roots international No. 2, 2018

Cover / Editorial / Content / Hands-on courses - Thursday, 28 June 2018 / Lecture programme - ROOTS SUMMIT 2018 / Chairpersons & invited speakers - ROOTS SUMMIT 2018 / Abstracts - ROOTS SUMMIT 2018 / The dental operating microscope in endodontics / Nd:YAG laser-assisted removal of instrument fragments / Cutting endodontic access cavities—for long-term outcomes / Bioactivity in restorative dentistry: A user’s guide / Trends & application / Bioactive materials for root canal obturation / Orthograde apical application of an MTA plug in a tooth without constriction / Long-term stable restoration of severely discoloured anterior teeth / Bisphosphonate-related osteonecrosis of the jaw / Manufacturer news / Successful communication in your daily practice - Part III: Millennial patients / “He brought a world of enthusiasm and knowledge to the global endodontic community" / International events / Submission guidelines / International imprint

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issn 2193-4673 • Vol. 14 • Issue 2/2018

roots

international magazine of endodontics

including

special

CE article

The dental operating
microscope in endodontics

trends & applications

Bioactivity in restorative dentistry:
A user’s guide

ROOTS SUMMIT special
Lecture programme, abstracts
and speaker information

2/18

[2] =>

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[3] =>

editorial

Stephen Jones
Guest Editor
Co-Chairman of the ROOTS SUMMIT

Dear readers and friends,
Welcome to ROOTS SUMMIT 2018! We are delighted
to be in historic Berlin in Germany and to be hosting
our meeting in the European School of Management
and Technology (ESMT). This majestic building was the
headquarters of the former German Democratic Republic State Council. The imposing architectural aesthetics
of the building are spectacular. After the great success
of ROOTS SUMMIT 2016 in Dubai, this year’s edition
could not have found a more ideal location.
When introduced to ESMT, I was pleased to find that
their focus is on three principles: leadership, innovation
and analytics. These items have also been very much
part of the DNA of ROOTS for the past 20 years. We are
pleased to be able to have our event in a school setting
that reflects our ideals too.
Leadership is shown by the over 50 countries represented at this meeting, guided by their top opinion leaders and most forward-thinking endodontists and dentists.
Innovation is what people are seeking whenever
they attend a continuing education course, innovation
in terms of treatment planning, visualisation, irrigation
protocol, instrumentation, filling techniques, etc.
Analytics are key to any successful treatment and
something that all ROOTS members take very seriously.
Analysing what to do, what equipment to use, single
appointment versus multiple, restorative options, etc.
is a critical component in treating patients. The fact
that ROOTS members confer with each other globally
24 hours a day speaks volumes to how seriously everyone attending the ROOTS SUMMIT regards the subject
of planning endodontic treatments.
Dr David E. Jaramillo has organised a topical and relevant meeting with an extremely high level of scientific
relevance. Our impressive list of some of the world’s
leading endodontic speakers will translate the science

to how it can benefit you by benefiting your patient. As is
always the case at a ROOTS SUMMIT, we have speakers from multiple countries and backgrounds, including
a mix of academia, education and clinical practice. In
addition to the ten speakers David has organised for us,
Dr Freddy Belliard has scheduled 17 diverse and unique
hands-on workshops, some of which sold out well in
advance of the SUMMIT.
To many participants, the highlight of a ROOTS SUMMIT
is viewing the poster and case presentations submitted by their fellow members of the ROOTS Facebook
group. Both of these competitions will take place on
29 June. We received an enthusiastic response and a
very high level of submissions to participate in this part
of the programme. David has narrowed it down to ten
posters and ten presentations. Over the years, several
of our main-stage speakers have come from this segment of the programme.
The entire programme, especially the hands-on workshops, would not be possible without the generous and
unconditional support of our sponsors. Please spend
some time talking to these kind people who support
ROOTS on an ongoing basis and help make this meeting possible. You will be among some of the best and
most knowledgeable people marketing endodontic
products anywhere in the world, so please make good
use of your time with these valuable partners. They are
a great resource for knowledge and technique information. You will be surprised how much they also have
to teach you.
We will have a very busy, interesting and extremely
educational few days in Berlin. Thank you for joining us
at ROOTS SUMMIT 2018!
Stephen Jones
Guest Editor
Co-Chairman of the ROOTS SUMMIT

roots
2 2018

[4] =>

| content
editorial
Dear readers and friends

03

Stephen Jones (Guest Editor)

ROOTS SUMMIT special
Lecture programme, abstracts and speaker information

06

CE article
The dental operating microscope in endodontics
page 16

16

Dr Frank C. Setzer

research
Nd:YAG laser-assisted removal of instrument fragments

22

Dr Georgi Tomov

technique
Cutting endodontic access cavities—for long-term outcomes

24

Dr L. Stephen Buchanan

trends & applications
page 36

Bioactivity in restorative dentistry: A user’s guide

30

Dr Fay Goldstep

Hot modified technique with a new biosealer

36

Drs Alfredo Iandolo, Massimo Calapaj & Dina Abdellatif

case report
Bioactive materials for root canal obturation

40

Prof. Bogdan Shumilovich, Dr Vladimir Rostovtsev, Dr Lianna Adunts,
Dr Andrey Fonstein & Dr Eugeniy Stanislavchuk
page 50

Orthograde apical application of an MTA plug

44

Long-term stable restoration of severely discoloured anterior teeth

50

Bisphosphonate-related osteonecrosis of the jaw

54

Dr Angela Gusiyska

Prof. Dr Daniel Edelhoff

Drs Claudia Dib, Sara Salloum, Edgard Jabbour & Philippe Sleiman

news
manufacturer news

60

practice management
Successful communication in your daily practice
Cover image courtesy of
FKG Dentaire (www.fkg.ch)
2/18

issn 2193-4673 • Vol. 14 • Issue 2/2018

roots

international magazine of endodontics

Part III: Millennial patients
Dr Anna Maria Yiannikos

tribute
“He brought a world of enthusiasm and knowledge to the global
endodontic community”

66

Fred Michmershuizen

meetings

including

International events

special

68

about the publisher

CE article

The dental operating
microscope in endodontics

trends & applications

submission guidelines
international imprint

Bioactivity in restorative dentistry:
A user’s guide

ROOTS SUMMIT special
Lecture programme, abstracts
and speaker information

04

64

roots
2 2018

69
70

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| ROOTS SUMMIT special

Hands-on courses
Thursday, 28 June 2018

Modern instrumentation of the root canal—
an introduction to the S1 reciprocation one file system
with the efficient, flexible and safe S1 Plus files
Speaker: Johan Ohlin/Sponsor: Sendoline AB
Impact of the dental operating microscope on the
diagnostic and therapeutic stages of root canal therapy
Speaker: Dr Sergio A. Rosler/
Sponsor: Seiler Instrument & Mfg Co., Inc.
Paradigm shift to 3-D endodontics:
XP-endo sequence, anatomical shaping and cleaning
with the exclusive adaptive core technology
Speaker: Klaus Lauterbach/Sponsor:
FKG Dentaire S.A./American Dental Systems GmbH
Technological advancements for safe root canal
preparations: reciprocating preparation
with simultaneous length determination
Speaker: Dr Mario Zuolo/Sponsor: VDW GmbH
10:30–11:00 Coffee break

11:00–12:30
Technological advancements for safe root canal
preparations: reciprocating preparation
with simultaneous length determination
Speaker: Dr Mario Zuolo/Sponsor: VDW GmbH
How to become a hero for your patients transforming
endodontic failures into successful cases:
5 different uses of MTA in endodontics
Speaker: Dr Ricardo Tonini/
Sponsor: Produits Dentaires SA
Intraosseous anesthesia:
the key for successfully and immediately
anesthetizing hot pulps
Speaker: Dr Stéphane Diaz/Sponsor: Dental Hi Tec
One file fits all? Facts and fiction
Speaker: Dr Bernard Bengs/
Sponsor: Coltène/Whaledent GmbH

06

The art of endodontics: A hands-on course
Speaker: Dr Stephen Buchanan/
Sponsor: Dental Engeneering Laboratories
12:30–14:00 Lunch break

14:00–15:30
A universal, safe and efficient combination
for success in root canal treatment
Speaker: Dr Hugo Sousa Dias/Sponsor: Mani Inc.
Irrigation: Past and current state
Speaker: Beatriz Del Valle/Sponsor: Neolix SAS
Back to the roots: Retreatments done the easy way
Speaker: Dr Sebastian Bürklein/
Sponsor: Komet Dental Gebr. Brasseler
Value added cleaning and disinfection with
Laser Activated Irrigation—new paths
with PIPS and SWEEPS: evidence and critical analysis
Speaker: Prof. Roeland De Moor/Sponsor: Fotona d.o.o.
15:30–16:00 Coffee break

16:00–17:30
Treatment of endodontic perforations
with bioceramic materials
Speaker: Dr Mario Zuolo/
Sponsor: Angelus Indústria de Produtos
Root canal retreatment lectureship
Speaker: Dr Bing Fan/Sponsor: Zumax Medical Co, Ltd
Morita TR ZX2: An innovative and clever device that
saves time and increases safety
Speaker: Dr Sebastian Riedel/
Sponsor: J. Morita Europe GmbH
Obturation in 3-D continuous wave technique or
hydraulic condensation: how, when and where?
Speaker: Dr Walter Vargas Obando/
Sponsor: Meta Biomed Inc.

Berlin © S.Borisov/Shutterstock.com

9:00–10:30

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2 2018

RO0218_06_HandsOn.indd 6

20.06.18 12:45

[7] =>

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09.03.18 15:46

[8] =>

| ROOTS SUMMIT special

Lecture programme
ROOTS SUMMIT 2018

Day 1: Friday, 29 June 2018

13:00–14:00 Lunch break

08:45–09:00 Opening
Dr Freddy Belliard & Stephen Jones

14:00–16:00 Improve your microscope skills
to improve outcomes
Dr Carlos Aznar Portoles

9:00–11:00 Invasive cervical resorption:
A clinical approach
Dr Elisabetta Cotti

16:00–16:30 Coffee break

11:00–11:30 Coffee break

16:30–18:00 The role of bioceramics
in clinical endodontics
Dr Josette Camilleri

11:30–13:00 Guided endodontics:
Possibilities and limitations
Dr Gergely Benyő cs

20:00–23:00 Evening event

13:00–14:00 Lunch break

Day 3: Sunday, 1 July 2018

14:00–16:00 Endodontists—
The last best hope for the natural tooth
Dr John Munce

08:30–09:00 Results of poster competition
and case presentations
Moderated by
Dr David Jaramillo

16:00–16:30 Coffee break

19:00–21:00 Welcome reception
Sponsored by META BIOMED

08

10:30–11:00 Coffee break

Day 2: Saturday, 30 June 2018

11:00–13:00 Improving retreatment
outcomes
Dr Mario Zuolo

09:00–10:30 Root canal therapy or vital pulp therapy?
Success determined by proper diagnosis Opening
Dr Jenner Argueta

13:00–14:00 Lunch break

10:30–11:00 Coffee break

14:00–17:00 The Art of Endodontics
Dr Stephen Buchanan

11:00–13:00 Pain and infection management
in a contemporary endodontics office
Dr Jorge Vera

17:00–17:15 Closing
Dr Freddy Belliard
& Stephen Jones

roots
2 2018

Berlin © S.Borisov/Shutterstock.com

16:30–19:00 Case Presentations
Moderated by Dr David Jaramillo

09:00–10:30 Reliable adhesive
post-endodontic restoration
in the hands of the endodontist
Dr Daniel Č erný

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[10] =>

[11] =>

[12] =>

| ROOTS SUMMIT special
From 2009 to 2013, he served on the editorial board of
LKS—Časopis České stomatologické komory (journal
of the Czech Dental Chamber). He is also the co-founder
of the Dental Summit congress in Prague, Czech Republic. He has been the co-owner and director of the
HDVI continuing education institute since 2010. Černý
has contributed four chapters to dental books and lectures both nationally and internationally.

Elisabetta Cotti
(Italy)
SPEAKER
Dr Elisabetta Cotti received her DDS from the
University of Cagliari in Italy. In 1991, she received
a certificate and a master’s
degree in endodontics from
the Loma Linda University in the
US. She is the chair of the department of conservative
dentistry and endodontics at the school of dentistry and
director of the one-year postgraduate programme in endodontics at the University of Cagliari. She also teaches
in the Advanced Education Program in Endodontics at
the University of Bologna in Italy and is a lecturer in the
Department of Endodontics at the Loma Linda University. She also works in a private practice limited to endodontics.
Cotti is the author of several papers in the field of endodontics and has a specific interest in periapical pathology, immature teeth, complex case management, imaging techniques, and interactions between periapical
periodontitis and systemic conditions. She is an active
member of the Italian Society of Endodontics, at which
she has served as executive member for ten years, and
a member of the European Society of Endodontology,
at which she has served as country delegate for seven
years. She is the past President of the Società Italiana
di Traumatologia Dentale (Italian society of dental traumatology).

David E. Jaramillo
(USA)
CHAIR
Dr David E. Jaramillo
is Associate Professor of
Endodontics at the University of Texas Health
Science Center at Houston
in the US.
He obtained his D.D.S. in 1986 from the Universidad
Autonoma de Guadalajara in Mexico, where he also completed his postgraduate training in endodontics 1990.
He was formerly Clinical Assistant Professor of Endodontics at the University of Southern California, Los Angeles,

roots
2 2018

and Loma Linda University. He was the Clinical Director
of Endodontics, endodontics course director in the International Dentist Program and a researcher at the Center
for Biofilms USC and Center for Dental Research at Loma
Linda University.
Jaramillo has lectured at meetings of endodontic
associations in 12 countries and has published more
than 20 peer-reviewed papers and six book chapters.
Dr Jaramillo is the official Scientific Chairman of the
ROOTS SUMMIT 2018 in Berlin.

Stephen Jones
(USA)
CHAIR
During a 30-year career
in dental sales, Stephen
Jones has been fortunate to hold positions with
many different areas of responsibility, particularly various sales and marketing roles
in the dental field. Jones is currently responsible for
international sales in Asia and Latin America at Centrix
Dental, and is the co-chairman of the 2018 ROOTS
SUMMIT in Berlin.

John Munce
(USA)
SPEAKER
Dr C. John Munce received both his dental
degree and his training
in endodontics from Loma
Linda University in the U.S.
Munce is Professor of Graduate Endodontics at both Loma
Linda University and the University of Southern California in the US. He is also founder and CEO of a
clinical endodontics products company, CJM Engineering.
Munce is a frequent international lecturer and the
primary author of the chapter “Preparation for endodontic treatment” in the 50th anniversary seventh edition
of Ingle’s Endodontics. Clinical concepts and techniques
originated by Munce have been published in a number of
primary endodontic textbooks, most recently in the sixth
edition of Ingle’s Endodontics and the tenth edition of
Pathways of the Pulp, and he co-authored a chapter on
mineral trioxide aggregate repair of post per forations in
Dr Nadim Baba’s prosthodontics textbook Contemporary Restoration of Endodontically Treated Teeth. Munce
is a Diplomate of the American Board of Endodontics, a
Fellow of the International College of Dentists and past
President of the California State Association of Endodontists.

[13] =>

ROOTS SUMMIT special

SPEAKER
Dr Carlos Aznar Portoles
received his BDS from the
International University of
Catalonia in Spain in 2004.
In 2009, he completed an
MSc programme in endodontics at the same university. In 2014,
he completed a postgraduate programme in endodontics
at the Academic Centre for Dentistry Amsterdam in the
Netherlands.
Aznar Portoles has been practising as a general dental surgeon for Integrated Dental Holdings since 2004.
He also currently runs a private practice limited to endodontics and endodontic microsurgery in Santpoort-Zuid,
Netherlands.
He is the author of several endodontic-related articles and lectures regularly at national and international
meetings.

Jorge Vera
(Mexico)
SPEAKER
Dr Jorge Vera graduated from the National
Autonomous University of
Mexico in Mexico City in
1989. In 1993, he received
a postgraduate endodontic
certificate from the Tufts University
School of Dental Medicine in Boston, Massachusetts, in
the US.
Vera teaches endodontics at the Universidad
Autónoma de Tlaxcala in Mexico and has been
running a private practice limited to endodontics since
1993.

The endodontist is a recipient of the 2005 Samuel
Seltzer award and a past President of the Asociación Mexicana de Endodoncia (Mexican association of
endodontists). Vera is a member of the scientific advisory board of the Journal of Endodontics, International
Endodontic Journal, International Journal of Endodontic
Rehabilitation and Giornale Italiano di Endodonzia (Italian journal of endodontics). He has published 80 articles
on endodontics and chapters in two books, Endodontic
Irrigation (2015) and Endodoncia (2011).

Mario Zuolo
(Brazil)
SPEAKER
Dr Mario Zuolo gained
his DDS from the University of São Paulo in Brazil in 1981. Afterward, he
specialised in endodontics.
He completed a master’s degree in molecular biology at the
Federal University of São Paulo in Brazil. Thereafter, he
earned a PhD in clinical dentistry with a special focus on
endodontics from the University of Campinas’s School of
Dentistry of Piracicaba in Brazil.
Zuolo was a teaching fellow in endodontics at the
University of Iowa College of Dentistry in the US and
Professor of Endodontics at the school of professional
development of the Associação Paulista de CirurgiõesDentistas (São Paulo dental association) in Brazil. He
has a private practice limited to endodontics in São
Paulo.
Zuolo has written several scientific articles and lectures
nationally and internationally on endodontic clinical topics focusing on contemporary endodontic treatment and
retreatment. He is a co-author of the book Reintervention in Endodontics (Quintessence, 2014), which has also
been published in Spanish, Portuguese, Greek, Russian
and German.

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2 2018

RO0218_10-13_Speakers.indd 13

Berlin © S.Borisov/Shutterstock.com

Carlos Portoles
(Spain)

|

13
20.06.18 12:46

[14] =>

| ROOTS SUMMIT special

Abstracts
ROOTS SUMMIT 2018

Day 1: Friday, 29 June 2018

Day 2: Saturday, 30 June 2018

09:00–11:00
Invasive cervical resorption: A clinical approach
Dr Elisabetta Cotti
Invasive external cervical resorption is a dangerous
form of invasive root resorption with an etiology that is still
unclear, but often related to traumatic injuries of the teeth,
ranging from mild to acute events. If not detected and
treated, it may lead to tooth loss. This pathology is not
easy to detect and define, and diagnosis requires a careful clinical examination, an evaluation of the history of the
tooth and the use of advanced radiographic techniques.
As far as treatment is concerned, the resorptive process should be interrupted. Root canal therapy may be
required, and it should ensure good disinfection of the
root canal system and optimal sealing of endodontic–
periodontal pathways. Further treatment may require
surgical intervention. Bioactive cements are useful in this
treatment approach.

09:00–10:30
Root canal therapy or vital pulp therapy?
Success determined by proper diagnosis
Dr Jenner Oscarly Argueta Zepeda
When it comes to the prevention or management of periapical pathosis, the job of an endodontist involves more
than just providing root canal therapy. The primary aim
should be a first-step intervention focused on the treatment
of the disease located in the pulp tissue, providing a proper
environment to allow recovery of the damaged tissue.

11:30–13:00
Guided endodontics: Possibilities and limitations
Dr Gergely Benyő cs
Guided endodontics could be a future tool for both
specialists and general practitioners to carry out more
conservative endodontic treatment in a feasible way.
In this presentation, Dr Gergely Benyőcs will share his
experience in guided endodontics, considering the most
recent evidence in the literature. He will point out the
possibilities and limitations of this procedure, illustrated
by successful cases and failures.
14:00–16:00
Endodontists—The last best hope for natural tooth
Dr John Mounce

14

roots
2 2018

The main goal of this lecture is to provide clinical and
scientific information regarding the clinician’s decision
between a conventional root canal therapy and giving the
pulpal tissue the opportunity to survive, with subsequent
multiple benefits for the patient.
At conclusion of the lecture, participants should be
able to:
· list the clinical criteria for a reliable long-term prognosis
for vital pulp therapy clinical cases;
· assess the biological mechanisms that current materials provide for pulp tissue recovery and reparative/
reactive dentine bridge formation; and
· describe all factors to be considered in deciding
whether a case is a good candidate for root canal
therapy or a vital pulp therapy procedure.

