DT Asia Pacific No. 11, 2016

Asia-Pacific News / World News / Convenient and reliable instrument reprocessing / Interview: “Going green is our business - not somebody else’s - but everybody’s responsibility” / Why interdental brushes are essential for good oral health / Treatment of localised gingival recession / Paring down a complex case / Endo Tribune Asia Pacific Edition

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DENTALTRIBUNE
The World’s Dental Newspaper · Asia Pacific Edition

Published in Hong Kong

www.dental-tribune.asia

INTERVIEW

Vol. 14, No. 11

ALL-CERAMICS

Dr Claudio P. Fernandes about
sustainability principles in dentistry, the preservation of natural
resources and the economic dynamics of going green.

The complex case of a patient
who was treated with toothsupported and implant-borne
restorations.

” Page 6

ENDO TRIBUNE

Read the latest news and clinical
developments from the field of
endodontics in our specialty section included in this issue.

” Page 14

” Page 17

(866) 999-2635

Oral health education by itself ineffective
By DTI
MELBOURNE, Australia: Evaluating
the effectiveness of oral health
promotion strategies for preventing dental caries and periodontal
disease among children, researchers from the Cochrane Public
Health Group have found that oral
health education alone, such as
classroom lessons, videos, comics
and brochures, was ineffective.

Cochrane Public Health Group,
on the findings in an article on
DrBicuspid.com. “However, this
thinking is fundamentally flawed,
as knowledge gained alone will
not lead to sustained changes in
oral health,” Hegde emphasised.

“There is a general perception that oral health education
will change oral health risk behaviours and promote good

When coupled with other measures, such as supervised toothbrushing with fluoridated toothpaste, oral health promotion interventions were generally
found to be effective in reducing caries in children’s
primary teeth. Moreover,
oral health education provided in an educational
setting, combined with
professional preventative
oral care in a dental clinic,
was effective in reducing
caries in children’s permanent teeth, the researchers
found.

disease among children from birth
The review, which was the first
to 18 years of age.
of its kind at an international level,
included data on 119,789 children in
21 countries from studies conducted
The review, titled “Communitybetween January 1996 and April
based population-level interven2014. All of the studies reviewed
tions for promoting child oral
focused on community-based oral
health”, was published online on
health promotion interventions for
15 September in the Cochrane
preventing
caries and periodontal
Database
of Systematic
Reviews.
IV_Image_Anz_102x128_Layout
1 01.12.11
17:10 Seite
1
AD

alone measure, had no significant
impact on caries in permanent or
primary teeth and surfaces. Nonetheless, some of the studies reported
improvements in gingival health,
oral hygiene behaviours and oral
cleanliness, the review showed.

Another most promising intervention approach
for reducing caries in
children—although additional research is needed—
appears to be improving
access to fluoride in its various forms and reducing
sugar consumption, Hegde
International researchers from the Cochrane Public Health Group have aimed to determine told Dental Tribune. Generwhich promotion strategies are most effective and equitable in preventing poor oral health. ally, the findings of this
review will have global implications in the area of models of
oral health practices,” commented
From analysis of the results
oral health care delivery and oral
of 38 international studies, the
Dr Shalika Hegde, a research fellow
health promotion, research, polCochrane researchers found that
at Dental Health Services Victoria
icy and practice, Hegde concluded.
oral health education as a standin Melbourne and part of the

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[2] =>

02

ASIA PACIFIC NEWS

Dental Tribune Asia Pacific Edition | 11/2016

First Indonesia Dental Exhibition
and Congress to be held in 2017
JAKARTA, Indonesia/COLOGNE,
Germany: Exclusively catering to
the needs of the Indonesian dental
industry and dental professionals,
the country’s first comprehensive
dental exhibition and congress will
take place next year from 15 to
17 September at the Jakarta Convention Center. The event is being
jointly organised by the Indonesian
dental association (Persatuan Dokter Gigi Indonesia) and trade show
organisers Koelnmesse and PT.
Traya Eksibisi Internasional. It will
be held in alternate years to the established IDEM Singapore, the leading dental exhibition and conference in the Asia-Pacific region.
Alongside IDEM, the Indonesia
Dental Exhibition and Conference
will be positioned as a designated
regional event, the organisers said
in a press release. It will consist of a
two-day scientific conference featuring localised educational con-

more about well-established and
effective technologies, research
and skills,” Koelnmesse Managing
Director Mathias Kuepper remarked.

© Aleksandar Todorovic/Shutterstock.com

By DTI

tent and a three-day exhibition
that will offer a platform for over
200 manufacturers to meet and do
business in the emerging Indonesian dental market, which is one of
the fastest growing in Asia.
“Although every edition of
IDEM Singapore has enjoyed strong

support from Indonesian dental
professionals we have come to
recognise that there is still unrealised potential in the Indonesian
market. Its healthcare industry is
expected to grow by up to 20 per
cent yearly, which points to an
emerging need for a platform
for dental professionals to learn

Commenting on the decision
to stage the new dental event,
Dr Farichah Hanum, president of
the Indonesian dental association,
said that, by collaborating with
two established exhibition organisers, dentistry in the country will
hopefully be taken to new heights.
“Indonesia has over 27,000 dentists nationwide, who face unique
challenges in their daily practice,”
Hanum said. The city of Jakarta—
representing over 5,000 dentists
alone—was chosen to host the
event because it is the country’s
central business and travel hub, he
explained.
More information about the
exhibition and the scientific programme will soon be available at
www.indonesiadentalexpo.com.

Accuracy of optical scans and
conventional silicone impressions
By DTI
IWATE, Japan: Aiming to evaluate
the accuracy of digital impres-

sions for use in implant placement, researchers from Iwate
Medical University in Japan have
compared optical impression

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scans from an intraoral scanner
with conventional silicone impressions. The analysis showed
that the distance error of the
optical impressions was slightly
greater that of the conventional
method.
For many dental practitioners,
digital technology has become
vital in daily practice. Others,
however, still rely on conventional methods used in the profession long before the introduction of digital alternatives.
However, the question that arises
in this connection is whether—
apart from benefits such as being
faster and often more convenient—digital methods are verifiably more accurate than traditional techniques.
Aiming to shed light on this
issue, the Japanese researchers
compared a virtual model created
from a scan by an intraoral scanner to a working cast fabricated
based on a conventional silicone
impression technique. The evaluation was limited to the use of
optical impressions for implant
placement. For this purpose, the
researchers placed two implant
abutments (Nobel Biocare), one
5 mm and one 7 mm in height, in
a master model.
To evaluate the error of the
intra-oral scanner, the master
model was scanned ten times with
the Lava Chairside Oral Scanner

(Lava COS; 3M ESPE). To evaluate
the error of conventional impressions, ten working casts were
scanned with a computer numerical control coordinate measuring
machine (Zeiss).
From comparison of the distance between two ball abutments that were connected to the
implants, the researchers found
that the trueness of distance error
was 64.5 µm for the scanner and
22.5 µm for the working casts,
making the conventional impression more accurate than the
scanner.
For the 5 mm healing abutment, the mean angulation error of the Lava COS was greater
than that of the working cast,
indicating significant differences
in trueness and precision, the
researchers wrote. However, this
was not observed for the 7 mm
abutment.
As distance errors of the optical impression were slightly
greater than that of the conventional impression, the researchers
concluded that currently digital
impressions are not equivalent
replacements of conventional impressions for restorative procedures. However, they predicted
that the development of information technology would most likely
lead to improvement in the accuracy of optical impressions in the
near future.

IMPRINT
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Torsten OEMUS
GROUP EDITOR/MANAGING EDITOR DT AP & UK:
Daniel ZIMMERMANN
newsroom@dental-tribune.com
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Claudia DUSCHEK
EDITOR:
Anne FAULMANN
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Kristin HÜBNER
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Sabrina RAAFF, Hans MOTSCHMANN
PRESIDENT/CEO:
Torsten OEMUS
CFO/COO:
Dan WUNDERLICH
MEDIA SALES MANAGERS:
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AD PRODUCTION:
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DESIGNER:
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INTERNATIONAL EDITORIAL BOARD:
Dr Nasser Barghi, Ceramics, USA
Dr Karl Behr, Endodontics, Germany
Dr George Freedman, Esthetics, Canada
Dr Howard Glazer, Cariology, USA
Prof. Dr I. Krejci, Conservative Dentistry, Switzerland
Dr Edward Lynch, Restorative, Ireland
Dr Ziv Mazor, Implantology, Israel
Prof. Dr Georg Meyer, Restorative, Germany
Prof. Dr Rudolph Slavicek, Function, Austria
Dr Marius Steigmann, Implantology, Germany

Published by DT Asia Pacific Ltd.
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[3] =>

WORLD NEWS

Dental Tribune Asia Pacific Edition | 11/2016

Dental fillings may contribute to
increased levels of mercury in the body
By DTI
ATHENS, USA: Although the potential adverse health effects of mercury have been the subject of
debate for a long time, the extent
to which dental fillings affect mercury levels in the body was still
unclear. New research has now
found that people with multiple
dental fillings exhibited significantly elevated levels of mercury
in their blood compared with
people who did not have dental
surface restorations.

The ADA and the US Food
and Drug Administration consider dental amalgam fillings
safe for adults. However, they advise against its use in pregnant

women and children under the
age of 6.

cury, methyl mercury and bisphenol A with dental surface restorations in the US population,
NHANES 2003–2004 and 2010–
2012,” will be published in the De-

The study, titled “Associations
of blood mercury, inorganic mer-

cember issue of the Ecotoxicology
and Environmental Safety journal.
It was conducted by researchers at
the University of Georgia and the
University of Washington.
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The study, which analysed
data from nearly 15,000 individuals, is the first to demonstrate
a link between dental fillings and
mercury exposure in a nationally
representative population. The researchers found that patients with
more than eight fillings had about
150 per cent more mercury in their
blood than those with none.

Save

55%
on time

They further analysed exposure by specific types of mercury
and found a significant increase in
methylmercury, the most toxic
form of mercury, associated with
dental fillings, suggesting that the
human gut microbiota, a collection of microorganisms living in
the intestines, may transform different types of mercury.

Mercury exposure from dental fillings is not a new concern,
but previous studies were inconsistent and limited, according to
Dr Xiaozhong Yu, co-author and Assistant Professor of Environmental
Health Science at the University of
Georgia’s College of Public Health.

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In response to the study, the
American Dental Association (ADA)
issued a press statement at the end
of September that clarified that
the association’s position on dental amalgam remains unchanged.
“The mercury levels cited in the
study did not exceed a level that
according to the National Academy
of Sciences would be known to
cause adverse health effects. Thus
no conclusions about the safety of
dental amalgam should be drawn
from this study. In addition, the
study used data that included two
different types of dental materials:
composite, which does not contain
mercury and dental amalgam,
made from a combination of metals including silver, copper, tin and
mercury. It is important to note
that since the study does not differentiate between the two filling
materials, the study’s findings may
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[4] =>

ADVERTORIAL

Dental Tribune Asia Pacific Edition | 11/2016

Convenient and reliable instrument
reprocessing
An interview with Dr Diego Vezzoli, Italy, about the new Lisa steriliser from W&H
By DTI
Hygiene is of top priority for many
dental practices. In addition to increased safety for both the practice
team and the patients, the efficient structuring of workflows with
state-of-the-art reprocessing technologies plays a particularly important role. Dr Diego Vezzoli, a dentist
at the Studio Dentistico Eurodent
in Palazzolo sull’Oglio in Italy has
been using the new Lisa from W&H
for several months. The W&H sterilizer provides support in the form
of rapid, reliable instrument reprocessing for practice to cope with
an average daily treatment volume
of 20–40 patients. The 8-member
practice team truly values the advantages offered by the new Lisa.
In a recent interview, Dr Vezzoli
spoke about the advantages of the
new W&H sterilizer.

