Endo Tribune Middle East & Africa No. 4, 2018

Endo Tribune Middle East & Africa No. 4, 2018

“He brought a world of enthusiasm and knowledge to the global endodontic community” / MTA placement with the Produits Dentaires (PD) MAP System / Preservation of root cementum: A comparative evaluation of power-driven versus hand instruments / Top performance Flexible NiTi file HyFlex EDM performs well internationally / More than just a long-lasting post – VDW’s Double Taper Shape preserves more dentin / Success evaluation of N2 treated teeth with open apical foramen - A retrospective study

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www.dental-tribune.me

Published in Dubai

July-August 2018 | No. 4, Vol. 8

“He brought a world of
enthusiasm and knowledge to the
global endodontic community”
dontic meetings together. Fred was a
character, but in the best sense of the
word. He was entertaining, charming
and unpredictable. That was Fred.
But to those of us who knew and
loved him, he was much more than
that. He was a loyal friend who made
a maximum effort to understand
each of us in a personal and supportive way. Really, at the end of the day,
Fred was a mensch. He will be very
much missed.”

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

By Fred Michmershuizen, USA
He will be remembered as a friend, a
teacher and a healer. Fred Weinstein,
DMD, a retired endodontist from
Vancouver, British Columbia, died
Oct. 15, 2017, at the age of 78, after a
brief illness. His fellow specialists
expressed sadness at his passing and
acknowledged how his passion for
the profession rubbed off on them
through many decades of friendship.
Many are also remembering him for
his ability to have fun — especially
when it came time to promote an
international endodontic conference
hosted in his native country.

“Fred has been an inspiration for me
for all these years, ever since we met
over 30 years ago,” said Gerald N.
Glickman, DDS, MS, professor and
chair at Texas A&M College of Dentistry in Dallas, one of many endodontists who shared fond memories
of Weinstein.
“What a remarkably kind and insightful individual he was — always
inquiring about me and others and
never letting on about himself,”
Glickman remembered. “He brought
a world of enthusiasm and knowledge to the global endodontic community. I will miss him dearly.”

“Fred was that special kind of person
who would do anything he could to
help out when needed. He cared for
everyone and was a dear friend,” said
John J. Stropko, DDS, of Prescott, Ariz.
“Fred was a teacher, always encouraging others to use the latest technology to deliver better treatment results
for their patients. During the process,
he went to great lengths to clearly
communicate his beliefs in an easyto-understand manner. Our specialty
has lost one of its great members.”
“I knew Fred for more than 25 years,
and I always found it entertaining to
be in his company,” said Anne Lauren Koch, DMD. “We went to hockey
games, basketball games and endo-

Weinstein was born in 1939 in Winnipeg, Manitoba. He graduated from
the University of Manitoba at the age
of 22 with a degree in general dentistry, and then he went on to study
endodontics at the University of
Pennsylvania School of Dental Medicine in Philadelphia, under the tutelage of Dr. Louis Grossman, known
as the “Father of Endodontics.” After
receiving his Certificate in Endodontics from the University of Pennsylvania in 1969, he moved his family to
Vancouver and established an office
in the Fairmont Medical Building,
where he would go on to practice for
more than 40 years.
“He loved his patients, and he equally enjoyed teaching and lecturing
throughout the world to advance the
learning within dentistry,” his family
wrote in an obituary published in the
Vancouver Sun.
Weinstein’s accomplishments within the profession were notable. He
served as an assistant clinical professor at the University of British Columbia and was a past president of
the Canadian Academy of Endodontics, the British Columbia Society of
Endodontics, the Interspeciality Society of British Columbia and the International Federation of Endodontic
Associations (IFEA). He was a member of the Royal College of Dentists,
and he was a fellow of the American
College of Dentists and the International College of Dentists.

SUBSCRIBE NOW
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Vol. 13 • Issue 4/2017

issn 2193-4673

roots
international magazine of

endodontics

2017

research
Photodamage of dental pulpa stem cells
during 700 fs laser exposure

case report
Apexification treatment with MTA REPAIR HP

interview
Understanding sonic-powered irrigation

He served on advisory boards for several leading dental manufacturers,
and he lectured extensively throughout the world. He also served as a
volunteer endodontist at the 2010
Vancouver Winter Olympics, and
performed root canal treatment on
world boxing champion Sugar Ray
Leonard in the 1980s.
He was especially proud to have
served as the general chairman for
the 2007 IFEA World Congress in
Vancouver. To drum up excitement
for that meeting, he dressed as a
Royal Canadian “Mountie” at several
events leading up to it — something
that friends and colleagues remembered for years.
“Fred always had a smile and was
known as ‘the Canadian Mountie’
for his outfit that he wore at every
dental meeting to promote the IFEA
meeting in Vancouver in 2007,” remembered Samuel O. Dorn, DDS.
“He was truly dedicated to the Canadian Academy of Endodontics and its
place in global endodontics. His passion for endodontics and his friendship will never be forgotten.”
“I cherish my photo of us with him
dressed as a Mountie when he was
president of IFEA,” said Dr. William
Ben Johnson. “Fred and I started out
as endodontic colleagues, then became friends. So much so he would
go snow skiing with me even when
he didn’t care for skiing, and I would
drink wine with him when I preferred
scotch. I’ve lost a friend.”
After his retirement from practice,
Weinstein continued to travel to dental meetings to keep his knowledge of
the specialty current and to visit with
his many friends.
For many years, Weinstein was editor in chief of roots magazine, the
international C.E. magazine of endodontics, published by Dental Tribune
America.