[15] =>

ROOTS SUMMIT special

The second part of the lecture will deal with common
anaesthetic problems and how to solve them, as well as
a rationale for the use of analgesics and antibiotics in an
endodontists office.
14:00–16:00
Improve your microscope skills to improve outcomes
Dr Carlos Aznar Portoles
The dental operating microscope is widely used in endodontics, but not always in the most effective manner.
In this lecture, Dr Carlos Aznar Portoles will describe how
the endodontist and his or her team can use the microscope most efficiently. He will provide guidance on how
the clinician can improve his or her microscope skills and
will describe common mistakes and how they negatively
affect the workflow. He will describe how proper use
of the microscope can improve clinical results, reduce
stress, and help avoid neck and back pain, which is common among dental practitioners.
16:30–18.00
The role of bioceramics in clinical endodontics
Dr Josette Camilleri
Bioceramics are a new range of endodontic materials.
These materials have a specific chemistry and microstructure. They are based on tricalcium silicate and contain additives to enhance the material properties in clinical
use. It is important that a clinician be able to differentiate
between the various material types and appreciate that
the material’s composition plays a role in its performance
clinically.

Day 3: Sunday, 1 July 2018
09:00–10:30
Reliable adhesive post-endodontic restoration in the
hands of the endodontist
Dr Daniel Č erný
For a long time, endodontists have been sending patients
back to their referring dentists even though the root canal
system was only temporarily closed, consequently facing
a risk of reinfection of the previously disinfected root canal
system. In his practice, lecturer Dr Daniel Černý identified
this concern over ten years ago and this led to redefining
the roles within his team. Since 2006, endodontic treatment is not completed without creating an adhesive seal
through a buildup of granular dual-cure composite and
fiber-reinforced composite posts. Based on approximately
5,500 completed cases and long-term data, Černý will
demonstrate clear and precise workflow protocols with
fewer complications and tips on how to avoid critical
mistakes, in this lecture.
11:00–13:00
Improving retreatment outcomes
Dr Mario Zuolo
This lecture will focus on clinical protocols and new
technologies for the management of teeth indicated for
gutta-percha retreatment. Key points for canal location
and removal of obturation material from the root canal
and apical repreparation will be discussed in introducing
more adequate and predictable treatment protocols that
can be applied in everyday clinical practice. Several cases
will be described and analysed step by step in order to
demonstrate selection of the best retreatment protocol
to preserve the teeth. The prognoses will be illustrated
with clinical cases and contemporary literature.
Berlin © S.Borisov/Shutterstock.com

11:00–13.00
Pain and infection management in a contemporary
endodontic office
Dr Jorge Vera
This lecture is designed to address common problems
in diagnosis encountered when dealing with patients
presenting with symptoms mimicking odontogenic pain.
Most of those patients have undergone multiple dental
interventions, which have resulted in exacerbation of their
symptoms rather than relief. Neurovascular orofacial, and
neuropathic pain syndromes are some examples.

14:00–17:00
The Art of Endodontics
Dr Stephen Buchanan

roots
2 2018

[16] =>

| CE article

The dental operating microscope
in endodontics
Dr Frank C. Setzer, USA

The practice of endodontics requires precision and
great attention to detail. These depend on the training,
skills and experience of the clinician. Most endodontic
procedures are carried out in dark and confined places,
and fractions of millimetres may decide the outcome
of treatment. Over the past decades, endodontics has
gained not only basic and clinical scientific knowledge,
but also has taken technological quantum leaps. Due to
the intricate nature of endodontic treatment, practitioners
have always sought to improve their vision of the operational field.

also rotate medially. This is similar to near object accommodation by the naked eye which can lead to eye muscle
strain and fatigue. By contrast, microscope binoculars are
arranged in a parallel orientation. This arrangement is facilitated by prisms that let the incoming light beams reach
the eyes also in a parallel direction. This simulates the observation of a distant object: a straight, forward-looking
gaze that causes less muscle stress and fatigue. In addition, from an ergonomic perspective, working correctly
with a dental microscope improves overall body posture
and may reduce neck and back pain.

Advantages of dental microscopes

Commercially available microscopes provide adjustable magnification ranging from approximately 4 x to 25 x
magnification, while most loupes provide fixed magnification between 2.5 x and 6 x. Magnification can be divided in low magnification (~ 2 x–8 x), mid magnification
(~ 8 x–16 x), and high magnification (~ 16 x–25 x). Low,
mid and high magnification are applicable for different
procedural steps throughout nonsurgical and surgical
endodontic treatment. Low magnification is mainly applicable for an overview of the operating field. Mid magnification is used for the main procedural steps throughout
root canal therapy and endodontic surgery. High magnification is used for the identification of minute structures
and documentation of the finest details. Using a microscope significantly increases a practitioner’s accuracy.1
However, it must be mentioned that there is a learning
curve and working at both mid and high magnification will

Better vision requires enhanced magnification and illumination, and both microscopes and loupes have been
widely adopted. Operating microscopes have a number
of advantages compared to loupes. Loupes are worn on
the head and may be used with or without external light
sources. This necessitates weight limitations and restricts
the oculars to the bare minimum of lenses needed for
magnification. By contrast, the microscope is a self-supported unit; therefore, additional lenses or prisms are not
a concern. This has meaningful implications with regard
to ergonomics and visualization.
The attachment of loupes to glasses dictates a design
that angles the binoculars inward in order for the viewer
to focus on the object. As a result, the practitioner’s eyes

Fig. 1

Fig. 2

Fig. 3

Fig. 1: High-magnification inspection of caries below crown margin (courtesy of Dr. Francesco Maggiore, Aschaffenburg, Germany. Photos: Provided by American Association
of Endodontists). Fig. 2: Evaluation of extent of mesial fracture line (arrows) in left second maxillary molar. Microscopic inspection confirmed restorability. Fig. 3: Deep canal
bifurcation. Microscope-controlled filling of first canal just below split (arrow).

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Fig. 4a

Fig. 4b

Fig. 4a: Situation after irreversible pulpitis of left maxillary first molar two weeks after delivery of fixed partial denture. High magnification allowed for identification and treatment of three mesiobuccal canals through existing restoration. Fig. 4b: Postoperative radiograph.

require the practitioner to slow down movements to avoid
unintended actions on the smallest of anatomical structures. As a result of working in a small-scale environment,
new types of micro-instruments also were introduced to
the dental profession.

History of microscopes in endodontics
The idea of using microscopes in dentistry is not new.
Bowles suggested and used a dental microscope as
early as 1907! 2 In endodontics, dental operating microscopes were first introduced by individual clinicians3, 4
and then adopted by endodontic specialty programmes
throughout the United States. The American Association
of Endodontists was an early proponent of training in microscopes for endodontic residents and successfully advocated for the Commission on Dental Accreditation to
include a microscope proficiency standard to the CODA
educational standards for postgraduate endodontic programmes in 1998. The latest standard requires the teaching of magnification devices “beyond that of magnifying
eyewear” at an in-depth level, which is the highest of the
levels of knowledge prescribed by CODA.5 Based on two
surveys in 1999 and 2008, the accessibility and use of the
microscope by endodontists increased from 52 per cent
to 90 per cent.6, 7 It is now also increasingly being used by
other specialties8 and in dental education.9

lines (Fig. 2), and the treatment of internal resorptions.
Under the microscope, subtle changes in dentine colour
and texture become apparent, such as developmental
lines on the pulp floor guiding the practitioner towards
root canal orifices, or the darker colour of the pulp floor
itself, allowing the practitioner safer dentine removal.
High magnification can help in the localisation and instrumentation of obstructed and calcified canals, the

Fig. 5a

Fig. 5b

Fig. 5c

Fig. 5d

Microscope use for nonsurgical procedures
For the endodontic practitioner, the dental microscope
is useful for diagnosis and clinical procedures. The microscope may aid diagnostically in identifying caries, insufficient crown or restorative filling margins (Fig. 1), or assessing craze or fracture lines. During root canal therapy,
magnification and illumination provided by the operating
microscope aids with caries removal, access preparation, removal of pulp chamber calcifications, identification
of root canal orifices, identification of cracks and fracture

Fig. 5a: Separated instrument in second mesiobuccal canal of left maxillary first molar
(arrow). Situation after uncovering of fragment with ultrasonic tips and debris removal. Fig. 5b:
Pre-operative radiograph. Fractured instrument in mesial root of lower left first molar. Patient
was referred for fragment removal and continuation of treatment. Fig. 5c: Access to instrument
fragment (arrows) in mesiobuccal canal using ultrasonic tips. Note loosely placed gutta-percha
in mesiolingual canal to prevent any fragments or debris from accidentally blocking the canal.
Fig. 5d: Radiograph verifying complete instrument removal. Temporary after first appointment.
Canals are filled with non-radiopaque calcium hydroxide.

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Microscope use for surgical procedures

Fig. 6: High-magnification inspection of resected root surface of left maxillary lateral incisor using a micro-mirror. Note leakage of previous root filling
stained with methylene blue.

Surgical endodontics has been completely transformed by microscopic procedures. For many years surgical burs and amalgam for root-end fillings were the standard of care. The incorporation of the microscope, and
also to a certain degree the endoscope, together with the
use of ultrasonic tips and biocompatible filling materials,
has evolved the classical apicoectomy into modern endodontic microsurgery.14 All steps of endodontic microsurgery are carried out under varying degrees of magnification, including flap preparation, osteotomy, identification
of root apices, root-end resection, inflammatory tissue removal, observation of the resected root surface (Fig. 6),
root-end preparation, root-end filling, and suturing.15 The
microscope is also helpful for cervical or external resorption or perforation repairs.

Treatment effects
identification of canal bifurcations (Fig. 3), the removal of
canal obstructions such as denticles and calcifications,
and obturation (Figs. 4a & b). Additional primary endodontic procedures benefitting from microscope use include vital pulp therapy and regenerative endodontics by
allowing careful and gentle manipulation of the pulpal tissues or a blood clot, respectively. Enhanced vision also
aids in the treatment of dental anomalies, such as dens
invaginatus, or fused teeth.
In endodontic retreatments, the microscope is helpful in identifying and removing leftover filling materials,
such as sealer remnants, pastes or gutta-percha,10 silver
points and carrier-based materials, posts or fractured instruments11 (Figs. 5a–d). It also aids in nonsurgical perforation repair, allowing the practitioner to clean the perforation site and place the perforation repair material more
precisely.12, 13

Fig. 7: Pre-op image of a mandibular right first molar in which nonsurgical
root canal treatment had been completed five years earlier. (Photos: Provided
by Dr Frank C. Setzer)

There has been great debate over whether the use of
magnification would actually increase the success rate
of endodontic procedures. It is an accepted fact in endodontics that microbes and their endotoxins are responsible for the majority of inflammatory periapical lesions.
Healing of these lesions in cases of a diagnosis of pulp
necrosis has been associated with disinfection of the root
canal system, reduction of the microbial content, filling of
the root canal system and the permanent restoration of
the tooth. It is thus assumed that the identification and
treatment of all parts of the root canal system increase
the chances of a successful treatment and good longterm prognosis. Ample literature has been published with
regard to the identification of additional canals with the
help of higher magnification and illumination.16, 17 The effectiveness of vision enhancement for the detection of
second mesiobuccal canals (MB2) in maxillary molars
was assessed both in vitro and in vivo. The detection
rate of MB2 canals in vitro was shown to be 90 per cent
with the operating microscope and 52 per cent without
aided vision. Gorduysus et al.18 demonstrated that the
percentage of MB2 canal negotiation increased with the
aid of higher magnification. Burley et al.19 described the
successful identification of MB2s in 312 maxillary first and
second molars in 57.4 per cent of the cases when using the operating microscope, 55.3 per cent with dental
loupes and 18.2 per cent with unaided vision. In first maxillary molars, the incidences of MB2 identification were
71.1 per cent, 62.5 per cent and 17.2 per cent for the microscope, dental loupes and no magnification groups, respectively. Stropko20 treated a total 1,732 maxillary molars working at times with unaided vision and at times
with a dental microscope. With more experience and a
dental microscope, the incidence of locating MB2 canals
increased from 73.2 per cent to 93.0 per cent in first molars
and from 50.7 per cent to 60.4 per cent in second molars. Microscope use also increased the number of root

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canal orifices located in mandibular molars,21 and significantly increased the quality of access cavity preparation
and the accuracy of canal identification when treatment
was performed by dental students recently instructed in
microscope use.22

Nonsurgical treatment outcomes
It was long uncertain if microscope usage resulted
in improvements in nonsurgical treatment outcomes.
Del Fabbro et al. conducted two Cochrane Reviews, in
200923 and 201524, to identify randomized controlled
trials and quasi-randomized controlled trials comparing endodontic therapy performed with or without one
or more magnification devices. Neither in 2009, nor in
2015, were the authors able to identify a single study
reporting the outcome of either nonsurgical or surgical
endodontic therapy matching the strict criteria put forward in their study. Hence, the authors concluded that
it was unknown if and how any magnification device affected the treatment outcome, in particular, since a great
number of factors besides the microscope can have a
significant impact on the success of endodontic procedures. The authors suggested future long-term, well-designed randomized clinical trials. Recently, however, a
study published by Monea et al.25 assessed the impact
of the operating microscope on the outcome of nonsurgical treatments of a consecutive series of 184 comparable teeth diagnosed with pulp necrosis and chronic apical
periodontitis performed by postgraduate students. Success was defined as a decrease or disappearance of the
radiolucency following the recommendations of the European Society of Endodontology. After follow-up periods
of six months and 18 months there were significant differences between microscope and control groups, with
94.8 per cent versus 87.5 per cent (healed and improved)
at six months, and 95.9 per cent and 91.9 per cent at
18 months. At 18 months, 89 per cent of cases available
for follow-up in the microscope group were classified as
completely healed.

Surgical treatment outcomes
Another systematic review by del Fabbro et al.26 to investigate the use of magnification devices in endodontics identified three prospective clinical trials evaluating
the outcomes of endodontic surgery. The authors were
unable to identify significant differences in outcomes depending on treatment with loupes, microscope or an endoscope and suggested that different magnification devices could only minimally affect the outcome. In two
meta-analyses, Setzer et al. described the differences in
outcome of three techniques for endodontic surgery.27, 28
Investigated were clinical studies that applied traditional
endodontic surgical techniques (TRS), including 12 studies with a total sample size of 925 teeth using no magnification, straight surgical handpieces and amalgam root-

end filling and a cumulative success rate of 59.0 per cent;
seven studies using contemporary surgical procedures
(CRS) with a collective sample size of 610 teeth, employing magnifying loupes, ultrasonic root-end preparation
and biocompatible filling materials and a cumulative success rate of 88.1 per cent; and nine studies on endodontic microsurgery (EMS) with a total of 699 teeth using
the identical techniques as CRS with the only differences
being the use of high-power magnification devices such
as microscopes or endoscopes instead of loupes and
a cumulative success rate of 93.5 per cent. The cumulative success rate of the EMS group was significantly
higher than the CRS group, which only employed loupes,
and the TRS group, which used no magnification. The
EMS group combined studies that employed both the
dental microscope and the endoscope. It needs to be
mentioned that these studies are comparable as both
microscopes and endoscopes provide high-power magnification and illumination and also because the microscope is used for the majority of the steps of the surgical procedure in the studies where an endoscope was
used during root-end preparation. The endodontic microsurgery procedures demonstrated significantly better
cumulative success rates than the studies that only employed loupes when all 16 studies with a total of 1,309
teeth were compared. Seven of 16 studies provided information on the individual tooth type (four for CRS and
three for EMS), demonstrating a significant difference in
probability of success between the groups for molars.
Tsesis et al.29 provided an updated systematic review on
endodontic surgery in 2013 and also confirmed a statistically significant difference in successful outcomes of
both microscope and endoscope-assisted procedures
compared to loupes.

Microscope features and upgrades
Modern dental microscopes have evolved considerably with regard to features and options available to
the dental clinician. Depending on personal preferences
and possible locations in the operatory, floor-standing,
wall- or ceiling-mounted units are available. While standard microscopes come with basic optics and light options, certain accessory features are recommended
for endodontic purposes. Surgical procedures will require greater angulations to view resected root surfaces
and other surgical details. At a minimum, a microscope
should be equipped with 180-degree-tiltable binoculars
to address the angulation requirements and an eyepiece
with a reticle. A reticle is a set of fine lines, most commonly in the shape of crosshairs or concentric rings, that
provides proper centering on the object in focus and allows for easier individual calibration (parfocaling) of the
microscope. It also is an indispensable tool for documentation. Since light and the object image reach the binoculars virtually free of shadows, microscope photography
and recording allow for excellent image quality for docu-

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Fig. 9

Fig. 8

Fig. 10

at 600–700 nm, ~3,300 K) and the brightest option is xenon (like daylight, homogeneous spectrum 400–700 nm,
~5,500 K), making it most useful for the identification of
fine details in deeper areas of the root canal system and
documentation. Recently LED lights (green part of emission spectrum, low at 450 nm and 550 nm, ~5,700 K) became available and offer a significantly longer lifetime,
however, at a reduced brightness compared to xenon.

Case study

Fig. 11

Fig. 12

Fig. 8: Clinical image shows previously treated canals with infected gutta-percha filling.
Fig. 9: Clinical image: a furcation canal is visible under high magnification (arrow). Fig. 10: Clinical
image: a third distal canal is also located under magnification. Fig. 11: Post-op radiograph shows
the retreated tooth with five main canals. Fig. 12: The one-year follow-up radiograph demonstrates the complete resolution of the periradicular radiolucencies and permanent restoration of
the tooth.

mentation and clinical operations. However, this requires
perfect calibration with an external monitor and a reticle
to center the image. Full high-definition and three-chip
cameras are the gold standard for video recording and
available as external or internal solutions. Screenshots
from video recordings can be obtained at higher quality
by using post-processing software applications that allow for image stacking.30 For still photography new generation digital mirrorless cameras have demonstrated advantages compared to DSLRs.
There is a variety of additional upgrades for core microscope functions. Instead of fixed focal distances that
limit the microscope to an object distance of 200 mm,
250 mm or 300 mm, variable focal distance adapters
have become available, allowing for easier switching between practitioners and easier adjustment to patients of
different statures. These are offered in top-of-the-line microscopes, often in conjunction with electrical zoom and
fine focus options that allow smooth and stepless adjustments of both magnification and focus. Extendable
(foldable) binoculars were introduced for better ergonomics. Magnetic arrest functions (clutch) are available
for increased stability, particularly for microscopes with
several documentation ports and attachments. The practitioner can choose from a variety of light sources. The
traditional standard is still halogen (yellowish hue, peak

Mandibular right first molar, nonsurgical root canal
treatment had been completed five years ago. Originally,
a new crown restoration had been planned. However, the
periapical radiograph revealed periradicular radiolucencies (periapical and in the furcation area; Fig. 7). The patient received a recommendation to extract the tooth due
to the bone loss in the furcation. There were no symptoms and periodontal probing depths were within normal
limits, suggesting an endodontic problem as the origin of
the furcation defect. Nonsurgical retreatment was initiated. The clinical image shows the previously treated four
canals with infected gutta-percha filling (Fig. 8). Under
high magnification, a furcation canal (Fig. 9, arrow) and a
third distal canal (Fig. 10) were located.
The postoperative radiograph shows the retreated
tooth with five main canals (Fig. 11). The one-year follow-up radiograph demonstrates the complete resolution
of the periradicular radiolucencies and permanent restoration of the tooth (Fig. 12).

Conclusion
The dental operating microscope has become an integral part of endodontic practice. For both nonsurgical
and surgical endodontic therapy it is indispensable for
excellency. Besides the obvious benefits for clinical practice, evidence has become available that demonstrates
better outcomes compared to treatment without vision
enhancement or magnifying eyewear. Treatment rendered using the dental operating microscope results in
superior care for patients, and modern endodontic therapy is more effective because of its use.
This article originally appeared in ENDODONTICS: Colleagues for Excellence, Winter 2016. Reprinted with
permission from the American Association of Endodontists, © 2016. The AAE clinical newsletter is available
at www.aae.org/colleagues.

References
1. Bowers DJ, Glickman GN, Solomon ES, He J. Magnification’s effect on
endodontic fine motor skills. J Endod. 2010;36:1135–1138.
2. Bowles SW. A New Adaptation of the Microscope to Dentistry. Dental
Cosmos 1907;49:358–362.