Particular attention was paid to
a user-friendly menu design when
developing the new Lisa. The four
main menu points are intended
to allow simple cycle selection.
How do you rate the quality of
the navigation concept? Does it
make work easier for your practice
team?
In my opinion, operation has
been simplified even further and
adapted to the requirements in
the practice. Apart from the simple navigation, our assistants also
appreciate the ergonomics of Lisa
in their day-to-day work. These
are two considerable advantages
compared with the sterilizers that
we used before. We’re satisfied on
all fronts.

The simplicity of the system
is a considerable advantage. For
example, you have the option
of creating a label for the sealed
sterile goods to confirm that they
are sterile. The cycle is completed
when the sealed instruments are
opened in the patient’s presence
and the label is added to the
patient’s file. In addition to the
professional hygiene processes,
the patient is also aware of the
safety and the high priority afforded to sterilization in our practice. The traceability offers the
patient security and is also an
important quality criterion in our
practice.
Do you also use the new Lisa mobile
app in your practice?
Our practice team loves the
new tool! In my opinion, the Lisa
Mobile App can offer valuable
support in times with high work
volumes and it helps with the optimization of workflows.

Efficient, time-saving work is a
focus of every modern dental practice. How would you assess Lisa’s

“The simplicity of the system
is a considerable advantage.”
What role does the new Lisa play in
the hygiene cycle in your practice?
Dr Vezzoli: It is very important.
The new Lisa sterilizer from W&H
boasts optimized cycle times and
thus speeds up our day-to-day
work. The reprocessing time between patient treatments is now
very short, so the instruments are
rapidly available for the next use.

accelerated type B cycle (patented
Eco Dry technology)?
In addition to a rapid sterilization cycle and low energy consumption, the processing time is
also noticeably shorter. What’s
more, the shorter sterilization
cycle takes less of a toll on the
instruments and they therefore
enjoy a longer service life.

What do you think of the design of
the new Lisa? Would you describe
the dimensions as “practical”?
I think that Lisa fits into rooms
well. The compact dimensions
and flexible front feet make it easy
to integrate the sterilizer in our
hygiene workflows.

Dr Diego Vezzoli is clearly delighted with the new Lisa. In addition to the simple
integration in the hygiene process, the sterilizer also supports rapid and reliable
reprocessing of instruments.

Nowadays, comprehensive quality
management is a fundamental standard in every dental practice. At the
same time, patient safety is always

afforded top priority. As such, complete documentation of sterilization
cycles is indispensable. How does the
new Lisa support you in this task?

To finish off, could we ask for your
personal evaluation of the new
Lisa?
I’m very satisfied with my
investment. And it’s not just me,
my practice colleagues are also
very happy with the new Lisa.
Thank you for your time!

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[5] =>

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[6] =>

BUSINESS

Dental Tribune Asia Pacific Edition | 11/2016

“Going green is our business, not somebody
else’s, but everybody’s responsibility”
An interview with Dr Claudio Pinheiro Fernandes, Brazil
By Kristin Hübner, DTI
Measures to reduce waste and
pollution and to conserve natural
resources such as water and energy
already play a major role in many aspects of daily life. Likewise, acting in
an environmentally friendly manner
is becoming increasingly impor tant
in dentistry as well. Dental Tribune
spoke with Dr Claudio Pinheiro
Fernandes, head of the Sustainable
Dentistry Center at Fluminense
Federal University in Nova Friburgo
in Brazil and consultant to the FDI
World Dental Federation’s Science
Committee, about sustainability
principles in dentistry, the preservation of natural resources and the
economic dynamics of going green.
Dental Tribune: Being environmentally friendly is becoming increasingly important in everyday
life. When did this topic first gain
momentum in dentistry?
Dr Claudio Pinheiro Fernandes:
Sustainability is relevant to everyone and we face this challenge
every day. Every single newspaper
that one opens includes some-

labelling on dental equipment? We
could introduce energy-efficient
dental equipment, with labels indicating the device’s energy use. That
would be one way of going green.

thing about climate change or
sustainable development. It is the
responsibility of dentistry too to
become involved as a profession
to pursue sustainability in the
field of oral health for the good of
society.

Another thing to keep in mind
is how much water we use. That
is an extremely important issue
in dentistry. A dentist uses eight
times more water than the average
person does—a large volume! Usually the equipment used in daily
practice causes this high consumption. For example, some brands of
suction equipment use clean water
to drive the suction mechanism.
On average, they use 200 litres
per hour and this water goes from
the pumps directly to the drain.
Of course, suction is important,
but could we not apply different
technologies to achieve the same
results? Do we have to waste clean
water for this?

The dental profession is being
challenged by the increasing demand for better oral health care
for more people in more countries
than ever. At the same time, we
have the challenge of needing to do
so using less resources. In this context, the question of how exactly
we are to do that arises.
What can dentists do and what defines a sustainable practice?
As dentists, we have to realise
that there are certain aspects and
areas of our work that can be organised better. From a procedural
point of view and concerning the
equipment used, there are certain
sustainability principles to consider. Take a simple example: when
one buys a refrigerator or an air
conditioner today, one looks for energy efficiency labels that indicate

Dr Claudio Pinheiro Fernandes

the most efficient device in terms
of its energy use. This means that it
is good both for one’s pocket, being

cheaper to run, and for the environment, since it needs less energy.
Why do we not have this kind of

In many respects, dentists cannot
implement a shift themselves alone;
awareness of the importance of
sustainability is important on the
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[7] =>

Dental Tribune Asia Pacific Edition | 11/2016

That is why the FDI is taking a
stand on the sustainability issue
right now. The whole thing started
back in 2012 during the Rio+20
meeting, the United Nations Conference on Sustainable Development, in which the FDI had decided
to participate. Back then, we had
already begun collecting information and thinking about what we
could do in dentistry. I represented
the FDI in those meetings and I was
able to see how much we could do
even without going to a great deal
of trouble. For example, the most
sustainable thing to do is to focus
on prevention. If we act on prevention of oral disease, this would reduce the need for extensive treatment and the related use of products and, in particular, the associated generation of a large volume
of waste, as well as the substantial
amount of water and energy required, and the large carbon footprint that all of this creates.
Speaking of waste management,
what should dentists consider?
A great deal of waste is generated in dentistry and some of it
very toxic. Another issue that the
FDI has pursued is the Minamata
Convention on Mercury, which
includes the phase-down of dental amalgam. We have to face
our responsibility of dealing with
amalgam waste, for example. Nordic countries are a good example
in this regard, having implemented well-established amalgam
management practices for many
years.
One area in which we could do
a great deal more is the management of recyclable materials. All
the disposable materials that we
use in dentistry generate hundreds
of kilograms of waste every day.
What can we do to address recycling of those materials? A considerable amount of waste is generated with disposable barriers,
gloves and masks. Much of this
could be safely recycled with current technologies.
How open is the dental community
regarding this? When it comes to
change, such as going digital, there
are early adopters and some that
find it difficult to adjust to something new.
That is a good point. Digital
dentistry represents a different
mindset on production. The primary objective is to have more
control and to be more efficient in
production; however, a third point
is that digital technology generates less emissions, since there is
less transportation and less product waste. This is just one example
that serves to demonstrate that
there are many more efficient
means of manufacture. Certainly,
digital dentistry is one of those
areas of increasing technology use
that results in greater sustainability. Science, technology and innovation play a key role in most
areas of business. Improvements
in efficiency, accessibility and
cost-effectiveness of products and
processes may allow fulfilment of
global need in a more sustainable
way. Furthermore, dental research

BUSINESS

“By utilising the environment in an
intelligent, sustainable manner, we allow
society to develop in a healthy way.”
needs to be directed towards improving sustainability in dentistry.
Dentistry may be considered a very
conservative profession. How difficult is it to change the predominant
mindset?
We are doing that already.
One way or another, people are
coming to realise that going green
is our business, not somebody
else’s, but everybody’s responsibility. We as dentists have to play our
part as well. In addition to efficient
equipment and waste management, we should consider the topic
of recycling, particularly in light of
all the products that we use in
daily practice.
I think that the most important thing is education. We need
to include education on sustainable development in undergraduate
programmes and in continuing
education programmes. That way,
new and experienced dentists
alike will learn how to actually
practise environmentally friendly
dentistry. The national dental associations too can do a great deal to
increase awareness and promote
sustainable development. A good
example is the Norwegian Dental
Association, which has decided to
include sustainability aspects of
dentistry in its agenda.
What is the situation right now? Is
the topic covered in the curriculum
at all?
There is a great deal going on
right now. I would say that we are
in the moment of great activity.
For example, the International
Organization for Standardization
has developed very good materials
for action. There is also a United
Nations Educational, Scientific and
Cultural Organization platform for
integrating education on sustainable development. It is called Education for Sustainable Development.
In addition, it should be noted that
many universities are already going
green today. So, there is progress.
Behind it all, there is one
driving force, the United Nations’
2030 Agenda for Sustainable Development. This agenda has defined
17 sustainable development goals
that were adopted by all member
states in September 2015. This is
very recent, but we are on a schedule of looking into the reduction of
poverty, the reduction of hunger,
better health for more people and
more educational opportunities—
a number of issues that will improve the environment on the one
hand, as well as social and economic development on the other.
By utilising the environment in an
intelligent, sustainable manner, we

allow society to develop in a
healthy way. We need to have jobs,
we need to produce, but we can all
do that in a responsible manner
and at the same time sustain a
good economy.
When it comes to food and clothing, an eco-friendly lifestyle is often
more expensive than the alternative. For dentists, is there an
economic barrier to going green as
well?
Yes, there are challenges regarding entry, and investment
is required because everything
must be reoriented to the future.
As with everything, it is very difficult to start all over again, but
when attitudes change, when den-

tists actively decide to pursue
sustainability, then they will start
reviewing their own procedures
and little by little implement
change. The good news is that, once
one actually starts to implement a
sustainable approach, it becomes
evident that energy and resources
were wasted before—which is not a
good business strategy. There will
be a return on investment. One’s
patients, one’s clients and the public will recognise one as an active
member of a responsible society.
It will take time and effort, but the
dental profession will achieve this.
So in the future it could be a selling
point for companies to identify
themselves as “green”.

Yes, this is already happening
in many business areas, because
the public is driving sustainability
awareness by seeking more sustainable alternatives. As always,
there may be some companies that
already say that about themselves
even if they have not achieved that
yet. However, standards have already been established to determine whether certain things have
been applied. Based on these indicators of sustainability, auditors
and reviewers are able to evaluate
objectively whether sustainability
is being achieved by the company.
Of course, investment is required in the beginning. However,
some business reports indicate
that going green can save as much
as 40 per cent of costs on water,
energy and unnecessary product
waste, which is a great deal of
money. Many companies, big and
small, are already considering it
their corporate responsibility to
act for the social and environmental good.
Thank you very much for the interview.
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[8] =>

TRENDS & APPLICATIONS

Dental Tribune Asia Pacific Edition | 11/2016

Why interdental brushes are essential
for good oral health

Despite advances in good oral
health care, many patients and
dental professionals remain un
certain about oral physiopathol
ogy and the concept of disruption
of biofilm instead of elimination
of dental plaque. According to var
ious studies, conventional tooth
brushing is not effective in re
moving interproximal plaque suc
cessfully. Recommendations on
oral hygiene practices from dental
practitioners have focused on the
methods of daily toothbrushing
and interdental cleaning instru
ments as standard for achieving
and maintaining good oral health.
However, uncertainty has re
mained about oral physiopathol
ogy and the concept of disruption
of interdental biofilm.

