DT Asia Pacific No. 12, 2015

Aussie scientists develop new coating to improve implants / World News / Opinion / What do our teeth betray about us?—Part II / Efficiently delivering full-mouth reconstructions / An innovative adhesive luting protocol / Endo Tribune Asia Pacific Edition

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DENTAL TRIBUNE
The World’s Dental Newspaper · Asia Pacific Edition
www.dental-tribune.asia

Published in Hong Kong

Vol. 13, No. 12

INTERVIEW

FULL-MOUTH RECONSTRUCTIONS

ENDO TRIBUNE

Sirona CEO Jeffrey T. Slovin about
the merger of his company with
DENTSPLY and its impact on the
global dental market.

How dental providers can provide
extraction, grafting and implant
placement within one appointment at one location.

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

” Page 2

” Page 12

” Page 17

Aussie scientists develop new
coating to improve implants

NZ heli
crash

By DTI

WELLINGTON, New Zealand: Last
month, the wreck of a helicopter was
found in a crevasse on Fox Glacier,
a glacier on the west coast of New
Zealand’s South Island. Although it is
still unclear what caused the crash, the
New Zealand Police have confirmed
that the pilot and the six passengers
died. On board the aircraft were a retired dentist from the UK and his wife.

MELBOURNE, Australia: Prebiotic
compounds, whose origin can be
traced back billions of years, have
been studied intensively since their
discovery several years ago. Now, a
team of researchers in Australia has
found that these prehistoric molecules can be used to modify surfaces
of medical implants, reducing the
risk of infection and rejection.

West Coast police released the
names of the people assumed to have
been on the helicopter when it crashed.
Among the victims were Britons
Nigel Edwin and Cynthia Charlton
from Hampshire. As reported online
by the Daily Mail, the 66-year-old
man was a retired dentist and his
70-year-old wife used to work in a
dental surgery in Totton in the UK.

The new coating method was developed by the Commonwealth Scientific and Industrial Research Organisation (CSIRO) in collaboration with microbiologists at Monash University.
Although surface modification
methods span a wide variety of applications, ranging from solar cells to
implantable medical devices, there
are very few simple generic aqueous
coating methods that are both robust and versatile, as well as easily
applicable over a range of substrate

By DTI

Dr Richard Evans has helped develop a coating for medical devices using prebiotic molecules.

materials, the researchers reported
in their paper. Therefore, they exam-

ined the suitability of the aminomalononitrile polymerisation process

for the formation of coatings on a
range of substrate materials. ” Page 3

The 28-year-old pilot, two young
women from New South Wales, and
another couple in their fifties from
Cambridge in the UK also died in the
crash.
AD

Victims of Pompeii
had excellent teeth
By DTI
NAPLES, Italy: To this day, researchers
have not been able to scan and
analyse the world-famous plaster
casts of the people and animals of
Pompeii who died in the volcanic
eruptions of Mount Vesuvius in AD
79. Now, with the help of a 16-layer
scanner, an interdisciplinary team
was able to create digital 3-D reconstructions of the skeletons and

Dental Tribune welcomes comments, suggestions and complaints
at newsroom@dental-tribune.com.
For quick access to
our contact form, you
may also scan the
following QR code.

dental arches of the volcano’s victims
for the first time.
Among other things, the scientific
tests, which included the use of a special multi-layer CT scanner, laser imaging and DNA sampling, revealed
that the city’s inhabitants had nearly
perfect teeth.
“We discovered the absence of
cavities in the teeth. This is very interesting and not that surprising, because we all know about the healthy
Mediterranean diet and this has really shown up in the early analyses,”
said Massimo Osanna, superintendent at the archaeological site.
According to the experts, the lack
of sugar in the Pompeian diet and the
high levels of fluorine in the air and
water near the volcano are all account-

able for the perfect state of their teeth.
In addition to an excellent oral health,
the researchers found that most of
the victims still had all their teeth.
However, the scans further showed
that the teeth wore away, because
they were used for cutting, orthodontist Dr Elisa Vanacore said.
The interdisciplinary research
project that began in April brought
together archaeologists, restorers,
radiologists, anthropologists and
many others. According to Osanna,
many more findings will emerge from
the analyses on most of the known
86 Pompeian casts:“It will reveal much
about the victims: their age, sex, what
they ate, what diseases they had and
what class of society they belonged to.
This will be a great step forward in our
knowledge of antiquity.”

Distinguished by innovation
Healthy teeth produce a radiant smile. We strive to achieve this goal on a daily basis. It inspires
us to search for innovative, economic and esthetic solutions for direct filling procedures and
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www.ivoclarvivadent.com
Ivoclar Vivadent AG
Bendererstr. 2 | FL-9494 Schaan | Liechtenstein | Tel.: +423 / 235 35 35 | Fax: +423 / 235 33 60

[2] =>

DTAP1215_01-03_Title 23.03.16 17:26 Seite 2

WORLD NEWS

Dental Tribune Asia Pacific Edition | 12/2015

“The global dental industry is in
the midst of a transformation”
An interview with Sirona President and CEO, Jeffrey T. Slovin

In September this year, DENTSPLY
International and Sirona Dental
Systems announced that they have
entered into a definitive merger
agreement, creating probably the
world's largest dental manufacturer, DENTSPLY SIRONA. Dental
Tribune spoke with Sirona President
and CEO, Jeffrey T. Slovin, who will
assume the role of CEO of the newly combined company, about the
merger and its impact on the global
dental market.
AD

Dental Tribune: Both Sirona and
DENTSPLY have been operating successfully in the dental market for
several decades. Why did the companies decide to join forces and
how will the companies benefit
from the merger?
Jeffrey T. Slovin: I am really excited
about the merger and so are the
dental professionals, distributors,
patients and employees from
around the world to whom I’ve
spoken.

As you know, the global dental
industry is in the midst of a transformation. The market is moving
toward more integrated solutions
and practitioners across the globe.
Furthermore, many practitioners
in new emerging markets are rapidly adopting digital dentistry.
Combining DENTSPLY and Sirona
will create the world’s leading
manufacturer of professional dental products and technologies,
strengthening our collective ability to be at the forefront of key
industry trends, help dental professionals improve patient care
and grow our business.
DENTSPLY and Sirona both have
strong commitments to innovation and research and development. In fact, we have collaborated
very successfully on product development with DENTSPLY in the past.
This merger is about harnessing
those shared strengths to create
new products with the aim of advancing patient care. Additionally,
Sirona’s technology and equipment offerings are complementary with DENTSPLY’s consumables
platform, enabling us to offer a
more robust product platform to
dental professionals and distribution partners.
Together, we will drive better,
faster and safer dentistry around
the world.
The new company will be the world’s
leading manufacturer of professional dental products and technologies. How will this affect the
global dental industry?
After the merge, DENTSPLY
SIRONA will be a stronger and
larger global company with a
broader product platform, deeper
focus on innovation and the largest
sales and services infrastructure
in the dental industry. When you

PUBLISHER:
Torsten OEMUS
GROUP EDITOR/MANAGING EDITOR DT AP & UK:
Daniel ZIMMERMANN
newsroom@dental-tribune.com
CLINICAL EDITOR:
Magda WOJTKIEWICZ
ONLINE EDITOR:
Claudia DUSCHEK

consider how much the global dental industry has recently changed,
it should be expected that dentistry would continue its rapid
evolution. Today, general practitioners are taking on more specialized procedures that require
integrated workflows with consumables and equipment that enhance their efficiency and patient
care offering. You’re also seeing an
increasing demand for dental care
from developing and emerging
markets. We expect these needs
to continue evolving and that
DENTSPLY SIRONA will provide solutions to address their continuous
needs.

Jeffrey T. Slovin.

IMPRINT

With our combined focus on
innovation and research and development, DENTSPLY SIRONA is
very well positioned to meet both
the current demands of the global
dentistry industry, as well as anticipate and address future demands. Coupled with the largest
sales and services infrastructure
in the dental industry and supported by leading dental distributors and a direct sales force, we will
be able to serve the dental industry
more effectively worldwide. The
merger is truly a win for everyone
involved.
The merger is expected to be completed in the first quarter of 2016.
Which regulations or closing conditions could still prevent a definitive
merger?
The transaction is currently on
track with the aim to complete the
process in the first quarter of 2016.
There are, as with any transactions,
certain regulatory approvals and
other customary closing conditions that we must achieve first.
These include anti-trust clearance
in the US, Europe and other
countries, all of which are outlined
in our SEC filings. We are confident that we will receive these approvals and the approval of our
shareholders and we look forward
to closing the transaction. Until
then however, both DENTSPLY and
Sirona will continue to run their
business as usual as separate entities.
Are you looking into opportunities
to acquire other dental companies?
Right now we are focused on
continuing to run the business
and execute our Sirona strategy
successfully, while also working
toward closing the merger with
DENTSPLY. Our future is full of opportunity and we are working hard
to deliver on that promise to our
employees, patients and the entire
dental community.
Thank you very much for this interview.

ASSISTANT EDITORS:
Anne FAULMANN, Kristin HÜBNER
COPY EDITORS:
Sabrina RAAFF, Hans MOTSCHMANN
PRESIDENT/CEO:
Torsten OEMUS
CFO/COO:
Dan WUNDERLICH
MEDIA SALES MANAGERS:
Matthias DIESSNER
Peter WITTECZEK
Maria KAISER
Melissa BROWN
Weridiana MAGESWKI
Hélène CARPENTIER
Antje KAHNT
MARKETING & SALES SERVICES:
Nicole ANDRAE
ACCOUNTING:
Karen HAMATSCHEK
BUSINESS DEVELOPMENT:
Claudia SALWICZEK
EXECUTIVE PRODUCER:
Gernot MEYER
AD PRODUCTION:
Marius MEZGER
DESIGNER:
Franziska DACHSEL
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.
DENTAL TRIBUNE INTERNATIONAL
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Tel.: +49 341 48474-302
Fax: +49 341 48474-173
info@dental-tribune.com
www.dental-tribune.com

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All rights reserved. Dental Tribune makes every
effort to report clinical information and manufacturer’s product news accurately, but cannot assume
responsibility for the validity of product claims,
or for typographical errors. The publishers also do
not assume responsibility for product names or
claims, or statements made by advertisers. Opinions
expressed by authors are their
own and may not reflect those
of Dental Tribune International.
Scan this code to subscribe
our weekly Dental Tribune AP
e-newsletter.

