roots international No. 2, 2017
Cover
/ Editorial
/ Content
/ Interview: “The field of tissue engineering has exploded during the last decade”
/ Lasers as an asset in both daily practice and marketing
/ Cleaning is key
/ All roads lead south
/ Management of a non-vital central incisor with an open apex
/ Blue light laser-assisted crown lengthening in restorative dentistry
/ Thermal damage behaviour of human dental pulp stem cells
/ Lighting in dental surgeries — frequently neglected requirements of the standard on illumination
/ Industry News
/ Solutions for the practice and laboratory of tomorrow—the opportunities of current technologies: IDS 2017
/ International Events
/ Submission guidelines
/ Imprint
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[1] =>
roots
issn 2193-4673
international magazine of
endodontics
2
2017
case report
Management of a non-vital
central incisor with an open apex
study
Thermal damage behaviour
of human dental pulp stem cells
meetings
Innovation fireworks—IDS 2017
Vol. 13 • Issue 2/2017
[2] =>
Madrid, Spain
29 August - 1 September 2017
Bringing the World together
to improve oral health
THE BIGGEST INTERNATIONAL
DENTAL CONGRESS
Abstract submission deadline:
3 April 2017
Early-bird registration deadline:
31 May 2017
www.world-dental-congress.org
[3] =>
editorial
|
Golden standards and
modern technology
Decades ago, the giants of modern endodontics put together the standards of root canal treatment,
and we have been following them ever since. At the time, they had only ideas and rather simple
research techniques and yet managed to formulate golden standards for a whole field of therapy.
Prof. Philippe Sleiman
Shaping and cleaning the root canal system (as proposed by Schilder) is a key phrase from Seltzer
and Bender: it is more important what we take out from the root canal system than what we put into
it (even today, with the warm vertical technique of obturation).
Images obtained with simple methylen blue dye showing the complexity of the system was their
precursor of our sophisticated micro-CT scanning, and yet it was them who opened our eyes to the
root canal system complexity. And such examples are many.
Today, we need to ask ourselves—especially when new, marketing-driven concepts are promoted
to us—what are we doing to our patients and are we still following those concepts? It is true that
with new tools we are able to work faster and potentially safer; it is also true that we managed to
add to those concepts or modify them a bit—nevertheless, we still work in the spirit of those guidelines.
At the end of the day, we need to see one simple thing—with all the great studies and publications
serving the same purpose—the outcome of the root canal treatment that we perform in our chair
for our patient. This is where we need to focus. What kind of service are we offering to our patients
and what is the viability of our treatment? Are we putting our skills and knowledge to the test?
Are we recalling our patients in order to check if what we did is still standing true and healthy?
It is definitely a difficult task, and takes huge effort from our staff and from our patients, especially
when they say, “I am fine and I am busy, I don’t feel a thing and maybe I cannot manage to pass by
the clinic for a follow-up”. It has to be a joint effort (maybe even included as a clause in the consent
form the patient signs, to make sure the patient understands that they need to come for regular
check-ups on a yearly basis). Hopefully, we will then be able to publish more data and learn from
what we see from the recalls—and use real-life clinical experience to introduce change to some of
our protocols.
Prof. Philippe Sleiman
Guest Editor
roots
2
2017
03
[4] =>
© Annareichel/Shutterstock.com
| content
page 14
page 18
page 44
| editorial
| study
03 Golden standards and modern technology
30 Thermal damage behaviour of human
dental pulp stem cells
Prof. Philippe Sleiman (Guest Editor)
Prof. Karsten König & Dr Anton Kasenbacher
| feature
06 “The field of tissue engineering
has exploded during the last decade”
An interview with Dr Ibrahim Abu Tahun
| trends & applications
| practice management
38 Lighting in dental surgeries—frequently
neglected requirements of the standard on
illumination
Antonín Fuksa
10 Lasers as an asset in both daily practice
and marketing
| industry news
| opinion
| meetings
14 Cleaning is key
44 Innovation fireworks—IDS 2017
Dr Imneet Madan
Aws Alani
| case report
18 All roads lead south
Dr Alfredo Iandolo
22 Management of a non-vital central incisor
with an open apex
Drs Mario Luis Zuolo & Arthur de Siqueira Zuolo
26 Blue light laser-assisted crown lengthening
in restorative dentistry
Dr Philipp Skora, Dr Dominik Kraus,
PD Dr Jörg Meister & Prof. Matthias Frentzen
04 roots
2 2017
42 VDW: Endodontics with a system
48 International Events
| about the publisher
49 submission guidelines
50 imprint
roots
issn 2193-4673
international magazine of
Vol. 13 • Issue 2/2017
endodontics
2
2017
case report
Management of a non-vital
central incisor with an open apex
study
Thermal damage behaviour
of human dental pulp stem cells
meetings
Innovation fireworks—IDS 2017
Cover image courtesy of
Koelnmesse GmbH.
[5] =>
3D agility_
The One to Shape your Success
Only one instrument to achieve
min. 30/.04
Superelasticity and expansion
capacity
Remarkable cyclic fatigue
resistance
A gentle, non-agressive and
conservative treatment
Excellent debris removal
Come visit us!
FKG Dentaire SA
www.fkg.ch
[6] =>
| feature interview
“The field of tissue engineering has
exploded during the last decade”
An interview with Dr Ibrahim Abu Tahun, Jordan
Author: Kristin Hübner, Germany
Being actively involved as a founding member
and president of several endodontic societies,
Dr Ibrahim Abu Tahun has experienced the
changes in the field significantly over the last decades. DTI had the opportunity to speak with Tahun,
who is an associate professor in the Department of
Conservative Dentistry at the University of Jordan,
about the most influential developments in the
specialty and how these advances are changing the
way endodontics is practised.
Dr Ibrahim Abu Tahun
Dentistry is changing rapidly, with new materials,
devices and treatment protocols being introduced constantly. What is the situation in endodontics in particular? What are the major developments currently?
At the beginning of the 21st century, we have
greater understanding of the pulp biology, pathophysiology and its powers of healing. The field of
tissue engineering has exploded during the last
decade, and extensive reviews on dental applications are available, producing a critical mass of
knowledge and methods that are likely to answer
the challenge issued decades ago.
Various animal and human studies have shown
high success rates for vital pulpal therapy. These investigations have demonstrated that the amputated pulp can be repaired by itself or after application of bioactive materials.
Recent approaches to pulpal wound treatment
have essentially followed two lines: one has continued the conventional path to seeking improved
synthetic materials that provide better seals, resulting in a breakthrough in bioactive materials, while
another line has taken a biological approach with
the hope of identifying a biologically based strategy
for treatment of clinical conditions.
What are the advantages of new treatment modalities compared with conventional root canal
therapy?
06 roots
2 2017
The potential benefits to patients and the profession are groundbreaking. From a public health point
of view, the recent advances in tissue management
and wound healing, compared with the current
form of root canal therapy, which is more of a mechanical and chemical process, should be reflected
in our clinical management to develop more biocompatible treatment modalities and increase
tooth longevity.
In the past, it was unthinkable that the tissue in
the periapical region of a non-vital infected tooth
could regenerate. Case reports published during
the last 15 years have demonstrated convincingly
in humans that this type of environment may create
“In the past, it was
unthinkable that the tissue
in the periapical region of
a non-vital infected tooth
could regenerate.”
the ideal clinical outcome if disinfection can be
achieved, just as it is for the canals in the case
of dental avulsion. These novel endodontic tissue
engineering therapies offer the possibility of restoring natural function and improving the long-term
outcome of teeth with a poor prognosis.
When it comes to implementing new treatment
modalities in daily practice, do you think the
endodontic community is somewhat divided or
is the specialty as a whole on the verge of a major
paradigm shift?
The debate on clinical technique and the concept
of regeneration and revascularisation per se is not
a product of modern medicine. The varying treat-
[7] =>
DIRECT SYSTEM
DIRECT SYSTEM
light guide
VENEER
OCCLUSIONVD
VENEER
COMPOSITE
OCCLUSIONVD
POST & CORE
COMPOSITE
DIGITAL
SMILE SYSTEM
POST
& CORE
opaque core
dentin A1
lense
design
DIGITAL SMILE SYSTEM
translucent
post
FUTURE INNOVATIONS
Anterior up
Universal post when
tooth walls remaining
Deepak Mehta
B.D.S, M.D.S, PhD
Bangalore, India
Anterior low
«The material of the edelweiss POST & CORE is barium
glass, strontium and zincoxide embedded in resin. The
crystals are sintered to a monoblock which leads to
perfect mechanics in the material. The flexural strength
is similar to that of the natural tooth. Congruent precision
dental drilling creates a perfectly prepared post space.
Different sizes of drills enable therapy for all dental
anatomies. The three different types of the edelweiss
POST & CORE are: anteriors, premolars and molars.»
•
•
•
•
•
•
•
•
•
•
•
«The difference lies in the force buffer
of the monoblock»
Dentin
Prefabricated POST & CORE
Translucent Post for periapical
light polymerisation
Innovative monoblock of post and core
with A1 buildup for natural integration
Monoblock avoids wedge effect
Biocompatible
Flexural Modulus 20GPa like Dentin (15 - 20 GPa)
Unmatched radiographic visibility
Cuts like dentin
Superior adhesion to the root canal
One session, reduced treatment time
Time and cost effective
Bond
Post
Homogeneous
inorganic structure
65 HV
Laser sintered
monoblock
Magn.
2000x
100 mü
Molar up&low
Premolar low
ADVANTAGES
edelweiss POST & CORE
Laser sintering /
vitrification process
Molar up&low
Premolar up
Magn.
1000x
50 mü
95 HV
Technical Data
POST & CORE
Flexural Strength
200 MPa
Compressive Strength
550 MPa
Flexural Modulus
20 GPa
Surface Hardness
95 HV
(Source: internal data: R&D and QM department
edelweiss dentistry)
[8] =>
| feature interview
Source: Ibrahim Abu Tahun &
Mahmoud Torabinejad. Management
of teeth with vital pulps and open
apices. Endodontic Topics 2012, 23,
79–104.
ments for the tooth pulp during the last three
centuries illustrate this clearly. Recently, various
treatment concepts have been suggested using
less-invasive approaches. Even though an optimal
treatment protocol is lacking, however, many case
reports and case series on pulpal therapy have been
published.
Once considered taboo, vital pulpal treatment of
symptomatic permanent teeth with mineral trioxide aggregate has been reported to be successful,
and greatly improved prognoses for permanent
retention are now possible.
A very recent study has found that regenerative
endodontic treatment has the potential to be used
to retreat teeth with persistent periapical periodontitis after root canal therapy.
More high-quality cohort studies would strengthen
the evidence-based recommendations. However, the
current best available evidence allows clinicians
to provide these treatment modalities safely to
patients.
Globally, what is necessary to implement this
new approach to endodontic treatment?
A reparative, biological approach to pulpal therapy is not only welcome, but also absolutely essential. Ideally, the delivery of biologically based
endodontic procedures must be more clinically
effective than current treatments and the method
of delivery must also be efficient, cost-effective
and free of health hazards or side-effects for patients. A recent study has suggested that endodontic practitioners are supportive and optimistic
about the future use of regenerative endodontic
procedures.
08 roots
2 2017
Best practice guidelines must be updated to
include guidance to maintain the self-respect of
the dental profession and the trust of the patients
we serve, as the fact remains that more biological
endodontic treatment means endodontics that is
more ethical than today.
In your opinion, what innovations will influence
endodontists most in the years to come?
The tremendous and exciting new research on
regenerative endodontics from Japan, the US
and other countries has made the cultivation of
potential in this field a strategic priority without
undermining the efficacy of conventional endodontic therapies, but positioning practitioners
at the forefront of this field.
We are changing protocols, towards going biological. This path to the future with various potential approaches based on clinical and scientific
results presented in the professional literature
will lead to predicable conservative treatment
that may enable practitioners to fill a root canal
with nature’s tissue instead of plastic materials
or artificial surgical prostheses. The important
challenge facing us now is to develop and adapt a
safe, effective and consistent method for regenerating a functional pulp–dentine complex in our
patients._
Thank you very much for the interview.
Editorial note: At the 19th Scientific Congress of the Asian
Pacific Endodontic Confederation, which was held from
5 to 8 April in New Delhi in India, Tahun addressed current
endodontic challenges and conflicting priorities between
conventional therapies and new treatment modalities in
his lecture “Can we do it forever?”.
[9] =>
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distinguished by their MADE IN GERMANY quality.
All Orthophos units offer a 5 x 5.5 cm 3D volume, which
combine with the High Definition (HD) mode to provide X-ray
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Their excellent image quality makes the Orthophos range
ideally suited for all requirements in the field of endodontics,
and combined with the 3D EndoTM software, you can go even
further.
