
Kit) or composite self-curing resin.19 Needles of different diameters may be used to match the size of
the broken instrument. This can only occur if the
coronal part of the fragment has been freed from
the dentinal walls. This technique is predictable but
three problems have been reported. The first is that,
to ensure that the cavity is clean and dry, the cavity
must be rinsed with pure alcohol and be perfectly
dry before using the needle filled with composite
resin. The second is that the operator must ensure
that the needle is filled with resin in order to surround the fragment. The third is that the operator
must ensure that the resin does not overflow from
the needle and remains inside the root canal. These
problems can be easily overcome however. The composite resin was injected into the needle. The hub of
the needle was then plugged with wax until the resin
emerged from the tip. The tip was wiped with gauze
to ensure that there was no resin on the outer walls
of the needle. In this way, the resin can surround the
fragment without any overflow. In the study, this
technique was performed using a needle of the
same diameter as the trephine for 12 of the 29 fragments. Ten of the 12 fragments were removed without leaving any composite resin to potentially block
the root canal. Two failures occurred because the
fragments were further fractured, leaving the most
apical part in the canal and the coronal part embedded in the resin.
18 I roots
2_ 2014
_Conclusion
Several techniques for removing fractured instruments have been described. Any procedure for
removing fractured instruments should seek to avoid
damage to the root structure, and should be predictable. The removal technique investigated in the
present study, based on the use of a micro-tube and
preparation of a staging platform by means of new
centring drills, was shown to be effective for the removal of fractured instruments. Although no technique can claim to be universal, the technique described in the study proposes a removal solution well
suited to fractured NiTi rotary instruments and offers
an alternative to the ultrasonic tips technique. Like
any endodontic technique, the Endo Rescue Kit is a
technique-sensitive approach and requires clinical
experience to be used successfully. However, this
preliminary study reported few cases and therefore
further studies must be conducted to corroborate
these results. The location of the instrument within
the root canal, the angle of curvature of the affected
root and the location of the broken instrument in relation to the root curvature appear to be decisive factors for the outcome of the removal technique._
Editorial note: A complete list of references is available
from the publisher.
_contact
Dr Dominique Martin
21 rue Fabre d’Églantine
75012 Paris
France
endomartin@wanadoo.fr
roots
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[20] =>
I industry report _ instrumentation
BT-Race: Biological and conservative
root canal instrumentation with the
final restoration in mind
Authors_ Dr Gilberto Debelian, Norway, & Dr Martin Trope, USA
Fig. 1_Median canal diameters.
Fig. 1
_Intra-canal microbes are the cause of endodontic disease.1–3 The removal of microbes from the root
canal system during treatment and the prevention of
microbes entering the canals determines whether
treatment will be successful.4,5
Root canal instrumentation is one of the major
tools with which to ensure the long-term success of
root canal therapy.6,7 The aim is to mechanically disrupt as much biofilm as possible so that, with the
addition of irrigants and/or intra-canal medicaments,
a very low microbial count can consistently be achieved
before root canal filling. Furthermore, the aim of root
canal instrumentation is to achieve the microbial reduction goals mentioned above without unnecessarily weakening the root by over-instrumentation, that
is, the reduction of the dentinal wall thickness. Preservation of native tooth structure, especially in the cervical region of the tooth, has been demonstrated to
correspond to better long-term survivability from a
loading and restorative standpoint. It is well established that the root decreases in its resistance to fracture as the remaining dentine thickness decreases.8
_What is the ideal root canal
instrumentation size?
The file alone does not remove the maximum
amount of biofilm but works in synergy with irrigation. What then is the ideal instrumentation size to
achieve the desired goal of biofilm elimination? In
order to answer this question, we need to analyse
anatomical studies, and evaluate whether and how it
is possible to remove biofilm from these canals.
Fig. 2_Benefits of BT-Race files.
Patented new screwing-in design
Triangular cross section
Electro-polished
Fig. 2
20 I roots
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[21] =>
industry report _ instrumentation
A review of anatomical studies demonstrates
striking consistency regarding instrumentation size.
Figure 1 summarises the anatomical aims for a
mandibular molar. Consider the mesiobuccal and
mesiolingual canals at the 1mm measurement from
the apical foramen, which corresponds most closely
to the dentinocemental junction. In the mesiodistal
direction, the diameters are 0.21mm and 0.28mm,
respectively. Thus, finishing at a #25 file would appear
to be sufficient when viewed on a periapical radiograph, since the mesiodistal direction is what we see
on the radiograph. However, if we look in the buccolingual direction, the correct sizes are between #35
and #40 files. For the distal canal, a #35 file would appear adequate on the radiograph (mesiodistal view)
but the correct size would be a #50 file. Thus, if we
want to clean in three dimensions, we need to instrument in the buccolingual dimension also.
I
BT tip
0.35 mm
0.15 mm
Normal tip
0.35 mm
_The BT-Race system, biological and
conservative
BT-Race files (FKG Dentaire; Fig. 2) are sterilised
in individual blisters so that sterility is ensured for
every file. The biological sizes mentioned above can be
achieved every time with three files once a glide path
has been achieved. The system is designed such that
these sizes can be attained with minimal removal of
coronal dentine to maintain the strength of the root.
The files have a non-screw-in design and triangular
cross-section to increase flexibility and cutting efficiency, and are electropolished to decrease the effects
of torsional and cyclic fatigue.
Fig. 3_Localisation of the cutting
point in the BT and normal tips.
The Booster Tip (BT) is the key feature of these files
and allows them to follow curvatures in canals without undue stress on the file or the root. The tip starts
as a non-cutting tip from the 0.0–0.15mm file diameter, and the cutting edges start from the 0.15mm
file diameter and upwards. This allows these files to
follow a canal safely, even one with a very narrow diameter. Thus, the BT2 file (Figs. 3 & 4a–c), for example,
which is a non-tapered file with a cutting size of
0.35mm, can still easily advance into the canal prepared by the glide path file, which is 0.15mm in diameter.
ISO 35
ISO 15
Fig. 4a
Figs. 4a–c_Efficiency of the normal
tip and the BT in the canal (a & b).
Path of the tip with guide (c).
ISO 35
BT tip
Adequate biological sizes with minimal taper with
the least number of files will ensure the ideal shape.
Thus, in order to achieve the aims stated above, that
is, maximal biofilm disruption with minimal weakening of the root, we should aim for apical sizes 35, 40
or 50 with no more than a 0.04 taper.9–11 These biological sizes with an adequate irrigation protocol will
ensure a consistently low microbial count for maximal success.
Booster Tip
BT tip
_What is the ideal shape of an
instrumented canal?
