Endo Tribune U.S. No. 4, 2011
‘Bridging the gap’ / Canal anatomy as it relates to effective instrumentation and obturation / Get to know the PLANMECA ProMax family
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[1] =>
ENDO TRIBUNE
The World’s Endodontic Newspaper · U.S. Edition
April 2011
www.endo-tribune.com
Vol. 6, No. 4
‘Bridging the gap’
Fig. 1: Illustration showing how a
round instrument cannot adequately
cleanse a irregular-shaped canal.
(Photos/Provided by Barry Musikant)
Canal anatomy
as it relates
to effective
instrumentation
and obturation
By Barry Musikant, DMD
Recently, there has been a discussion of the shaping techniques that are
most consistent with effective cleansing
of the canal spaces both in length and
cross section. While cleansing length
has been the main focus of earlier discussions, there is an increasing awareness of the importance of cross-sectional cleansing.
It is somewhat understandable why
cleanliness and shaping have been
limited to the mesio-distal length of
canals given the fact that this is the only
view seen when clinical radiographs
are taken.1
For years, we have considered the
standard of equating a highly radiopaque appearance throughout the
mesio-distal length of the canal as evidence of a well-shaped and well-obturated canal. The introduction of CBCT
radiographs now give us the ability
to attain an accurate and easily read
picture of the canal anatomy in three
dimensions, clearly demonstrating
that in an abundance of situations the
bucco-lingual diameter hardly reflects
the same mildly tapered mesio-distal
anatomy.
In short, most canals, at least along
major portions of their length, are not
round in cross-section. They may be
highly oval with many asymmetric tissue outpouchings, fins, sheets and cul
de sacs (Fig. 1).
With this more realistic understanding of canal anatomy gradually making its way into the literature, a more
critical review of the shaping claims
made by manufacturers of rotary NiTi
is warranted.2
We single out rotary NiTi because
staying centered is a requirement for
their safe usage. Yet centered usage,
as has been shown by an increasing
g ET page 2B
The San Antonio Convention Center will be the site of the American Association of Endodontists’ annual meeting,
which takes place April 13–16. (Photo/Provided by the San Antonio Convention & Visitors Bureau)
AAE’s annual session offers 130 educational
opportunities, including roundtables, live surgeries
The American Association of
Endodontists invites general dentists and dental specialists to attend
its upcoming annual session, April
13–16 in San Antonio, Texas. The
event offers the chance to earn up to
31 continuing education credits from
the nation’s most credible provider
of endodontic education while enjoying the historic city of San Antonio
and its annual Fiesta celebration.
The theme of the meeting, “Bridging the Gap: Partners in Interdisciplinary Care,” focuses on collaboration among dental professionals for
optimal patient care.
“The AAE emphasizes the importance of working with general dentists and other specialists to improve
patient outcomes,” said AAE President Dr. Clara M. Spatafore. To this
end, multiple sessions are geared
toward general dentists, and a special presentation by an endodontist
and dentist duo will share best practices in endodontic treatment planning. “Endodontists and General
Dentists: Partners in Patient Care”
will address topics such as proper
case selection, referral dynamics
and the practical benefits of partnership for the patient and the dental
practice.
To further enhance communication and strengthen relationships
among dental practitioners, the AAE
2011 annual session includes two
new events that promote networking
and the sharing of ideas and experiences. A Lunch-n-Learn event and
roundtable discussions will allow
attendees to share professional opinions and questions in a less structured environment.
For exposure to endodontic techniques, the AAE’s popular Master
Clinician Series will showcase live
surgeries by leading experts in the
field.
The master clinicians include
Drs. Dan B. Ang, Todd M. Geisler,
James L. Gutmann, James C. Kulild,
Stephanie L. Mullins, Richard A.
Rubinstein and Fabricio B. Teixeira. Attendees will witness implant
placement, molar surgeries and a
demonstration of regenerative endodontic procedures.
“We want to give our members
and all attendees an intimate look
at the best technique for performing
endodontic procedures,” Spatafore
said. “Participants will return to their
own practices with a new appreciation for the spectrum and efficacy of
the endodontist’s armamentarium.”
The AAE also will host its Access
to Care Project during the annual session. Through a partnership with the
San Antonio Christian Dental Clinic and Henry Schein Dental/Henry
Schein Cares, prescreened patients
will receive care from licensed Texas
endodontists and endodontic residents from dental schools throughout
the state. To learn more about Access
to Care, visit www.aae.org/access
tocare.