Dr. Fred Weinstein with ‘Queen Elizabeth,’ at the IFEA meeting in 2007.
(Photo/Fred Michmershuizen, Managing Editor of DT America)

Dr. Fred Weinstein in Hamburg, Germany, in the summer of 2017.
(Photo/Fred Michmershuizen, Managing Editor of DT America)

“Above all of Fred’s accomplishments and titles, his family remained
his number one priority in his life,
always,” his family wrote in the Sun.
“He had a gentle heart of gold, compassion and sincerity and a smile that
would illuminate a room.”

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A2

endo tribune

Dental Tribune Middle East & Africa Edition | 4/2018

MTA placement with
the Produits Dentaires (PD) MAP System

By Dr. Mauro Amato, Switzerland
More than 20 years ago, Torabinejad et al. (1993) first described a
new root-end filling material called
mineral trioxide aggregate (MTA).
MTA showed in vitro better sealing
ability than amalgam or Super EBA
when used as a root-end filling material. Later, several in vivo and in vitro
studies demonstrated more applications for MTA. Pulp capping, apexification, repair of root perforations
and root-end filling are commonly
described clinical procedures to seal
the pathway of communication between the root canal system and the
external surface of the tooth. The application of MTA was first described
as being achieved with aid of plastic
or metal spatulas (Torabinejad and

Chivian 1999). Unfortunately, proper placement was not possible in this
manner.
Therefore, Produits Dentaires introduced a universal carrier system for
clinical and surgical MTA placement.
Its Micro-Apical Placement (MAP)
System offers different application
points for every clinical situation.
The Intro Kit and the Universal Kit
are for orthograde obturation and
the Surgical Kit for retrograde obturation. The NiTi Memory Shape
tips can be manually shaped to any
required curvature. After autoclave
sterilization, the needle returns to
its initial shape. With the use of the
MAP System, proper placement of
MTA has become an easy task for
every dentist.

In combination with the MAP System, Produits Dentaires offers a
white MTA specially developed for
placement with the MAP System.
The optimized practical size means
economical application for each
treatment. There are many indications for the PD MTA White, and with
the MAP System, proper placement
is easy in every situation.

Pulp capping
Vital pulp therapy has become more
popular in recent years. Calcium hydroxide has been the most common
material for pulp capping, but MTA
has shown even better results in biocompatibility and outcome (Aguilar
and Linsuwanont 2011). Cases with
large carious pulp exposure can be
treated successfully with partial pul-

potomy and MTA as a capping agent,
keeping teeth vital (Figs. 1a–e).

MTA may save compromised teeth
(Mente et al. 2014) (Figs. 3a–e).

Apexification

Apical surgery

In order to prevent extrusion of
root canal filling material in immature teeth with open apices, MTA is
used as an apical plug. The results of
many studies have shown that MTA
induced apical hard tissue formation
more often and its use was associated with less inflammation than
with other test materials (Simon et
al. 2007) (Figs. 2a–g).

MTA is the material with the most favorable outcome as a root-end filling
material for apical surgery. MTA has
been associated with significantly
less inflammation, cementum formation over MTA and regeneration
of the periradicular tissue (Torabinejad and Chivian 1999) (Figs. 4a–f).

Repair of root perforations

Dr. Mauro Amato is a lecturer and researcher at the department of periodontics, endodontics and cariology of the University of Basel in Switzerland. Dr. Amato
is a committee member of the Swiss Society for Endodontology. He can be contacted at mauro.amato@unibas.ch

Accidental perforation of the pulp
chamber or of the root canal significantly changes the prognosis of the
tooth. Perforation repair with a biocompatible sealing material such as

Figs. 1a–e: (a) Deep carious lesion. (b) Partial pulpotomy. (c) MTA application with the MAP System and PD MTA White. (d) Filling. (e) Post-op radiograph showing the pulp capping with MTA.

Figs. 2a–g: (a) Endodontically treated tooth with fistula. (b) After retreatment, the tooth showed an open apex. (c) MTA application with the MAP System and PD MTA White. Condensation of the MTA with pluggers (d) or paper
points (e). (f) MTA plug. (g) Post-op radiograph showing the MTA plug and the reconstruction with a fiber post.

Figs. 3a–e: (a) Radiolucency in the cervical part of the canine. (b) Bleeding from the perforation. (c) MTA
application with the MAP System and PD MTA White.(d) Original canal and repair of root perforation. (e)
Post-op radiograph showing the root canal filling.

Figs. 4a–f: (a) Pre-op radiograph with a large periradicular lesion. (b) Periapical surgery. (c) MTA application with the
MAP System and PD MTA White. (d) Condensation of the MTA with pluggers. (e) Mirror view of the root-end cavity
filled with MTA. (f) Post-op radiograph showing the root-end filling.