[3] =>

ASIA PACIFIC NEWS

Dental Tribune Asia Pacific Edition | 12/2015

Deviation between
implant positions found
By DTI
HANGZHOU, China: In measuring
the effect of surgical templates on
the accuracy of implant placement,
a Chinese study recently found
that actual and planned implant
positions varied significantly. According to the researchers, errors in
computer-guided implant surgery
are caused by either the operator
during surgery or the surgical template preoperatively.
In order to evaluate the effect of
surgical templates on the accuracy
of implant placement, jaws from
16 patients were scanned using
cone beam computed tomography
(CBCT). Fifty-three implants were
planned in a virtual 3-D environment, of which 35 were placed
in the mandible and 18 in the
maxilla.

ated. The template was then fitted
on a plaster model and both were
scanned with a CBCT device. The

images obtained were matched to
images of the virtual planned implant position. The actual implant

position was acquired from the
registration position of the surgical
template.
In comparing the data, the researchers found significant deviation between actual and planned
positions caused by the surgical
template. The mean central deviation at the hex and apex was
0.456 mm and 0.515 mm, respectively. The mean horizontal de-

viation at the hex was 0.193 mm
and at the apex was 0.277 mm.
The mean vertical deviation at the
hex was 0.388 mm and at the apex
was 0.390 mm. The mean angular
deviation was 0.621°.
The results of the study indicate
that clinicians should not rely
solely on the safety of surgical templates in seeking to avoid critical
anatomical structures.
AD

Tetric N-Ceram Bulk Fill
®

The nano-optimized 4-mm composite

Discover the new

For the analyses, a stereolithographic surgical template was cre-

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composite

Page 1

They found that this polymerisation, carried out in buffered
aqueous solutions, can be used to
coat a wide range of organic and
inorganic substrate materials.
The coating is biofriendly and
cells readily grow on and colonise it
and could therefore be applied to
medical devices, such as dental implants, catheters and pacemakers
to improve their performance and
acceptance by the body, according
to the researchers.

4 mm

“The non-toxic coating is adhesive and will coat almost all
material, making its potential
biomedical applications really
broad,” said lead research Dr
Richard Evans. “This research opens
the door to a host of new biomedical possibilities that are yet to be
explored.”
As the coating process is very
simple and uses methods and substances that are already available,
biomedical manufacturers can
produce improved results more
cost effectively compared with existing techniques.
CSIRO is the first organisation to
investigate practical applications
of this kind using prebiotic chemistry. It is currently seeking to partner with manufacturers to exploit
this technology.
The study, titled “Prebioticchemistry inspired polymer coatings for biomedical and material
science applications”, was published online on 13 November in
the NPG Asia Materials journal.

4 mm to success
• Bulk filling is possible due to Ivocerin®, the patented light initiator
• Special filler technology ensures low shrinkage stress
• Esthetic results are achieved quickly and efficiently in the posterior region

www.ivoclarvivadent.com
Ivoclar Vivadent AG
Bendererstr. 2 | 9494 Schaan | Liechtenstein | Tel.: +423 235 35 35 | Fax: +423 235 33 60

[4] =>

OPINION

04

Dental Tribune Asia Pacific Edition | 12/2015

“Must have been
a rough year.”

AD

Visit:
www.promedica.de
for detailed information
regarding our upcoming
exhibitions

Light-curing nano-ceram composite
 highly esthetic and biocompatible
 universal for all cavity classes
 comfortable handling, easy modellation
 also available as flowable version

Glass ionomer filling cement
 perfect packable consistency
 excellent durable aesthetics
 also available as application capsules

Temporary crown & bridge material
 less than 5 min. processing time
 strong functional load
 perfect long-term aesthetics
 excellent biocompatibility
Visit www.promedica.de to see all our products

Dental Material GmbH
24537 Neumünster / Germany
Tel.
+49 43 21 / 5 41 73
Fax
+49 43 21 / 5 19 08
eMail
info@promedica.de
Internet www.promedica.de

[5] =>

WORLD NEWS

Dental Tribune Asia Pacific Edition | 12/2015

Study conﬁrms CBT
to be successful in
reducing dental phobia
By DTI

because they require urgent dental treatment or they are having

particularly invasive treatments,”
Newton said.

LONDON, UK: The latest government figures estimate that one in
ten people in the UK suffer from
dental anxiety. New research from
King’s College London involving
pre-treatment use of cognitive
behavioural therapy (CBT) has
shown that the method is largely
effective in helping patients overcome their fear of treatment.
In a study involving patients
suffering from high levels of dental phobia, the researchers found
that the overall majority were
able to undergo treatment without sedation after having undergone therapy at the Dental Institute Health Psychology Service at
Guy’s and St Thomas’ NHS Foundation Trust. Only six per cent of
the patients surveyed had to be
treated with sedation.
“Our study shows that after on
average five CBT sessions, most
people can go on to be treated by
the dentist without the need to be
sedated,” said Tim Newton, lead
author and Professor of Psychology as Applied to Dentistry.

PRINT
L
DIGITA N
TIO
A
C
U
D
E
EVENTS

A short-term therap, CBT has
been shown to help with depression and a number of anxietyrelated disorders, such as obsessive–compulsive disorder and
bulimia. Typically, over six to ten
sessions, a therapist aims to help
patients change their feelings and
behaviours by restructuring their
thinking and breaking negative
thought cycles.
According to the researchers, the
most common anxiety-inducing
factors in the study were identified as drilling and having an
injection.
Newton recommended that,
despite the positive outcome, CBT
should be viewed as comple menting sedation services rather
than as an alternative, the two
together providing a comprehensive care pathway for the ultimate
benefit of patients. Furthermore,
patients should be carefully assessed by trained CBT practitioners, since they could be suffering
from additional psychological
conditions.
Over one-third of those patients surveyed in the study
showed signs of general anxiety,
while one in ten had depression
or suicidal thoughts.
“CBT provides a way of reducing
the need for sedation in people
with a phobia, but there will
still be those who need sedation

With CBT a therapist aims to help patients change their feelings and behaviours
by restructuring their thinking and breaking negative thought cycles.

The DTI publishing group is composed of the world’s leading
dental trade publishers that reach more than 650,000 dentists
in more than 90 countries.

[6] =>

WORLD NEWS

Dental Tribune Asia Pacific Edition | 12/2015

“Dentists can use social media as a very
powerful tool”
An interview with book author Sara Natt och Dag, Sweden
Just as social media has become
a part of everyday life, so too has
it entered the health sector. With
patients blogging about dental
visits and practitioners promoting
their business on Facebook, a number of legal and ethical issues arise.
Dental Tribune had the opportunity to speak with book author and
health counsellor Sara Natt och
Dag about the possibilities and
risks entailed in the use of social
media in health care.
Could you describe how social
media has found its way into the
health sector over the last several
years?
Sara Natt och Dag: In Europe,
social media began to influence

A blog can offer support and
comfort to terminally ill people,
but this frankness certainly poses
new challenges for health care
professionals. I meet many sick
people who run blogs and always
advise them not to write when
they are upset or disappointed.
Instead, I tell them to talk to
the doctor or the nurses about
their feelings instead of posting
it online.

health care maybe seven or eight
years ago, whereas in the US it
started maybe ten years ago, and
its importance is growing exponentially. It has become normal
for health care and social media
to be interlinked. In Sweden, for
example, the e-health sector already plays an important role.
From scheduling a doctor’s appointment to ordering medication, one can do virtually everything online.
However, the dental industry
appears to have been a bit slower
than the rest of the sector. The
importance of social media in
dentistry has exploded in the
last year especially. Although

Sara Natt och Dag

there is probably no such thing as
private dental blogs, dental topics
are creeping into the lifestyle industry with people writing about
orthodontic and aesthetic treatments to a large extent.

So, there is a great deal of information—both professional and personal—available on the Internet?
In the Western world, most people have access to the Internet at
home and virtually everywhere.
Thus, they have access to unlimited information from all over the
world. However, regarding health

In other areas, as I mentioned
earlier, health topics are starting
to overlap with lifestyle topics.
One can find review videos for
whitening strips on YouTube,
people talking about their latest
dental appointment on Facebook
and so on. For many young people, it is natural to share their
personal experiences. Medical
professionals can take advantage
of this as a way to better understand and familiarise themselves
with what patients are doing and
thinking.
Would you agree that this trend
has great potential, both positive
and negative?
Yes, absolutely. If a lifestyle
blogger writes about his or her
dental appointment, with the
name of the dentist tagged, and
does that several times, the den-

“It is all about standing
out from the crowd
and showing
some personality.”
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topics a lack of boundaries may
be a matter of concern. Take cancer blogs, for example. In Sweden,
there are many of these types of
personal blogs, where patients
share everything about their diagnosis, treatment plan, medication, set-backs, feelings—everything. I have followed some of
these patients until their death
on their blogs. They share their
personal disease progression
with the whole world and that is
a bit crazy, I think.
As a counsellor at Karolinska University Hospital, you have met many
of these disease bloggers and even
written a book, Den bloggande
patienten [The Blogging Patient]
(2013), on the subject. What is it that
makes people turn to the Internet
with their health issues?

tist will rank higher in search engines. Even one person can make
a difference—is that not crazy?
A Swedish lifestyle blogger just
recently wrote about her dental
treatment and how fantastic her
dentist is. She has about 200,000
readers, so you can imagine what
happened. The dentist, in turn,
published a link to her posts on
the clinic website, because he was
proud of being mentioned by an
online “celebrity”. This demonstrates the interconnectedness of
social media channels—which
can be very good and also very
bad for one’s reputation, depending on what was written online.
Focusing on the advantages: how
can dentists use social media most
effectively to promote their busi-

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[8] =>

WORLD NEWS

ness or to stay in touch with the
dental community?
Social media is a fantastic way
to promote a business, but every
dentist must be aware of the risk
and most importantly be fa miliar with the legal regulations.
In most countries, patients’
rights are very strongly protected by law. Practitioners will
not be able to provide patient
information, such as name, age
and treatment details, online,
let alone case photographs. Even

Dental Tribune Asia Pacific Edition | 12/2015

“Dental topics are creeping into the lifestyle industry
with people writing about orthodontic
and aesthetic treatments to a large extent.”
if practitioners do have permission from the patient, they cannot share case details online, not

in health care. At least, it is illegal
in Sweden.