Fig. 3
Normal tip
Furthermore, if we look at the measurements at
2 and 5mm from the end of the root, it is apparent
that a 0.04 taper is all that is needed to contact the
walls in these areas further from the apex if we do, in
fact, instrument to the apical sizes required (a #35 or
40 file mesially and a #50 file distally). Using tapers
larger than 0.04 is not required to remove microbes
and unnecessarily weakens the root. Anatomical
studies on all roots follow this basic biological rule,
that is, size 35 or 40 for the smaller canals and size 50
for the larger canals.9–11
ISO 15
Fig. 4b
Fig. 4c
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I 21
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_ 2014
[22] =>
I industry report _ instrumentation
Fig. 5_BT-Race sequence.
BT 1 – 10/0.06
Scouting
BT 2 – 35/0.00
Apical
BT 3 – 35/0.04
Shaping
Fig. 5
The BT allows a file of any diameter to follow the
shape of a canal that has been prepared with a #15
glide path stainless-steel file. However, the sequence
of three files (Fig. 5) is designed to relieve undue stress
on the root and files, while instrumenting the canal to
the correct biological sizes.
cyclic fatigue is also reduced. Thus, by using a high
speed and limiting file use to one patient, we can limit
the risk of file breakage.
_BT-Race sequence
BT1 (a 10.06 file)
_Essential aspects for the successful
application of the BT-Race sequence
1. Glide path
In order to guarantee minimal file breakage, a 15.02
glide path is essential. Hand files can usually achieve
this aim. However, if a #6 or #10 file is extremely difficult to take to working length, then ScoutRace files
allow one to achieve a glide path more quickly.
This file establishes the final glide path and determines the coronal diameter. In any canal in which a
15.02 glide path has been achieved, the file will contact mainly the coronal third of the canal. At 12mm
from the working length, the diameter will be 0.82mm.
These files have no BT, since the tip diameter is already
0.10mm and smaller than the glide path established
with a 15.02 K-file.
BT2 (a parallel #35 file with a BT)
2. Speed of 800–1,000 rpm
A high speed reduces the risk of breakage due to
torsional fatigue. Since these files are for use with individual patients only, the risk of breakage due to
Fig. 6_BT-Race XL for finishes at
sizes 40 and 50.
BT 40 – 40/0.04
BT 50 – 50/0.04
Fig. 6
22 I roots
2_ 2014
The BT2 file is used to prepare the apical third of
the canal. The file is extremely flexible owing to its
non-tapered design, yet penetrates into the narrow
canal easily and efficiently owing to the BT.
[23] =>
industry report _ instrumentation
BT Race
BT Race
Biological treatment with Booster tip
Biological treatment with Booster tip
Symptomatic
Pulpitis
36
MB and ML: BT3
D: BT4
Obturation:
Total Fill BC sealer
Fig. 7
Courtesy: Dr. Johan Ulstad, Norway
Symptomatic
Pulpitis
MB and ML: BT3
D: BT4
Fig. 8
Courtesy: Dr. Gilberto Debelian, Norway
BT Race
Biological treatment with Booster tip
Biological treatment with Booster tip
MB1 and MB2: BT3
DB: BT4
P: BT5
Courtesy: Dr. Gilberto Debelian, Norway
Obturation:
Total Fill BC sealer
Fig. 9
BT3 (a 35.04 file with a BT)
This file is used to join the coronal and apical thirds
prepared with the BT1 and BT2 files, thus creating a
35.04 final shape that allows maximal irrigation and
a tight cone fit. The file is able to go to working length
with minimal stress, since the coronal third has been
cleared with the BT1 file and the apical third with the
BT2 file.
Importantly, the maximum diameter at the 12mm
level in the canal is 0.83mm. Thus, the removal of
coronal dentine is minimal, allowing for the strongest
root possible after restoration.
BT-Race XL: BT 40 (a 40.04 file) and BT 50 (a 50.04 file),
600–800rpm
These two instruments (Fig. 6) enable finishes at
ISO #40 and 50 when larger adequate apical sizes are
required. If apical preparations even larger than size
50 are required, the Race range of instruments is
recommended in the required sizes, preferably with a
small taper of 0.02.
_Conclusion
With this unique file system, all canals can be conservatively instrumented to the correct biological
sizes, while maintaining maximum cervical tooth
structure. The BT ensures that the original canal shape
is maintained, thus keeping even the larger files cen-
Symptomatic
Pulpitis
16
MB1 and MB2: BT3
DB: BT4
P: BT5
Courtesy: Dr. Gilberto Debelian, Norway
Figs. 7–10_Example cases. Note
that these cases fulfil the objective
of biological apical sizes with conservative removal of coronal dentine.
Thus, they have a high probability of
endodontic success and survivability.
Obturation:
Total Fill BC sealer
BT Race
Symptomatic
Pulpitis tooth
16 and 17
I
Obturation:
Total Fill BC sealer
Fig. 10
tred in the canal. With this centring, in addition to the
minimal taper required to achieve these biological
sizes, the canal is maximally cleaned without weakening or stressing the root._
Editorial note: A complete list of references is available
from the publisher.
_about the authors
roots
Dr Gilberto Debelian (Oslo, Norway)
Dr Debelian received his DMD degree from the University of
São Paulo, Brazil, in 1987. He completed his specialisation in
Endodontics at the University of Pennsylvania, Philadelphia, USA,
in 1991. He completed his PhD studies at the University of Oslo in
1997. He is an adjunct visiting professor in the postgraduate programmes in Endodontics at the University of North Carolina at
Chapel Hill and the University of Pennsylvania. Dr Debelian maintains a private
specialist endodontics practice in Bekkestua, Norway.
Dr Martin Trope (Philadelphia, USA)
Dr Trope received his BDS degree in dentistry from University in Johannesburg, South Africa, in 1976. In 1980 he moved to Philadelphia to specialize in Endodontics at the University of Pennsylvania.
After graduating as an Endodontist he continued at the University
of Pennsylvania as a faculty member until 1989 when he became
Chair of Endodontology at Temple University, School of Dentistry.
Dr Trope is now Clinical Professor, Department of Endodontics, School of Dental Medicine, University of Pennsylvania. He is also in private practice in Philadelphia, USA.
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[24] =>
I case report _ pre-endodontic reconstruction
Managing coronal
destruction
A clinical case demonstrating the
pre-endodontic reconstruction of a tooth
Author_ Dr Andreas Schult, Germany
Fig. 1_Various preparations in
a maxillary molar.
Fig. 2_A restoration covering the
cusps with complete replacement of
the occlusal surface.
Fig. 1
_For many years, post systems have been an important component of post-endodontic core buildups. Post crowns or posts and cores used to be manufactured in a dental laboratory with the primary
goals of repairing the restoration on significantly destroyed teeth and stabilising the tooth structure. With
the development of adhesive systems, mechanical
anchoring of the denture to the remaining tooth
structure became increasingly less important, to such
an extent that clinicians now debate whether a post is
even needed.
Whether a tooth requires stabilisation must be
critically questioned as well, particularly in view of the
risk of fracture and its causes. In this regard, root
fractures, vertical root fractures and crown fractures
have to be assessed differently. The risk of a fracture
of the crown increases with the size and depth of the
cavity being prepared in the tooth (Fig. 1).
