Endo Tribune U.S. No. 1, 2013
Endodontists to convene in Hawaii / AAE Foundation is offering $2.5 million to fund regenerative endodontic research / The real state of endodontic instrumentation
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ENDO TRIBUNE
The World’s Endodontic Newspaper · U.S. Edition
january 2013 — Vol. 8, No. 1
www.dental-tribune.com
Clinical opinion
Endodontists
to convene
in Hawaii
The real state
of endodontic
instrumentation
By Barry Lee Musikant, DMD
While the quality of endodontic instrumentation and obturation are generally
based on our final mesio-distal X-rays, we
must not believe for a moment that such
an X-ray is necessarily a predictable or
even accurate reflection of a job well done
even when the results look excellent.
I say this today because research over
the past several years has clearly established that canals are often quite oval,
deviating significantly from the conical shapes we most often associate with
thorough instrumentation and obturation (Figs. 1,2).
In this regard, the inadequacy of rotary NiTi in shaping such canal configurations is established by a plethora of research articles.1,2 The use of rotary NiTi
aggravates incomplete shaping by its
need to stay centered at all times within
the canal. It takes little imagination to
realize that an instrumentation system
that requires constant centering lest it
be more prone to separation, is not going to cleanse what are often the buccal and lingual extensions of highly
oval canals.1,2 To further compound
inadequate debridement, single instrument NiTi instrumentation systems
have been introduced that have also
been clearly shown via micro CT scans
” See INSTRUMENTATION, page C2
The AAE will hold its annual meeting April 17 to 2o in Hawaii. Education, networking and exhibits are planned. Photo/Provided by www.sxc.hu
E
ach year, the American Association of Endodontists (AAE)
hosts the largest endodontic
meeting in the world, with
more than 3,500 attendees and more
than 100 vendors.
The 2013 AAE Annual Session will be
held April 17 to 20 at the Hawaii Convention Center in Honolulu.
In addition to offering attendees plen-
ty of time to enjoy the tropical setting,
the meeting will offer the following:
• A full meeting program with up to
22.5 hours of C.E. credit.
• A Master Clinician Series and handson workshops.
• Exhibits from Wednesday through
Friday, including an exhibit hall breakfast.
• “Mega-Session Wednesday,” providing
an introduction to educational tracks.
• Pre- and post-meeting hotel discounts in Hawaii.
More information about the meeting
will be available in future issues of Endo
Tribune, as well as on the AAE’s website,
www.aae.org.
(Source: AAE)
AAE Foundation is offering $2.5 million
to fund regenerative endodontic research
The American Association of Endodontists and the AAE Foundation
are seeking applications to support
research to investigate regenerative
endodontic treatment. The goal is to
obtain reliable evidence about the conditions under which pulpal regeneration occurs in patients.
Applications are due by Aug. 1, and up
to $2.5 million in funding will be allocated to support one or more studies.
The guidelines and application can be
downloaded from the AAE website at
www.aae.org/AAE_Foundation/Research_
Grants_and_Awards/Other_Grants.aspx.
“Regenerative endodontics is a revolutionary approach to managing and
saving teeth with open apices that
may otherwise be extracted,” said Dr.
Avina Paranjpe, member of the AAE
Regenerative Endodontics Committee.
“Through this AAE Foundation-funded
research we hope to document pulpal
regeneration and, ultimately, sponsor
clinical research in this fast-emerging
field.”
Examples of research that could be
funded include studies on factors associated with pulpal regeneration, such
as patient and tooth characteristics,
clinical history or treatment methods. These studies need to build the
evidence base to support regenerative
endodontic therapy in clinical practice
and may also aid in the design of future
clinical trials to investigate the efficacy
or effectiveness of pulpal regenerative
treatment.
“The AAE and its members are among
the leaders in regenerative dentistry,”
‘With this multimillion dollar commitment to
regenerative endodontics research, we are
working to ensure the specialty’s place at the
forefront of the dental health arena.’
said AAE Foundation President Dr. Keith
V. Krell. “With this multimillion dollar
commitment to regenerative endodontics research, we are working to ensure
the specialty’s place at the forefront of
the dental health arena.”