Sixteen billion bacteria
in one interdental site
So why does interdental clean
ing actually matter? The anatomy
of the interdental space does not
allow for an efficient salivary
self-cleaning mechanism and
makes cleaning this area difficult.
As a means of further understand
ing the mechanism of periodontal
pathologies, Bourgeois was the
first to use real-time polymerase
chain reaction to quantify and
qualify the interdental biofilm
in healthy adults and explain
the role of interdental biofilm
management in preventative oral
health.
In his study, an astounding
approximately 16 billion bacteria were collected on average
from each interdental site. Of the
19 major periodontal pathogens
quantified in the study, bacteria of
red and yellow complexes consti
tuted the majority of interdental
bacteria. In particular, red com
plexes such as Porphyromonas
gingivalis, Tannerella forsythia
and Treponema denticola were
recognised as the most important

pathogens in adult periodontal
disease. P. gingivalis was detected
in 19 per cent of healthy subjects
and represented 0.02 per cent of
the interdental biofilm. As dental
research has confirmed, P. gingi
valis alone can induce alveolar
bone loss, and in combination
with T. denticola and T. forsythia,
periodontal disease is likely to
occur. This means that the inter

ease or clinical gingivitis have
xperienced interdental bleeding
e
at least once. This information
should be considered critical for
daily oral hygiene and interdental
cleaning in particular. “There is a
need to use interdental cleaning
tools in order to achieve optimum
oral health. If you do not use
them, you could essentially stop
using a toothbrush, as bleeding

week and 71 per cent after three
months. Bourgeois and his team
concluded that interdental clean
ing can be considered as “an effec
tive means to help individuals
maintain and/or achieve optimal
oral health.”
As the general access widths
of interdental spaces were mostly
unknown in young adults, Bour
© DTI

Prof. Denis Bourgeois is not only
the Dean of the University of Lyon’s
dental faculty in France but also a
pioneer in research on oral prophylaxis, interdental biofilm management and interdental brushing
techniques. He was the first to
test for 19 major pathogens in the
interdental biofilm known to be
involved in periodontitis in young
healthy adults. Furthermore, he
has suggested interdental brushes
to prevent interdental biofilm accumulation as well as to decrease the
development of periodontal diseases and even systemic diseases.
“An interdental brush can remove
around 16 billion bacteria from each
interdental space,” said Bourgeois
during his presentation at the FDI
Annual World Dental Congress in
Poznań, Poland.

Prof. Denis Bourgeois spoke about the efficacy of CURAPROX interdental brushes during his presentation at the FDI congress
in Poland this year.

dental biofilm of even healthy in
dividuals is composed of bacteria
that could lead to periodontitis.
“The effective presence of these
periodontal pathogens is a strong
indicator of the need to develop

will occur otherwise anyway in
the future.”
In a study titled “Efficacy of
interdental calibrated brushes on
bleeding reduction in adults: a

geois and his colleagues also as
sessed the distribution of these
widths in this group in a study
titled “Access to interdental brush
ing in periodontal healthy young
adults: A cross-sectional study”.

“There is a need to use interdental cleaning
tools in order to achieve optimum oral health.”
new methods for disrupting in
terdental biofilm in daily oral
hygiene,” concluded Bourgeois.

Bleeding as a clinical
reference
Despite good oral hygiene
habits, many patients experience
interdental bleeding. “As we have
seen, the interdental space is a
source of bacterial contamination
and has an effect on overall
health,” said Bourgeois in his
presentation. According to the lat
est research, 41 per cent of young
adults without periodontal dis

3-month randomized controlled
clinical trial”, a test group was
asked to use a standard manual
toothbrush twice daily and an
interdental brush daily. Based on
the hypothesis that interdental
brushes reduce interproximal
bleeding, Bourgeois and his team
instructed periodontally healthy
and young individuals how to
use interdental brushes daily and
correctly. In addition, a calibrated
colorimetric probe helped to ef
fectively determine the inter
dental space and right brush size.
As the study suggests, the overall
interproximal bleeding was re
duced by 47 per cent after one

Importantly, 40 per cent of the
sites studied showed bleeding
upon passage of an interdental
brush. An unexpected finding
was the high number of adults
(69.9 per cent) with greater than
30 per cent of bleeding sites. It was
observed that this did not have a
significant effect on the width of
the interdental space. By measur
ing the interproximal space, the
researchers concluded that the
latest generation of interdental
brushes was able to access 94 per
cent of interdental spaces. Over
80 per cent of the sites required a
small-diameter interdental brush
(0.6–0.7 mm) from the Curaprox

CPS Prime series. As a result, the
study concluded that most inter
dental sites can be cleaned using
interdental brushes, but accessi
bility of interdental spaces would
need to be established in the den
tal practice by the dental profes
sional.

Interdental brushes
prove to be superior
Conventionally, interdental
brushes were only recommended
for patients with large interdental
spaces, while dental floss was
recommended for narrow spaces.
As technology advanced, so did
the innovation with interdental
brushes, and as a result, interden
tal brushes can now be used for
very small interdental spaces to
clean the space between teeth
effectively. “Dental floss used to
be the common tool for narrow
spaces. However, dental floss is no
longer preferred, as its use is not
supported by conclusive scientific
evidence. For interdental brushes,
we have scientific evidence. Inter
dental brushes have now become
the best tool for cleaning inter
dental spaces,” said Bourgeois.
As Bourgeois concluded at
the end of his presentation, “The
interdental brush currently re
presents the primary and most
effective method available for in
terproximal cleaning. Interdental
brushes are specifically designed
to clean between the teeth in
accordance with the interdental
space access diameter. The method
of choice for interdental cleaning
when brush space permits is to
select the largest size that can
penetrate into the interdental
space and then to fill this space
completely without causing dis
comfort or trauma.” By using a
calibrating Curaprox IAP colori
metric probe, a suitably sized
interdental brush will help indi
viduals achieve optimal biofilm
disruption through thorough in
terdental cleaning with minimal
trauma.
For all studies, Bourgeois and
his team selected the CPS prime
series of interdental brushes
of the Swiss oral care brand
CURAPROX.
More information can be
found at www.curaprox.com.

Prof. Denis Bourgeois is working
as a professor in the Faculty of
Dentistry at the University of Lyon
(11 Rue Guillaume Paradin, 69372
Lyon Cedex 08), France, and can be
contacted by phone at +33 478778684
or by e-mail at denis.bourgeois@
univ-lyon1.fr.

[9] =>

Dubai Clinical Masters Program
TM

in Esthetic and Restorative Dentistry

7 days of intensive live training with the Masters in Dubai (UAE)

2 sessions, hands-on in each session, plus online learning and mentoring.
Learn from the Masters of Esthetic and Restorative Dentistry:

Online access to our
library of Lectures & Clinical Videos

Registration information:
7 days of live training with the Masters
in Dubai (UAE) + self study

Details on www.TribuneCME.com

Curriculum fee: €6,350

(Based on your schedule, you can register for this program one session at a time.)

Collaborate
on your cases
and access hours of
premium video training
and live webinars

University
of the Pacific
this course is created
in collaboration with
University of the Pacific

Tribune Group GmbH is an ADA CERP provider. 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.

100

C.E.

CREDITS

Certificates will be
awarded upon completion

Tribune Group GmbH is designated as an Approved PACE Program Provider by the Academy
of General Dentistry. The formal continuing dental education programs of this program
provider are accepted by AGD for Fellowship, Mastership and membership maintenance
credit. Approval does not imply acceptance by a state or province board of dentistry or AGD
endorsement. The current term of approval extends from 7/1/2014 to 6/30/2016.
Provider ID# 355051.

[10] =>

TRENDS & APPLICATIONS

Dental Tribune Asia Pacific Edition | 11/2016

Treatment of localised gingival recession
A clinical case utilising ZEISS EyeMag Pro F loupes with Feather Light LED
By Dr Matthew Garnett, UK

The Dental Tribune
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A 32-year-old female patient complaining of discomfort and pain from
her mandibular anterior region was
referred for a specialist periodontal
opinion. She was experiencing sensitivity of the teeth, tenderness and
intermittent gingival bleeding. She
felt that there had been progressive
deterioration over the last two years
(Fig. 1).
The patient regularly saw her
general dental practitioner, who
was undertaking supportive care
that included scaling, polishing
and desensitisation with the use of
fluoride varnishes. Having been
given oral hygiene advice, she was
using a soft-bristled manual toothbrush on a twice daily basis in
order to maintain her plaque levels.
Medically, she was a fit and healthy
non-smoker, working as a primary
school teacher. As far as she was
aware, she did not have any parafunctional habits such as clenching
or grinding her teeth. There was
no history of previous orthodontic
treatment.
Clinical examination using the
ZEISS EyeMag Pro F loupes (Carl
Zeiss) established that all permanent teeth were present, excluding
her third molars, and she had a caries-free dentition. She showed a
good level of oral hygiene, although
there were some small plaque and
calculus deposits present throughout the dentition. Assessment of the
area of main concern found there
was a reduced vestibular sulcus with
a relatively broad mandibular labial
frenal insertion. The superior insertion of the frenum was at the mucogingival junction of teeth #41 and
#31. There were 3 mm of labial recession associated with tooth #41 and
4 mm associated with tooth #31.
Both the mandibular central incisors were sensitive to cold air at the
cervical aspects of the teeth, where
calculus deposits were present.
Although there was no significant pathological pocketing, the
gingiva in the region of teeth #41

and #31 was erythematous and
swollen; this was tender and bled
easily upon probing. The interdental papillae were intact, albeit
the midline papilla particularly inflamed. There was very little in the
way of attached keratinised tissue
apical to the recessive defects.
Teeth #41 and #31 were labially
displaced owing to mild overcrowding and there was mild attritive
tooth surface loss affecting both the
maxillary and mandibular central
incisors. Protrusive and lateral guidance involved these teeth, but there
was no significant mobility (Fig. 2).
Radiographically, there was no apical
pathology and there was minimal
interdental crestal bone loss. The interdental bone between teeth #41
and #31 was, however, limited owing
to the mild overcrowding (Fig. 3).
A diagnosis of Class IIb Miller’s
defects affecting teeth #41 and #31
was made, along with the associated marginal gingivitis. This had
probably been exacerbated by a
high mandibular labial frenal insertion and pre-existing labial bone
deficiency (dehiscence or fenestration) as a result of the mild overcrowding. The condition may have
been exacerbated by some occlusal
overload and attrition (Figs. 4 & 5).
After the diagnosis, the patient
was advised on additional preventative measures with appropriate
toothbrushing techniques. She was
subsequently reviewed after further
simple scaling and polishing procedures. She then consented for mucogingival surgery to the mandibular anterior region. The proposed
treatment was an internal frenotomy procedure utilising a tunnelling
technique, to allow for an autogenous
connective tissue graft and coronal
advancement flap. Surface relieving
incisions were to be avoided.

Surgical treatment
First, the creation of a partialthickness supra-periosteal pouch

[11] =>

in the region of teeth #42 to #32 was
achieved with the use of tunnelling
instruments. There were partial papilla separation and internal frenotomy (Fig. 6). After this, an autogenous connective tissue graft was
harvested from the left anterior lateral aspect of the palate. This was
subsequently guided through the
tunnel to rest over the exposed root
surfaces of teeth #41 and #31. In addition to this, the graft would provide supplemental support for the
overlying soft tissue in the region
(Fig. 7). The gingival soft tissue lay
passively over the connective tissue
graft prior to suturing and wound
closure (Fig. 8).

TRENDS & APPLICATIONS

Dental Tribune Asia Pacific Edition | 11/2016

nised tissue had been increased,
in addition to the vestibular sulcus being deepened. All of these
features enabled the patient to

fully maintain the area. The crucial aspects for a successful outcome for the case were to ensure
careful soft-tissue handling, good

adaptation and stability of the connective tissue graft at the recipient
site, and tension-free wound closure.