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A3

endo tribune

Dental Tribune Middle East & Africa Edition | 4/2018

Preservation of root cementum:
A comparative evaluation of power-driven
versus hand instruments
By Bozbay E, Dominici F, Gokbuget
AY, Cintan S, Guida L, Aydin MS,
Mariotti A, Pilloni A., Italy

Background

Grzesik et al. suggested that cementum plays an important regulatory
role in periodontal regeneration. One
of the major goals of periodontal
treatment is the removal of pathogenic micro-organisms by scaling
and root planning. In the past the
misconception was to obtain a root
surface with smooth and hard surface characteristics that was free of
endotoxins which resulted in the removal of the subgingival plaque and
calculus deposits, and the removal
of all or most of the cementum.
Recent studies have reported that
endotoxins were not located within
cementum and removal of ‘diseased’
cementum was not necessary for a
successful periodontal treatment.
Saygin et al concluded that preservation of cementum on the root
surface was necessary for new attachment and as a source of growth factor. Hence non-aggressive removal
of cementum is essential for optimal
periodontal health and regeneration.
Ultrasonics with new shaped tips
and subgingival air polishing devices
has been developed for removal of
root accretions with minimal root
damage. Air polishing has been suggested as a treatment modality for
root debridement resulting in probing depth reductions and removal of
subgingival biofilm. No scientific evidence exists today showing the loss
of root substance or surface roughness produced by either ultrasonics
or Air polishing.

Aim

To assess the amount of cementum
remaining following in vivo root instrumentation as well as the surface
characteristics of the retained cementum

Material and Methods

- 48 caries free, single-rooted teeth
in 27 patients diagnosed with severe
chronic periodontitis with periodontal probing depth (PPD) ≥5 mm in at
least two sites per tooth with radiographical bone loss of more than two
thirds of root length and scheduled
for extraction were included in this
study
- Teeth were randomly divided into
four treatment groups: Instrumentations were performed with medium
power settings
1. Piezoelectric ultrasonic scaler - (AirFlow Master Piezon, Instrument Tip
PS; EMS SA)-U
2. Piezoelectric ultrasonic scaler - (AirFlow Master Piezon, Instrument Tip
PS; EMS SA) followed by air polishing
with the glycine powder (Air-Flow
Powder Perio, Perio-Flow Nozzles;
EMS SA) - U + AP
3. Air polishing with the glycine powder (Air-Flow Powder Perio, PerioFlow Nozzles; EMS SA) - AP;
4. Hand instruments (Gracey curettes
5/6, 11/12, 13/14 American Eagle, Missoula, MT, USA)-HC

Treatment

- One approximal root surface of
each tooth was randomly subjected
to debridement, and the other approximal surface was used as control.
- Following instrumentation, the
teeth were immediately extracted

traumatically and analyzed with a
dissecting microscope
- Remaining calculus, root surface
roughness and loss of root substance
were evaluated along with scratches,
gouges, cracks, and any other changes in the cementum that was present
were noted.

Results

Remained cementum:
- Percentage of coronal cementum

remaining following subgingival instrumentation was 84% for U, 80%
for U + AP, 94% for AP and 65% for
HC.
- The amount of retained cementum
with AP was significantly greater
than with HC.
SEM
- Smoothest root surfaces were produced by the HC followed by the AP
- Coronal and apical sections showed
that AP produced the least amount

of cementum loss and therefore the
greatest retention of residual cementum
- Root surfaces instrumented by U
or U + AP presented grooves and
scratches.
Time taken to complete root instrumentation
- Shortest time taken was using AP
and the longest time was with U + AP.
- AP required 31% less time for root
preparation in comparison to HC,

whereas U + AP needed 30% more
time

Conclusions

- Air polishing was significantly more
effective and superior in preserving
cementum.
- Hand instrumentation using curettes was most effective in removing cementum in comparison to ultrasonics or hand instruments

www.ifea2018korea.com

The 11th

International Federation of Endodontic Associations

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

W

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

Andreas K. Braun

Filippo Cardinali

Australia

The Netherlands

Italy

Is there still a role for medicaments
in endodontics?

Root resorption after dental trauma findings and treatment possibilities

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

Antonis Chaniotis

Gustavo De-Deus

Franck Diemer

Greece

Brazil

France

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

The relationship among reciprocation,
glidepath and canal scouting

Samuel O. Dorn

Gianluca Gambarini

USA

Italy

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

Nick Grande
Gianluca Plotino
Italy
The paradox of minimal invasive
endodontics

Extraction-Replantation: An alternative
surgical technique

3D endodontics: Shaping root canals
in 3 dimensions

Mo K. Kang

Syngcuk Kim

Anil Kishen

USA

USA

Canada

Pulp tissue regeneration: Challenges
and new outlook

Long term prognosis of endodontic
Tx vs. Implant Tx

Nanomaterials in endodontics: A potential
game changer

Sergio Kuttler

Seung Jong Lee

Francesco Maggiore

USA

Korea

Italy

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

Are the viable cells the only predictor for
delayed replantation?

Tara Mc Mahon

Zvi Metzger

Belgium

Israel

Does heat treated NiTi facilitate
endodontic therapy?

