Endo Tribune Middle East & Africa No. 3, 2019
Endodontics white paper calls for treatment to consider patient health / 3-D endodontic instrumentation: Revision of a historical protocol
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DTMEA_No.3. Vol.9_ET.indd
NL
Y
O
LS
NA
IO
SS
FE
O
PR
NT
AL
DE
www.dental-tribune.me
Published in Dubai
May-June 2019 | No. 3, Vol. 9
Endodontics white paper calls
for treatment to consider patient health
By FDI World Dental Federation
retention and impact on overall
health. Patients are concerned with
eliminating pain and keeping the affected tooth healthy and strong over
the long term. Considering the patient’s perspective in the provision
of endodontic care has significant
implications for existing treatment
guidelines.
GENEVA, Switzerland: FDI World
Dental Federation (FDI) recently released its first white paper on endodontic care, providing an important
resource for dentists, national dental
associations (NDAs) and other oral
health actors.
Rather than focusing purely on the
roots of the tooth, this paper calls for
endodontic care to address a broader
set of health outcomes that directly
affect the patient, including tooth
© Nuk2013/Shutterstock
The white paper defines the scale of
the global burden of endodontic disease and proposes patient-centred
solutions to improve endodontic
health. The paper was published as
part of FDI’s Endodontics in General Practice initiative, supported by
Dentsply Sirona.
The FDI initiative Endodontics in General Practice guides dentists in providing endodontic care.
FDI President Dr Kathryn Kell said:
“A comprehensive approach to endodontic care puts the patient first.
We need to shift away from treatment outcomes that focus solely on
technical goals and clinical symptoms after treatment and take a closer look at how we can deliver better
care to our patients.”
The paper summarises results of a
survey completed by FDI member
NDAs to identify obstacles to providing endodontic care. Members
reported that limited access to care
is an ongoing challenge in many
countries, and the misconception of
endodontics as a complex or painful
procedure frequently deters patients
from seeking treatment.
“Untreated endodontic conditions
can drastically affect one’s quality of
life, causing cranio-facial pain, difficulty chewing, and trouble sleeping.
We are proud to support FDI’s work
to actively address these challenges
and propose tangible solutions to
improve endodontic health worldwide,” commented Dr Terri Dolan,
Vice President and Chief Clinical Officer at Dentsply Sirona.
The report, titled “White Paper on Endodontic Care”, was published on the
FDI website on 11 March 2019.
AD
EXPAND
YOUR
MIND
ADAPTIVE. EASY. SAFE. EFFICIENT.
www.fkg.ch/xpendo
[2] =>
DTMEA_No.3. Vol.9_ET.indd
A2
ENDO TRIBUNE
Dental Tribune Middle East & Africa Edition | 3/2019
3-D endodontic instrumentation:
Revision of a historical protocol
By Dr Kenneth S. Serota, USA
of endodontic instrumentation. The
XP-3D Shaper was designed to adapt
to the anatomical shape of the canal
while respecting the native framework of the root canal space without
packing debris into untouched areas.
The XP-3D Finisher (Brasseler USA)
has a reach of at least 3mm, thereby
touching even the widest canal diameters while not changing the original shape of the canal.10
The past
The goal of the instrumentation
phase of root canal therapy is to
debride, disinfect and shape the
root canal space prior to root filling
while retaining an optimal amount
of tooth structure. This is of paramount importance in the regions of
peri-cervical dentine and isthmus/
furcal anatomy.1 Historically, the
significant flaws of stainless-steel
files and reamers were their cutting
geometry and rigidity. The technical protocol for these instruments,
even Dr Schilder’s innovative envelope of motion,2 failed to correct
debridement inadequacies. The root
canal does not natively present in
the round; Dr Schilder’s approach,
while an improvement, failed to
address the instrument design and
technique changes required to optimise shaping and cleaning of the canal space (Figs. 1 & 2). The root shape
mimics the canal shape.3 Therefore,
it is impossible to adequately sculpt
the interfacial dentine of the canal
unless the file chosen corresponds
to the largest diameter of the nonround canal (Fig. 3), which can lead
to weakening or perforation of
the root structure. Studies assessing the planes of geometry of the
root canal repeatedly demonstrate
that the buccolingual diameter is
greater than the mesiodistal diameter—canals are predominantly
ovoid throughout the dentition, not
round.4
Until recently, our reliance upon flat
film radiography to assess the spatial
dimensions of root filling furthered
the lack of appreciation for file taper
sizes and flexibility fundamentals.