At three months post-treatment, the hard palate donor site
was fully healed with no signs of
scarring (Fig. 12).
AD

Coronal advancement of the
overlying pouch/flap was achieved
with a continuous suture technique. Tension-free closure of the
wound was possible; however, specific caution was required particularly in the region of tooth #31
owing to the previous separated
frenal insertions. Were there to be
excessive coronal advancement of
the pouch/flap, this could have led
to potential wound breakdown due
to increased tension in the region.
The connective tissue graft was
intentionally left exposed to allow
for an increase in the zone of keratinised tissue after healing (Figs. 9
& 10).
At the two-year review, the
patient reported no sensitivity or
tenderness in the region and was
delighted with the outcome. She
was able to fully clean the teeth and
excellent gingival health was observed (Fig. 11). At the review stage,
there were no signs of inflammation, no bleeding on probing, and
no swelling or oedema present. Although there was still minor recession (1 to 2 mm) present affecting
teeth #41 and #31, it was not possible to achieve full root coverage
owing to the general positioning of
the teeth, the attritive wear present,
and the limited support and width
for the interdental papillae, especially in between teeth #41 and #31.
The persistent mild recession was
no cause of concern for the patient.

01
Intuitive user
interface

Accelerated
type B cycle

The thickness of the gingiva
and the zone of attached kerati-

Dr Matthew
Garnett is a
specialist periodontist and
currently works
as a consultant
in restorative
dentistr y at
Newcastle Dental Hospital. He also
works independently in private practice in the North East region of England. Garnett can be contacted at
matthew.garrett@uclh.nhs.uk.

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[13] =>

The complete implant workflow – easiness with one software

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Achieve an optimal restorative result and maximised patient satisfaction!
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[14] =>

TRENDS & APPLICATIONS

Dental Tribune Asia Pacific Edition | 11/2016

Paring down a complex case
Extensive all-ceramic restoration for the upper and lower jaws
By Dr Tetsuya Uchiyama and Michiro Manaka, Japan

Figs. 1a–c: Pre-op situation with various defective restorations, impaired aesthetics
and an untreated gap in the lower jaw.—Fig. 2: Evaluation of the aesthetic facial
parameters.—Fig. 3: The diagnostic wax-up.—Figs. 4a–f: Transfer of the wax-up
details to the provisional restoration using the cross-mounting method.—Figs. 5a & b:
The long-term temporary comprising three segments.

This awarded entry in the AsiaPacific category of the IPS e.max
Smile Award 2016 describes the
case of a patient who was treated
with tooth-supported and implant-borne restorations. This initially complex case was expertly
solved by using a straightforward
treatment approach and establishing a uniform colour base for the
all-ceramic restorations.
The abundant variety of solutions offered by contemporary
dentistry—diverse materials, different technologies, customised
approaches—is very much appreciated by patients and clinicians
alike. Nevertheless, complex cases
continue to present many challenges. In prosthetic dentistry in
particular, extensive restorations
in the upper and lower jaws are
often necessary. In these cases, it
is important to obtain a full view
of the situation and to analyse it
in detail and then to develop a
treatment plan. The main aim is to
pare down the complex situation
to a simple and sound base for
the fabrication of the restorations.
Well-grounded planning is the
key element in this process.

free-end gap extended from tooth
#35 to #37. The crown on tooth #34
was also loose. The gingival margin
of tooth #13 had clearly shifted towards the apical aspect. The curve
of Wilson (transversal curvature)
deviated, which added to the general disharmony. The shade of the
different restorations varied quite
considerably. Furthermore, the optical properties of the individual
restorations did not match properly. The patient requested restorations that would look and function
like natural healthy teeth.
The main goal was to establish
a stable occlusal situation that
would enable natural masticatory
functions and a harmonious aesthetic maxillofacial situation. For
this purpose, the existing crowns

and bridges had to be replaced
and the gingival contour had to
be adjusted. Tooth #24 had to be
replaced with an implant, which
would function as an additional
abutment. Further treatment with
implants was planned for the
mandibular posterior region.

pensable part of complex treatment planning. The loss of tooth
substance, which is the vertical dimension of occlusion, is verified
in wax. The teeth are then adjusted on the model using additive (in some cases subtractive)
means to achieve the desired situation.

From wax-up
to provisional

The treatment plan was discussed with the patient and modified as necessary. In this case, the
diagnostic wax-up served as the
foundation for all the subsequent

The diagnostic wax-up is generally considered to be an indis-

Clinical case
The 66-year-old patient complained about her inability to chew
properly, as well as the unattractive appearance of her teeth. In the
upper jaw, she had various defective metal–ceramic restorations, of
which some had already become
loose (Figs. 1a–c). In the lower jaw, a

Fig. 6: Situation after the removal of the old restorations.—Fig. 7:Teeth being prepared for the placement of the all-ceramic
restorations.—Figs. 8a & b: Impression of the emergence profile of tooth #14.—Fig. 9: Situation in the upper jaw after tissue
control was completed.

working steps. The horizontal and
vertical aesthetic lines and planes
were determined and the upper
and lower facial heights were evaluated by means of a radiographic
image (Fig. 2). In addition to the
clinical and aesthetic diagnosis, a
manual functional and structural
analysis provided important reference points for the treatment
plan.
For the wax-up procedure, the
incisal plane was lowered in the
articulator. The incisal edges were
slightly reduced (1 mm) to obtain
an ideal lower face height. In addition, the angle of the occlusal
plane was tilted (6°) anticlockwise.
The chewing surface was successively modelled until optimum
occlusal conditions were achieved
(Fig. 3). The cross-mounting method
—articulating the upper wax-up
against the lower jaw and vice
versa—was used to fabricate the
provisional composite restorations (Figs. 4a–f).
Once the old restorations has
been removed, we were faced
with an additional challenge
(Fig. 6). Metal build-ups and various fillings in the abutment teeth
created a rather patchy overall
impression. As a result, the appearance of the abutment teeth

[15] =>

[16] =>

TRENDS & APPLICATIONS

13a

Dental Tribune Asia Pacific Edition | 11/2016

13b

13c

Fig. 10: Framework with zirconium dioxide copings.—Figs. 11 & 12: IPS e.max ZirPress
was pressed to the zirconium dioxide copings. Subsequently, the restorations were
veneered.—Figs. 13a–c: Successful functional and aesthetic integration of the all-ceramic
restorations.—Fig. 14: The patient was visibly satisfied with the result.—Fig. 15: Stable
situation and excellent aesthetics three years after placement of the restorations.

had to be harmonised before
the permanent restorations were
placed.

Surgical treatment
The patient was given a local
anaesthetic and then an implant
was placed in the region of tooth
#14. Tooth #13 was extracted.
The gingival contours of tooth
#13 needed to be improved
significantly. Therefore, targeted
soft-tissue conditioning measures were initiated. For the next
few months, the patient had to
wear the temporary restorations,
which had previously been fabricated. The area around the implant was able to heal properly
during this period. In addition,
the patient was able to accustom
herself to the new functional and
aesthetic situation.
AD

The shape and shade of the
prepared abutment teeth had to be
adapted. The two lateral incisors
and the maxillary canines were
non-vital and discoloured. When
stained areas of prepared teeth
have to be concealed and tooth
shades are suitably adjusted, it is
important to visualise the completed crown for each of the individual teeth (Fig. 7). Changing
the perspective from full view
(maxillofacial) to detailed view (soft
tissue) simplifies the visualisation
process and tooth preparation.

Impressions and
provisional restorations
The peri-implant soft-tissue
contour around tooth #14 was optimally shaped by the provisional
restoration. As a result, an impres-

sion could be taken of the emergence profile (Figs. 8a & b). The
impressions of the prepared teeth
in the upper and lower jaw were
taken with the double-cord technique, and the master casts were
produced in the laboratory. The
long-term temporary was fabricated in three segments. The first
segment comprised teeth #23–12;
the second segment, the restored
posterior teeth #13–17; and the third
segment, teeth #44–47 (Figs. 5a & b).
Once the first segment had been
finished, the incisal pin of the articulator was lowered in order to create a space of approximately 1 mm
in the anterior region. This gap was
closed with the provisionals of the
other two segments. The temporary restoration was now ready for
placement in the mouth (Fig. 9).

als on to the frameworks and then
customise the restorations with
layering ceramics. This approach
may sound somewhat complicated, but it would ultimately help
to reinforce the stability and reliability of the treatment result.

After the provisionals had
been placed, their functional and
aesthetic parameters were checked
and the patient was released from
the practice. During the subsequent months, she managed very
well with the long-term temporary and she was satisfied with the
aesthetic aspects. The implants
that would replace teeth #35–37
had not yet been placed at this
stage. Experience has shown that
a step-by-step treatment approach
minimises the risk of error. Therefore, the implants were placed
eight months later.

In the next step, these zirconium dioxide copings, which were
to conceal the discoloured tooth
structure (Fig. 10), were covered
with pressed ceramic. The press
technique allows the wax-up and
its functional details to be reproduced in ceramic with utmost
precision. In preparation for the
ceramic press process, the restorations were built up in wax on the
copings and then pressed with
the fluorapatite glass-ceramic
IPS e.max ZirPress in Shade A3
(Ivoclar Vivadent). Next, they were
cut back as required, ensuring the
full contour of the functional parts
and the incisal area. Finally, the
restorations were layered with IPS
e.max Ceram veneering ceramic
(Ivoclar Vivadent; Figs. 11 & 12).

Owing to the focused approach, the complex initial situation was reduced to a comparatively straightforward case that
could be treated with permanent
all-ceramic restorations. The main
challenge for the dental laboratory technician was to conceal the
differently coloured abutment
teeth effectively. The objective
was to cover the non-vital and
stained teeth with zirconium dioxide frameworks. In order to fulfil all of the functional and aesthetic requirements, the decision
was taken to press ceramic materi-

Fabrication of the
restorations
First, the provisional restoration, or rather its functional characteristics, had to be copied. The
cross-mounting method was used
for this purpose. Subsequently, a
precision wax-up was fabricated
and digitalised. It was correspondingly cut back prior to the CAD/
CAM fabrication of the zirconium
dioxide frameworks.

The teeth were characterised
in accordance with the age-related
requirements of the patient using
Dentin, Incisal, Impulse and Mamelon materials. The all-ceramic
restorations were tried in after the
first firing and then completed.
After the last try-in, the restorations were permanently placed
according to the established pro-

tocol. The stained tooth structure
was optimally concealed. The
healthy natural soft tissue successfully adapted to the ceramic
surface. The implants healed completely and the radiograph showed
a stable situation. The vertical dimension, incisal edge contour and
occlusal plane corresponded to
the conditions established during
the provisional phase (Figs. 13a–c,
14 & 15). The shape and shade of
the ceramic restorations successfully matched those of the natural
mandibular anterior teeth and
harmonised with the face of the
patient.

Conclusion
Comprehensive restorative
therapy demands a clear and
well-organised treatment strategy. The route and the goal must
be defined right at the beginning
in order to establish a sound
and straightforward basis for the
treatment procedure even in complex cases. This approach simplifies the treatment for all the
parties involved and meets their
highest demands.

Dr Tetsuya
Uchiyama is a
dentist at the
Uchiyama Dental Clinic in Tokyo
in Japan. He
can be contacted
at tetsuya221@
gmail.com.

Michiro Manaka
is a dental technician at Dent
Craft Studio M’s
Art in Saitama
in Japan. He can
be contacted
at mamcr75@
gmail.com.

