roots C.E. No. 3, 2015

Cover / Editorial / Content / The treatment of traumatic dental injuries / Cutting endodontic access cavities — for long-term outcomes / PIPS and retreatment / Sonendo: Challenging the standard of care with the GentleWave System / Industry news / Imprint

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roots
issn 2161-6558

the international C.E. magazine of

3

2015

_C.E. article

The treatment of traumatic
dental injuries

_technique

Cutting endodontic access
cavities — for long-term
outcomes

_trends

PIPS and retreatment

International Edition • Vol. 6 • Issue 3/2015

endodontics

[2] =>

[3] =>

editorial _ roots

Inside baseball
We endodontists are a curious bunch. We are constantly honing our craft. We are always looking for
ways to treat cases better and more predictably for our patients. But to stay on top of our game, we must
always keep up to date on the latest technology and treatment options.
Much of this knowledge is esoteric — call it “inside baseball,” if you will.
In this issue of roots, you can find many articles designed to enhance your specialized skill set.
Dr. Asgeir Sigurdsson offers an article on the treatment of traumatic dental injuries. Dr. L. Stephen
Buchanan presents a number of cases treated with smaller-than-average access cavities. Dr. Reid Pullen
describes using laser technology in a retreatment case, and Dr. Tyler F. Baker shares his experience using
new sound wave technology for endodontic disinfection.
The article by Dr. Sigurdsson, which originally appeared in ENDODONTICS: Colleagues for Excellence,
the newsletter published by the American Association of Endodontists, is being made available in this issue
of roots with the permission of the AAE. By reading this article, and then taking a short online quiz at www.
DTStudyClub.com, you will gain one ADA CERP-certified C.E. credit. Keep in mind that because roots is a
quarterly magazine, you can actually chisel four C.E. credits per year out of your already busy life without
the lost revenue and time away from your practice.
To learn more about how you can take advantage of this C.E. opportunity, visit www.DTStudyClub.
com. You need only register at the Dental Tribune Study Club website to access these C.E. materials free of
charge. You may take the C.E. quiz after registering on the DT Study Club website.
I know that taking time away from your practice to pursue C.E. credits is costly in terms of lost revenue
and time, and that is another reason roots is such a valuable publication. I hope you will enjoy this issue
and that you will take advantage of the C.E. opportunity.
As always, I welcome your comments and feedback.
Sincerely,

Fred Weinstein, DMD, MRCD(C),
FICD, FACD

Fred Weinstein, DMD, MRCD(C), FICD, FACD
Editor in Chief

roots
3
I 03
_ 2015

[4] =>

I content_ roots

page 12

page 06

I C.E. article
06

The treatment of traumatic dental injuries

_Asgeir Sigurdson, DDS, MS

page 18

I about the publisher
30

_imprint

I technique
12

Cutting endodontic access cavities — for
long-term outcomes

_L. Stephen Buchanan, DDS, FACD, FICD

I trends
18	PIPS and retreatment

_Reid Pullen, DDS, FAGD

22	Sonendo: Challenging the standard of care
with the GentleWave System
_Tyler F. Baker, DDS, MS

3

endodontics

2015

The treatment of traumatic
dental injuries

_technique

25	FKG Denntaire in the 2015 ESE congress

I industry
26	Vista’s SmearOFF: One product, multiple
benefits
28	Essential Dental Systems (EDS) introduces
Tango-Endo

page 22

3_ 2015

the international C.E. magazine of

_C.E. article

I industry news

04 I roots

roots

International Edition • Vol. 6 • Issue 3/2015

issn 2161-6558

Cutting endodontic access
cavities — for long-term
outcomes

_industry

Sonendo: Challenging
the standard with the
GentleWave System

I on the cover

The Tango-Endo reciprocating handpiece, available
from Essential Dental Systems (EDS), allows for twoinstrument shaping, shown with before-and-after
images of an endodontic case treated with Tango-Endo.
(Photos/Provided by EDS)

page 25

page 28

[5] =>

[6] =>

I C.E. article_ trauma

The treatment of
traumatic dental injuries
Author_Asgeir Sigurdsson, DDS, MS

_c.e. credit
This article qualifies for C.E.
credit. To take the C.E. quiz, log
on to www.dtstudyclub.com.
Click on ‘C.E. articles’ and
search for this edition (Roots
C.E. Magazine — 3/2015). 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 below.

Fig. 1a_Clinical case of two
uncomplicated crown fractures in
which the two broken pieces were
located and reattached. (Photos/
Provided by American Association of
Endodontists)
Figs. 1b, c_After the two pieces had
been attached, a chamfer was cut
along the fracture line and additional
composite cured in place. This will
both increase the strength of the
attachment and better hide the
fracture line.

Fig. 1a

_When treating dental trauma, the timeliness of
care is key to saving the tooth in many cases. It is,
therefore, important for all dentists to have an understanding of how to diagnose and treat the most
common dental injuries. This is especially critical in
the emergency phase of treatment.
Proper management of dental trauma is most
often a team effort with general dentists, pediatric
dentists or oral surgeons on the front line of the
emergency service, and endodontic specialists joining the effort to preserve the tooth with respect to the
pulp, pulpal space and root. An informed and coordinated effort from all team members ensures that the
patient receives the most efficient and effective care.
Recently, a panel of expert members of the American Association of Endodontists prepared an updated
version of Guidelines for the Treatment of Traumatic
Dental Injuries.1,2 These guidelines were based, in part,
on the current recommendations of the International
Association of Dental Traumatology (see www.iadtdentaltrauma.org for more information). This article
provides an overview of the AAE guidelines; the complete guidelines are available for free download at www.
aae.org/clinical-resources/trauma-resources.aspx.
The benefit of adhering to guidelines for treatment of dental trauma was recently shown in a study
by Bucher et al.3 The study found that, compared
with cases treated without compliance to guidelines,
cases that adhered to guidelines produced more
favorable outcomes, including significantly lower
complication rates. The study also found that early
follow-up visits were essential to ensure prompt
treatment of complications when they arose.3

_Emergency care
Prior to any treatment, one must evaluate the

Fig. 1b

06 I roots
3_ 2015

injury thoroughly by careful clinical and radiographic
investigation. It is recommended to follow a checklist
to ensure that all necessary information regarding
the patient and the injury is gathered, including:
1) Patient’s name, age, sex, address and contact
numbers (include weight for young patients).
2) Central nervous system symptoms exhibited
after the injury.
3) Patient’s general health.
4) When, where and how the injury occurred.
5) Treatment the patient received elsewhere.
6) History of previous dental injuries.
7) Disturbances in the bite.
8) Tooth reactions to thermal changes or sensitivity to sweet/sour.
9) If the teeth are sore to touch or during eating.
10) If the patient is experiencing spontaneous
pain in the teeth.
Once all of this information is gathered, a diagnosis can be made and appropriate treatment rendered.
If the injured individual is not a patient of record,
all necessary demographic information should be
gathered as soon as the patient arrives and prior to
any assessment. In the case of avulsion and the tooth
being out of its socket, one should immediately place
the tooth in a physiological solution of specialized
media (such as Hank’s Balanced Salt Solution™) or
milk, or saline if those are not available. Only after
the tooth is secured in solution should one obtain
the patient’s information. Once the patient is seated
in the dental chair, it is necessary to do a quick central
nervous system (CNS) evaluation before proceeding
with further assessments.
Often, the dentist is the first health-care provider to
see the patient after a head injury (any dental trauma
is, by definition, a head injury) and must assess the risk

Fig. 1c

[7] =>

application.
It is advisable
showing promise
for this
application.to
It create
is advisable
a 1-2 mm reservoir
to create
1-2 mm
reservoir
ulp with a high-speed diamond bur and copious water cooling, place the capping material,
and athen
either
reattach
the tooth
C.E.
article_
trauma
bur and
copious water
cooling, place
the2).
capping material, and then either reattach the tooth
orhigh-speed
restore thediamond
crown with
a composite
resin material
(Figure
the crown with a composite resin material (Figure 2).
ot Fractures

a chamfer was cut along the fracture line and additional composite cured in place. This will both increase the
and better hide the fracture line (C).