The meeting will commence with
a keynote presentation by Christopher Gardner, an acclaimed motivational speaker and author of the bestg ET page 2B
[2] =>
2B
News
f ET page 1B
selling autobiography, “The Pursuit
of Happyness.”
Gardner will share the important steps to creating a successful
and fulfilling life while telling his
personal story of seemingly neverending obstacles and the ways he
overcame them. Other special guests
include comedians John Pinette and
Kathleen Madigan, who will entertain attendees the last evening of the
annual session during the President’s
Endo Tribune | April 2011
Dinner.
For more information and to view
the full annual session program, visit
the AAE website at www.aae.org/
annualsession. To receive the member discount of more than 40 percent
for session registration, general dentists are encouraged to join the AAE as
associate members.
About the AAE
The American Association of Endodontists, headquartered in Chicago,
represents more than 7,200 members
(Source: AAE)
ENDO TRIBUNE
The World’s Endodontic Newspaper · U.S. Edition
Publisher & Chairman
Torsten R. Oemus
t.oemus@dental-tribune.com
Chief Operations Officer
Eric Seid
e.seid@dental-tribune.com
Group Editor & Designer
Robin Goodman
r.goodman@dental-tribune.com
Editor in Chief Endo Tribune
Frederic Barnett, DMD
BarnettF@einstein.edu
International Editor Endo Tribune
Prof. Dr. Arnaldo Castellucci
f ET page 1B
number of studies, prevents adequate
cleansing of the wider extensions of
oval canals, those walls that constitute
the boundaries of the major diameters
of the canals. Because rotary NiTi is
limited more or less to the preparation of round holes, the only way to
achieve cleanliness when using them
is to make wider round holes. If a
canal starts off oval then, by shaping
the minor diameter to the width of the
major diameter, all the walls will be
cleansed.
Unfortunately, one can easily see
that this cleansing strategy increases
the likelihood that the walls constituting the minor diameter can easily be weakened significantly, undermining the resistance of the root to
vertical fracture. Turning oval canals
into wider round canals is a strategy
because it is the only way rotary NiTi
instruments can address the problem
of asymmetry (Fig. 2).
It is unpredictable when this strategy will produce more problems than
it solves. To know when to apply this
strategy would require knowledge of
the cross-sectional width of the roots as
well as the canals within them, requiring each patient to routinely have a
CBCT scan.
At best, we would know when not to
employ this strategy while still needing
a technique that would clean the canals
adequately without weakening the
walls of the minor diameter. Logically,
if we can devise a technique that allows
us to clean canals without removing
excessive tooth structure, that technique could then be used all the time.
Recently, a new tool has been introduced that makes an effort at cleansing the canal spaces without removing excessive tooth structure from the
minor diameters.
The self-adjusting file (SAF) is a hollow tube mesh that is used in a rapid
up-and-down stroke that cleanses the
Tell us
what
you
think!
worldwide. Endodontics is one of nine
dental specialties formally recognized
by the American Dental Association.
The AAE, founded in 1943, is dedicated to excellence in the art and
science of endodontics and to the
highest standard of patient care. The
association inspires its members to
pursue professional advancement and
personal fulfillment through education, research, advocacy, leadership,
communication and service. ET
Fig. 2: Illustration highlighting how
a round-shaped instrument cannot adequately shape or cleanse an
oval- or irregular-shaped canal.
walls. Being made of NiTi, it is highly
flexible both in length and cross-section. It adapts to the walls of the canal
and, in so doing, removes a thin layer of
dentin along length, be it in the major
or minor diameter.
If the canal’s original diameter is
oval, it remains oval at the end of the
shaping procedure. This sounds like
an ideal solution to the alternative
approach: enlarging the minor diameter to that of the major diameter, which
can excessively weaken the root.
The shortcoming of the SAF is related to its overall diameter. If at any given
level the total circumferential area is
less than that of the canal space, then
the sides of the instrument will not
touch the walls of the canal unless
the instrument is aggressively pressed
against those walls. This becomes
increasingly challenging in the apical
third where the SAF is often much thinner than the cross-sectional anatomy of
the canal.
Furthermore, the hollow mesh
design of the NiTi tubing is so flexible
that it cuts very little dentin. The very
flexibility that allows it to conform to the
canal walls reduces the efficiency with
which it removes dentin from the walls
of the canal, necessitating approximately five minutes for the cleansing procedure. Despite the amount of time dedicated to the cleansing process, a recent
article has shown that the apical third is
no better than one-third cleansed.