[17] =>

ENDOTRIBUNE
The World’s Endodontic Newspaper · Asia Pacific Edition

Published in Hong Kong

www.dental-tribune.asia

Vol. 14, No. 11

Twisted files and adaptive motion technology
A winning combination for safe and predictable root canal shaping
By Dr Gary Glassman, Canada; Prof. Gianluca Gambarini, Italy & Dr Sergio Rosler, Argentine
The ultimate goal of endodontic
treatment is the prevention and/or
treatment of apical periodontitis,
such that there is complete healing
and absence of infection1 while
the overall long-term goal is the
placement of a definitive, clinically
successful restoration and preservation of the tooth.2 Successful
endodontic treatment depends on
a number of factors, including
proper instrumentation, successful
irrigation and decontamination of
the root-canal system right to the
apical terminus in addition to hard
to reach areas such as isthmuses,
and lateral and accessory canals3, 4
(Fig. 1a & b).
The challenge for successful
endodontic treatment has always
been the removal of vital and
necrotic remnants of pulp tissue,
debris generated during instrumentation, the smear layer, microorganisms, and micro-toxins from
the root-canal system.5 It has been
accepted that even with the use of
rotary instrumentation, the nickel-titanium instruments currently
available only act on the central
body of the root canal, resulting
in a reliance on irrigation to clean
beyond what may be achieved
by these instruments.6 ‘Shaping
canals creates sufficient space to
hold an effective reservoir of irrigant that, upon activation, can penetrate, circulate and digest tissue
from the uninstrumentable portions of the root canal system.’ 7, 8
Several challenges often arise
during root canal preparation.
Some of the most common ones
are anatomic factors that may prevent negotiation to the apical termini, as well as ledge formation,
perforation and file separation.The
introduction of Nickel-Titanium
(NiTi) alloy in endodontics presented a significant improvement,
allowing good results in terms
of cleaning and shaping of root
canals, while reducing operative
time and minimising iatrogenic
errors.9, 10
Thanks to the superior mechanical properties of the NiTi
alloy, it was possible to use endodontic instruments of greater
tapers in continuous rotation, increasing the effectiveness and
rapidity of the cutting. However,
several studies reported a significant risk of intracanal separation
of NiTi rotary instruments.11–14 In
fact, file separation via torsional
and cyclic fatigue has created the
biggest fear and risk for dentists
using rotary NiTi files for root
canal treatment.11, 12, 15

Because TF files are twisted and not
ground, no surface microfractures
occur on their surface and therefore do not need be polished away;
thereby not dulling the cutting
edges and retaining their efficient
cutting ability.21–23

1a

1b

Figs. 1a & b: The complexity of root canal anatomy is demonstrated by these
cleared samples of maxillary molars.

Although multiple factors contribute to file separation, cyclic
fatigue has been shown as one of
the leading causes.16 Fatigue failure
usually occurs by the formation of
microcracks at the surface of the
file that starts from surface irregularities often caused by the grinding process during the manufac-

treatment technology that changes
the crystalline structure completely so the triangular cross section NiTi file blank can be twisted
while maintaining the natural
grain structure. More precisely, TF
instruments are created by taking
a raw NiTi wire in the austenite
crystalline structure phase and

Because of the increased flexibility, the TFs maintains the original canal shape better, minimises
canal transportation and stays
centred even in severely curved
root canals.24, 25 In addition to the
development of heat treated TF
technology to improve the performance and safety of NiTi instruments, the file design has
also been changed with respect
file dimensions, tip configuration,
cross-section and flute design.
More recently, a third factor has
become important in this search
for stronger and better instruments: Movement Kinematics, the
branch of motion in which the
objects move.26

3

2

Fig. 2: Colour-Coded File Identification. An intuitive, colour-coded system designed for efficiency and ease of use. Just like a
traffic light – start with green and stop with red.—Fig. 3: ElementsTM Motor. Settings for TFTM Adaptive, TFTM, K3, Lightspeed,
M4 Safety Handpiece and custom settings for personal preference.

turing. During each loading cycle
microcracks develop, propagating
getting deeper in the material,
until complete separation of the
file occurs.17 All endodontic files
show some irregularities on the
surface, and inner defect, as a consequence of the manufacturing
process, and distribution of these
defects influence fracture strength
of the endodontic instruments.18, 19
Since the introduction of NiTi
in 198820, varied instrument designs with claims of superior cyclic
fatigue resistance have been propagated. However, there were no
major changes in the manufacturing process/raw materials until
the introduction of the second
generation of NiTi files, ie, M-Wire
(DENTSPLY Tulsa Dental Specialties) in 2007 and Twisted File (TF,
Kerr Endodontics Formerly Axis/
SybronEndo) in 2008.

transforming it into a different
phase of crystalline structure
(R-phase) by a process of heating
and cooling. In the R-phase, NiTi
cannot be ground but it can be
twisted. Once twisted, the file is
heated and cooled again to maintain its new shape and convert it
back into the austenite crystalline
structure, which is super elastic
once stressed. The manufacturing
process aims at respecting the
grain structure for maximum
strength as grinding creates microfracture points during the
manufacturing of the instruments.

Recent literature data shows
that a reciprocating motion can
extend cyclic fatigue resistance of
NiTi instruments when compared
to continuous rotation,27, 28 mainly
because it reduces instrument
stress. As the instrument rotates
in one direction (usually the larger
angle) it cuts and becomes engaged into the canal then it disengages in the opposite direction
(usually with the smaller angle)
and the stresses are therefore reduced. Following these concepts
new instruments have been recently commercialised; Reciproc
(VDW) and WaveOne (DENTSPLY
Maillefer), which uses specifically
developed motors that produce a
specific reciprocating movement
(using approximately 150 to 30°
angles).
This reduction of instrumentation stress (both torsional and
bending stress) is the main advantage of reciprocating movements.
It has been shown that a lot of different reciprocating movements
can be used, each one affecting the
performance and the safety of
the NiTi instruments. Therefore,
when discussing the advantages
and disadvantages of reciprocation,
the exact motion should also be
mentioned, since the actual angle
of reciprocation can have substantial influence on both the clinical
and experimental behaviour of
NiTi instruments.15
Another possible advantage
of reciprocation could be better
maintenance of original canal trajectory, mainly related to lower
instrumentation stress and consequently its elastic return. However, it must be underlined that
reciprocation does not affect the
inherent rigidity of the instruments. If a quite rigid NiTi instrument of greater taper is slightly
forced into a curved canal, it will
create more canal transportation
than a more flexible one, due to its
inherent tendency to straighten.
Moreover, tip design could strongly influence canal transportation,

SM1: #20/ .04

SM2: #25/ .06

SM3: #35/ .04

ML1: #25/ .08

ML2: #35/ .06

ML3: #50/ .04

SMALL (SM)

MEDIUM/
LARGE (ML)
4

TF instruments are manufactured using a proprietary heat

For more than a decade, NiTi
instruments have been traditionally used with a continuous rotary
motion, but more recently a new
approach to the use of NiTi instruments in a reciprocating movement had been introduced by
Yared.11 The clockwise (CW) and the
counterclockwise (CCW) rotations
used by Yared were four-tenths
and two-tenths of a circle respectively and the rotational speed
utilised was 400 rpm. The concept
of using a single NiTi instrument to
prepare the entire root canal was
made possible due to the fact that

a reciprocating motion is thought
to reduce instrumentation stress.

5

Fig. 4: The motion of TFTM Adaptive instrument changes from rotary into reciprocation mode, with specifically designed CW
and CCW angles which may vary from 600–0° to 370–50°.—Fig. 5: File size reference chart.

[18] =>

18
with a cutting tip being more
dangerous that a non-cutting pilot
tip.
While reciprocation with NiTi
instruments have become very
popular in recent years, with a significant number of published articles, some of these studies have
shown that there is also inherent
disadvantages in the reciprocating

ENDO NEWS

torque demand on the file, due to
entrapment of debris within the
flutes. To reduce this tendency
some authors have advocated the
use of NiTi rotary glide path instruments, before using a WaveOne or Reciproc instruments, but
in this case the overall technique is
no longer a single file technique
but a more complex and more
costly technique which utilises

stant, but vary depending on the
anatomical complexities and the
intracanal stresses placed on the
instrument. This ‘adaptive’ motion
is therefore meant to reduce the
risk of intracanal failure, without
affecting performance, due to the
fact that the best movement for
each different clinical situation is
automatically selected by the
Adaptive motor. It is quite interest-

Fig. 6: Deep shaping. The clinical use of a second instrument (06/35) after the 08/25 significantly increases the preparation
in the apical one third, improving the quality of canal shaping and allowing room for enhanced irrigation. This will also allow the use of the apical negative pressure devices such as the EndoVac to safely deliver abundant quantities of sodium hypochlorite to the apex without the risk of apical extrusion.—Fig. 7: M4 Safety Handpiece.

movements. It is well known that
a small inadvertent extrusion of
debris and irrigants into the periapical tissues is a frequent complication during the cleaning and
shaping procedures, both with
manual stainless steel and nickel-titanium rotary instrumentation techniques.29, 30 However, recent studies have shown that
commercially available reciprocating instrumentation techniques
seem to significantly increase the
amount of debris extruded beyond
the apex31, 32 and, consequently, the
risk of postoperative pain. A clinical study comparing Reciproc and
NiTi rotary instruments has also
confirmed these findings.33 Since
reciprocation movement is formed
by a wider cutting angle and a
smaller releasing angle, while rotating in the releasing angle, the
flutes will not remove debris but
push them apically. Reciproc and
WaveOne motions are very similar
(even if not precisely disclosed by
manufacturers), and this fact could
also explain the higher incidence
and intensity of postoperative pain
that has been found in recent research studies.33, 34
Moreover, both WaveOne and
Reciproc techniques use a quite
rigid, large single-file of increased
taper (usually 08 taper, size 25),
which is directed to reach the apex.
In many cases, in order to reach the
apical working length, reciprocating instruments are used with apically directed pressure, which produces an effective piston to propel
debris through a patent apical foramen, and possibly directing debris
laterally, making canal debridement more difficult. Since instruments are commonly used without first performing preliminary
coronal enlargement, this may
result in a greater engagement of
the file flutes and consequently
may produce more torque and/or
applied pressure on the file. Moreover, the cutting ability of a reciprocating file is decreased when
compared to continuous rotation.
Debris removal is also less, thus increasing the frictional stress and

TF Adaptive

ing that the clinician will hardly
perceive the differences in the
changing motion, due to a very sophisticated algorithm, which permits a smooth transition between
the changing angles.

The TF Adaptive technique
has been proposed in order to
maximise the advantages of reciprocation, while minimising its
disadvantages. By using a unique,
patented motion, the innovative
TF Adaptive Motion technology,
together with an original three-file
technique, most clinical cases can
be treated effectively and safely
(Fig. 2).