What should be taken into account
then? What is your advice for practitioners?

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It is as simple as thinking before publishing online. Dentists
who remain aware of their professional status at all times can use
social media as a very powerful
tool.
But if dentists are not allowed to
discuss cases and patients in particular, what could they write
about online?
They should promote themselves instead. Introduce themselves (including their education), their practice and the staff.
It is all about standing out from
the crowd and showing some personality. They could write about
their travels to conferences, for
example, send out Merry Christmas wishes, introduce new tools
that they have bought for the
practice; basically, it is about staying in touch with patients. One
does not have to post daily, but if
one writes regularly, maybe once
a week, it can be an excellent way
to promote one’s business.
Still one has to draw a definite
line between one’s professional
and private lives. One’s business
page is not the place to discuss
one’s children, one’s last holiday,
or feelings or personal opinions
regarding one’s patients. In social media, just like with any
professional doctor–patient relationship, it is all about defining
boundaries and maintaining
them.
How should health care professionals best respond when patients cross these boundaries and
write harmful comments online?
I am sure some people choose
to ignore these instead of confronting the writer. Personally,
I would rather address the matter
directly. However, I know many
colleagues who rather not respond. From a legal point, it can
be difficult to erase negative
comments from Facebook or the
Internet in general, so maybe it is
best to settle the issue privately.
But, as I said, people choose to
deal with such situations in different ways.
In the US, many dentists publish
dental news, research data and
practice information on their personal blogs too. Do you think
Europe will follow that lead in the
future?
I do not necessarily like that
approach, but I think Europe will
eventually follow suit. Bloggers
have already started to do just
that and further changes towards
an “Americanisation” of sorts can
be expected.
Thank you very much for the interview.

[9] =>

[10] =>

TRENDS & APPLICATIONS

Dental Tribune Asia Pacific Edition | 12/2015

What do our teeth betray about us?—Part II
By Dr Stanislav Cícha,
Czech Republic
In the first part of this article series,
I described the significance of individual teeth in terms of emotional
and health status, considering specifically the canines. In the second part,
I will focus on the premolars and molars. The first premolars represent our
desires and our own self, simply described with the words“I want”(Fig. 1).
The maxillary right first premolar
reflects how we would like to appear
on the outside and the left one represents our emotional desires.
The maxillary first premolars are
among the most frequently treated
teeth, with interventions ranging
from fillings to endodontic treatment, crowns and extractions (Fig. 2).
This does not come as a surprise,
since every day we are confronted
with notions perpetuated by the
media regarding how we should look
and what we should buy to reach this
ideal. Instead of fulfilling our true
emotional desires, we are urged to
follow the crowd.
The mandibular right first premolar
reflects the ability to realise our
goals and the left premolar shows
our ability to convey our feelings
and wishes in our environment.
With the first premolars, there arises

the question of orthodontic extractions. The author of the book
Quand les dents se mettent à parler
[When the teeth talk], Dr Michèle
Caffin, mentions that extractions of
first premolars weaken the sense
of self, and children with extracted
premolars tend to submit easily to
authority figures despite not wanting
to do so. I cannot confirm nor refute
this, as I have only had a few patients
who have undergone this treatment
and was not able to observe them
over a longer period.

The second premolars can be characterised by the sentence “I want to
create” or the term “our creative ego”
(Fig. 3). The maxillary right second
premolar represents our development in the outside world, our children and our hobbies, and the left
second premolar our natural abilities. The mandibular right second
premolar, similar to the adjacent
first premolar, reflects the ability to
realise our goals, particularly in our
professions. After the reconstruction of anodontia using an inlay

bridge, an indecisive young female
patient successfully finished school

to the great joy of her parents (Fig. 4).
In contrast, Figures 5 & 6 are photo-

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[11] =>

TRENDS & APPLICATIONS

Dental Tribune Asia Pacific Edition | 12/2015

10a

10e

graphs of patients who always used
to come second place in their career
progression.
The mandibular left second premolar indicates the assimilation of the
maternal energy in our lives. Lingual
inclination, the persistence of primary tooth #75 and its reinclusion
point to the situation in which a child
does not want to or cannot mature
into an adult. Behind this is often the
dominant influence of the mother,
similar to the case of retrusion of
tooth #22, which we learnt about in
the first part of this article series.
Fortunately, mothers generally do
not know about these effects. Thus,
after successful orthodontic treatment initiated by them and the subsequent realignment of the permanent second premolar, they are very
surprised by the transformation of
their once-obedient child with a selfconscious personality.
The first molars (Fig. 7) are closely
associated with the status that we
desire both in society and in our families. Fulfilling ideals to improve our
position in society is linked to the
maxillary and mandibular right first
molars, and they reflect our professional lives and our successes in this
regard. The patient shown in Figure 8
had to leave her beloved profession
owing to family circumstances. She
had to move and stay at home. After
having endodontic treatment performed on teeth #15 and 16, she
presented with a large periapical lesion on tooth #16 several years later
(Fig. 9). She probably has still not accepted her new situation.
The maxillary left first molar reflects
the expression of our feelings. As
this is often suppressed in our modern society, this tooth is treated very
often. The mandibular left first molar reflects our desire to be loved.

Dr Stanislav Cícha
is working as a
dentist in Prag
in the Czech Republic. He can
be contacted at
mojezubysro@
gmail.com.

10b

10c

This tooth is restored often and from
very early on, a sad finding in this
context. As an example, Figures
10a–e shows a female patient who
broke this tooth after a failed relationship. A radiographic examination revealed that all of the other
teeth remained intact.

10d

mentally and physically. I adopt a
very conservative approach towards
radical and preventive extractions
of the third molars because I consider them to play an important part
in the energy balance of the whole
organism.

In order to learn much more about
this topic, I recommend that you
read the latest edition of Quand les
dents se mettent à parler (Fig. 14).
I wish you many interesting discoveries in observing the manifestations of the professional and

emotional lives of your patients in
their teeth.
Editorial note: This is the second of a
two-part article which first appeared in
Cosmetic Dentistry 2/15. A complete list of
references is available from the publisher.
AD

The second molars reflect our relationships with the world around us
and in particular with our closest relatives (Fig. 11). Both right second molars reveal, through their status and
alignment, ordinary circumstances
of daily life. Long-term recurring situations, often considered trivial in
our contexts, that annoy us but that
we are not able to change may manifest in these teeth.
The left second molars can show how
harmonious the relationships with
our family members are. I had a juvenile patient who was struggling
to cope with an ongoing love triangle
in his family. Endodontic treatment
was indicated for his maxillary left
second molar, yet the entire dentition showed hardly any tooth decay
(Fig. 12). His brother, who did not
have to deal with such a situation,
did not have any dental problems. In
this context, I would like to emphasise that teeth reflect life circumstances according to the subjective
perception of the person concerned.

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As dentists, third molars are usually
of marginal interest to us, except for
surgeons and endodontists, who can
show off with perfectly filled root
canals of bizarre shapes in these teeth.
From a holistic perspective, however,
third molars express the individual
energy of a person (Fig. 13). The maxillary right third molar corresponds
to our efforts to contact the material
and spiritual worlds. The maxillary
left third molar represents the fear
of rejection by both these worlds.
The mandibular right third molar is
a barometer of our physical energy.
If one looks at the characteristics
of all third molars, one will discover
the typical adolescent problems a
young person faces at the time of
eruption of these teeth. For example,
I repeatedly see complicated eruptions of mandibular third molars in
students during the examination
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[12] =>

TRENDS & APPLICATIONS

Dental Tribune Asia Pacific Edition | 12/2015

Efﬁciently delivering full-mouth
reconstructions
By Dr Ara Nazarian, USA
Having the ability to take a patient
from point A to point Z in fewer appointments within one’s practice
allows one to position oneself as
a provider that can fulfil patient’s
surgical and restorative needs.
With the proper training, a dental
provider may provide extraction,
grafting and implant placement
within one appointment at one
location. Not only does this allow
the reduction of the number of
visits for the patient, but this type
of service also helps the patient
stay within his or her budget. Most
importantly, this enables the dental
provider full control of the surgical
and prosthetic outcome.
Depending on the patient’s desires, the clinical conditions of
the oral environment and the
skills of the dentist, the dentist
may choose to extract teeth, level
bone, and graft with simultaneous dental implant placement.
In this case, a patient in his mid-

sixties presented to the office
with discomfort owing to multiple
rampant caries and generalised
advanced periodontal disease

of these options did not complement the other, the patient
decided to come to us for full
treatment after being referred by