A tooth with a mesial-occlusal-distal cavity (MOD)
and an endodontic trepanation has a much higher
risk of fracture than an undamaged tooth does.1 The
Fig. 2
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2_ 2014
[25] =>
case report _ pre-endodontic reconstruction
I
Fig. 3_Various degrees of destruction
of a root-filled anterior tooth.
Fig. 3
risk of a cusp fracture can be significantly reduced
through a preparation covering the cusps for endodontically treated teeth with an MOD cavity (Fig. 2).2,3
Vertical root fractures differ from fractures in the
area of the crown. Lost endodontically treated teeth
owing to a vertical fracture are often treated with a
post. The difference in the elastic modulus between
the hard tooth structure and post material has been
suggested as a cause of a vertical fracture. It can thus
be concluded that post treatment and root canal treatment are the primary reasons for a vertical fracture.4
Preparation that preserves hard tooth substance is
considered to be a superior solution for preventing
fractures. In addition, the fracture resistance in the
coronal area is stabilised through adhesive build-up
materials and restorations that cover the cusps. The
post and the dentine should have a similar elastic
modulus in order to reduce the risk of a vertical root
fracture. The decision whether to use a post in the case
of an endodontic build-up critically depends on the
degree of destruction of the tooth: the more hard
tooth tissue present, the less the need for a post.
The diagram in Figure 3 shows three different
degrees of destruction of an anterior tooth. In the
case of a coronally intact but root-filled anterior root,
an adhesive restoration is sufficient. When treating
teeth with damage to the hard tissue and for which
a crown is planned, the remaining core height and
width to be enclosed by the crown play a decisive role
(ferrule effect). If the ferrule is more than 2mm wide,
a build-up secured with an adhesive is sufficient. If it
is narrower than 2mm, the use of a glass fibre post is
indicated.
_Clinical case
A busy sales representative came to our practice
with tooth 12 broken. Owing to time constraints, we
only had one hour available for the reconstruction of
the crown. The fracture line ran circumferentially at
the level of the gingiva (Fig. 4). A root canal treatment
had been performed on this tooth by another dentist
three months before.
Initially, the patient requested preservation of the
tooth but, after discussion, he said that he was not
able to invest time in undergoing systematic tooth
treatment. The clinical findings showed a retained
root. The degree of tooth mobility was Grade 0–I and
the probing depth was 1–2mm around the tooth.
X-ray images showed a root filling up to approximately
Fig. 4_Clinical baseline findings:
tooth 12 showed a coronal fracture
circumferentially at the level of the
gingiva.
Fig. 5_Radiological baseline
findings: intra-radicular radiopacity
and apical radiolucency.
Fig. 4
Fig. 5
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_ 2014
[26] =>
I case report _ pre-endodontic reconstruction
Fig. 6
Fig. 7
Fig. 9
Fig. 10
Fig. 6_Isolation of the working
field with a rubber dam and
preparation of the post bed.
Fig. 7_Conditioning of the cavity
with 35 % phosphoric acid.
Fig. 8_Working in the freshly
mixed adhesive for 20 seconds.
Fig. 9_Filling the post cavity
with LuxaCore Z-Dual.
Fig. 10_Insertion of the selected
root post, which was previously
covered with LuxaCore Z-Dual.
Fig. 11_Incremental build-up
of the crown.
Fig. 12_Finished build-up of tooth 12
after contouring and polishing.
Fig. 8
Fig. 11
Fig. 12
3mm before the radiological apex, as well as apical
radiolucency (Fig. 5).
The micro-suction device was again utilised to remove any excess.
We diagnosed chronic apical periodontitis in tooth
12. The apical radiolucency should be subsequently
observed and, if necessary, root canal treatment
should be revised prior to placing a crown.
In order to prepare the bonding material, Bond A
and B were mixed in equal portions for 5 seconds and
massaged into the dentine surface for 20 seconds
(Fig. 8). Then they were blown to a thin layer and light
cured for 10 seconds. The tooth was built up with the
dual-curing core build-up material LuxaCore Z-Dual
(DMG Dental; Fig. 9) and the post cavity was filled with
LuxaCore Z-Dual. The LuxaPost post (DMG Dental) was
positioned and the material was light activated (Fig. 10).
Being able to position a rubber dam clamp is a
basic prerequisite for endodontic treatment and for
pre-endodontic reconstruction. If a clamp cannot be
positioned, surgical crown lengthening is indicated,
if applicable (Fig. 6). The retained root was cleared of
remaining tissue, caries and plaque. Then the optimal
post diameter was determined using a stencil. A size
of 1.5mm was selected.
Since there was only a small amount of remaining
tooth substance, the post cavity was prepared to a
depth of 6mm and thoroughly rinsed. The canal and
remaining exposed dentine were conditioned with
35% phosphoric acid for 15 seconds and then rinsed
with a multifunctional syringe for 15 seconds (Fig. 7).
Excess fluid was suctioned off with a micro-suction device. The pre-bond was applied using an application tip and worked into the surface for 15 seconds.
26 I roots
2_ 2014
The crown was built up in small increments, activated, and contoured and polished with diamond
grinding tools (Figs. 11 & 12)._
Editorial note: A complete list of references is available from
the publisher.
_contact
roots
Dr Andreas Schult is a dentist in a joint practice in
Bad Bramstedt in Germany. He can be contacted at
zahnpflegepraxis@t-online.de
[27] =>
FDI 2014 · New Delhi · India
Greater Noida (UP)
Annual World Dental Congress
11-14 September 2014
Standard charges
for registrations ends
31 July 2014
A billion smiles welcome the world of dentistry
www.fdi2014.org.in
www.fdiworldental.org
[28] =>
I feature _ case report from Bristol Zoo
Root canal therapy setting
your teeth on edge?
Author_ Dr Peter Southerden, UK
deterioration in his condition, which would ultimately
lead to an infection in his mandible, making life even
more difficult for the poor animal.
As a veterinary dentist, I have worked on thousands of cats and dogs during my 28 years in practice. In terms of anatomy, the canine was very similar to that of my regular patients; it was just scaled
up in proportion. Radiographic examination (Figs. 1a
& b) showed evidence of an infection around the root
apex. Root canal therapy was indicated. Before our
patient was ready to undergo surgery, we had to order extra-long endodontic files from the US that
would fit into a 9cm-long root canal. The only files
fit for the purpose are so-called “Tiger Files”. These
Hedstrom files are 12cm long.
Fig. 1a
Fig. 1b
Figs. 1a & b_A radiograph showing
the root canal.
_Every endodontic treatment is different. However, if you as a dentist have only half an hour before
risking your life, if your patient weighs about 22 stone
(139.71kg) and if his canines are 14cm long, you are
literally in the lion’s den.