Do you have general comments or criticism
you would like to share? Is there a particular topic you would like to see more articles
about? Let us know by e-mailing us at
feedback@dental-tribune.com. If you would
like to make any change to your subscription
(name, address or to opt out) please send us an
e-mail at database@dental-tribune.com and
be sure to include which publication you are
referring to. Also, please note that subscription
changes can take up to six weeks to process.
An alternative way to clean canals
that minimizes the amount of crosssectional distortion (turning oval cross
sections into round ones) is via the
use of relieved reamers in a 30-degree
reciprocating handpiece.3
The reamers are made of stainless
steel and have enough body to be effectively placed against all the walls of the
canals in a circumferential fashion. The
vertically oriented blades cut the dentin
as the reamers oscillate thru 30-degree
arcs of motion at the rate of 3,000-4,000
cycles/minute.
Cleansing the canals with these
instruments accomplishes four goals:
1) The reamers are virtually immune
to breakage.
2) Consequently, they can be used six
to eight times before replacement,
dramatically reducing costs.
3) By using them on the pull stroke in
a circumferential manner, the original shape of the canal while being
enlarged retains the original canal
anatomy.
4) The instruments have enough body
in them to effectively remove upward
of 200 microns of dentin from all the
walls. This is critical because bacteria
have been shown to penetrate 200
microns or more when the canals are
infected. This is not the case with the
SAF and is not recommended for the
safe usage of rotary NiTi.
The stainless-steel relieved reamers are far more flexible than K-files
and are used routinely through size
35. The tight arc of motion keeps the
canals centered in the canal during the
manual down stroke and allows them
to be directed against the circumferential walls during the upstroke.
The up-and-down strokes provide
both centered control at the tip of the
instrument while the instruments are
able to remove dentin from all the walls.
This is the exact action that is needed to
adapt to the shapes of the canals that
g ET page 4B
ET
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
Sierra Rendon at s.rendon@
dental-tribune.com.
Managing Editor/Designer
Implant, Endo & Lab Tribunes
Sierra Rendon
s.rendon@dental-tribune.com
Managing Editor/Designer
Ortho Tribune & Show Dailies
Kristine Colker
k.colker@dental-tribune.com
Online Editor
Fred Michmershuizen
f.michmershuizen@dental-tribune.com
Account Manager
Humberto Estrada
h.estrada@dental-tribune.com
Marketing Manager
Anna Wlodarczyk-Kataoka
a.wlodarczyk@dental-tribune.com
Marketing & Sales Assistant
Lorrie Young
l.young@dental-tribune.com
C.E. Manager
Julia Wehkamp
j.wehkamp@dental-tribune.com
International C.E. Sales Manager
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c.ferret@dtstudyclub.com
Dental Tribune America, LLC
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Fax: (212) 244-7185
Published by Dental Tribune America
© 2011 Dental Tribune America.
All rights reserved.
Dental Tribune America makes every effort
to report clinical information and manufacturer’s product news accurately, but cannot
assume responsibility for the validity of product claims, or for typographical errors. The
publishers also do not assume responsibility
for product names or claims, or statements
made by advertisers. Opinions expressed by
authors are their own and may not reflect
those of Dental Tribune America.
Editorial Advisory Board
Frederic Barnett, DMD (Editor in Chief)
Roman Borczyk, DDS
L. Stephen Buchanan, DDS, FICD, FACD
Gary B. Carr, DDS
Prof. Dr. Arnaldo Castellucci
Joseph S. Dovgan, DDS, MS, PC
Unni Endal, DDS
Fernando Goldberg, DDS, PhD
Vladimir Gorokhovsky, PhD
Fabio G.M. Gorni, DDS
James L. Gutmann, DDS, PhD (honoris causa),
Cert Endo, FACD, FICD, FADI
William “Ben” Johnson, DDS
Kenneth Koch, DMD
Sergio Kuttler, DDS
John T. McSpadden, DDS
Richard E. Mounce, DDS, PC
John Nusstein, DDS, MS
Ove A. Peters, PD Dr. med dent., MS, FICD
David B. Rosenberg, DDS
Dr. Clifford J. Ruddle, DDS, FACD, FICD
William P. Saunders, Phd, BDS, FDS, RCS Edin
Kenneth S. Serota, DDS, MMSc
Asgeir Sigurdsson, DDS
Yoshitsugu Terauchi, DDS
John D. West, DDS, MSD
[3] =>
ENDO Tribune | April 2011
Industry Opinion & Products 3B
[4] =>
4B
Industry Opinion
f ET page 2B
Fig. 3:
Epoxy resin
cement being
whipped laterally with
usage of a
bi-directional
spiral for
application
during the
obturation
process.