“An increasing number of patients
are presenting to dental practices
who seem to require
this type of reconstruction.”
(Figs. 1 & 2). Having already visited
multiple providers for a consultation, he was very frustrated with
the treatment options offered
with varying treatment plans
that were segmented into different disciplines. Since many

one of our patients who had undergone a Total Dental Solutions
Reconstruction.
Before the surgical appointment, a CBCT scan was taken to
accurately plan treatment for

this case to make certain that no
complications would arise from
completing all of the procedures
(extract, graft and implant place-

ment) in the Total Dental Solutions Reconstruction protocol.
coDiagnostiX software (Dental
Wings) was used through 3D Diagnostix virtual assistance to precisely plan the placement of six
Engage (OCO Biomedical) dental

Fig. 1: Retracted pre-op view.—Fig. 2: Pre-op panoramic radiograph.—Fig. 3: Maxillary virtual treatment plan.—Fig. 4: Mandibular virtual treatment plan.—Fig. 5: Engage
dental implant.—Fig. 6: Aseptico surgical motor.—Fig. 7: Using the pilot guide.—Fig. 8: Osstell ISQ unit.—Fig. 9: Good Fit Instant Custom Tray.—Fig. 10: Full-arch impression.—
Fig. 11: Post-op panoramic radiograph.—Fig. 12: Retracted post-op view.

implants in the maxillary arch,
as well as seven Engage dental
implants in the mandibular arch
using CT-based surgical pilot
guides (3D Diagnostix; Figs. 3 & 4).
The final treatment plan was
fixed bridges on implants in
the maxillary and mandibular
arches. Engage implants were selected (Fig. 5) because I have personally experienced their high
implant stability at placement,
which is a critical success factor
during the early healing process
of osseointegration with these
types of cases. With the combination of its patent-pending Bull
Nose Auger tip and Mini Cortic-O
Thread, this implant system offers practitioners a bone-level
implant with high initial stability
for selective loading options. In
fact, the Engage implant body
creates a tapping pattern when
threaded for an enhanced mechanical lock in the bone. Other
dental implant systems with aggressive threading may include,
but are not limited to, NobelActive (Nobel Biocare), SEVEN
(MIS Implants Technologies),
ET III (Hiossen), I5 (AB Dental) and
AnyRidge (Megagen).
For effectiveness and greater
proficiency during the Total Dental Solutions Reconstruction procedures, intravenous sedation
should be performed. Not only
does it make the appointment
easier, but patients also prefer to
have the treatment completed
in one visit. Since the patient is
sedated, a mouth prop is needed
to keep his or her mouth open. Because of this, teeth are extracted
in quadrants, starting from the
upper left to the upper right and
then down to the lower right and
lower left. This allows great timesavings, as it is easier to keep the
patient’s mouth open and be able
to proceed around the arches
safely. Once the teeth have been
extracted, the tissue has to be reflected in order to seat the bonelevel surgical guides and fix them
with their respective retention
pins. Using these pilot surgical
guides, the osteotomies for the
implants were begun with a
1.95 mm pilot drill utilising the
Mont Blanc surgical handpiece
(Anthogyr) and Aseptico surgical
motor (AEU 7000) at a speed of
1,200 rpm with copious amounts
of sterile saline (Figs. 6 & 7).
Paralleling pins were placed in
the sites of the osteotomies to
confirm the accuracy of the surgical guide and radiographs were
taken to check the angulations
of the pins within the maxilla
and the mandible. Once the
osteotomies were complete, an

[13] =>

TRENDS & APPLICATIONS

Dental Tribune Asia Pacific Edition | 12/2015

implant finger driver was used to
place the dental implants until
increased torque was necessary.
The ratchet wrench was then
connected to the adapter and the
implants torqued to final depths,
reaching a torque level of approximately 40–50 Ncm.
Adequate implant fixation was
further verified using an Osstell
ISQ (implant stability quotient)
meter, which uses resonance frequency analysis as a method of
measurement (Fig. 8). Several
studies have been conducted
based on resonance frequency
analysis measurements and the
ISQ scale. They provide valid indications that the acceptable stability range lies above 55 ISQ.
Extended healing caps were
hand tightened to the implants.
A postoperative radiograph was
taken of the implants and the
healing caps to ensure complete
seating. The immediate dentures
were soft relined with a siliconebased soft denture relining material (Ufi Gel SC, VOCO). Some of
the advantages I have personally
experienced with this material
are that it is biocompatible, tasteless and odourless. By using the
extended healing caps with the
soft reline, the immediate dentures were much more retentive.
The soft tissue and implants were
evaluated clinically after one
week. The patient stated that he
had had very little postoperative
discomfort or swelling.
Within ten days, the patient
returned to the practice. The soft
tissue around the extended healing caps had healed very nicely
with a healthy pink colour. Using
impression posts, full-arch impressions were taken with Instant
Custom C&B Trays (Good Fit).
These custom trays can be
adapted and fitted in minutes,
eliminating the need for models,
light-cured materials, monomers
and extra laboratory time for
custom impression tray fabrication because they are made of a
material (PMMA) that becomes
mouldable when heated (Fig. 9)
and maintains its shape while
cooling.
Once the trays had been
moulded for the patient, full-arch
impressions were taken using
a polyvinyl siloxane impression
material (Take 1 Advanced, Kerr;
Fig. 10). Bite relations, as well as instructions for size, shape and
colour of the full-arch provisionals, were forwarded to the dental
laboratory. With only a five-day
turnaround, the custom abutments and provisionals were forwarded to the dental office and
inserted. The patient was very
pleased with the aesthetics and
function of these provisional
restorations. He was instructed
about their care and use in eating,
speaking and biting.
Approximately four months
after the initial placement of
the dental implants, the patient returned for the definitive

porcelain-fused-to-metal restoration impressions. The provisional
restorations were removed using
the Easy Pneumatic Crown and
Bridge Remover (Dent Corp). Any
temporary cement was removed
and the abutments inspected.
If there was any settling or recession of the gingival tissue, the
abutments were modified using
a carbide bur with copious
amounts of water not to overheat
the abutments. This way, the margins could be brought right to or

to slightly below the free gingival
margin. A full-arch impression
was taken in a similar fashion for
the abutments and the provisionals. In addition, the relations between maxillary and mandibular
arches were captured. Within
three weeks, the porcelain-fusedto-metal restorations were inserted and a panoramic radiograph taken (Figs. 11 & 12).
In conclusion, an increasing
number of patients are present-

13
ing to dental practices who seem
to require this type of reconstruction. By providing multiple services in a shorter number of visits
with the use of CBCT and other
technologies, the dental provider
will find that more patients will
accept treatment. In doing so, not
only are you helping your patients regain proper form and
function, but you are also helping
them achieve a Total Dental Solutions Reconstruction in fewer
appointments.

Dr Ara Nazarian
maintains a private practice in
Troy in Michigan in the US
with an emphasis on comprehensive and
restorative care.
He has also conducted lectures and hands-on workshops on aesthetic materials and dental
implants throughout the US, Europe,
New Zealand and Australia.
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[14] =>

TRENDS & APPLICATIONS

Dental Tribune Asia Pacific Edition | 12/2015

An innovative adhesive luting protocol
All-ceramic anterior crowns (IPS e.max Press lithium disilicate) placed with Monobond Etch & Prime
By Prof. Claus-Peter Ernst,
Germany
Anterior crowns come in many different variations, from purely functional
to highly aesthetic, depending on the
requirements and means of the patient, the skill of the dental technician,
availability of materials, and preparation and cementation procedures
used. Many anterior crowns considered to be aesthetic in the past no
longer meet the demands of today’s
patients. The example detailed in this
article is a case in point.
When she presented to our practice, the 20-year-old high school
graduate wished to have the crowns
on her two central incisors replaced
(Fig. 1). At the age of 14, she had sustained anterior tooth trauma that apparently damaged the mesio-incisal
part of the incisal edges of both teeth.
The dentist she had consulted at that
time restored her teeth with porcelain-fused-to-metal (PFM) crowns.
Even though the extent of the
trauma can no longer be assessed,
today’s alternative—in light of the
patient’s young age in particular—
would most probably have been a
direct composite restoration.
Figure 2 shows the two central incisors in detail from the labial aspect
and Figure 3 shows an incisal view.
The crowns did not exhibit any functional defects. As a result, the main
treatment aim was to improve the
aesthetic appearance of the anterior
teeth as requested. Subsequently, the
patient was informed about the treatment procedure, in particular about
any possible additional preparation
requiring the removal of tooth structure, as well as the cost involved.
The treatment was begun at a separate appointment. The restorations
were fabricated by the dental laboratory of Hildegard Hofmann
(Mainz, Germany). Pressed all-ceramic IPS e.max lithium disilicate

Fig. 1: Unattractive, old porcelain-fused-to-metal restorations on teeth #11 and 21 in a 20-year-old patient.—Fig. 2: Close-up photograph of the functionally intact anterior
crowns showing unattractive PFM work due to the metal framework showing through.—Fig. 3: Incisal view of the existing crowns.—Fig. 4: The self-conditioning ceramic
primer Monobond Etch & Prime is scrubbed in for 20 seconds.—Fig. 5: Additional reaction time of Monobond Etch & Prime of 40 seconds.—Fig. 6: Apical view of the IPS e.max
Press lithium disilicate crown after Monobond Etch & Prime had been rinsed off.—Fig. 7: Conditioning of the prepared teeth for the adhesive cementation of the restorations
under cotton roll isolation. Retraction cords were placed in the sulcus to prevent any contamination with sulcular ﬂuids.—Fig. 8: Incisal view of the prepared teeth.—
Fig. 9: Application of Adhese Universal adhesive with the pen applicator.

(Ivoclar Vivadent) crowns were selected for this case, since they are the
first choice for this type of indication.
This has been confirmed by numerous
clinical studies, including the recently
published German S3 Clinical Practice
Guideline on ceramic restorations.
The teeth were anaesthetised at
the placement appointment. The
crowns were removed and the bonding surfaces were carefully cleaned
with ultrasound and a fluoride-free
cleaning paste. Since the new Variolink Esthetic DC (Ivoclar Vivadent)
had been chosen as the luting material, the crowns were tried in with
the corresponding try-in pastes. An
immediate match to the adjacent
and the mandibular anterior teeth

was achieved with the Neutral shade.
No adjustments were necessary with
regard to a lighter (Light) or darker
(Warm) shade of the luting composite. We attributed this excellent
match to the dental technician having selected the shade at the chairside. The extra expense of this step
far outweighs the inconvenience of
having to make numerous adjustments or new restorations because
of a shade mismatch.