he more challenging types
challenging
types
re
to treat is
the crownA
B
eat
the crowntureisbecause
the fracture
A
B
ause
fracture around
as
to the
be exposed
1 1/2 to 2 mm high-speed
e/crown
exposed
around restore
to properly
diamond bur with
1 1/2 to 2 mm high-speed
Pulp capping agent
C
o
properly
restore
copious water cooling
diamond
bur
with
Glass-ionomer
Pulp capping agent
C
. This can be accomplished
copious water cooling
Glass-ionomer
nectomy
be accomplished
if the fracture line Fig. 2. (A) Schematic diagram of minimal pulpotomy, where an approximately 2-mm reservoir is cut with a high-speed
ifsulcus.
the fracture
line extreme
Fig. 2. (A) Schematic
diagram
minimalwater
pulpotomy,
where
an approximately
is cutwater
with placed.
a high-speed
diamond
bur andofcopious
cooling
and calcium
hydroxide2-mm
mixedreservoir
with sterile
(B) Glass ionomer or a
In more
diamond
bur
and
copious
water
cooling
and
calcium
hydroxide
mixed
with
sterile
water
placed.
(B)
Glass
ionomer
orbonding.
a
protective
liner
is
placed
over
the
pulp
capping
agent
to
ensure
it
stays
in
place
during
etching
and
(C) Clinical
In more extreme
Fig. 2a
Fig. 2b
e tooth will have to
be linerpictures
protective
is placed
overminimal
the pulppulpotomy.
capping agent
to ensure
it stays in
place during
and bonding. (C) Clinical
of the
Schematic
drawings
courtesy
of Dr. etching
Sigurdsson.
will have to be pictures of the minimal pulpotomy. Schematic drawings courtesy of Dr. Sigurdsson.
of concussion or hemorrhage. It has been estimated responsive for several weeks after a traumatic injury,
3
by a meta-analysis that the prevalence
3 of intracranial so a pulp test should be done at every follow-up
hemorrhage after a mild head injury is 8 percent, and appointment until a normal response is obtained.7
the onset of symptoms can be delayed for minutes to
Once the diagnosis is confirmed and more serious
4
hours. The most common signs of serious cerebral complications such as CNS and jaw or other facial bone
concussion or hemorrhage are loss of consciousness fractures have been ruled out, the emergency phase of
or post-traumatic amnesia. Nausea/vomiting, fluids the treatment needs to be initiated. The aim of treating
from the ear/nose, situational confusion, blurred vision dental trauma should be to either maintain or regain
or uneven pupils, and difficulty of speech and/or slurred pulpal vitality in traumatized teeth. This is because denspeech may also indicate serious injury.5
tal trauma most frequently occurs in pre-teens or young
Once the patient has been cleared of any CNS teens in whom the teeth have not yet fully developed,
issues, the dental trauma should be assessed. The and root development will cease without a vital pulp.
key is to obtain comprehensive information about
the injury and, to do so, one must conduct thorough _Clinical examples
extraoral and intraoral clinical exams as well as appropriate radiographic evaluations.
Dental trauma can be roughly divided into two
The new AAE guidelines recommend taking one groups: fractures and luxation injuries. The fractures
occlusal and two periapical radiographs with dif- are then further divided by type: crown, crown-root
ferent lateral angulations for all dental injuries, and root fractures. If the pulp is exposed to the oral
including crown fractures. If cone-beam computed environment, it is called a complicated fracture; if not
Colleagues
for Excellence
tomography is available, it should be considered for ENDODONTICS:
exposed, it is called
an uncomplicated
fracture.
more serious injuries, such as crown/root, root and
extruded with orthodontic forces or surgically repositioned. In the emergency session, if the pulp is exposed, it needs to be
alveolar
fractures, as well as all luxation injuries.
Crown fractures: The first thing to do in any
protected in the same fashion as complicated crown fractures. If it is not exposed, all accessible exposed dentin areas should
Additionally,
sensibility
should be conducted crown or crown-root fracture is to look for the
be covered for the
patient’s tests
comfort.
for as
all well
these as
fracture
types is
generally
however, endodontic
treatment may
be indicated
(15,
on allPulpal
teethsurvival
involved
opposing
teeth.
Coldgood;broken-off
tooth fragment.
With
modernlater
bonding
16). Therefore, it is of utmost importance that a recall schedule is followed and that the teeth involved in the trauma are
testing is recommended over electric pulp testing technology it is possible to rebond the fragment to
tested every time. Tables
1 and 2 outline the recommended recall rates for most common dental injuries. It is not uncommon
6
in young
individuals.
Bothtotesting
methods
the and
tooth,
which
is esthetically
thedoes
bestnotsolution.
for there
to be no response
vitality tests
for up should
to three months,
a lack
of response
to vitality tests
always
indicate that root
canal treatment
is needed
especially
in young
andtoimmature
teeth. the
Rather,
it isfragment,
advisable tothe
lookremainfor at
be considered,
however,
especially
when– there
is no
Prior
reattaching
tooth
least
one
other
sign
of
pulpal
necrosis,
like
vestibule
swelling,
periapical
lesions
and/or
dramatic
color
change
of
the
crown.
response to one of the two. The pulp might be non- ing dental thickness immediately covering the pulp

Fig. 2c

Fig. 2a_Schematic diagram of
minimal pulpotomy, where an
approximately 2-mm reservoir is
cut with a high-speed diamond
bur and copious water cooling and
calcium hydroxide mixed with sterile
water placed. (Schematic drawings/
Provided by Dr. Sigurdsson)
Fig. 2b_Glass ionomer or a protective
liner is placed over the pulp capping
agent to ensure it stays in place
during etching and bonding.
Fig. 2c_Clinical pictures of the
minimal pulpotomy.

If no signs exist, continue to monitor the patient at regular appointments every three months, for up to one year.

Table 1. Follow-Up Procedures for Fractured Permanent Teeth and Alveolar Fractures

Crown Fracture

Crown-Root Fracture

Root Fracture

Alveolar Fracture

Splint removal*,
clinical and
radiographic control

Splint removal and clinical
and radiographic controls

Clinical and
radiographic control

Clinical and radiographic
control

4 Months

Splint removal**,
clinical and
radiographic control

Clinical and radiographic
control

6 Months

Clinical and
radiographic control

Clinical and radiographic
control

Clinical and
radiographic control

Clinical and radiographic
control

Clinical and
radiographic control

Clinical and radiographic
control

TIME

Uncomplicated

Complicated

Uncomplicated

Complicated

4 Weeks

6-8 Weeks

1 Year

Clinical and
radiographic
control

Yearly for
5 Years

*Splint removal in apical third and mid-root fractures; **Splint removal with a root fracture near the cervical area

(Tables/Provided by American
Association of Endodontists)

Table 2. Follow-Up Procedures for Luxated Permanent Teeth
TIME

2 Weeks

Concussion/Subluxation
Splint removal (if applied for
subluxation)
Clinical and radiographic

Extrusion
Splint removal
Clinical and radiographic
examination

Lateral Luxation

Intrusion

Clinical and radiographic
examination

roots
3

_ 2015

I 07

[8] =>

I C.E. article_ trauma

Fig. 3a

Fig. 3b

Fig. 3c

Fig. 3d

Fig. 3e

Fig. 3f

Fig. 3a_Schematic drawing of a
common situation after root fracture:
The crown portion is displaced inward
toward the palate and the fractured
piece is stuck to the facial cortical plate.

needs to be assessed radiographically and clinically. the pulp is not exposed, all accessible exposed dentin
If there is at least 0.5 mm of the dentin remaining, areas should be covered for the patient’s comfort.
Pulpal survival for all these fracture types is generthere is no need to cover it with a protective liner. If
it is estimated that the remaining dentin is less than ally good; however, endodontic treatment may be in0.5 mm, it is advisable to cover the deepest part, clos- dicated later.15,16 Therefore, it is of utmost importance
Colleagues
for Excellence
est to the pulp, with a cavity liner, and then dimple the ENDODONTICS:
that a recall schedule
is followed
and that the teeth
8,9
Figs. 3b, c_It is impossible to move fragment accordingly. If the tooth fragment was involved in the trauma are tested every time. Tables
extruded with orthodontic forces or surgically repositioned. In the emergency session, if the pulp is exposed, it needs to be
the coronal portion back to its original kept dry, it should be rehydrated in distilled water or 1 and 2 outline the recommended recall rates for
protected in the same fashion as complicated crown fractures. If it is not exposed, all accessible exposed dentin areas should
for 30 minutes prior to reattachment. This proc- most common dental injuries. It is not uncommon for
location without releasing it from the besaline
covered for the patient’s comfort.
10
will increase
itsall
bonding
strength
1a-c). good;there
to beendodontic
no response
to vitality
for up tolater
three(15,
cortical plate. This is accomplished ess
Pulpal
survival for
these fracture
types(Figs.
is generally
however,
treatment
maytests
be indicated
it is of utmost
importance
a recall
schedule
is followed
the teeth to
involved
the does
trauma
In a complicated
fracture,
the goalthat
is to
create
a months,
and aand
lackthat
of response
vitalityintests
notare
by pulling the coronal portion down 16). Therefore,
tested
every
time.
Tables
1
and
2
outline
the
recommended
recall
rates
for
most
common
dental
injuries.
It
is
not
uncommon
and then repositioning it. bacteria-tight seal to protect the pulp, after ensur- always indicate that root canal treatment is needed —
for there to be no response to vitality tests for up to three months, and a lack of response to vitality tests does not always
ing that the pulpal wound is clean and all inflamed especially in young and immature teeth. Rather, it is
indicate that root canal
treatment is needed – especially in young and immature teeth. Rather, it is advisable to look for at
11,12
tissue
The two
best like
capping
materials
advisablelesions
to lookand/or
for atdramatic
least one
other
signofofthe
pulpal
Fig. 3d_A periapical radiograph least
oneremoved.
other sign of pulpal
necrosis,
vestibule
swelling, periapical
color
change
crown.
today
are calcium
hydroxide
andatmineral
necrosis, such
vestibule
swelling,
of a root fracture a few hours after Ifavailable
no signs exist,
continue
to monitor
the patient
regular appointments
everyasthree
months,
for up toperiapical
one year. lesions
the injury. It was established that trioxide aggregate (MTA),13,14 but newer bioceramic and/or dramatic color change of the crown. If no signs
Table 1. Follow-Up Procedures for Fractured Permanent Teeth and Alveolar Fractures
both fragments were in good materials are showing promise for this application. It exist, continue to monitor the patient at regular apa 1-2
mm reservoir into theCrown-Root
pulp pointments
approximation of each other. is advisable to create
Crown
Fracture
Fracture every three months, for up to one year.
Root Fracture
Alveolar Fracture
TIMEa high-speed
diamondComplicated
bur and copious
water
Splinting was done for two weeks. with
Uncomplicated
Uncomplicated
Complicated
cooling, place the capping material, and then either
Root fractures: The
pulp is affected in all root fracSplint removal*,
removal and clinical
Weeks
and
fragments
areSplint
approximated
the tooth fragment or restore the crown tures. However, if theclinical
Fig. 3e_At the nine-month recall, 4reattach
and
radiographic controls
radiographic control
soon after the fracture, there is a good chance that no
internal root resorption was noted, but with a composite resin material (Figs. 2a-c).
Clinical and
Clinical and
Clinical and
Clinical andtreatment is necessary, just observation.
endodontic
no defect in the PDL or adjacent bone,
Clinical and
Clinical and radiographic
6-8 Weeks
radiographic
radiographic
radiographic
radiographic
radiographic control
control
control
control
controlapproximation, it is likely that the pulp will
With good
Crown-rootcontrol
fractures: One of
the more challengindicating a ‘normal’ healing process.
the fracture
ing types of fracture to treat is the crown-root frac- revascularize across Splint
removal**, regardless of the age
Clinical and radiographic
4
Months
clinical
and A recent retrospective
17,18
(Figs.
3a-f).
Fig. 3f_Five-year recall, no ture because the fracture margin has to be exposed of the patient
control
radiographic control
endodontic treatment was needed. around the tooth/crown to properly restore the tooth. study included assessment of splinting type and time
Clinical and
Clinical and radiographic
6This
Months
can be accomplished by gingivectomy if the of root fracture. The
study control
determined that,
if the
radiographic
control
fracture line Clinical
is in the
In more
cases,
cervical
portion
of theClinical
tooth
is stableClinical
onceandthe
two
and sulcus. Clinical
and extreme
Clinical
and
Clinical
and
and
radiographic
1 Year
radiographic
radiographic
radiographic
radiographic
radiographic controlno splint orcontrol
the tooth will have
to be extruded
with orthodontic
pieces control
have been approximated,
a flexible
control
control
control
forces or surgically repositioned. In the emergency splint for two weeks Clinical
produces
the best
treatment
Yearly for
and
Clinical and radiographic
2,18
5 Years if the pulp is exposed, it needs to be protected
control
session,
outcome. Longerradiographic
splintingcontrol
time is recommended
in the same fashion
complicated
crown
If only
when
the fracture
is fracture
close tonear
thethecervical
*Splint as
removal
in apical third
andfractures.
mid-root fractures;
**Splint
removal
with a root
cervicalarea.
area
Table 2. Follow-Up Procedures for Luxated Permanent Teeth