As far as disadvantages of
reciprocation are concerned, TF
Adaptive motion is a reciprocating
motion with cutting angles (CW
angles) much greater than WaveOne/Reciproc movements. This
results in the TF Adaptive instrument is working for a longer time
with a CW angle, which allows better cutting efficiency and removal

two different types of Niti instruments, glide path instruments and
then shapers.35, 15

TF Adaptive employs a patented unique motion technology,
which automatically adapts to instrumentation stress, when used
in the Elements Motor while in
TF Adaptive setting (Fig. 3). When
the TF Adaptive instrument is not
(or very lightly) stressed in the
canal, the movement can be described as a continuous rotation,
allowing better cutting efficiency
and removal of debris. The crosssectional and flute design are
meant to perform at their best in
a clockwise motion.
More precisely, it is an interrupted motion with the following
CW-CCW angles: 600–0°. This interrupted motion is as effective as
continuous rotation in lateral cutting, allowing optimal brushing
or circumferential filing for better
debris removal in oval canals.
This interrupted motion also minimises iatrogenic errors by reducing the tendency of ‘screwing in’
(aka pull down), that is commonly
seen with NiTi instruments of
great taper that are used in continuous rotation.
On the contrary, while negotiating the canal, due to increased
instrumentation stress and metal
fatigue, the motion of the TF Adaptive instrument changes into a reciprocation mode, with specifically
designed CW and CCW angles that
may vary from 600–0° to 370–50°
(Fig. 4). These angles are not con-

Endo Tribune Asia Pacific Edition | 11/2016

As mentioned before, flexibility is a fundamental property to
minimise iatrogenic errors while
negotiating canals, both in reciprocation and in continuous rotation. The use of a reciprocating
movement, therefore, does not significantly help a NiTi instrument
of greater taper to negotiate
curved canals with no iatrogenic
errors. It mainly helps to reduce
instrumentation stress and the
risk of intracanal failure. In addition, a study aimed to compare the
frequency of dentinal microcracks
after root canal shaping with two
reciprocating (Reciproc and WaveOne) and one combined continuous reciprocating motion Twisted
Files Adaptive (TFA) rotary system.
Ninety molars were chosen and
divided into three groups of 30
each. Root canal preparation was
achieved by using Reciproc R25,
Primary WaveOne and TFA systems. All the roots were horizontally sectioned at 15, 9 and 3 mm
from the apex. The slices were
then viewed each under a microscope at x 25 magnification to determine the presence of cracks.
The absence/presence of cracks
was recorded, and the data were
analysed with a Chi-square test.
The significance level was set at
P < 0.05. The results found that
instrumentation with Reciproc
produced significantly more complete cracks than WaveOne and
TFA (P = 0.032). The TFA system
produced significantly less cracks
then the Reciproc and WaveOne
systems apically (P = 0.004). The
study concluded that within the
limits of this study, the TFA system
caused less cracks then the full

used only when a greater apical
enlargement is needed due to
larger original canal dimensions
and/or enhanced final irrigation
techniques. The sequences are also
different in their shaping concepts. Each file of the sequence
being used is taken to full working
length in a ‘crown down’ manner
so that the root canal wall is internally sculpted incrementally,
allowing dentin debris and tissue
to be evacuated coronally rather
than to be pushed apically. This
may reduce the risk of canal blockage and the extrusion of debris
into the apical tissues. The SM 1 file
(single colour band green, 04 taper
20 tip size) is an excellent flexible
Glide Path file which may be
used with either sequence to preenlarge the canal thereby decreasing instrument stress for the next
larger size file in sequence. This
also allows better maintenance
of the original canal trajectory
(Figs. 2 & 5).
The final apical enlargement
with a size #35 file is not only
meant to allow the use of the
Endovac (EndoVac Kerr Endodontics,
Orange, CA) irrigation technique,
but to improve canal shaping by
touching more canal walls. Figure 6
clearly shows how improved and
deeper the apical one-third shape
is when a 06 taper 35 tip instrument follows a 08 taper 25 tip instrument. This is why in the majority of cases two instruments
are much better than a single file
technique, provided that the second instrument is a flexible one.
The superior flexibility allowed by
the use of TF technology permits

Fig. 8: TFTM Adaptive Technique Card. Size and Sequence Determination.—Fig. 9: EndoVac Apical Negative Pressure Irrigation
System. The Master Delivery Tip (MDT) accommodates different sizes of syringes filled with irrigant, the macro cannula is
attached to the autoclavable aluminum hand piece and the micro cannula is attached to an autoclavable aluminum finger
piece. The macro cannula, the micro cannula and the MDT are connected via clear plastic tubing. The tubes are connected to
the high volume suction of the dental chair via the Multi-Port Adaptor.

of debris (and less tendency to
push debris apically and laterally),
because the flutes are designed to
remove debris in a CW rotation.
This results in TF Adaptive taking
advantage of the use of a motion
that is more similar to continuous
rotation for optimal debris removal. There are obviously some
changes in the angles depending
on canal anatomy (the more complex, the smaller the CW angle), but
they do not seem to significantly
influence the overall result. On the
contrary, these changes influence
resistance to metal fatigue, since
TF instruments used with Adaptive motion were found to have
superior resistance to cyclic fatigue
when compared to the same TF
instruments used in continuous
rotation.36

reciprocating system (Reciproc
and WaveOne). Single-file reciprocating files produced significantly
more incomplete dentinal cracks
than full-sequence adaptive rotary motion.39
The TF Adaptive technique is
basically a three file technique,
designed to treat the majority of
cases encountered in clinical practice. Available are two sets of three
file systems, one for small, calcifying and severely curved canals and
one system for more ‘standard’
and larger canals, allowing adequate taper and increased apical
preparation in both scenarios. The
number of instruments within
each sequence can also vary and
adapt to canal anatomy, with the
last instrument of the sequence

TF Adaptive to follow these criteria, and safely enlarge canals with
minimal risk of iatrogenic errors
like tooth weakening and canal/
apical transportation. The use of
a more rigid alloy would have not
made this possible, especially in
curved canals.”15

TF Adaptive technique
TF Adaptive is an intuitive,
color-coded system designed for
efficiency and ease of use. The
colour-coded system is based on
a traffic light. The first instrument
in sequence is green. The second
instrument in sequence is yellow
and the third instrument in sequence, if required, is red. Green
means go. Yellow means continue
or stop. Red means stop (Fig. 2).

[19] =>

Endo Tribune Asia Pacific Edition | 11/2016

ENDO NEWS

Coronal access
and glide path

Adaptive matching Paper Points
may be used to dry the canals.

1. Place rubber dam.
2. Obtain straight line coronal
access with slightly diverging
axial walls adhering to the concept of Minmimally Invasive
Endodontics.37
3. Achieve apical patency and establish an apical glide path using
#8 hand file, follow that with
a #10 hand file and continue at
least with a #15 hand file. Glide
path may be facilitated with
the M4 Safety Handpiece (Kerr
Endodontics, Orange, CA) (Fig. 7).
The pulp chamber should be
filled brimful with NaOCl (Sodium Hypochlorite).

Obturation

Canal size and
file sequence
determination (Figs. 5 & 8)
Small Canals (SM)
Using tactile feel, if you struggle to get a #15 K-File to working

Dr Gary Glassman is the author of
numerous publications. He lectures
globally on endodontics, is on staff at
the University of Toronto, Faculty of
Dentistry in the graduate department
of endodontics, and is Adjunct Professor of Dentistry and Director of Endodontic Programming for the University
of Technology, Kingston, Jamaica. Gary
is a fellow of the Royal College of Dentists of Canada, Fellow of the American
College of Dentists and the endodontic
editor for Oral Health dental journal.
He maintains a private practice, Endodontic Specialists in Toronto, Ontario,
Canada. His website is www.drgary
glassman.com and his office website is
www.rootcanals.ca. He can be reached
at drg@drgaryglassman.com.

Gianluca Gambarini is a full-time
Professor of Endodontics, University of
Rome, La Sapienza, Dental School. He
is head of the Endodontic Department
International lecturer and researcher.
He is author of more than 450 scientific articles, three books and chapters
in other books. He has lectured all
over the world (more than 350 presentations) and has been invited as a
main speaker in the most important
international (AAE, IFEA, ESE) and
national endodontic congresses in
Europe, North and South America,
Asia, Middle East, Australia and South
Africa. Prof. Gianluca Gambarini still
maintains a private practice limited to
Endodontics in Rome, Italy.

Dr Sergio A. Rosler has been the Assistant Clinical Teacher in numerous
graduate and post-graduate Endodontic Programs and was Clinical
Fellow Teacher at Warwick Dentistry
University in the United Kingdom.
Dr Rosler has lectured at conferences
and several universities around the
world. He maintains a private practice limited to Endodontics in Buenos
Aires, Argentine and can be reached at
sergiorosler@gmail.com.

TF Adaptive matching Gutta
Percha in combination with the
Elements Free Cordless Obturation
system37 may be used to obturate
the root canal system. Alternatively,
TF Adaptive carriers may be used.

Conclusions
10

Fig. 10: CBCT (Cone Beam Computerised Tomography) three dimensional visualisation of TFA preparation (SM sequence) in a complex molar, showing proper
shape, tapered preparation and excellent maintenance of canal trajectories.
(Courtesy of Dr Lucila Piasecki, Brazil and Prof. Gianluca Gambarini, Italy)

length (WL) then the canal size
is deemed to be ‘small’. Use the
Small Pack (one colour band) and
its instrument sequence. The small
sequence may also be used in severely curved canals as well as
roots that may be very thin and
the risk of strip perforation is a
possibility.
Medium/
Large Canals (ML)
Using tactile feel, if a #15 K-File
feels loose at working length then
the canal size is deemed to be
‘medium/large’. Use the Medium/
Large Pack (two colour bands) and
its instrument sequence.
Establish working length
Working length should be established with a reliable apex
locator. A radiograph may help the
clinician as well.

TF Adaptive
canal shaping
technique
1. Use the ‘TF Adaptive’ setting on
your Elements Motor (Fig. 3).
2. Ensure the pulp chamber is
flooded with NaOCl or EDTA and
make sure the file is rotating as
you enter the canal.
3. Slowly advance the green (SM1
or ML1) with a single controlled
motion until the file engages
dentin then completely withdraw the file from the canal.
Do not force apically. Do not
peck.
4. Wipe off the flutes. Deliver irrigant to the pulp chamber and
confirm canal patency with a
#15 handfile K-File.
5. Repeat steps 3 and 4 using the
file you started with until working length is achieved.
6. Repeat steps 3 and 4 with the
yellow SM2 or ML2 until the file
reaches working length. If the
desired apical size is achieved
the sequence is complete. For
larger apical sizes, repeat steps
3 and 4 with the red SM3 or ML3
until the file reaches working
length.
Note: All TFA files may be used
in a brushing manner directed
towards the external surface of
the root away from the canal
curvature when retrieving the file
from the canals.

Irrigate and dry
When irrigating with EndoVac
(apical negative pressure irrigation
system),2 in small canals, you must
take SM3 to working length. In medium/large canals, you must take
at least ML2 to working length.
Note that the Microcannula is
.32 mm in diameter (Fig. 9). TF

have also found that Adaptive
Motion Technology works well with
other ground file rotary systems
making their use safer especially
in smaller and curved canals. This
technology allows the TF Adaptive
file to adjust to intra-canal torsional forces depending on the
amount of pressure placed on the
file. This means the file is in either
a rotary or reciprocation motion
depending on the situation and
adjusts appropriately.
This winning combination results in exceptional debris removal
with the tried and trusted classic
rotary Twisted File design and less
chance of file pull down and debris
extrusion with Adaptive Motion
Technology.

TFA employs Twisted File
technology and Adaptive Motion
Technology. The TF Adaptive file
design is based on clinically proven
Twisted File technology, which
means the file is twisted to shape
for improved file durability, features R-Phase Technology to improve file flexibility and strength
while maintaining the original
canal curvature minimizing canal
and apical transportation (Fig. 10).

Editorial Note: A complete list of references is available from the publisher.
This article originally appeared in
Oral Health dental journal MAY 2016.

Adaptive Motion Technology
is based on a patented, smart algorithm designed to work with the TF
Adaptive file system. The authors

Disclaimer: Drs. Gambarini and
Glassman are the inventors of Adaptive Motion and receive a nominal
royalty from Kerr.
AD

[20] =>

ENDO BUSINESS

Endo Tribune Asia Pacific Edition | 11/2016

A commitment to German quality
By Marc Chalupsky

In the field of endodontics, instruments of different sizes and angles
and with various handles have been
developed for root canal therapy—
from simple stainless-steel files to
today’s high-tech instrumentation
systems. VDW is one of the most
well-known manufacturers of endodontic products in the world.
Most of the 52 million instruments
it produces annually are manufactured in Munich in Germany. For
more than 145 years, VDW has been
operating from its site in the heart
of Europe, where it manufactures
endodontic instruments in a shift
operation. The company granted
Dental Tribune an exclusive look
behind the scenes of its high-tech
facility, spanning 3,000 m2.
Every dentist knows that optimal root canal preparation requires a highly flexible file system
with extremely good cutting performance and low material fatigue.
Furthermore, the file system must
be easy and quick to use and suitable for preparing even severely
curved root canals. Today, there
is a range of systems available
to dental specialists including
those based on reciprocating or
continuously rotating motion, as
well as hand instruments. With
its single-file reciprocating system
RECIPROC, for example, VDW offers a safe solution for optimal root
canal preparation.