Root canals come in all shapes and sizes. There are
multiple canals, hidden accessory canals or even
horizontal branches. And sometimes root canals
are just unusually long. In the case of my most
prominent patient so far, the root canal was 9cm
long to be precise. It was a fine male specimen of
Panthera leo persica, an Asiatic lion. When I received a call from Bristol Zoo to say that they
had an adult lion with an apparent tooth problem, I was rather intrigued to say the least.
Fig. 2_GuttaFlow 2 set.
28 I roots
2_ 2014
It turned out that the patient was a 17-yearold Asiatic lion named Kamal. The zoo’s veterinary
surgeon informed me that the animal was suffering from a fractured canine tooth and was unable to
chew on bones. After our first conversation, we needed
to come up with a special treatment plan. Leaving the
infected tooth untreated would have meant a painful
_Operating in less than 2 hours
One of the challenges we faced was the time
constraints we would be working under; the whole
procedure had to be done as efficiently as possible.
Fig. 2
[29] =>
feature _ case report from Bristol Zoo
I
Owing to his age and the fact that the lion was
anaesthetised in field conditions (not in a hospital),
we did not want the lion to be anaesthetised for too
long. We thus had to come prepared. In advance, my
team and I had to obtain the correct equipment for
such a special treatment. The Swiss dental specialist
Coltène/Whaledent provided us with a fast-flowing
filling system (GuttaFlow 2), which helped us tremendously in keeping down the treatment time. In this
case, we definitely had to reduce “chair time”, if you
know what I mean.
The operation was performed on-site at Bristol
Zoo. After the lion was anaesthetised and placed on
the operating table, we had to perform the treatment
quickly. Dispensing with a dental dam owing to the
special circumstances, I started to clean and shape
the canal with the Hedstrom files. Their effectiveness
in terms of swift dentine removal was a great benefit to us. Irrigating the canal did not prove to be easy
either. The main cleaning agent was a sodium
hypochlorite solution with a concentration of 5%.
A feline urinary catheter was used for flushing.
After all necrotic pulp tissue and dentine shavings had been successfully removed, the canal had
to be obturated with a reliable permanent filling. It
goes without saying that the average masticatory
force in lions is considerably larger than it is in human beings. We placed a single master gutta-percha
point with the help of a plugger. The master point
was 60mm long and covered with GuttaFlow 2. This
new filling system combines cold free-flow guttapercha and a sealer to create a fast-flowing filling
material that is easy to handle and provides a reliable barrier against bacteria and liquids re-entering
the root canal. Its working time is approximately
10–15 minutes. After placing the gutta-percha in
the canal from the syringe, it was carried into the
canal using the Hedstroem files. Even in these unusual working conditions, handling was easy and
the application of the material really straightforward. The short working and curing times helped us
to establish a safe seal for the canal within minutes.
After the successful obturation of the canal, the
final restoration was created with a layer of glass
ionomer and a normal nano-hybrid composite. It
took us less than 2 hours to complete the whole procedure.
_Conclusion
The needs of a very large feline patient are not
that different to those of a human patient. The key to
a successful endodontic treatment is the effective
and complete removal of any infected tissue, as well
as quick and safe obturation of the canal. New, innovative filling systems have excellent flow properties.
Fig. 3
Fig. 4
They are easy to handle and help to speed up treatment sessions. Two-in-one products, moreover,
combine sealer and gutta-percha in powder form to
guarantee a tight seal of the root canal for optimum
protection against reinfection. And reduced chair
time is a big bonus to the dentist, whether treating
children, patients with dental fear, or lions._
_about the author
Fig. 3_Filling the root canal with
GuttaFlow 2.
Fig. 4_Radiographic control.
roots
Dr Peter Southerden
is a recognised European
Veterinary Dental Specialist.
He is the founder of the
Eastcott Veterinary Clinic
and Hospital in Swindon
in South West England,
where he sees referred
dentistry, and oral and maxillofacial surgery cases.
He is a regular presenter at both UK and international
veterinary conferences.
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_ 2014
[30] =>
I research _ phototherapy
Diclofenac, dexamethasone
or laser phototherapy?
Part I
Author_Jan Tunér, Sweden
[PICTURE: ©ROBERT KNESCHKE]
_Introduction
In the May 2013 edition of Photomedicine and
Laser Surgery, the editorial written by Prof. Tina Karu
is titled “Is it time to consider photobiomodulation as
a drug equivalent?” Well, is it? Let us have a look and
see what the literature has to say about two very popular drugs:
NSAIDs (non-steroidal anti-inflammatory drugs)
are the best sold pharmaceuticals ever. The shortterm effects on pain and inflammation are obvious
and valuable. The long-term effects, however, have
been questioned and this is especially valid considering the many side effects of NSAIDs. Millions of patients are on long-term medication with NSAIDs, and
even lifelong. Indeed, many persons die from their
medication. So an alternative option is required. I believe it is already available: laser phototherapy! First,
let us have a look at the strength of the scientific evidence for NSAIDs as such, and long term use of these
in particular:
The meta-analysis by Bjordal1 on the effect of
NSAIDs on knee osteoarthritis pain appears to become important for the recognition and future development of LPT. Let us read the abstract: The research
group summarises that non-steroidal anti-inflam-
30 I roots
2_ 2014
matory drugs (NSAIDs), including cyclo-oxygenase-2
inhibitors (coxibs), reduce short-term pain associated
with knee osteoarthritis only slightly better than
placebo, and long-term use of these agents should be
avoided. Up for analysis were 23 placebo-controlled
trials involving 10,845 patients, 7,767 of whom received NSAID therapy and 3,078 placebo therapy. All
in all 21 of the NSAID-studies were funded by the
pharmaceutical industry, and the results of 13 of
these studies were inflated by patient selection bias as
previous NSAID-users were excluded if they had not
previously responded favourably to NSAID. Such an
exclusion criterion for non-responders has never
been seen in any controlled trial of LPT or other nonpharmacological therapies of osteoarthritis. In the remaining ten unbiased NSAID-trials, the difference
from placebo was only 5.9 mm on a 100 mm pain
scale.
This is far less than established data on differences
that are considered minimally perceptible (9 mm) or
clinically relevant (12 mm) for knee osteoarthritis patients. In addition, none of the trials found any effects
beyond 13 weeks. This bleak support for long term use
of NSAIDs is an excellent support for non-pharmaceutical methods, such as LPT. Diclofenac is one of the
best-selling NSAIDs. Several investigators have compared the effect of LPT and diclofenac.
[31] =>
research _ phototherapy
I
Ramos3 investigated the effects of LPT (810 nm) in
rat-induced skeletal muscle strain. Male rats were
anaesthetised with halothane prior to the induction
of muscle strain. Previous studies have determined
that a force equal to 130 % of the body weight corresponds to approximately 80 % of the ultimate rupture
force of the muscle tendon unit. In all animals, the
right leg received a controlled strain injury while the
left leg served as control. A small weight corresponding to 150 % of the total body weight was attached
to the right leg in an appropriate apparatus and left to
induce muscle strain twice for 20 minutes with threeminute intervals. Walking index, C-reactive protein,
creatine kinase, vascular extravasation and histological analysis of the tibial muscle were performed after
six, twelve and 24 hours of lesion induction. LPT in an
energy-dependent manner markedly or even completely reduced the Walking Index, leading to a better
quality of movement. C-reactive protein production
[PICTURE: ©INESBAZDAR]
The aim of a study by Marcos2 was to evaluate the
short-term effects of LPT or sodium diclofenac
treatments on biochemical markers and biomechanical properties of inflamed Achilles tendons.