For more information on our 3D systems, visit: sirona.com
[10] =>
Lasers as an asset
in both daily practice
and marketing
Author: Dr Imneet Madan, UAE
In the era of advanced technologies, patients’ expectations are multiply increasing: They want to have
the least invasive treatment procedure with only
minimal bleeding, more effective healing, greater
precision and the least number of appointments.
For many years now, lasers have been proven to
be an effective device for a minimally invasive treatment. Nevertheless, any dental office that wants to
implement lasers in its daily practice has to keep in
mind several issues. These issues are:
· Safety
· Employee education
· Marketing
· Revenue channels
· Advantages
Amongst the issues mentioned here, marketing
is one that is very pivotal but in most cases not yet
well prioritised. Although, current trends in practice
do focus a lot on marketing. The winning edge of today’s practice lies in a formula saying: “I project who
I am.” This philosophy brings forth the transparency
of laser-based practice. Since the costs incurred to
the patients are higher with laser treatments, the
imperative as well as the benefits coming with lasers
needed to be well known by the patients.
10 roots
2 2017
oceans of conventional approaches and competition
by creating uncontested market space that finally
leaves any competition irrelevant.1
The Blue Ocean Strategy in dentistry
As stated by Masahiro Fujita, President of Sony’s
System Technological Laboratories: “The risk of not
innovating is greater than the risk of innovating.”
The success of brands relies on cutting an edge in
the existing market. The introduction of dental lasers
is the most practical application of the principles of
Blue Ocean Srategy in the dental business. Marketing and treatment protocols can be well shaped in
lines of this principle. Even though laser can prove to
be a high-end investment, the success and uniqueness that follows has been well researched and documented by several practitioners around the globe.
The Blue Ocean Strategy
Investment above investment
The investment in laser devices for a company is an
extra mile. Combining both hard and soft tissue lasers
could add up to about 100,000 US$ to the total cost
of investment. Even though this amount sounds substantial in the initial stage, the return on investment
with lasers can range between 280 to 600 per cent.2
These kind of returns are possible when we successfully combine technological benefits with appropriate marketing strategies.
Most corporations do smart things and also less
smart things from time to time. In order to improve
the quality of success, it is important to evaluate what
has made the positive difference and understand
how to replicate this in a systematic manner. It is also
understood that the strategic move that matters
centrally is to create blue oceans. The Blue Ocean
Strategy challenges companies to break out of red
Changing patients’ trends
The patients walking into the practice these days
are “drone patients”. Prior to their consultation, they
like to read about possible procedures, optional treatments and latest advances. Since patients are partly
aware of the technology, stating further benefits enhances their knowledge. Hence, decisions are made
more easily and naturally in favour of lasers.
© Markus Mainka/Shutterstock.com
| trends & applications lasers
[11] =>
lasers trends & applications
Benefits of lasers
Marketing fundamentals
The usage of laser in the daily dental practice
is undoubted. From a practitioners point of view
there are several benefits which basically can be
divided into intangible and tangible benefits. Intangible benefits refer to the high technological
status of lasers and the subsequent referrals that
its reputation generates. Lasers do make the procedure easier and more comfortable for the patient. Almost all hard tissue procedures can be
done without using anaesthesia. This certainly
reduces the stress for the patient who normally
relates dentistry with needles and drills. The
most important factor in private practice is “time
management”, which ranks amongst tangible
benefits. With lasers, multiple restorations can
be performed in the same appointment as there
is no numbness involved. Additional procedures
like hygienist appointment and exam schedule
with specialists can be also accommodated at the
same time. This directly adds on to saving time and
increasing profitability.3
Dr Philip Kotler defines marketing as “the science
and art of exploring, creating, and delivering value
to satisfy the needs of a target market at a profit.
Marketing identifies unfulfilled needs and desires.”4
More benefits of laser usage in the dental practice are:
Marketing 1.0 was selling the factory’s output of
products to all who wanted to buy them. The products were quite basic and designed to serve a mass
market. The goal was to standardise productions’
costs so that goods could be priced lower and made
be more affordable to buyers. This marketing strategy
was part of the product-centric era.
Fear factor control
Most patients walking into the practice have dental fears or phobias for various underlying reasons.
Their fears could be caused by negative past experiences, a shared experience from someone close or
just the anticipation of needles and drills. With lasers, the approach to dentistry becomes different.
The need for anaesthesia is either completely ruled
out or substituted by only a few drops of intergingival infiltration.
More certain prognosis
When it comes to the treatment of endodontically compromised teeth, lasers work quite accurate
in combination with conventional treatment approaches. A recent approach of combining diode and
erbium lasers has given vast success rates in grossly
decayed teeth with peri-apical infections.
No drill dentistry
Since laser is a non-contact procedure, there is no
pressure or touch sensation involved; this increases
the patients’ acceptance of the treatment.
No antibiotics after minor procedures
It has been a common trend to prescribe antibiotics after any kind of surgical intervention or
in endodontically compromised teeth. With laser
there is no scar formation, tissue healing is faster,
site of interventions is more sterile; hence, the need
of antibiotics has decreased.
|
Marketing, in simple terms, is a management
process through which goods and services move
from concept to customer. It includes the coordination of four elements called the four P's of
marketing:
1. Identification, selection and development of a
product,
2. determination of its price,
3. selection of a distribution channel to reach the
customer's place, and
4. development and implementation of a promotional strategy.
Changing trends
Over the years, marketing has evolved through
three stages: Marketing 1.0, 2.0 and 3.0.
Marketing 2.0 is the principle attached to marketing in current times which is information age
where the core is information technology. Thereby,
the job of marketing no longer stays simple. The
golden rule of marketing 2.0 is: “Customer is king.”
Customers are better off as their needs and desires
are prioritised.
Marketing 3.0 denotes a “value driven” era. This
concept of marketing uplifts into the arena of human aspirations, values and spirits. It believes that
consumers are complete human beings whose complete needs and hopes should never be neglected.
Therefore, this principle complements emotional
and human spirit marketing.
Lasers as a tool for Marketing 3.0
Marketing 3.0 incorporates lasers pretty well as it
keeps in consideration the benefits to the patients,
the producers credentials, and the high-end technological status. The current age also follows the new
wave technology which enables connectivity and
interactivity of individuals and groups. This enables
the customers and the dentists to be well aware of
the advances in lasers availability.
roots
2
2017
11
[12] =>
| trends & applications lasers
Editorial note:
A list of references is available
from the publisher.
This article was first published
in laser magazine 4/2016.
contact
Dr Imneet Madan
Specialist Pediatric Dentist
MSc Lasers Dentistry (Germany)
MDS Pediatric Dentistry
MBA (Hospital Management)
Children’s Dental Center, Dubai
Villa 1020 Al Wasl Road,
Umm Suqeim 1, Dubai
United Arab Emirates
Tel.: +971 506823462
imneet.madan@yahoo.com
www.drmichaels.com
12 roots
2 2017
FDA approval for dental laser marketing
Applications for and research on lasers in dentistry
continues to expand since their introduction to the
dental profession. Dental laser systems are cleared
for marketing in the United States via the Food and
Drug Administration (FDA) Premarket Notification
[510(k)] process. The review team determines whether
the product under review meets relevant criteria for
“substantial equivalence” to a predicate device (the
term “predicate” is used to describe any device that is
marketed for the same use as the new device, even if
the actual technologies are not the same).5
Significant decrease in missed appointments
Pain is certainly an abstract phenomenon and its
perception changes from one patient to another. Having lasers in the dental practice with their added advantages certainly decreases the perception of pain
to a large extent. Patients are no longer afraid to sit
in the chair and receive the care they need. This helps
decreasing the number of missed appointments.
Dental lasers add a lot on the functioning of dental
practices. They not only boost up the revenues, primarily due to the cost differences between laser and
conventional treatments, but also improve the actual
functioning of the practice in several manners.
Following the principles of the Blue Ocean Strategy, practices that offer compassionate care using
advanced technologies such as lasers will be the
offices that experience the largest influx of new
patients in the future._
Increased new patient volume
Satisfied patients add a lot to any practice. Dental lasers give dentists the opportunity to increase
new patient referrals because of the unique experiThere are three key points in the marketing of ence l asers enable for existing patients. Patients feel
dental lasers:
so positively motivated that they talk about their
1. Efficiency: In a dental practice, efficiency is one experience to family and friends, thereby spreading
of the key factors that draw the thin line between the name of practice by word of mouth.
growth and failure. Efficiency is based on the application of technology. The more we succeed in More referrals
incorporating the latest advances, the more we
Being unique projects the practice as a cut above
ensure that our practice is increasing revenues, the rest. This helps increasing the referrals from other
enhancing patient experiences and expanding re- practices and also from colleagues in the same pracferrals. Efficiency in a practice accounts to increase tice. When the practice comes to be known as laser
the happiness quotient of both patient and dentist. specialty practice, it becomes a known referral base
2. Reduced chair time: Speed is another major var- for specific procedures and also for those who are
iable to consider when choosing the dental laser. technology-friendly.6
Lasers are certainly a bit slower than the conventional drill, but this lapse of time does get well New procedures
compensated with the fact that there is no waiting
Laser equips the dentist to perform a wide variety
period of numbing involved.
of procedures that could not be handled otherwise.
3. Improved patient experience: Drill-free and no The lack of anaesthesia, blood, sutures and minimal
anaesthetic procedures are always more welcom- postoperative discomfort enables dentists to pering to the patients. Dental lasers create a virtually form procedures such as labial and lingual frenectopain-free experience, which is a definite game mies, fibroma removals to exposures, crown lengthchanger for the vast majority of patients.
ening and much more. New procedures get added
to a dentist’s repertoire that would previously have
The above mentioned points can be easily used as key been referred out or untreated. Many of these promarkers in promoting dental lasers. Since there are ump- cedures can be performed during the same visit;
teen amounts of data supporting these facts, patients thereby, increasing revenue growth without having
can also be encouraged to search around online before to add a s econd appointment.
booking in their appointments. Relevant information
can be communicated by different forms of media:
Conclusion
· Social media such as Facebook, Twitter, Snapchat,
Instagram
There has been a long road between the times
· Advertisements through radio or TV channels
when lasers were taken as the adjunct only for high· School screenings: information leaflets on lasers end practices and procedures, to the current times,
can be included along with the school dental re- where laser is used as a regular armamentarium. In
ports. This makes information reach home and the world of marketing, lasers have brought dentistry
triggers the first step of curiosity to get to know to Blue Ocean. The frequent use of a laser by offices
more and use the service if or when required.
has resulted in a higher level of patient comfort,
increased case acceptance for routine care, larger
Laser marketing and practice
cases, and improved doctor productivity.7
[13] =>
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[14] =>
| opinion root canal disinfection
Cleaning is key
Author: Aws Alani, UK
m
.co
2 2017
ck
14 roots
It seems that irrigation and instrumentation are
both highly inter-related in canal disinfection. Take
washing your car for instance, purely covering it with
soapy water and rinsing won’t remove the motorway
bugs and bird produced projectiles. A good scrubbing
with a sponge is needed, or if you are really
serious about cleaning, a pressure
© An
nar
eic
washer! This begs a further queshe
l/ S
hu
tion—how would your patients
feel if they knew that, more
or less, the same or very
similar liquid they use to
clean bathroom suites is
the same that we use to
clean the inside of their
teeth? On recent evidence of a dentist to the
“stars” appearance on national TV not much—he advocated using charcoal to
whiten teeth, which you may be
able to buy from your local petrol
station for barbecues.
s to
During the 1980s, Bystrom
and colleagues investigated the
effect of mechanical instrumentation
with and without adjunctive use of hypochlorite.
They found, unsurprisingly so, that when compared
to pure mechanical instrumentation, the use of
hypochlorite in combination with hand filing significantly reduced bacterial load. As such chemomechanical instrumentation was shown to be crucial
for endodontic success. They compared irrigation
with saline, 0.5 % and 5 % hypochlorite over a sequence of 5 appointments. Interestingly they found
no difference in the reduction of bacterial load between 0.5 and 5 % hypochlorite. Despite what was
likely to be a comprehensive protocol for these teeth,
7 of the 15 specimens in this study still had bacteria
that they could grow at the end of treatment. The
presence of cultivable bacteria does not necessarily
mean we have failure—it merely means that there
may be a cohort of bacteria that have resisted treatment. Mechanical instrumentation does reduce bacterial load by itself—this is by way of physical removal
of tissues where bacteria reside, while also facilitating the dispersal of the irrigant into the canal. Siquiera and colleagues found that enlarging the canal
from size 30 to 40 resulted in a significant decrease
in endodontic pathogens.
r
tte
Completely disinfecting the canal system is challenging when all factors are considered. If we are
looking at the nano level there are approximately
76,000 dentinal tubules per square millimetre of dentine. Each of which can harbour a colony of bacteria.