Early diagnosis and biomechanics of
vertical root fractures

Soft tissue management in endodontic
microsurgery

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

Cliff Ruddle

Frank Setzer

Hagay Shemesh

USA

USA

The Netherlands

Endodontic Disinfection: 3D Irrigation

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

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

Michael Solomonov

Asgeir Sigurdsson

Ibrahim Abu Tahun

Israel

USA

Jordan

Contemporary approaches to
instrumentation of non-round root canals

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

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

Yoshi Terauchi

Martin Trope

Ghassan Yared

Japan

USA

Canada

Predictable and minimally invasive
method to retrieve a separated file

The expanding role of vital pulp therapy

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

[4] =>

endo tribune

Dental Tribune Middle East & Africa Edition | 4/2018

Top performance Flexible NiTi file
HyFlex EDM performs well internationally
Full control in
the dental practice
As an established Endo provider,
COLTENE has been working closely
with leading dentists, universities
and endo experts for many years.
The multitude of sophisticated
treatment aids, ranging from specially hardened instruments to bioactive obturation materials, reflects
the self-image of the Swiss innova-

HyFlex EDM File Sequence

By Coltene
In the course of two major international events in the dental industry,
Swiss dental specialist COLTENE
interviewed over 130 dentists and
Endo experts about their experiences with its latest NiTi file system.
The results of the product tests are
more than impressive: 98% of the
participants would continue to use
the HyFlex EDM for the treatment
of their endodontic cases, even after
the tough test.

The necessary cutting edge
Every two years, both the International Dental Show in Cologne (IDS
for short) and the Congress of the European Society for Endodontics (ESE
Congress) serve as an international
platform for professionals with an
interest in endodontics to exchange
experiences between colleagues.
Thus, both events in 2017 provided
the ideal occasion for a large-scale
test campaign for the latest NiTi file
generation from COLTENE. Selected
dentists and joint practices throughout Europe were given the opportunity to put the flexible HyFlex
EDM’s file system through its paces.
76% of the participants particularly
praised the high flexibility that leads
to good adaptation in the canal. The
pre-bendable files work reliably in
all the lengths and sizes currently
available on the market without displacing the centre of the canal. Like
the proven HyFlex™ CM files, the
HyFlex™ EDM files also possess the
so-called “Controlled Memory“ effect and are distinguished by their
high level of flexibility. In contrast
to classic NiTi files, they have almost
no recovery effect and can be prebent. As a result, the files move perfectly through the centre of the canal, which significantly reduces the
risk of ledging, transportation and
perforation. During autoclaving,
they recover their original shape so
that they can be reused safely until
a visible break in their spiral structure clearly indicates the end of their
service life. At the same time, the innovative manufacturing process by
means of spark erosion contributes
to the high breakage resistance of
the HyFlex EDM files, particularly

under heavy-duty use. In fact, HyFlex EDM files are up to 700% more
resistant to cyclic fatigue compared
to traditional NiTi files. A special
combination of material surface
and tapering allows a significant
reduction in the number of files
used without compromising the
preservation of the natural root canal anatomy. These smart features
were also evaluated positively in the
test and the dentists use the robust
high-performance instruments primarily for cases where they want to
produce reliable results quickly with
a reduced number of files.

Additional files sizes allowing more flexible application
Due to limited access endo experts
often want more flexibility from
their instruments. Pre-bendable
tools can extend the horizon into
new dimensions. Particularly in a
limited working space, modular
nickel-titanium systems display
their full strength. With a total of
seven highly flexible file variants,
COLTENE offers a wide-ranging HyFlex NiTi program. In addition to the
usual lengths of 25 mm, all preparation files of the popular EDM series
are also available in 21 mm working
length. The application of the more
agile, shorter models is particularly
recommended in of the posterior
molars and in patients with craniomandibular problems.
The new HyFlex EDM 20/.05 preparation file augments the existing
HyFley EDM line. The additional
file enables fans of the flexible NiTi
range to treat curved channels only
with the efficient EDM files. After
creating a glide path with the Glidepathfile 10/.05, the new file with the
same taper allows minimally invasive, fast preparation of the canal.
Subsequently the actual shaping can
be done in the usual manner with
the universal file HyFlex EDM OneFile, size 25. Depending on the channel anatomy, apical preparation can
be finished with EDM files up to ISO
size 60. Even in these large sizes the
files work safely and without transportation of the canal center.

tion leader. True to the company’s
motto “Upgrade Dentistry”, the
COLTENE service team regularly
asks practice owners and endodontic specialists about their wishes for
even more confident work in virtually all situations. This also formed
the basis for the development of the
production process called “Electrical Discharge Machining” (EDM for
short) by the dental manufacturer’s

renowned R&D department, which
ultimately gave the exceptionally
break-resistant files their name. The
practice-oriented Endo offer is complemented by a large number of application-related workshops, training materials and personal services.

Further product information:
https://hyflex.coltene.com/

[5] =>

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endo tribune

Dental Tribune Middle East & Africa Edition | 4/2018

More than just a long-lasting post – VDW’s
Double Taper Shape preserves more dentin
By VDW

the dentist avoids unnecessary dentin removal to fit in the post.

MUNICH, Germany: Improved den-

Tooth protection
and better aesthetics

tin preservation and better aesthetics are two of the convincing advantages of VDW’s DT Posts. These are
resulting from VDW’s Double Taper
Shape de-sign and quartz fiber technology: the key to a long-lasting endo-dontic treatment success.

reactive color pigments of VDW’s
DT ILLUSION® XRO® SL posts enable
their location after the placement.
Being barely visible at body tempera-

ture, they become clearly detectable
after cooling below 29° Celsius.