Wistar rats Achilles tendons (n = 6/group) were injected with saline (control) or collagenase at peritendinous area of Achilles tendons. After one hour
animals were treated with two different doses of LPT
(810 nm, 1 and 3 J) at the sites of the injections, or
with intramuscular sodium diclofenac. Regarding
biochemical analyses, LPT significantly decreased
COX-2, TNF-alpha, MMP-3, MMP-9, and MMP-13
gene expression, as well as PGE2 production when
compared to collagenase group. Interestingly, diclofenac treatment only decreased PGE2 levels. Biomechanical properties were preserved in the lasertreated groups when compared to collagenase and
diclofenac groups.
was completely inhibited by laser treatment, even
more than observed with Sodium diclofenac inhibition (positive control). Creative Kinase activity was
also significantly reduced by laser irradiations. In conclusion, LPT operating in 810 nm markedly reduced inflammation and muscle damage after experimental
muscle strain, leading to a highly significant enhancement of walking activity.
The aim of the study by de Almeida4 was to analyse
the effects of sodium diclofenac (topical application),
cryotherapy, and LPT on pro-inflammatory cytokine
levels after a controlled model of muscle injury.
For such, we performed a single trauma in the tibialis
anterior muscle of rats. After one hour, animals
were treated with sodium diclofenac (11.6 mg/g of
solution), cryotherapy (20 min), or LPT (904 nm;
superpulsed; 700 Hz; 60 mW mean output power;
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_ 2014
[32] =>
I research _ phototherapy
[PICTURE: ©RACORN]
1.67 W/cm2; 1, 3, 6 or 9 J; 17, 50, 100 or 150 s). Assessment of interleukin-1 and interleukin-6 (IL-1 and
IL-6) and tumour necrosis factor-alpha levels was
performed at six hours after trauma employing enzyme-linked immunosorbent assay method. LPT with
1 J dose significantly decreased IL-1, IL-6, and TNF-alpha levels compared to non-treated injured group as
well as diclofenac and cryotherapy groups. On the
other hand, treatment with diclofenac and cryotherapy does not decrease pro-inflammatory cytokine
levels compared to the non-treated injured group.
Therefore, the authors conclude that 904 nm LPT with
1 J dose has better effects than topical application of
diclofenac or cryotherapy in acute inflammatory
phase after muscle trauma.
The purpose of a study by Albertini5 was to investigate the effect of LPT on the acute inflammatory
process. Male rats were used. Paw oedema was induced by a sub-plantar injection of carrageenan, the
paw volume was measured before and one, two, three
and four hours after the injection, using a hydroplethysmometer. To investigate the action mechanism of the GaAlAs laser on inflammatory oedema,
parallel studies were performed using adrenalectomised rats or rats treated with sodium diclofenac.
Different laser irradiation protocols were employed
for specific energy densities (EDs), exposure times and
repetition rates. The rats were irradiated with laser for
80 s each hour. The EDs that produced an anti-inflammatory effect were 1 and 2.5 J/cm2, reducing the
oedema by 27 % and 45.4 %, respectively. The ED of
2.5 J/cm2 produced anti-inflammatory effects similar
to those produced by the cyclooxigenase inhibitor
sodium diclofenac at a dose of 1 mg/kg. In adrenalectomised animals, the laser irradiation failed to inhibit
the oedema. These results suggest that LPT possibly
exerts its anti-inflammatory effects by stimulating
the release of adrenal corticosteroid hormones.
32 I roots
2_ 2014
The aim of a work by Meneguzzo6 was to investigate the effects of infrared 810 nm on the acute inflammatory process by the irradiation of lymph
nodes, using the classical model of carrageenan-induced rat paw oedema. Thirty mice were randomly divided into five groups. The inflammatory induction
was performed in all groups by a sub-plantar injection
of carrageenan (1 mg/paw). The paw volume was
measured before and 1, 2, 3, 4 and 6 hours after the
injection using a plethysmometer. Myeloperoxidase
(MPO) activity was analysed as a specific marker of
neutrophil accumulation at the inflammatory site.
The control group did not receive any treatment (GC);
GD group received sodium diclofenac (1mg/kg) 30
minutes before the carrageenan injection; GP group
received laser irradiation directly on the paw (1 Joule,
100 mW, 10 sec) one and two hours after the carrageenan injection; GLY group received laser irradiation (1 Joule, 100 mW, 10 sec) on the inguinal lymph
nodes; GP+LY group received laser irradiation on both
paw and lymph nodes one and two hours after the
carrageenan injection. MPO activity was similar in the
sodium diclofenac as well as in the GP and GLY groups,
but significantly lower than the GC and GP + LY
groups. Paw oedema was significantly inhibited in GP
and GD groups when compared to the other groups.
Interestingly, the GP+LY groups presented the biggest
oedema, even bigger than in the control group. LPT
showed an anti-inflammatory effect when the irradiation was performed on the site of lesion or at the correlated lymph nodes, but showed a pro-inflammatory
effect when both paw and lymph nodes were irradiated during the acute inflammatory process.
The aim of a study by Barretto23 was to investigate
the analgesic and anti-inflammatory activity of LPT
on the nociceptive behavioural as well as histomorphological aspects induced by injection of formalin
and carrageenan into the rat temporomandibular
joint. The 2.5 % formalin injection (FRG group) induced behavioural responses characterized by rubbing the orofacial region and flinching the head
quickly, which were quantified for 45 min. The pretreatment with systemic administration of diclofenac
sodium-DFN group (10 mg/kg i.p.) or irradiation with
infrared LPT (LST group, 780 nm, 70 mW, 30 s, 2.1 J,
52.5 J/cm2), significantly reduced the formalininduced nociceptive responses. The 1 % carrageenan
injection (CRG group) induced inflammatory responses over the time-course of the study (24 h, three
and seven days) characterised by the presence of
intense inflammatory infiltrate rich in neutrophils,
scanty areas of liquefactive necrosis and intense interstitial oedema, extensive haemorrhagic areas, and
enlargement of the joint space on the region. The DFN
and LST groups showed an intensity of inflammatory
response that was significantly lower than in CRG
group over the time-course of the study, especially in
[33] =>
research _ phototherapy
the LST group, which showed exuberant granulation
tissue with intense vascularization, and deposition of
newly formed collagen fibres (three and seven days).