Not all files are equal
Endodontic instruments are
essentially of three designs: K-typefiles, reamers and Hedstrom files.
Reamers and K-type-files have a
triangular or square cross-section
and a cutting edge angle that determines the cutting and debriding
performance and therefore the
effectiveness of the instrument.
The design of the instrument tip,
which cuts either actively or passively, is crucial. An inactive tip
advances the instrument safely
within the canal. The instruments
generally have a handle, a shaft and
a working part. While the length of
the working part always remains
the same at 16 mm, the length of
the shaft can measure between
5 mm and 15 mm.
A colour-coding system is used
for easy visual identification of the
diameter. The ISO standard specifies the lengths, dimensions, toler-

ances and minimum requirements
for mechanical resistance. Colour
coding of white, yellow, red, blue,
green and black, and various symbols indicate the individual types
and sizes of instruments. The
standard also precisely specifies
the conicity, accurate to the millimetre. The tolerance range is less
than 0.02 mm, but the measurement of the tolerance may be significantly over the limit, depending on the manufacturer. Additionally, silicone stoppers are used to
determine the length of the root
canals.
The manufacturing process for
Hedstrom files consists of eight
steps: straightening the wire,

The instrument’s cross-section and
the material used play an important part here, and this in turn has
an effect on the production. Finally,
the angle of twisting (deflection)
and the strength determine the
quality of the instrument, especially the cutting performance.
Sharpness decreases with repeated
use.

Visions of endodontic
heaven
Dental Tribune was granted direct access to operations at one of
the most innovative manufacturers in the field of endodontics.
While the company has a 145-year

grinding, washing, ring marking,
injection moulding of the handle,
printing, attaching the stopper and
packaging. For barbed broaches,
the wire is also first straightened,
then machined, washed and
straightened again, the handle injection moulded and the instrument finally packaged. Reamers
and files are generally machined
into a triangular or square form
and then twisted. In this way,
depending on the bending moment, torsion and deflection, instruments are formed that have
absolute flexibility and the highest
possible fracture resistance. The
bending moment indicates that
moment of the bending of the instrument during production when
it no longer reverts to its original
form. An instrument once bent
cannot be bent again, otherwise
there is a risk of brittleness and
fracture. The torsion, that is the
twisting of the files, differs depending on the force effect and material.

divided into sterile and non-sterile
instruments. Using the Flexicut
and NiTi K-type-files, preparation
is problem-free even in the case of
severely curved and narrow root
canals. The company is particularly
proud of its RECIPROC system,
consisting of reciprocating instruments for mechanical preparation,
paper points and gutta-percha.
Apex locators, obturation systems
such as GUTTAFUSION, an ultrasonic device and materials for
filling root canals are displayed in
another glass case.
The tour began with the machines for cutting and straightening the wires (Fig. 1). Most file
systems use highly flexible, frac-

finished instruments using a digital measuring system and visually
inspecting them under a microscope. This system, like the entire
production process, is fully automated (Fig. 2). The process is properly validated to ensure that VDW
can always provide the same quality and reliable monitoring. The
washing plant cleans the instruments and completely removes the
oil used in production, for example. A gripper then takes the deposited instruments and machines in
the ring marking. The colouring is
done within a few seconds. The ink
is then dried and the instrument is
inspected again by camera (Fig. 3).
The next procedure is attaching
the handle. The robot trims the
instrument at the top so that it is
wide enough to connect the wire
firmly to the handle. “This step is
often left out with fake copies so
that the handle slips off,” said
Picard, referring to the counterfeit
products on the market, which is
a global concern for both manufacturers and dentists. This is followed
by the injection process to form
handles around the wires, which
are first placed into moulds, depending on the ISO diameter of
the instruments. The plastic used is
a high-performance polymer that
can be sterilised repeatedly and
can therefore be used in autoclaves.
The granules are recycled to a
certain extent. Injection moulding

history, the well-maintained business premises look very modern.
VDW was one of the first European manufacturers of endodontic instruments, and today offers
products for the entire treatment
process—including preparation
and irrigation, root canal filling
and post-endodontic maintenance.
VDW emphasises simplicity and
efficiency in its systems, allowing
both general practitioners and specialists to provide optimal treatment in a few steps. At the facility
in Munich, Gregor Picard, Director
of Operations at VDW, took us
through the entire production
process for the company’s manual,
rotating and reciprocating instruments.
Just in front of the main entrance, visitors are given an overview of VDW’s products, such as
file and reamer sets for root canal
preparation with rotational cutting, debriding and filing action,

ture-resistant stainless steel combined with a special alloy. For
almost 30 years, the industry has
relied not only on chromium–
nickel–stainless-steel alloys but
also on nickel–titanium alloy
(NiTi), known for its pseudo-elasticity. NiTi files are used particularly
in severely curved root canals.
Owing to other beneficial properties, including shape memory (the
material returns to its original
form), super-elastic behaviour and
good biocompatibility, dentists are
increasingly opting for NiTi files,
but not dispensing with stainless-steel files. “We are constantly
working on new alloys, materials
and geometries. However, it is just a
question of refinements these days;
the conical tapered form of the instruments and the NiTi alloy have
proven themselves,” said Picard.
The wires are subsequently
machined. Straight after this procedure, an employee checks the

is applied gently, but extremely
quickly. The precise injection
moulding machines are some of
the fastest in the industry. Injection moulding of the handles requires a great deal of expertise and
experience. The high-performance
robot produces 16 instruments in
14 seconds.
The instruments are printed on
using tampography (pad printing),
a special process used for printing
on the front and side of the instrument. The silicone stoppers are
then applied according to instrument length. The stopper is brought
from the hopper machine in an automated process and a collet chuck
holds it firmly while the instrument is pushed through the stopper. The instruments go into large
machines during the washing process, and here a technician must
constantly ensure a sterile environment. Therefore, a machine creates
a clean room environment in order

[21] =>

ENDO BUSINESS

Endo Tribune Asia Pacific Edition | 11/2016

21
cially as standards of living continue to improve,” said Di Hu, Export Manager for Asia at VDW.

to allow sterile packaging after the
washing procedure. An automated
packing facility sorts all of the instruments into boxes and blister
packs. The instruments are then
deposited into crates within the
clean room environment. Employees line these with sterile bags and
they are then sealed with lids in
the clean room area and sent for
final packaging. They are marked to
indicate sterilisation status. VDW
sends the goods for sterilisation
again before shipping in order to
ensure that there are no bacteria
when they leave the warehouse.
If desired by a customer, a small
laser can be used to mark the blisters for individual needs.
6

The warehouse follows a chaotic storage process—in a positive
sense. With storage locations defined according to aisles, the products are stored in available spaces
where they fit best, rather than according to category. This allows for
the most efficient use of space. The
system tracks the available spaces,
scans the goods and knows automatically when sufficient goods
have been removed. Each order is
digitised and production begins
immediately after receipt. Because
the logistics and production are
precisely controlled according the
number of each product, there is no
over- or underproduction. At the
time of the visit, an employee was
preparing a few pallets for China
(Fig. 4).

Everything is monitored
Even more impressive than the
almost fully automated production is the monitoring technology.
The specially developed camera
system is probably one of the most
advanced in the dental industry.
One example is the ring marking.
Each ring is checked for diameter,
width and colour application. The
system will then indicate “green”,
signifying that all is OK, or “red” to
flag a problem (Fig. 5). Instruments
with no ring colour are automatically removed. Another camera
checks the twisting of reamers and
files according to length and degree
of twisting, preventing any warped
instruments from going any further in the production process. Yet
another camera checks the barbs
on the broaches. A further camera
monitors the status of the boxes
and blisters and verifies the geometries of the instruments and their
colours by means of images. The
camera detects the tiniest deviations in the instruments and packaging—even individual particles—
and these packs are separated automatically. Another camera checks
the labels. If there has been a printing error or an incorrect label has
been used, the affected item is
immediately separated by the machine.
Each process step undergoes
quality control by camera (Fig. 6).
This means that no rejects proceed
to the next stage. “The longer a defective item is in the production
process, the greater the associated
costs incurred. A single defective
file in a blister means that the en-

tire pack must be removed,” explained Picard. In this way, the
company guarantees the safety
and quality of its products and
fulfils the strict regulatory requirements.

machines rather than trying to get
the last out of the old machines.
As a result, a new technology centre
is created almost every two years.”
Achieving German quality requires
German thinking.

Tried and tested and
constant change

That nasty term
“file breakage”

Even after 145 years, manual
work still has its place in production. Each reamer and file are elaborately finished by hand (Fig. 7).
VDW initially wished to automate
this manual work too, but the employees are so good at their work
that they can produce the tip with
exactly the required cutting angle
very quickly. Thirty-five million instruments therefore include some
manual production and additional
inspections. In another respect too,
people remain central at VDW.
Throughout the building complex,
there are boxes and blackboards for
idea generation where employees
can give their suggestions. Particularly good ideas are rewarded. This
may be one of the reasons that
every employee appeared to be so
focused—but friendly and receptive too. Most of the employees
have been with the company for
many years, have detailed knowledge of the processes and participate actively, according to Picard.

During the tour, the term “file
breakage” came up often. All dentists are familiar with the nuisance
of an instrument breakage, for
both themselves and their patients.
There are many reasons for a breakage, ranging from a complicated
root canal anatomy to incorrect
preparation techniques or poor
processing of materials. In the case
of severely curved root canals especially, the file fragment can only
be removed with a great deal of patience. As recently as 30 years ago,
stainless-steel instruments with

ing the possibility of file breakage
even further. Owing to a new production process, the files are significantly more flexible, and the dentist can prebend the instruments
in order to gain easier access to
severely curved canals. These new
properties are made possible by a
particular heating protocol. Once
the RECIPROC instruments have
been manufactured according to
the proven process followed, they
are subjected to a heating process
that is specified in detail. This
changes the molecular structure
of the NiTi in such a way that the
RECIPROC instrument acquires the
additional properties described.
The colour of the file changes to
blue owing to the heating process. Otherwise, the application of
RECIPROC blue is the same and it
can be used with the tried-andtrusted VDW endodontic motors.
RECIPROC blue will be available in
the coming months.

