Endo Tribune Middle East & Africa No. 4, 2019
Project for improved root canal therapy launched / Strategies for the treatment of extremely curved root canals
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DTMEA_No.4. Vol.9_ET.indd
NL
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FE
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PR
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DE
www.dental-tribune.me
Published in Dubai
July-August 2019 | No. 4, Vol. 9
Project for improved
root canal therapy launched
By DTI
this IPUCLEAN joint research project
is the development of a piezoelectric
ultrasonic cleaning system to support root canal therapy with rotating super-elastic files made of shape
memory alloys.
ROSTOCK, Germany: In Germany,
Research teams from Rostock, Dresden, Leipzig and Lemgo in Germany
have begun a new project aimed at
improving root canal therapy. Sponsored by the German Federal Ministry of Education and Research’s
(BMBF’s)
funding
programme
Twenty20—Partnership for Innovation, and the smart3 consortium,
members of the medical faculty at
the University of Rostock and the
Fraunhofer Institute for Ceramic
© LEDOMSTOCK/Shutterstock
about 7.5 million root canal therapies
are carried out annually. With the
help of an innovative system, it may
soon be possible to carry out ultrasonic preparation of the root canal
and to monitor the condition of the
file during treatment. In addition,
protection against thermomechanical overloading will prevent the instrument from breaking.
In Germany, about 7.5 million root canal therapies are carried out annually
Technologies and Systems are working together on the project.
“We are pleased to have strong part-
ners at our side in this project and
are working very closely and in an
interdisciplinary way with them.
We are counting on great benefits
for our patients,” emphasised Prof.
Emil Reisinger, dean and scientific
director of the medical faculty at the
University of Rostock. The aim of
“The joint project is intended to improve the treatment process and
patient safety during root canal
therapy in the medium term—at the
same time ensuring and increasing
the quality of the treatment results
achieved,” said Prof. Rainer Bader,
head of the FORBIOMIT research
laboratory for biomechanics and implant technology at Rostock University Medical Center.
The project is being funded by a
BMBF grant of more than €1 million.
The research is being supported by
Komet Dental, Werner Industrielle
Elektronik and Zahntechnik Leipzig.
AD
ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality
providers of continuing dental education. ADA CERP does not approve or endorse individual courses or
instructors, nor does it imply acceptance of credit hours by boards of dentistry.
[2] =>
DTMEA_No.4. Vol.9_ET.indd
A2
ENDO TRIBUNE
Dental Tribune Middle East & Africa Edition | 4/2019
Strategies for the treatment of extremely
curved root canals
By Dr Bernard Bengs, Germany
One of the major challenges in endodontics is the enormous complexity
of root canals. Among other things,
a large number of difficulties must
be overcome in terms of the number, position, possible branches and
curvatures of the canals. Case studies are used to demonstrate how
predictable treatment results can be
achieved in adverse anatomies too.
The aim of root canal preparation
is the complete removal of all vital
and necrotic tissue, infected canal
wall dentine, foreign matter and root
filling material. Adequate chemical
disinfection should be made possible and shaping should allow wall-towall obturation of the canal system.
As early as 1974, Herbert Schilder
published guidelines on this topic,
which have virtually remained unchanged, including the creation of
a continuously conical canal shape
from the access cavity to the apex,
respecting the course of the root canal and maintaining the position of
the apical foramen at a size as small
as practicable.1
Fig. 1: Pre-op radiograph of tooth #25
In the presence of very pronounced
curvatures, espeially abrupt or even
S-shaped (i.e. double) curvatures, it
can prove extremely difficult to implement these guidelines. The angle
of curvature is not the only factor
here; the length of the distance after the curvature is also decisive for
the demands on the instruments. As
the degree of difficulty increases, the
risk of step formation, splinting and
instrument fracture quite naturally
increases.
In vital cases, the size of the preparation may be more moderate than in
cases of pulp necroses or revisions,
as less removal of dentine will be
required here. Ultimately, of course,
the treatment size should be determined by apical gauging (apical
measurement). As this is only practicable to a limited extent in the case
of very extreme, even opposing
curvatures, even more attention
should be paid to tactile feedback
during instrumental canal preparation. Sufficient preparation is always
required for root canal irrigation
and subsequent obturation so that a
shape of at least size 30.04, or better
of size 30.06 or 35.06 (rarely larger in
the case of strong curvatures), which
is usually required in extreme cases,
must be prepared manually using
the step-back technique. Otherwise,
it will not be possible to achieve sufficient disinfection and filling of the
root canal.
Treatment planning
Notes on preparation
Initial information is provided by the
preoperative radiographic image. In
complex anatomies, such as those
that often occur in the posterior region, a CBCT scan provides valuable
information on 3-D curvatures and
the confluence of canals.2 This information is extremely important for
treatment planning, as it allows the
clinician to determine a strategy regarding the instruments to be used
and canal preparation in advance.
