Endo Tribune U.S. No. 9, 2012

Designing endodontic instruments for success / Efficient and ergonomic apical resection using the Kaiserswerth algorithm / Specialists to discuss traumatic injuries / Interview: Starting fresh in the Black Hills / Industry

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ENDO TRIBUNE
The World’s Endodontic Newspaper · U.S. Edition

october 2012 — Vol. 7, No. 9

www.dental-tribune.com

Designing
endodontic
instruments
for success

Efficient and ergonomic
apical resection using the
Kaiserswerth algorithm

By Barry Lee Musikant, DMD

By Prof. Marcel Wainwright, DMD

Clinical opinion

deal mechanically successful endodontics is directly related to the
removal of all pulpal tissue within
the canals; the removal of a more
or less uniform layer of dentin from all
the canal walls, be they round or varying
degrees of oval; the maintenance of the
original canal anatomy in a larger form;
and maintaining the integrity of the
canal walls during the entire cleansing
procedure.
The ideal is rarely met, but the correct design and utilization of the instruments will go a long way in approaching
that ideal. The present state of design
and utilization of the instruments that
are now being marketed by the major
manufacturers and advocated by their
well-paid lecturers do not come close to
the ideal, as will be clearly pointed out in
this article.
Let’s start with the primary goal, gaining initial patency of the canals from the
orifice to the apex. The vast majority of
dentists will use K-files to start shaping
the canal. If they do not use NiTi either
in rotation or asymmetric reciprocation,
then they will use K-files for the entire
procedure. If they do use NiTi in one
form or another, they will most likely
shape the canal to a minimum of 20 prior to incorporating NiTi. In either case,
the K-files are poorly designed to initially traverse the small patent pathways
that may be present and to then enlarge
them in a sequential manner.
Why do we say poor design? K-files
have 30 predominantly horizontal flutes
along their 16 mm of working length.
If used with a watch-winding motion,
these horizontally oriented flutes will
engage and disengage the dentinal walls
without actually removing any dentin
until the pull stroke is applied. It takes
two strokes to shave dentin away when
using K-files — the twist that supplies
the engagement, and the pull that shaves
away what has been engaged.
With the flutes engaging dentin along
its length, the K-files produce a poor tactile perception of exactly what the tip of
the instrument is encountering. If unaware that the tip of the instrument is
encountering a solid wall, it is all to easy
to ledge at this point, creating a manmade defect that may be a great obstacle
to further accurate apical negotiation.
When the pull stroke is applied to shave
dentin away in a curved canal, there is a

” See INSTRUMENTS, page C2

Thanks to minimally invasive techniques, such as ultrasonic surgery and the
availability of reliable restorative materials, the surgical revision and rehabilitation of endodontically treated teeth have a
significantly better prognosis than only 10
years ago. Apical resection is a challenging
surgical procedure not least because of the
limited accessibility of the surgical field.
Instrumentation of an apical resection case
therefore requires a surgical technique that
is as simple as it is safe and ergonomic.
This report presents two clinical cases
in illustrating a system for applying retrograde endodontic filling materials that
has proven a consistently viable option
in our clinical practice.

Fig. 1: OPG showing active infection at sites
#14, 36 and 46. Photos/Provided by Prof. Marcel

Fig. 2: Bone block, stored in Ringer’s solution.