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3.
Carr G. Microscopes in endodontics. Calif Dent Assoc J 1992;
11:55–61.
4.
Pecora G, Andreana S. Use of dental operation microscope in
endodontic surgery. Oral Surg Oral Med Oral Pathol 1993;75:751–758.
5.
A AE Special Committee to Develop a Microscope Position Paper.
AAE Position Statement. Use of microscopes and other magnification
techniques. J Endod 2012;38:1153–1155.
6. Mines P, Loushine RJ, West LA, Liewehr FR, Zadinsky JR. Use of
the microscope in endodontics: a report based on a questionnaire.
J Endod 1999;25:755–758.
7. Kersten DD, Mines P, Sweet M. Use of the microscope in endodontics:
results of a questionnaire. J Endod. 2008;34:804–807.
8. Mamoun JS. A rationale for the use of high-powered magnification or
microscopes in general dentistry. Gen Dent 2009;57:18–26.
9. K nowles KI, Ibarrola JL, Ludlow MO. The dental operating microscope as
an educational tool. J Dent Educ. 1998;62:429–431.
10. Baldassari-Cruz LA, Wilcox LR. Effectiveness of gutta-percha removal
with and without the microscope. J Endod 1999;25:627–628.
11. Fu M, Zhang Z, Hou B. Removal of broken files from root canals by using
ultrasonic techniques combined with dental microscope: a retrospective
analysis of treatment outcome. J Endod. 2011;37:619–622.
12. Daoudi MF. Microscopic management of endodontic procedural errors:
perforation repair. Dent Update. 2001;28:176–180.
13. K rupp C, Bargholz C, Brüsehaber M, Hülsmann M. Treatment outcome
after repair of root perforations with mineral trioxide aggregate: a retrospective evaluation of 90 teeth. J Endod. 2013;39:1364–1368.
14. Rubinstein RA, Kim S. Short-term observation of the results of endodontic surgery with the use of a surgical operation microscope and
Super-EBA as root-end filling material. J Endod. 1999:43–48.
15.
Kim S, Kratchman S. Modern endodontic surgery concepts and
practice: a review. J Endod. 2006;32:601–623.
16.
de Carvalho MC, Zuolo ML. Orifice locating with a microscope.
J Endod. 2000;26:532–534.
17. Cabral dos Santos Accioly Lins C, Verçosa de Melo Silva EM, Agnelo
de Lima G, Acioly Conrado de Menezes SE. Coelho Travassos RM.
Operating microscope in endodontics: A systematic review. Open Journal
of Stomatology. 2013:1–5.
18.
Görduysus MO, Görduysus M, Friedman S. Operating microscope
improves negotiation of second mesiobuccal canals in maxillary molars.
J Endod. 2001;27:683–686.
19. Buhrley LJ, Barrows MJ, BeGole EA, Wenckus CS. Effect of magnification on locating the MB2 canal in maxillary molars. J Endod 2002;
28:324–327.
20. Stropko JJ. Canal morphology of maxillary molars: clinical observations
of canal configurations. J Endod 1999;25:446–450.
21. Karapinar-Kazandag M, Basrani BR, Friedman S. The operating microscope enhances detection and negotiation of accessory mesial canals
in mandibular molars. J Endod. 2010;36:1289–1294.
22. Rampado ME, Tjaderhane L, Friedman S, Hamstra SJ. The benefit
of the operating microscope for access cavity preparation by
undergraduate students. J Endod 2004:863–867.
23. Del Fabbro M, Taschieri S, Lodi G, Banfi G, Weinstein RL. Magnification
devices for endodontic therapy. Cochrane Database Syst Rev. 2009;
8:CD005969.
24. Del Fabbro M, Taschieri S, Lodi G, Banfi G, Weinstein RL. Magnification
devices for endodontic therapy. Cochrane Database Syst Rev. 2015;
12:CD005969.

25. Monea M, Hantoiu T, Stoica A, Sita D, Sitaru A. The impact of operating
microscope on the outcome of endodontic treatment performed by postgraduate students. Eur Sci J. 2015;305–311.
26. Del Fabbro M, Taschieri S. Endodontic therapy using magnification
devices: a systematic review. J Dent. 2010;38:269–275.
27. Setzer FC, Shah S, Kohli M, Karabucak B, Kim S. Outcome Of Endodontic
Surgery: A Meta-Analysis Of The Literature—Part 1: Comparison Of
Traditional Root-End Surgery And Endodontic Microsurgery. J Endod.
2010;36:1757–1765.
28. Setzer FC, Kohli M, Shah S, Karabucak B, Kim S. Outcome of Endodontic Surgery: A Meta-analysis of the Literature—Part 2: Comparison
of Endodontic Microsurgical Techniques With and Without the Use of
Higher Magnification. J Endod. 2012;38:1–10.
29.
Tsesis I, Rosen E, Taschieri S, Telishevsky Strauss Y, Ceresoli V,
Del Fabbro M. Outcomes of surgical endodontic treatment performed by
a modern technique: an updated meta-analysis of the literature. J Endod.
2013;39:332–339.
30. Suehara M, Nakagawa K, Aida N, Ushikubo T, Morinaga K. Digital video
image processing from dental operating microscope in endodontic treatment. Bull Tokyo Dent Coll 2012;53:27–31.

CE credit: This article qualifies for CE credit. To take
the CE quiz, log on to www.dtstudyclub.com. Click
on “CE articles” and search for this edition. If you are
not registered with the site, you will be asked to do so
before taking the quiz.

contact
Dr Frank C. Setzer, DMD, PhD, MS, is a
Diplomate of the American Board of Endodontists, and an Assistant Professor at the
Department of Endodontics at the University
of Pennsylvania School of Dental Medicine.
He teaches undergraduate students and
post-doctoral residents. Dr Setzer specialises
in root canal therapy, trauma and surgical
root canal procedures. He received his first dental degree from
the Dental School of the Friedrich-Alexander-University Erlangen-
Nuremberg, Germany, in 1995, where he also received his
doctoral degree in 1998. He pursued his endodontic specialty
training at the University of Pennsylvania after working for
nine years in a multi-specialist private practice as associate
and partner. Setzer graduated from the endodontic programme
of the University of Pennsylvania in 2006, receiving the Louis I
Grossman Postdoctoral Award in Endodontics. He earned a
Master of Science in Oral Biology and a DMD degree in 2008
and 2010, respectively. Setzer is teaching as clinic director and
pre-doctoral program director at the Department of Endodontics
of the University of Pennsylvania. Setzer lectures frequently
nationally and internationally, has published in peer-review
journals and serves, among others, as the associate editor
for endodontics for Quintessence International and on
the editorial advisory board of the Journal of Endodontics
and the Journal of the American Dental Association.
He can be contacted at fsetzer@upenn.edu.

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Nd:YAG laser-assisted removal
of instrument fragments
Dr Georgi Tomov, Bulgaria

The Nd:YAG lasers tested in laboratory studies have
been claimed to be able to successfully manage the removal of instrument fragments within root canals1–4. This
is done in four ways, all correlated to temperature effects:
1. Laser melts the dentine around the fragment and then
Hedstrom files are used to bypass and retrieve the
fragment.
2. Laser melts the entire fragment.
3. Laser energy melts the solder, connecting the fractured
instrument with a brass tube charged with solder and
placed at the exposed coronal end of the fragment.
4. Laser welds the file fragment positioned within a metal
hollow tube (e.g. Endo-Eze® Tip, Ultradent Products;
Figs. 1a & b).
The removal of a claimed minimum amount of root dentine1, 2, 4 can be attributed to the potential given to the user
of Nd:YAG laser to distinguish dentine1 from obstructions
by the difference in acoustics produced by the two materials. Ebihara et al. observed that some orifices of the

dentinal tubules were blocked with melted dentine after
laser irradiation.1 Yu et al. found that the temperature rose
by 17 °C to 27 °C, but argued that, since the initial temperature was lower than human body temperature, these
results were irrelevant.2
The findings demonstrated that a pulsed Nd:YAG laser
irradiation has the capability of removing broken files. The
success rate reported by Yu et al. was 55 per cent.2 However, the thermal effects found after Nd:YAG irradiation in
dry root canals were considerable (Figs. 2a–c). Thus, the
focus now is on the outcomes of using a laser fibre inserted into a hollow tube (alone or in the presence of solder) both to avoid dentinal carbonisation and to achieve
welding between the separated file and metal tube.

Intraoral laser welding
The intraoral laser welding phenomenon is well researched.1–4 Even for metals that absorb well, such as
steel, the laser light is initially reflected. A small percentage

Fig. 2b

Fig. 1a

Fig. 1b

Fig. 2a

Fig. 2c

Figs. 1a & b: Welding of separated K-type file in Endo-Eze® Tip (18 gauge) using Nd:YAG laser irradiation at 400 mJ and 10 Hz (a). Longitudinally cross-sectioned metal tubes with melted K-type files inside (b). Figs. 2a–c: Undesirable thermal effects of Nd:YAG irradiation (3 W, 300 mJ, 10 Hz) in a dry root canal
(a). When the optic fibre comes into contact with the dentinal wall it can cause carbonisation and melting. SEM image of a control dentinal surface (b) and
dentine irradiated with an Nd:YAG laser, revealing areas of melting and dentinal tubule closure (c).

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research

Fig. 3

Fig. 3: SEM image of a K-type file after Nd:YAG laser irradiation at 400 mJ and 10 Hz revealing a melted metal surface with an irregular granular structure after solidification.

of the laser light is absorbed, heating the metal surface.
The increased surface temperature increases the absorption of the laser power. This creates a snowball effect, in
which the material is rapidly heated by the laser, leading to
melting and the consequent formation of a weld.
Hagiwara et al. performed laser welding on stainless
steel or nickel-titanium files using an Nd:YAG laser in
order to evaluate the retention force between the files
and the metal extractor.3 Additionally, they evaluated
the increase in temperature on the root surface during
laser irradiation. They reported that the retention force
on stainless steel was significantly greater than that on
nickel-titanium. The maximum temperature increase was
4.1 °C. The temperature increase on the root surface was
greater in the vicinity of the welded area than at the apical area. Scanning electron microscopy (SEM) revealed
that the files and extractors were welded together. Similar
results were found by Tomov (unpublished data; Fig. 3).

contact
Dr Georgi T. Tomov
DDS, MS, PhD
Associate Professor and Head of the Department of Oral Pathology
Faculty of Dental Medicine, Medical University of Plovdiv, Plovdiv, Bulgaria
dr.g.tomov@gmail.com
AD

S E E U S AT

M IT
R O OTS S U M I N
BERL

In vitro study
Cvikl et al. used a brass tube charged with solder and
placed at the coronal end of the fractured instrument in
their in vitro experiment.4 Nd:YAG laser energy was used
to melt the solder, connecting the fractured instrument
with the brass tube. They reported that the fractured endodontic instruments were removed successfully in 17 out
of 22 cases (77.3 per cent) in which more than 1.5 mm
was tangible. When less than 1.5 mm was tangible, the
removal success rate decreased to three out of 11 cases
(27.3 per cent).
These results obtained from in vitro experiments indicate that the laser welding method is effective in removing broken instruments from root canals, but its efficacy
has to be further verified in clinical trials.

NEW
GUTTAPERCHA REMOVAL
INSTRUMENT WITH PEEK-HANDLE
according to Dr. Yoshi Terauchi
Bodenseeallee 14-16
78333 Stockach, Germany

Tel. +49 7771 64999-0
Fax +49 7771 64999-50

info@kohler-medizintechnik.de
www.kohler-medizintechnik.de

All figures: © Georgi Tomov, 2016

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| technique

Cutting endodontic access cavities
—for long-term outcomes
Dr L. Stephen Buchanan, US

Fig. 1

Fig. 2

Fig. 3

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

Errors accumulate during procedures. That’s the reason botching the access at the start of an RCT is so
much more devastating than say, problems that come
from misfitting a gutta-percha cone just before finishing
the case. Miss a canal and the case is going down, regardless of how brilliant the remaining procedure is carried out. Perforate the tooth, and suddenly titanium starts
looking better. Cut huge access cavities, and expect to
see relatively huge numbers of root-fractured teeth within
five years of treatment. Simply cheat the access procedure by beginning the instrumentation of canals before
a straight, perfectly smooth path has been cut to each
canal orifice, and be punished every time a file, an irrigating needle, an explorer, a gutta-percha point, a paper point or a plugger is taken into each of the canals
scores of times.
This is not a critique so much as an admission of the
ways that teeth and their root canal systems have taught
me, usually the hard way, to spend whatever time is
needed to create perfect entry paths into canals, before
I attempt to work in them. So why do I have to have a
talk with myself before beginning every access cavity—
even after doing this for 35 years—to be certain to hit
the mark I know must be met before it is safe to venture
further?

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Zen and the art of endo access
Robert Persig, in his book Zen and the Art of Motorcycle Maintenance,1 described being deeply frustrated
when a bolt stripped as he was attempting to remove
the side covers to the engine of his motorcycle, before
rebuilding it. The rebuild could not continue until he was
able to circumvent this problem. He had expected to
spend several days completing the mission, yet he was
amazed at the fury he experienced when faced with this
conundrum.
The more he thought about it, the more mystified he
became about his instinctual response, until he realized
that he was tweaked because he had grossly undervalued this part of the long rebuild procedure, thinking
mostly about the more dramatic routines to follow, such
as cracking the cylinder case, honing the cylinder, replacing the piston and putting it all back together afterward.
When he realised that nothing was going to progress
until he had successfully removed the side cover, he
made removing that side cover a separate and important mission, an accomplishment that would deliver satisfaction in and of itself, if it could be completed during the
next several hours spent.

[25] =>

technique

So it is with endodontics. When we realise how critical
the quality of our access preparations is to the remainder of the case, it feels like fingernails on a chalkboard
to head into a canal before securing an ideal path into it.
Aristotle got it right—excellence is a habit, not a character trait. So what do the habits of access excellence look
like in this 21st century?

Failing to plan is planning to fail
Fig. 4a

Atul Gawande, in his book The Checklist Manifesto,2
describes the importance of planning not just which
procedure to do, but how every single aspect of that procedure must be planned in detail, from start to finish, if
consistently ideal results are the goal.
Does the preoperative imaging accurately describe the
anatomical challenges? Does the clinician have adequate
magnification and light? Are the cutting tools adequate
and well chosen? Are the locations, angles and depths
of entry determined before beginning the procedure?
Have maximal safe cutting lengths been marked on access burs? Are there procedures in place to deal with
calcified canals that defy location? And so on.
In other words, the Alfred E. Neumann attitude of
“What, me worry?” is not appropriate during this critical
event. Conversely, when each of these critical elements
is included in the treatment planning and execution of
an ideal access cavity preparation, the rest of the pro
cedure becomes progressively simpler as the finish is
approached.

Fig. 5

Fig. 6

Fig. 4b

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

Radiographic imaging
We wouldn’t even attempt RCT without Roentgen’s
invention of the dental radiograph, so it is not much of
a stretch to claim the critical necessity of ideal pre
operative radiography. Ideal preoperative X-ray imaging
must include a straight-on angle that splits the mesial
and distal contacts perfectly—taken either as a periapical
or as a bitewing X-ray image, then at least one ideal
off-angle view in order to capture data from the Z-plane
(buccolingual) of the tooth in question.
In my practice, a mesial off-angle view of anteriors and
premolars works well, because it is much easier to capture than a distal angle, and in anteriors and premolars
the mesial view reveals as much radicular anatomy as

Fig. 7

Fig. 5: Postoperative radiograph of a mandibular molar treated through the mesial carious defect and a second small entry cut through the central fossa.
Preserving dentine between entry points is referred to as a ‘truss’ access configuration. (Photo: Provided by Dr John Khademi) Fig. 6: This postoperative
radiograph shows a very diminutive access cavity opening with both mesial and distal lateral pulp horns left intact during the RCT procedure and filled during the
postendodontic restorative effort. This appearance is a matter of pride among those in the ‘IBAC’ club. (Photo: Provided by Dr Jeff Pafford) Fig. 7: Mandibular
molar with nearly total calcification of the pulp chamber prior to RCT, accomplished through two perfectly dead-on access entry ports, leaving a 0.75 mm high
pulp chamber isthmus between. Note the definitive treatment results in the apical thirds of each canal. (Photo: Provided by Dr N. Pushpak)

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| technique

Fig. 8

Fig. 9

Fig. 10

Fig. 8: This restored access cavity design was opportunistic in the best sense of the word. This patient’s endodontic disease state was resolved with almost no
tooth structure being cut, preserving the structural integrity of the tooth by using the cleaned out carious defect as access cavity. No need for a full-coverage
crown. (Photo: Provided by Dr Michael Trudeau) Fig. 9: This lower molar was treated through an access opening that was less than 2 mm square, cut just
behind the MB triangular ridge. Note the definitive treatment of the apical thirds of all four canals, despite the narrow entry portal. (Photo: Provided by Dr Charles
Maupin) Fig. 10: Postoperative radiograph of a mandibular molar treated through an alternative to the truss configuration—an ‘X-entry’ access cavity—
a design that minimizes removal of tooth structure in the critical trunk of the tooth (author’s case).

a distal view. In molars it is different. In molars a distal
view is far preferable to a mesial off-angle view, as the
mesial view superimposes the body of the root over the
distally curved root structure, while the distal view casts
the apical root end sideways, where it can be more easily
seen on the radiographic image.
Of course, cone-beam CT (CBCT) imaging is the unfair endodontic imaging advantage. If told I could have
either a microscope or a CT machine, but not both,

I would choose 3-D imaging every time. Only CBCT imaging can capture the mesial view of root structure—the
view in which we see “The Secret Life of Root Canals”—
the buccolingual plane containing the greatest degree of
anatomic complexity. One of the greatest joys of having a
CT machine in practice is knowing, for sure, before the
access procedure is begun, that there is only a single
canal in the mesiobuccal root of an upper molar. Conversely, one of the few negative experiences to be had
with this technology is when the reconstructed volume

shows two or three canals, in a root that has given up
only one to the clinician’s exhaustive search.
The first gift of CBCT imaging to the field of endodontics has been the gift of finding all canals in a given tooth.
Its second gift is the great diminution of access size possible, because the access cavity is no longer the primary
viewing port into the pulp chamber and beyond. In fact,
CT imaging is the only view needed into the anatomic
verities of root canal spaces, allowing access cavities to
be used exclusively as treatment, rather than as exploratory portals. Ultimately, RCT access procedures will be
done with CT-generated drill guides, allowing molars to
be treated through three to four 1-mm pea-holes, rather
than the 2- to 4-mm access cavities used today.3

Outline form

So what are the objectives we consider when planning
the invasion of a root canal space? Basically, all the best
access cavities are
cut in a balance between conservation
and convenience form.
We cut as little tooth
structure as possible, while ensuring
ideal pathways into
each canal. Access
outline form objectives become fairly
simple then; we deFig. 11a
Fig. 11b
Fig. 11c
mand convenience
Figs. 11a–c: From left: Virtual treatment planning for CT-guided endodontic access (CT-GEA). The tooth to be treated is form, otherwise we
segmented from the CT volume, ideal access entry paths are plotted through the occlusal surface of the tooth, and a CT-GEA cannot complete our
drill guide is 3-D printed.
task, yet we always

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[27] =>

strive to preserve the structural integrity of the tooth. This
boils down to three easily remembered objectives:
1. In anteriors and premolars, conservation form is found
in the mesial-to-distal dimension. Traditionally, anterior
access cavity outline form has been triangular because
of the mesial and distal pulp horns in these teeth—
logical until we consider the structural consequences,
a needless weakening of coronal tooth structure to
insure these lateral pulp horns are cleaned out, when
the smallest undercut with a #2 Mueller Bur or Buc-1
ultrasonic tip (Spartan) could suffice as well. Premolars have pulp chambers like the shape of a hand,
which is fortunately arranged in a buccolingual direction, the angle of the recommended slot-like access
cavity outline form is buccolingual as well, simultaneously combining convenience and conservation form.
In anterior teeth, convenience form is harder won as
the incisal edge is to be avoided, out of respect for
postendodontic aesthetic objectives, thus requiring a deeper cut under the cingulum, to allow a more
straight-line entry path, while minding the “no-fly zone”
of the incisal edge. The most dangerous anterior access cavity error is not cutting adequately through
what Dr Schilder called the “lingual dentinal triangle”
under the cingulum, and this can be accomplished with
minimal structural weakening when the mesiodistal
dimension is kept to a 1 to 1.5 mm width (Fig. 1).
2. In posterior teeth, premolars and molars, it is important
to remember that their occlusal surfaces are not centred over the root structure, but are skewed toward the
idling cusp side of the root structure. As pulp chambers
are centred in the root structure, not centred under
the occlusal surface, access in posterior teeth is best
accomplished by cutting near working cusps, while
staying 1–2 mm away from idling cusps (Fig. 2).
3. In molars, conservation form is held by avoiding the
distal half of the occlusal plane, as ideal file paths from
the distal canals of upper and lower molars are canted
severely to the mesial, so much so that distal canals
of lower molars are best referenced to the MB or ML
cusp tips, and distobuccal canals of upper molars are
best referenced to the palatal cusp tips. Convenience
form is achieved by cutting the mesial wall of molar access cavities parallel to the mesial surface of the tooth
(Fig. 3).