For example, very narrow, strongly
curved roots should, if applicable, be
prepared with a smaller ISO size or a
slimmer taper, since even very flexible nickel-titanium (NiTi) file systems
become significantly stiffer with increasing dimensions, which entails
unwanted transportation or even
strip perforations as risks. Each case
should be considered individually to
allow sufficient removal of infected
tissue without risking unwanted excessive removal of dentine.
Fig. 6: The master point image
The preparation of an optimal primary and secondary access cavity is
extremely important, particularly in
the case of strong curvatures. Therefore, a most straightline access to the
canal system is very important, as
otherwise steps or blockages are created right at the beginning of treatment that can only be corrected with
great difficulty.
First, the course of the canal should
be probed with an ISO size 6, 8 or 10
scouting file, if necessary, after coronal pre-flaring with an orifice shaper
or Gates–Glidden drill. Irrespective
of the file system used, the preparation of a glide path is essential for
safe canal preparation. Particularly
in the case of strongly curved, narrow canals, the use of rotary NiTi
glide path files is not only less prone
to complications than with manual
instruments, but also more comfortable. The gliding space created allows
Fig. 2: Trepanation
Fig. 3: The untwisted PathFile after use in the canal.
Fig. 4: Radiographic measurement
Fig. 5: The HyFlex CM file sequence
a significantly lower-risk use of the
following rotary NiTi files for canal
preparation.3
The point of confluence of canals
represents a special case of curvature, as this often occurs particularly
abruptly. It, therefore, makes sense,
for example in the case of two canals
in the mesial root of a mandibular
first molar, to initially prepare only
one canal fully to its working length.
This will often be the mesiolingual
canal. To determine the confluence,
a gutta-percha point is then positioned in the prepared canal and a
Kerr file is inserted into the other
canal. The marking of the instrument tip in the gutta-percha point
determines the length up to which
the second canal must now be prepared. This avoids risky stressing of
the instruments, as well as the unnecessary removal of dentine. Furthermore, the chemical preparation
of the canal system is an indispensable part of the preparation, since
only part of the canal wall surface is
addressed during mechanical preparation.
Figs. 7 & 8: Root canal filling and check of tooth #25
Case 1: Pulp necrosis in an S-shaped
canal
In November 2013, a 46-year-old
emergency patient with acute symptoms of tooth #25 presented. The
tooth had been restored with a ceramic inlay, the sensitivity test for
cold was negative, and the tooth was
sensitive to percussion and pressure.
The preoperative radiograph revealed periapical periodontitis (Fig.
1). The diagnosis was pulp necrosis
after a previous preparation close to
the pulp. The inlay was removed and
an adhesive pre-endodontic buildup was fabricated from composite.
During trepanation, pus drained
from the canal entrances. Working
length was then determined, followed by initial preparation with
Kerr files up to only ISO size 8, for
time reasons, together with intermittent irrigation with heated 6%
sodium hypochlorite (NaOCl). Subsequently, a drug deposit was inserted by rotating in Ledermix. Owing to
the small preparation size, the use of
calcium hydroxide would only have
been possible to a limited extent.
Root canal therapy was continued
approximately six weeks later: after
anaesthesia and placement of a rub-
ber dam, tooth #25 was trepanned
under the microscope (Fig. 2). The
glide path was first prepared manually with C+ Files of ISO sizes 6 and 8
(Dentsply Maillefer), then mechanically with PathFiles of size 13, 16 and
19 (Dentsply Maillefer). The more
flexible HyFlex Glidepath files (COLTENE) were not yet available at the
time of treatment. A detailed image
of the brand-new PathFile illustrated
how extremely the S-shaped canal
configuration had stressed the rotary NiTi instruments after a single use
(Fig. 3). It depicted the plastic deformation of the instrument, a clear indication that this instrument could
only withstand the requirements
with good fortune. A fractured instrument would certainly have been
within the realms of possibility.
After radiographic confirmation of
the working length, the canals were
prepared with the HyFlex CM (controlled memory) NiTi files (COLTENE;
Figs. 4 & 5). The following sequence
was used: 15.04, 20.04, 20.06, 25.04,
25.06, 30.04 and 30.06. Intermittent irrigation was again per- formed
with heated 6% NaOCl.
ÿPage A3
[3] =>
DTMEA_No.4. Vol.9_ET.indd
A3
ENDO TRIBUNE
Dental Tribune Middle East & Africa Edition | 4/2019
◊Page A2
Taper hand files S1 and S2 (Dentsply Maillefer),
which were prebent with the Endo-Bender
(Kerr). Rotary preparation was performed with
the HyFlex CM.
In this case, the following sequence was used
with ascending sizes and tapers: 15.04, 20.04,
20.06, 25.06, 30.04, 30.06 and 35.06. The path
of the canal was manually expanded intermittently with prebent ProTaper hand instruments F1 to F3 and then perfectly shaped with
the corresponding rotary HyFlex files, as the
instruments were stopped in the mesial root
by the speed limiter of the endodontic motor
owing to the extreme curvature. The entire
preparation was performed under intensive
irrigation with heated 6% NaOCl. In addition,
an ultrasound-activated final irrigation with
17% EDTA and NaOCl was performed three
times for 20 seconds. After the master point
try-in, the root canal was obturated vertically
with warm gutta-percha using the modified
Schilder technique (Figs. 16–18). Tooth #37 was
sealed adhesively with a glass-fibre pin and
composite (Fig. 19). Postoperative radiographic
con- trol after one year and approximately 4.5
years showed continued uneventful apical
conditions (Figs. 20 & 21).