Wainwright, DMD

Case No. 1
A 34-year-old male patient presented
at our clinic for the first time. The orthopantomogram (OPG) yielded an accidental finding of apical translucencies
at teeth #14, 36 and 46, which had been
insufficiently treated endodontically.
Clinically, these translucencies were asymptomatic and diagnosed as instances
of chronic apical periodontitis or apical
osteitis (Fig. 1).
Together with the patient, we planned
for an apical resection in conjunction
with a retrograde root-canal filling with
subsequent removal of the non-salvageable teeth #14 and 46. Following extensive consultation and patient education,
surgery was performed under local infiltration anaesthesia. With our protocol, block anesthesia is unnecessary in
98 percent of all surgical interventions
in the mandible, and dispensing with it
minimizes the risk of iatrogenic nerve
damage.
An incision was performed in the marginal gingiva, with a mesiodistal relief
incision, followed by preparation of a
full flap for adequate access to the surgical site. Using the Piezotome 2 (Acteon),
a buccal bone window of adequate depth
was prepared to gain access to the apical
region at tooth #36 in order to perform
the apical resection.
It is helpful for the preparation to provide for undercuts in order to facilitate
subsequent removal of the bone block.
As no rotary instruments were used, and
because ultrasonic surgical instruments
have a vaso-constrictor effect, the surgical
field remained impressively free of bleeding and afforded a clear view of the site. The
” See RESECTION, page C8

Fig. 3: Surgical site after removing a bone
block and performing apical resections on
tooth #36.

Fig. 4: The MAP System.

Fig. 5: Autoclavable box with syringe, mixing
cup and tips.

Fig. 6: Endo tips with different angulations.

Fig. 7: Applying MTA using the MAP System.

Fig. 8: The bone block is repositioned and
secured with bone cement (VitalOs).

[2] =>

clinical opinion

C2
“ INSTRUMENTS, Page C1
marked tendency to selectively shape to
the outer wall. When the instrument is
repeatedly inserted into the canal, these
same horizontally oriented flutes tend
to impact debris apically, creating blockages and loss of length.
Recognizing the loss of length encourages the dentist to twist the K-file into
the canal to gain greater depth and then
pull up to shave what has been engaged.
Done repeatedly in a canal that has been
unknowingly blocked apically leads to
canal transportation and, if carried further, to frank perforation. At a minimum,
the original canal anatomy has been lost,
something NiTi cannot compensate for
even if used after the glide path has been
established.
Many dentists have encountered the
problems described above. Yet, they have
been taught that such problems are a
result of their inadequate use of the instruments, that expertise in their proper
usage would avoid such problems. While
this statement has some merit, it avoids
the more important possibility that superior design and utilization might produce more predictable desirable results
in a simpler manner.
Such would be the case if the K-file with
its highly compacted horizontal flutes
were replaced with reamers, instruments
with half the number of flutes along the
same 16 mm of working length and a
flute orientation that is twice as vertical.
If such an instrument is used with the
same watch-winding stroke, the blades
will immediately shave dentin away
from the canal walls rather than first engaging them.
The pull stroke is not required to shave
dentin away from the wall, and in fact
the vertically oriented flutes would do a
poor job of it if it were required. Unlike
the K-files, pulling up on the K-reamers
will not selectively remove dentin from
the canal outer walls.
The reamers produce a superior tactile
perception of what the tip of the instrument is encountering, because there
is significantly less engagement along
length and what engagement is present
is being removed with the first clockwise motion of the instrument. Knowing when the instrument is encountering a solid wall directs the dentist to
remove the instrument, bend it at the
tip and manually negotiate around the
impediment.
The reamers supply the vital information for the dentist to do what is necessary for non-distorted shaping in curved
calcified canals. The K-files do not. While
the advantages of reamers are based on a
combination of the more effective shaving of dentin and less engagement along
length, these advantages are further enhanced by placing a flat along its entire
working length, further reducing en-

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.