Read more about VDW’s DT Posts at:
https://www.vdw-den-tal.com/en/products/post-endo/

The DT Posts’ break-resistant quartz
fiber material has advantageous mechanical characteristics. Its low modulus of elasticity distributes chewing
forces correctly and minimizes the
risk for root fractures. Thanks to the
quartz fiber material’s translucency
properties the pa-tient benefits from
better aesthetics.

For endodontically treated teeth
with more than one missing dentin
wall the placement of a post to maintain the coronal structure is strongly
suggested. To place it properly, it is
key to retain as much dentin as possible while preparing the root canal
beforehand. VDW’s DT Posts with
Double Taper Shape preserve more
dentin as the two-stage design corresponds optimally to the morphology of the prepared root canal. Thus,

Safe retention
and easy post location
VDW’s DT Posts offer more convincing features. The Safety Lock® coating ensures maximum bond properties and thus a safe long-standing
retention of the post. The thermal

Fig. 1: DT LIGHT®, DT LIGHT® SL, DT ILLUSIONTM
XRO® SL, each size #1

Fig. 2: With Double Taper Posts (1) less dentine removal is required than with
single tapered posts (2) © Prof. Boudrias / Prof. Sakkal

Success evaluation of N2 treated teeth
with open apical foramen.
A retrospective study
By Dr Anette Joschko, Dr Robert
Teeuwen & Prof. Jerome Rotgans,
Germany

Endodontic failures resulted in ten
cases (13.3%). Statistic significance was
found regarding failure rate of VitA
(7.1%) and root canal treatment of
non-vital teeth (28.6%, p = 0.0157).

Abstract
95 teeth with open foramen were
identified in a general dentist practice
during the years 1985—2006, 75 of
which could be followed-up by X-ray
after an average time of 70 months
(follow-up X-ray). 40 teeth were subject to vital extirpation (VitE), 28 teeth
to vital amputation (VitA), and seven
teeth with necrotic
pulp underwent conservative root
canal treatment (RT). Apexification
success rate amounted to 85.3% (VitE
90%, VitA 85.7%, non-vital RT 57.1%).
Another 12% could be judged as partial success in molars, as a certain
number of the molar roots showed
apexification, however, others not
yet. The percentaged difference of a
successful apexification between vitally extirpated teeth and root canal
treatment of non-vital teeth was significant (p = 0.0243). Apexification result was irrespective of the filling level
of root canal treated teeth as well as of
endodontic success.

Within the observation period 19 out
of the 95 teeth with open foramen
(20%) were extracted. There was a
significant difference regarding extraction frequency between the VitE
group (14.6%) and the non-vital group
(50%, p = 0.0169).

Introduction
Endodontic treatment of teeth with
incomplete root growth poses a special challenge. In young patients, the
necessity for endodontic treatment
results from an accident or profound
caries. Aside from damage control,
this treatment aims at promoting
tooth maturation including narrowing respectively closure of the apical
foramen (apexification) and possibly
root extension (apexogenesis).
According to Zeldow (1967) the following treatment options are commonly used:

100

300

250

months

%
40

100
50

0
50

100

150

200

Various methods favouring maturation of the immature teeth are described. Surgical interventions turned
out to be less promising (Kreter
1959, Khoury 1992). Herforth (1981)
obtained a very high healing rate of
apical periodontitis with Jodoform

150

Krakow et al. (1977) disapprove of a
VitA inevitably following root canal
filling. Joschko (2012) points out that
the often diverging roots of immature teeth exclude a dense root canal
filling, and that open apical foramen
promotes overfilling. Some authors,
like Kvinnsland et al. (2010) and Rafter (2005), state that the dental papilla
may simulate an apical periodontitis
in the area of the open apical foramen.

200

VitE
VitA
non-vital

- For vital teeth: Pulpotomy (VitA)
with subsequent conservative root
canal treatment (RT)
- For non-vital teeth:
– either RT or
– RT in connection with apicoectomy/retrograde root canal filling or
– inducing of bleeding with root canal
filling in the coronal root part only.

250

300

months

Fig. 1: Probability of survival of the 3 therapy groups with the target criterion “No Extraction

10
n = extractions

Fig. 2: Time history of the extractions (N = 19).

deposits, however the success rate
regarding stimulation of hard tissue induction only amounted to 3%
versus 83 % with calcium hydroxide (Ca(OH)2). Hermann (1920, 1930)
introduced calcium hydroxide as
material with osteogenic potential.
Frank (1966) was the first to use it as
medical dressing in teeth with incomplete root growth. These dressings
should be replaced approx. every
three months for a time period of
six through 18 months. Cvek (1972)
and Feiglin (1985), however, do favour a replacement of the dressing
only in case of pathology. The long
treatment duration—and thus loss
of patient compliance—as well as a
decrease of fracture resistance (Cvek
1972, Andreasen, Fabrik and Munksgaard 2002, Andreasen, Munksgaard
and Bakland 2006, Trope 2006) are
regarded as adverse features of the
calcium hydroxide method.
As formaldehyde also features an osteogenic potential (Orban 1935), tests
with formocresol versus calcium hydroxide were made as well. Within
a pulpotomy study, Spedding et al.
(1965) judged formocresol as being
more appropriate for apexification.
Latest literature prefers mineral trioxide aggregate (MTA) over calcium
hydroxide (Andreasen et al. 2006,
Schwartz et al. 2008, Schäfer 2003,
2004). Shabahang et al. (1999) as well
as ElMeligy et al. (2006) made a comparison between mineral trioxide aggregate and calcium hydroxide ending up in favour of MTA.
In a prospective study, Simon et al.
(2007) report on 43 one-stage MTA
treatments, which were followed up
after a control period of at least 12
months (up to 36): 65% of apical le-