The AAE collects data on regenerative
endodontics through its Regenerative
Endodontics Database, where practitioners can submit information related
to revascularization cases. This data
will be used in endodontic research,
to assist in establishing treatment best
practices and to clarify future research
initiatives for these cutting-edge therapies. The current considerations for regenerative procedures can be viewed
on the AAE website. These considerations are continuously updated based
on current research.
(Source: AAE)
[2] =>
C2
clinical opinion
“ INSTRUMENTATION, Page C1
to miss removing more than 50 percent
of the tissue in the canals (Fig. 3).
Knowing that NiTi instruments of
greater tip size and taper are more
prone to separation, rotary NiTi and
to a lesser extent asymmetric NiTi reciprocation creates an incentive in the
dentist to prepare canals conservatively with an increased incidence of
debris left behind. Recent research has
now demonstrated an increased occurrence of dentinal micro-fractures
when the canal walls are exposed to
NiTi instruments generating full arcs
of motion.3–6 It should also be noted at
this time that both hand instrumentation and engine-generated movement
not resulting in full arcs of motion are
not associated with the development of
micro-fractures.
In short, 20 plus years after the introduction of rotary NiTi and its close
cousin asymmetric reciprocation, we
are becoming more aware of the limitations imposed by these systems including modification of technique
to prevent separation, non-deviation
from centered canal preparations
leaving debris in the wider extensions of oval canals to again prevent
separation, the understanding that
NiTi instruments of increasing tip size
and taper are not only more prone to
breakage, but are more likely to create
dentinal micro-fractures.
Given the aggressive marketing of
these instruments and their universal
adoption by our dental educational
institutes, it is imperative that we understand what these instruments cannot predictably and safely do and what
alternatives exist that can produce a
safer and more thorough result. The
research has clearly established that
apical canal preparations must be to at
least a 30 and preferably a 35 to provide sufficient space for effective irrigation. Given the insecurities of the
present NiTi systems such apical preparations will be a rarity particularly in
curved canals of molars.
The first improvement in instrumentation must be the elimination
of instrument breakage as a source of
concern. If breakage can be eliminated,
the challenges to the dentist doing endodontics is now limited to negotiating
and widening the canal without distortion, a far easier task when separation is
no longer a worry.
It’s one thing to talk about the benefits of non-separation, but exactly how
is this accomplished when it is common wisdom that breakage is something that anyone doing endodontics
must contend with?
The fact is that if the movement of
the instruments is limited to a tight
arc of motion manually and does not
exceed a 30-degree arc of motion
when engine-generated, the elastic
limit of the instruments will not be
exceeded and the instruments will remain intact. The twin factors that lead
to the separation of NiTi instruments
are torsional stress and cyclic fatigue,
both generated by high degrees of rotation. Substitute 30-degree reciprocation for full arcs of rotation and the
instruments will remain intact even
when used at 3,000–4,000 cycles per
minute.
The consequences of no longer needing
Endo Tribune U.S. Edition | January 2013
ENDO TRIBUNE
Publisher & Chairman
Torsten Oemus t.oemus@dental-tribune.com
Chief Operating Officer
Eric Seid e.seid@dental-tribune.com
Group Editor
Robin Goodman r.goodman@dental-tribune.com
Editor in Chief ENDO Tribune
Frederic Barnett, DMD barnettF@einstein.edu
Managing Editor ENDO Tribune
Fred Michmershuizen
f.michmershuizen@dental-tribune.com
Managing Editor Show Dailies
Kristine Colker k.colker@dental-tribune.com
Managing Editor
Sierra Rendon s.rendon@dental-tribune.com
Managing Editor
Robert Selleck, r.selleck@dental-tribune.com
Product/Account Manager
Humberto Estrada h.estrada@dental-tribune.com
Figs. 1,2: CT scan of a mandibular central incisor.
Note the irregular canal shape. Images/Provided
by www.rootcanalanatomy.blogspot.com
Fig. 3: The green areas of this CT photograph
show areas missed during the root canal procedure.