08 I roots
3_ 2015

TIME

Concussion/Subluxation

Extrusion

Lateral Luxation

Intrusion

2 Weeks

Splint removal (if applied for
subluxation)
Clinical and radiographic
examination

Splint removal
Clinical and radiographic
examination

Clinical and radiographic
examination

4 Weeks

Clinical and radiographic
examination

Splint removal
Clinical and radiographic
examination

6-8 Weeks

Clinical and radiographic
examination

Clinical and radiographic
control

6 Months

Clinical and radiographic
examination

1 Year

Clinical and radiographic
examination

2-5 Years

Yearly up to 5 years

[9] =>

C.E. article_ trauma

Fig. 4a

Luxation injuries: All luxation injuries will cause
some damage to the periodontal ligament and, in
some cases, the pulp as well. The immediate treatment is to limit further damage to the PDL and allow
for the best possible healing. As with all dental injuries, follow-up is essential. Late complications, such
as internal or external root resorptions, are relatively
frequent and require endodontic treatment, especially in more severe injuries. In many of these cases,
referral to an endodontist is advisable.
Luxation injuries are divided into subcategories,
mainly by degree of severity. The two mildest are
termed “concussion” and “subluxation.” In those
cases, the tooth is still in its original location, but
is tender to percussion and/or, in the case of subluxation, has increased mobility. While no immediate
treatment is needed for these injuries, follow-up is
critical because the pulp may become necrotic, making endodontic intervention paramount.
When trauma has moved the tooth out of its normal
position, it needs to be replaced gently as soon as possible. The only exceptions are cases of intrusion when
it might not be possible or advisable to manipulate
the tooth immediately. When an immature tooth is
intruded up to 7 mm, it is recommended to wait three
weeks and watch for signs of re-eruption. If no signs
exist, one can initiate orthodontic repositioning. For
intrusion of more than 7 mm, surgical or orthodontic
repositioning should be performed within three weeks.
In the case of an intruded tooth with a closed apex, there
is a possibility of re-eruption if the tooth is slightly intruded (less than 3 mm) and the patient is younger than
17 years old. If the tooth is not moving after two to three
weeks, however, orthodontic extrusion or extraction
and reimplantation is recommended. If a tooth with a
closed apex is intruded more than 3 mm, orthodontic
or surgical repositioning should be performed within
three weeks. The risk with all intrusions is that the
intruded tooth may ankylose in the infraposition. Once
that begins, the tooth may not be movable except possibly surgically. It is well to advise the patient and the
parents/guardians that the long-term prognosis of an
intruded tooth is unpredictable, as it is likely to eventually be lost due to ankylosis.19-21
Splinting of a luxated tooth is recommended only
for teeth that are still mobile after repositioning. In all
types of trauma cases, a splint must allow for physiological movement.22,23 (See Figs. 4a-c and 5, and
Table 3, regarding splinting time.)

Fig. 4b

4c
ENDODONTICS: Fig.
Colleagues
for Excellence

Fig. 5

RootWhen
Fractures
assessing luxation trauma, it is important

Fig. 4a_In lateral luxation injuries
The
pulp isthe
affected
in of
allthe
root
fractures.
However,
fragments
s
maxillary
teeth, theare
apexapproximated
is
to consider
maturity
apex.
If it is still
open, ifofthe
good
chance
thatthat
no the
endodontic
treatment
necessary,
just observation.
With
frequently
pushed through
the good appro
there is
a chance
pulp will survive
the is
trauma
will
revascularize
across
the
fracture
regardless
of
the
age
of
the
patient
(17, 18) (Figure
or revascularize, allowing the growth of the tooth to cortical plate facially.

included
assessment
continue (Figs.
6a-c). of splinting type and
time
of root
study determined
If the
apexfracture.
is closed,The
endodontic
treatment is likely
that,
if
the
cervical
portion
of
the
tooth closely
needed. It is advisable to follow the patient
is
stable
once
two
have
been
(Table
1) or
referthehim
or pieces
her to an
endodontist
for
approximated, no splint or a flexible splint
further evaluation. Because of the injury to the PDL,
for two weeks produces the best treatment
rapid inflammatory root resorption can occur (within
outcome (2, 18). Longer splinting time is
days or a few weeks) if the necrotic pulpal tissue
only recommended when the fracture is
becomes infected. For mature teeth diagnosed with
close to the cervical area.

Figs. 4b, c_To reposition the tooth,
it has to be released prior to moving
the crown forward.

Fig. 5_Once the tooth has been
repositioned, the patient bites into
a softened pink wax plate that had
been previously rolled one or two
times. This will ensure that the
luxated (or avulsed) tooth stays in
place while being splinted. In this
case, a 16-pound fishing line was
used as the splint on the luxated
tooth.

necrotic pulps, placing calcium hydroxide for two
to four weeks
Luxation
Injuriesprior to obturation is recommended;
however,
one should
allow
PDL tosome
heal for two
All
luxation
injuries
willthecause
weeks before
(seeligament
treatment
forinavulsion,
damage
to theplacement
periodontal
and,
below).
Apexification
revascularization
is recomsome
cases,
the pulp asorwell.
The immediate
24,25
mended foristeeth
with open
apices.
treatment
to limit
further
damage to
is important
to remember
that dental
injuries do
theItPDL
and allow
for the best
possible
not always
into
group
or category,
but often
healing.
Asfall
with
allone
dental
injuries,
followD
E
a combination
several
categories. Injuries
up
is essential.ofLate
complications,
such asin multiinternal
or external
rootthe
resorptions,
areexample,
ple categories
will impact
outcome. For
Fig. 3. (A) Schematic drawing of a common situation after ro
relatively
frequent
and require
endodontic
it was recently
demonstrated
that
the existence ofinward
a towards the palate and the fractured piece is stuck to
to move the coronal portion back to its original location with
treatment,
especially
in with
more
severe
concurrent luxation
injury
an uncomplicated
is accomplished by pulling the coronal portion down and the
injuries.
In many
ofcomplete
these cases,
to
of a root fracture a few hours after the injury. It was establis
crown fracture
and
rootreferral
development
are
approximation of each other. Splinting was done for two we
an
endodontist
is advisable.
significant
risk factors
of pulp necrosis.26
resorption was noted, but no defect in the PDL or adjacent b

Luxation injuries are divided into
Five-year recall, no endodontic treatment was needed. Sche
subcategories,
mainly
degree
severity.
Avulsion: The
time by
outside
ofofthe
socket for an
The two mildest are termed “concussion” and “subluxation.” In those cases, the tooth is
avulsed tooth is the most critical of its survival. If the
tender to percussion and/or, in the case of subluxation, has increased mobility. While no
tooth is replanted within 30 minutes, or alternatively
for these injuries, follow-up is critical because the pulp may become necrotic, making end
kept in a physiological solution of specialized media or
When trauma has moved the tooth out of its 27,28
normal position, it needs to be replaced ge
milk
for
a
few
hours,
it
has
a
fairly
good
prognosis.
exceptions are cases of intrusion when it might not be possible or advisable to manipulate
If the toothtooth
has been
dry for more
one
the
immature
is intruded
up to than
7 mm,
it ishour,
recommended
to wait three weeks and watch f
periodontal
ligament
cannot
be
expected
to
survive
exist, one can initiate orthodontic repositioning. For intrusion of more than 7 mm, surg
and thebe
tooth
will likely
become
ankylosed
(Fig.
should
performed
within
three
weeks. In
the7).case of an intruded tooth with a closed
eruption if the tooth is slightly intruded (less than 3 mm) and the patient is younger tha
moving after two to three weeks
Table 3. Splinting Time for Various Types of Injuries
or extraction and reimplantation
a closed apex is intruded more th
Type of Injury
Splinting Time
repositioning should be perform
Subluxation
2 weeks
with all intrusions is that the intr
Extrusive luxation
2 weeks
infraposition. Once that begins,
Avulsion
2 weeks
except possibly surgically. It is w
parents/guardians that the long
Lateral luxation
2 weeks
tooth is unpredictable, as it is lik
Intrusion
4 weeks
ankylosis (19-21).
Root fracture (middle 1/3)
4 weeks
Splinting of a luxated tooth is
Alveolar fracture
4 weeks
are still mobile after repositionin
splint must allow for physiologic
Root fracture (cervical 1/3)
4 months
5

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3
I 09
_ 2015

[10] =>

I C.E. article_ trauma
Fig. 6a_An immature tooth that was
laterally luxated, as can be seen by
the empty socket space around the
apex on the radiograph.
Fig. 6b_The tooth was repositioned
and splinted for two weeks.
Fig. 6c_At the six-month recall
there is good evidence that the apex
is maturing and the pulp responds
normally to cold. At the three-year
recall the pulp chamber is completely
calcified; however, the tooth
responds normally to EPT and there
is no apical pathology.
Fig. 7_Ankylosis or replacement
root resorption, in which the root
structure is lost and replaced by
bone. Note that no apparent PDL
space is seen.