AD
exist, widening and cleansing them
without distortion in the process.
At the end of the shaping procedure,
those advocating a round hole as a
final preparation may state that it is
now impossible to produce a decent
seal during obturation. This would be
true if the fill were dependent on guttapercha either laterally condensed or
thermoplastically adapted to the canal
shape.4-6
The former situation cannot be remedied by gutta-percha in the cold state.
In the heated state, whatever adaptation that occurs will almost immediately be compromised as the thermoplastically adapted material cools and
shrinks between 4–5 percent. The most
predictable way to fill oval canals is
via a combination of gutta-percha and
cement.
Endo Tribune | April 2011
However, the cement must flood the
entire canal space prior to the placement of the pre-fitted gutta-percha
point. The only way to accomplish this
goal without concern for driving the
cement over the apex is the application of the sealer with a bi-directional
spiral (Fig. 3) specially made to flood
the canal while preventing its extrusion
beyond the walls of the canal.
Once the canals are flooded, the
placement of the well-coated master
point drives the excess cement laterally, filling the nooks and crannies
along the walls of the canals before the
excess escapes coronally.
In canals that are highly oval, the
creation of lateral space using a spreader with no more force than the weight
of one’s hand, allows for the placement of one or more additional wellcoated points. This technique allows
for the thorough obturation of oval
Fig. 4
Fig. 5
Fig. 6
Figs. 4–6: Radiographs highlighting excellent clinical results using
relieved instruments in a reciprocating handpiece for instrumentation
and epoxy resin cement applied with
a bi-directional spiral for obturation.
spaces with a combination of cement
and gutta-percha.
The purpose of the gutta-percha
is to act as a carrier and driver of the
cement and then a spacer that can be
removed at a later date, if a post-hole
is needed or the canals have to be
retreated.
Integral to the success of this
approach is the use of epoxy resin
cement as the sealer.
The properties of epoxy resin (see
examples in Figs. 4-6) include:
1) Its low viscosity allows for excellent
flow and adaptation to the canal
walls.
2) The ability to bond chemically and
physically to both the dentinal walls
and the gutta-percha.
3) Dimensional stability as it polymerizes.
4) High resistance to hydrolytic degradation.
5) Its placement at room temperature
and its subsequent mild expansion
as it warms to body temperature.
In summary, we see the shortcomings of rotary NiTi and the SAF. These
shortcomings are well-documented in
dental literature. We offer an alternative method of shaping followed by an
equally necessary technique of filling
asymmetrical spaces.
The former is necessary to ensure
well-cleansed canals. The latter is necg ET page 5B
[5] =>
ENDO Tribune | April 2011
essary to produce a good seal without the potential of undermining the
minor diameter of oval-shaped roots in
the misdirected quest to make all oval
canals round in cross-section.
If you would like additional
information, I offer a free two- to
three-hour one-on-one workshop so
dentists can test these concepts for
themselves. If you are interested in
being able to judge for yourself the
merits of these alternative approaches, call (888) 542-6376 to set up a time
for this workshop. ET
References
1. Wu M-K, Roris A, Barkis D, Wesselink PR (200). Prevalence and
extent of long oval canals in the
apical third. Oral Surgery, Oral
Medicine, Oral Pathology, Oral
Radiology and Endodontics 89,
739–42.
2. Sattapan B, Nervo GJ, Palamara JE,
Messer HH. Defects in rotary nickel-titanium files after clinical use. J
Endod. 2000 Mar;26(3):161–5.
3. Wan J, Rasimick BJ, Musikant
BL, Deutsch AS. Cutting efficiency
of 3 different instrument designs
used in reciprocation. Oral Surg
Oral Med Oral Pathol Oral Radiol
Endod. 2010;109:e82–5.
4. Capurro MA, Goldberg F, Balbachan L, Macchi RL. Evaluation of
the dimensional stability of different thermoplasticized gutta-percha
fillings using simulated glass root
canals. Endod Dent Traumatol.
1993;9(4):160–4.
5. Meyer KM, Kollmar F, Schirrmeister JF, Schneider F, Hellwig
E. Analysis of shrinkage of different gutta-percha types using
optical measurement methods.
Schweiz Monatsschr Zahnmed.
2006;116(4):356–61.
6. Tsukada G, Tanaka T, Torii M,
Inoue K. Shear modulus and thermal properties of gutta percha for
root canal filling. J Oral Rehabil.