The aim of a study by de Almeida7 was to analyse
the effects of sodium diclofenac (topical application)
and LPT on morphological aspects and gene expression of biochemical inflammatory markers. The researchers performed a single trauma in the tibialis anterior muscle of rats. After one hour, animals were
treated with sodium diclofenac (11.6 mg/g of solution) or LPT (810 nm; continuous mode; 100 mW; 1, 3
or 9 J; 10, 30 or 90 s). Histological analysis and quantification of gene expression (real-time polymerase
chain reaction-RT-PCR) of cyclooxygenase 1 and 2
(COX-1 and COX-2) and tumour necrosis factor-alpha
(TNF-alpha) were performed at six, twelve and 24 h after trauma. LPT with all doses improved morphological aspects of muscle tissue, showing better results
than injury and diclofenac groups. All LPT doses also
decreased COX-2 compared to injury group and to diclofenac group at 24 h after trauma. In addition, LPT
decreased TNF-alpha compared both to injury and diclofenac groups. LPT mainly with dose of 9 J is better
than topical application of diclofenac in acute inflammation after muscle trauma.
Yet another study by Marcos8 investigated if a
safer treatment such as LPT could reduce tendinitis
inflammation, and whether a possible pathway could
be through inhibition of either of the two-cyclooxygenase (COX) isoforms in inflammation. Wistar rats
(six animals per group) were injected with saline (control) or collagenase in their Achilles tendons. Then
they were treated with three different doses of IR LPT
(810 nm; 100 mW; 10 s, 30 s and 60 s; 3.57 W/cm2; 1 J,
3 J, 6 J) at the sites of the injections, or intramuscular
diclofenac, a nonselective COX inhibitor/NSAID. It
was found that LPT dose of 3 J significantly reduced
inflammation through less COX-2-derived gene expression and PGE2 production, and less oedema formation compared to non-irradiated controls. Diclofenac controls exhibited significantly lower PGE2
cytokine levels at 6 h than collagenase control, but
COX isoform 1-derived gene expression and cytokine
PGE2 levels were not affected by treatments. As LPT
seems to act on inflammation through a selective inhibition of the COX-2 isoform in collagenase-induced
tendinitis, LPT may have the potential to become a
new and safer non-drug alternative to coxibs.
The aim of the study by de Paiva Carvalho9 was to
evaluate the effect of single and combined therapies
(LPT, topical application of diclofenac and intramuscular diclofenac) on functional and biochemical aspects in an experimental model of controlled muscle
strain in rats. Muscle strain was induced by overloading tibialis anterior muscle of rats. Injured groups re-
I
ceived either no treatment, or a single treatment with
topical or intramuscular diclofenac (TD and ID), or LPT
(3 J, 810 nm, 100 mW) 1 h after injury. Walking track
analysis was the functional outcome and biochemical analyses included mRNA expression of COX-1 and
COX-2 and blood levels of prostaglandin E2 (PGE2). All
treatments significantly decreased COX-1 and COX-2
gene expression compared to the injury group. However, LPT showed better effects than TD and ID regarding PGE2 levels and walking track analysis. The
author concludes that LPT has more efficacy than
topical and intramuscular diclofenac in treatment of
muscle strain injury in acute stage.
Crystalopathies are inflammatory pathologies
caused by cellular reactions to the deposition of crystals in the joints. The anti-inflammatory effect of HeNe laser and that of the non-steroidal anti-inflammatory drugs (NSAIDs) diclofenac, meloxicam, celecoxib, and rofecoxib was studied in acute and chronic
arthritis produced by hydroxyapatite and calcium pyrophosphate in rats. The presence of the markers fibrinogen, L-citrulline, nitric oxide, and nitrotyrosine
was determined. In the study by Rubio10, crystals were
injected into the posterior limb joints of the rats. A
dose of 8 J/cm2 of energy from a HeNe laser was applied for three days in some groups and for five days
in other groups. The levels of some of the biomarkers
were determined by spectrophotometry, and that of
nitrotyrosine was determined by ELISA. In arthritic
rats, the fibrinogen, L-citrulline, nitric oxide, and nitrotyrosine levels increased in comparison to controls
and to the laser-treated arthritic groups. When comparing fibrinogen from arthritic rats with disease induced by hydroxyapatite to healthy and arthritic rats
treated with NSAIDs, the He-Ne laser decreased levels to values similar to those seen in controls. Inflammatory and oxidative stress markers in experimental
crystalopathy are positively modified by photobiostimulation._
Editorial note: To be continued with further studies on
the effectiveness of diclofenac and LPT and conclusion
in roots 3/2014. An list of references is available from the
author.
_contact
roots
Jan Tunér
Spjutvagen 11
772 32 Grängesberg
Sweden
jan.tuner@swipnet.se
roots
2
I 33
_ 2014
[34] =>
I industry news _ Sirona
SIROLaser Factbook:
Comprehensive information
on diode lasers
Fig. 1_Compact information on
lasers: SIROLaser Factbook.
_Sirona reports on the wide range of applications of diode lasers in a special edition of the English-language “Laser – International Magazine of
Laser Dentistry.” The "SIROLaser Factbook—Clinical
articles about SIROLaser Advance and Xtend applications" includes research by well-known experts as
well as informative field reports from experienced
users of laser technology.
Compact and informative: Sixty pages full of solid
expertise and practical applications await the readers of English texts collected by Sirona in “SIROLaser
Factbook—Clinical articles about SIROLaser Advance
and Xtend applications.” Academic articles and reallife user reports by well-known experts provide information on the many uses and treatment options
of diode lasers with a wavelength of 970nm. Interesting facts and figures, study results, documented
case studies with descriptive pictures, and recommendations for further reading complete the compendium.
“Anyone with an interest in laser dentistry should
read the SIROLaser Factbook,” says Ingo Höver, product manager at Sirona. The book is especially meant
for beginners, says the laser specialist. “However, experienced users will also find it worth reading. I am
sure that they will be surprised to learn the many possibilities of diode lasers and the range of applications
that are open to them with models like the SIROLaser
Advance or SIROLaser Xtend.”
_Routine and less common aspects of
dental treatment
The 970 nm diode laser discussed in the SIROLaser
Factbook covers a variety of dental indications, says
co-publisher and co-author Prof. Andreas Braun
from the Center for Dental and Oral Medicine of the
University of Marburg. These include incision/excision associated with gingivectomy, gingivoplasty,
implant exposure, and removal of abnormal tissue
and reducing bacteria as a supporting measure in
periodontal, peri-implant or endodontic procedures
as well as adjunctive therapy in the treatment of
aphthous ulcers. “The selected articles cover both
routine and less common aspects of dental treatment with a particular focus on new treatment
strategies combined with conventional techniques,”
says Prof. Braun.