Then there may be inaccessible anatomy such as lateral canals, apical deltas or fins. These are factors that
need considering outside of canal curvatures that
may or may not be entirely visible in the
plane of the radiograph. It is clear
that outside of the contact our
files make with the walls of
the root canal there needs
to be chemical disinfection to further reduce
bacterial load. Irrigants disinfect as well
as lubricate instruments and they dissolve the pulp. Sodium
hypochlorite has been
the mainstay irrigant
for decades.
Hypochlorite is an effective bactericidal but does
not remove the smear layer. The smear layer is a mix of
organic material (protein, pulp remnants, saliva, microorganisms) with an inorganic components consisting
of minerals from the dentine. The smear layer prevents
bacteria residing in the dentinal tubules from being exposed to the irrigant as well as reducing the contact
between the dentine and sealant during obturation.
Hence, utilising EDTA to remove the smear layer prior
to obturation but after completion of preparation and
instrumentation is sensible. A penultimate rinse with
EDTA then a final rinse with hypochlorite prior to drying
has been advocated heavily in the literature.
Bacteria and the biofilms
Unlike what we once thought, bacteria do not tend
to just sit alone and remote from each other. If only
they were this antisocial and could be picked off
one by one! Bacteria join forces and create symbiotic
groups, share resources and protect each other from
external influence. This is commonly known as a “bio-
[15] =>
[16] =>
| opinion root canal disinfection
film”, which has a thin but robust layer of mucilage that
adheres to a solid surface housing the community of
microorganisms. They not only share resources, they
also share information that promote each other’s survival through RNA or DNA. As the majority of bacteria
will be encapsulated in this layer, purely irrigating
without disrupting this layer is inefficient. The word
disrupting is a bit kind really—it needs to be destroyed
to reveal all its contents and expose it to the bleach for
chemical action. It is the methods of disruption of the
canal biofilm that has seen a lot of development over
the last 10 years or so. Much in the same way a pressure
washer can clean that more quickly and efficiently
than a sponge, energising the disinfectant results in
improved cleanliness.
Energising the irrigant
This can take many forms. The simple and straightforward form ensures appropriate exchange of the
fluid and displacement into the recesses where airlocks may reside. This can be achieved through applying a GP point into the prepared canal to displace and
disperse.
Editorial note: Aws Alani is leading
a two-year postgraduate diploma
in operative dentistry at King’s
College London Dental Institute
www.restorativedentistry.org.
More information is available
online at www.kcl.ac.uk/study/
postgraduate/taught-courses/
operative-dentistry-pgdip.aspx.
contact
Aws Alani is a Consultant in
Restorative Dentistry at Kings
College Hospital in London, UK.
He can be contacted at
awsalani@hotmail.com.
www.restorativedentistry.org
16 roots
2 2017
Ultrasonic irrigation transmits energy by an oscillating instrument. This results in two different phenomena. Cavitation is the growth and subsequent collapse of small gas bubbles due to a drop in pressure.
Acoustic streaming is the bulk movement of fluid
when pressure waves are projected, resulting in vortex
motion around a fast moving oscillating instrument.
This results in shear stresses to tear the biofilm apart.
Keeping the canal clean
Once irrigated and prepared, the clinician has a
choice—to obturate or to dress. Some may argue that
the canal is cleanest at the end of instrumentation
and that for convenience, obturating in a one visit
arrangement is the best option. As we know, not all
bacteria are removed or killed during treatment.
Dressing the canal with calcium hydroxide may continue the process of eradication of the residual microorganisms over a 2-week period. The choice between the two schemes sometimes boils down to the
presenting factors of the case. Where a tooth is difficult to instrument, has a large lesion or is quite obviously chronically infected with a history of pain, then
dressing may be more of a consideration. If a tooth is
treated in a de novo manner and treatment goals are
achieved with no history of pain then a single visit
treatment could be utilised.
The goal of obturation is to seal the canal system to
prevent any reinfection and entomb any bacteria not
eradicated by chemomechanical debridement. If the
obturation is through the apex, this can have signifi-
cant implications. GP through the apex can carry bacteria outwith of the canal and exacerbate symptoms.
A foreign body reaction could also develop.
We also have to remember that a beautiful obturation of a canal achieved without rubber dam and
utilising saline or local anaesthetic irrigation is sub-
standard treatment. It can be difficult to assess the
“quality” of treatment when a radiograph of a “failed”
tooth is examined in this context. Indeed, an obturation that is short of the radiographic apex having
been treated under rubber dam and with copious
amounts of irrigation is more likely to be successful
than the previous scenario. Attributing too much
significance to the radiographic appearance of the
obturation is short-sighted. Indeed, Katebzadeh
and colleagues in the late ‘90s witnessed healing in
the absence of obturation where teeth where instrumented and irrigated optimally under isolation.
Sealants are also antibacterial and aide filling the
voids between the GP and the canal system. One
further option would be to provide a sub-seal to
each of the canal orifices. This can be achieved by
removal of 1 mm of GP and packing a good thick
mix of IRM packed with a plugger.
Covering the cusps
The provision of a coronal restoration (if provided
optimally) can improve the coronal seal while also
structurally protecting the underlying tooth tissue.
Due to endodontic treatment, resulting in reduction
of tissue bulk and stiffness the risk of fracture increases. Where both mesial and distal margins have
not been breached and the access cavity is confined
to the occlusal surface, a crown restoration may not
be required. Once a margin is breached the tooth is
more likely to flex and result in cracks or fractures.
A commonly asked question, “When should the crown
be provided? Soon after the root canal treatment or
when the treatment has proven to be successful?”
If the success of endodontic treatment is significantly
in doubt then this should be communicated to the
patient and a well compacted direct restoration may
be the best option, otherwise an onlay or if tooth
tissue is significantly reduced, a crown should be
provided soon after completion.
Conclusion
Bacteria are public enemy number one in dentistry.
Disinfecting the root canal system by irrigating in
combination with mechanical instrumentation is key
to success in root canal therapy. Preventing further
re-infection or persistence of residual bacteria after
the formal stages of treatment through dressing
initially and a quality coronal seal subsequently is
as important as the root canal therapy._
[17] =>
the
sm rt casu l
dentistry
Σymposium
13 - 15 October, 2017 Athens, Greece
scientific co-chair
Ilia Roussou - Konstantinos D. Valavanis
invited speakers
■Alessandro Agnini, Italy
■Andrea Agnini, Italy
■Eric Van Dooren, Belgium
■Egon Euwe, Holland
■Galip Gurel, Turkey
■Henry Ho, Singapore
■Francesco Maggiore, Germany
■Henry Salama, USA
■Gilberto Sammartino, Italy
■Alain Simonpieri, France
■Livio Yoshinaga, Brazil
■George Goumenos, Greece
■Stavros Pelekanos, Greece
■Ilia Roussou, Greece
■Konstantinos D. Valavanis, Greece
organized by
early bird until 31/07/2017
236€
registration fee from 01/08/2017
media partners:
information & registrationΤel.: +30 210 22.22.637,+30 6972 036900
e-mail: info@smartcasualdentistry.eu website: smartcasualdentistry.eu
360€
[18] =>
| case report root canal preparation with NiTi files
All roads lead south
Author: Dr Alfredo Iandolo, Italy
As usual in the human anatomy, root canals come
in all forms and sometimes develop in very random
structures. Luckily, pre-bendable nickel titanium
(NiTi) files allow us to prepare and clean the canal in
next to no time. In this article, we will compare three
different endodontic cases, you will quickly find that
a thorough and efficient root canal preparation is
easy with the right set of instruments—regardless
of the shape of the canal itself.
Reading endodontic case reports, you sometimes
get the impression that root canals always spot an
extreme, double curved morphology. With the latest
technology and treatment auxiliaries the endodontic world has to offer, you should, of course, feel
confident to take on even the most unusual shapes
of canals. Would not it be nice though to have a universal, flexible NiTi file system that allows you to
prepare all sorts of canals, whether they are S- or
J-shaped or lead straight down to the apex? In Italy,
we say “tutte le strade portano a Roma”. For a
well-versed endo expert “all root canals lead to
the apex is just as true—you only have to know
how to use your equipment the right way”. Fig. 4
Fig. 1: Pre-operative radiograph
of case 1.
Fig. 2: Specially hardened surface
of the HyFlex EDM file under the
microscope.
Fig. 3: Cutting in the canal using a
HyFlex EDM 25/.12 Orifice Opener.
Fig. 4: HyFlex EDM OneFile.
Fig. 1
Dr Alfredo Iandolo
18 roots
2 2017
Case 1: Straight down to business
A 48-year-old female patient introduced to our
surgery complaining of pain caused by chewing in
the maxillary left side. We quickly found that the
necrotic pulp of tooth 24 caused the complaint. The
pre-operative radiograph showed a deep caries
as well as a medium-sized periapical lesion (Fig. 1).
Fig. 2
The root canals were positioned in a comparatively
straight, almost parallel way with hardly any curvature. Quick preparation with a reduced sequence of
NiTi files consequently should be possible in that
particular case, as there were no contraindications
to a root canal therapy in general.
To provide a clean and dry operating field, dental
dam was applied to isolate tooth 24 for the following treatment. First of all, we handfiled the main
canals up to ISO 10 size. We were thus able to create
a suitable glide path, before the actual preparation
took place.
In our endodontic practice, we normally use the
latest generation of nickel titanium files by Swiss
dental specialist COLTENE for cleaning and shaping
the canal. As the name already indicates, the HyFlex
EDM is a “highly flexible” NiTi file, which proves to
be incredibly fracture resistant. In close cooperation with leading universities and international
endo-specialists, the renowned research department of the innovative provider of endo
equipment developed a literally sharp solution
for their instruments. To come up with a new,
powerful tool they employed a clever idea that is
widely used in other industry branches to dentistry. The abbreviation "EDM" stands for a specific
manufacturing process named "electrical discharge machining". Spark erosion improves the
cutting performance of the instrument as it produces a unique surface in the file. You can compare this kind of refinement with the serrated
Fig. 3
Dr Alfredo Iandolo
[19] =>
root canal preparation with NiTi files case report
Dr Alfredo Iandolo
Figs. 5 & 6: Postoperative
radiographs, case 1.
Dr Alfredo Iandolo
Fig. 5
edge of a kitchen knife you use for cutting bread to
make bruschetta (Fig. 2). Due to its special material
properties, the file is virtually unbreakable and predestined for dentists who require fast and reliable
results using a reduced file sequence.
With the HyFlex EDM, we were able to prepare the
root canal system in the blink of an eye. Access was
quickly gained with the HyFlex 25/.12 Orifice
Opener (Fig. 3). For the main procedure we
used only one universal file that saved a lot of
time during the treatment. For a quick and thorough preparation, a size 25 file with variable
taper was applied in the common single length
technique. The shaping took only a couple of minutes and we were able to navigate the instru-
|
Fig. 6
ment swiftly through the canal in a soft pecking motion (Fig. 4). Even when a bit more pressure was put on
the file it neither blocked nor got stuck in the dentine.
To obtain the ideal chemomechanical cleansing
we then irrigated the canal several times for a total of
at least 30 minutes. Following the classic irrigation
protocol, we used intracanal heated sodium hypochlorite (Iandolo technique), 17 % EDTA solution
and 2 % chlorhexidine digluconate solution to remove all debris and possible irritants from the canal. After eradicating the infection, we dryed the
canal with the corresponding paper points size 25.
The last step was to create a proper seal to prevent
microorganisms from reentering the root canal
system and thus protect the root from future
Fig. 7: Pre-operative radiograph of
teeth 45 and 46, case 2.
Fig. 8: 3-in-1 obturation material
GuttaFlow bioseal.
Fig. 9: In vitro comparison of single
cone technique (left) to improved
3-D obturation (right).
Fig. 8
Dr Alfredo Iandolo
Fig. 7
Fig. 9
roots
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[20] =>
Dr Alfredo Iandolo
Fig. 10: Postoperative radiograph
case 2 showing an obturated small
lateral canal.
Fig. 11: Follow-up four months later.
Fig. 11
Fig. 10
recontamination. A bioactive 3-in-1 obturation material was applied in a special technique as described
in the following case to ensure that all lateral and side
canals were filled. The postoperative radiograph after
the treatment most notably showed a lateral canal in
the apical third as well as an isthmus between the
main canals, which got both filled safely (Fig. 5). The
result was a tight, durable seal of the whole root canal
system, as the final radiograph reflected (Fig. 6).