Back from the abyss
I was taught Schilder technique at University of the
Pacific by Dr Michael Scianamblo and after grad school
by Dr Cliff Ruddle. I understood the clinical imperative
Dr Schilder had placed on cutting an access adequate to
treat the entire root canal system in a predictable manner,

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| technique

Fig. 12a

Fig. 12b

Fig. 12c

Fig. 12d

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

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

The Itty Bitty Access Committee
Since that initial awakening in the ’80s, it has felt like
being a lone voice in the wilderness until the past ten
years, when a new generation of dentists and endodontists, steeped in the new reality of implant dentistry as an
alternative to RCT, have taken up the cry for longer-term
outcomes through improved structural preservation, ultimately becoming what I jokingly call The Itty Bitty Access
Committee (IABC).
As so often happens, somebody outside of our specialty, a general dentist named Dr David Clark, started
lecturing on the access elephant in the endodontic living room. He got my buddy Dr John Khademi turned on
to the possibilities that more conservative access cavities could offer the specialty,4 and one by one a group
of young endodontists joined the game of who can do
a perfect RCT through the smallest access cavity. This
ad hoc group of talent began the IBAC club.

The cases shown in Figures 4 to 10—mostly done
by IBAC members—make me very happy and afraid at
the same time. What the heck are they doing? Little, tiny
entries, leaving pulp chamber roofs intact, lateral pulp
horns unroofed as well, or just total RCT through previously cut restorative cavities!
After getting over my initial shock at what they were
accomplishing, I came to understand that the future of
endo is very good in these extremely talented hands, and
I saw that the procedure I was developing for endodontic surgery—CT-guided endodontic surgery (CT-GES)—
could be applied to conventional treatment as well
(Figs. 11a–12d).
And morning breaks over the field of endodontics.

Editorial note: This article was first published in the Clinical
Masters magazine, Vol. 1, 1/2015.
A complete list of references is available from the publisher.

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

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[29] =>

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[30] =>

| trends & applications

Bioactivity in restorative dentistry:
A user’s guide
Dr Fay Goldstep, Canada

Introduction
The word “bioactivity” is one of the latest buzzwords
in the dentistry. It is highlighted as a feature in many restorative products with different and conflicting claims.
This has stirred up confusion and controversy surrounding the concept. This article will attempt to provide clarity
for the practising restorative dentist regarding the following: What is bioactivity? What are bioactive products?
How can they be used to provide the best dental care?
The term “bioactive material” originated with Dr Larry
Hench in 1969. He was looking for an improved graft material for bone reconstruction needed by injured returning
soldiers of the Vietnam war. Hench was searching for a
material that could form a living bond with tissues in the
body. All the available materials at the time were rejected
by the body. He developed bioglass (calcium silicophosphate glass), a completely synthetic material that chemically bonds to bone.1 Hench defined a bioactive material
as “one that elicits a specific biological response at the
interface of a material which results in the formation of a
bond between the tissues and the material”.2
Today, there are many different definitions of bioactivity
found in the dental literature, dependent on the research
and on the researcher. The definition fits the research,
whereas it should fit the concept. In order to achieve clarity of meaning, it is best to go with what can be most eas-

Table 1: Examples of bioactive restorative materials by their mechanism
of action. Bioactivity increases with each mechanism: materials that
remineralise, only remineralise; materials that deposit hydroxyapatite also
remineralise; materials that stimulate pulpal regeneration also remineralise
and deposit hydroxyapatite.

ily understood by clinicians and patients alike, the definition found in the dictionary: “bioactivity”, noun: any effect
on, interaction with or response from living tissue.
Historically, dental materials were designed to have a
“neutral” effect on the tooth.3 Many current dental materials are not neutral. They are “active”, not “passive”, participants in the restorative process. New materials are being
developed to harness this potential behaviour. These are
“bioactive” materials.
For simplification and clarity in discussing bioactive
restorative materials, it is best to separate them according to their mechanism of action. There are three separate mechanisms that are demonstrated by bioactive
restorative materials (Table 1 lists examples of bioactive
restorative materials by their mechanism of action). A bioactive restorative material can display one or more of the
following actions:
1. remineralises and strengthens tooth structure through
fluoride release and/or the release of other minerals;
2. forms an apatite-like material on its surface when immersed in body fluid or simulated body fluid over time;4
3. regenerates live tissue to promote vitality in the tooth.

Materials that remineralise
Dental caries is the cumulative result of consecutive cycles of demineralisation and remineralisation at the interface between biofilm and the tooth surface. Oral bacteria
excrete acid after consuming sugar, leading to demineralisation. Hydroxyapatite crystals are dissolved from the
subsurface. Remineralisation is the natural repair process for non-cavitated lesions. It relies on calcium and
phosphate ions, assisted by fluoride, to rebuild a new surface on the existing crystal remnants in the subsurface.5
Under normal physiological conditions at a pH of 7,
saliva is supersaturated with calcium and phosphate
ions, making caries progress slow. As the pH is lowered,
higher concentrations of calcium and phosphate are required to reach saturation with respect to hydroxyapatite.5 This is called the “critical pH”, the point where equilibrium exists and there is no mineral dissolution and no

Fig. 3a

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trends & applications

Fig. 1

Fig. 2

Fig. 1: Cycling of oral pH during cariogenic challenges in naturally occurring hydroxyapatite. Fig. 2: Cycling of oral pH during cariogenic challenges in fluoridated
hydroxyapatite.

mineral precipitation. The critical pH of hydroxyapatite is
around 5.5 and that of fluorapatite is around 4.5. This varies with individual patients. Below critical pH, demineralisation occurs, while above critical pH, remineralisation
occurs (Figs. 1 & 2).43
If fluoride is present in the plaque fluid, it will penetrate the enamel, along with the acids at the subsurface,
adsorb to the apatite crystal surface and protect the

crystals from dissolution.6 This coating makes the crystals similar to fluorapatite (critical pH of 4.5), ensuring that
no demineralisation takes place until the pH reaches this
point. Fluoride present in solution at low levels among
the enamel crystals can markedly decrease demineralisation.7, 8
When the pH returns to 5.5 or above, the saliva, which
is supersaturated with calcium and phosphate, forces
minerals back into the tooth.8 Fluoride increases remineralisation by bringing calcium and phosphate ions
together and is preferentially incorporated into the remineralised surface, which is now more acid-resistant.

Fig. 3a

Fig. 5a

The benefits of fluoride are maintained long term
through the mechanism of fluoride reservoirs. Fluoride is
retained intraorally after fluoride treatments, such as fluoridated toothpaste and fluoride varnish application, and
is then released into the saliva over time.9, 10 Fluoride can
remain on teeth, mucosa or dental plaque or within bioactive restorative materials. Fluoride retention is c
linically
beneficial, since it can be released during cariogenic
challenges to decrease demineralisation and enhance
remineralisation.5
When the enamel and dentine no longer have adequate structure to maintain their mineral framework,
cavitation takes place and simple remineralisation is an
insufficient treatment. Tooth preparation and restoration
are now required.
Bioactive restorative materials replace dental hard
tissue and help to remineralise the remaining dental

structures. Glass ionomer cements and their derivatives,
such as resin-modified glass ionomers, compomers and
giomers, fall into this category.

Fig. 3b

Figs. 3a & b: Examples of glass ionomers, riva self cure (SDI) and EQUIA Forte (GC). These are bioactive materials that remineralise.

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| trends & applications
ing benefits, dental researchers have produced an assortment of glass ionomer derivatives: resin-modified
glass ionomers, compomers and giomers. Two product
lines in this category are ACTIVA BioACTIVE-RESTORATIVE (Pulpdent; Fig. 5) and the Beautifil giomer family
of restorative materials, including Beautifil II and Beautifil
Flow Plus (SHOFU; Fig. 6). Studies have shown ACTIVA’s
remineralisation potential through fluoride release and
recharge and calcium release.14, 15 Giomers are used in
restorative dentistry as equivalent to composite resin, in
all their applications.
Fig. 4: Glass ionomers create an ion-enriched, harder dentine surface
adjacent to the glass ionomer surface.

Glass ionomer cements
Glass ionomer cements were developed in the early
1970s. They are particularly valuable for caries control in
high caries risk patients and in areas where location or
isolation create restorative challenges (Figs. 3a & b). Glass
ionomers have a true chemical bond with dental tissue.
They encourage remineralisation of the surrounding tooth
structure and prevent bacterial microleakage through
ion exchange adhesion with both enamel and dentine.11
A new, ion-enriched layer is created at the tooth–glass
ionomer interface. This layer contains phosphate and
calcium ions from the dental tissue, and calcium (or strontium), phosphate and aluminium from the glass ionomer
cement.11 The remineralisation process creates a harder
dentine surface (Fig. 4).12, 43 Restoration fracture is usually
cohesive, leaving the ion exchange layer firmly attached
to the cavity wall. The dentinal tubules are sealed and
protected from bacterial penetration.13
In order to eliminate the physical property disadvantages of glass ionomers and harness their remineralis-

Fig. 5

Giomers
Giomers represent the hybridisation of glass ionomer
and composite resin properties: the fluoride release and
recharge of glass ionomers, and the aesthetics, physical properties and handling of composite resins.16 The
giomer concept is based on PRG (Pre-Reacted Glass)
technology: a glass core, surrounded by a glass ionomer
phase enclosed within a polyacid matrix. Studies show
that dentine remineralisation occurs at the preparation
surface adjacent to the giomer.17
Giomers, through the creation of fluoride reservoirs, release and recharge fluoride efficiently, significantly better
than do compomers18 and composite resins, although
not as well as glass ionomers.19 The clinical performance
of giomers has been tested against those of hybrid resin
composites. Giomers have been found to compare positively for all criteria.20

Materials that deposit hydroxyapatite
Some bioactive materials not only remineralise by adding minerals to tooth structure, but also create an apatite-like material on their surfaces when immersed in
body fluid or simulated body fluid over time.4 There are

Fig. 6
Fig. 5: ACTIVA BioACTIVE-RESTORATIVE is a bioactive restorative material that remineralises. Fig. 6: The Beautifil giomer family of restorative materials,
including Beautifil II and Beautifil Flow Plus, are bioactive restorative materials that remineralise.

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|

two chemical classes of these bioactive restorative materials: calcium silicates and calcium aluminates.21, 22 These
materials are non-resin-based. Both materials set with
an acid–base reaction and produce an alkaline pH after
setting. High pH levels (7.5 or higher) appear to stimulate
more active and complete bioactivity.4
Ceramir (Doxa Dental; Fig. 7) is a calcium aluminate
material developed for cementation. An in vitro study
found that this apatite-forming bioactive cement can
occlude artificial marginal gaps. This is beneficial clinically at the margin of the prepared tooth and cemented
restoration. It suggests that bioactive dental materials
may significantly improve clinical outcomes and longevity of dental restorations.23
Calcium silicates have also been shown to deposit
hydroxyapatite.23 Even more importantly, they can stimulate the regeneration of live tissue: dentine, pulp, blood
vessels and bone.24–26

Materials that can regenerate live tissue
Some bioactive materials not only remineralise and
form hydroxyapatite, but also regenerate live tissue.
This is crucial in many restorative and pulp-related treatments. One major example is vital pulp therapy. The
goal of vital pulp therapy (direct pulp capping and pulpotomy) is to treat reversible pulpal injury arising from
trauma, caries or restorative dentistry. These injuries destroy the normal tissue architecture at the pulp–dentine
interface, but can be healed if the wound is properly
protected.27
Treatment must maintain pulp vitality and function
and restore dentine continuity below the injury through
hard-tissue bridge formation.28 Optimal quality of this
hard-tissue bridge is essential to the long-term success
of vital pulp therapy.29, 30 There is a pulp tissue-specific
response to the capping material, and this determines
the quality of the dentine bridge.28

Fig. 7: Ceramir is a bioactive cement that remineralises and deposits
hydroxyapatite.

MTA is a calcium silicate-based material (derived from
Portland cement) with high sealing ability and excellent
biocompatibility. MTA-based materials stimulate faster
formation of dentinal bridges that are of better quality
than those of calcium hydroxide.35, 36 Since the mid1990s, MTA has been recognised as the standard in
conservative pulp vitality treatment.37 MTA-based materials have limitations however:
– long setting time;38
– weak mechanical properties; 38
– difficult handling; 38
– may produce tooth discoloration; 39
– may contain heavy metals.40
Much research has followed to build on the advantages
of MTA while eliminating most of the disadvantages.
One such material is Biodentine (Septodont; Fig. 8).
It was formulated by improving the physical and handling properties of MTA-based endodontic repair cement
technology and creating a dentine replacement material
with significant reparative qualities.

Calcium hydroxide products have been used in vital
pulp therapy for many years. The ability of calcium hydroxide to promote dentine bridge formation and enhance wound healing is well established.31 However,
calcium hydroxide has inadequate physical properties
and produces poorly formed dentinal bridges containing tunnels.32 This has directed research to seek out new
materials for this therapy.

Biodentine can be used as a complete dentine replacement material to treat damaged dentine in both
the crown and the root with clinical indications that
exceed those of MTA and other related Portland cement
calcium silicate products.21 Biodentine can be used
as a:

The first of these materials created for practical clinical use was mineral trioxide aggregate (MTA).33 MTA
was originally developed as a root end filling material for
apicectomy procedures and to repair root perforations.34
Indications for its use have expanded broadly within restorative dentistry and paediatric dentistry.21

– cavity base/liner in deep carious lesions;
– pulp capping agent in vital pulp therapy (both direct
pulp capping and pulpotomy);
– root repair material for perforations, resorptions, apexification and root end filling material in endodontic
surgery; and

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| trends & applications
– restorative material to replace missing or defective
dentine.

The calcium silicate setting reaction is as follows:

It cannot be used to replace enamel.
The advantages of Biodentine over MTA and modified
MTA materials include:
– ease of handling;
– high viscosity;
– shorter setting time (12 minutes);
– better physical properties;41
– composition containing raw materials with known degree of purity;42 and
– good colour stability, so there is no discoloration.43
Biodentine is a tricalcium silicate-based material. Its
mechanical properties compare to those of dentine, and
it can be used as a dentine substitute in both the crown
and the root.44–46 It stimulates deposition of hydroxyapatite when exposed to tissue fluids.47 It is non-toxic as
tested on human pulp cells.48 Studies have shown complete dentinal bridge formation after six weeks in human
teeth.49
Biodentine provides a hermetic seal that protects the
dental pulp by preventing bacterial infiltration. This creates
a protected environment where healing can take place.
The seal is created through micromechanical retention
by infiltrating the dentine tubules and by stimulating odontoblasts to deposit dentine.25
It is the calcium-releasing ability of pulp capping materials that induces pulp tissue regeneration. Tricalcium
silicate-based materials like Biodentine produce calcium
hydroxide as a product of hydration.50

Calcium silicate in the powder interacts with water, leading to the setting and hardening of the cement.
This produces hydrated calcium silicate gel and calcium
hydroxide. Calcium hydroxide can now stimulate pulp
regeneration within a gel-like material that is strong and
not porous; this harnesses the regenerative powers of
calcium hydroxide without its physical disadvantages.
Biodentine in vital pulp therapy, through the action of
calcium hydroxide in this enhanced physical state, boosts
the deposition of reparatory dentine by odontoblasts.
This creates a dense dentine barrier,51, 52 as well as heals
damaged pulp fibroblasts.53 Clinical results have confirmed Biodentine’s ability to preserve pulp vitality even
in very difficult cases. It has the potential to heal pulps,
avoiding what may have been inevitable endodontic
involvement in the past.
Resin-modified calcium silicates
Studies have shown that the presence of a resin
matrix modifies the setting mechanism and calcium
leaching of calcium silicates.54 A partial pulpotomy clinical
study compared TheraCal (BISCO), a light-cured, resin-
modified calcium silicate base/liner designed for direct
and indirect pulp capping, with non-resin-containing materials Biodentine and ProRoot MTA (Dentsply Sirona).
The results showed that Biodentine achieved complete dentinal bridge formation in all teeth. The rates for
bridge formation were 56 % for ProRoot MTA and 11 %
for TheraCal.55 Normal pulp organisation was seen in
66.6 % of the teeth in the Biodentine group, 33.3 %
of the ProRoot MTA group and 11.1 % of the TheraCal
group. The study concluded that the non-resin-based
partial pulpotomy materials perform better than the
resin-based materials and present potential for the best
clinical outcomes.55
Another recent study compared Biodentine with
TheraCal with respect to how they each affect inflam
mation and regeneration of the pulp in a direct pulp capping in vitro model. TheraCal was shown to increase
inflammatory cells and decrease the regenerative processes of the pulp, whereas Biodentine did not increase
inflammation and supported the regenerative processes
of the pulp.56

Fig. 8: Biodentine is a bioactive restorative material that remineralises, deposits
hydroxyapatite and r egenerates live tissue.

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These two studies seem to suggest caution in using
resin-based materials for vital pulp therapy. Biodentine
has good biocompatibility and bioactivity for use in vital
pulp therapy.

[35] =>

trends & applications

Calcium silicates as endodontic sealers
The ability to deposit hydroxyapatite and regenerate
live tissue has brought calcium silicate technology into
the scope of endodontic sealers. After obturation, there
is generally contact between the obturating materials and
the periapical tissue. The success of treatment greatly
depends on the integrity of the obturated seal to prevent
recurrent infection of the periapical space.
The introduction of bioactive endodontic sealers has
changed the concept of obturated seal from hermetic
sealing with inert materials to biological bonding with
bioactivity.57 The sealer becomes a filler, not only a sealer.
Calcium silicates are well suited to endodontic obturation owing to the following properties:58
– high pH (antibacterial);
– hydrophilic (use moisture present in dentinal tubules to
initiate set);
– biocompatible;
– do not shrink or resorb;
– excellent seal (bond chemically and mechanically to
dentine); and
– ease of use (can be used with many methods of condensation).
Furthermore, they are bioactive:
– remineralise hard tissue;
– deposit hydroxyapatite to improve the seal over time;
– regenerate and heal surrounding periapical tissue.
BioRoot (Septodont; Fig. 9) has been developed to
incorporate these bioactive traits. Research has shown:
– Hydroxyapatite formation upon setting reaction: Bio
ceramic sealers bond to dentine through the process
of alkaline etching. This is due to the alkalinity of the
sealer. A mineral infiltration zone develops between the
dentine and the sealer.59
– Tissue healing: A study that compared the effects of
BioRoot RCS on human periodontal ligament cells
with the standard zinc oxide eugenol-based root canal
sealer, Pulp Canal Sealer (Kerr Dental), showed BioRoot to have fewer toxic effects on periodontal ligament
cells and that it induced greater secretion of angiogenic
and osteogenic growth factors. These properties are
essential in periapical tissue regeneration.60, 61 BioRoot
also showed excellent biocompatibility when compared
with many other contemporary endodontic sealers.62

Conclusion
With a bit of simplicity and focus on the essentials of
bioactivity in dentistry, it becomes clear that bioactivity
is now an essential part of the practice of clinical den-

Fig. 9: BioRoot is a bioactive endodontic sealer that remineralises, deposits
hydroxyapatite and regenerates live tissue.

tistry. Dentists can now harness the potential to remineralise and generate tooth material and heal biological
structures for their ultimate objective: attaining the best
possible clinical outcomes for their patients.
Editorial note: A list of references is available from the
publisher.

contact
Dr Fay Goldstep has been an ADA
(American Dental Association) Seminar
Series Speaker and lectured at the
ADA, Yankee, American Academy
of Cosmetic Dentistry, Academy of
General Dentistry and Big Apple dental
conferences. She has lectured nationally
and internationally on proactive/minimal
intervention dentistry, soft-tissue lasers,
electronic caries detection, healing dentistry and innovations
in hygiene. Dr Goldstep has served on the teaching faculties
of the postgraduate programmes in aesthetic dentistry at the
State University of New York at Buffalo, universities of Florida
and Minnesota, and University of Missouri–Kansas City in the
US. She sits on the editorial boards of the Oral Health Journal
(healing/preventative dentistry), Dental Tribune U.S. Edition and
Dental Asia. She is a fellow of the American College of Dentists,
International Academy for Dental-Facial Esthetics and American
Society of Dental Aesthetics. Dr Goldstep has been a contributing
author to four textbooks and has published more than 60 articles.
She has been listed as one of the leaders in continuing
education by Dentistry Today since 2002. Dr Goldstep
is a consultant to a number of dental companies
and maintains a private practice in Toronto in Canada.
She can be contacted at epdot@rogers.com.