34 I roots
2_ 2014
[35] =>
industry news _ Sirona
“There are few instruments that symbolize
modernity and innovation in dentistry more than the
laser,” says Prof. Roland Frankenberger. Laser applications in dentistry are now scientifically established. The President of the German Society for
Restorative Dentistry (DGZ) writes in his foreword,
“I am especially pleased that a variety of interesting
aspects of routine work are examined and laser
treatment is conveyed objectively, but with enthusiasm.” Prof. Braun hopes, “Perhaps new recommendations for day-to-day practice will result from the
treatment procedures described.”
quality, and top design. The SIROLaser Advance and
SIROLaser Xtend ensure relaxed dentists and relaxed
patients. More information for dentists and the compendium “SIROLaser Factbook – Clinical articles about
SIROLaser Advance and Xtend applications” are available for download at www.sirona.de._
_contact
I
Fig. 2_SIROLaser Advance and Xtend
– two models for safe, precise,
pain-free treatment.
roots
_Relaxed dentists and relaxed patients
Sirona, global innovation leader for dental equipment, has two laser models in its product portfolio
that set new standards: SIROLaser Xtend with an upgrade option for beginners and SIROLaser Advance
for experts. The lasers stand for safe, precise procedures, gentle, pain-free treatment, lasting product
Sirona Dental GmbH
Sirona Straße 1
5071 Wals bei Salzburg
Austria
www.sirona.com
roots
2
I 35
_ 2014
[36] =>
I industry news _ Planmeca
Planmeca and the University
of Turku found Nordic Institute
of Dental Education
Fig. 1_The objective of the new
institute is to export and share Nordic
expertise in digital dentistry on the
basis of academic knowledge and
technologies. (Photo: Planmeca)
_Dental technology company Planmeca and the
University of Turku have founded a joint venture company, the Nordic Institute of Dental Education. The institute will offer high-quality continuing education
courses to dental professionals.
The objective is to export and share Nordic expertise in digital dentistry on the basis of the
academic knowledge of the University of
Turku and the technologies developed by
Planmeca, as well as their global dental
networks.
The courses will be held at the University of Turku and at Planmeca’s headquarters in Helsinki from autumn
2014. The course topics cover rapidly evolving dental technologies
and their application in modern
dentistry, including 3-D imaging, prosthodontics, endodontics, biomaterials science, orthodontics and CAD/CAM technologies.
The University of Turku awards ECTS
credits (a standard for higher education
in Europe) and course certificates to the
students. The joint venture company
complements Planmeca’s broad range
of training activities and collaboration
with universities around the world.
roots
_contact
Planmeca Oy
Asentajankatu 6
00880 Helsinki
Finland
www.planmeca.com
36 I roots
2_ 2014
The University of Turku is an active
participant in the export of education.
“We have now established a partnership
with one of the world’s leading companies in dental technology. Together with
Planmeca we are a strong education
provider globally,” stated Prof. Kalervo
Väänänen, Rector of the University of
Turku._
[37] =>
www.DTStudyClub.com
Y education everywhere
and anytime
Y live and interactive webinars
Y more than 500 archived courses
Y a focused discussion forum
Y free membership
Y no travel costs
Y no time away from the practice
Y interaction with colleagues and
experts across the globe
Y a growing database of
scientific articles and case reports
Y ADA CERP-recognized
credit administration
Register for
FREE!
ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providersof continuing dental education.
ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry.
[38] =>
I meetings _ AAE
“Striving for perfection”—
AAE holds 2014 Annual
Session in Washington
Author_ Fred Michmershuizen, DTA
Fig. 1_ Meeting participants work
with apex locators during a hands-on
workshop, „The Rationale and Use of
Electronic Apex Locators,” presented
by Dr L. Stephen Buchanan.
Fig. 2_AAE President Gary Hartwell
welcomes meeting attendees to the
2014 AAE Annual Session.
Fig. 3_Meeting attendees try
new endodontic technology
available from Sonendo Inc.
Fig. 4_Dr Manor Haas demonstrates
the use of a surgical operating
microscope at the Zeiss booth.
Fig. 1
Fig. 2
_Endodontists from around the world and across
the country gathered at the Gaylord National resort
just outside Washington, D.C., for the 2014 AAE Annual Session. From lectures to hands-on workshops
to formal and informal social gatherings, the meeting,
held from April 30 to May 3, offered a wide range of
opportunities for attendees.
photograph of the flag raising at Iwo Jima, offered an
inspirational message to those in attendance: Nothing is impossible.
James Bradley, author of the New York Times bestseller “Flags of Our Fathers,” gave the keynote address.
Bradley, whose book follows the lives of the five US
Marines and one US Navy Corpsman who would
eventually be made famous by Joe Rosenthal’s lauded
A “Corporate Workshop and Lecture” series was
presented on the show floor. Some of the highlights
included “Surgical Applications of Bioceramics,” sponsored by Brasseler USA, presented by Dr Ali Nasseh;
“The Rationale and Use of Electronic Apex Locators,”
sponsored by J. Morita USA, presented by Dr L. Stephen
Buchanan; and “Sound Science: Multisonic Ultracleaning,” sponsored by Sonendo Inc., presented by
Dr. Mehrzad Khakpour.
The exhibit hall featured products and services
from several hundred companies, as well as various
educational opportunities.
A number of companies used the meeting as an
occasion to launch new products.
Fig. 3
Fig. 4
38 I roots
2_ 2014
Sonendo unveiled its new GentleWave System utilizing patented Multisonic Ultracleaning technology
that is designed to quickly, easily and safely loosen and
remove pulp tissue, debris, decay and bacteria within
minutes. The system is designed to clean the entire
canal system, automatically and simultaneously.
[39] =>
meetings _ AAE
I
Fig. 5_Dr Rich Mounce (left) and
Dr C. John Munce.
Fig. 6_Dr Mehrzad Khakpour
presents „Sound Science: Multisonic
Ultracleaning,” one of several „To the
Point” lectures offered on the exhibit
hall floor.
Fig. 5
Fig. 6
Bjarne Bergheim, president and CEO of Sonendo,
has been directly involved in the development of the
GentleWave since its early inception. “Very soon, endodontists performing root canal therapy will have
the ability to provide an ultraclean environment for
their patients in a more comprehensive, efficient and
predictable way,” he said. “We remain focused on creating a new standard of care for the patient as well as
improving the clinical quality and business performance of doctors performing root canal therapy.”
Brasseler introduced its ESX Rotary File. Designed
with several performance-enhancing patented features, ESX Rotary Files are designed for a powerful
yet minimally invasive performance, maximizing the
long-term success of the treated tooth, the company
says.
DENTSPLY Tulsa Dental Specialties launched ProTaper Gold rotary files, featuring what it calls “the
same efficient, variable tapered shapes and predictable performance that clinicians have known
and trusted from ProTaper Universal, with increased
flexibility.”
According to DENTSPLY Tulsa, ProTaper Gold’s
proprietary advanced metallurgy creates a difference
clinicians can see and feel. ProTaper Gold files have
the same geometry as ProTaper Universal, but with an
increase in flexibility. This is especially important in
the finishing files, which must navigate challenging
curves in the apical region of the canal, the company
says. The files also feature a shorter, 11-mm handle
for improved accessibility to teeth.