Figs. 9–11: Pin check and post-op check after one year and 4.5 years, respectively
Discussion
These cases demonstrate that the safe preparation of even extreme curvatures is predictable
Fig. 12: Preoperative radiograph of tooth #37
Fig. 13: The opened pulp
Figs. 15 & 16: Radiographic measurement and master point image
Fig. 14: Removal of the coronal pulp
Figs. 17 & 18: Root canal filling and check of tooth #37
owing to the use of highly flexible instruments
such as the HyFlex CM.4
Figs. 19–21: Pin check and post-op check after one year and 4.5 years, respectively
After apical gauging, the final
preparation was performed in
steps of 0.5 mm from ISO size 35 to
ISO size 60 using manual NiTi Kerr
files in the step-back technique for
safety rea- sons. Thus, a cone of ten
was created in the apical region.
Although possible in principle, the
use of a 35.06 HyFlex CM was deliberately abstained from, as while
these instruments offer high
flexibility in general, the stiffness
might still have been too great for
the S-shaped course of the canals.
Finally, irrigation was performed
with a 17% EDTA solution and 6
% NaOCl, activating the irrigation
liquids by ultrasound.
After the master point try-in with
configured gutta-percha points,
warm vertical root canal filling
was performed using the modified Schilder technique (Figs. 6–8).
The tooth was sealed adhesively
with composite and a glass- fibre pin (Fig. 9). Postoperative radiographs after one year and 4.5
years, respectively, showed the
complete healing of the extensive
osteolysis (Figs. 10 & 11).
Figs. 22 & 23: HyFlex Glidepath files and HyFlex EDM 10.05 Glidepath file.
Case 2: Pulpitis aperta of tooth #37
A 46-year-old patient presented
with pulpitis complaints regard-
ing tooth #37 in October 2013. The
tooth had been restored with a
partial gold crown, and the marginal seal was incomplete (Fig. 12).
After local anaesthesia, the restoration and the cement build-up
were removed. Underneath was
the opening of the pulp chamber
(Fig. 13). The diagnosis was pulpitis aperta. First, an adhesive, preendodontic composite abutment
was created under rubber dam
isolation. At the same time, the
coronal pulp was removed during
trepanation of the pulp chamber
(Fig. 14). As pain treatment, Ledermix was applied as a drug owing
to the time limitation, and the
tooth was closed adhesively with
composite.
Further treatment was performed
in one visit in December 2013. After local anaesthesia, the drug was
removed and the course of the canal was probed with C+ Files of ISO
sizes 6, 8 and 10 under control of
an endodon- tic motor. The radiographic confirmation of the working length showed a pronounced,
abrupt curvature of the canals in
the apical third of the mesial root
(Fig. 15). The glide path was prepared with PathFiles of sizes 13, 16
and 19, then expanded with Pro-
Meanwhile, additional instruments have become available in sizes 15.01, 15.02 and 20.02, as
has HyFlex EDM size 10.05, which are superior
to the files used at the time in terms of material properties and thus offer greater safety in
difficult cases (Figs. 22 & 23).5 Furthermore, it
can be seen that hybridisation with manual
instruments can be helpful or even necessary
to minimise the risk of fracture and to control
abrupt curvatures. The file sequences used are
of course material-intensive, especially since
the files were discarded after use in each patient case. This procedure is costly, but offers
the best possible safety to avoid cross-contamination and instrument fracture.
Conclusion
The postoperative radiographic checks after
several years proved that even very complex
anatomies can nowadays be treated safely, predictably and sustainably with suitable instruments. For the patient, this implies the longterm preservation of the natural dentition,
even in challenging cases.
Editorial note: A full list of references is available
from the author.
This article was originally published in rootsinternational magazine of endodontics, Issue
4/2018.
About the Author
Dr Bernard Bengs
is a specialist in endodontics certified by the German
Society of Endodontology and Traumatology.
Voxstraße 1, 10785 Berlin, Germany
He can be contacted on dr.bengs@gmx.de
[4] =>
DTMEA_No.4. Vol.9_ET.indd
WaveOne® Gold
Now with WaveOne® Gold Glider
Surf the canal
with confidence
WaveOne® Gold offers you the simplicity of a one-file
shaping system combined with higher flexibility* to respect
the canal anatomy. Now available with a corresponding glide
path file to optimize your shaping preparation. Experience
the feeling of confidence throughout your treatment.
*compared to WaveOne
© 2018 Dentsply Sirona, Inc.
Rx Only
ST8/ B EN W1G0 ADV 000 / 03/2017 – updated 04/2018
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