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| trends & application

Hot modified technique
with a new biosealer
Drs Alfredo Iandolo, Massimo Calapaj & Dina Abdellatif, Italy

Introduction
The long-term success of endodontic
treatment is basically

based on adequate 3-D
cleaning of the endodontic space after root
canal shaping, followed
by complete 3-D obturation of the complex root
canal system. The endodontic space is composed of areas that are
easily accessible to hand
and rotary instruments
(the main canals) and,
as confirmed by many
clinical and histological
studies, some spaces Fig. 1: Apical third of the mesial root of a first mandibular molar showing a complex anatomy.
that are difficult to access or even inaccessible (isthmuses, loops, lateral caodontic biochemical cleaning (for the accessible and innals, ramifications, deltas and dentinal tubules; Fig. 1).
accessible areas). Once these areas have been cleaned,
For that reason, mechanical shaping is not able to reach
they can be filled and obturated with gutta-percha and
all areas of the complex root canal system, regardless
sealer during the obturation phase.
of the technique used, leaving parts of the root canals
untreated. Therefore, it is necessary to carry out endWhen it comes to obturation, there are different
techniques, mainly warm and cold techniques. In the literature, there are no
significant differences regarding whether
warm obturation techniques are better
than cold techniques, but it is logical and
well-demonstrated that the warm filling
techniques can fill the endodontic space
in a 3-D way.

Fig. 2: GuttaFlow 2 biosealer.

As already mentioned, it is not only the
main canal that is present in the endodontic space, but there are different
anatomical configurations. Therefore, if

we use cold filling techniques, most of
these spaces will not be filled. In brief, in
the pursuit of excellence, we must try to
clean almost all of the endodontic space
and then fill it nearly completely.

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trends & application

Together with gutta-percha, the most commonly used sealers are those based on zinc
oxide, as well as eugenol and resin. In recent

years, a new generation of sealers, the bioactive sealers, less toxic and with greater healing capacity, have been released on the market.
However, these biosealers have two major dis
advantages:
– The first is that they must be used with the cold
single-cone technique because they cannot be
heated; therefore, they are not able to obturate
the endodontic space in 3-D.
– The second disadvantage is their consistency
after hardening. They harden a great deal, and in
the case of retreatments, the problem becomes Fig. 3: Explaining steps of the hot modified technique.
more complicated.
Recently, a new biosealer was introduced, ROEKO
GuttaFlow bioseal (COLTENE). This is not a pure biosealer because it is composed partly of gutta-percha
fluid and partly of calcium silicate particles. It is less toxic
than other sealers and biosealers, guarantees micro-
expansion within the endodontic space after hardening,
and therefore more hermetic filling, and has excellent
regenerative capacity.

After choosing the correct gutta-percha master cone,
we prepared the biosealer and inserted it into the root
canal with the proper tip. We then inserted the gutta-
percha cone to the working length and began the 3-D
obturation technique. In order to reach our aim, we
decreased the heat carrier temperature to 130–150 °C
instead of the average 200–250 °C, as this is sufficient.

Furthermore, its composition offers two great
advantages:
– The first is that it can be used with warm
vertical compaction, so it can obturate in a 3-D
way.
– The second is its consistency after hardening.
It does not become extremely hard like other
biosealers do, so it can be easily removed in
the case of retreatments.

Using GuttaFlow bioseal
This article demonstrates and discusses a
modified warm filling technique using GuttaFlow
bioseal. Several clinical cases are shown with
follow-ups using this technique (Figs. 2–4).

Fig. 4

Obturating all of the endodontic space is very
important for the final treatment outcome. This
new biosealer combines fluid gutta-percha with
a suitable sealer at room temperature and bioceramics in an automix syringe (Fig. 5). Setting time
ranges between 10 and 15 minutes.
What we call the 3-D obturation technique is, in
fact, an efficient and reliable way to fill even a complex anatomy. For the current warm modified tech- Fig. 5
nique, we used the System B heat source (Kerr),
Figs. 4 & 5: In vitro test showing better sealer penetration into a lateral canal.
but any similar device could also be used.

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[38] =>

| trends & application
one stroke, but can use another stroke until the desired
length is reached.
With this modified technique, the gutta-percha itself
does not have to enter the accessory canals, as the
bioceramic sealer will flow into any hidden canals. In
in vitro tests, it was shown that the modified obturation
technique allowed the sealer to advance deeper inside
lateral canals in comparison with the conventional single-cone technique (Figs. 6–8).
By increasing the penetration speed of the heat carrier,
we increase the pressure and this is needed to ensure the
biosealer penetrates throughout the endodontic space.
With the new warm modified technique, the biosealer
sets only around two minutes earlier than with the normal technique. This happens owing to using the reduced
heat settings and fast penetration.

Fig. 6

With aid of 3-D obturation, the sealer is allowed to do
its job in areas that are difficult to reach, while it is pushed
further down into the canal by the slightly melted gutta-
percha on top.

Conclusion
Shaping, 3-D cleaning and 3-D obturation are the
three key parameters for achieving short- and long-term
success in endodontics. Nowadays, many sealers are
available, including biosealers, but the latter have some
disadvantages, such as being limited to use with cold
techniques and hardening a great deal. In order to guarantee a secure obturation, we must try to fill the endodontic space as much as possible, and achieving this with
cold techniques is not possible.

Fig. 7

Fig. 8
Fig. 6: Endodontic treatment of tooth #11. Fig. 7: Endodontic retreatment
of tooth #46 associated with periapical lesions related to the mesial and
distal roots and a furcation lesion. The perforation on the floor was closed
with GuttaFlow bioseal, and 3-D obturation was achieved using the hot
modified technique. Fig. 8: Endodontic treatments with healing and followup at six months. 3-D obturation was achieved using the hot modified
technique.

Penetration depth was reduced to three seconds, rather
than the usual five seconds, and the heat carrier was inserted to 4 mm short of working length. Conventionally,
to dissolve the gutta-percha in the apical third, the heat
carrier has to reach 3 mm from working length. However, with this modified technique, the heat carrier can be
stopped also at 6–10 mm from working length. The clinician does not have to reach the desired working length in

Instead, with the benefit of a new biosealer, GuttaFlow
bioseal, we can achieve 3-D obturation using a modified obturation technique. This new biosealer has less
toxicity than other sealers and biosealers do, and the
bioactive components of the obturation material enhance
the healing process, as they stimulate the rebuilding
of bone and dentinal tissue, which is favourable for the
actual sealing of the canal.

contact
Dr Alfredo Iandolo is a
contract professor of Endodontics
at the U niversity of Naples Federico II
in Italy. He can be contacted at
iandoloalfredo@libero.it.

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[40] =>

| case report

Bioactive materials
for root canal obturation
Prof. Bogdan Shumilovich, Dr Vladimir Rostovtsev, Dr Lianna Adunts,
Dr Andrey Fonstein & Dr Eugeniy Stanislavchuk, Russia

Fig. 1: GuttaFlow bioseal.

Introduction
In our previous cases (published in 2012 and 2013)
have already described the properties and clinical capabilities of the ROEKO GuttaFlow and GuttaFlow 2
systems (COLTENE), based on the polydimethylsiloxane (PDMS) chemical compound, which is a linear polymer of dimethylsiloxane.1–3 The properties are due to the
chemical capabilities of the substance. The amount of
dimethylsiloxane units in the structure can reach up to
15,000. Depending on the chain length of the polymer,

substances with different physical properties can be obtained. The viscosity of such compounds increases with
increasing length, which corresponds to a transition from
very motile, gas-like liquids, to more viscous oils and,
finally, to resinous substances.3–5

Cold obturation technique for bioactive
sealing and filling
The GuttaFlow and GuttaFlow 2 systems operate on
the principle of absolute bio-inertness. All materials and
substances used in clinical dentistry can be conditionally divided
into three major groups:
1.
Bio-inert: do not interact with
surrounding tissue
2.
Bio-resorptive: during contact
with surrounding tissue are
absorbed and/or destroyed
3. Bioactive: affect the surrounding tissue during contact.

Fig. 2a

Fig. 2b

Fig. 2a: Control radiograph after obturation. Fig. 2b: Radiograph after seven years.

Given the increased interest of
clinicians and researchers in the
bioactive methods of root canal obturation, the new bioactive
system of cold free-flow guttapercha was created by COLTENE.6–8
The system was based on the

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case report

lready existing GuttaFlow and
a
GuttaFlow 2 and given all the
best qualities of its predecessors.
GuttaFlow bioseal (Fig. 1) was

created according to the formula
of sealer + free-flow gutta-percha
+ bioglass and consists of the
following components:
– basis with gutta-percha (in powder form with a particle size of
less than 30 μm), zinc oxide and
barium phosphate
– bioglass
–
sealer with PDMS, silicone oil,
paraffin oil, zinc dioxide (X-ray
contact s lowness), platinum catalyst, colouring pigment and micro- Fig. 3
Fig. 4
crystals of silver (bactericidal
Fig. 3: Control radiograph of tooth #35 after obturation. Fig. 4: Control radiograph of tooth #47 after obturation.
effect).
Such an arrangement provides to the system, in addition to the unique properties of GuttaFlow, a number of
characteristics:
– no need for mechanical compaction;
– the presence of a prolonged bactericidal effect;
– obturation on the principle of no heating, no shrinkage
(0.2% expansion);
– excellent fluidity;
– simplicity and speed of clinical use; and
–
the ability to absorb hydroxyapatite crystals on the
biocrystal particles (the importance of this property and
its role in determining the clinical effectiveness of the
system are explained later in the article).
The properties of bioglass as a material capable of
contacting the native bone were first described in 1969.9

Fig. 5a

It consists of silicon, calcium oxide, hydroxyphosphates
and sodium phosphates. Today, owing to the expressed
osteoinductive effect, bioglass is widely used in medicine
(e.g. traumatology and dentistry). Owing to its high pH,
antibacterial properties are strongly pronounced. Thus,
GuttaFlow bioseal has unique chemical, physical and
bioactive properties regarding the formation of hydroxyapatite crystals, the main structural unit of hard tooth tissue, which ensures the maximum quality of sealing and
the biocompatibility of the material.10, 11
As already mentioned, GuttaFlow bioseal contains a
finely dispersed gutta-percha, PDMS, platinum catalyst,
zirconia, silver (preservative) and colourant. In addition to all
these, the new material contains finely dispersed particles
of bioactive glass-ceramic, which provides the formation
of hydroxyapatite crystals on the surface, which causes

Fig. 5b

Fig. 5c

Fig. 5a: Initial situation. Fig. 5b: Extremely curved root canals. Fig. 5c: After obturation.

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| case report
excellent adhesion to the dentine and tightness of the
obturation. In addition, the presence of silver particles
in ceramics, according to some data, has the effect of
conservation of the root canal. Nowadays, only mineral
trioxide aggregate and bioglass have similar regenerative
properties.12, 13

Seven-year follow-up of a clinical case
obturated with GuttaFlow 2
Tooth #45 (Figs. 2a & b) was obturated with GuttaFlow 2
and served for seven years as a retainer tooth for a clasp
prosthesis, experiencing additional loads. It is evident
that the slight extrusion of the material at the apex did
not affect the periodontal condition. At the same time,
the material was not absorbed, proving its absolute
bio-inertness.

Step-by-step protocol
The step-by-step protocol for activating the new system
is absolutely identical to that of GuttaFlow 2. Before using
the syringe applicator, the protective cap should be removed and replaced with a mixing tip (automix). When the
plunger is pressed, the evenly mixed material without bubbles leaves the mixing tip in a 1:1 ratio. Flexible mixing tips
can only be used once and must be disposed of after use.
1. It is extremely important to ensure the dryness of the
biomechanically processed root canal. For insurance,
lay down another one of the same size with an exposure of 40 seconds after removing the last paper point
in a dry condition. If it is dry and dense upon removal,
you can proceed to obturation.
2. Determine the correct size gutta-percha master point
(from the master apical file).
3. Distribute the GuttaFlow bioseal on the mixing block
and introduce it into the canal on the master point.
4. Introduce the master point for the entire working length
and adapt it.

Fig. 6a

Fig. 6b

Fig. 6c

5. Introduce the tip of the mixing tip to the maximum
possible depth (no closer than 5 mm to the apex;

the size of the spout corresponds to ISO file size 80)
depress the plunger until the material appears in the
mouth of the canal, ensuring a gradual and smooth
flow from the tip.
6. Cut the master point heated to 200 °C.

Clinical examples obturated
with GuttaFlow bioseal
In 2016, the system was applied for clinical approbation
at the postgraduate dentistry department of the V
oronezh
State Medical University named after N.N. B
urdenko in
Russia. In both cases, endodontic treatment was primary, the apex locator behaved as usual (DentaPort ZX,
Morita) and there were no clinical complaints after the
root obturation (Figs. 3 & 4).
Molar with chronic fibrous pulpitis
A 47-year-old patient complained of spontaneous radiating pain in the region of the lower jaw on the left that
amplified with temperature stimuli. Visual and instrumental examination revealed a cavity in tooth #38. After the
standard diagnostic protocol, the diagnosis was chronic
fibrous pulpitis of tooth #38 (Fig. 5a).
At the request of the patient, endodontic treatment was
performed. The preparation was carried out using the
HyFlex CM and HyFlex EDM file systems (both COLTENE).
The choice of the system is obvious. Once the glide
path had been established to ISO size 15, we analysed
the pronounced curve (Fig. 5b) and selected a rotary
tool for increased flexibility and an obturation system
that does not require condensation, which would have
been impossible under the conditions. In our opinion,
GuttaFlow bioseal coped brilliantly with the task, achieving reliable obturation not only along the entire length of
the canals, but also of a pronounced delta in the apical
part (Fig. 5c).

Fig. 6d

Fig. 6a: Initial situation. Fig. 6b: Control radiograph after obturation. Fig. 6c: Radiographic situation after six months. Fig. 6d: Radiographic situation after nine months.

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case report

Fig. 7a

Fig. 7b

Fig. 7c

Fig. 7a: Radiograph of initial situation. Fig. 7b: After obturation. Fig. 7c: Six-month follow-up.

Repeated endodontic treatment
A 49-year-old patient presented with acute pain affecting tooth #46. According to the patient, the tooth had previously been treated for compound caries. For ten years,
the tooth had been covered with a metal-ceramic crown.
The pain had begun three days before, and the patient
had visited the clinic where she had been treated previously. After CBCT examination, the patient was referred
to the department (Fig. 6a).
After the standard diagnostic protocol, the diagnosis
was chronic granulomatous periodontitis of tooth #46.
The tooth had previously been treated with resorcinol-formalin method. At the request of the patient, repeated
endodontic treatment was performed. After debridement
and negotiation of the glide path to ISO size 15 with hand
tools (reamer and H-file), the subsequent preparation was
carried out using the HyFlex CM system with a standard
irrigation protocol (5 % sodium hypochlorite; 17 % EDTA;
water; EndoActivator, Dentsply Sirona). The treatment steps
at the first visit were canal access, irrigation, preliminary
preparation and temporary obturation with UltraCal XS
(Ultradent Products) for 14 days.
As there were no complaints at the second visit, the
final mechanical and chemical treatment followed by obturation was carried out. The radiographic monitoring
(Fig. 6b) showed that the material had extruded into the
periapical tissue on the mesial root and covered the resorbed apical part of the root. The radiographic controls
after six and nine months (Figs. 6c & d) traced the positive dynamics of regenerative processes after repeated
endodontic treatment.
Paranasal sinus diagnosis with surprising finding
A 27-year-old patient was referred to us with no complaints. A radiolucency (Fig. 7a) in the area of tooth #37
was found by accident during CBCT imaging of the paranasal sinuses. Owing to the absence of a clinic near

the patient’s home, we decided to conduct a repeat endodontic treatment in one visit. The root canals were sealed
with zinc oxide eugenol paste. The retreatment and creation of the glide path to ISO size 15 was carried out
with hand instruments (reamer and H-file). Subsequent
preparation was done using the HyFlex CM system with
a standard irrigation protocol (5 % sodium hypochlorite,
17 % EDTA, water, EndoActivator). The treatment steps
were irrigation, preliminary and final mechanical and
chemical treatment, followed by obturation and radiographic inspection (Fig. 7b). At the recall after six months,
the patient was without complaints, and radiographic
monitoring (Fig. 7c) showed positive dynamics of regenerative processes a
fter endodontic treatment.

Conclusion
GuttaFlow bioseal is the logical continuation of the
existing materials of GuttaFlow and GuttaFlow 2, and in
addition to its own unique osteoinductive qualities, has
the same obturation properties as its predecessors.
We express the firm belief that the availability of the
GuttaFlow bioseal system in the dentist’s arsenal will

significantly expand the clinical possibilities of the endodontic practice, since there is nothing more physiological than the patient’s natural tooth.

Editorial note: A list of references can be obtained from
the publisher.

contact
Prof. Bogdan Shumilovich is head of the postgraduate
dentistry department at the Voronezh State Medical University
named after N.N. Burdenko in Russia. He can be contacted
at bogdanshum@gmail.com.

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| case report

Orthograde apical application
of an MTA plug
in a tooth without
constriction

© Catalin Petolea/Shutterstock.com

Dr Angela Gusiyska, Bulgaria

Introduction
The minor apical foramen should be maintained at its
initial position and size after chemomechanical endodontic procedures. If the apical constriction is breached and
transported, cleaning procedures will be compromised
and obturation significantly difficult to carry out well.

Fig. 1

Apical root resorption is a pathological condition of the
inflammatory response, characterised by the processes
of cement and/or dentine depletion, resulting from the
activity of resorptive cells called dentoclasts (a subclass
of osteoclasts).1–3 Treatment of the apical resorptive processes is likely to occur through removal of the pulp and
granulation tissue, as well as interruption of the blood

Fig. 2

Fig. 1: Initial radiographic status of tooth #46. Fig. 2: Control radiograph to assess the removal of a separated lentulo.

44

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case report

supply to these tissues, which is necessary for the development of resorptive cells. In many cases of incomplete root canal therapy, there are resorptive changes in
the apical zone. One of the major challenges in endodontic treatment of teeth with open apices due to resorption is achieving effective debridement, canal disinfection
and subsequent sealing of the root canal space. The key
point is to form an apical barrier or a stop against which
one can place the sealer and gutta-percha while avoiding over-extrusion.4, 5 Mineral trioxide aggregate (MTA) is
a reliable material owing to its biocompatibility and good
sealing properties, which provide opportunities for the
regeneration of periapical tissues, such as periodontal
ligament, bone and cementum.6–8
These properties make MTA a suitable material for the
management of apical zone sealing in cases of resorption
and without physiological constriction. The present case
report describes a retreatment case of a mandibular molar, complicated by lack of constriction and a separated
endodontic instrument.