Case 2: 3-D obturation technique
In our second case, a 65-year-old female patient
was referred to our practice with chief complaint of
pain in the right side mandible. The radiograph
showed defects in two teeth: in tooth 45, an insufficient former root canal treatment had led to a periapical lesion. In the neighbouring molar, a deep restoration was clearly visible. Tooth 46 was therefore
diagnosed with a necrotic pulp (Fig. 7). Again, the
HyFlex EDM helped us to shape the canal effectively
without transporting or changing the natural path
of the root canal. After gaining access with the orifice
opener, we once again used the HyFlex OneFile
Fig. 13
20 roots
2 2017
Dr Alfredo Iandolo
Fig. 12: Pre-operative radiograph
case 3, tooth 47.
Fig. 13: HyFlex EDM
25/.12 Orifice Opener.
Fig. 12
Dr Alfredo Iandolo
| case report root canal preparation with NiTi files
to get to the apex. A few finishing touches were
provided with the help of a 40/.04 EDM file.
Obturating all portals of exit turned out to be particularly challenging in our second case, therefore a
modified three-dimensional obturation technique was
applied using GuttaFlow bioseal. The 3-in-1 obturation
material combines fluid gutta-percha with a suitable
sealer at room temperature and bioceramics in an automix syringe (Fig. 8). This composition results in an
easy to handle material with excellent flow properties
and working times of 10 to 15 minutes. What we call
three-dimensional obturation technique is, in fact,
an efficient and reliable way to fill even complex root
canal structures.
First, we warm the gutta-percha using system B
heat source. For our purpose, we decrease the temperature to 130 degrees from the average 200 degrees, as this totally suffices. Penetration depth is
reduced to 3 seconds as well compared to the usual
5 seconds with a heat carrier to 4 millimetres from
working length. This way the GuttaFlow does not
set, but keeps a sticky consistency, which allows us to push it further down the canal with
a plugger, if necessary. However, with our new
technique the gutta-percha itself does not have
to get inside the accessory canals, as the bioceramic sealer will already flow into any hidden canals. In previous test settings, you can see that
the modified obturation technique allowed the
sealer to advance deeper inside lateral canals in
comparison to a traditional single cone technique (Fig. 9). Inserting the obturation material
with more speed also generates higher pressure:
you do not have to reach the desired working
length in one go, but can use another stroke until
you reach the desired length. The sealer sets only
around 2 minutes earlier than normal with the reduced heat settings and fast penetration. Thanks to
3-D obturation, you let the sealer do its job in areas
which are hard to reach, while it gets pushed further
[21] =>
root canal preparation with NiTi files case report
|
Fig. 14
Dr Alfredo Iandolo
down into the canal by the slightly melted guttapercha on top.
The fine white line in the postoperative radiograph of tooth number 45 showed the obturated
small lateral canal leading away from the main canal (Fig. 10). Moreover, in the follow-up session,
we noted that healing of the affected teeth 45
and 46 had already taken place. The bioactive
components of the obturation material further
added to the regeneration process, as they stimulated the rebuilding of bone and dentine tissue,
which was a favourable side effect to the actual
sealing of the canal (Fig. 11).
Fig. 14: HyFlex EDM 10/.05.
Fig. 15: Postoperative radiograph
case 3 showing a severe double
curvature in the mesial root.
Case 3:
Severe double curvature to finish off
Last but not least, we come to the extraordinary S-shaped canal as mentioned in the introduction. With strong curves it is always
good to know that NiTi files with a so-called
“controlled memory” (CM) effect can be prebent like classic stainless steel files, but do not
bounce back. Using their unique material properties, you can work comparatively stress-free,
even under difficult conditions.
This time, the patient with the rather challenging canal anatomy was a 40-year-old female patient with complaints in her right side
mandible. In our analysis, the clinical diagnosis
revealed an irreversible pulpitis in tooth 47. The radiograph indicated that we needed to get around a very
sharp angle in the mesial root (Fig. 12); endo specialists know how distant molars are notorious for their
winding root canal system!
We used the following sequence to get to the length
very quickly without straightening the canal at all:
HyFlex EDM 25/.12, 10/.05 and the afore-mentioned
HyFlex EDM OneFile 25/~ (Figs. 4 , 13, 14). The flexible
files can even find their way around tricky anatomies
and are virtually unbreakable. They move perfectly in
the centre of the canal, therefore I have never come
across any perforations or ledges during my numerous treatments so far. After using “CM”-treated NiTi
files, they can be quickly regenerated by autoclaving
and are ready for their next application until they
reach the end of their life cycle by displaying an
uneven, bent shape. As long as they are not unwound
they can be re-used safely, otherwise they have to be
discarded.
After drying and successfully obturating the canal,
we were able to dismiss the patient with a very promising prognosis. The immediate postoperative radiograph showed the naturally formed, filled mesial ca-
Fig. 15
nal with its striking double curvature at the end
(Fig. 15). We are very glad that even in more challenging cases like the present one we can rely on
the versatility of the latest generation of rotary instruments.
Conclusion
The latest generation of nickel titanium files
adapt easily to all shapes of root canals thanks to
their flexible design and unusual cutting power.
Whatever way you choose to reach the apex, prebendable NiTi files like the HyFlex EDM help you to follow the natural path of the root canal and quickly remove debris for chemical cleansing and long-term
obturation of the various root canal structures. The
extremely fracture resistant files are literally “cutting
edge” technology, which make an excellent travel
companion on virtually every road._
contact
Dr Alfredo Iandolo was awarded Doctor of Dental Medicine by the
University of Naples Federico II in 2006. As Professor A.C. he has continued speaking on endodontic courses at his home university since
2014. Iandolo is a certified member of the ESE (European Society of
Endodontics) as well as an active member of the SIE (Italian Society of
Endodontics) and AIOM (Italian Academy of Microdentistry). As winner
of the “Riitano Award” 2016 for best research in Endodontics Iandolo
is a regular speaker at national and international congresses. The
inventor of the Iandolo Gauging File (IG-File) and a new protocol in irrigation activation is
widely published both nationally and internationally.
Dr Alfredo Iandolo
Via A. Ammaturo 126 B
I-83100 Avellino, Italy
iandoloalfredo@libero.it
roots
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[22] =>
| case report use of MTA
Management of a non-vital
central incisor with an open apex
Using a novel MTA-based repair material in a young patient
Authors: Drs Mario Luis Zuolo & Arthur de Siqueira Zuolo, Brazil
Fig. 1
Fig. 2
Fig. 1: Initial radiograph showing tooth
#11 with an open apex and a
periradicular lesion.
Fig. 2: A radiograph after the first
appointment with calcium hydroxide-based paste in the canal.
Figs. 3a & b: Radiographs during
obturation. The position of the apical
barrier is indicated by arrows (a).
Final obturation and restoration (b).
22 roots
2 2017
Fig. 3a
The treatment of immature necrotic teeth with non-
vital pulps and open apices often presents a challenge
to the clinician. Cleaning and shaping the thin canal
walls, controlling the infection, and performing satisfactory sealing of the apex are sometimes not possible.1 In most cases, the treatment involves the induction of apical closure by apexification procedures to
allow more favourable conditions for the conventional treatment.2
Fig. 3b
absorbable material, another treatment option was
proposed.13 This material has the ability to set in a short
period and in the presence of moisture. It solidifies into
a hard structure in less than three hours.14 This property, along with its capability of inducing cementum-
like hard tissue when used in the periradicular tissue,15
allows its use in the immediate obturation of an open
apex.16–18
Several studies show that apexification with MTA
Traditionally, calcium hydroxide has been the ma- has a high success rate with fewer visits and less time
terial of choice used to induce the formation of an to completion.18–21 Also, in a study that compared clinapical hard tissue barrier before placing the perma- ical and radiographic results of apexification with
nent filling.3 Although many studies have reported MTA or calcium hydroxide, all of the cases sealed with
favourable outcomes when this treatment is used,4–7 MTA healed, whereas in the calcium hydroxide cases,
disadvantages have also been reported. The use of two out of 15 did not heal.9 However, MTA has some
calcium hydroxide apical barriers has been associated disadvantages too. Because of its consistency, its mawith some problems, such as unpredictability of api- nipulation and placement in the site of repair can be
cal closure,8 risk of reinfection due to leakage of the challenging.22 Additionally, its use can cause discolorprovisional filling9 and risk of root fracture as a result ation of the tooth, and it should be used with caution
of the long-term application of calcium hydroxide.10, 11 in aesthetic zones.23 A novel material, MTA REPAIR HP
Furthermore, poor patient compliance has a negative (high plasticity; Angelus), was recently introduced
influence on the prognosis of conventional apexifica- with the intention of improving some of those chartion procedures.12
acteristics.24 This new formula retains all the chemical
and biological properties of the original MTA; howWith the advent of the mineral trioxide aggregate ever, it changes its physical properties of manipula(MTA), a calcium silicate-based, biocompatible, non- tion, resulting in greater plasticity, thereby facilitat-
[23] =>
use of MTA case report
|
ing handling and insertion. Additionally, its formula
uses a different radiopacifier (calcium tungstate),
which does not cause staining of the root or dental
crown, according to the manufacturer.24 In this case
report, we present the clinical identification, diagnosis and management of a non-vital central incisor
with an open apex, treated using MTA REPAIR HP.
Fig. 4a
Case report
A 12-year-old male patient with a non-contributory
medical history presented for examination with the
chief complaint of pain in tooth #11. Clinical examination found that the tooth had been restored with a
temporary filling and responded with pain to percussion and palpation and presented with a discrete
oedema in the area. There was no probing defect or sinus tract stoma. According to the patient, root canal
therapy had been started in the tooth approximately
12 months before. In the radiographic examination, a
radiopaque material inside the canal a few millimetres
short of the apex could be observed. Also, on the radiograph, it could be seen that the apex was not completely formed and presented with a periapical lesion
(Fig. 1). A clinical diagnosis of a pulpless tooth with
unsatisfactory previously initiated therapy and symptomatic periapical periodontitis was established.
The treatment plan was to first perform the cleaning and shaping of the canal and to place a calcium
hydroxide dressing. Then, after one to two weeks, with
the regression of the symptoms, we would recreate an
apical barrier with a new MTA-based material, obturate the tooth and restore it. The treatment plan was
presented to the patient’s parents, who agreed to it.
After the consent form had been signed, 1.8 ml of
local anaesthetic (2 % lidocaine with adrenaline
1:100,000) was administered, the restorative material
was removed, and endodontic access corrected. After
rubber dam isolation, the material inside the canal
was removed under thorough irrigation using a 2.5 %
sodium hypochlorite solution (Fórmula & Ação) and a
CPR-7 ultrasonic tip (Obtura Spartan Endodontics).
Fig. 4b
After the removal of the material from the canal, #2
and #3 Largo burs were used to prepare the first twothirds of the canal. Then, the apical foramen was located with the aid of an apex locator (RAYPEX, VDW),
and the working length was established at 0.0 and
confirmed with a radiograph. Instrumentation proceeded using stainless steel K-type hand files in a
crown-down technique until a #80 hand file achieved
the working length. Between each file change, copious irrigation with 2.5 % sodium hypochlorite solution was performed (approximately 100 ml throughout the entire treatment).
During the procedure, passive ultrasonic irrigation
was performed for one minute several times to ensure
complete removal of the old material and to maximise
the irrigation technique. After the completion of instrumentation, the canal was irrigated with 5 ml of
17 % EDTA (Fórmula & Ação) for three minutes and a
final rinse with 5 ml of saline solution. A calcium
hydroxide-based paste was placed in the canal as an
inter-appointment dressing, and the tooth was temporarily restored (Fig. 2). After ten days, the patient
came to the clinic for conclusion of treatment. The
tooth was asymptomatic, and the area was no longer
Figs. 4a & b: CBCT images.
Axial view just after MTA REPAIR HP
placement (a). Axial view at the
nine-month follow-up. The bone
formation, including the cortical plate,
can be observed (b).
Figs. 5a & b: CBCT images.
Sagittal view just after MTA REPAIR HP
placement (a). Sagittal view at the
nine-month follow-up. Reformulation
of the cortical plate is visible, as well as
partial apical closure (b).
Fig. 5a
Fig. 5b
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[24] =>
| case report use of MTA
Fig. 6a
Fig. 6b
Fig. 6c
Figs. 6a & b: MTA REPAIR HP.
Capsule containing the powder (a).
Vial containing the liquid (b).