Fig. 6a

Fig. 6b

Once reimplanted, most teeth need to be stabilized
with a physiological splint for two weeks.29
If the avulsed tooth has an open apex and was reimplanted within the hour, there is a possibility that the
pulp will revascularize. In this case, delaying endodontic
treatment at the emergency stage is recommended.
Endodontic treatment should be performed later only if
signs of pulpal necrosis, root resorption and/or arrested
root development are confirmed.
In the case of a closed apex, revascularization is
not expected. Therefore, endodontic treatment must
be initiated two weeks after the tooth is reimplanted,
and prior to removal of the splint. Treatment should
not be initiated earlier because any further manipulation of the tooth prior to or immediately after
reimplantation can cause further damage to the PDL.
In addition, it has been shown that placing calcium
hydroxide as an intracanal medicament immediately
after reimplantation will promote inflammation that
can lead to PDL damage.30 If the tooth had been kept
dry longer than 60 minutes, performing root canal
treatment prior to replantation is indicated.31
After the emergency situation has been managed
and the tooth/teeth stabilized, the second phase
begins, in which the pulpal condition and likelihood
of root resorption have to be carefully evaluated
and the patient followed over a period of months, if
not years. A follow-up timeline is essential to allow
for intervention if signs of complications appear. In
such cases, the expertise and training of endodontists become important. Diagnosing, preventing and
treating any pulpal complications are an integral
part of endodontic training as are performing pulp
regenerative procedures and treating inflammatory
root resorption (Figs. 8a,b).

_Conclusion

10 I roots
3_ 2015

Traumatic dental injuries present difficult challenges for both patients and their dentists. Current
evidence allows the dental health care provider to
manage situations that, in the past, often resulted
in crippled dentition and unsightly appearance. Appropriate treatment can turn what at first glance
looks like a hopeless situation into a very satisfactory
outcome for patients. The endodontic specialist can

Fig. 6c

Fig. 7

play an important role in the team approach to treating patients with traumatic dental injuries._

_References
1.

Diangelis AJ, Andreasen JO, Ebeleseder KA, Kenny DJ,
Trope M, Sigurdsson A, et al. International Association
of Dental Traumatology guidelines for the management
of traumatic dental injuries: 1. Fractures and luxations of
permanent teeth. Dent Traumatol 2012;28:2-12.
2. Andreasen JO, Ahrensburg SS, Tsilingaridis G. Root
fractures: the influence of type of healing and location of
fracture on tooth survival rates - an analysis of 492 cases.
Dent Traumatol 2012;28:404-409.
3. Bucher K, Neumann C, Thiering E, Hickel R, Kuhnisch J.
Complications and survival rates of teeth after dental trauma
over a 5-year period. Clin Oral Invest 2013;17:1311-1318.
4. Hofman PA, Nelemans P, Kemerink GJ, Wilmink JT. Value of
radiological diagnosis of skull fracture in the management of
mild head injury: meta-analysis. J Neurol Neurosurg Psych
2000;68:416-422.
5. McCrory P, Meeuwisse WH, Aubry M, Cantu RC, Dvorak J,
Echemendia RJ, et al. Consensus statement on concussion
in sport: the 4th International Conference on Concussion in
Sport, Zurich, November 2012. J Athl Train 2013;48:554-575.
6. Fuss Z, Trowbridge H, Bender IB, Rickoff B, Sorin S.
Assessment of reliability of electrical and thermal pulp
testing agents. J Endodon 1986;12:301-305.
7. Skieller V. The prognosis for young teeth loosened after
mechanical injuries. Acta Odonta Scand 1960;18:171-173.
8. About I, Murray PE, Franquin JC, Remusat M, Smith AJ.
The effect of cavity restoration variables on odontoblast cell
numbers and dental repair. J Dent 2001;29:109-117.
9. Murray PE, About I, Lumley PJ, Franquin JC, Windsor LJ, Smith AJ.
Odontoblast morphology and dental repair. J Dent 2003;31:75-82.
10. Capp CI, Roda MI, Tamaki R, Castanho GM, Camargo MA,
de Cara AA. Reattachment of rehydrated dental fragment
using two techniques. Dent Traumatol 2009;25:95-99.
11. Cox CF, Bergenholtz G, Fitzgerald M, Heys DR, Heys RJ,
Avery JK, et al. Capping of the dental pulp mechanically
exposed to the oral microflora – a 5 week observation of
wound healing in the monkey. J Oral Path1982;11:327-339.
12. Cvek M, Lundberg M. Histological appearance of pulps after
exposure by a crown fracture, partial pulpotomy, and clinical
diagnosis of healing. J Endodon 1983;9:8-11.
13. Cvek M. A clinical report on partial pulpotomy and

[11] =>

C.E. article_ trauma

Fig. 8a

Fig. 8b

capping with calcium hydroxide in permanent incisors with
complicated crown fracture. J Endodon 1978;4:232-237.
14. Torabinejad M, Chivian N. Clinical applications of mineral
trioxide aggregate. J Endodon 1999;25:197-205.
15. Andreasen FM, Noren JG, Andreasen JO, Engelhardtsen
S, Lindh-Stromberg U. Long-term survival of fragment
bonding in the treatment of fractured crowns: a multicenter
clinical study. Quintessence Intern 1995;26:669-681.
16. Robertson A, Andreasen FM, Andreasen JO, Noren JG. Longterm prognosis of crown-fractured permanent incisors. The
effect of stage of root development and associated luxation
injury. Int J Paedi Dent 2000;10:191-199.
17. Zachrisson BU, Jacobsen I. Long-term prognosis of 66
permanent anterior teeth with root fracture. Scan J Dent Res
1975;83:345-354.
18. Cvek M, Tsilingaridis G, Andreasen JO. Survival of 534
incisors after intra-alveolar root fracture in patients aged
7-17 years. Dent Traumatol 2008;24:379-387.
19. Alkhalifa JD, Alazemi AA. Intrusive luxation of permanent
teeth: a systematic review of factors important for treatment
decision-making. Dent Traumatol 2014;30:169-175.
20. Andreasen JO, Bakland LK, Andreasen FM. Traumatic
intrusion of permanent teeth. Part 2. A clinical study of
the effect of preinjury and injury factors, such as sex, age,
stage of root development, tooth location, and extent of
injury including number of intruded teeth on 140 intruded
permanent teeth. Dent Traumatol 2006;22:90-98.
21. Andreasen JO, Bakland LK, Andreasen FM. Traumatic
intrusion of permanent teeth. Part 3. A clinical study of the
effect of treatment variables such as treatment delay, method
of repositioning, type of splint, length of splinting and
antibiotics on 140 teeth. Dent Traumatol 2006;22:99-111.
22. Kahler B, Heithersay GS. An evidence-based appraisal of
splinting luxated, avulsed and root-fractured teeth. Dent
Traumatol 2008;24:2-10.
23. Andreasen JO, Andreasen FM, Mejare I, Cvek M. Healing of
400 intra-alveolar root fractures. 2. Effect of treatment factors
such as treatment delay, repositioning, splinting type and
period and antibiotics. Dent Traumatol 2004;20:203-211.
24. Huang GT. A paradigm shift in endodontic management of
immature teeth: conservation of stem cells for regeneration.
J Dent 2008;36:379-386.

25. Trope M. Treatment of the immature tooth with a non-vital pulp
and apical periodontitis. Dent Clin N Am 2010;54:313-324.
26. Wang C, Qin M, Guan Y. Analysis of pulp prognosis in 603
permanent teeth with uncomplicated crown fracture with or
without luxation. Dent Traumatol [Epub ahead of print]: 2014
27. Blomlof L, Lindskog S, Hedstrom KG, Hammarstrom L.
Vitality of periodontal ligament cells after storage of monkey
teeth in milk or saliva. Scand J Dent Res 1980;88:441-445.
28. de Souza BD, Bortoluzzi EA, da Silveira Teixeira C, Felippe
WT, Simoes CM, Felippe MC. Effect of HBSS storage time
on human periodontal ligament fibroblast viability. Dent
Traumatol 2010;26:481-483.
29. Hinckfuss SE, Messer LB. Splinting duration and periodontal
outcomes for replanted avulsed teeth: a systematic review.
Dent Traumatol 2009;25:150-157.
30. Lindskog S, Blomlof L, Hammarstrom L. Cellular colonization
of denuded root surfaces in vivo: cell morphology in dentin
resorption and cementum repair. J Clin Perio 1987;14:390-395.
31. Day P, Duggal M. Interventions for treating traumatised
permanent front teeth: avulsed (knocked out) and replanted. The
Cochrane database of systematic reviews 2010(1):CD006542.

Fig. 8a_Inflammatory root
resorption secondary to pulpal
necrosis and infection in the pulpal
space after avulsion. If diagnosed
in time, it is possible to arrest the
root resorption and maintain the
tooth. Extensive inflammatory
root resorption on a tooth that
was avulsed and reimplanted, but
no further treatment done for six
weeks.
Fig. 8b_Calcium hydroxide was
placed in the tooth for three months.
Apparent healing of the peri-root
lesions and some reconstitution of a
normal looking PDL.

This article originally appeared in ENDODONTICS:
Colleagues for Excellence, Summer 2014. Reprinted
with permission from the American Association of
Endodontists, ©2014. The AAE clinical newsletter is
available at www.aae.org/colleagues.