Conditioning
of the crown
Saliva and residue of the try-in
paste were removed (Ivoclean,

Fig. 10: Light polymerisation of the adhesive after careful distribution with blown air.—Fig. 11: The polymerised adhesive layer
on teeth #11 and 21.—Fig. 12: The IPS e.max Press lithium disilicate crowns, cemented with Variolink Esthetic DC, at the follow-up
examination after four weeks.—Fig. 13: Incisal view of the crowns at the follow-up examination after four weeks.

Ivoclar Vivadent) from the crowns
before they were conditioned. It is
advisable to fabricate a “handle” to
allow the inner crown surfaces to be
conditioned without having to touch
the crown with the fingers. In this
case, the crowns were attached to a
brush holder with a light-curing provisional composite. This handle also
allowed the crowns to be placed with
ease during the luting procedure. As
an alternative, an OptraStick (Ivoclar
Vivadent) could have been used. Hydrofluoric acid etching of glass-based
ceramics and subsequent silanisation has been an accepted conditioning method for decades. The newest
studies confirm its effectiveness. It
even generates a strong bond on
state-of-the-art ceramic materials
such as hybrid ceramics. An acid concentration of 5 % has been established, which represents a reasonable
compromise according to the latest
research.
The new Monobond Etch & Prime
(Ivoclar Vivadent), which was introduced at the 2015 International Dental
Show, is a conditioning material based
on ammonium polyfluoride. The
product is actively scrubbed on the
bonding surface (Fig.4)for 20 seconds,
thereby removing any contamination with saliva or silicone. After another 40 seconds (Fig. 5), the ammonium polyfluoride reacts with the
ceramic surface and produces a rough
etching pattern. Even though this
pattern is not as pronounced as that
of conventional 20 seconds etching
with 5 % hydrofluoric acid, the bonding results achieved in both cases are
comparable. The enlarged surface
created in this way helps to activate
the ceramic bonding surface.

The restoration is subsequently
rinsed to remove the ammonium
polyfluoride and its reaction products.
The reaction of the silane and the activated glass-ceramic then begins.
A thin layer of chemically bonded
silane remains on the ceramic after its
distribution with blown air. This product, therefore, combines the steps of
hydrofluoric acid etching and silanisation and it even appears to render
cleaning with Ivoclean superfluous.
The currently available in vitro data
justifies using this new product with
due care to replace the hydrofluoric
acid etching and silanising method.
Even though it has not been shown
to improve the bonding values in relation to the established references,
no negative effects on the adhesive
bond have been found to date either.
Moreover, since the adhesive bond to
glass-ceramics is considered to be the
most unproblematic interface in the
bonding process of indirect restorations, no clinical irregularities are to
be expected.
In the case presented, the crowns
could even have been placed by conventional or self-adhesive means. The
loss of retention would have been as
unlikely as the occurrence of a ceramic
fracture due to inadequate adhesive
support. Figure 6shows one of the two
crowns after Monobond Etch & Prime
had been rinsed off and the surface
dried with blown air.

Cementation
of the crowns
Variolink Esthetic DC was used for
the adhesive cementation of the

[15] =>

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[16] =>

TRENDS & APPLICATIONS

Fig. 14: Frontal view of the anterior teeth.
A signiﬁcant aesthetic improvement
over the initial situation was achieved.

crowns. As this luting system is a full
adhesive, sufficient moisture control
must be ensured. Owing to the equigingival preparation margin, the
healthy condition of the gingiva and
the excellent cooperation of the
patient, the placement of a rubber
dam was not essential. Therefore,
cotton roll isolation was used to
seat the crowns. Two retraction cords
(Ultradent Products) were placed
to prevent any contamination with
sulcular fluids (Figs. 7 & 8).

The bonding surfaces were cleaned
with a fluoride-free prophy paste.
Next, Adhese Universal adhesive
(Ivoclar Vivadent) was applied from
the pen applicator (Fig. 9). The remaining thin enamel margin was
not etched, in order to prevent any
gingival bleeding. Adhese Universal
was scrubbed into the conditioned
tooth surface for >20 seconds as
stated in the directions for use. According to the manufacturer, this
time should not be reduced, as it is

Dental Tribune Asia Pacific Edition | 12/2015

not sufficient to simply paint the adhesive on to the tooth surface. Next,
the adhesive was dried with blown air
until an immobile, glossy film was
left. The adhesive was then light
cured for 10 seconds (Fig. 10).
Since the universally compatible
adhesive forms a considerably thinner film than does Heliobond (Ivoclar
Vivadent), for example, it can be light
cured without encountering any
subsequent problems of fit or bite

AD
15

Fig. 15: Photograph of the satisﬁed patient.

elevation. The polymerised adhesive
layer on teeth #11 and 21 is visible in
Figure 11. Figures 12 and 13 show the adhesively cemented IPS e.max lithium
disilicate crowns at the final follow-up
appointment, four weeks after the
treatment. The gingiva was free from
any irritation and the crowns blended
in smoothly with the surrounding
teeth. The tremendous improvement
in the appearance of the anterior teeth
achieved with the all-ceramic restorations on teeth #11 and 21 is visible in
the close-up photograph shown in
Figure 14. For the first time in many
years, the patient dared to smile again
(Fig. 15).

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Since the etching time has a significant influence on the strength of the
ceramic when hydrofluoric acid is
used to condition ceramic restorations, the specifications of the manufacturer must be strictly observed.
IPS e.max Press lithium disilicate
should be etched for 20 seconds if
5 % hydrofluoric acid is used. Other
conventional glass-ceramics require
60 seconds of etching. DeguDent
(DENTSPLY) recommends that its
material CELTRA be etched for 30 seconds. The reaction time of Monobond
Etch & Prime is 60 seconds on all types
of ceramics. Thus, it offers a first step
in the direction of error prevention. It
remains to be seen whether external
studies can confirm the effectiveness
of the product in establishing an adhesive bond on ceramics other than
those from Ivoclar Vivadent.

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It takes quite a bit of courage to use
innovative products and procedures,
such as those described in this article.
Adequate clinical data is not yet available, let alone the much-needed longterm studies. Nonetheless, a start
must be made somewhere. For those
dental practitioners who would like to
be rid of hydrofluoric acid sooner
rather than later, the described selfconditioning glass-ceramic primer
may offer a viable option.

SDI Limited
Telephone +61 3 8727 7111
Info@sdi.com.au
Fax +61 3 8727 7222

PNG - Meddent - Tel: + 675 320 3718
Cambodia - Pro Dent Trading Co., Ltd.
- Tel: +855 23 883 179
Singapore - Eastland Dental - Tel: 6296 5660
Philippines - GDS Dental Supply - Tel: +632 631 3316
Myanmar - Silver Lotus - Tel: + 95 1 290 847
New Caledonia - EURL IDEM - Tel: + 687 286511

Hong Kong - Horseley - Tel: 2889 1218
Sri Lanka - Yu & Co - Tel: + 94 11 269 1740
India - Dental Avenue - Tel: + 91 22 6699 7599
Pakistan - Al Qiam Traders - Tel: + 92 423 732 3049
Vietnam - Vietdan - Mobile Tel: + 84 9095 04034
Malaysia - Indra Sari Trading - Tel: + 603 5121 7193
Thailand - Shanghai Dental - Tel: + 66 2 866 3477

Pola Ofﬁce+: The world’s fastest bleach: Based on the total treatment time compared to that of all other competitor’s printed literature. THE DENTAL ADVISOR, Vol. 25, No. 9, November 2008.

Prof. Claus-Peter
Ernst works at
the Johannes
Gutenberg University of Mainz
Medical Center’s
policlinic for restorative dentistry in Mainz in
Germany. He can
be contacted at ernst@uni-mainz.de.

[17] =>

ENDO TRIBUNE
The World’s Endodontic Newspaper · Asia Pacific Edition
www.dental-tribune.asia

Published in Hong Kong

Vol. 13, No. 12

Irrigation dynamics in root canal therapy
By Prof. Anil Kishen, Canada
Irrigation dynamics deals with the
pattern of irrigant flow, penetration,
exchange and the forces produced
within the root canal space. Current
modes of endodontic irrigation include the traditional syringe needle
irrigation or physical methods, such
as apical negative-pressure irrigation or sonic/ultrasonically assisted
irrigation. Since the nature of irrigation influences the flow of irrigant
up to the working length (WL) and
interaction of irrigant with the canal
wall, it is mandatory to understand
the irrigation dynamics associated
with various irrigation techniques.
Endodontic irrigants are liquid
antimicrobials used to disinfect
microbial biofilms within the root
canal. The process of delivery of endodontic irrigants within the root
canal is called irrigation. The overall
objectives of root canal irrigation
are to inactivate bacterial biofilms,
inactivate endotoxins, and dissolve
tissue remnants and the smear
layer (chemical effects) in the root
canals, as well as to allow the flow of
irrigant entirely through the root
canal system, in order to detach the
biofilm structures and loosen and
flush out the debris from the root
canals (physical effects). While the
chemical effectiveness will be influenced by the concentration of
the antimicrobial and the duration
of action, the physical effectiveness
will depend upon the ability of
irrigation to generate optimum
streaming forces within the entire
root canal system.
The final efficiency of endodontic disinfection will depend upon
both chemical and physical effectiveness.1–3 It is important to realise
that even the most powerful irrigant will be of no use if it cannot penetrate the apical portion of the root
canal, interact with the root canal
wall and exchange frequently
within the root canal system.1

as closed-ended and open-ended
needles. In the case of open-ended
needles (flat, bevelled, notched),
the irrigant stream is very intense
and extends apically along the
root canal. Depending upon the
root canal geometry and the depth
of needle insertion, reverse flow of
irrigant occurs near the canal wall
towards the canal orifice.
1a