sions were completely healed and an
apical barrier could be observed in
11 cases (26%). 78.7% were free from
apical periodontitis, whereas apexification took place in only 64 out of
75 cases (85.3%). The time period for
control of apical development was
clearly longer, though, amounting to
70 months.
Aside from the therapy with various
medicaments, the ‘revascularization’
therapy was established also (Ham et
al. 1972, Hülsmann et al. 2008, Bose
et al. 2009, Cehreli et al. 2012, GarciaGody and Murray 2011) provoking a
light bleeding into the pulp by punction beyond the apex. Dressing is
placed coronary: MTA, calcium hydroxide, formocresol or a triple antibiotic paste. The latter one provided
thicker canal walls than calcium
hydroxide respectively formocresol.
Also the length growth was stronger
versus MTA application (Ebeleseder
2004).
Based on the knowledge that formaldehyde preparations have a similar
(necrotizing, osteogenic) effect to
the pulp like calcium hydroxide, the
secondary author of this study as
long-time owner of a general dental
practice suggested an analysis of his
endodontic treatment cases with
open apical foramen regarding apexification/apexogenesis, which had
been carried out by Joschko (2013) as
then doctoral candidate from which
this article reports.

Material and method
99 endodontic treatments of teeth
with open apical foramen were taken

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Dental Tribune Middle East & Africa Edition | 4/2018

◊Page A6
Case 1: Male (born 5 June 1987): Tooth 35

Fig. 3a: 18 March 1997 ante pulpotomy.

from the files of the practice examined in this study in the years 1985
through 2006. Treatment method
was the so-called N2 method according to Sargenti and Richter(1954),
which meant: no canal rinsing and
application of the paraformalde
hyde-containing N2. Rubberdam was
not used. The N2 powder contained
7% formaldehyde before admission
by the EU, afterwards the content was
decreased to 5%.

Fig. 3c: 6 May 2005 status

Fig. 3b: 18 March 1997 post pulpotomy

Result
The average age of the patients was
10.7 years (6–25). Most cases (N=54)
were attributed to mandibular molars (72 %), among these mostly the
first lower molars with 48 cases (50.5

% of the cases to be analyzed), followed by nine cases of maxillary
incisors. 75 cases were subject to one
or—in intervals—multiple follow-up
X-rays. 40 teeth (53.3%) were extirpated vitally, 28 teeth (37.3%) were ampu-

tated vitally and seven non-vital teeth
(9.3%) underwent conservative endodontic treatment. Post-endodontic
clinical control averaged at 73 months
(12–271), the follow-up X-rays to be
evaluated at 70 months (10–228). In

Four cases were excluded:
· A non-vital case where the initial
X-ray did not clearly reveal whether
the apical radiolucency of both roots
were a matter of apical periodontitis
or apical papilla.
· A VitA-case was extracted alio loco a
few days up to 18 months after VitA.
· X-ray was insufficient in the third
case, VitE of an upper molar
· In the fourth case, the patient did not
show up again after devitalization of
an upper premolar.
Thus, 95 cases to be judged remained,
of which only two non-vital teeth
were treated in a two-stage therapy.
93 cases were treated in one appointment inclusive definite filling. For
root canal filling, the N2 powder was
mixed with N2 liquid to a creamy texture, a harder consistency was needed
for VitA. N2 application for root canal
filling was done by lentulo, for VitA a
carrier instrument was used to bring
the material into the excavated pulp
cavity up to 1–2mm into the canal accesses.
The 95 anonymous made cases were
clinically followed-up without recall
at an average of 73 months after treatment. 75 cases underwent X-ray control (follow-up X-ray) after an average
of 70 months; 64 cases as single-tooth
X-ray in parallel technique and 11 cases as orthopantomogram.
Judged as endodontic failure were:
pain or fistula at treated tooth, development of apical periodontitis,
lingering or newly developed apical
periodontitis.
Treatment success of the 75 cases was
analysed in two modes considering
the questions:
· Did apexification/apexogenesis occur?
· Did the apex remain unaffected of
apical periodontitis?

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In multi-rooted teeth with different
apical diagnosis, the worst diagnosis
was assumed as being valid for the
tooth. A double magnifier served as
diagnostic aid. Three persons evaluated the X-rays independently from
each other: The doctoral candidate
(author AJ), a dentist with ten years of
professional experience and the practice owner (author RT). The final diagnosis resulted from the consensus of
the three ratings.
Statistic significance was assumed for
an error assumption of p < 0.05 for
comparison of two parameters and
calculated by means of the logrank
test.

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41 cases, X-ray evaluation was done
more than 48 months after endodontic therapy.

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◊Page A7
Case 2: Male (born 28 December 1980): Tooth 14

Fig. 4a: 18 August 1989 ante vitalextirpation.