_about the author

roots

Asgeir Sigurdsson, DDS,
MS, was born and raised in
Reykjavik, Iceland. He received a dental degree from
University of Iceland, Faculty
of Dentistry, in 1988. After
one year in private practice in
Iceland, he moved to Chapel
Hill, N.C. He graduated from
University of North Carolina
(UNC) at Chapel Hill in 1992
with a certificate in endodontics and a master of science with emphasis on neurobiology
and pain perception. He was a full-time faculty member at UNC
School of Dentistry from 1992 until 2004, first as an assistant
professor and then associate professor with tenure beginning
in 2000. He was appointed as the graduate program director
of endodontics (specialty training) in 1997 and served in that
position until 2004. From 2004 to 2012 he was in a private endodontic practice in Reykjavik, Iceland, and London, England.
In September 2012 he became the chairman of the department
of endodontics at New York University College of Dentistry.
Additionally, he holds the following academic positions: From
2004 adjunct associate professor at UNC; honorary clinical
teacher in endodontology, UCL Eastman Dental Institute,
London, from 2006; and from 2011 honorary clinical associate professor in the Faculty of Dentistry, the University of Hong
Kong. He has lectured extensively around the world on dental
trauma, endodontics, pain diagnosis and forensic dentistry. He
is active in many professional organizations and is past president of the International Association for Dental Traumatology
(IADT). He received the Edward M. Osetek Educator Award from
the American Association of Endodontists in 1998.

roots
3
I 11
_ 2015

[12] =>

I technique_ access

Cutting endodontic
access cavities — for
long-term outcomes
Author_L. Stephen Buchanan, DDS, FACD, FICD

Fig. 1_Maxillary central incisor with
slot-like access cavity that is cut
short of the incisal edge, adequately
under the cingulum, and has been
kept narrow in its mesial-to-distal
dimension. (Photos/Provided by
Dr. L. Stephen Buchanan, unless
otherwise noted)
Fig. 2_Mandibular premolar with
slot-like access cavity for a single
canal root. Note how the access cavity
is skewed toward the working buccal
cusp tip and shy of the idling lingual
cusp, yet is centered above the root
structure, as evidenced by the rubber
dam clamp jaws engaged at the CEJ.
Fig. 3_Sagitally dissected maxillary
molar with mesially inclined access
cavity, parallel to the mesial surface
of the tooth and shy of the distal half
of the tooth.

Fig. 1

12 I roots
3_ 2015

every access cavity — even after doing this for 35
years — to be certain to hit the mark I know must be
met before it is safe to venture further?

_Errors accumulate during procedures. That’s
the reason botching the access at the start of an
RCT is so much more devastating than say, problems
that come from misfitting a gutta-percha cone just
before finishing the case. Miss a canal and the case is
going down, regardless of how brilliant the remaining procedure is carried out. Perforate the tooth, and
suddenly titanium starts looking better. Cut huge
access cavities, and expect to see relatively huge
numbers of root-fractured teeth within five years
of treatment. Simply cheat the access procedure by
beginning the instrumentation of canals before a
straight, perfectly smooth path has been cut to each
canal orifice, and be punished every time a file, an
irrigating needle, an explorer, a gutta-percha point,
a paper point or a plugger is taken into each of the
canals scores of times.
This is not a critique so much as an admission of
the ways that teeth and their root canal systems have
taught me, usually the hard way, to spend whatever
time is needed to create perfect entry paths into
canals, before I attempt to work in them. So why do
I have to have a talk with myself before beginning

Robert Persig, in his book “Zen and the Art of
Motorcycle Maintenance,”1 described being deeply
frustrated when a bolt stripped as he was attempting to remove the side covers to the engine of his
motorcycle, before rebuilding it. The rebuild could
not continue until he was able to circumvent this
problem. He had expected to spend several days
completing the mission, yet he was amazed at
the fury he experienced when faced with this
conundrum.
The more he thought about it, the more mystified
he became about his instinctual response, until he
realized that he was tweaked because he had grossly
undervalued this part of the long rebuild procedure,
thinking mostly about the more dramatic routines to
follow, such as cracking the cylinder case, honing the
cylinder, replacing the piston and putting it all back

Fig. 2

Fig. 3

_Zen and the art of endo access

[13] =>

[14] =>

I technique_ access
Figs. 4a, b_Access cavities cut in a
crown-prepped molar requiring RCT (left).
Postoperative radiograph (right) showing
beautiful management of root canal shaping,
cleaning and filling — despite the minimal
size of entry. Note the largely remaining
pulp chamber roof. (Photos/Provided by
Dr. Steve Baerg)

Figs. 4a, b

Fig. 5

Fig. 6

Fig. 7

Fig. 7_Mandibular molar with
nearly total calcification of the pulp
chamber prior to RCT, accomplished
through two perfectly dead-on
access entry ports, leaving a 0.75
mm high pulp chamber isthmus
between. Note the definitive
treatment results in the apical thirds
of each canal. (Photo/Provided by Dr.
N. Pushpak)
Fig. 8_This restored access
cavity design was opportunistic in
the best sense of the word. This
patient’s endodontic disease state
was resolved with almost no tooth
structure being cut, preserving the
structural integrity of the tooth by
using the cleaned out carious defect
as access cavity. No need for a fullcoverage crown. (Photo/Provided by
Dr. Michael Trudeau)

14 I roots
3_ 2015

Fig. 8

together afterward. When he realized that nothing
was going to progress until he had successfully
removed the side cover, he made removing that side
cover a separate and important mission, an accomplishment that would deliver satisfaction in and of
itself, if it could be completed during the next several
hours spent.
So it is with endodontics. When we realize how
critical the quality of our access preparations is to
the remainder of the case, it feels like fingernails on
a chalkboard to head into a canal before securing an
ideal path into it. Aristotle got it right — excellence is
a habit, not a character trait. So what do the habits of
access excellence look like in this 21st century?

_Failing to plan is planning to fail
Atul Gawande, in his book “The Checklist Manifesto,”2 describes the importance of planning not just
which procedure to do, but how every single aspect of
that procedure must be planned in detail, from start
to finish, if consistently ideal results are the goal.
Does the preoperative imaging accurately describe
the anatomical challenges? Does the clinician have
adequate magnification and light? Are the cutting
tools adequate and well chosen? Are the locations,
angles and depths of entry determined before beginning the procedure? Have maximal safe cutting
lengths been marked on access burs? Are there procedures in place to deal with calcified canals that defy
location? And so on.

Fig. 5_Postoperative radiograph of a
mandibular molar treated through the mesial
carious defect and a second small entry cut
through the central fossa. Preserving dentin
between entry points is referred to as a ‘truss’
access configuration. (Photo/Provided by
Dr. John Khademi)
Fig. 6_This postoperative radiograph shows a
very diminutive access cavity opening with
both mesial and distal lateral pulp horns left
intact during the RCT procedure and filled
during the postendodontic restorative effort.
This appearance is a matter of pride among
those in the ‘IBAC’ club. (Photo/Provided by
Dr. Jeff Pafford)

In other words, the Alfred E. Neumann attitude
of “What, me worry?” is not appropriate during this
critical event. Conversely, when each of these critical
elements is included in the treatment planning and
execution of an ideal access cavity preparation, the
rest of the procedure becomes progressively simpler
as the finish is approached.

_Radiographic imaging
We wouldn’t even attempt RCT without Roentgen’s invention of the dental radiograph, so it is not
much of a stretch to claim the critical necessity of
ideal preoperative radiography. Ideal preoperative
X-ray imaging must include a straight-on angle that
splits the mesial and distal contacts perfectly — taken
either as a periapical or as a bitewing X-ray image,
then at least one ideal off-angle view in order to
capture data from the Z-plane (buccolingual) of the
tooth in question.
In my practice, a mesial off-angle view of anteriors
and premolars works well, because it is much easier
to capture than a distal angle, and in anteriors and
premolars the mesial view reveals as much radicular
anatomy as a distal view. In molars it is different.
In molars a distal view is far preferable to a mesial
off-angle view, as the mesial view superimposes
the body of the root over the distally curved root
structure, while the distal view casts the apical root
end sideways, where it can be more easily seen on the
radiographic image.

[15] =>

technique_ access

Of course, cone-beam CT (CBCT) imaging is the
unfair endodontic imaging advantage. If told I
could have either a microscope or a CT machine,
but not both, I would choose 3-D imaging every
time. Only CBCT imaging can capture the mesial
view of root structure — the view in which we see
“The Secret Life of Root Canals” — the bucco-lingual
plane containing the greatest degree of anatomic
complexity. One of the greatest joys of having a CT
machine in practice is knowing, for sure, before
the access procedure is begun, that there is only
a single canal in the mesiobuccal root of an upper
molar. Conversely, one of the few negative experiences to be had with this technology is when the
reconstructed volume shows two or three canals, in
a root that has given up only one to the clinician’s
exhaustive search.
The first gift of CBCT imaging to the field of endodontics has been the gift of finding all canals in a
given tooth. Its second gift is the great diminution
of access size possible, because the access cavity
is no longer the primary viewing port into the pulp
chamber and beyond. In fact, CT imaging is the only
view needed into the anatomic verities of root canal
spaces, allowing access cavities to be used exclusively
as treatment, rather than as exploratory portals. Ultimately, RCT access procedures will be done with CTgenerated drill guides, allowing molars to be treated
through three to four 1-mm pea-holes, rather than
the 2- to 4-mm access cavities used today.3