J. Morita unveiled its Root ZX II OTR Module, a new,
low-speed handpiece for its popular apex locator.
According to the company, the new OTR Module safely
and efficiently prepares canals while simultaneously
taking measurements.
Several companies exhibited at the AAE meeting
for the first time. Among them: Edge Endo, whose
“biker chicks” and rock ’n’ roll-themed booth had attendees looking twice; Avalon Biomed, with its new
Grey MTA bioactive root and pulp treatment material;
and Rapid City, S.D.-based Mounce Endo, offering its
own MounceFiles, plus a full range of supplies from
Mani, Aseptico, San Diego Swiss Ultrasonics and
MetaBiomed.
The 2015 AAE meeting is scheduled for May 6 to 9
in Seattle._
Photos: Fred Michmershuizen
Fig. 7_James Bradley, author
of the New York Times bestseller
„Flags of Our Fathers,” offers the
keynote address.
Fig. 8_Dr Allen Ali Nasseh offers
a presentation on endodontic files
in the „To the Point” educational
theater on the exhibit hall floor.
Fig. 7
Fig. 8
roots
I 39
2
_ 2014
[40] =>
I events _ meetings
International Events
2014
18th World Congress on Dental Traumatology
19–21 June 2014
Istanbul, Turkey
www.iadt-dentaltrauma.org/2014conference/
index.html
2014 AAE/AAP/ACP Join Symposium
Teeth for a life time: Interdisciplinary Evidence
for Clinical Success
19–20 July 2014
Chicago, USA
www.perio.org/meetings/jointsymposium2014.htm
Scand Endo Reykjavik 2014
21–23 August 2014
Reykjavik, Iceland
FDI Annual World Dental Congress
17–19 June 2014
Dubai, UAE
www.apdentalcongress.org
Italian Academy of Endodontics (AIE)
22nd National Congress
2–4 October 2014
Montecatini Terme, Italy
www.accademiaitalianaendodonzia.it
155th ADA Annual Session
9–12 October 2014
San Antonio, USA
www.ada.org
Digital Dentistry Show
16–18 October 2014
At the International Expodental Milano, Italy
www.digitaldentistryshow.com
ROOTS Summit
7–9 November 2014
Chennai, India
www.rootssummit2014.com
BES: 2014 Regional Meeting
14–15 November 2014
Manchester, UK
www.britishendodonticsociety.org.uk
ADF Meeting
25–29 November 2014
Paris, France
www.adf.asso.fr
Great New York Dental Meeting
28 November–3 December 2014
New York, USA
www.gnydm.com
Austrian Society of Endodontology Annual
Meeting & PENN ENDO Global Symposium
4–6 December 2014
Vienna, Austria
www.pennglobalvienna2014.at/
40 I roots
2_ 2014
[41] =>
about the publisher _ submission guidelines
submission guidelines:
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I
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The author’s contact information and a head shot of the author
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Please consider this when formatting your document.
Questions?
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m.wojtkiewicz@oemus-media.de
roots
2
I 41
_ 2014
[42] =>
I about the publisher _ imprint
roots
international magazine of
endodontology
Publisher
Torsten R. Oemus
oemus@oemus-media.de
CEO
Ingolf Döbbecke
doebbecke@oemus-media.de
Published by
Oemus Media AG
Holbeinstraße 29
04229 Leipzig, Germany
Tel.: +49 341 48474-0
Fax: +49 341 48474-290
kontakt@oemus-media.de
www.oemus.com
Magda Wojtkiewicz, Managing Editor
Printed by
Members of the Board
Jürgen Isbaner
isbaner@oemus-media.de
Lutz V. Hiller
hiller@oemus-media.de
Managing Editor
Magda Wojtkiewicz
m.wojtkiewicz@oemus-media.de
Executive Producer
Gernot Meyer
meyer@oemus-media.de
Designer
Josephine Ritter
j.ritter@oemus-media.de
Copy Editors
Sabrina Raaff
Hans Motschmann
Silber Druck oHG
Am Waldstrauch 1
34266 Niestetal, Germany
Editorial Board
Fernando Goldberg, Argentina
Markus Haapasalo, Canada
Ken Serota, Canada
Clemens Bargholz, Germany
Michael Baumann, Germany
Benjamin Briseno, Germany
Asgeir Sigurdsson, Iceland
Adam Stabholz, Israel
Heike Steffen, Germany
Gary Cheung, Hong Kong
Unni Endal, Norway
Roman Borczyk, Poland
Bartosz Cerkaski, Poland
Esteban Brau, Spain
José Pumarola, Spain
Kishor Gulabivala, United Kingdom
William P. Saunders, United Kingdom
Fred Barnett, USA
L. Stephan Buchanan, USA
Jo Dovgan, USA
Vladimir Gorokhovsky, USA
James Gutmann, USA
Ben Johnson, USA
Kenneth Koch, USA
Sergio Kuttler, USA
John Nusstein, USA
Ove Peters, USA
Jorge Vera, Mexico
Copyright Regulations
_roots international magazine of endodontology is published by Oemus Media AG and will appear in 2014 with one issue every quarter. The magazine
and all articles and illustrations therein are protected by copyright. Any utilisation without the prior consent of editor and publisher is inadmissible and liable
to prosecution. This applies in particular to duplicate copies, translations, microfilms, and storage and processing in electronic systems.
Reproductions, including extracts, may only be made with the permission of the publisher. Given no statement to the contrary, any submissions to the
editorial department are understood to be in agreement with a full or partial publishing of said submission. The editorial department reserves the right to
check all submitted articles for formal errors and factual authority, and to make amendments if necessary. No responsibility shall be taken for unsolicited
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the opinion of the afore-mentioned, and do not have to comply with the views of Oemus Media AG. Responsibility for such articles shall be borne by the author.
Responsibility for advertisements and other specially labeled items shall not be borne by the editorial department. Likewise, no responsibility shall be assumed
for information published about associations, companies and commercial markets. All cases of consequential liability arising from inaccurate or faulty
representation are excluded. General terms and conditions apply, legal venue is Leipzig, Germany.
42 I roots
2_ 2014
[43] =>
roots
international magazine of
endodontology
You can also subscribe via
www.oemus.com/abo
Subscribe now!
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roots 2/14
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/ Passive micro-volume management of sodium hypochlorite in endodontic treatment
/ Instrument fracture removal revisited
/ BT-Race: Biological and conservative root canal instrumentation with the final restoration in mind
/ Managing coronal destruction A clinical case demonstrating the pre-endodontic reconstruction of a tooth
/ Root canal therapy setting your teeth on edge?
/ Diclofenac - dexamethasone or laser phototherapy? Part I
/ SIROLaser Factbook: Comprehensive information on diode lasers
/ Planmeca and the University of Turku found Nordic Institute of Dental Education
/ “Striving for perfection”— AAE holds 2014 Annual Session in Washington
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