Fig. 6c: The material after proper
manipulation.
swollen. The temporary filling was removed, and the
calcium hydroxide paste was removed from the canal
using a 2.5 % sodium hypochlorite solution and passive ultrasonic irrigation as previously described. The
#80 hand file was used again to working length. The
canal was then irrigated with 5 ml of 17 % EDTA for
three minutes to remove the smear layer, and 5 ml of
saline solution was used for the final rinse. The canal
was dried with paper points, and MTA REPAIR HP
was manipulated according to the manufacturer’s
instructions and placed with the aid of pluggers
(B&L Biotech) in the last 3 mm of the root canal,
forming an apical plug. After ten minutes, the material had set, and the tooth was obturated using BC
Sealer (Brasseler USA) and gutta-percha cones with
the lateral condensation technique (Figs. 3a & b).
The pulp chamber was cleaned with a sponge
soaked in 70 % alcohol, and the access cavity was restored using composite (Figs. 4a & b). A high-resolution CBCT scan of the patient was requested immediately after treatment so that it could be used for
comparison later in the follow-up.
The patient presented for recall one month later
without any symptoms. Postoperative radiographic
and clinical evaluations were performed at three, six
and nine months. The tooth was asymptomatic, and
the area did not have any signs of inflammation. After
nine months, another CBCT examination was conducted. Comparison of the CBCT images was performed, and bone healing and apical closure of the
open apex could be observed (Figs. 4a & b, 5a & b).
Discussion
Previous clinical studies in humans have demonstrated that an apical barrier of MTA can be used with
success in the technique of apexification of teeth with
open apices. El-Meligy and Avery ran a clinical trial
comparing the use of calcium hydroxide and MTA in
30 teeth of 15 patients who had lost pulp vitality
through caries or trauma.9 The conventional technique of apexification with calcium hydroxide was
performed in one tooth, whereas the barrier technique with MTA was applied to the other tooth in the
same patient. The teeth were then followed up for
three, six and 12 months. Two of the teeth filled using
calcium hydroxide failed, while none of the teeth
filled with MTA showed clinical or radiographic signs
of pathology. Simon et al. carried out a prospective
clinical trial in 57 teeth of 50 patients with open apices treated with MTA plugs and definitive filling of the
canal and observed success in 81 % of the cases.16
In this case report, the use of a modified MTA (MTA—
bioceramic-based high-plasticity reparative cement)
achieved a good clinical result over the short fol-
24 roots
2 2017
low-up period. Comparison of CBCT images just after
placement of the MTA barrier and after a nine-month
period demonstrated bone formation and apical closure by hard tissue. It should be noted that a radiolucent area too could be seen at this time. Such a healing
pattern could be classified as incomplete healing,
according to Molven et al.24
From a clinical perspective, the handling and placement of the MTA REPAIR HP was easier than with the
conventional MTA. According to the manufacturer,
the difference between MTA REPAIR HP and the original Angelus MTA is the replacement of distilled water
with a liquid that contains water and another organic
plasticiser that gives the new product high plasticity25
(Fig. 6). The manufacturer claim that the new MTA
does not promote dental discoloration could not be
studied in this case, since the material was placed
in the apical portion of the canal.
The importance of case reports is the demonstration of what is possible in our patients using scientific
clinical treatment protocols. Reports from clinical
practitioners have played important roles in the field
of dentistry, but should be validated through proper
laboratory and clinical research studies. In conclusion, the clinical protocol using the new MTA REPAIR
HP, as described in this case report, enabled the successful apexification of a central incisor in a young
patient._
Editorial note: This article first appeared in the Endodontic
Practice US magazine (Vol. 9, No. 2). Reprinted with permission. A list of references is available from the publisher.
contact
Dr Mario Luis Zuolo
Endodontist Dr Mario Luis Zuolo
from São Paulo in Brazil is an
internationally prominent
speaker in the specialty.
He can be contacted at
mlzuolo@uol. com.br.
Dr Arthur de Siqueira Zuolo
runs a private practice in São
Paulo and is Adjunct Professor of
Endodontics at the Associação
Paulista de Cirurgiões Dentistas,
the São Paulo association of
dental surgeons. He can be
contacted at artz@msn.com.
[25] =>
[26] =>
| case report laser-assisted treatment
Blue light laser-assisted
crown lengthening in
restorative dentistry
Authors: Dr Philipp Skora, Dr Dominik Kraus, PD Dr Jörg Meister & Prof. Matthias Frentzen, Germany
Figs. 1a–e: X-rays of the
upper jaw.—Subgingival
carious lesions at 11 and 21.
Abstract
Introduction
Basic investigations of the laser-tissue interaction
of a new type of laser device with a wavelength of
445 nm—the blue light spectrum—promise considerable advantages in comparison with infrared laser
systems due to the known optical parameters of oral
soft tissue. The procedure for a comprehensive laser-based gingivectomy before restorative treatment
using this new type of laser is presented in the following case report. Due to the outstanding haemostasis
with the blue light laser, both gingivectomy and adhesive filling treatment were possible in only one session. The follow-up examination showed the rapid
healing of the wound with no complications and with
no postoperative gingival recession. The treatment
led to a very good aesthetic result at a moderate effort.
Blue light-emitting diode lasers present an innovative alternative to the already established diode laser
systems with wavelengths within the infrared spectrum. Due to the strong absorption of blue laser light
in oral soft tissue1, the cutting capacity is improved
when comparable laser parameters are used. Blue
light lasers have very powerful coagulation effects
that enable blood-free work.2 In addition, the high
antimicrobial effect of blue light has been demonstrated in many fundamental studies.3, 4 Due to these
specific characteristics, blue light lasers are extremely
suitable for corrective periodontal surgery in terms of
gingivectomies. In contrast to electrosurgery, laser-
assisted plastic-aesthetic periodontal surgical procedures do not cause problems of electro-magnetic
Fig. 1a
Fig. 1d
Fig. 1b
Fig. 1c
26 roots
2 2017
Fig. 1e
[27] =>
laser-assisted treatment case report
interactions that could in turn present a contraindication in the case of patients with symptoms of cardiac disease. In the case of multimorbid patients who
are frequently prescribed anticoagulants, the danger
of secondary haemorrhage can be minimised. In addition, in these cases, a bloodless surgical field can be
created ad hoc, so that moisture-sensitive restorative
measures (adhesive dentistry) can be carried out.
In general, for multi-morbid patients it is important
that restorative procedures can be carried out in a short
time and that the use of anaesthetics should be reduced to a minimum. Excision wounds should heal in a
short time period. A dry environment is advantageous,
in particular when a dental rubber dam cannot be used.
In case of extended subgingival loss of dental hard
tissue, e.g. as a result of carious defects, it is always
necessary to enable a visual inspection of the preparation margin before the restoration can be placed.
Furthermore, a bloodless, clean, and dry adhesive surface must be guaranteed before application of restorative material. Here, laser-assisted procedures provide a fundamental advantage in comparison to
classical surgical procedures. Adequate haemostasis
after soft tissue excision with the scalpel, scalers and
cuvettes is often not achievable by styptics.
This case study presents a treatment protocol for
restorative and endodontic treatment of patients
with extensive subgingival carious lesions in the
anterior tooth area.
|
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Case report
Fig. 2: Preoperative situs.
Fig. 3: OP-situs after laser surgery
(gingivectomy).
Fig. 4: Situation after adhesive
composite restauration following laser
surgery.
Fig. 5: Postoperative recall
after seven days.
A 72-year-old patient visited the Dental School of
the University of Bonn to obtain a dental consultation
regarding prostodontic aspects. The medical history
was unremarkable. The patient did not suffer pain.
Among other things, insufficient composite restauration in the anterior tooth regions of the upper jaw were
noticeable at the initial examination. In addition, subgingival probing showed defects in dental hard tissues
at 11 and 21. For tooth 11, a fistula and an apical radiolucency were found in the vestibular marginal area in
the X-ray image (Figs. 1a–e). Teeth 12 and 21 reacted
positively to a sensitivity test, in contrast to tooth 11.
The probing depths of the teeth 11 and 21 were 4–5 mm.
The treatment plan was explained thoroughly to
the patient. In the first session, tooth 11 was trepan
ated as part of an emergency procedure. After exposure of the root canal, it was rinsed with NaOCl and
calcium hydroxide was applied. Ahead of this emergency endodontic procedure, the carious lesions on
11 and 21 were excavated incompletely and treated
temporarily with glass ionomer cement.
The patient came for further treatment five days
later. The fistula on 11 had closed, clinical symptoms
were no longer present (Fig. 2). After an infiltration
anaesthesia (1.8 ml UDS), the subgingival carious
defects in teeth 11 and 21 were visualised in a gingivectomy (Fig. 3). For both teeth, approximately 4 mm
of soft tissue had to be removed to expose the af-
roots
2
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[28] =>
| case report laser-assisted treatment
Fig. 6
Fig. 8
Fig. 7a
Fig. 7b
Fig. 6: Follow-up inspection
after 14 days.
Figs. 7a–c: X-rays documentation of
the endodontic treatment of 11.
Fig. 8: Postoperative recall after three
months.—Healthy gums and aesthetic
restauration of the carious lesions
at 11 and 21.
contact
Prof. Matthias Frentzen
Welschnonnenstraße 17
53111 Bonn, Germany
Tel.: +49 228 287-22470
frentzen@uni-bonn.de
28 roots
2 2017
Fig. 7c
fected area. The gingivectomy was carried out using
a 445 nm diode laser (Sirona K-Laser blu, Sirona) with
a power output of 1.5 W in cw mode and an application tip with a diameter of 320 μm. This device is
a pre-serial model equivalent to SIROLaser Blue
(Sirona). The resection was carried out in six minutes.
The surgical procedure was performed with no pain.
After finishing the gingival excision, the surgical
field was bloodless and dry (Fig. 3), so that the temporary fillings at 11 and 21 could be removed and the
caries completely excavated under visual control.
The defects were treated with adhesive restorations
with a composite material in a multi-layer technique
(Herculite®; A3,5). Figure 4 shows the situation after
the restoration had been completed, including finishing and polishing of the aesthetically complex
restauration. After laser treatment, haemostatic
measures were no longer necessary for all subsequent treatment steps. In the postoperative recall
after seven days (Fig. 5), the patient reported that
there was no postoperative pain. After the procedure, the patient did not find it necessary to use the
analgetics that had been made available.
After 14 days (Fig. 6), the excision wounds had
healed to a very great extent. There was still slight
redness in the marginal area. No swelling occurred in
the entire postoperative phase. At this time, endodontic treatment was also performed for the devitalised tooth 11. After preparation and sealing of the root
canal, the trepanation cavity was closed using a composite material (Figs. 7a–c). Three months after the operative procedure, the endodontic treatment of tooth
11 resulted in no further clinical symptoms. In the
treated area, the probing depth was 1.5 mm. No bleeding was found during probing. No further recession of
the gingival margin was found after the primary healing, approximately two weeks after treatment or at
the follow-up inspection after three months. Gingival
colour and surface texture (gingival stippling) corresponded to a healthy appearance (Fig. 8). To ensure
long-term good oral hygiene and to prevent approximal gingival recession at 11/21 in a further step a
frenectomy (laser-assisted) should be performed.
Discussion
The presented treatment protocol for laser-assisted
gingivectomy enabled the badly destroyed teeth 11 and
21 to be restored in an aesthetically satisfactory manner. Due to the safe procedure and the drying of the
surgical field after laser-assisted excision, adhesive fillings were placed in the same session and exhibited no
discoloration in the marginal zone, even after three
months. This indicates a good bonding between the restorative material and the dentin. There was only little
discomfort for the 72-year-old patient which derived
from this complex therapy. After an emergency treatment, definitive rehabilitation, including adhesive restorations and endodontics, was carried out in two sessions. The patient did not report any discomfort related
to the laser treatment. The patient's aesthetic appearance in the anterior teeth of the upper jaw was restored
with moderate means. This treatment procedure improves the patient’s compliance, because it allows the
patient to partake in a systematic care and treatment
concept, which enables the continuation of additional
necessary treatment measures._
Editorial note: A list of references is available from the
publisher. This article was first published in laser magazine
4/2016.
[29] =>
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[30] =>
| study temperature-related damage of the DPSC
Thermal damage
behaviour of human
dental pulp stem cells
Authors: Prof. Karsten König & Dr Anton Kasenbacher, Germany
Table 1: Live/Dead Assay one hour
and 24 hours after thermal treatment.
30 roots
2 2017
Objective
Material and methods
This study was designed to examine the influence
of temperatures ranging from 37 to 65 °C on the cell
morphology of DPSC (dental pulp stem cells) via light
and electron microscopy, a synthesis of Heat Shock
Proteins (HSP) with fluorescence-marked antibodies and vitality via the Live/Dead Fluorescence Kit.