_Outline form
So what are the objectives we consider when
planning the invasion of a root canal space? Basically, all the best access cavities are cut in a balance
between conservation and convenience form. We cut
as little tooth structure as possible, while ensuring
ideal pathways into each canal. Access outline form
objectives become fairly simple then; we demand
convenience form, otherwise we cannot complete
our task, yet we always strive to preserve the structural integrity of the tooth. This boils down to three
easily remembered objectives:
1) In anteriors and premolars, conservation form
is found in the mesial-to-distal dimension. Traditionally, anterior access cavity outline form has been
triangular because of the mesial and distal pulp horns
in these teeth — logical until we consider the structural consequences, a needless weakening of coronal
tooth structure to insure these lateral pulp horns are
cleaned out, when the smallest undercut with a #2
Mueller Bur or Buc-1 ultrasonic tip (Spartan) could
suffice as well. Premolars have pulp chambers like
the shape of a hand, which is fortunately arranged
in a bucco-lingual direction, the angle of the rec-

Fig. 9

Fig. 10

Figs. 11a-c

ommended slot-like access cavity outline form is
bucco-lingual as well, simultaneously combining
convenience and conservation form.
In anterior teeth, convenience form is harder won
as the incisal edge is to be avoided, out of respect for
postendodontic esthetic objectives, thus requiring
a deeper cut under the cingulum, to allow a more
straight-line entry path, while minding the “no-fly
zone” of the incisal edge. The most dangerous anterior
access cavity error is not cutting adequately through
what Dr. Schilder called the “lingual dentinal triangle”
under the cingulum, and this can be accomplished
with minimal structural weakening when the mesiodistal dimension is kept to a 1 to 1.5 mm width (Fig. 1).
2) In posterior teeth, premolars and molars, it is important to remember that their occlusal surfaces are not
centered over the root structure, but are skewed toward
the idling cusp side of the root structure. As pulp chambers are centered in the root structure, not centered
under the occlusal surface, access in posterior teeth is
best accomplished by cutting near working cusps, while
staying 1-2 mm away from idling cusps (Fig. 2).
3) In molars, conservation form is held by avoiding
the distal half of the occlusal plane, as ideal file paths
from the distal canals of upper and lower molars are
canted severely to the mesial, so much so that distal
canals of lower molars are best referenced to the
MB or ML cusp tips, and distobuccal canals of upper
molars are best referenced to the palatal cusp tips.
Convenience form is achieved by cutting the mesial
wall of molar access cavities parallel to the mesial
surface of the tooth (Fig. 3).

Fig. 9_This lower molar was treated
through an access opening that
was less than 2 mm square, cut just
behind the MB triangular ridge. Note
the definitive treatment of the apical
thirds of all four canals, despite the
narrow entry portal. (Photo/Provided
by Dr. Charles Maupin)
Fig. 10_Postoperative radiograph
of a mandibular molar treated
through an alternative to the truss
configuration — an ‘X-entry’ access
cavity — a design that minimizes
removal of tooth structure in the
critical trunk of the tooth (author’s
case).
Figs. 11a-c_From left: Virtual
treatment planning for CT-guided
endodontic access (CT-GEA). The
tooth to be treated is segmented
from the CT volume, ideal access
entry paths are plotted through the
occlusal surface of the tooth, and a
CT-GEA drill guide is 3-D printed.

roots
3

_ 2015

I 15

[16] =>

I technique_ access

Figs. 12a-d
Figs. 12a-d_From left: Author’s
root-fractured #18; that tooth set in a
stone model after extraction, with the
printed CT-GEA drill guide mounted
and the first drill in place; the two
small access entry holes cut using
the drill guide; and a post-exercise
radiograph showing cones fit in
canals after they were negotiated
and shaped.

_Back from the abyss
I was taught Schilder technique at University of
the Pacific by Dr. Michael Scianamblo and after grad
school by Dr. Cliff Ruddle. I understood the clinical
imperative Dr. Schilder had placed on cutting an access adequate to treat the entire root canal system in
a predictable manner, and I enjoyed working through
the large access cavities and the generous coronal
canal shapes he recommended until I was brought up
short by Dr. Carl Reider, a well-known prosthodontic
lecturer from Southern California.
When I asked what he most wanted from the endodontists he referred his patients to, he said he wished
we could “just suck the pulp out, without cutting any
tooth structure.” As we talked, I came to better understand the structural imperative of saving teeth in the
long term, setting me on a quest for tools and methods
that would allow us to achieve the same consistently
ideal endodontic outcomes, through smaller access
openings and coronal canal shapes.
Ultimately, it was the inspiration for my invention
of the Maximum Flute Diameter (MFD) limitations on
GT and GTX rotary files (DENTSPLY Tulsa Dental Specialties), the LAX (line angle extension) Guided Access
Diamond Burs by SybronEndo, as well as obturation
methods using flexible condensation devices, such
as System-B Continuous Wave electric heat pluggers
(SybronEndo) and GT/GTX Obturators (DENTSPLY
Tulsa Dental Specialties).

_The Itty Bitty Access Committee
Since that initial awakening in the ’80s, it has felt
like being a lone voice in the wilderness until the past
10 years, when a new generation of dentists and
endodontists, steeped in the new reality of implant
dentistry as an alternative to RCT, have taken up the
cry for longer-term outcomes through improved
structural preservation, ultimately becoming what I
jokingly call The Itty Bitty Access Committee (IABC).
As so often happens, somebody outside of our
specialty, a general dentist named Dr. David Clark,
started lecturing on the access elephant in the
endodontic living room. He got my buddy Dr. John
Khademi turned on to the possibilities that more con-

16 I roots
3_ 2015

servative access cavities could offer the specialty,4
and one by one a group of young endodontists joined
the game of who can do a perfect RCT through the
smallest access cavity. This ad hoc group of talent
began the IBAC club.
The cases shown in Figures 4 through 10 — mostly
done by IBAC members — make me very happy and
afraid at the same time. What the heck are they doing? Little, tiny entries, leaving pulp chamber roofs
intact, lateral pulp horns unroofed as well, or just
total RCT through previously cut restorative cavities!
After getting over my initial shock at what they
were accomplishing, I came to understand that
the future of endo is very good in these extremely
talented hands, and I saw that the procedure I was
developing for endodontic surgery — CT-guided
endodontic surgery (CT-GES) — could be applied to
conventional treatment as well (Figs. 11a-12d).
And morning breaks over the field of endodontics._
Editorial note: This article was first published in
the Clinical Masters™ magazine, volume 1 — issue 1,
March 2015 . A complete list of references is available
from the publisher.

_about the author

roots

L. Stephen Buchanan, DDS,
FACD, FICD, is a diplomate
of the American Board of
Endodontics, a fellow of the
American and International
Colleges of Dentists and
serves as part-time faculty
to the UCLA and USC graduate endodontic programs. He
holds patents on the Endobender Plier (SybronEndo),
System-B and Continuous
Wave obturation tools and methods (SybronEndo), GT and
GTX file systems (DENTSPLY Tulsa Dental Specialties), LA
Axxess Burs (SybronEndo), and Buc ultrasonic tips (Spartan/
Obtura). Buchanan lives in Santa Barbara, Calif., where he
enjoys a practice limited to conventional and microsurgical
endodontics and dental implant surgery. He is the founder of
Dental Education Laboratories, a hands-on training facility in
Santa Barbara that he has directed for 28 years.

[17] =>

[18] =>

I trends_ laser therapy

PIPS and retreatment
Author_Reid Pullen, DDS, FAGD

_Retreatment can be difficult and time-consuming.
The first order of business is to figure out why the
primary root canal treatment is failing. Sometimes the
answer will be evident after the patient interview, clinical exam and radiographic analysis, but other times the
root canal failure is a mystery. Some of the questions
I recommend thinking about are: Was a rubber dam
used? Is there a root fracture? Is there a missed canal?
Did the practitioner use sodium hypochlorite and use
proper irrigation methods? Is the root canal underfilled
and/or undercondensed?
Is there periodontal involvement? If the supporting periodontum appears healthy and the root
does not appear to be fractured, than typically the
root canal failure is originating from inside the canal
system. With all of these factors in play, it is not surprising that the retreatment success in endodontics
is lower than primary root canal success by 10 to 20
percent. While retreatment success can vary from
70 to 90 percent, non-surgical root canal treatment
success hovers around 90 percent. This article will
review the Photon Induced Photoacoustic Streaming
(PIPS) (Lightwalker Laser from Fotona) literature and
discuss a retreatment case where the PIPS irrigation
technique was instituted in hopes of increasing the
success rate.
Fig. 1_Pre-op #18 (Photos/Provided
by Technology4Medicine)
Fig. 2_Intact gutta-percha cone
removal.
Fig. 3_Intact gutta-percaha cone
removal with Hedstrom file.

Fig. 1

_PIPS introduction
PIPS is a technique that uses Erbium:YAG laser
energy to agitate the irrigation solution inside a root
canal system and cause a strong shockwave effect
that can lyse bacteria cells and remove biofilm. By
placing the tapered PIPS tip into the access and ir-

Fig. 2

18 I roots
3_ 2015

rigation solution, subablative laser is used to push
a tsunami of irrigation solution into the main root
canal, the lateral, secondary and accessory canals,
isthmuses and the deep complex apical anatomy of
the treated tooth. PIPS creates an irrigant shockwave
of bacterial destruction.