The z-axis was hidden from view in
flat film periapical radiographs; only
the narrower mesial–distal dimensions of the root canal space were
evidenced (Fig. 4). Faux 3-D imagery
could be produced in theory by
combining of angled mesial, distal
and central ray radiographic projections. In 2-D, cleaning to the narrowest diameter appears adequate
in post-treatment radiographs. The
introduction of microcomputed
tomography (μCT) and cone beam
computed tomography (CBCT) has
changed our understanding of the
planes of geometry produced by
our current treatment protocols.
Mapping of the root canal space by
μCT after instrumentation demonstrates that barely 50% of the canal
is cleaned (Fig. 5).5, 6 The idiom, “you
can’t put a square peg into a round
hole” suggests an endodontic idiom:
you can’t put a round file into an
ovoid canal and achieve the desired
result.
The most under-appreciated sequela
of round files is the creation of significant amounts of dentinal debris.
Traditionally, the focus has been on
the debris pushed through the apex
during instrumentation to avoid
posttreatment pain caused by periapical inflammation. The assumption
that residual debris moves coronally
and is flushed from the canal by irrigants is questionable. In fact, debris is
pushed into the non-round parts of
the canal, blocking these areas from
further cleaning and disinfection by
irrigation solutions and adjunctive
technologies.7, 8
Fig. 1: The envelope of motion, as described by Dr Schilder, is generated by pre-curving a reamer and rotating and withdrawing the
instrument during the working cycle. All the work is done on the outstroke, obviating the potential for ledge creation.
Fig. 2: An axial view (cross section) of the mesial root of a mandibular molar demonstrates that the geometry of the canal space is
irregular, elliptic/ovoid, but not round. (Unknown source)
Fig. 3: The root shape mimics the canal shape. As such, making a round shape using the largest diameter file is clinically impractical.
Using a preset taper greater than 0.04 jeopardises the integrity of the root structure.
Fig. 4: CBCT provides a z-axis image that demonstrates the number of canals the second mesiobuccal canal could readily have been
compromised with a relied upon. (Courtesy of Dr Martin Trope)
Fig. 5: Micro-CT shows green (untreated canal) and red (treated portion of the canal after the use of a round file of minimum diameter). Less than 50% of the interfacial dentine was touched and debrided. (Courtesy of Dr Frank Paqué)
Fig. 6: An irregular canal space is shown after instrumentation with a file (round core).
Note the existing debris accumulation in the canal irregularities resultant from instrumentation. (Courtesy of Dr Gustavo De-Deus)
Additionally, when irregularities are
compacted with detritus, increased
pressure is exerted within the canal
space with the attendant possibility
of microfractures (Fig. 6). This is of
critical concern with the new generation of nickel-titanium (NiTi) files,
but not a factor with use of the XP-3D
Shaper (Brasseler USA).9 The trend
towards fewer files and larger tapers
exacerbates this potential fracture
problem.
Cognitive dissonance
The introduction of NiTi files fostered a transition to instruments
that would potentially obviate the
flaws inherent in the use of carbon
and stainless-steel files. NiTi files are
super-elastic and self-centring, and
avoid ellipticisation of the apical
terminus. With appropriate taper
selection, NiTi instruments should
prevent thinning of the coronal and
middle thirds of the root minimising
thus preventing wall weakening or
strip perforation. However, each generation of NiTi files, whether ground,
twisted or heat-treated, shaped and
cleaned far less debris than expected
from the root canal space. Unfortunately, while a few systems included
0.04 tapers, the vast majority of single- or multi-tapered files have 0.06,
0.07 and 0.08 tapers. Some of the latest systems use asymmetrical rotary
motion, conforming S-shaping and
reciprocal motion. Unfortunately,
separation of an NiTi instrument
due to taper lock, cyclic fatigue and
torsional resistance remains an omnipresent concern. The advantages
of super-elasticity and self-centring
were incalculable; however, the improvements were compromised by
the persistence of round-core manufacturing (Figs. 7 & 8). The flaw in
every iteration of NiTi files remains
the same: the cutting geometry produces a round shape.
Inevitability of bio-minimal
adaptive shaping
A new generation of adaptive/virtual core files, the XP-3D system, has
dramatically changed the landscape
Booster Tip
The Booster Tip (BT) lead section fits
into the preestablished glide path,
ensuring precise guidance and centring of the instrument. A traditional
glide path instrument produces a
15.02 or 10.04 size/taper. There are
no cutting flutes on the lead section
of the BT, ensuring precise guidance
and centring of the instrument. The
XP-3D Shaper has a BT, which enables the instrument to follow the
glide path into the apical component
to a depth of 0.25 mm. The next 0.25
mm section of the BT is configured
with six cutting flutes. Rotation of
these flutes sizes the next 0.25mm
of the canal space from a 15.02 to a
30.02 (size/taper) instrument; thus,
the apical size chosen for the XP-3D
Shaper is size 30 (Fig. 9).