Production is being restructured currently with the individual injection moulding machines
being combined, creating dedicated areas within the manufacturing process. Monitoring by camera will ensure that no products are
mixed up or swapped. The restructuring process is to be completed
by the end of the year, but may
require additional changes once
VDW buys and installs more new
machines “It is extremely important to us to improve ourselves and
remain at the cutting edge. We have
to keep pace with the dynamics of
the market and steer them,” stated
Picard. Although many of the older,
mostly green-coloured, machines
are still running without problems
and an in-house workshop monitors and repairs the equipment,
replacement parts are often not
available. “Therefore, we feel new
acquisitions are a better investment. Provided there is proper justification, the group opts for new
grinding and injection moulding

only a rotational cutting action led
to frequent file breakage. The cutting action of reciprocating instruments, however, virtually rules out
file breakage if these instruments
are used correctly. To further reduce the likelihood of breakage,
dentists should opt for torquecontrolled motors instead of hand
instruments. The motor detects when
the pressure on the instrument is
too high and prevents breakage
with a backward movement. Furthermore, material fatigue is reduced if files are used only once.
Just in August, VDW announced
the next generation of reciprocating root canal preparation instruments with RECIPROC blue, reduc-

A specific focus on Asia
VDW is focusing particularly
on this prospering region at the
moment. With an annual growth
rate of 5 per cent, China, India and
South Korea are currently among
the most important markets for
endodontic instruments. “We feel
that there is an increasing need for
safe, high-quality root canal therapy in these countries. Only several
years ago, hardly anyone was talking about reciprocating instruments, endodontic motors with integrated apex locators or root canal
irrigation systems like our EDDY.
Particularly in the last five years,
however, we have witnessed an
increasing demand for them, espe-

Indeed, the standard of living
of the population in the Asia-Pacific
region has significantly improved
in the last ten years. Rising salaries
and improvements in health care,
especially for older patients, have
led to greater demand for durable
endodontic instruments. Dentists
in India and China cannot afford to
have a file break in a root canal either. Finally, the level of information about endodontic treatment
has improved in these particular
countries. Dentists are progressively educating their patients and
showing them that root canal therapy with the right instruments is
no more unpleasant than a filling.
Owing to their quality, Germanmanufactured products are becoming first choice for a growing
number of dentists.
VDW has been represented in
Japan for 60 years, and the other
Asia-Pacific countries have been
directly served since 2007. “The
Asian market has great potential
for us. Since 2015, China has been
the number one market in Asia.
Of course, we are continually entering new markets for our products;
for example, VDW has been represented in Vietnam since the beginning of 2016,” Hu explained.
For some years, VDW has been
focusing more intensely on China
(Fig. 8). “In June, VDW had its own
stand at the Sino-Dental exhibition
in Beijing. Being the largest dental
trade fair in China, it attracted
about 60,000 visitors. Sino-Dental

went very well for VDW. We focused
on established products that are already successful, such as RAYPEX 6,
VDW.GOLD RECIPROC motors and
RECIPROC instruments. At the
stand, we offered various lectures
and hands-on activities, which
were very well received.”
There is a great need for information on and products for endodontic treatment in China and its
neighbouring countries. However,
Germany and Europe remain home
and the most important market
for VDW. Therefore, the company’s
production facilities in Munich
will remain and be steadily expanded, reflecting the company’s
commitment to German quality.

[22] =>

TRENDS & APPLICATIONS

Endo Tribune Asia Pacific Edition | 11/2016

Apical transportation

cleaning, disinfection and proper
filling. Thus, these steps should be
performed as well as possible and
be followed by an apical microsurgery to remove the untreated apical
region.

Microsurgical handling of a procedural error during apical mechanical preparation
Prof. Leandro A.P. Pereira, Brazil
Endodontics is the dental specialty
that is concerned with treating or
preventing pulpal pathologies and
apical periodontitis. The main objectives of endodontic treatment are to
clean and disinfect the entire length
of the root canal system up to a
healthy level.1 When, through meticulous treatment, such objectives are
achieved, success rates can exceed
94 per cent.2, 3 In pursuit of such
results, during endodontic therapy,
mechanical preparation is carried
out with endodontic instruments
and chemical preparation with irrigating solutions.

facilitating flow of larger volumes
of irrigating solutions to the apical
third.6, 1 It also creates a favourable
conical shape for endodontic filling.
Therefore, it directly influences the
quality of the disinfection process
and, consequently, the prognosis of
the case.
Procedural errors during mechanical preparation may make
it impossible to achieve the required disinfection levels. Yousuf
et al. evaluated 1,748 endodontically
treated teeth using digital radiography and found procedural errors in

tion; may lead to ledge formation
and possible perforation.”
The inadvertent use of rigid
endodontic files, such as stainless
steel, especially of larger diameters,
without previous examination of
the internal dental anatomy as part
of the procedure, increases the risk
of transportation of the foramen.
Insufficient cleaning of canals,
especially the apical third, predisposes treatment to endodontic
failure.10, 11 Transportation of the
foramen may not only impair dis-

Clinical case

• Type I represents a minor movement of the physiological position
of the foramen.
• Type II represents a moderate
movement of the physiological
position of the foramen, resulting
in a considerable iatrogenic relocation on the external root surface. In this type, a larger communication with the periapical space
exists.
• Type III represents a severe movement of the physiological position
of the foramen and the canal, resulting in a significant iatrogenic
relocation.

A 55-year-old female patient
(American Society of Anesthesiologists Physical Status Class I) visited
the dental office complaining about
spontaneous, constant pain, exacerbated during mastication and
apical palpation in the region of
teeth #13 and #11, which had been
treated endodontically over the
course of the last three months. The
patient reported that she did not
feel pain before the initial endodontic treatment began. After the
first endodontic session, during
which teeth #13 and #11 were

Fig. 1: Initial clinical view of tooth #11.—Fig. 2: Initial clinical view of tooth #13.—Fig. 3: Initial radiograph.—Fig. 4: Tomographic image demonstrating the transportation of the foramen of tooth #11.—
Fig. 5: Tomographic image demonstrating the transportation of the foramen of tooth #13.—Fig. 6: Clinical image captured under the operating microscope showing the original canal trajectory and apical
deviation of tooth #11.—Fig. 7: Radiograph of an endodontic file positioned in the apical deviation of tooth #11.

After cleaning and shaping, endodontic filling must be performed
to fill three-dimensionally and seal
the endodontic space in order to
prevent bacterial recontamination,
maintaining the sanitation conditions achieved through the previous steps. The mechanical preparation of the root canal system is of
utmost importance in the process
of establishing endodontic sanitisation. 4, 5 It is responsible for physically removing the infected dentine and, consequently, bacteria
located within the dentinal tubules.
In addition, it increases the diameter and shapes the main canals,

32.8 per cent (574 teeth) of them.
Transportation of the apical foramen, whether leading to root perforation or not, is among the most
common errors during endodontic
treatment, especially in curved canals.7–9
The Glossary of Endodontic
Terms by the American Association of Endodontists defines “canal
transportation” as “Removal of
canal wall structure on the outside
curve in the apical half of the canal
due to the tendency of files to restore themselves to their original
linear shape during canal prepara-

infection of the canal system by disabling access to its original trajectory, but also irritate the periapex
by extruding bacteria and their
by-products and derail the ideal
apical adjustment of a gutta-percha
cone. These technical hindrances
due to operational error in the
preparation phase can negatively
influence apical sealing and appropriate bacterial control.12 As a result,
they worsen the prognosis of the
clinical case involved.
According to Gluskin et al.,
transportation of the foramen can
be classified into three categories:

Treatment of apical transportation cases can be performed according to various clinical approaches.
Canals with Type I transportation
can usually be cleaned and filled.
Type II may be filled after the application of an apical barrier to control
bleeding and to serve as a physical
shield to prevent extrusion of
the endodontic filling material. In
these situations, placing an apical
cap with mineral trioxide aggregate
(MTA), followed by conventional endodontic filling, can be considered.
However, in clinical cases with apical transportation of Type III, it is
generally not possible to achieve

Fig. 8: Apical cap with MTA Repair HP.—Fig. 9: Canal drying of tooth #12 with SurgiTip (MANUFACTURER).—Fig. 10: Retrofilling of tooth #12 with MTA Repair HP.—
Fig. 11: Immediate postoperative radiograph.—Fig. 12: Control radiograph five months later of the periapical repair.

treated at the same time, the pain
began and had worsened after the
third day. On the fourth day, the
patient had to receive intravenous
dipyrone and ketoprofen to control
the pain. Concurrent with the systemic medication, an occlusal adjustment was performed. After
two days, the pain returned and
the patient went to another dentist,
who administered sodium dipyrone
500 mg/ml every four hours and
nimesulide 100 mg every 12 hours
orally for seven days. The pain decreased, but did not cease.
Two days after systemic medication ended, the patient again felt
pain. She went to a third dental professional, who initiated endodontic
retreatment of teeth #11 and #13.
However, the therapy performed
was not able to control the pain
effectively. After four days, the
patient also began showing febrile
conditions. It was reported that, in
none of the endodontic procedures
performed, was absolute sealing
achieved.
Clinical examination established endodontic access at teeth
#13 and #11. Inadequate geometric

[23] =>

Endo Tribune Asia Paciﬁc Edition | 11/2016

conﬁguration of endodontic access
already suggested problems in
chemical-mechanical preparation
of the root canal system (Figs. 1 & 2).
Endodontic therapy was begun in
teeth #13 and #11, and transportation of the foramen Type III was radiographically observed. On tooth
#12, there was a full crown, a metallic intra-radicular retainer and
signs of a poor endodontic treatment (Fig. 3). On the CT scan, it was
possible to visualise the transportation of the foramina of the two
teeth (Figs. 4 & 5).
Owing to the severe apical deviation of teeth #11 and #13, the
recommended treatment was endodontic retreatment, complemented
by an apical microsurgery. Treatment of tooth #12 was also needed
through cleaning, shaping and
disinfection of the canal system
with consequent endodontic ﬁlling.
However, as the prosthetic crown of
this tooth was adapted and microsurgery was already planned for the
neighbouring teeth, the decision
was to perform a retrograde endodontic treatment.
Treatment was initiated with
the endodontic retreatment of
tooth #11, followed by that of tooth
#13. The canals were irrigated with
2.5 % sodium hypochlorite, followed
by 17 % EDTA, both with passive
ultrasonic irrigation and prepared
with RECIPROC 50 (VDW). Using an
operating microscope and periapical radiographs, it was possible
to visualise the apical deviation of
tooth #11; however, it was not possible to follow the original trajectory
(Figs. 6 & 7). The same occurred with
tooth #13. Owing to the great irregularity of the walls of the canals
after transportation of the foramina, it was not possible to perform
the proper locking of a gutta-percha
cone. For this reason, the decision
was to perform an apical cap of
4 mm with MTA Repair HP cement
(Angelus; Fig. 8). The ﬁlling of the
rest of the canals was performed
using thermo-plasticised guttapercha with MTA-Fillapex cement
(Angelus). MTA-Fillapex contains
particles of MTA in its composition.
After the end of this stage, the
patient underwent apical microsurgery, during which the apical area
corresponding to the apical iatrogenic region was removed with a
piezoelectric instrument and a W1
tip (CVDentus). On tooth #12, a piezoelectric apicectomy using the same
instrumentation was performed,
and the canal was retro-prepared
to the depth corresponding to the
apex of the molten metal core
present. After drying the canal with
a surgical suction pump coupled to
a vacuum pump, the procedure
continued with retroﬁlling using
MTA Repair HP (Figs. 9–11).
MTA has been the material of
choice for sealing perforations,
retrograde preparations and apices
with irregular, not circular, morphology due to root resorption
or incorrect apical preparation. Its
superior features of marginal adaptation, biocompatibility, sealing
ability in wet environments, induc-

tion and conduction of hard-tissue
formation, and cementogenesis
with consequent formation of normal periodontal adhesion make it
the most suitable material for these
clinical situations. MTA Repair HP
is available in powder and liquid
form. It preserves all the features of
traditional MTA with the addition
of easier clinical handling. This last
property is due to a change in the
particle size of the MTA powder and
the addition of a plasticiser to the
liquid.

TRENDS & APPLICATIONS

Five months after microsurgery, the patient returned for
clinical and radiographic control.
Clinically, she did not complain
about pain or discomfort. Radiographically, a rapid repair of the
periapex of the three teeth involved
was observed (Fig. 12).

Conclusion
The chemical-mechanical preparation phase of the root canal
system is of utmost importance for

the success of endodontic therapy.
Operational errors at this stage, including transportation of the foramen, can dramatically compromise
the prognosis of a case.
Therefore, it is extremely important to prevent these. Depending on the severity of the error,
however, it can be repaired. Postoperative clinical and radiographic
control showed that microsurgical
complementation can be a safe and
predictable clinical option.

Editorial note: A list of references is
available from the publisher.

Leandro A.P.
Pereira is a professor at the
São Leopoldo
Mandic dental
school in Brazil. He can be
contacted at
leandroapp@gmail.com.
AD

[24] =>

Dental Tribune International

ESSENTIAL
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[cover] => DT Asia Pacific No. 11, 2016

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