_PIPS and research
An article in 2011 showed that the PIPS technique
was superior in removing bacteria when compared
with standard needle aspiration and passive ultrasonic irrigation when using 6 percent sodium
hypochlorite in an extracted premolar tooth prepped
to a size 20 foramen with an 07 taper.1 Another
article shows 100 percent inhibition of regrowth of
Enterrococcus faecalis after using the PIPS irrigation
technique for 20 seconds with 6 percent sodium
hypochlorite in a single rooted tooth. These teeth
had soaked in an Enterococcus faecalis broth for four
weeks.2 PIPS also effectively removed biofilm from
within the root canal system. In a bovine study model,
PIPS outperformed standard needle irrigation, the
EndoActivator and passive ultrasonic irrigation in
removing biofilm from infected bovine dentin.3 In an
article published this year, PIPS was shown to remove
debris and increase canal space 2.6 times more than
standard needle irrigation in the isthmuses of lower
molars.4

_PIPS and retreatment
A 62-year-old female patient presents with a
chronic, persisting pain in the mandibular left second

Fig. 3

[19] =>

[20] =>

I trends_ laser therapy

Fig. 4

Fig. 5
Fig. 4_PIPS in action.

molar (#18) with a duration of two weeks. The tooth
had been endodontically treated approximately two
Fig. 5_Post-op #18. years prior. The patient was unable to bite on #18
without significant discomfort.
Clinical testing revealed that #18 was percussion- and bite-stick-sensitive, while #19 and #20
tested normal to all tests. Radiographic analysis revealed that #18 had an adequate root canal without
a periapical lesion (Fig. 1). Because of the positive
clinical tests, it was determined that #18 needed a
non-surgical root canal retreatment.
The patient was anesthetized and a rubber dam
was placed. The composite core access was removed
with a 701 carbide and 557 surgical length carbide
bur. Upon inspection of the gutta-percha it appeared an uncontaminated “healthy” pink and did
not contain any odor. It did not look or smell like the
majority of retreatments where the gutta-percha
appeared to be a mixture of black and pink color with
a nefarious odor.
Before using chloroform, the ProTaper Retreatment #2 and #3 rotary files (DENTSPLY Tulsa) were
used at 500 rpm to carefully remove the majority of
the coronal and middle gutta-percha. In two of the
three canals the #2 or the #3 retreatment rotary file
removed the entire cone from the canal, making it an
extremely efficient retreatment and allowing extra
treatment time for 6 percent NaOCL to soak inside
the canal system.
The technique was as follows: Carefully drill
into the gutta-percha with the retreatment rotary
file and after a 5- to 10-mm bite stop rotation. Let
it cool for a few seconds and then with one hand
pull up on the rotary handpiece head while the
other hand is protecting the maxillary teeth from
any blunt trauma in case the handpiece head pulls
out of the canal with high velocity. In some cases
if a single cone has been used and/or if the sealer
did not set or was inadequately placed, the entire
cone will come out in one piece.
In this case, two of the three cones were
extracted fully intact while using the rotary
technique mentioned above. The third cone was
removed intact with a #35 Hedstrom file (Figs. 2,
3). The canals were then “PIPSed” for 30 seconds

20 I roots
3_ 2015

with 6 percent NaOCL as the irrigation solution
and then patency and working length were established using hand files and an electronic apex
locator (EAL). The canals were then reshaped
with a reciprocating WaveOne Primary file
(DENTSPLY Tulsa) and a final PIPS protocol was
followed using 6 percent NaOCL, distilled water,
17 percent EDTA and then distilled water (Fig. 4).
Because it appeared that a single cone technique was used and that the resin sealer did not
fully set, or was not adequately placed into the
canal, the case was completed in one visit. The
canals were obturated with bioceramic guttapercha coated cones and bioceramic sealer
(Brasseler USA). A modified warm vertical condensation technique was used to help condense
and pack the gutta-percha and sealer. The canals
were backfilled with warm gutta-percha (Fig. 5).

_Conclusion
PIPS is a ER:YAG laser-enhanced irrigation technique where laser energy is used to strongly agitate
canal irrigant. Studies have shown that it is more
effective in killing bacteria, removing biofilm, removing canal debris and increasing canal space
than standard needle irrigation, sonic irrigation and
passive ultrasonic irrigation.
In my experience of “PIPSing” more than 2,000
cases, I see an increase in the obturation of lateral canals and deep complex apical anatomy. PIPS also aids
in removing pulp stones, retreatment canal debris and
separated files that have been loosened by ultrasonics. Photon induced photoacoustic streaming gives
clinicians confidence that they are doing everything
in their power to clean the entire root canal system._
A list of references is available from the publisher.

_about the author

roots

Reid Pullen, DDS, FAGD,
graduated from USC dental
school in 1999 and served
three years in the U.S. Army
as a dentist in Landstuhl,
Germany. While in the army,
he completed a one-year advanced education in general
dentistry residency. After the
military, Pullen practiced as a
general dentist for two years
in southern California, prior
to attending the endodontic residency at the Long Beach
Veterans Hospital in 2004. He graduated from the endodontic
residency in 2006 and has maintained a private practice limited to endodontics in Brea, Calif., since 2007. Pullen obtained
his endodontic board certification in 2012.

[21] =>

[22] =>

I trends_ disinfection

Sonendo: Challenging the standard
of care with the GentleWave System
Author_Tyler F. Baker, DDS, MS

Fig. 1_Pre GentleWave Tx. (Photos/
Provided by Sonendo Inc.)
Figs. 2a, b_Post GentleWave Tx with
apical bifurcation and webbing.

Fig. 1

22 I roots
3_ 2015

_Conventional endodontic therapy has suffered
from the inability to consistently clean and disinfect the
entire root canal system. While incremental improvements and modifications have been made, conventional techniques are largely unchanged from original
endodontic ideology. We know that files do not clean
canals.1 Yet, dental companies continue to market their
new files with the idea that changes in flexibility and
file shape will make outcomes more successful. There
has also been a push to use multiple different types of
irrigants to more effectively clean the canals.
However, current irrigation devices have proven
to leave much of the bacteria, biofilm and smear
layer behind. The theory being that certain bacteria
are more resistant than others to differing forms of
cleaning solutions. Studies have consistently shown
that the classic combination of 5.25 percent NaOCl
and 15 percent EDTA are highly effective cleaning
agents, and alternative agents have yet to show a
significant antimicrobial improvement.2, 3
In an attempt to more effectively eliminate bacteria, pulpal tissue and debris from the canal system,
clinicians instrument the canals to a large enough
size to ideally debride and irrigate all the walls of
the canal system.4 Unfortunately, these techniques
are not completely effective and may pose risks to
the long-term survival of the tooth. Clinicians will
never be able to instrument all the walls of the canal
system.5 Attempts to do so generally lead to excessive weakening of the tooth and possible iatrogenic
complications. Likewise, it is not our cleaning solutions that require improvement. It is our inability

to effectively work the cleaning agents into the
difficult-to-reach anatomy that is the problem. This
combination of inadequate disinfection and excessive removal of tooth structure continues to lead to
root canal failure.
Sonendo® has departed from conventional
thought to develop new technology that dramatically improves cleaning of the root canal system and
breaks past the barriers that have limited endodontic success. The company’s patented GentleWave™
handpiece generates and delivers sound energy with
a broad spectrum of frequencies to detach tissue
and bioﬁlm from the entire root canal system.6 The
mechanism of action is so effective that file instrumentation of the canals can be kept to a minimum to
preserve dentin and overall tooth strength. This is one
of the very few endodontic technologies designed
specifically for our specialty and is not an adaptation
of an existing one.
Clinicians should use the GentleWave system in a
clinical setting to fully appreciate and believe the power
of this new technology. A clinician has no idea what a
fully cleaned tooth looks like until after the GentleWave
system has been used. In the case below (Figs. 1-2b),
separate apical radiolucencies were present at the apex
of the palatal root as seen on the CBCT scan. Predictably
cleaning an apical bifurcation like the one shown can be
very difficult, if not impossible. After using the GentleWave system, the dentin gives off a clean luster due to
the system’s ability to clean deep into dentinal tubules
to remove stains and debris. The system’s enhanced
ability to clean lateral canals and fins shows up as more

Fig. 2a

Fig. 2b

[23] =>

[24] =>

I trends_ disinfection
‘It is difficult to predictably clean complex
anatomy, even when you know it’s there.
The GentleWave system allowed me
to thoroughly clean the bifurcation and
webbing in this palatal root to ensure the
longevity of my patient’s tooth.’
—Tyler F. Baker, DDS, MS,
San Marcos, Calif.

Fig. 3_The GentleWave System by
Sonendo.

Sonendo has grown from a concept in 2006 to
its selective commercial release today. The device is
FDA cleared._

_References
1.
2.
Fig. 3

obturated accessory anatomy on post-op radiographs.
Obturation is more predictable, as can be seen in the
post-op image. A clean and smooth flowing canal system allows obturation material to flow into eccentricies
without micro debris blocking the flow of material. An
ideal apical cleaning and preservation of the constriction allows obturation material to more effectively fill
apical ramifications. Overall tooth strength was also
kept to a maximum without the need to over-enlarge
the canals. Most importantly, my excitement factor is
off the charts in knowing I can predictably clean and
obturate complex anatomy.
The patient can also tell the difference. The mechanism of action is very unassuming to the patient
without any scary sounds or aggressive movements
during treatment. Treatments can be compressed to
shorter treatment times or single-visit appointments
due to less instrumentation along with thorough
disinfection of the canal system. Patients also notice
less post-op pain due to a gentle mechanism of action and minimal remaining bacteria that can cause
post-procedure pain. It has become common in my
practice for patients to comment on the minimal level
of post-op discomfort the day following the procedure. It is nice to have the peace of mind that when
I treat the patients, they will feel better in a shorter
period of time.
Again, Sonendo’s GentleWave Multisonic Ultracleaning™ technology has taken root canal treatment to that next level of three-dimensional cleaning for greater success. Once the results are seen
clinically, it is hard to accept anything less. For more
information, visit www.sonendo.com or contact
info@sonendo.com.

24 I roots
3_ 2015

Dalton, et al. Bacterial Reduction with Nickel-Titanium
Rotary Instrumentation. J Endod. 1998.
Johal S, Baumgartner JC, Marshall JG. Comparison of the
antimicrobial efficacy of 1.3% NaOCl/BioPure MTAD to
5.25% NaOCl/15% EDTA for root canal irrigation. J Endod.
2007 Jan;33(1):48-51.
Del Carpio-Perochena AE, Bramante CM, Duarte MA,
Cavenago BC, Villas-Boas MH, Graeff MS, Bernardineli N,
de Andrade FB, Ordinola-Zapata R. Biofilm dissolution and
cleaning ability of different solutions on intraorally infected
dentin. J Endod. 2011;37(8):1134-1138.
Khademi A1, Yazdizadeh M, Feizianfard M. Determination
of the minimum instrumentation size for penetration of
irrigants to the apical third of root canal systems. J Endod.
2006 May;32(5):417-20. Epub 2006 Feb 7.
Paqué, F, Balmer M, Attin T, Peters OA. Preparation of
oval-shaped root canals in mandibular molars using
nickeltitanium rotary instruments: a micro-computed
tomography study. J Endod. 2010;36(4):703–707.
Haapasalo, M, Wang Z, Shen Y, Curtis A, Patel P, Khakpour
M. Tissue dissolution by a novel multisonic ultracleaning
system and sodium hypochlorite. J Endod. 2014;40(8):11781181.