Case report
A 34-year-old female patient was referred for endodontic treatment of tooth #46 because of a separated
endodontic instrument in the mesial root, which was observed on the initial radiograph (Fig. 1). The patient’s chief
complaint was mild pain in the mandibular right posterior
region during chewing. She gave a history of a root canal
therapy on the same tooth four years earlier. There was
no other relevant medical history.
Based on the clinical and radiographic findings, root
canal therapy was initiated. A rubber dam was placed
and the tooth was accessed without the need for anaesthesia. Crown-down preparation was performed for
orthograde endodontic treatment. The mesiobuccal ca-

Fig. 5a

Fig. 4

Fig. 3: MAP System carrier with prepared MTA.

nal was negotiated with a size 0.06 C-file and the separated instrument was removed under magnification with
a dental operating microscope (16 ×, Zeiss), and a control radiograph was taken (Fig. 2). The root canals were
cleaned and shaped with ProTaper rotary instruments
(Dentsply Maillefer). The mesial canals were prepared
up to F3. All of the canals were irrigated with a copious
amount of 5.25 % sodium hypochlorite and 17 % EDTA.
This was followed by irrigation with 0.9 % saline to remove any remnants of hypochlorite and EDTA. Haemorrhage and exudate from the apical region of the distal
canal were observed during the instrumentation, which
suggested resorption exteriorisation. The canals were
dried with absorbent paper points, and calcium hydroxide paste (ApexCal, Ivoclar Vivadent) was placed in the
canals as an intracanal medicament, followed by temporary restoration with glass ionomer cement.
The calcium hydroxide paste was removed ten days
later. The complete removal of paste from the root canal

Fig. 5

Fig. 4: Obturation of mesial canals and a 5 mm apical plug of MTA distally. Fig. 5: Control radiograph after final obturation.

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| case report

Fig. 6

Fig. 7

Fig. 6: Control radiograph after one month. Fig. 7: Control radiograph after three months.

walls was accomplished by passive ultrasonic irrigation
and 10 % citric acid, using an endodontic tip (ESI, EMS)
for more precise cleaning. Taking into consideration the
extent of the apical root resorption, it was decided to perform orthograde MTA obturation of the distal canal space
to arrest the resorption. The material was placed into the
canals with the MAP System carrier (Produits Dentaires;
Fig. 3) by the means of a 5 mm apical plug and was condensed vertically with a hand plugger. After radiographic
examination of the accuracy of the apical plug (Fig. 4) and
a setting period, the entire canal and the mesial canals
were obturated with TotalFill BC (FKG Dentaire; Fig. 5).
The orifices were adhesively sealed and the tooth was
definitively restored with light-curing composite and prepared for a crown.
The patient was recalled after one month (Fig. 6), three
months (Fig. 7) and six months (Fig. 8) for clinical and radiographic follow-up. Clinical examination of tooth #46
found it to be functional without sensitivity to percussion
or palpation. The tooth showed normal physiological mobility and no periodontal pockets on probing. The periapical radiographs showed satisfactory periapical bone
density with no sign of periapical radiolucencies and no
further progression of the resorptive process around the
distal apical zone. The treatment was definitively finished
with a crown. After one year, the patient was recalled
again, and the tooth was found to be symptom-free.
No percussion sensitivity was observed. The periapical
radiograph showed a satisfactory image (Fig. 9).

Discussion
Not every resorptive process in the apical zone can
be observed on an initial periapical radiograph. Only
thickening of the periodontal ligament space was discovered in this case, and the resorptive process in the
apical zone was detected clinically and measured with

endodontic instruments because of the superimposition
of the structures.
Three-dimensional sealing of the endodontic space is
one of the main goals of root canal therapy and is essential for preventing apical and coronal leakage.8 One of the
characteristics of a biomaterial is its ability to form an apatite-like layer on its surface when it comes into contact
with physiological fluids in vivo or with simulated body
fluid in vitro. MTA is a bioactive material that is mainly
composed of tricalcium silicate. Scientific investigations
have shown that MTA can release various ions that conduct and induct hard-tissue formation.9, 4 MTA presents
some advantages, including its physical characteristics
that guarantee expansion during the attachment, which
favours sealing, and the biological properties of calcium
hydroxide.10, 11 MTA forms calcium oxide when in contact
with water, which then, when in contact with tissue fluids,
forms calcium hydroxide and triggers the same repair
process in the tissue.12 Some recent studies have reported on the success of MTA as a root apical barrier,
with rates ranging from 76.5 % to 91.0 %.13, 14
The antimicrobial activity of MTA seems to be associated with elevation of pH. Torabinejad et al. observed an
initial pH of 10.2 for MTA, rising to 12.5 in three hours, and
it is known that a pH level of 12.0 can inhibit most micro
organisms, including Enterococcus faecalis.15 When
there is an open pathway of communication between the
root canal and the periodontium, it must be sealed to
prevent bacterial leakage. This obturation sealer should
be biocompatible and should favour regeneration of the
supporting periapical structures.16
The apical level of root canal preparation and the border of obturation have been discussed in the literature
for several decades. Sealers for the root canal space in
cases of advanced resorption have also been thoroughly

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[48] =>

| case report

Fig. 8

Fig. 9

Fig. 8: Control radiograph after six months. Fig. 9: Control radiograph after one year.

examined. Therefore, the development and maintenance
of a seal is considered to be a major prerequisite to improving the outcome of root canal therapy. The absence
of physiological narrowing is a challenge to the achievement of satisfactory early and late therapeutic results.
It makes probable either the overpressing of necrotic,
infected material when preparing the endodontic space
or the overpressing of the sealer when sealing the root
canal.
There is ongoing discussion about the application of
calcium hydroxide paste as an intracanal medicament.
Some research has shown that the remains of calcium
hydroxide on the dentinal walls had no significant effect
on MTA microleakage.17 In contrast, others have suggested that the remnants react and form calcium carbonate, which interferes with apical sealing.18 Others
have suggested that the combination of calcium hydroxide and MTA in apexification procedures may favourably
influence the regeneration of the periodontium.19 In teeth
with chronic periapical lesions, there is a greater prevalence of Gram-negative anaerobic bacteria. When the
root canal is mechanically prepared, 35 % of the area remains untouched, including the apical bacterial biofilm.20
Because these areas are not reached by instrumentation,
the use of an intracanal medicament such as calcium
hydroxide paste is recommended to aid in the elimination
of the bacteria and lipopolysaccharides, and to increase
the likelihood of clinical success.21–24 Lipopolysaccharide, a bacterial endotoxin, causes the formation of periapical lesions. Currently, calcium hydroxide paste is still
a medicament of choice for inactivation and detoxification of this bacterial endotoxin in vivo.25 Based on previous research, we used a calcium hydroxide paste in the
treatment protocol for the present case and observed a
successful clinical outcome. Recurrent examinations and
radiographs are necessary for follow-up of the clinical outcome and to avoid the need for surgical interventions.26

Conclusion
MTA is an appropriate material for apical sealing in
cases of resorption, as it leads to the avoidance of surgical apical procedures with a similar prognostic outcome.
The author denies any conflicts of interest related to this
study.
Editorial note: A list of references can be obtained from
the publisher.
This article originally appeared in IJSR Vol. 5 Issue 2,
February 2016.

about
Dr Angela Gusiyska received her degree in dentistry from
the Faculty of Dental Medicine at the Medical University of Sofia
in Bulgaria in 1997, and she specialised in operative dentistry
and endodontics at the same university in 2003. Since 1998,
she has been an assistant professor in the Department of
Conservative Dentistry at the university. Her research interests
are in the regeneration of the periapical zone, nanotechnology
and bioceramics in endodontics and aesthetic rehabilitation
of dentition. She completed her PhD thesis,
Orthograde Treatment of Chronic Apical Periodontics—
Biological Approaches, in 2011. She has presented scientific
papers at national and international dental meetings.
Dr Gusiyska’s practice is focused on microscopic endodontic
treatments. She is a member of the Bulgarian Dental
Association, Bulgarian Scientific Dental Association, Bulgarian
Endodontic Society, Bulgarian Academy of Esthetic Dentistry,
International Team for Implantology and Bulgarian Association
of Oral Implantology. She can be contacted at
gusiyska@yahoo.com.

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| case report

Long-term stable restoration of
severely discoloured anterior teeth
Prof. Dr Daniel Edelhoff, Germany

Fig. 1

Fig. 2

Fig. 1: Frontal view of initial situation. Seriously impaired aesthetic appearance due to extreme discolouration and malpositioning of the maxillary central
incisors. Fig. 2: Palatal view of the initial situation. As well as micro-leakage around the margins, secondary caries is also evident under the composite fillings,
which were placed more than five years ago.

Introduction
Severely discoloured endodontically treated maxillary
incisors can have a considerable detrimental impact on
aesthetic appearance and also present a particular challenge for the restorative team. When planning treatment,
the focus is firmly on reconstruction of the biomechanical
and visual properties of the affected teeth combined with
minimal biological cost. In a well-coordinated approach,
internal bleaching measures, the use of a fibre post
(depending on the degree of destruction), selected adhesive build-up materials and a preparation technique
tailored to the restoration material can be combined to
achieve a satisfactory treatment result which, compared
to classic full crown preparations, can significantly reduce the loss of hard tooth structure.

Fig. 3

In the following case report, the restoration of two
maxillary central incisors using bleaching measures, insertion of DT ILLUSION XRO SL fibre posts with direct
composite build-ups and final restorative treatment with
360° glass ceramic-based veneers is illustrated and
documented after a clinical service period of seven years.

Case report
Initial situation
A 28-year-old male patient presented with the demand
to have his endodontically treated and severely discoloured
maxillary central incisors restored. He stated that since undergoing an apicoectomy a number of years ago, he no longer experiences any symptoms on the two anterior teeth.
However, he expressed his discontent with the appearance

Fig. 4

Fig. 3: Post-preparation for the DT ILLUSION XRO SL Post (diameter 2.2 mm, blue). The marginal post section becomes translucent upon trying-in in the root
canal as it is warmed up to body temperature. Fig. 4: DT ILLUSION XRO SL Post (diameter 2.2 mm, blue). The post is translucent when warmed up to body
temperature, here in the apical third area after being handled.

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case report

Fig. 5

Fig. 6

Fig. 5: Palatal view of try-in of both DT ILLUSION XRO SL posts on the prepared incisors. The marginal post section of the DT Post is already translucent
upon trying-in in the root canal as it is warmed up to body temperature. Fig. 6: Palatal view of the built-up incisors prepared for the full veneers (360° circular
veneers). The DT ILLUSION XRO SL Posts were translucent when warmed up to body temperature.

of his teeth resulting from the considerable aesthetic imperfections (Fig. 1). After evaluating the clinical findings and the
X-ray images, root canal fillings presented in compliance
with the state-of-the-art were diagnosed on teeth 11 and
21. Root canal posts were not present. However, the extensive composite fillings in both teeth showed micro-leakage
and secondary caries had begun to develop (Fig. 2). The
patient explained that the fillings on the two affected incisor
teeth had been placed more than five years ago.
The particular challenges presented by this initial situation arose from the patient’s demand for a prompt improvement of the aesthetic imperfections and, with this,
restoration of an adequate tooth shade and position and,
as far as possible, permanent stabilisation of the remaining hard tooth structure.

Treatment planning
Prior to planning the definitive treatment, the insufficient composite fillings in both anterior teeth were replaced and the secondary caries was removed. This was
a key prerequisite to obtaining a good overview of the
degree of destruction of the teeth and to rule out possible
contamination of both root canals with microorganisms
as a result of the insufficient and leaking fillings over the

Fig. 7

years. As both root canal fillings were sealed tight by
separate adhesive fillings at the cement-enamel junction,
there was no need to inspect the canals.
Following the initial laboratory and clinical analysis, the
patient and treatment team opted for the following treatment plan:
Firstly, the malpositioning (crowding) and the existing
tooth proportions were to be corrected with a diagnostic wax-up. During the pre-treatment phase, the affected
teeth were to be lightened to a shade that harmonises
with the adjacent teeth by means of internal bleaching measures. Given the pronounced nature of the defects, the adhesive technique was to be used for the
post-endodontic structure with the aid of fibre-reinforced
posts in the direct technique. For the final restoration of
the severely damaged anterior teeth, adhesively placed
360° veneers based on glass ceramic were to be used.
Pretreatment and preparation
After cleaning the coronal pulp chamber, an additional seal for the root canal fillings was created on the
level of the enamel-cement junction in order to rule out
penetration of the subsequently applied bleaching agent
into sensitive areas. Internal bleaching was performed

Fig. 8

Fig. 7: Palatal view of try-in of full veneers (360° circular veneers) made of glass ceramic. The underlying abutment teeth could be masked extremely well even
with a minimal layer thickness. Fig. 8: Transmitted light image of the maxillary anterior teeth following finalisation and insertion. Thanks to the combination
of the DT Post with translucent build-up materials and glass ceramic veneers, light transmission was achieved, which corresponds to that of natural teeth.

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| case report
precision impression of the prepared teeth and an impression
of the opposing jaw were taken.
These were sent to the laboratory together with the facebow,
the maxillomandibular relationship record and a photo of the
prepared abutment teeth.
Fig. 9

Try-in and insertion of the
glass ceramic veneers
Fig. 9: Follow-up examination seven years after insertion. Even after seven years of clinical service, a highly
After removing the provisional
satisfactory situation from both an aesthetic and functional perspective can be perceived. (Dental technician:
restorations, the preparation
Oliver Brix, Bad Homburg, Germany) Fig. 10: Tooth radiograph after seven years of clinical service. The dense
surfaces were freed from all
structure of the post anchor is evident together with an excess of root filling material on tooth 21.
remains of the bonding agent
using cleaning brushes and
a fluoride-free cleaning paste (Zircate, Dentsply Sirona).
using a mixture of sodium perborate powder and distilled
To check the shape and shading, the restorations were
water applying the walking bleach method. The palatal
tried in with a coloured glycerine gel. As such, perfect
access to the coronal pulp chamber was sealed using a
cotton pellet soaked in bonding agent and low-viscosity
masking of the abutment teeth was possible, resulting in a
composite and the patient was requested to return in one
uniform appearance irrespective of the subsurface (Fig. 7).
week’s time. During this session, the bleaching agent
was changed again in order to extend the exposure
For final insertion, the inner surfaces of the glass ceramic veneers were etched with hydrofluoric acid and
period by another week. After the second week of expothen coated with an silane coupling agent. A multiple-step
sure, the shade of both abutment teeth was satisfactorily
dentine adhesive system was used on the tooth side.
improved. In order to neutralise the bleaching agent, a
calcium hydroxide preparation (CalciPure) was applied
to the pulp chamber. Following this neutralisation phase,
Conclusion
post-endodontic build-up of the abutment teeth could
be commenced. To this end, the coronal seals on the
Thanks to the combination of translucent build-up maroot canal fillings were firstly removed and standard holes
terials with glass ceramic veneers, light transmission was
for fibre-reinforced posts (type: DT ILLUSION XRO SL,
achieved, which corresponds to that of natural teeth (Fig. 8).
The final inspection of the functional and aesthetic paramdiameter 2.2 mm, colour at 21 °C: blue) were created
eters showed that all patient’s demands could be fulfilled.
(Fig. 3). The DT ILLUSION XRO SL Posts are coloured
The tooth shade harmonised perfectly with the neighbour
according to their size at room temperature; this colourteeth. Alongside rectification of the extreme discolouration
ing disappears following insertion and when warmed up
of the hard- and soft-tissue structures, malpositioning and
to body temperature. If the post needs to be removed,
tooth proportions were also satisfactorily corrected. The
the colouration can be rendered visible again by cooling
patient was fully satisfied with the aesthetically pleasing
gently, e.g. with an air spray (Fig. 4). The DT Posts were
secured in place using a fully adhesive technique with a
result and experienced no phonetic problems whatsoever
multiple-step adhesive system (Fig. 5). The direct builddue to the corrected positioning of the incisors. After a clinups were created in two stages; after covering the posts
ical wearing period of seven years, no loss of retention of
with a low-viscosity (flowable) composite, a pre-warmed
the post, build-ups or veneers was evident nor were there
signs of bonding problems in the X-ray image (Figs. 9 & 10).
(54 °C) highly filled viscous composite of shade Bleach XL
was used for the main volume of the build-up. The minimally invasive preparation was produced with the guidEditorial Note: The article has been original published by
ance of a template derived from the diagnostic wax-up
OEMUS MEDIA AG and appeared in ZWP 5/18.
(deep-drawn film); this template contained all the information for correction of the malpositioning and the outer
contact
contour of the subsequently definitive restorations (Fig. 6).
Fig. 10

Temporary restoration
The temporary direct veneers were produced using
a reusable diagnostic template and Bis-GMA-based
temporary restoration material. After a four-week evaluation phase of the tooth shape and position determined
in the wax-up by means of the temporary prosthesis, a

Prof. Dr Daniel Edelhoff
Director
Department of Prosthetic Dentistry
University Hospital, LMU Munich
Goethestraße 70
80336 Munich, Germany
daniel.edelhoff@med.uni-muenchen.de

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[54] =>

| case report

Bisphosphonate-related
osteonecrosis of the jaw
Drs Claudia Dib, Sara Salloum, Edgard Jabbour & Philippe Sleiman, Lebanon

therapy.9 At the moment, it is unpredictable whether this
interconnection can be traced back to a coincidence or
to the existence of a true causal relationship.10 However,
Marx et al. claimed in 2003 that bisphosphonates would
lead to disrupted bone homeostasis by suppression
of osteoclast function.11 An accumulation of non-vital
osteocytes and microfractures would be the effect of
the disturbance of the normal bone remodelling.

Fig. 1

Fig. 2

Figs. 1 & 2: Swelling on the mandible.

Introduction
Bisphosphonates are a class of drugs that prevent the
resorption of bone by osteoclasts.1 These antiresorptive
medications have become the principal mode of therapy
for osteoporosis, Paget’s disease of the bone, bone metastasis, breast cancer and other conditions that display
bone fragility disease.2–4 Their usage has continued to
grow despite the concerns expressed recently regarding
potential side effects, such as bisphosphonate-related
osteonecrosis of the jaw (BRONJ).5
Apparently, a number of medical studies have been
recently published that document patients who developed
osteonecrosis of the jaw after receiving bisphosphonate

However, it should be declared that BRONJ might be a
persistent condition. As a matter of fact, withdrawal of bisphosphonate treatment would not decrease the risk rate
of BRONJ, since the drugs may persist in the skeletal tissue for years. Several studies have highlighted that, if bisphosphonates were prescribed temporarily or interrupted
for a specific reason (e.g. completed or discontinued the
course or taking a drug break), the patient would have to
be considered at risk. To clarify, BRONJ symptoms such
as delayed healing after a dental extraction or other oral
surgery, pain and soft-tissue infection may appear after
dental treatment. Accordingly, any necessary dental treatment should be done under strict safety conditions.12, 13
Setting aside the spinous questions of the aetiological
mechanisms of BRONJ and the extent of bisphosphonates’ contribution to this process, it seems purposeful to
reflect on recent clinical studies to seek the most effective
treatment for BRONJ.

Case presentation

6–8

Fig. 3: Panoramic radiograph showing bone loss around the first implant.

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An oral oedema is considered to be the most common of symptoms caused by oral disease, and its cor-

[55] =>

case report

Fig. 4

Fig. 5

Figs. 4 & 5: Damaged bone structure around the first implant was evident, but the bone surrounding the second implant seemed to be in good condition.

rect diagnosis and successful management is most challenging.14
A 55-year-old female patient presented to a dental
clinic with no pre-existing oral disease for urgent care.
An extraoral examination showed one-sided facial swelling under the lower jaw that had followed implant placement (Figs. 1 & 2). The panoramic radiograph revealed an
extensive osteolytic reaction surrounding the first implant
on the left side (Fig. 3). Although the symptoms and the
radiological signs from the examination could have indicated implant failure, a CT scan of the left part of the mandible was requested for better evaluation of the soft tissue and osseous involvement of the swelling. In addition,
information gathered from the patient’s medical history
showed that she had been treated with bisphosphonates.
The cross sections of the scan exposed sclerotic lesions
with cortical bone destruction. The necrosis of the bone
with an open wound was determined from delineated
focal lesions located at the first implant site (Figs. 4 & 5).15
Therefore, BRONJ was diagnosed. A treatment plan detailed the therapeutic interventions.

later, a piece of bone where the implant had been placed
became so loose that it could be removed with a pair of
tweezers. At the same time, the patient was experiencing pain arising from the mandibular anterior teeth; two
of them were confirmed necrotic, and root canal therapy
was performed using TF Adaptive (Kerr Dental) and most
importantly negative pressure (EndoVac, Kerr Dental)
for chemical preparation, as any irritation to the apical
area would have had poor consequences. Two months
later, a fistula discharging green pus was found under the
mandibular anterior teeth. Correspondingly, the patient
was prescribed another cycle of antibiotics (clindamycin) for ten days, as well as instructed to use a chlorhexidine-based mouthwash for several weeks. The antibiotic treatment decision was taken in consultation with her
physician. That was the last episode of swelling that the
patient had. Two years later, when no more symptoms
occurred, the patient requested some aesthetic work to
be done, only if it was safe for her (Figs. 9–13).
It was explained to the patient that, owing to her stable condition and since aesthetic work would not require
any surgery or procedure involving trauma to the bone,
it could be performed with a very mild anaesthetic without vaso-constrictors as a safety precaution. Mouthwash
was prescribed for several days prior to any dental work
and after it. The patient was very happy to have her smile
back finally (Fig. 14).