The longer therapy dated back, the
earlier achievement of the treatment
aim apexification or apexogenesis
could be verified. Two cases featured
open apical foramina even 16 respectively 30 months post treatment. In
nine molars, the apical foramina of
various roots were partly still open,
partly already closed after an average
of 28 months. Thus their results could
only be judged as partial success. An
average post-observation time of 71
months was registered in 55 cases
with the diagnosis ‘apex closed without lengthening of the root’. A ‘closed
apex with root growth’ could be stated in nine cases after anaverage of 117
months (see case 1) . The average age
of the nine young patients with root
growth amounted to 9.5 years, those
without root growth had an average
age of 11.2 years.
Overall, an apexification success
was found in 64 cases (85.3 %, confidence interval 77.3–93.3 %). In nine
other multi-rooted teeth (12 %), the
maturation process of the roots was
differently distinct: The same tooth
featured a root with closed apical
foramen, whereas another root still
showed an open foramen. Maturation progress of the immature teeth
was ob served on the basis of the 49
cases with multiple follow-up X-rays
in different intervals. A first follow-up
X-ray was available after an average of
34.6 months (4–130). 18 cases (36.7 %)
featured advancement, whereas the
status of the other cases remained
unchanged.
Not considering the nine partial successes as mentioned above, an apexification success rate with/ithout root
lengthening of 90 % (confidence interval 80.7–99.3%) was determined
in the VitE group, the success rate of
the VitA group was 85.7% (confidence
interval 72.7–98.7%), the non-vital
group showed a success rate of 57.1 %
(confidence interval 20.5–93.8 %). The
percentaged difference of apexification success VitE versus VitA with a
probability of error of p = 0.5893 and
VitA versus non-vital group with p =
0.0910 was not significant statistically. A statistic significance could be
determined when comparing VitE
with the non-vital group (p = 0.0243).
Apexification success in root-filled
teeth proved not to be depending on
the filling level (p = 0.2441).
Ten endodontic failures (13.3%), nine
of which radiographically and one
clinically due to fistula formation (see
case 2), were observed: six following
VitE (15%), two following VitA (7,1%)
and two following conservative root
canal treatment of the seven non-vital teeth (28,6%). Regarding endodontic success/failure of VitE versus nonvital group, a statistic significance
revealed (p = 0.0587). A statistic significance could be stated when comparing VitA with the non-vital group
(p = 0.0157). Apexification occurred in
nine of the ten failures. Patient classification in age groups of younger
than 125 months and older than 125
months was not relevant regarding

Fig. 4c: 16 January 2004 status.

Fig. 4b: 18 August 1989 post vitalextirpation

avoidance of endodontic failure (p =
0.448).

Case 3: Female (born 8 August 1988): Tooth 11

19 teeth (20 % of the 95 treated teeth)
were extracted during the observation period. Seven of these teeth
belonged to the VitE group, eight to
the VitA group and four to the nonvital group. A statistic significance of
extraction frequency existed when
comparing the VitE with the non-vital
cases (p = 0.0169). Figure 1 shows the
three groups’ probability of survival
with the aim of no extraction.
Nine teeth (47%) were extracted within the first 50 months after treatment.
The time history of all extractions is
featured in Figure 2. Main reason for
extraction was damage/fracture of
the natural tooth crown (42%) or an
endodontic failure (31%). 33 of the 48
endodontic treatments of first lower
molars had been done prior to the age
of ten years. 14 first lower molars (73.7
% of all extractions) were extracted, 12
of which prior to the age of 20 years.

Discussion
The present study is a retrospective
one with data collected out of a regular dental practice, where endodontic treatments were done according
to the Sargenti N2 technique (1954)
exclusively, a method not accepted
in the established dental doctrine,
primarily due to the formaldehyde
content in the N2 powder, but also
because of elimination of root canal
rinsing. 95 cases could be evaluated.
Whereas apexification literature is
generally based on front teeth with
necrotic pulp, only 10 % of the 95
evaluated teeth were non-vital (see
case 3). 38% were treated by VitA, 52%
by VitE. The first mandibular molars
were represented most with 48 cases.
Patient recall did not take place. In
contrast to clinics, patient loyalty nevertheless allowed a clinical control of
all 95 cases, which was done after an
average of 73 months. 75 cases were
subject to X-ray control. The actually
evaluated X-ray had been taken after
an average of 70 months. 49 of the 75
cases had more than one follow-up Xray taken so that X-ray interpretations
could have been done for various
time intervals thus allowing control
of the further apical development. A
first control X-ray was generally available after 34.6 months. 18 cases of
the more than one follow-up X-rays
documented a continuous maturation. For lack of previous X-rays, the
result of 31 cases of final apical condition after 34.6 months does not mean
that apexification or apexogenesis
could not have been occurred prior
to this time, which could have been
clarified in a prospective study only.
However, the radiographic observation period of 70 months is long compared to other publications. The longest is indicated by Herforth (1981) with
3.9 years after treatment of 541 front
teeth, condition after accident, with
calcium hydroxide and Jodoform and
with four years by Cvek (1972), who
evaluated the data of 328 immature
luxated/subluxated maxillary front

Fig. 5a: 4 September 1995 ante RCF
(non-vital).