XP-3D Shaper
To better explain the unique properties of the file, the physical characteristics of the MaxWire technology must be understood. At room
temperature, the XP-3D Shaper is in
the martensitic phase, enabling it to
be bent and more readily placed in
the canal. No more than three to five
easy up-and-down strokes (swaths)
of the serpentine XP-3D Shaper
with the BT should result in an apical terminus shaped to a size 30 file
and a canal taper of 0.02 (Figs. 10 &
11). The choice of a 0.3mm diameter
enables a 31-gauge irrigating needle
to approximate the working length,
preventing vapour lock. Maximum
irrigation efficiency is ensured. Additionally, a shelf for seating the guttapercha point prior to root filling is
created. With an increasing number
of strokes, the file has the capacity to expand from tapers of 0.01 to
0.02/0.04/0.06/0.08 while maintaining the flexibility of the original
0.01 taper. At body temperatures,
the file attains its austenitic characteristics and attempts to achieve its
potential of an 0.08 taper, a maximum that is needed in only the most
unique cases.
ÿPage A3
Fig. 7: The majority of the root canal space is ovoid. As demonstrated by the canal shape at successive levels from the apex, round files, in spite of self- centring, can weaken the root
structure with a typical 0.06-tapered instrument and will NOT debride the canal in its entirety. (Courtesy of Dr Gustavo De-Deus)
Fig. 8: There are approximately 157 file systems available globally. Most are made from round blanks; canals, however, are not “made” in the round.
Fig. 9: The Booster Tip has no cutting flutes on the first 0.25mm. The next 0.25mm section has six cutting flutes, which alters the apical extent of the canal to a size 30.02 (size/
taper) instrument. The tip design of traditional NiTi instruments enables the instrument to follow the glide path rather than actively cutting and risk ledging or torsional failure if
the tip inadvertently catches in an irregularity in the canal wall. (Courtesy of Dr Sebastián Ortolani Seltenerich)
[3] =>
DTMEA_No.3. Vol.9_ET.indd
Dental Tribune Middle East & Africa Edition | 3/2019
A3
ENDO TRIBUNE
◊Page A2
As much healthy tissue as possible
must be maintained; therefore, it is
recommended that when the working length has been achieved in the
first three to five strokes, an additional ten long strokes will achieve
a 0.04 taper, which is sufficient to
adequately disinfect the root canal
space in very tight canals. In larger
canals, the file will easily create larger
tapers, as lesser dentinal resistance is
met. As a function of its serpentine
shape, light brushing and up to 30
long strokes will result in over 90%
of the walls being touched in these
larger non-complex canals (Figs. 12
& 13).
To summarise: the file is adaptive to
the original shape of the canal; thus,
the tooth shapes the canal space, in
contrast to round NiTi files, where
the file shapes the tooth. As shown
in Figure 10, the file has a sinusoidal/
serpentine shape. The space available for this shape in motion enables
a light brushing technique to adapt
and debride 90% or more of the
walls in larger non-complex canals,
which contrasts dramatically with
the debris removal with round NiTi
files. As previously discussed, round
files will pack debris into the canal
irregularities, a major drawback in
sufficiently cleaning a canal. The serpentine shape, virtual core and 0.01
taper of the XP-3D Shaper enable it to
adapt to the canals and ensure that
debris remains in turbulent solution,
ensuring its optimal removal from
the canal (Fig. 14). This enables the irrigants to work maximally as the canal is shaped. Tests using photoelastic models have shown that apical
pressure is not built up using the
XP-3D Shaper, obviating concerns
regarding microcracks. Round-core
files should significant generation of
apical pressure (Fig. 15).
Recently, new and costly irrigation
devices have been introduced in
the endodontic armamentarium
as adjuncts to the traditional sidevented needle and passive ultrasonic irrigation. The EndoActivator
(Dentsply Sirona), the EndoSafe Plus
(Vista Dental), the Endovac Pure (apical negative pressure irrigation; Kerr)
and the GentleWave (Sonendo) are
all relatively new.11 The GentleWave
system claims to be capable of removing residual tissue, the smear
layer, biofilm and bacteria from the
tubules.12 Further scientific assessment of this device remains to be
done.
Fig. 12: In small (mesial) canals, the XP-3D Shaper file will first reach a 0.3mm diameter and in time increase the canal taper subject to the resistance of the dentine. The virtual/
adaptive core prevents packing of debris in irregularities.
Fig. 13: The μCT image to the left shows the packing of the debris into the isthmus by a reciprocating file. The image on the right shows the canal after preparation with the XP-3D
Shaper. Increased resistance due to packing of debris is a common flaw in round NiTi files and can result in fracture.