DPSCs were cultivated at 37 °C and 5 % CO2 in
sterile cell chambers (MiniCeM, JenLab GmbH). The
cells were irrigated with pre-heated culture medium
(Eagle’s MEM, Gibco BRL; 37 °C) with 20 % FCS, 2 mM
L-Glutamin and 100 µM L-Ascorbate-2-Phosphate
in order to remove cellular debris previously to the
temperature trials. Filling the chamber with the culture medium followed and a preheated water bath
of different temperatures was introduced. Up to an
incubation temperature of 46 °C, the experiments
were conducted with temperatures rising every
2 °C and 0.5 °C in the sensitive temperature scale of
46 °C to 58 °C. In addition, trial series were carried
out at 60 °C and 65 °C. After a total of 15 min of thermal treatment, the cells were cooled down in the incubator at a temperature of 37 °C for one hour.
Temperature
Lethality %
°C
1h
24 h
37
0
0
39
0
0
42
0
0
45
0
0
46
0.5
2
47
10
17
48.5
18
29
50
17
27
55
24
59
56.5
48
54
58
100
100
60
100
100
65
100
100
Some of the cells which had undergone thermal
treatment were examined with the Live/Dead
Fluorescence Assay (Molecular Probes) in order
to assess vitality via fluorescence microscopy and
Axiovert 200 (ZEISS) after incubation. A mixture of
2 µM Calcein AM and 4 µM Ethidium-homodimer-D1
was added to the cells which were slowly cooling
down at 37°C in the incubator either 1 h or 24 h after
thermal treatment and incubated for 10'. Vital cells
exhibited a green fluorescence caused by calcein,
while lethal cells showed a red core fluorescence
(Ethidium-homodimer-D1 and coupled DNA). 100 cells
of each type were enumerated.
Table 1
In order to examine the synthesis of HSP, the cells
having undergone thermal treatment were processed
as follows:
·· Opening of the chamber and removal of the coverslip containing the cells
[31] =>
temperature-related damage of the DPSC study
|
Fig. 1
·· Suction of the nutritive medium, two rinses with
PBS (isotonic: 67 mM phosphate buffer pH 7.2–7.4,
0.5 % NaCl)
·· 12' fixation in 2 % paraformaldehyde in 0.1 M
cacodylate buffer pH 7.2; Rinse: 3 x PBS, 2 x TBS
(Tris buffered saline, 50 mM Tris-HCl buffer,
1.25 % NaCl)
·· Parting of the coverslip with Pap-Pen pen (oil pen),
possibly correct with paraffin
·· Incubate one half of the coverslip overnight at 4 °C
with 1:500 diluted antibody AK HSP25, Rabbit
(Biomol), diluting solution: fish gelatin 1 %, Triton
x 100 1 % in TBS)
·· Cover the other half of the coverslip exclusively in
diluting solution (without AK)
·· Wash in TBS for 3 x 10'
·· Conjugate with the second antibody AK Anti-Rabbit-Alkaline Phosphatase for two hours at room
temperature (Ziege, dilution: 1:50 with fish gelatine 1 % and Triton X 100 1 % in TBS)
·· Wash in TBS for 3 x 10'
·· 15' Alkaline-Phosphatase verification with 3 mM
Levamisol in Chedium (induces blue-brown colouring according to Seidel).
Examinations with the transmission electron microscope were conducted:
·· Washing of the cells with cacodylate buffer (0.1 M)
with 6.8 % Sucrose
·· Fixation of 30' with 1 % glutaraldehyde
·· Washing with cacodylate buffer
Fig. 1: Vitality test of thermally treated
DPSC.
Fig. 2: HSP-detection caused by an
antibody colour reaction.
In order to perform examinations with scanning
electron microscope, the cells were processed as follows:
·· Washing of the cells in cacodylate buffer (0.1 M)
·· Fixation with 2.5 % Glutaraldehyde in cacodylate
buffer for 20'
·· Washing with cacodylate buffer for two times, followed by two washings with Aqua dest.
·· Dehydration with increasing alcohol concentration:
20 %, 30 %, 50 %, 70 %, 90 %, 2 x in 100 % EtOH for
10' each
·· Further processing of the samples at the Centre for
Electron Microscopy (Critical Point Drying and
sputtering with gold; SCD 005, BAL-TEC AG)
·· Microscope: Zeiss EM 902A.
Fig. 2
roots
2
2017
31
[32] =>
| study temperature-related damage of the DPSC
Fig. 3
Fig. 3: Control cells exhibited a normal
appearance at 37 °C under REM. Cell
processes, microvilli-like structures on
the cell surface (their numbers seems
to depend on the level of cell activity)
as well as the elongated
cell shape are clearly visible.
·· Contrasting with 1 % Osmiumtetroxyde and 1 %
potassium ferrocyanide for two hours
·· Rinsing with cacodylate buffer for three times as
well as with Aqua dest.
·· Dehydration with increasing alcohol concentration:
20 %, 30 %, 50 %, 70 %, 90 %, 2 x in 100 % EtOH for
10' each
·· Embedding in Epon (epoxy resin), polymerisation
for four days at 60 °C
·· Ultramicrotomy, ultra-thin sections (70 nm; Leica
Ultracut S, Leica Mikrosysteme GmbH)
·· Dyeing of the sections with 1 % Uranyl acetate in
methanol and 1 drop of acetic acid for 10'
·· Microscope: Zeiss EM 906
Results
Light microscopy and vitality test
The cells received thermal treatment at temperatures ranging from 37 °C to 60 °C and varying inFig. 4: REM: Thermally treated DPSC
showed external signs of cellular
damage at 46.5 °C: The cell usually
changes its elongated shape and
starts to round. At 50 °C, an increased
rounding can be observed. The cell
seems to contract so fast that a part of
the cytoplasm processes tears off
(arrows). The surface structure of the
cells is effected as appearance and
number of microvilli change.
Fig. 4
32 roots
2 2017
termediate temperature levels. Light microscopy
examinations showed significant morphological
changes at temperatures from 46.5 °C ± 0.5 °C.
At temperatures from 37 °C to 45 °C, all cells
exhibited a green calcein fluorescence. At tem
peratures of 46 °C and above, lethal results were
detected in some of the cells that had undergone
thermal treatment. The number of lethal cells increased in correspondence to a rise in temperature.
At temperatures of 46 °C to 56.5 °C, the number
of lethal cells had almost doubled 24 h after thermal treatment in comparison to the number of lethal cells one hour after thermal treatment (Table 1,
Fig. 1). Starting at 56.5 °C, this phenomenon ceased,
with about the same number of lethal cells. This
temperature of 56.5 °C corresponded to the LD50
value (50 % lethality). No cell survived thermal
treatment at 58 °C.
[33] =>
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[34] =>
| study temperature-related damage of the DPSC
Fig. 5
Fig. 5: REM: Thermal treatment at
60 °C. While the exterior shape
remains mostly intact,
their surface does not exhibit any
structuring anymore.
HSP production
Examinations with regard to the production
of HSP via light microscope or transmission laser
microscopy showed a slight, unspecific colouring
of the cells after incubation of 37 °C (control, Fig. 2).
An increase in HSP production (intense colouring)
was noted at a temperature of 50 °C, while thermal
treatment at 60 °C again resulted in slight, unspecific colouring of the cells.
REM
Scanning electron microscopy showed a typical
flat, long distribution of the control cells (37 °C cells,
Fig. 3). These cells exhibited many processes and
microvilli-like structures. In addition, cell-to-cell
connections with neighbouring cells were observed.
34 roots
2 2017
TEM
The fibroblast-like DPSCs (Fig. 6) exhibited long,
extended mitochondria (M) within the 3-D network of the cell at 37 °C (control). The nucleus (K)
appeared to be undivided and to have a normal
nuclear envelope (arrows). ER/RER, free ribosomes as well as the Golgi apparatus did not show
any anomalies. A significantly expressed cytoskeleton (Z) whose filaments were aligned parallely to
the longitudinal axis (probably microfilaments)
was observed. The cells featured a number of inclusions.
The successive rise in temperature resulted in the
first critical temperature level of 46.5 °C ± 0.5 °C.
From this level onwards, significant initial changes
of the cells were registered via light and electron microscope, especially an initial deformation and
rounding of the cells. The cell structure (microvilli-like structures) was reduced. However, microvilli
were observed at temperatures of up to 50 °C
(Fig. 4). At 50 °C (chance of survival > 70 °C according to Live/Dead Assay), the cells left distinct cytoplasm protuberances on the base of the coverslip
(Fig. 4, arrow), probably caused by a rapid contraction or rounding.
At 50 °C, cell rounding became irreversible (Fig. 7).
Mitochondria (M) exhibited structural changes,
especially an inflation which concurred with the
destruction of the christae alignment, the parallelism of which got lost. There was no longer a
three-dimensional network. The Golgi apparatus
was significantly deformed and hardly any vesicles were constricted. The cytoskeleton was partially disintegrated and could no longer be detected. The cell membrane appeared to have
increases vacuolisation. The nucleus (K) appeared
to be damaged irreversibly. The nuclear envelope
was inflated and partially disintegrated (*). The
nuclear plasma condensed at the chromatin, resulting in a reduction of the euchromatin-areas
which condensed at the heterochromatin. The nucleus exhibited segmented chambering (arrow).
Incubation at a temperature of 60 °C, at which
none of the cells survived, resulted in a different
outcome. There was no apparent deformation or
rounding of the cells, with the original cell shape
remaining mostly intact and some small reductions.
The cells appeared to have been “thermally fixed”
instantly. Neither microvilli nor other surface structures were visible. Cell processes in contact with the
coverslip remained intact, but exhibited denaturation and fixation caused by rapid heating (Fig. 5).
Contrarily, the external shape of DPSCs incubated at 60 °C (Fig. 8) remained mostly intact.
However, cytoplasm was hardly detectable.
Mitochondria (M) were destroyed, membranes
and christae were partially wound up (arrows).
Golgi apparatus and cytoskeleton were not
detected. The euchromatin areas were reduced
at the nucleus (K) and condensed at the heterochromatin (*). The nuclear membrane was
significantly vesiculated.
[35] =>
temperature-related damage of the DPSC study
|
Fig. 6
Discussion
The first indications to a temperature-related
damage of the DPSC were seen in the Live/Dead
Assay. Calcein is able to penetrate the membrane
and is only converted to a fluorescent colouring
agent inside of an intact cell. If the cell membrane
becomes permeable as a result of damages, calcein
will not remain inside the cell. As a consequence,
Ethidium-homodimer-D1 will enter the cell in exchange. This substance is not permeable for intact
membranes and will fluoresce red when combined
with DNA.
Interestingly significant thermally-induced damages were only observed at temperatures ranging
from 46.5 °C ± 0.5 °C. Starting at this temperature,
cell membranes are destroyed apparently. Temperatures from 56.5 °C ± 0.5 °C form another threshold
at which the 50 % lethality limit was reached.
If the vitality test was conducted 24 h after thermal treatment, almost twice as much lethal cells
as observed 1 h after incubation were seen at temperatures from 46.5 °C to 56.5 °C. It appears that
repairing processes cannot eliminate the thermal
damage. Contrarily, thermal treatment will result
in a lethal reaction even 1 h later.
Starting at 56.5 °C, most cells died immediately,
probably due to denaturation of the proteins (coagulation). Usually, a temperature level of 62 °C
is given as the starting point for coagulation in the
literature.
Fig. 6: TEM: Control cells at 37 °C.
K: Nucleus; ER: endoplasmatic
reticulum, RER: rough endoplasmatic
reticulum; M: mitochondria;
Z: cytoskeleton; arrows: markers of the
nuclear membrane.
However, the Live/Dead Assay does not allow
any conclusions on the effects of the damages on
the cell organells, compartments or physiological
reactions such as protein production. Consequently,
HSP tests and electron microscopic examinations
of the ultrastructure were conducted additionally.
Heat Shock Proteins (HSP) were detected very
well at 50 °C by an antibody reaction. The cells were
distinctly coloured, which implies a significant reaction of the cell on the temperature-related stress.
These cells were still able to synthesise the proteins
and to survive for some time. Controls only showed
only a light colouring, which may be the result of an
unspecific reaction of the antibody with different
Fig. 7: TEM: Due to thermal treatment
at 50 °C, the cells are rounded and the
cell membrane forms vesicles (left).
Mitochondria exhibit a disrupted
structure of the christae, while the
nuclear plasma starts to condense and
the nucleus (K) itself often appears to
be uncharacteristically flapped (arrow).