1b

1c

1d

Figs. 1a–d: Velocity magnitude of irrigation showing the extent of dead zone. With the open-ended needle tip (a), the velocity
progressively decreased 1.5 mm apical from the tip. With the side-vented needle tip (b), there was a much lower velocity than with
the open-ended tip, and it extended only 0.5 mm. With the apical negative-pressure irrigation (c), there was a constant velocity
slightly higher than the side-vented needle irrigation that was constant as the irrigant moved coronally. The ultrasonically
assisted irrigation (d) showed the highest magnitude of velocity, constant to at least 3 mm coronal to the tip placement.35

where it is evacuated. A detailed
understanding of the irrigation
dynamics associated with syringebased irrigation would aid in improving its effectiveness in clinical
practice.
Irrigant flow during
syringe irrigation
The flow of irrigants is influenced by its physical characteristics, such as density and viscosity.5
These properties for the commonly used endodontic irrigants

are very similar to those of distilled
water.6, 7 The surface tension of endodontic irrigants and its decrease
by surfactants have also been studied extensively. The rationale of
this combination is that it may
significantly affect (a) the irrigant
penetration into dentinal tubules
and accessory root canals8, 9 and
(b) the dissolution of pulp tissue.10
However, it is important to note
that surface tension would only influence the interface between two
immiscible fluids, and not between
the irrigant and dentinal fluid.5, 11

Experiments have confirmed that
surfactants do not enhance the
ability of sodium hypochlorite to
dissolve pulp tissue12, 13 or the ability of chelating agents to remove
the smear layer.14, 15
The type of needle used has a significant effect on the flow pattern
formed within the root canal, while
parameters such as depth of needle
insertion and size or taper of the
prepared root canal have only a limited influence.16–19 Generally, the
available needles can be classified

In the case of closed-ended needles (side-vented), the stream of irrigant is formed near the apical side
of the outlet and is directed apically. The irrigant tends to follow
a curved route around the needle
tip, towards the coronal orifice. The
flow of irrigant apical to the exit of
the needle is generally observed
to be a passive fluid flowing zone
(dead zone), while the flow of irrigant in the remaining aspect of the
root canal is observed to be an active fluid flowing zone (active zone;
Figs. 1a–d & 2a–d). A series of vortices of flowing irrigant are generated apical to the tip. The velocity
of irrigant inside each vortex decreases towards the apex.
Large needles when used within
the root canal hardly penetrate beyond the coronal half of the root
canal. Currently, smaller-diameter
needles (28- or 30-gauge) have been
recommended for root canal irrigation.20, 21 This is mainly because of
their ability to advance further up
to the WL. This facilitates better irrigant exchange and debridement.22–24
In addition, the use of a larger needle would result in decreased space
being available for the reverse
flow of irrigant between the needle
and the canal wall. This scenario
has been associated with (a) an
increased apical pressure for openended needles and (b) decreased
irrigant refreshment apical to the
tip for closed-ended needles.17, 19
The influence of tooth location
(mandibular, maxillary) on irrigant flow has been observed to be
minor.16, 25
Irrigant refreshment

Syringe irrigation
Irrigation methods are categorised as positive-pressure or
negative-pressure, according to
the mode of delivery employed.4
In positive-pressure techniques,
the pressure difference necessary
for irrigant flow is created between
a pressurised container (e.g. a syringe) and the root canal. In negative-pressure techniques, the irrigant is delivered passively near the
canal orifice and a suction tip (negative-pressure) placed deep inside
the root canal creates a pressure
difference. The irrigant then flows
from the orifice towards the apex,

2a

2b

2c

2d

Figs. 2a–d: Time-averaged distribution of shear stress on the root canal wall showing a more uniform distribution on the canal
wall with the open-ended needle tip (a). The side-vented needle tip (b) showed a localised region with a high amount of shear
stress, while there was not an observable level with the EndoVac irrigation (Kerr; c). The ultrasonically assisted irrigation (d)
displayed the highest levels of shear stress over the greatest area of the canal wall.35

Irrigant exchange in the root
canal system is a key prerequisite
for achieving optimum chemical
effect, because the chemical efficacy of the irrigants are known to
be rapidly inactivated by dentine,
tissue remnants or microbes.24, 26, 27
Investigations have explained the
limitations in the irrigant refreshment apical to needles.21, 28–30 Enlarging the root canal to place the
needle to a few millimetres from
the WL and ensuring adequate
space around the needle for reverse
flow of the irrigant towards the
canal orifice allow effective irrigant
refreshment coronal to the needle
tip.17, 19 Furthermore, increasing the

[18] =>

ENDO NEWS

18
volume of irrigant delivered could
help to improve refreshment in
such cases.20, 31, 32

expected even in severely curved
canals.
Wall shear stress

The effect of curvature on irrigant exchange has been studied indirectly by Nguy and Sedgley.33
They report that only severe curvatures in the order of 24–28°
hampered the flow of irrigants. If
the canal is enlarged to at least size
30 or 35 and a 30-gauge flexible
needle placed near the WL is used,
then irrigant refreshment can be

The frictional stress that occurs
between the flowing irrigant and
the canal wall is termed “wall shear
stress”. This force is of relevance in
root canal irrigation because it
tends to detach microbial biofilm
from the root canal wall. Currently,
there is no quantitative data on the
minimum shear stress required for

the removal of microbial biofilm
from the canal wall. Yet, the nature
of wall shear stresses produced
within the root canals during irrigation provides an indication of the
mechanical debridement efficacy.
In open-ended needles, an area of
increased shear wall stresses develops apical to the needle tips, while
in closed-ended needles, a higher
maximum shear stress is generated
near their tips, on the wall facing the
needle outlet.34 Thus, in open- and

Endo Tribune Asia Pacific Edition | 12/2015

closed-ended needles, optimum debridement is expected near the tip
of the needle.16, 34 Consequently, it is
necessary to move the needle inside
the root canal, so that the limited
area of high wall shear stress involves as much of the root canal wall
as possible. The maximum shear
stress decreases with an increase in
canal size or taper. Thus, overzealous root canal enlargement above a
certain size or taper could diminish
the debridement efficacy of irrigation (Figs. 1a–d & 2a–d).

The Dental Tribune International
C.E. Magazines

Enhancing
irrigation dynamics
using physical
irrigation methods
Fluid dynamics studies on apical
negative-pressure irrigation have
demonstrated maximum apical
penetration of the irrigant, without
any irrigant extrusion. This finding
highlights the ability of apical negative-pressure irrigation to be safely
used at the WL, circumventing the
issues of vapour lock effect.35 Nonetheless, the apical negative-pressure
irrigation produced the lowest wall
shear stress. This decrease in the wall
shear stress could be attributed in
part to the reduction in the flow rate
with this irrigation system.
Passive ultrasonically assisted irrigation, when compared with other
irrigation methods, showed the
highest wall shear stress along the
root canal wall, with the highest turbulence intensity travelling coronal
from the ultrasonic tip position. The
lateral movement of the irrigant
displayed by this method has important implications with respect to
its ability to permit better interaction between the irrigant and the
root canal wall, and to potentially
enhance the interaction of irrigants with intra-canal biofilms2, 3, 35
(Figs. 1a–d & 2a–d).

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In the case of a closed-ended needle, placement should be within
1 mm short of the WL, so that optimum irrigant exchange can be ensured. The apical negative-pressure
irrigation did not generate marked
wall shear stress values, but allowed
the flow of irrigant consistently up to
the WL. It was the safest mode of irrigation when used close to the WL. The
passive ultrasonically assisted irrigation generated the highest wall shear
stress. The use of combined methods
to obtain optimum disinfection and
to circumvent the limitations of one
method is recommended.
Editorial note: A list of references is available from the publisher.

Credit Card
Credit Card Number

The requirements of adequate irrigant penetration, irrigant exchange,
mechanical effect and minimum risk
of apical extrusion oppose each other
and a subtle equilibrium is required
during irrigation. Ideally, in a canal
enlarged to size 30 or 35 and taper
0.04 or 0.06, an open-ended needle
should be placed 2 or 3 mm short of
the WL to ensure adequate irrigant
exchange and high wall shear stress,
while reducing the risk of extrusion.

Expiration Date

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fax: +49 341 48474 173 | e-mail: subscriptions@dental-tribune.com

Anil Kishen obtained his dental education in
India and is Professor of Endodontics at the
University of
Toronto’s Faculty of Dentistry
in Canada. He can be contacted at
anil.kishen@dentistry.utoronto.ca.

[19] =>

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does not approve or endorse individual courses or instructors, nor does it
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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 provincial board of
dentistry or AGD endorsement.

[20] =>

TRENDS & APPLICATIONS

Endo Tribune Asia Pacific Edition | 12/2015

Use of mineral trioxide aggregate in
endodontic retro-ﬁlling
By Fernanda Maria Klimpel, Brazil
Mineral trioxide aggregate (MTA) is
an endodontic sealer that emerged
on the market in 1998. Through
proven scientific results it has became
the true miracle of endodontics. An
excellent sealing material, it provides
setting expansion and integrity of the
seal owing to low solubility, tissue
biocompatibility and high biological
regeneration. The release of calcium
ions provides antibacterial activity. Its
radiopacity is excellent, and it can be
used for thermal condensation owing
to its melting point of 150 °C.
MTA also has good capacity for
adhesion to dentine, making it resistant to the forces of displacement, and greater sealing power
than other cements when tested to
assess the quantity of bacterial infiltration. It is indicated for treatment
of perforations in the furcation region, of internal resorption, and of
root perforations via surgery when
it is impossible to treat the perforation via the canal or treatment has
been unsuccessful; for use in paraendodontic surgery as a retro-filling
material; and for direct pulpal protection, pulpotomy, apexogenesis
and apexification.