Fig. 5b: 4 September 1995 post RCF.

Fig. 5c: 22 April 2002 status.

teeth treated with calcium hydroxide by 58 practitioners. 12 months after MTA treatment of 30 single-root,
non-vital teeth with open apical foramen Annamalai and Mungara (2010)
obtained the following results: apical
healing 100%, apexification 86.6 %,
root extension 30%. After an observation time of 12–44 months, Holden et
al. (2008) determined a success rate of
85 % (N=17) for their 20 teeth treated
by MTA in several appointments. The
healing and apexification process was
not subject to recall interval. However, advanced growth of the apices
after N2 application over a period of
several years could have been well observed in the present study (average:
without extension 71 months, with
extension 117 months), possibly due
to the different characteristics of MTA
versus N2.

containing N2: 90 % following VitE,
85.7 % following VitA, 57.1 % following
conservative root canal treatment of
non-vital teeth. The success rate of
57.1 % for non-vital teeth should not
be taken too seriously because of the
20.5–93.8 % wide confidence interval
due to the small number of cases.
The percentaged success referred to
the respective teeth as a whole. Another 12% referred to some molar
roots with partly open, partly closed
apices. Sheehy and Roberts (1997)
comparatively report on the formation of a hard substance barrier after
calcium hydroxide application after
5–20 months in 7–100 % of the cases.
In contrast, the authors Roberts and
Brilliant (1975) considered the interpretation of an X-ray as being unrealistic for determination of a possible
apical closure matching the Liang et
al. proof of insufficient diagnostics
of the periapical X-ray versus digital
volume tomography (DVT). 23 teeth
were reexamined according to both
techniques two years after endodontic treatment. 74 % of periapical radiolucencies could not have been visualized with conservative X-ray and 61 %
with DVT. Despite of the diagnostic
deficits to be assumed, X-ray in combination with a clinical examination
remains the only practical method.
An inter pretation bias in this study
can be largely eliminated due to the
consensus finding of the three X-ray
evaluators.

Garcia-Godoy and Murray (2012)
made up a survey with hints to deficits in apexification literature. According to this survey, 200 case studies on calcium hydroxide had been
published. Reports on unfavourable
and long-term effects would be missing. One problem of long-term calcium hydroxide dressings would be an
alteration of the mechanical dentine
characteristics, which could lead to
fractures. Long-term studies regarding MTA would be missing. However,
for achieving apexification, mineraltrioxide aggregate would be more effective than calcium hydroxide.

The authors Simon et al. (2007) observed 43 single- rooted teeth with
open apical foramen that had been
one-stage treated with MTA for a time
of 12 up to 36 months. They stated a
complete healing in 65%, an incomplete healing in 30 % and an ‘apical
closure’ in 26 % of these cases (N =
11). The radiographic diagnosis of the
present study is: 78.8 % positively
without apical periodontitis, 9.3 %
apical periodontitis questionable,
12 % apical periodontitis with 85.3
% featuring ‘apical closure’ and 36.7
% root extension. However, a direct
comparison between the Simon and
the present study is not admissible
due to the low number of cases, the
different observation periods and the
non-coordinated interpretations of
the evaluation modalities.
El Meligy et al. (2006) examined 30
pulpotomy cases (15 Ca(OH)2, 15 MTA),
24 of which were first molars, which
suggests a comparison with our
study. The following assumptions
were applied: no clinical problems,
radiographically no apical periodontitis, apexification occurred. 13 calcium
hydroxide cases (87 %), but all MTA
cases came up to this.
The three above mentioned therapy
groups of this study achieved an
apexification success of totally 85.3
% by means of the formaldehyde-

While in short-term studies with low
case numbers extractions are not
mentioned, this study counted 19
extractions, 14 of which were allotted
to the first mandibular molars. Thus
the mandibular molars represented
73.7% of all extractions with a 50.5 %
share in treatments. This relatively
high extraction frequency may be
due to the fact that these teeth erupt
early as the first permanent molars
thus having been exposed to toothdamaging influences for the longest
time. Extraction is avoided less in the
posterior area versus the anterior areas, as in young patients the gap normally closes the natural way without
orthodontic or prosthodontic treatment.

Also regarding regenerative procedures, only case studies and case
series would exist. The ‘blood clot’
generated during this therapy should
however have no contact to the inserted sealer, as sealers were not biocompatible and featured a cell-toxic
effect.
In the present study, pulp tissue, possibly blood as well, had contact to the
cell-toxic N2. As the long-term observation showed, this contact had no
disadvantageous effect to the respective teeth. Regarding apexification
and apexogenesis, a perennial study
rather proved that the success rate
was at least equal to MTA and calcium
hydroxide. Root fracture, as suspected in calcium hydroxide cases, could
not have been noticed in any of the
cases. One-stage treatment has to be
considered as special advantage of N2
application aiming at apexification,
which at the same time is a time- and
cost-saving method.
Editorial note: A list of references is
available from the publisher.

Dr Anette Joschko
General Dentist, Cologne, Germany
Dr Robert Teeuwen
General Dentist, Geilenkirchen,Germany
Prof. Jerome Rotgans
RWTH Aachen University, Medical Faculty,
Aachen, Germany

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[cover] => Endo Tribune Middle East & Africa No. 4, 2018

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