The nuclear membrane (*) seems to be
partially inflated or dissolved.
Fig. 7
roots
2
2017
35
[36] =>
| study temperature-related damage of the DPSC
Fig. 8
Fig. 8: TEM: Thermal treatment at
60 °C. Parts of the cytoplasm are
damaged or dissolved as can be seen
by the mitochondria (M) with inflated
or wound-up christae (arrows).
The nucleus (K) shows severely
condensed areas (*).
cell proteins as well as a production of HSP which
is not related to thermal stress.
Similarly, a temperature level of 60 °C only lead
to light colouration, which can be explained by the
immediate lethal effect resulting in a missing time
scale for the biosynthesis of HSP. In general, it
should be noted that the first HSP examinations
did not exhibit the expected intracellular resolution
due to a low specificity.
The results of REM and TEM at the different guide
values of 37 °C, 46.5 °C, 50 °C, 60 °C and 65 °C fit
very well with the results from light microscopy. The
effects of a sudden and massive heating to more
than 46 °C on the exterior cell shape (rounding and
partial reduction of external structures) are distinctly visible. The extremely fast contraction of the
cells at temperatures around 50 °C might result in
the observed tearing of cytoplasm-processes. Thermally-related membrane openings were not detected via REM even at temperatures of 60 °C and
above. These high temperatures probably resulted
in an immediate coagulation of membrane proteins
and other intracellular proteins, which lead to a
“conservation” or fixation of the cells in their current shape. While the external cell shape was maintained because of the lacking time window for morphological modification, irreversible damages to
the organells, nuclear membranes, nuclei and cytoplasm were detected electron-microscopically.
Starting at a temperature of 46.5 °C, a vacuolated cell membrane was observed via TEM in the
rounded cells. Nucleus, organells and cytoskeleton
were subject to beginning morphological changes.
The cells reacted differently on heating, probably
because their differences in physiological age, activity and cycle states influenced immediately visible effects. For example, the cells differed in the level
of microvilli reduction.
36 roots
2 2017
If the survival of thermally treated cells will prevail
for a time span of more than 24 h and if there are
thermally-related damages of the reproductive behaviour remains to be examined by further studies.
However, it may be postulated with caution that the
presented data indicate a chance of survival of the
examined DPSC up to a temperature of 46 °C. These
results on the thermal damage behaviour of human
dental pulp stem cells are important for the development of ultrashort dental laser systems._
Acknowledgements: The authors would like to thank
Dr Walter Richter, Dr Iris Riemann and Mr Helmut Hörig
(Clinical Centre of FSU Jena, Germany) for their support in
producing electron microscopic and light microscopic
images.
contact
Prof. Karsten König
Saarland University
Campus A5.1, Room 2.35
66123 Saarbrücken
Germany
Tel.: +49 681 302-3451
Fax: +49 681 302-3090
k.koenig@blt.uni-saarland.de
Dr Anton Kasenbacher
Obere Hammerstraße 5
83278 Traunstein
Germany
Tel.: +49 861 4692
Fax: +49 861 12853
a.k@ts-net.de
[37] =>
Essential Dental Media
Dental Tribune International
The World’s Largest News
and Educational Network
in Dentistry
www.dental-tribune.com
[38] =>
| practice management lighting
Lighting in dental surgeries
frequently neglected requirements
—
of the standard on illumination
Author: Antonín Fuksa, Czech Republic
Fig. 1a
Fig. 1b
Fig. 1a: Typical situation in dental
surgeries in Eastern Europe:5
lighting is designed using
requirements for office workplaces.
Most of the requirements
are not met, see Table 1.
Fig. 1b: Balanced illumination of
dental surgery employing a directional/
indirectional panel luminaire above the
chair and using additional ceiling and
furniture luminaires, see Table 2.
[39] =>
lighting practice management
Parameter
Fig. 1
Overall surgery illumination
Overall uniformity
Patient illumination
Instruments illumination
Material preparation area
illumination
Nurse’s desk illumination
Doctor’s desk illumination
Background illumination
General colour rendering index
Compliance with Standard
The model surgery has dimensions 5 x 6 m and
ceiling height of 2.8 m. The luminaire above the chair
is suspended in the height of 2.2 m above the floor.
Positions of the additional luminaires are a compromise between functionality and aesthetics.
Besides the visual task in the mouth cavity, many
other facets exist in the dental surgery that need to
be illuminated in order to carry out tasks: instrument
trays, controls and displays of diagnostic instruments,
material preparation areas, PC table, filing cabinet,
etc. Illumination requirements have to be fulfilled
at all these places, too. A minimum overall room illumination of 500 lx has to be maintained as well.
One of the principal items in the updated standard
is the background surrounding the dentist’s workspace, which is a stripe aligned to the surrounding
area of the dentist’s workspace, at least 3 m wide,
within the size of the room. According to the standard, this has to be illuminated 1/3 of the illumination
of the surrounding area. Installations according
to the older standard rarely meet this requirement.
A luminance of 5,000 lx directed at the patient can
be measured under a powerful luminaire. The back-
Fig. 2
20–500 lx
poor
300–500 lx
500–700 lx
50–200 lx
600–1,500 lx
very good
1,000–3,000 lx
500–700 lx
500–750 lx
20–200 lx
30–100 lx
20–500 lx
70–80
NO
500–750 lx
700–800 lx
600–1,000 lx
> 90
YES
|
Table 1: Comparison and evaluation
of very basic parameters
of illumination.
ground lighting in this case would be 1,670 lx, which
is quite expensive to achieve. This requirement has
not been met in any of tens of surgeries measured
where a powerful directional pendant luminaire was
placed above the chair. The updated standard helps us
to understand the room as a whole, not just a set of
task areas. Not only the illumination of the patient,
but also the uniformity and acceptable contrast in
the whole space is important.
The focused beam of the operating light provides
illumination of about 15,000 lx that is necessary
for the dentist’s task in the mouth cavity. The high-
output directional/indirectional panel luminaire
above the chair provides illumination of the task
background area of about 3,000 lx, providing a 1 : 5
contrast, which is already an acceptable level.
Colder tones of light further improve the perceived
contrast to about 1 : 4. Besides illuminating the
patient, the high-output directional/indirectional
panel luminaire serves as an ergonomic aid to ease
the visually demanding task of the dentist.
Measurements carried out in dental surgeries across
some Eastern European countries5 clearly show that
Symbol
Meaning
Purpose
Overall illumination
Patient
illumination
Em
Maintained Illuminance
Adequate level of light
500 lx
1,000 lx
UGRL
Limit of Glare index UGR
Glare limitation, acceptable contrast
19
–
Uo
Minimum illuminance uniformity
Acceptable distribution of light
0.6
0.7
Ra
Minimum general colour rendering index
Required colour discrimination
90
90
–
Special requirements
According to selected task or area
Light should not
dazzle the patient
–
Table 2: Requirements on lighting
in dental surgeries, according
to table 5.48 of the standard.1
roots
2
2017
39
[40] =>
| practice management lighting
Fig. 2a: 3-D visualisation
of situation from Figure 1a.
Lighting is designed using
requirements for office workplaces.
The installation does not respect
additional task areas.
Fig. 2a
Fig. 2b: 3-D visualisation
of situation from Figure 1b.
An insight into a model room with a
directional/indirectional panel
luminaire and additional
luminaires to respect
additional task areas.
Fig. 2b
even the very basic requirement of task illumination
is often neglected. Also task background and overall
illumination are often far too low, which has both eye
and overall fatigue implications. As little as 30 lx have
been repeatedly m
easured on the material preparation areas and computer desks. Many surgeries installed in existing buildings kept the original (office)
luminaires, not quite following the lighting project.
These systems were often projected according to an
old standard that required as little as 300 lx for office
work. Savings on lighting tend to generate much larger
expenses later. The need for light grows with age.
40 roots
2 2017
Editorial note: This article was first published in cosmetic
dentistry magazine 1/2017.
References
[1] EN 12464-1:2011 Light and lighting—Lighting of work places—
Part 1: Indoor work places.
[2] Czech Government Regulation No. 361/2007 establishing the
conditions of occupational health protection.
[3] EN ISO 9680:2007 Dentistry—Operating lights (repl. 2014).
[4] Fuksa, Antonín. Lighting in dental surgeries. StomaTeam. 2/2014.
ISSN 1214-147X.
[5]
Svoboda, Filip. Lighting in dental surgeries in Romania—
a summary report. Personal communication, 2015.
Other parameters of lighting like uniformity, glare,
colour rendering or non-visual effects of light and lighting control will be discussed later in a dedicated article.
about
Lighting the surgery with office luminaires only is
not sufficient to fulfil basic requirements. Lighting
using a single, powerful central luminaire provides
enough light in the visual task area, but may easily
fail to meet additional requirements. That is why
additional luminaires are needed to provide background area illumination and uniformity._
Antonín Fuksa graduated (MSc) in 2000 at the
Czech Technical University in Prague, Faculty
of Electrical Engineering in the field of study
Measurement and instrumentation. He currently works
as a developer of intelligent luminaires,
smart lighting systems and chronobiological
phototherapy devices in NASLI.
[41] =>
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[42] =>
| industry news solutions for endodontic treatment
VDW: Endodontics
with a system
Every dentist wants to perform safe and efficient
endodontic treatment to preserve patients’ teeth for
as long as possible, but can root canal therapy be
easily integrated into general everyday practice? With
almost 150 years of experience in endodontics, VDW
provides perfectly coordinated solutions for the four
key stages of endodontic treatment: preparation,
irrigation, obturation and post-endodontic care.
“We offer new solutions that save time, simplify
procedures and ensure the long-term success of
treatments. We have adapted all of these innovations
to VDW’s entire system solution approach,” said Arjan
de Roy, Commercial Development Director of VDW.
“We demonstrate that endodontics as a system
solution pays off.”
Simple preparation perfectly combined
No dentist wants to deal with the hassle of an instrument breaking—for his or her own sake and above all
that of the patient. Reasons for a fracture can be many
and varied, including a complicated root canal anatomy,
incorrect preparation techniques or poor processing of
materials. Especially with severely curved root canals,
a broken-off file can be removed only with a great deal
42 roots
2 2017
of patience and skill. However, the alternating motion
of reciprocating instruments, such as RECIPROC,
significantly reduces the risk of file breakage. With
RECIPROC blue, VDW went one step further: the latest
generation of the single-file system is particularly
flexible owing to a revolutionary production process.
The result is a significantly reduced risk of fracture
and even greater safety for the dentist and patient.
With the RECIPROC blue, VDW provides the most
effective tool for preparing all canals.
No endo without an endo motor
In modern treatment, wireless endodontic motors
for reciprocating and rotating file systems have
proved to be reliable. The handling of VDW’s motors is
extremely simple: fully rotatable contra-angle handpieces with small heads allow easy access, excellent
visibility and quick change of rotation. For optimum
use and patient information, there are now also apps
available with many functions, including preset programmes and a file library. Different file sequences
and precise torque specifications allow safe operation while the dentist can also inform and best advise
the patient. The innovative VDW.CONNECT Drive wireless motor combines all of these advantages for opti-
[43] =>
solutions for endodontic treatment industry news
mum endodontic workflows, and the VDW.GOLD
RECIPROC classic motor even has an integrated apex
locator as a two-in-one solution.
Successful endo means thorough cleaning
Often under-estimated and yet crucial, proper
irrigation and disinfection improve the likelihood of
successful endodontic treatment. However, irrigation has so far posed a major challenge for many
practitioners. General dentists and endodontists do,
indeed, use different means of cleaning canals efficiently and preparing them for obturation. However,
there is always a compromise in terms of either effectiveness or preservation of tooth substance. VDW offers a simple and clever solution for everyday practice
that provides highly-effective cleaning of the root
canal with minimal effort: the EDDY irrigation system. Using acoustic streaming and cavitation effects,
the sonic-activated irrigation tip of the EDDY ensures efficient cleaning of the complex canal system,
leaving no tissue residue or dental chips. The tip is
made of polyamide, which is softer than dentine.
Recent studies have proved that sonic activation with
EDDY is at least as efficient as ultrasonic activation,
but significantly safer owing to the polyamide.
Obturation easier than ever
|
can be detached easily without additional instruments. Obturation with GUTTAFUSION saves a great
deal of time, in contrast to lateral condensation, as
practitioners can apply the warmed gutta-percha
more easily. A further advantage is that root fractures are virtually eliminated.