Marketing director
Anna Kataoka-Wlodarczyk
a.wlodarczyk@dental-tribune.com
C.E. DIRECTOR
Christiane Ferret c.ferret@dtstudyclub.com
Tribune America, LLC
116 West 23rd Street, Suite 500
New York, NY 10011
Phone (212) 244-7181
Fax (212) 244-7185
Fig. 4: A photograph showing a relieved K-reamer. Note the horizontal orientation of the flute
design and flat side. Photos/Provided by Barry Lee Musikant, DMD
Published by Tribune America
© 2013 Tribune America, LLC
All rights reserved.
Tribune America strives to maintain the utmost accuracy in its news and clinical reports. If you find a
factual error or content that requires clarification,
please contact Managing Editor Fred Michmershuizen
at f.michmershuizen@dental-tribune.com.
Tribune America cannot assume responsibility for
the validity of product claims or for typographical errors. The publisher also does not assume responsibility for product names or statements made by advertisers. Opinions expressed by authors are their own
and may not reflect those of Tribune America.
Editorial Board
Fig. 5: Radiograph of a maxillary molar instrumented with a relieved reamer.
Frederic Barnett, Editor in Chief
Dr. Roman Borczyk
Dr. L. Stephen Buchanan
Dr. Gary B. Carr
Prof. Dr. Arnaldo Castellucci
Dr. Joseph S. Dovgan
Dr. Unni Endal
Dr. Frnando Goldberg
Dr. Vladimir Gorokhovsky
Dr. Fabio G.M. Gorni
Dr. James L. Gutmann
Dr. William “Ben” Johnson
Dr. Kenneth Koch
Dr. Sergio Kuttler
Dr. John T. McSpadden
Dr. Richard E. Mounce
Dr. John Nusstein
Dr. Ove A. Peters
Dr. David B. Rosenberg
Dr. Clifford J. Ruddle
Dr. William P. Saunders
Dr. Kenneth S. Serota
Dr. Asgeir Sigurdsson
Dr. Yoshitsugu Terauchi
Dr. John D. West
Tell us what you think!
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Fig. 6: Radiograph of a maxillary molar instrumented with a relieved reamer.
[3] =>
Endo Tribune U.S. Edition | January 2013
to be concerned about instrument separation are several:
1) The earliest instruments can be
used aggressively against all the walls
of the canals including the thin isthmuses that may be present either between canals or the extensions of oval
canals.
2) The instruments can be used several times until they become dulled.
They need not be replaced after one
use because the downside to over usage is dullness not breakage, a fact that
relieves a good deal of gastric distress
while dramatically reducing the cost.
3) The canals are widened to a minimum of 35 in accordance with the research that shows how such preparations correlate to superior irrigation.
What we have not mentioned up to
now is just what design is optimal. Here
we deviate from the traditional use of
K-files, substituting K-reamers through
a 10 and then relieved K-reamers (Fig.
4) starting with the 15 and continuing
on with instruments of this design for
the complete shaping procedure. The
advantages of reamers both unrelieved
and relieved are superior to K-files and
eliminate the need for either rotary or
asymmetric reciprocating NiTi’s subsequent use for the following reasons:
1) K-reamers have half the number
of flutes with a flute orientation that
is twice as vertical producing less engagement along length.
2) Used with the same watch-winding
motion as K-files, the reamers will immediately shave dentin away from the
canal walls because the more vertical
orientation of the flutes puts them
more or less at right angles to the plane
of motion, similar to what occurs
when shaving with a safety razor that
is on a T. The same way a blade at right
angles to the plane of motion produces
smooth skin, it will effectively shave
dentin away from the canal walls. The
traditional use of K-files results in the
engagement, not the removal of dentin, until the pull stroke is employed.
Yet these same horizontally oriented
flutes on a K-file have a high potential
to impact dentinal debris when being
introduced into the canal.