Literature review
MTA is a biocompatible material
with numerous clinical applica-

Fig. 1: Panoramic radiograph.—Fig. 2: Periapical radiograph of the apex showing the presence of a ﬁstula.—Fig. 3: Periapical
radiograph of the endodontic retreatment.

tions in endodontics. It was first
used experimentally by Lee and
Monsef.1 However, approval of its
use in humans by the American
Dental Federation was not granted
until 1998.2

responsible for the material’s radiopacity. The principal molecules
present in MTA are calcium and
phosphorus ions, which are also
the main components of dental
tissue, giving MTA excellent bio-

of root canals. Although the retrofilling material is very important,
good sealing of the suitable apex is
made for this purpose. According
to Assis et al., many techniques and
instruments have been recom-

“Both brands of MTA have been signiﬁcantly
evaluated and no other material has shown
more progressive results.”
It is composed primarily of tricalcium silicate, tricalcium aluminate, tricalcium oxide and silicate
oxide, as well as a small quantity of
other mineral oxides and the addition of bismuth oxide, which is

compatibility when in contact with
cells and tissue.3

mended for carrying out apical
preparations.4

MTA has been investigated as an
alternative material in endodontics and can be used in retro-filling

Both brands of MTA have been
significantly evaluated and no
other material has shown more

Figs. 4 & 5: Instruments for endodontic retro-ﬁlling.—Fig. 6: Supra-periosteal anaesthesia.—Figs. 7 & 8: Detachment of the ﬂap.—Fig. 9: Cutting of the root apex with
a high-rotation drill.—Fig. 10: Mini-handpiece for preparation of the apex.—Fig. 11: MTA restorative material (liquid and powder).—Fig. 12: Compounded MTA.

progressive results.5 According to
Pozza et al., the use of MTA in cavity walls, unlike other materials,
achieves the best seal against infiltrations.6 Different materials have
been used to seal the paths connecting the root canal and the paraendodontic tissue. However, none
of them have achieved results as
promising as those of MTA, and various studies have proven that MTA
is the best on the market today.7
According to Leal, MTA cement has
effective sealing capacity.8
According to Bernabé et al., conventional endodontic treatment
is not able to resolve some cases
and para-endodontic surgery is
required to obtain a good result.9
The filling material used must not
be toxic or mutagenic, and has to
be biocompatible and insoluble.
The material used in retro-filling
distinguishes a good para-endodontic surgery from a bad one. MTA
achieves the best result specifically
for sealing between the tooth and
external surface.
Endodontic treatment has become more practical owing to the
new methods and techniques, with
the emergence of materials with
excellent physical and biological
properties. The literature deals
with various materials used in
retro-filling, but generally speaking these materials do not have all
the requisite properties to be able
to remain in the cavity, such as
biocompatibility, radiopacity, insolubility in periapical fluids, easy
compounding, non-staining of the
periradicular tissue, good adaptation and sealing capacity.10 An
ideal material to replace amalgam
should offer adhesion, promote
hermetic sealing, be biocompatible, be radiopaque, be easy to
compound and provide for an environment favourable for tissue
regeneration.11
According to Hellwig et al., paraendodontic surgeries expose and
remove dental apices, promote
retro-cavitations along the axis of
the root canals, and retro-fill them
with materials that promote their
sealing.11 Para-endodontic surgery
is an excellent option for conservative treatment of teeth with
chronic periapical lesions, and
treatment by the conventional
method is impractical in some
cases.12
According to Jacobovitz et al.,
treatment of inflammatory resorption must be directed at combating
endodontic infection.13 In certain
cases, clinical resolution using conventional endodontic treatment
can become unfeasible owing to
the difficulties of performing instrumentation and adequate fill-

[21] =>

Endo Tribune Asia Pacific Edition | 12/2015

TRENDS & APPLICATIONS

ing of the apical region. In these
situations, alternative techniques
for preparation of the root canal
and filling may be necessary, in addition to the use of supplementary
surgical treatment. Some cases
may be treated with the use of
a laser, but this does not change
the pattern of microfiltration of
retro-fillings with MTA.14
13

Para-endodontic surgeries have
various procedural methods that
aim to resolve failures or accidents
that occur in conventional endodontic treatment.15 According
to Girardi et al., apicectomy is a
method of para-endodontic surgery that entails the separation of
the apical portion from the root.16
It is performed when there is no
regression of the apical lesion after
the alternatives of conventional
endodontic therapy have been exhausted in an attempt to eliminate
the apical micro-organisms and
their toxic products.
The use of a high-quality retrofilling material is indispensable; if
an inferior quality material is used,
an increase in apical infiltration
may occur, since the dentinal
tubules are more exposed by certain cutting angles and permeability is hence increased, and this is
important at the time of applying
the filling material.17
According to Oliveira et al., in an
apicectomy with retro-filling using
MTA and monitoring after five
years, it was observed that teeth
with a persistent periapical fistula,
after having undergone a suitable
endodontic treatment, the surgical
retreatment with retro-filling may
be an efficient option in the resolution of the infection and repair of
the periapical tissue.18
The literature confirms that MTA
presents excellent physical, chemical and biological properties, which
justify it as the material of choice in
the treatment of radicular resorption. It is a material that, compared
with other restorative materials,
has less microleakage and is capable of inducing the formation of
mineralised tissue, such as bone,
dentine and cementum, owing to
it reaching a pH plateau of around
12.5 in 3 hours. According to Costa
et al., who analysed the clinical
application of MTA in relation to
radicular resorption, in cases in
which radicular resorption is minimal, the canal is filled with calcium
hydroxide to stimulate the repair,
closing the access cavity with zinc
oxide and eugenol.19
Among the various advantages
of MTA is minimal radiopacity,
which has proven to be an important criterion and contributes to
it being considered the best choice
by the dental surgeon in relation
to biomaterials to be used in paraendodontic surgery.20
According to Barros and Araújo
Filho, MTA has been used successfully in filling the apical space
of the root canal. In addition to
its excellent sealing capacity, it
is biocompatible with the peri-

the region, proving the success of
the case. At the end of the surgical
treatment, the patient was referred
for prosthetic treatment.

radicular tissue, and induces the
formation of cementoblasts and
osteoblasts.21

Clinical case
This case illustrates the use of
MTA for sealing the root perforation and the effectiveness of the
retro-filling material after apicectomy (additional surgery; Figs. 1–17).
A 51-year-old patient presented to
the Universidade Tuiuti do Paraná
dental clinic (Brazil) complaining
about a gap in the gingiva above
tooth #11, from which a large quantity of purulent discharge was draining. In the radiographic examination,
an extensive radiolucent area was
found, indicating a fistula (periapical lesion) involving the periapical
region of the tooth in question.
During the endodontic treatment, the secretion into the tooth
could not be controlled. Even 23 days
after treatment, with changes to
the intra-canal medication, the
fistula returned and the exudate
drainage via the canal persisted.
Definitive sealing of the root perforation was then opted for, utilising
MTA and continuing with changes
of calcium hydroxide in the root
canal. Owing to the persistence of
the exudate via the canal, it was decided to perform endodontic filling, followed by supplementary
surgical treatment (apicectomy)
with retro-filling with MTA, conserving the tooth structure as
much as possible.
The surgery was performed under local anaesthetic with an infraorbital nerve block and supplementary infiltrative anaesthesia
at the apex of the tooth, as well as
a nasopalatine nerve block. The
anaesthesia used was 3 % mepivacaine with 1:1,000,000 adrenaline.
The incision was made with a #15
scalpel blade and a flap was raised.
The osteotomy was performed
with a high-rotation drill of the
700 series in order to gain access to
the periapical region. The lesion
was curetted with a short curette.
An apicectomy was performed
with the drill and 2 mm of the apex
was removed. The cavity for retrofilling was prepared with a spherical drill under constant irrigation
with saline solution, and then the
retro-filling with MTA was performed. After condensation of the
material in the cavity, the excess
was removed with a periodontal
curette. Finally, the flap was repositioned and then sutured.
One 750 mg pill of acetaminophen every 6 hours for two days

Conclusion
17

Fig. 13: Removal of the extra pre-existing cones.—Fig. 14: Placement of the MTA
material.—Fig. 15: Condensation of the MTA in the canal.—Fig. 16: Suturing with
4-0 silk thread.—Fig. 17: Final radiograph of the apicectomy.

was prescribed. In the seven-day
postoperative control period, the
patient had no symptoms incompatible with the surgery performed
and the healing appeared normal.

These circumstances held for the
full monitoring period, over the
course of a year, as the radiograph
one year after treatment established new bone formation in

According to the methodology
used in this case and considering its
results, it can be concluded that the
MTA material used was efficient in
the formation of a new mineralised
tissue barrier, completely sealing
the apical portion of the canal.

Fernanda Maria Klimpel is working as
a dentist in Brazil.
AD

The South African Society of
Endodontics & Aesthetic Dentistry

3-6 June 2016
Cape Town
South Africa
www.ifea2016.com

Abstract &
Poster
Submissions
now open

Endodontic Excellence at the Apex of Africa
SPONSORS

[22] =>

TRENDS & APPLICATIONS

Endo Tribune Asia Pacific Edition | 12/2015

The One Shape Procedure Pack
A unique solution for root canal shaping
Dr Tara Mc Mahon, Belgium

Fig. 1: One Shape Procedure Pack.—Fig. 2: Pre-op radiograph of tooth #17.—Fig. 3: Opening of the pulp chamber (P: palatal canal; DB: distobuccal canal; MB: mesiobuccal canal).—Fig. 4: Elimination of overhangs
with ENDOFLARE (P: palatal canal; DB: distobuccal canal; MB: mesiobuccal canal).—Fig. 5: After the passage of ENDOFLARE, access to the distobuccal canal is straightened (P: palatal canal; DB: distobuccal canal;
MB1: ﬁrst mesiobuccal canal; MB1: second mesiobuccal canal).—Fig. 6: Exploration ﬁle, #10 MMC, in the distobuccal canal.—Fig. 7: One G.—Fig. 8: Radiograph of One G in the second mesiobuccal canal.