Correct post-endodontic care
The long-term prognosis of an endodontically
treated tooth with a badly damaged clinical crown
ultimately depends on the quality of the root post
securing the crown to the root canal. Furthermore, it
is essential that the coating allow an optimum bond
between the post and the luting composite. VDW’s
DT ILLUSION XRO SL offers even greater safety for the
practitioner and patients. The colour pigments of the
quartz-fibre posts react thermally, making the posts
invisible at body temperature, but clearly visible during treatment and especially in radiographs. Durability and fracture resistance are further advantages.
Finally, the innovative Safety Lock coating enables a
secure and lasting bond for all adhesive systems and
composite cements.
Combined solutions instead of individual
products
Where endodontic treatment used to be perceived
Only a homogeneous, solid root canal filling prevents as complicated, with its pursuit of “Endo Easy Efficient”,
the risk of recontamination and ensures the long- VDW heralds the start of a paradigm shift. Systems
term success of the treatment. With GUTTAFUSION, that are precisely coordinated provide dentists with
VDW has been offering a simple system for several greater safety and simplicity while reducing treatyears that combines single-post technology with ment costs and time. Those who want to preserve
warm 3-D obturation. The warm gutta-percha con- teeth successfully choose endodontics with a system.
denses into all isthmuses and ramifications, resulting Endo is just as "easy" as that._
in a homogeneous filling that can easily be prepared.
The specially designed handle allows precise placement using tweezers, even in the molar area, and it
More information at: www.vdw-dental.com
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[44] =>
| meetings IDS 2017
Innovation fireworks
Solutions for the practice and laboratory
of tomorrow—the opportunities of current
technologies: IDS 2017
By Koelnmesse GmbH
In the field of dentistry, the opportunities of current
technologies are very concrete, very tangible as the
International Dental Show 2017 (IDS) in Cologne
demonstrated. In this way, the visitors experienced
substantial enhancements to established digital
workflows—from imaging techniques through to 3-D
printing. In addition, the exhibiting companies also
presented innovations for traditional working methods in the laboratory and practice.
What form will the work in practices and laboratories
take on tomorrow and how can dentists and dental
technicians seize the opportunities that are already
visible today?
This specifically applies to the digital processes. In
the field of implantology, they have already signifi-
44 roots
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cantly contributed towards exploiting the healing
potential of the body to a maximum through optimised planning.
Implantology has long since been considered to be
the flagship discipline for the implementation of digital technologies. How far these have pushed forward
in the spectrum of dentistry is demonstrated in a field
that some people initially considered to be rather difficult terrain: orthodontics. With virtual models for
orthodontics not only can diagnostic issues be processed and a virtual set-up created, but also more and
more often orthodontic appliances can be planned,
such as, for example, fixed devices. Even the largest
orthodontics challenge for digital technology is increasingly coming under focus: removable devices
such as stretching plates, activators, etc.
[45] =>
IDS 2017 meetings
|
3-D printing—which displays great future potential—is a production process that is already implemented in orthodontics, as well as in other disciplines.
Alongside drilling templates, different splints, dental
technology models, individual impression trays and
plastic base casts for the metal cast will most probably
depict the most frequent indications.
In general, speed plays an increasingly more important role in all sections of dentistry. For example,
patients ideally want prosthetic treatments to be
carried out in one session if possible or at least completed on the same day. Digital technologies make this
possible more frequently than to-date.
Practice and laboratory
riding at high speed
The increased speed is achieved through pure chairside therapies or by accelerating the workflows across
the entire process chain in the practice and laboratory,
from A for activators to Z for zirconium oxide. Attractive optimisation options are arising now at all levels.
This begins with digital moulding. At IDS, a whole
series of new intraoral scanners enriched the existing
offer. Some of them can simply be carried from one
treatment room to the next, almost as conveniently
and inconspicuously as a pen in the pocket of the
dentist's coat. Beyond this, connecting it to the tablet
facilitates the patient communication. Other intra
oral scanners are consciously kept small to ensure
high patient comfort and yet exploit the possibilities
of voice and motion control.
A prosthetic restoration can subsequently be carried
out in the practice more and more often. A milestone
here is the production of bridges from zirconium oxide,
which enables the dentist to carry out more than just
single-tooth restorations. Dentures that are printed
out of plastic in the practice using the DLP method
(Digital Light Processing) are also almost within reach.
The process for classic production in the dental
laboratory is being accelerated enormously. At the
same time, the communications are becoming more
intensified; the dentist and the dental technician
are moving closer together. Technology in the laboratory—for example a new dental microscope with a
3-D mode —is assisting here. Besides quality control,
it can be used for the direct exchange of digital images with the practice (screenshots, videos, splitscreen function). Furthermore, it ensures a constantly relaxed, ergonomic posture.
But even the production steps themselves are becoming faster all the time. For instance, the guidance
of instruments on curved shape tracks when process-
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[46] =>
| meetings IDS 2017
ing glass and hybrid ceramics promises great time
savings in comparison to the conventional milling or
sanding techniques. A fine structure feldspar ceramic
infiltrated with polymer now offers an interior colour
gradient with six layers in fine nuances in a timesaving and convenient process for patient-friendly
aesthetics. The general trend is moving towards the
more frequent production of monolithic restorations.
Interesting new surface finishing materials are
appearing here. The dental technician sprays a thin
layer of a transparent version on sintered zirconium
oxide restorations; the spray diffuses during the firing process in the surface where it bonds intensively,
homogenously, non-porously and smoothly after the
first firing without additional polishing.
In addition to milling and sanding the possibilities
of the printing techniques are expanding considerably.
A wide range of splints, models, drilling templates, indirect bonding trays, in the near future temporary and
permanent dentures—almost everything can be printed.
Laboratory systems now offer even bigger building
platforms and convenient remote maintenance for
network-compatible models. Meanwhile, the speed is
picking up—just to get an idea of the magnitude: seven
splints in one hour are definitely possible today.
Innovative software even enables a combined additive/subtractive production: where it comes down
to the highest precision, the machine subsequently
carries out an automatic milling process and thus creates overall a consistently high surface finish. Today,
multi-material printers are perhaps visible on the
horizon. For example, six plastics are mixed to make a
new compound with the defined required properties;
for instance, with specific colouring or interior colour
gradients for a patient-specific design.
As an alternative to their own production, the laboratory can also outsource jobs to a central or industrial supplier. Models can be delivered within short lead times,
prompt service is offered using digital technology.
46 roots
2 2017
Forward planning in endodontics
New digital technology is also available for endo
dontics; after planning tools initially established
themselves in the field of implantology and more recently in orthodontics, a root canal treatment can
now also be simulated in advance—its complexity
more accurately estimated and ultimately planned
step by step. A 3-D X-ray and innovative software
form the basis here. This enables the dentist to follow
the course of the canals on the monitor using dot
markers through to the root tip. Subsequently he
sees in (orthogonal) cuts (to the canal), at which
points calcifications are present for example. He can
also pre-test virtual filing. All of the information
gained from the simulation is taken into account
when carrying out the treatment, or in the case of a
general dentist, if necessary a referral to the specialist is provided.
Part thermally treated filing assists in safely and
hygienically preparing even strongly curved canals.
The stiffer material at the shaft increases the tactile
control when navigating through the root canals,
whereas the tip of the instrument is particularly
flexible.
If a root pin is attached before the crown is restored,
models made of a fibreglass reinforced composite
make canal extensions superfluous. Because such
a pin can be extended across the entire root canal,
it adapts to suit the natural anatomy and thus
enables a substance-friendly treatment.
Gaining through combination:
microscopy and diagnostics
Because endodontics always involves particularly small structures, further developed OP microscopes also offer interesting opportunities here.
These are even becoming increasingly interesting
for other dentistry part disciplines thanks to current innovations. For example, an integrated fluo-
[47] =>
IDS 2017 meetings
rescence mode enhances one microscope, which
enables the intraoperative check for tooth decay
during the substance removal. The newly designed
interface allows one-handed control. The opportunities of such systems range from endodontics
through to preserving dentistry, periodontology
and implantology.
Different functionalities are growing together in
a different area too. Small lamps combine a lamp for
the hardening of dental materials with fluorescence
diagnostics. Both bacterial activities, such as the
smallest leakages in the edges of fillings, become
visible. However, this is more and more frequently
avoided from the onset, among other things thanks
to a constant reduction in polymerisation shrinkage
with current values down to just 0.85 %.
The terminal tooth always presents a special problem in filling therapy: the matrix cannot be wedged,
and after its removal, distocervical surplus composites have to be laboriously filed away. The solution is a
matrix that is produced in Germany in a completely
manual process, which can be placed in one hand
movement in four seconds and which automatically
lies distocervically.
Fibre-reinforced composites are used as superstructure material to provide a “shock absorber”
effect, which offers a plus in durability and biting
feeling. Corresponding CAD/CAM blocks can be
processed chairside in the meantime even without
separate firing processes.
Images courtesy of
Koelnmesse GmbH.
When fixing implant prosthetic constructions using locators (often an alternative to full dentures)
a high pivoting capacity now allows divergences of
up to 40 degrees between two implants. And thanks
to a special holding mechanism, the dentures can be
extracted particularly easily using a hydraulic release
system during the recall appointment.
If a conventional mucosa-supported full denture
is chosen, cold curing resin with many of the material
characteristics of heat curing polymer offer the
dentist totally new possibilities. Such pink denture
plastics are high impact, lie nicely on the gums of the
patient and can nevertheless still be comfortably
processed in the laboratory.
Step towards the practice and laboratory
of tomorrow
If a tooth is no longer worth preserving despite today's endodontic and tooth preserving possibilities, implantology treatment is more and more frequently an
option, which is now becoming even more interesting:
new instruments with sharp working tips and a thin
profile enable a tissue-saving extraction and thus often make elaborate bone augmentations superfluous.
New super-sharp scalers, new tiny mini implants,
new ceramics for press technology processing,
new embedding materials—this list is ongoing. The
industry heads the ranks in many areas with both
analogous and digital innovations. During their
tour around IDS in Cologne the dentists and dental
technicians took advantage of this to collect ideas
for their practice and laboratory of tomorrow, based
on well-founded knowledge thanks to the comprehensive offer of the exhibitors._
New implant systems are appearing that considerably increase the primary stability through comprehensive further developments. Certain engines now
dispose of a non-invasive stability measurement
so that the optimal service life of an implant can
accurately be determined.
Editorial note: IDS (International Dental Show) takes place
in Cologne every two years and is organised by the GFDI
Gesellschaft zur Förderung der Dental-Industrie mbH, the
commercial enterprise of the Association of German Dental
Manufacturers (VDDI) and is staged by Koelnmesse GmbH,
Cologne.
Target figure = primary stability
|
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[48] =>
| meetings events
International Events
2017
HK IDEAS—
International Dental Expo and Symposium
4–6 August 2017
Hong Kong
www.hkideas.org
FDI Annual World Dental Congress
29 August–1 September 2017
Madrid, Spain
www.world-dental-congress.org
18th ESE Biennial Congress
14–16 September 2017
Brussels, Belgium
www.e-s-e.eu
9th Annual Congress of Czech Endodontic
Society
23 September 2017
Prague, Czech Republic
Dental-Expo 2017
25–28 September 2017
Moscow, Russia
www.dental-expo.com
American Association of Oral and
Maxillofacial Surgeons—99thAnnual Meeting
9–14 October 2017
San Francisco, USA
www.aaoms.org
ADA 2017
19–23 October 2017
Atlanta, USA
www.ada.org/en/meeting
BDIA Dental Showcase
19–21 October 2017
Birmingham, UK
www.dentalshowcase.com
DenTech China
25–28 October 2017
Shanghai, China
www.dentech.com.cn
XXXVIII AEDE
Annual Meeting
1–3 November 2017
Coruña, Spain
www.aede.info
GNYDM
24–29 November 2017
New York, USA
www.gnydm.com
Madrid, Spain. Photo: © joyfull / Shutterstock.com
48 roots
2 2017
ADF 2017
28 November–2 December 2017
Paris, France
www.adf.asso.fr
[49] =>
submission guidelines about the publisher
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Questions?
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roots
2
2017
49
[50] =>
| about the publisher imprint
roots
international magazine of
endodontics
Publisher/President/CEO
Torsten R. Oemus
t.oemus@dental-tribune.com
Executive Producer
Gernot Meyer
Managing Editor
Magda Wojtkiewicz
m.wojtkiewicz@dental-tribune.com
Accounting Services
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Clemens Bargholz, Germany
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roots international magazine of endodontics is published by Dental Tribune International (DTI) and appears in 2017 with four issues. The magazine and
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50 roots
2 2017
[51] =>
[52] =>
is coming to
BERLIN
28 June –1 July 2018
Berlin, Germany
www.ROOTS-SUMMIT.com
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