The patient was put on antibiotic treatment, a combination of 1 g of amoxicillin and 500 mg of metronidazole twice daily for ten days with a chlorhexidine-based
mouthwash. The symptoms cleared and the patient was
kept under control without any additional dental work.
During this time, a tiny piece of bone
that was showing through the gingiva
was delicately removed and sent to
a pathology laboratory, and the results confirmed that it was bone necrosis. After three months, the patient
showed the same signs of swelling
and again she was prescribed the
same antibiotics. During the AB cycle,
the patient felt that the implant was
becoming very loose, so removing
the implant was the only solution, as
Fig. 6
Fig. 7
it was floating and a scan was taken to
check the progression. Several weeks Fig. 6: Clinical situation after the piece of bone come out. Fig. 7: The piece of bone sent for histopathologic examination.

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[56] =>

| case report

Fig. 8: Panoramic radiograph after the piece of bone come out and root canal therapy was performed on the mandibular lateral incisor.

Discussion
From a number of clinical studies, it is well substantiated that bisphosphonates cause drug-induced osteonecrosis.16–19 Osteonecrosis is a condition that occurs

Fig. 9

when there is loss of blood to the bone. Bisphosphonates inhibit the resorption of bone by osteoclasts and
may have an effect on osteoblasts.20 By the same token,
these two types of cells represent the origin of the bone
remodelling cycle. Therefore, any cell dysfunction would
influence the cycle, preventing bone formation and resulting in bone necrosis.21–23
In dentistry, the association of osteonecrosis with bisphosphonate therapy is a matter of recent knowledge.
Nevertheless, Schuster et al. suggest that, when the risk
factors of the disease change, the intensity changes accordingly.24 The risk factors induced by bisphosphonates
increase with the increase of the uptake and potency of
this class of drugs. Science declares that the body is exposed to higher levels of drugs via intravenous administration than via the oral route.25, 26 That is why it has been
observed that osteonecrosis related to oral bisphosphonate therapy is less common than that related to intravenous administration.27
Wood et al. showed that bisphosphonates can be
classified into two groups as nitrogen-containing and
non-nitrogen-containing bisphosphonates. Nitrogencontaining bisphosphonates pose a higher risk regarding BRONJ development.28

Fig. 10

Fig. 11
Figs. 9–11: Complete healing of the bone structure.

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2 2018

Another factor that should be taken into consideration is the duration of therapy. According to a study,
it was discussed earlier that oral bisphosphonates have
lower bioavailability than intravenous ones, but the risks
of BRONJ increase with the prolonged duration of administration.29–31
Equally important, ceasing the use of bisphosphonates
would not be considered safe, since the BRONJ risk
might remain. Some practitioners still prefer stopping the
drugs for six months to one year before and after a traumatic procedure. Bisphosphonates could be preserved
in bone for months, even years, after the drugs have been
used. According to some research, unfavourable effects
from these drugs would not appear until three years
after treatment ends, and after that time, the possibility of
developing BRONJ remains very low.32, 33

[57] =>

[58] =>

| case report

Fig. 12

Fig. 13

Fig. 12: Complete closure of the wound with new epithelium (one year post-op). Fig. 13: One year post-op radiograph.

Furthermore, bisphosphonates have been shown to
inhibit the proliferation of keratinocytes in the oral mucosa;
thus, injury of the oral mucosa due to any dental procedure may increase the risk of BRONJ in bisphosphonate
users. In most cases, dental procedures such as tooth
extraction and surgeries were considered the initiator of

Fig. 14: The patient’s healthy smile.

the BRONJ. However, some papers have reported the
spontaneous development of BRONJ without a prior invasive dental procedure.34
Unfortunately, BRONJ is irreversible, meaning the bone
cannot regenerate. There are no controlled studies on the
long-term management of BRONJ.
Under these circumstances, making a treatment plan decision must consider the stage, or progression, of the disease. Ruggiero et al. identified four stages of BRONJ.31, 35, 36
Not so long ago, the stage of BRONJ was one of the
most significant factors in choosing treatment options;37
however, a new protocol has recently been proposed.
It is noted that one should ensure the completion of a
dental examination before the commencement of bisphosphonate treatment. Any dental procedure concerning the patient should be done with two weeks preceding
the administration of the medication.

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Accordingly, patients are grouped into high risk and
low risk.38 The factors in the high-risk category include
intravenous administration of bisphosphonates, the intake of oral bisphosphonates with immunosuppressants
and the existence of BRONJ in the medical history of the
patient. The treating dentist should determine whether
an extraction can be avoided. If so, root canal therapy
and coronectomy can then be considered. However, if
not, the dentist should discuss the case with an oral and
maxillofacial surgeon.37
The factors in the low-risk category include the oral
administration of bisphosphonates. If an extraction is indicated and the patient has risk factors such as smoking
or poor oral hygiene, before proceeding with the plan, the
dentist should work on reducing the risk factors. If there
are no threatening risk factors, the patient should be prepared for the extraction with the provision of 0.2 % chlorhexidine. Either an atraumatic or surgical extraction can
be applied. If the latter is chosen, periosteal flaps and
bone exposure should be kept to the minimum and antibiotics should be prescribed postoperatively. The wound is
given a period of four to eight weeks to heal, and if healing
does not occur in the given time, the dentist should refer
to an oral and maxillofacial surgeon. It should be noted
that treatments are intended to control the condition and
resolve certain symptoms of osteonecrosis of the jaw.39
Editorial note: A list of references is available from the
publisher.

contact
Dr Philippe Sleiman is an assistant
professor at the Faculty of Dentistry
of the Lebanese University in Beirut
in Lebanon. He can be contacted at
profsleiman@gmail.com.

[59] =>

[60] =>

| manufacturer news
30 years of national and international experience

META BIOMED: An active force in Europe

VISIT US
META BIOMED at the
2018 ROOTS SUMMIT

BERLIN

© dencg/Shutterstock.com

28 June to 1 July

A hidden champion in the field of medical technology, META
BIOMED has exported its products to a European customer base
through qualified distributors ever since its establishment in
1990. Recently, however, the company has redoubled its efforts
to become an active force on the continent, establishing European
headquarters in Mülheim in Germany in 2016. As the sole gold
sponsor of the upcoming ROOTS SUMMIT—the premier global
discussion forum for endodontics—META BIOMED will be looking to further its brand recognition and presence in Europe, a key
factor for the company’s continued growth.

BIOMED EUROPE. With previous experience at METASYS, Morita
Europe and the NWD Gruppe, Wirtz brings a wealth of first-hand
industry knowledge to the position.
“Wirtz has over 30 years of national and international experience
in marketing and selling high-quality dental products,” remarked
META BIOMED Managing Director Ian Yun on the appointment.
“With such experience in the dental industry, he is the perfect
candidate to further expand and establish the META BIOMED
brand in Europe.”
META BIOMED at the 2018 ROOTS SUMMIT
The ROOTS SUMMIT will be held in Berlin from 28 June to 1 July at
the European School of Management and Technology, a historical
site in the centre of the German capital. Over the past two decades,
the biennial meeting has established itself as an open and inclusive learning forum for those interested in endodontic therapy, and
approximately 500 visitors are expected at the upcoming event,
including many global opinion leaders in endodontics.

META BIOMED in Europe
With more than 1,000 employees worldwide, META BIOMED is
recognised for its emphasis on research and development, and
its commitment to providing innovative, high-quality solutions for
endodontics and restorative dentistry at low prices. Founded in
South Korea, the company is perhaps best known for its i-ROOT
electronic apex locator, EQ Master cordless gutta-percha obturator, and EQ-V obturation gun and pen.
META BIOMED’s entry into the European market has allowed it to
widen its customer base, as the company already has branches
in Cambodia, China, Japan and the US. In February, Frank Wirtz
was appointed the new Sales and Marketing Manager for META

60

“We are extremely proud and excited to be a gold sponsor at the
ROOTS SUMMIT, and to celebrate we are going to do a prize draw
at the welcome reception,” said Wirtz. “The winner of the draw will
receive a free flight to the 11th IFEA World Endodontic Congress,
to be held from 4 to 7 October 2018. What’s more, he or she will
get an exclusive guided tour of the META BIOMED headquarters in
Osong in South Korea on 8 October.”
“We look forward to meeting current and future customers at the
ROOTS SUMMIT and discussing our wide range of products with
them,” he concluded.
www.meta-europe.com

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2 2018

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[61] =>

manufacturer news

Surgical microscopes
The Seiler Alpha Air, one of the lightest microscopes
on the market, offers up to six steps of magnification,
bright LED illumination, an apochromatic lens and superior movement.

Seiler Alpha Air and
Promise Vision 3D
Seiler Instrument & Mfg Co., Inc. has over 75 years of optical
experience. As one of the world’s leaders in dental surgical microscopes, the company has continued to advance the technology
in conventional microscopes. In 2017, Seiler introduced the new
Alpha Air series, one of the lightest microscopes on the market
and equipped with over 150,000 lux LED illumination, six steps
of magnification, apochromatic lenses and superior movement.
The newest product offering from Seiler is its Promise Vision 3D
surgical microscope, which is revolutionising dentistry, according
to the company. With no need for a binocular head to use the
microscope, the dentist can sit in an upright position and practise
four-handed dentistry seamlessly. At 60 frames per second, there
is no lag time, and the depth of field and field of view are superior
to those of a conventional microscope.

www.seilermicro.com

Seiler’s Promise Vision 3D is revolutionising dentistry.
It provides the freedom to work without eyepieces, with
normal depth perception and with an unprecedented
depth of field.

FREE

– education everywhere
and anytime
– live and interactive
webinars
– more than 1,000 archived
courses
– a focused discussion
forum
– free membership
no travel costs

– no time away from
the practice
– interaction with
colleagues and experts
across the globe
– a growing database
of scientiﬁc articles
and case reports
– ADA CERP-recognized
credit administration

www.DTStudyClub.com

RO0218_60-62_Manufacturer.indd 61

Dental Tribune Study Club

Join the largest
educational
network
in dentistry!
ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality
providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors,
nor does it imply acceptance of credit hours by boards of dentistry.

20.06.18 12:54

[62] =>

| manufacturer news
Ergonomic way of working

Updated MTA instruments
Kohler Medizintechnik of Stockach in Germany has introduced updated and enhanced versions
of the Lee MTA Pellet Forming Block and Lee MTA Carver. Although the Lee MTA Block has been available
in the dental marketplace for several years, the Kohler version has several improvements. Following the recommendations of a
number of European endodontists, Kohler has added two larger grooves (1.2 mm) to the block to allow for the dispensing of a larger
volume of MTA. Also, each of the grooves now has laser-marked measurements (0.6 mm, 0.8 mm, 1.0 mm and 1.2 mm). This makes
the block much easier to read and use.

The new ENDOBLACK® Lee MTA Carver is much more ergonomic than any version from other companies. It has a larger, more lightweight black PEEK handle (weighing only 12 g). It also has the Kohler ENDOBLACK® surface to provide for better visibility during use,
as well as greatly reduced reflected light during procedures.
Combined, these two products are superior to older syringe or carrier devices, which have problems with too-large cannula sizes,
excessive quantities of MTA being delivered, difficulty in delivery of MTA to some areas of the mouth, and clogging of and damage to
those devices.

Kohdent Roland Kohler Medizintechnik • www.kohler-medizintechnik.de

Practical and efficient

Guttapercha removal made easy

Especially for the orthograde revision of an
endodontic treatment, guttapercha removers according to Dr. Yoshi Terauchi are very
suitable. The instruments have been proven
for years in their daily clinical use, yet there
is nothing that cannot be made even better.
Thus, manufacturer Kohler and Dr. Terauchi
have modernised the removers. Now, microhooks boasting outstanding tensile strength
and stability on the fine working ends ensure
firm hooking into the guttapercha, and these
are produced to the utmost precision.
The new handles are made of PEEK, a shapeand colour-stable high-performance plastic,
and are extremely light, each instrument

roots
2 2018

weighing only 12 g. Furthermore, the black
surface of the handles reduces light reflection
under magnification. The handle design combines the advantages of simple cleaning and
sterilisation with outstanding grip.
The guttapercha removers are available in
four versions, adapted to different clinical
situations: with working ends of 30 mm or
18 mm in length, and hooks to the left or
right or the top or bottom.

Kohdent Roland Kohler Medizintechnik
www.kohler-medizintechnik.de

[63] =>

www.ifea2018korea.com

The 11th

International Federation of Endodontic Associations

IFEA 2018 Seoul
October 4lThul -7lSunl, 2018 Coex, Seoul, Korea
Endodontics : The Utmost Values in Dentistry
Overview
Confirmed
Invited
Speakers

W

www.ifea2018korea.com
www.facebook.com/ifea2018seoul
Paul Abbott

Andreas K. Braun

Filippo Cardinali

Australia

The Netherlands

Italy

Is there still a role for medicaments
in endodontics?

Root resorption after dental trauma findings and treatment possibilities

Solutions to simplify shaping and cleaning:
improving the quality of the root canal treatment

Antonis Chaniotis

Gustavo De-Deus

Franck Diemer

Greece

Brazil

France

Management of severe curvatures and
complex anatomy with controlled memory
files: A new approach

The relationship among reciprocation,
glidepath and canal scouting

Samuel O. Dorn

Gianluca Gambarini

USA

Italy

How asymmetric geometry and heattreatment influence the behavior of
rotary root canal instrument

Nick Grande
Gianluca Plotino
Italy
The paradox of minimal invasive
endodontics

Extraction-Replantation: An alternative
surgical technique

3D endodontics: Shaping root canals
in 3 dimensions

Mo K. Kang

Syngcuk Kim

Anil Kishen

USA

USA

Canada

Pulp tissue regeneration: Challenges
and new outlook

Long term prognosis of endodontic
Tx vs. Implant Tx

Nanomaterials in endodontics: A potential
game changer

Sergio Kuttler

Seung Jong Lee

Francesco Maggiore

USA

Korea

Italy

“Past, present and future of endodontic
files”: Where science meets technology

Are the viable cells the only predictor for
delayed replantation?

Tara Mc Mahon

Zvi Metzger

Belgium

Israel

Does heat treated NiTi facilitate
endodontic therapy?

Early diagnosis and biomechanics of
vertical root fractures

Soft tissue management in endodontic
microsurgery

Yosef Nahmias
Canada
How to prevent instrument breakage
by creating a mechanical reproducible
glide path (don’t rotate, reciprocate)

Cliff Ruddle

Frank Setzer

Hagay Shemesh

USA

USA

The Netherlands

Endodontic Disinfection: 3D Irrigation

Management of iatrogenic errors by
non-surgical and surgical retreatment.

A realistic look at root canal fillings.
Trends, evidence and clinical performance.

Michael Solomonov

Asgeir Sigurdsson

Ibrahim Abu Tahun

Israel

USA

Jordan

Contemporary approaches to
instrumentation of non-round root canals

Is it toothache? non-odontogenic pain
presenting as dental pain

Re-establishing biological order in
reengineering the pulp-dentin complex

Yoshi Terauchi

Martin Trope

Ghassan Yared

Japan

USA

Canada

Predictable and minimally invasive
method to retrieve a separated file

The expanding role of vital pulp therapy

Management of second mesio-buccal,
narrow and curved canals with only one
reciprocating instrument.
Lecture titles are tentative and subject to change.

[64] =>

| practice management

Successful communication
in your daily practice
Part III: Millennial patients
Dr Anna Maria Yiannikos, Germany & Cyprus

© IROOM STOCK/Shutterstock.com

Welcome to the 3rd part of the series “Successful
communication in your daily practice”. The series that
includes the most popular and challenging scenarios
that might occur in your dental practice and teaches
you, how to deal with them so that your patients always
leave your practice feeling: “My dentist is THE BEST!”
Each individual article of this series will teach you a new
specialised protocol that you can easily use, customise and adapt from the same day on to your own dental
clinic’s requirements and needs.

Millennial patients
Let’s start with today’s challenging topic which
is… how to attract, communicate and retain millennial patients, who are our present and future patients!
I will show you 7 crucial steps to always have in mind
when dealing with millennial patients.

64

First, who are the millennials? Millennials are those
patients that were born between 1980 and 2000, in fact,
the patients that are from 17 to 37 years old. Because
patients that belong to this age group are our present
and future clients, let’s start examining how to attract
them to come to our dental offices!

7 steps to attract millennials
In the following, I will teach you 7 steps of how to attract
millennials to come to your dental practice.
Step 1: Have a unique and intense online presence
The world wide web is an essential part of the millennials’ life. With this in mind, you should spend some time
in creating a unique and attracting website and actively
serve your social media channels. The millennial patients
are highly attracted by promo actions, they love to check

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[65] =>

practice management

reviews, read about your CSR (Corporate Social Responsibility) and your philanthropic activities. Also be aware to
have a clear differentiation point and description of your
services—they pay a huge attention to all these tools and
points!
Step 2: Have a service-fighter
A service-fighter is a treatment, like for example home
bleaching, which is offered at the lowest price in the
market. This will help you to attract the interest of those
for whom price is very essential.

Millennials want to identify
themselves with their
surroundings. This affects
above all their health
suppliers, amongst them you
as their dentist! With loyalty
programmes you can offer
them the possibility to
specially connect with
your practice.
Step 3: Be honest and keep it short
While treating a millennial patient always remember to
be honest, informative and brief! Millennials hate it when
you fool around with them. Also be as informative as possible while in the same time keep it short. Millennials are
used to getting concentrated information and thus they
will double check what you are telling them. They may
have already googled it before they came to you!
It is also helpful to use some trigger words like
flexible, community, dynamic, friendly, stimulating, environment. For example, you can say: “Our clinic is environmentally friendly.” They will respect and appreciate
that because they are highly environmentally conscious
themselves!
Step 4: Have a millennial employee
If you do not belong to the millennials’ age group, it is
of advantage to have at least one employee of your team
who does. You will see: Your millennial patients will feel
more comfortable to ask him or her possible questions
instead of you—and this is a fact!

Step 5: Use loyalty programmes
Millennials want to identify themselves with their surroundings. This affects above all their health suppliers,
amongst them you as their dentist! With loyalty programmes you can offer them the possibility to specially
connect with your practice. Thereby, it is a good idea
to add your clinic’s loyalty programme to your clinic’s
mobile application (if you have one). They will just love
it as their mobile phones are their whole life and something they always carry with them!
Step 6: No face-to-face communication to follow-up
After a successful treatment, avoid to make a lot of
follow-up appointments with face-to-face-communi
cation. Millennials rather love it short and simple, as
we have already learnt above. So better send them an
e-mail, SMS, WhatsApp or messenger with a brief but
at the same time detailed message about their current
health status and further treatment options.
Step 7: Be fast
When you respond to your millennial patients, be fast!
Since they have grown up in a world where information
is available in only short time, being fast is notable and
very important for them!