Fig. 14: The image shows the comparison of the mechanism of cutting by a file made from a round blank and by the XP-3D Shaper. No matter how much relief is provided by
reducing the taper along a file with an apical third taper of 0.06/0.07/0.08, enhanced resistance is created and irrigation turbulence is not enhanced. The OPPOSITE is true of the
Shaper.
Fig. 15: Photoelastic stress analysis using a monochromatic light source and plastic models demonstrates that a reciprocating file (A) creates high stress in the apical third, a rotational file (B) shows strong stress in the apical third and the XP-3D Shaper file (C) shows no stress in the apical third.
Fig. 16: The dimensions of the XP-3D Finisher are shown in the martensitic and austenitic phases. At body temperature, the last 10 mm of the instrument during rotation achieves
a sickle shape with a diameter of 3 mm. Pressure on the bulb can further enhance the tip diameter.
Fig. 17: The anatomy of the canal will cause the XP-3D Finisher to expand or contract and enter small irregularities in the canal walls with an up-and-down motion. No other file
can reach these indentations.
XP-3D Finisher
The XP-3D Finisher is used adjunctively to the XP-3D Shaper. The Finisher’s design allows it to access and
scrape untouched components of
the canal walls without altering the
canal shape created by the XP-3D
Shaper. The file has a tip diameter
of 0.25 mm with an 0.00 taper. It is
extremely flexible and thus has tremendous resistance to cyclic fatigue.
For more information contact:
Dr Kenneth Serota
graduated with a DDS from the University
of Toronto Faculty of Dentistry in Canada
in 1973 and received his Certificate in Endodontics and Master of Medical Sciences
from the Harvard–Forsyth Dental Center
in Boston in Massachusetts in the US.
Active in online education since 1998, he
is the founder of the ROOTS endodontic
forum and the NEXUS interdisciplinary
forum.
Dr Serota is an adjunct clinical instructor
in the University of Toronto postdoctoral
endodontics department.
Fig. 18: The natural expansion and contraction of the XP-3D Finisher contacts the irregularities of the canal walls. It is insufficiently sturdy to alter the original shape created by the
XP-3D Shaper.
Fig. 19: The XP-3D Finisher creates a robust turbulence within the irrigating solutions. Studies have shown it to remove microflora to a depth of 40 μ.
The spoon-shaped design of this file
is created in a mould in the austenitic phase. At room temperature, the
martensitic phase can be manipulated to any shape. Upon insertion into
the canal, the file is heated to body
temperature (35°C), and the material seeks to revert to the austenitic
phase (Fig. 17). In the austenitic phase,
it forms a uniquely shaped cleaning
instrument. At body temperature,
the apical 10.0 mm of the file transforms into a bulb/sickle shape, while
retaining a depth of 1.5mm. Without
squeezing the bulb, rotation of the
file produces a tip size of 3 mm. However, if the bulb is squeezed, the tip
will expand to a maximum of 6 mm.
The instrument cannot cut; thus, its
only impact is scraping, which removes microbes up to 40μ up the
tubules (commensurate with root
planing in periodontal therapy).13, 14
As it is moved up and down in the
canal, a vigorous agitation of the irrigants (sodium hypochlorite and
EDTA) occurs, which adds to an enhanced inhibition or eradication of
microflora presence from the root
canal space (Figs. 18 & 19).
Retreatment
The XP-3D Finisher file has been
modified for retreatment. The core
is 0.03 mm in diameter with an 0.00
taper. This provides a more robust
adaptation to the interfacial dentine,
enhancing the removal of residual
gutta-percha and debris from the irregularities (Fig. 20).
Conclusion
Preliminary studies of XP-3D files
have shown remarkable removal of
soft tissue, fewer residual dentinal
chips in an isthmus, and bio-minimalistic shapes of the root canal
space (optimal taper of 0.04), resulting in lower dentinal stress (fewer
microcracks). An efficient debridement and disinfection of the apical
third area is achieved by the BT and
the serpentine design of the Shaper.
Have we achieved the ideal fusion
of technology and biology for long-
Fig. 20: A study by Alves et al. demonstrated that the reduction of residual debris in the
canal space using the XP-3D retreatment Finisher was 69% greater by comparison to
standard round files.15
term positive patient-centred treatment outcomes? Perhaps. What has
been achieved is a redress of a design
flaw that has persisted for much too
long. This design change will bring
endodontics closer to the desired objective of bio-minimal shaping that
is tooth-directed. This will protect
the native anatomy of the root, mini-
mising functional stress and fracture
potential.
Editorial note:
A list of references can be obtained
from the publisher.
This article was originally published
in roots international magazine of
endodontics, Issue 4/2018.
[4] =>
DTMEA_No.3. Vol.9_ET.indd
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