The objective of endodontic treatment is the elimination of pulp
debris or the bacterial biofilm and
its toxins from the root canal system in order to prevent or eliminate any periapical lesion.1 For this
purpose, root canal shaping is an
essential, necessary and complex
step. Essential because it allows
indispensable irrigation, necessary
to achieve 3-D obturation of the
endodontic root canal system2 and
complex because of the infinite
complexity of the root canal anatomy.3
Over the past several years, the
definition of an endodontically
successful root canal treatment
has changed considerably. In 1986,
success was based on the complete
disappearance of the periapical lesion.4 In 2004, the concept evolved
and the terms “recovered tooth”,
“tooth on the way to recovery”
and “diseased tooth”5 were used.
In 2011, the terminology of
“functional tooth” versus “nonfunctional tooth” was finally in-

troduced.6 Despite this, the concepts for root canal shaping established by Schilder in 1974 remain
unchanged,7 namely with respect
to the initial root canal anatomy
and position of the apical foramen, as well as conservation of
root canal patency and obtainment
of a sufficient taper to guarantee
the penetration of the irrigating
solutions to the apex.
Practitioners are familiar with
these concepts and try to implement them in the best possible
way. However, endodontic treatment remains an area that poses
great difficulties for dental surgeons, and time constraints can
often lead to inadequate treatments. Thus, general practitioners
desire a simple, efficient and rapid
solution that allows reproducible
treatments. The introduction of
rotary nickel-titanium (NiTi) instruments in endodontics in the
late 1980s has revolutionised the
discipline. The material’s extreme
elasticity imparts great flexibility

to instruments with greater diameters and tapers than those of
hand files. Stainless-steel hand
files are more rigid and can lead
to the creation of an apical ledge,
canal transportation, a crack in
the apical foramen or even instrument fracture.8, 9
Although NiTi instruments allow reliable and reproducible
results, they present a higher risk
of fracture than do stainless-steel
files, particularly those used in
continuous rotation, which is due
to cyclic fatigue or higher torsional stress. Instrument fractures
caused by cyclic fatigue occur
without prior deformation visible
to the naked eye. They are therefore impossible to foresee with
certainty.10
Too often does this elevated risk
of instrument fracture result in
general practitioners abandoning
endodontics altogether. However,
respecting several simple principles, such as using the speed

and torque recommended by the
instrument manufacturer, preenlarging the root canal, using
vertical up-and-down movements,
as well as cleaning and performing
visual control of the instrument
after each passage, makes the
practitioner’s work less stressful
and more relaxed.
The introduction of single-use
instruments not only eliminates
the risk of cross-contamination,
but also considerably reduces the
risk of instrument fracture due
to cyclic fatigue and simplifies
the operating procedure. MICROMEGA has designed the One Shape
Procedure Pack, which contains
an ENDOFLARE file, a #10 MMC
file, a One G file, a #15 MMC file and
a One Shape file (Fig. 1). It simplifies
the operating procedure, removes
the need for instrument maintenance and makes stock management easier. All of the necessary
instruments for the endodontic
treatment are single-use files supplied in sterile packaging.

Operating procedure
Each endodontic treatment requires a preoperative radiograph
taken with a radiograph film
holder (Fig. 2). Once a dental dam
has been placed and the access
cavity has been prepared, the
root canal entrances are localised
and the pulp chamber is irrigated with sodium hypochlorite
(Fig. 3).
The first step of the root canal
preparation is the enlargement
of the canal entrances. As the
first instrument in the One Shape
Procedure Pack, ENDOFLARE (with
a diameter of 0.25 and a 0.12 taper)
is used with up-and-down movements and pressure on the canal
walls in the first 3–4 mm of the
root canal to enlarge the canal
orifices. In this case, ENDOFLARE
eliminates the dentinal overhang at the entrance to the distal
root canal (Fig. 4) and lays open
the second mesiobuccal canal
(Fig. 5).

Fig. 9: Photograph of One G in the second mesiobuccal canal (P: palatal canal; DB: distobuccal canal; MB1: ﬁrst mesiobuccal canal; MB1: second mesiobuccal canal).—Fig. 10: One Shape.—Fig. 11: Passage of
One Shape in the canal: two-thirds of the WL, 3 mm short of the WL, and WL.—Fig. 12: Radiograph of One Shape in the second mesiobuccal canal.—Fig. 13: Photograph of One Shape in the second mesiobuccal canal.—
Fig. 14: Radiograph with the master cone.—Fig. 15: Post-op radiograph.—Fig. 16: Post-op radiograph of tooth #17.

[23] =>

TRENDS & APPLICATIONS

Endo Tribune Asia Pacific Edition | 12/2015

17a

17b

23
torque of 2.5 Ncm. Root canal
shaping is performed in three
steps with progression of One
Shape to two-thirds of the WL,
3 mm short of the WL, and the
WL (Fig. 11). Between each passage,
the root canal is abundantly irrigated with sodium hypochlorite
and patency is checked with a #10
file. The instrument’s spires must
be systematically cleaned and
visually inspected.

17c

Figs. 17a–e: Pre-op photograph (a). Radiograph of One G in the second mesiobuccal
canal (b). Radiograph of One Shape in the
second mesiobuccal canal (c). Radiograph
with the master cone (d). Post-op radiograph (e).”

17d

The exploration file (#10 MMC)
serves to evaluate the root canal’s
complexity. It is introduced into
the root canal without axial constraints in the coronal zone, owing
to the previous action of ENDOFLARE. Any coronal interference
that might hinder the file’s passage must be eliminated to make
the treatment as safe as possible
(Fig. 6).
The second step of the root canal
preparation is the exploration of
the root canal and the creation
of a glide path. This step entails the
pre-enlargement of the root canal
and facilitates the passage of the
following rotary shaping instrument. Root canal exploration and
glide path development are performed with stainless-steel hand
files or rotary NiTi files.8 It has
been shown that the use of a
highly flexible instrument with an
asymmetrical cross-section reduces the risk of canal transportation.9 In addition, this kind of
cross-section combined with a
variable helical pitch diminishes
screwing effects.11
The second rotary instrument
in the One Shape Procedure Pack is
One G (Fig. 7). This NiTi instrument
with a diameter of 0.14 and a

Stress-free, relaxed working: Since
the instruments are single-use only,
the risk of instrument fracture due
to cyclic fatigue is considerably reduced and there is no risk of crosscontamination.
Short learning curve: All of the rotary
instruments are used in continuous
rotation.
Rapidity of the root canal preparation:
The gain in time during root canal
shaping allows for a more thorough
final irrigation.
Simplification of the operating procedure: A single instrument is used for
glide path creation, and one instrument for root canal shaping.
Gain in time for the dental assistant:
Simpler and quicker preparation of
the working materials, since no
cleaning and no sterilization of the
instruments are required after the
treatment. Thus, there is more time
to assist the practitioner during
treatment.
Optimised organisation in the dental
office: Stock management is easier
and less storage space is required.

better upward transport of the
debris and limit screwing effects.
Owing to its characteristics, One
Shape causes less extrusion of debris and irrigating solution in the
apical zone than other single-file
systems available on the market.14

17e

0.03 taper has an asymmetrical
cross-section. Its three cutting
edges are situated on three different radiuses to the root canal axis.
One G also has a variable helical
pitch and thus variable helical
angles. The narrower the angle,
the more active the rotating instrument, and the wider the angle,
the greater the efficiency of the
instrument’s traction.8 All of these
features provide One G with a high
flexibility and great efficiency.
Clinically, if the root canal is
patent, One G is taken to the working length (WL) previously determined with the #10 MMC file and
an apex locator. However, if the root
canal is not patent, One G penetrates
with vertical up-and-down movements on the canal axis down to the
length attained by the #10 MMC
file. This allows the elimination
of constraints in the cervical and
middle thirds of the root canal. The
#10 file is then pre-curved in order
to check the canal patency. The
WL is determined and transferred
to One G, which is then taken to
the WL at a speed of 250–400 rpm
and a maximum torque of 1.2 Ncm
(Figs. 8 & 9). After the creation of the
glide path with One G, the #15 MMC
file must penetrate down to the WL
without constraints. The root canal
is now ready for shaping.
The third rotary instrument
is One Shape (Fig. 10). This NiTi
instrument with a diameter of
0.25 and a 0.06 taper has a variable
cross-section. The apical 2 mm of
its active blade with a global length
of 16 mm has a triple-helix crosssection with three cutting edges
situated on three different radiuses to the canal axis. The following 7.5 mm constitutes a transitional zone that terminates in a
double-helix section of 6.5 mm in
the coronal part of the file.12
The cutting effect of the two cutting angles in the coronal zone is
more important and allows more
efficient elimination of the debris,
whereas the three cutting angles
in the apical zone provide the
instrument with a better centring
ability, a higher resistance totorsional constraints and a better

capacity to negotiate curves.13 The
instrument’s tip is inactive and
allows for a smooth progression
in the root canal. The helical pitch
and angle are variable along the
instrument and thus guarantee

The instrument progresses with
an up-and-down movement of
low amplitude and without excessive pressure. One Shape is used in
continuous rotation with a speed
of 350–450 rpm and a maximum

One Shape performs the root
canal preparation quicker than
other single-file system.15 This
gain in time must be used for the
indispensable final irrigation.
Editorial note: A list of references is
available from the publisher.

Dr Tara Mc Mahon
is a working as
a dentist in an
endodontic practice in Brussels,
Belgium.

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[cover] => DT Asia Pacific No. 12, 2015

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