3) Having half the number of flutes
compared to a K-file, the reamer is less
work-hardened, making it more flexible. The incorporation of a flat along
its entire working length makes it still
more flexible. That along with its reduced engagement along length allows
it to negotiate curved and tortuous canals with far less resistance than a Kfile will encounter, allowing the canal
to be shaped to the proper dimensions
in significantly less time. It should also
be noted that the creation of the glide
path is where blockages, ledges and
loss of length most frequently occur, a
Corrections
Endo Tribune strives to maintain the
utmost accuracy in its news and
clinical reports. If you find a factual
error or content that requires
clarification, please report the
details to Managing Editor
Fred Michmershuizen at
f.michmershuizen@dental-tribune.
com.
clinical opinion
C3
Barry Lee Musikant,
DMD, is a member
of the American Dental Association, American Association of Endodontists, Academy
of General Dentistry,
the Dental Society of
New York, First District
Dental Society, Academy of Oral Medicine,
Alpha Omega Dental
Fraternity and the American Society of Dental Aesthetics. He is also a fellow of the American College
of Dentistry (FACD). He is a partner in the largest
endodontic practice in Manhattan. Musikant’s 35plus years of practice experience have established
him as one of the top authorities in endodontics. To
find more information from Musikant, visit www.
essentialseminars.org, email info@essentialseminars.
Fig. 7: Radiograph of a maxillary molar instrumented with a relieved reamer.
direct result of the poor K-file design.
This is far less likely to happen when
using the reamers both unrelieved
and relieved either manually or in the
30 -degree reciprocating handpiece.
4) A system based on the design of a
relieved reamer and utilized in a way
that minimizes the amplitude of motion is best made of stainless steel.
NiTi requires only a small extension of
distortion beyond the elastic limit to
produce a breakage. Stainless steel will
work under far more distortion before
it separates, making it a more practical
metal than NiTi.
5) Stainless steel can be pre-bent to
adapt to any canal configuration. NiTi,
in most preparations snaps back to the
straight position with a tendency to
shape curved canals to the outer wall.
Those preparations of NiTi that can
record a bend are so flexible that they
can easily lock apically while rotating
or reciprocating coronally. There is a
downside to being too flexible.
6) The greater stiffness of stainless
steel means it must not be used in rotation, but has no limitations when used
with a short arc of motion either generated manually or in the reciprocating handpiece. The greater hardness of
stainless steel means the instruments
will retain their cutting edge far longer than NiTi. Considering the fact that
these instruments should be used at
least six times before replacement, the
retention of a sharp blade is a decided
advantage.
It is an easy task to enumerate the advantages of the reamers over that of Kfiles and the subsequent use of NiTi. The
proof, however, is in the pudding and a
recent example of the work that we produced in our office will illustrate the advantages gained from their usage.
Figures 5–7 show a maxillary molar
that was prepared apically to a minimum of 35, 1 mm back to a 40 and the
implementation of the single NiTi
instrument we use in reciprocation,
the 25/06 to blend in the middle and
apical thirds. The dimensions of the
preparation were in accordance with
the research that recommended a 35
for effective irrigation.
From the outset, using the thinnest
06 reamers, all the walls of the canals
were shaped by the reamers’ vertically
oriented blades. If we are serious about
removing the tissue in the thin isthmus extensions that often exist, we
must address them at the very begin-
ning of instrumentation when instruments are the thinnest.
The reamers far more easily negotiate curved canals than K-files and if
increasing resistance is encountered
are pre-bent and negotiated manually
around any tortuous canal present.
A combination of superior dentinal
shaving, less initial engagement and
increased flexibility give the reamers
the ability to provide the dentist with
excellent tactile perception, letting
him know exactly when an instrument
may require pre-bending.
org or call (888) 542-6376.
With the ability to be pre-bent and
limited to a short arc of motion, the
stainless-steel reamers both unrelieved and relieved can adapt to any
situation that may be encountered.
The result is not only one that looks
good in the mesio-distal plane, but is
cleansed three dimensionally to a degree that assures cleaner canals and
superior obturation while leaving the
walls of the canal defect free.
Editorial note: A complete list of references is available from the publisher.
AD
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[toc_titles] => Endodontists to convene in Hawaii
/ AAE Foundation is offering $2.5 million to fund regenerative endodontic research
/ The real state of endodontic instrumentation
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