Just do it!
Imagine working for the next years and still have a “full
house” clinic because you know how to deal with your
millennial patients! Isn’t this just fabulous?
In the next issue of roots magazine, I will present to
you the fourth part of this unique new series of communi
cation concepts that will teach you how to promote
a service and/or technology before you apply it in
practice—5 unique steps that will guarantee the increase
of your patients’ interest!
Until then, remember that you are not only the d
entist
of your clinic, but also the manager and leader. You can
always send me your questions and request for more
information and guidance at dba@yiannikosdental.com
or via our website www.dbamastership.com. Looking
forward to our next trip of business growth and educational development!

contact
Dr Anna Maria Yiannikos
Adjunct Faculty Member of AALZ
at RWTH Aachen
University C
ampus, Germany
DDS, LSO, MSc, MBA
dba@yiannikosdental.com
www.dbamastership.com

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65
20.06.18 12:54

[66] =>

| tribute

“He brought a world of enthusiasm
and knowledge to the global
endodontic community”
Fred Michmershuizen, DT US

“What a remarkably kind and insightful individual he
was—always inquiring about me and others and never
letting on about himself,” Glickman remembered. “He
brought a world of enthusiasm and knowledge to the
global endodontic community. I will miss him dearly.”

Dr Fred Weinstein, DMD, MRCD(C), FICD, FACD, who passed away 15 October 2017, at the age
of 78, is pictured in Anaheim, Calif., at the California Dental Association meeting, CDA Presents
the Art and Science of Dentistry, in 2012. A retired endodontist from Vancouver, British Columbia,
Weinstein often travelled to dental meetings to keep his knowledge of the specialty current and
to visit with his many friends. (Photo: Fred Michmershuizen)

He will be remembered as a friend, a
teacher and a healer. Dr Fred Weinstein, a
retired endodontist from Vancouver, British
Columbia, died 15 October 2017, at the age
of 78, after a brief illness. His fellow specialists expressed sadness at his passing
and acknowledged how his passion for
the profession rubbed off on them through
many decades of friendship. Many are also
remembering him for his ability to have
fun—especially when it came time to promote an international endodontic conference hosted in his native country.
“Fred has been an inspiration for me for
all these years, ever since we met over
30 years ago,” said Gerald N. Glickman,
DDS, MS, professor and chair at Texas
A&M College of Dentistry in Dallas, one
of many endodontists who shared fond
memories of Weinstein.

“Fred was that special kind of person who would do
anything he could to help out when needed. He cared for
everyone and was a dear friend,” said John J. Stropko,
DDS, of Prescott, Ariz. “Fred was a teacher, always encouraging others to use the latest technology to deliver
better treatment results for their patients. During the process, he went to great lengths to clearly communicate his
beliefs in an easy-to-understand manner. Our specialty
has lost one of its great members.”
“I knew Fred for more than 25 years, and I always
found it entertaining to be in his company,” said Anne
Lauren Koch, DMD. “We went to hockey games, basketball games and endodontic meetings
together. Fred was a character, but in
the best sense of the word. He was
entertaining, charming and unpredictable. That was Fred. But to those of
us who knew and loved him, he was
much more than that. He was a loyal
friend who made a maximum effort to
understand each of us in a personal and
supportive way. Really, at the end of the
day, Fred was a mensch. He will be very
much missed.”
Weinstein was born in 1939 in Winnipeg, Manitoba. He graduated from the
University of Manitoba at the age of 22
with a degree in general dentistry, and
then he went on to study endodontics
In a print ad published in the August 2007 issue of
Endo Tribune, Dr Fred Weinstein dressed as a Royal
Canadian “Mountie” to promote the IFEA meeting, held
that year in Vancouver, British Columbia.

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2 2018

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20.06.18 12:55

[67] =>

tribute

Weinstein’s accomplishments within the profession
were notable. He served as an assistant clinical professor at the University of British Columbia and was a past
President of the Canadian Academy of Endodontics, the
British Columbia Society of Endodontics, the Interspeciality Society of British Columbia and the International
Federation of Endodontic Associations (IFEA). He was
a member of the Royal College of Dentists, and he was
a fellow of the American College of Dentists and the International College of Dentists.
He served on advisory boards for several leading dental manufacturers, and he lectured extensively throughout the world. He also served as a volunteer endodontist
at the 2010 Vancouver Winter Olympics, and performed
root canal treatment on world boxing champion Sugar
Ray Leonard in the 1980s.

at the University of Pennsylvania School of Dental Medicine in Philadelphia, under the tutelage of Dr Louis
Grossman, known as the “Father of Endodontics”.
After receiving his Certificate in Endodontics from the
University of Pennsylvania in 1969, he moved his family
to Vancouver and established an office in the Fairmont
Medical Building, where he would go on to practice for
more than 40 years.
“He loved his patients, and he equally enjoyed teaching
and lecturing throughout the world to advance the learning within dentistry,” his family wrote in an obituary published in the Vancouver Sun.

“Fred always had a smile and was known as ‘the Canadian Mountie’ for his outfit that he wore at every dental meeting to promote the IFEA meeting in Vancouver in
2007,” remembered Samuel O. Dorn, DDS. “He was truly
dedicated to the Canadian Academy of Endodontics and
its place in global endodontics. His passion for endodontics and his friendship will never be forgotten.”
“I cherish my photo of us with him dressed as a
Mountie when he was President of IFEA,” said Dr William
Ben Johnson. “Fred and I started out as endodontic colleagues, then became friends. So much so he would go
snow skiing with me even when he didn’t care for skiing,
and I would drink wine with him when I preferred scotch.
I’ve lost a friend.”
After his retirement from practice, Weinstein continued
to travel to dental meetings to keep his knowledge of the
specialty current and to visit with his many friends.
For many years, Weinstein was editor in chief of roots
magazine, the international C.E. magazine of endodontics,
published by Dental Tribune America.
“Above all of Fred’s accomplishments and titles, his
family remained his number one priority in his life, always,” his family wrote in the Sun. “He had a gentle heart
of gold, compassion and sincerity and a smile that would
illuminate a room.”
Dr Fred Weinstein in Hamburg, Germany, in the summer of 2017. (Photo:
Haye Hinrichs)

roots
2 2018

Dr Fred Weinstein with “Queen Elizabeth II” at the IFEA meeting in 2007.
(Photo: Fred Michmershuizen)

He was especially proud to have served as the general
chairman for the 2007 IFEA World Congress in Vancouver. To drum up excitement for that meeting, he dressed
as a Royal Canadian “Mountie” at several events leading
up to it—something that friends and colleagues remembered for years.

[68] =>

| meetings

International Events
2018

CALL FOR ABSTRACT
Extended Deadline

15 May
2 018

HKIDEAS
Hong Kong International

Dental Expo And Symposium

G U ST
26 AandUExhibition
24–Convention
Centre

EARLY-BIRD REGISTRATION

Hong Kong

Deadline

31 May
2018

www.hkideas.org

HKIDEAS

DenTech China –
Exhibition & Symposium

24–26 August 2018
Hong Kong
www.hkideas.org

31 October – 2 November 2018
Shanghai, China
http://www.dentech.com.cn

NEW MILLENNIUM OF ORAL HEALTH
PRELIMINARY FACULTY

(Sweden)

Professor Tomas Albrektsson
Dr. David Craig (UK)
Dr. Michel Dard (USA)
Dr. James Foster (UK)
Dr. Christopher Ho (Australia)
Dr. Jerry Hu (USA)
Dr. Sabrina Huang (Taiwan)
Dr. Terence Jee (Singapore)
Dr. Alfred Lau (Hong Kong)
Dr. Donald Li (Hong Kong)
Dr. Jingping Li (Mainland China)
China)
Professor Xiaobing Li (Mainland
Dr. Edmond Pow (Hong Kong)
Dr. Alan Reid (Australia)
Dr. Mario Roccuzzo (Italy)
Dr. Frankie So (Hong Kong)
Dr. Chong-meng Tay (Singapore)
Professor Wim Teughels (Belgium)
Kong)
Professor Maurizio Tonetti (Hong
Dr. Victoria Yu (Singapore)

Organizer

8 | 9 | 10 | NOV | 2018 | EXPONOR

| PORTO | PORTUGAL

BUENOS AIRES 2018

World Dental Congress

Buenos Aires
Argentina

5-8 September 2018

ENT
ITM
OMM
A PASSION FOR MANY, A C

FO

LL
RA

Expo-Dentária

FDI World Dental Congress
UM PROGRAMA CIENTÍFICO

5–8 September 2018
Buenos Aires, Argentina
www.world-dental-congress.org

Scientific Programme
now online

ss.org
www.world-dental-congre

DE EXCELÊNCIA

EM SIMULTÂNEO COM A EXPO-DENTÁRIA

PORTUGAL

CIRURGIA ORAL
> FOUAD KHOURY | GER |
| FOTOGRAFIA
> DUDU MEDEIROS | BRA
FIXA
> ANDREA RICCI | ITA | PRÓTESE
> CHEEN LOO | USA | ODONTOPEDIATRIA

| ORTODONTIA
> FLÁVIO FERRARI | BRA
| ARG | ENDODONTIA
> FERNANDO GOLDBERG
| PERIODONTOLOGIA
> ANTON SCULEAN | SWI
| IMPLANTOLOGIA
> MAURÍCIO ARAÚJO | BRA
| ESP | PERIODONTOLOGIA
> JUAN BLANCO CARRIÓN
| DENTISTERIA ESTÉTICA
> VICTOR CLAVIJO | BRA
| ORTODONTIA
> KARIN BECKTOR | DNK
PRÓTESE FIXA
> MARCO FERRARI | ITA |
| BRA | IMPLANTOLOGIA
> CARLOS EDUARDO FRANCISCHONE
> SÉRGIO KAHN | BRA | PERIODONTOLOGIA

www.omd.pt
ORGANIZAÇÃO

PLATINIUM SPONSOR

PARA A SUA MARCA
ESCOLHA JÁ O MELHOR LOCAL
DENTÁRIA DENTÁRIA
NA MAIOR FEIRA DE MEDICINA
REALIZADA EM PORTUGAL.

COM MAIS DE 16.600 VISITANTES
SILVER SPONSORS

GOLD SPONSORS

EM 2017
INTERNATIONAL
MEDIA PARTNER

8–10 November 2018
Porto, Portugal
www.omd.pt/congresso/2018/
en/expodentaria/

2018-2019
Dental-Expo
September 24-27, 2018

Dental Salon
April 22-25, 2019

Crocus Expo exhibition grounds
550 exhibitors
30000 visitors

www.dental-expo.com
om
international@dental-expo.c

Dental-Expo

JADR Annual Meeting

24–27 September 2018
Moscow, Russia
www.dental-expo.com

17–18 November 2018
Hokkaido, Japan
http://jadr66.umin.jp

BDIA Dental Showcase

GNYDM

4–6 October 2018
London, UK
www.dentalshowcase.com

25–28 November 2018
New York, USA
www.gnydm.com

www.ifea2018korea.com

The 11th

International Federation of

Endodontic Associations

IFEA 2018 Seoul
October 4lThul -7lSunl, 2018

Coex, Seoul, Korea

Values in Dentistry
Endodontics : The Utmost

Overview
Confirmed
Invited
Speakers

W

www.ifea2018korea.com
eoul
www.facebook.com/ifea2018s

trauma Root resorption after dental
findings and treatment possibilities

alternative
Extraction-Replantation: An
surgical technique

Nick Grande
Gianluca Plotino
Italy

Gianluca Gambarini
Italy

USA

3D endodontics: Shaping
in 3 dimensions

root canals

invasive
The paradox of minimal
endodontics

Anil Kishen

Syngcuk Kim

Mo K. Kang

Canada

USA

USA

Long term prognosis of
Tx vs. Implant Tx

Challenges

endodontic

Nanomaterials in endodontics:
game changer

Are the viable cells the only
delayed replantation?

endodontic
“Past, present and future oftechnology
files”: Where science meets

predictor for

Soft tissue management in
microsurgery

Canada

Israel

Belgium

Early diagnosis and biomechanics
vertical root fractures

of

breakage
How to prevent instrument
by creating a mechanical reproducible
glide path (don’t rotate, reciprocate)

Hagay Shemesh

Frank Setzer

Cliff Ruddle

The Netherlands

USA

USA

errors by
Management of iatrogenicretreatment.
non-surgical and surgical

Disinfection: 3D Irrigation

fillings.
A realistic look at root canal
performance.
Trends, evidence and clinical

Asgeir Sigurdsson

Michael Solomonov

USA

Israel
to
Contemporary approaches root canals
instrumentation of non-round

pain
Is it toothache? non-odontogenic
presenting as dental pain

Martin Trope

Yoshi Terauchi

USA

Japan

The expanding role of vital

ADF

4–7 October 2018
Seoul, Korea
www.ifea2018korea.com

27 November – 1 December 2018
Paris, France
www.adfcongres.com

endodontic

Yosef Nahmias

Zvi Metzger

Tara Mc Mahon
Does heat treated NiTi facilitate
endodontic therapy?

A potential

Italy

Korea

USA

IFEA 11th World Endodontic
Congress 2018

Francesco Maggiore

Seung Jong Lee

Sergio Kuttler

68

and heatHow asymmetric geometry
of
treatment influence the behavior
rotary root canal instrument

The relationship among reciprocation,
glidepath and canal scouting

Samuel O. Dorn

invasive
Predictable and minimally
file
method to retrieve a separated

Franck Diemer
France

Brazil

Greece
curvatures and
Management of severe
memory
complex anatomy with controlled
files: A new approach

and cleaning:
Solutions to simplify shaping
root canal treatment
improving the quality of the

Gustavo De-Deus

Antonis Chaniotis

Endodontic

Italy

The Netherlands

Australia

Pulp tissue regeneration:
and new outlook

Filippo Cardinali

Andreas K. Braun

Paul Abbott
Is there still a role for medicaments
in endodontics?

pulp therapy

Ibrahim Abu Tahun
Jordan
order in
Re-establishing biological
complex
reengineering the pulp-dentin

Ghassan Yared
Canada
Management of second mesio-buccal,
with only one
narrow and curved canals
reciprocating instrument.
Lecture titles are tentative and

subject to change.

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© 32 pixels/Shutterstock.com

submission guidelines

|

How to send us your work?
Please note that all the textual components of your submission must be combined into one MS Word document.
Please do not submit multiple files for
each of these items:
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·· the complete list of sources consulted
and
·· the author or contact information (biographical sketch, mailing address,
e-mail address, etc.).
In addition, images must not be embedded into the MS Word document. All
images must be submitted separately,
and details about such submission follow below under image requirements.

Text length
Article lengths can vary greatly—from
1,500 to 5,500 words—depending on
the subject matter. Our approach is that
if you need more or less words to do the
topic justice, then please make the article
as long or as short as necessary.
We can run an unusually long article in
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topic for which each part can stand alone
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In short, we do not want to limit you in
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word count above as a general guideline
and if you have specific questions, please
do not hesitate to contact us.

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Please use single spacing and make
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Any formatting contrary to stated above
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Please number images consecutively
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In addition, please note:

We also ask that you forego any special formatting beyond the use of italics
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·· We require images in TIF or JPEG format.
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Larger image files are always better,
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Also, please remember that images
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You may submit images via e-mail, via
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with the necessary information (60 words
or less).

Questions?
Magda Wojtkiewicz
(Managing Editor)
m.wojtkiewicz@dental-tribune.com

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[70] =>

| international imprint

Imprint

International Administration

Publisher/President/CEO
Torsten R. Oemus
t.oemus@dental-tribune.com

Chief Financial Officer
Dan Wunderlich

Director Content Creation
Claudia Salwiczek-Majonek
Managing Editor
Magda Wojtkiewicz
m.wojtkiewicz@dental-tribune.com
Designer
Franziska Schmid
Copy Editors
Sabrina Raaff, Ann-Katrin Paulick
Editorial Board
Fernando Goldberg, Argentina
Markus Haapasalo, Canada
Clemens Bargholz, Germany
Michael Baumann, Germany
Benjamin Briseno, Germany
Asgeir Sigurdsson, Iceland
Adam Stabholz, Israel
Heike Steffen, Germany
Gary Cheung, Hong Kong
Unni Endal, Norway
Esteban Brau, Spain
José Pumarola, Spain
Kishor Gulabivala, United Kingdom
William P. Saunders, United Kingdom
Fred Barnett, USA
L. Stephan Buchanan, USA
James Gutmann, USA
Ben Johnson, USA
Kenneth Koch, USA
Sergio Kuttler, USA
John Nusstein, USA
Ove Peters, USA
Jorge Vera, Mexico

Chief Technology Officer
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Junior Business Development
& Marketing
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Christiane Ferret
Product Manager CME
Sarah Schubert
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Nadine Dehmel
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Executive Producer
Gernot Meyer
Advertising Disposition
Marius Mezger

International Offices
Dental Tribune International
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Tel.: +49 341 48474-302
Fax: +49 341 48474-173
info@dental-tribune.com
www.dental-tribune.com
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roots international magazine of endodontics is published by Dental Tribune International (DTI) and appears in 2018 with four issues. The magazine and all articles and illustrations therein
are protected by copyright. Any utilisation without the prior consent of editor and publisher is inadmissible and liable to prosecution. This applies in particular to duplicate copies, translations, microfilms,
and storage and processing in electronic systems. Reproductions, including extracts, may only be made with the permission of the publisher. Given no statement to the contrary, any submissions to the
editorial department are understood to be in agreement with a full or partial publishing of said submission. The editorial department reserves the right to check all submitted articles for formal errors and
factual authority, and to make amendments if necessary. No responsibility shall be taken for unsolicited books and manuscripts. Articles bearing symbols other than that of the editorial department, or
which are distinguished by the name of the author, represent the opinion of the aforementioned, and do not have to comply with the views of DTI. Responsibility for such articles shall be borne by the author.
Responsibility for advertisements and other specially labeled items shall not be borne by the editorial department. Likewise, no responsibility shall be assumed for information published about associations,
companies and commercial markets. All cases of consequential liability arising from inaccurate or faulty representation are excluded. General terms and conditions apply. Legal venue is Leipzig, Germany.

roots
2 2018

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[71] =>

Easy and convenient cordless obturator
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Phone: +82 43 218 1981
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Meta Biomed Europe GmbH
Wiesenstrasse 35
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Phone: +49 208 309 9190
europe@metabiomed-inc.com
www.buymetabiomedonline.com

[72] =>

3D agility_
The One to Shape your Success
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Bronze sponsor
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FKG Dentaire SA
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[cover] => roots international No. 2, 2018

[toc] => Array ( [0] => Array ( [title] => Cover [page] => 1 ) [1] => Array ( [title] => Editorial [page] => 3 ) [2] => Array ( [title] => Content [page] => 4 ) [3] => Array ( [title] => Hands-on courses - Thursday, 28 June 2018 [page] => 6 ) [4] => Array ( [title] => Lecture programme - ROOTS SUMMIT 2018 [page] => 8 ) [5] => Array ( [title] => Chairpersons & invited speakers - ROOTS SUMMIT 2018 [page] => 10 ) [6] => Array ( [title] => Abstracts - ROOTS SUMMIT 2018 [page] => 14 ) [7] => Array ( [title] => The dental operating microscope in endodontics [page] => 16 ) [8] => Array ( [title] => Nd:YAG laser-assisted removal of instrument fragments [page] => 22 ) [9] => Array ( [title] => Cutting endodontic access cavities—for long-term outcomes [page] => 24 ) [10] => Array ( [title] => Bioactivity in restorative dentistry: A user’s guide [page] => 30 ) [11] => Array ( [title] => Trends & application [page] => 36 ) [12] => Array ( [title] => Bioactive materials for root canal obturation [page] => 40 ) [13] => Array ( [title] => Orthograde apical application of an MTA plug in a tooth without constriction [page] => 44 ) [14] => Array ( [title] => Long-term stable restoration of severely discoloured anterior teeth [page] => 50 ) [15] => Array ( [title] => Bisphosphonate-related osteonecrosis of the jaw [page] => 54 ) [16] => Array ( [title] => Manufacturer news [page] => 60 ) [17] => Array ( [title] => Successful communication in your daily practice - Part III: Millennial patients [page] => 64 ) [18] => Array ( [title] => “He brought a world of enthusiasm and knowledge to the global endodontic community" [page] => 66 ) [19] => Array ( [title] => International events [page] => 68 ) [20] => Array ( [title] => Submission guidelines [page] => 69 ) [21] => Array ( [title] => International imprint [page] => 70 ) ) [toc_html] =>

Table of contents

[toc_titles] =>

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