_about the author

roots

Tyler F Baker, DDS, MS, received his DDS degree from
Loma Linda University. He
received an AEGD certificate and other awards while
serving as a dentist in the
United States Air Force. He
returned to Loma Linda University, where he received
a certificate in endodontics
and a master’s degree. He
has been published in the
Journal of Endodontics. He currently practices endodontics
in San Marcos, Calif., where he was voted one of San Diego
Magazine’s Top Dentists.

[25] =>

industry news_ FKG Dentaire

FKG Dentaire in the
2015 ESE congress
Market leader in endodontic instruments to take active part
Author_FKG Dentaire staff
This year marks the first time FKG Dentaire will be
a Bronze Sponsor of ESE congress, which takes place
Sept. 16–19 at the International Conference Centre
of Barcelona.
“The ESE congress is incredibly important for us,
as it brings together over 2,000 specialists in endodontics,” says Thierry Rouiller, CEO of FKG Dentaire.
“It’s a unique opportunity in Europe to present our
different products and demonstrate how they work.
It also gives us a chance to share and exchange ideas
with a group of passionate individuals coming from
different perspectives.”
To mark the occasion, FKG Dentaire is focusing on
the big picture. It has invited three distinguished endodontic experts who will present in detail a hand-picked
selection of FKG instruments, including the company’s
flagship product this year, the XP-endo Finisher.
Kicking off proceedings on Wednesday, Sept. 16,
will be Dr. Martin Trope from the United States.
“We are honored to have Dr. Trope animate two
pre-congress sessions organized by FKG on the
theme of ‘Biologic and conservative endodontics:
3-D disinfection of the root canal system using
memory shape technology,’” explains Patricia Borloz,
marketing director at FKG Dentaire. “From shaping
to obturation, participants at this hands-on lecture
will be able to follow a step-by-step demonstration
at the microscope.
“On Thursday, Dr. Gilberto Debelian from Norway
will lead a lecture on the challenges of cleaning the
root canal and present the characteristics and advantages associated with the XP-endo Finisher. This
latest FKG innovation is a revolutionary instrument
that allows practitioners to treat highly complex root
canal systems and clean hard-to-reach areas with
minimal impact on the dentin.
“Finally, on Friday, Sept. 18, we have the pleasure
of welcoming Dr. Bertrand Khayat from France,”
Borloz adds. “He will showcase from start to finish

a short sequence of exclusively rotary instruments
developed by FKG to maximize the quality and efficiency of root canal preparation. We are really
looking forward to these sessions and to hearing
participants’ comments and suggestions.“
Advance online registration for pre-congress
sessions, together with the full schedule of congress
lectures, is now available on the ESE website: www.
e-s-e.eu. For more information, please visit the FKG
Dentaire stand in area 49/36 of the exhibition hall or
get in touch using the contact details below._

_contact

Thierry Rouiller, CEO of FKG Dentaire
(Photo/Provided by FKG Dentaire)

roots

FKG Dentaire SA
Crêt-du-Locle 4
2304 La Chaux-de-Fonds, Switzerland
info@fkg.ch, www.fkg.ch

roots
3
I 25
_ 2015

[26] =>

I industry_ Vista Dental Products

Vista’s SmearOFF:
One product, multiple
benefits
Removes smear layer — and bacteria —
at a fraction of the cost
Author_Vista Dental Products staff
_SmearOFF™ by Vista Dental Products is designed
to effectively replace two commonly used solutions:
EDTA and CHX. SmearOFF is an EDTA-based formula
enhanced with chlorhexidine. SmearOFF not only
effectively removes the smear layer, but also kills
bacteria in one easy step, according to Vista.
SmearOFF removes significantly more canal debris compared with standard 17 percent EDTA and
leaves the root canal surface cleaner by opening
a greater percentage of dentin tubules, according
to the company. Additionally, SmearOFF provides
the added benefit of killing root canal bacteria, the
company says.
Unlike other two-in-one mixes, SmearOFF is compatible with sodium hypochlorite and will not form
a precipitate, eliminating steps and saving time with
each procedure.
According to Vista, SmearOFF is the clear choice
among other two-in-one solutions and offers the
following features and benefits:
• Will not form a precipatae when mixed with
NaOCl.
• Superior chelation and enhanced cleansing.
• Optimal smear layer removal.
• Kills 99.99 percent of bacteria in 10 seconds.
• 30 percent savings compared with other leading
brands.
To find out more information, visit vista-dental.
com or call (877) 418-4782_

(Photo/Provided by Vista Dental Products)

26 I roots
3_ 2015

[27] =>

[28] =>

I industry_ Essential Dental Systems (EDS)

Essential Dental Systems
(EDS) introduces
Tango-Endo
Author_ Essential Dental Systems (EDS) staff

Tango-Endo, new from Essential
Dental Systems (EDS), allows for twoinstrument shaping. Below: Beforeand-after images of an endodontic case
treated with Tango-Endo.
(Photos/Provided by EDS)

28 I roots
3_ 2015

_Essential Dental Systems (EDS) recently
announced a new endodontic system —
Tango-Endo.
“With new Tango-Endo, it only takes two
instruments,” the company says. “Tough and
reusable Tango-Endo instruments boast a
unique, patented flat along the entire length.
This flat allows for faster engagement with
less resistance, increased flexibility without
sacrificing strength, and virtually eliminated
instrument separation.”
The Tango-Endo system includes its own
reciprocating handpiece. The latch-type
handpiece is designed to aid in the prevention
of binding, and to assist in the preservation
of the canals unique anatomy, according to
EDS. The kit also includes precision-matched
gutta-percha points, designed for a perfect
fit every time.
The Tango-Endo Introductory Kit is available immediately through dental dealers
worldwide.
More information is available at www.
edsdental.com/tangoendo or by calling (201)
487-9090._

[29] =>

[30] =>

I about the publisher _ imprint

roots

the international C.E. magazine of endodontics

U.S. Headquarters
Tribune America
116 West 23rd Street, Ste. 500
New York, NY 10011
Tel.: (212) 244-7181
Fax: (212) 244-7185
feedback@dental-tribune.com
www.dental-tribune.com
Publisher
Torsten R. Oemus
t.oemus@dental-tribune.com
President/Chief Executive
Officer
Eric Seid
e.seid@dental-tribune.com
Group Editor
Kristine Colker
k.colker@dental-tribune.com

Roots Managing Editor
Fred Michmershuizen
f.michmershuizen
@dental-tribune.com
Managing Editor
Sierra Rendon
s.rendon@dental-tribune.com
Managing Editor
Robert Selleck
r.selleck@dental-tribune.com
Education Director
Christiane Ferret
c.ferret@dtstudyclub.com
Business Development Manager
Travis Gittens
t.gittens@dental-tribune.com

Product/Account Manager
Humberto Estrada
h.estrada@dental-tribune.com
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m.kaiser@dental-tribune.com
Product/Account Manager
Will Kenyon
w.kenyon@dental-tribune.com
Feedback & General Inquiries
feedback@dental-tribune.com

Editorial Board

Marcia Martins Marques, Leonardo
Silberman, Emina Ibrahimi, Igor Cernavin,
Daniel Heysselaer, Roeland de Moor, Julia
Kamenova, T. Dostalova, Christliebe Pasini,
Peter Steen Hansen, Aisha Sultan, Ahmed
A Hassan, Marita Luomanen, Patrick Maher,
Marie France Bertrand, Frederic Gaultier,
Antonis Kallis, Dimitris Strakas, Kenneth Luk,
Mukul Jain, Reza Fekrazad, Sharonit
Sahar-Helft, Lajos Gaspar, Paolo Vescovi,
Marina Vitale, Carlo Fornaini, Kenji Yoshida,
Hideaki Suda, Ki-Suk Kim, Liang Ling Seow,
Shaymant Singh Makhan, Enrique Trevino,
Ahmed Kabir, Blanca de Grande, José Correia
de Campos, Carmen Todea, Saleh Ghabban
Stephen Hsu, Antoni Espana Tost, Josep
Arnabat, Ahmed Abdullah, Boris Gaspirc,
Peter Fahlstedt, Claes Larsson, Michel Vock,
Hsin-Cheng Liu, Sajee Sattayut, Ferda Tasar,
Sevil Gurgan, Cem Sener, Christopher Mercer,
Valentin Preve, Ali Obeidi, Anna-Maria
Yannikou, Suchetan Pradhan, Ryan Seto, Joyce
Fong, Ingmar Ingenegeren, Peter Kleemann,
Iris Brader, Masoud Mojahedi, Gerd Volland,
Gabriele Schindler, Ralf Borchers, Stefan
Grümer, Joachim Schiffer, Detlef Klotz,
Herbert Deppe, Friedrich Lampert, Jörg
Meister, Rene Franzen, Andreas Braun, Sabine
Sennhenn-Kirchner, Siegfried Jänicke, Olaf
Oberhofer and Thorsten Kleinert

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30 I roots
3_ 2015

[31] =>

Introducing . . .

Tango-Endo

™

It Only Takes Two

Increase quality
while reducing your costs!
89 Leuning St, S. Hackensack, NJ 07606 • 1-800-22-FLEXI • www.edsdental.com

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[cover] => roots C.E. No. 3, 2015

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