2004;31(11):1139–44.
ET About the author
Dr. Barry Lee Musikant is a
member of the American Dental
Association,
American
Association
of
Endodontists,
Academy
of General
Dentistry,
The Dental
Society of
N.Y., 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).
As a partner in the largest
endodontic practice in Manhattan, Musikant’s 35-plus years of
practice experienc have established him as one of the top
authorities in endodontics.
Munce Discovery Bur
Munce Discovery Burs are the
answer to calcified canals, separated instruments, isthmus troughing,
cement-line dissection and deepaccess caries.
Shallow and deep troughers are
31 mm and 34 mm long, respectively, with six easy-to-read color-coded
round carbide head sizes (#¼, #½, #1,
#2, #3 & #4).
Stiff 1 mm-diameter shafts ensure
positive operational control, and the
even narrower 0.7 mm-diameter stiff
shaft of the tiny #¼ deep trougher
makes it ideal for high-magnification delicate isthmus troughing and
cement-line dissection around posts,
silver points, etc.
There is also the unique 31 mmlong #6 Endodontic Cariesectomy Bur.
By contrast, standard slow-speed burs
are only 28 mm long and have bulky
2.6 mm-diameter shafts that impinge
on deep access cavity walls, unfavorably guiding the bur head toward ledging or perforation.
Unlike ultrasonic tips, Munce Discovery Burs are heatless, not prone to
spontaneous breakage and have the
familiar tactile feedback of slow-speed
round burs.
For more information, call (888)
256-0999 or visit cjmengineering.com.
(Photo/Provided by CJM Engineering)
f ET page 4B
Industry Opinion & Products 5B
AD
[6] =>
6B
Industry News
Endo Tribune | April 2011
Get to know the PLANMECA ProMax family
ProMax Digital
• saves time.
PLANMECA ProMax X-ray’s unique
SCARA technology (Selectively
Compliant Articulated Robot Arm)
enables precise, complex movements
required in rotational maxillofacial
radiography. The ProMax’s digital
CCD imaging system delivers highly
detailed radiographic images for each
patient type and for virtually any need
of maxillofacial diagnostics.
ProMax combines several imaging modalities: panoramic; advanced
panoramic for specific diagnostics of
the arch, the jaw, maxillary sinuses
and TMJ; tomographic slices for morphologic diagnostics and cephalometry.
DICOM-compliant Romexis imaging software is supplied with the unit,
and is now Mac OS compatiblie. The
ProMax Digital X-ray can be upgraded to high-tech functionality as needed, including adding cephalometric
capabilities and upgrading from film
or digital to 3-D (cone-beam computed tomography, CBCT).
ProMax 3D (ø8x8)/3D s (ø5x8)
— CBCT
PLANMECA’s
AD
ProMax
3D
with
ProMax 3D Max
Here’s a look at the PLANMECA ProMax family. (Photo/Provided by
PLANMECA)
advanced CBCT 3-D technology
provides clear, dependable volume
imaging in a three-dimensional format with limited patient radiation;
about half the radiation of a medical
CT scan.
This versatile and dynamic imaging system brings new possibilities for
diagnostics, treatment planning and
patient counseling.
With the ProMax 3D, you can scan
three-dimensional volumes, pan-
oramic images, panoramic bitewings
and cephalometric and tomographic
images.
The Unique SmartPan Imaging
Option allows the use of a single 3-D
sensor for both 3-D and SmartPan 2-D
imaging, which means:
• no need to change sensors.
• choose one of nine panoramic layers after exposure.
• reduces positioning errors and is
easy to use.
Cone-beam technology’s full visual “reality” has traditionally been
reserved for medical CT technology,
but now this same visual “reality”
can be owned and implemented by
any dental professional at a low cost
and at 1/10th the amount of radiation
to the patient than traditional medical CT.
PLANMECA’s ProMax 3D Max follows the company’s clinical values that
emphasize the use of the least amount
of radiation to achieve the best results
possible.
This commitment to “as low as
reasonably achievable,” or the ALARA
radiation principle, keeps both dentist
and patient safe.
The ability to have so many volume
selections and use the least amount of
radiation is made possible by PLANMECA’s patented SCARA technology
built into its ProMax platform. This
robotic arm allows for precise imaging
anywhere in the maxillofacial/cranial
region.
For more information on the
PLANMECA ProMax family, see
www.planmeca.com. ET
[7] =>
ENDO Tribune | April 2011
Industry and Products 7B
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