‘The ideal is rarely met,
but the correct design
and utilization of
the instruments will
go a long way in
approaching
that ideal.’
gagement and creating two vertical columns of chisels that shave dentin away
in both the clockwise and counterclockwise motion that enhance the removal of
dentin via the vertically oriented flutes.
Canals that prove difficult to negotiate
with K-files are far less resistant when negotiated with relieved reamers.
These reamers may also be employed
in a 30-degree reciprocating handpiece
that mimics a manual instrument in motion, but at a much higher frequency. The
result is rapid and accurate instrumentation of the canals.
One might think that the above description of the relieved reamers compared to K-files would lead to their substitution as the choice of instrumentation
for creation of the glide path, and indeed
for some dentists this is exactly the case.
Yet, so effective are the relieved reamers — whether used manually, in the
30-degree handpiece or some combination of both — that there is no reason to
stop their usage at a 20 or 25. They may
be used to create the entire canal space,
eliminating any use of NiTi in either rotation or asymmetric reciprocation.
By eliminating the need for NiTi, several advantages are gained. An instrument limited to a tight watch-winding
stroke or a 30-degree arc of motion
generated by the handpiece completely
eliminates the two factors most responsible for instrument separation, torsional stress and cyclic fatigue. As a result,
separated instruments are no longer a
concern, even when shaping the most
tortuous of canals.
With separation anxiety removed, the
dentist is far more confident in aggressively applying the instrument against
all the walls of canals, be they round or
oval. Buccal and lingual tissue extensions in oval canals have been shown to
be often untouched when using rotary
or asymmetric reciprocating NiTi, leaving tissue behind that can adversely affect the success of the procedure. This is
less likely to be the case when using relieved reamers, because they will be used
aggressively against all the walls of the
canal and can safely be used to instrument the apical preparations of canals to
a minimum of 35 in most situations.
A preparation of 35 is not arbitrary. Research has clearly shown that 35 is the
minimum preparation required for effective irrigation, a step that removes
any tissue remnants chemically that
have not been removed mechanically
while more effectively removing the
smear layer and opening up the dentinal tubules, a step vital for the deeper
penetration of bacteriocidal cements
into the dentinal tubules where bacteria
may still reside.
With the data clearly demonstrating
the shortcomings of NiTi in the shaping of oval canals, that in itself might be

Endo Tribune U.S. Edition | October 2012

enough to seek out the better ways our
alternative techniques suggest. However, recent research over the past three
years has now implicated NiTi used in
great arcs of motion in the production of
micro-fractures along the length of the
canal. Separate studies have shown that
micro-fractures can coalesce and propagate to the point of inducing vertical root
fractures.
These micro-fractures are not infrequent occurrences. Depending upon
the rotary system used, they will induce
micro-fractures anywhere from 25 to 60
percent of the time they are employed.
This same research has shown that short
arcs of motion and hand instrumentation do not induce micro-fractures.
Along with the fact that short arcs of
motion — be they manual or enginegenerated — do not produce instrument
separation, we can make the overall observation that the safety of both the instruments and the canals that they are
shaping will increase wherever a manual watch-winding motion and/or 30-degree reciprocation is substituted for full
rotation or asymmetric reciprocation.
What we have attempted to broach is
the misplaced sanctity of K-files as the
given initial instrument in canal shaping. It is illogical and not supported by
common sense and simple mechanical principles. Rotary NiTi, initially
thought of as the answer to the deficiencies of K-files, has been proven to produce more problems than they solve.
Under any circumstances there are alternatives to rotary NiTi that allow for
safer but more aggressive instrumentation while eliminating instrument
separation, which in turn removes the
need for rapid replacement.
Multiple use of relieved reamers is the
norm and saves dramatic amounts of
money compared to the single usage of
NiTi instruments that are an absolute requirement so strongly advocated by the
major manufacturers of these products.
When instruments are designed and
utilized correctly, you will find that the
more you learn how to use them, the
more they will be used. This is just the
opposite of NITi, where the more you
learn how to use them, the more selectively they are used. Just to make things
absolutely crystal clear, more selective
use means less. And reduced usage as a
result of greater experience in their use
is proof positive they were not designed
correctly from the onset.
Some things to think about.

Barry Lee Musikant,
DMD, is a member
of the American Dental Association, American Association of En-

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Editorial Board
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

dodontists, 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). As a partner
in the largest endodontic practice in Manhattan,
Musikant’s 35-plus 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.org or call (888) 542-6376.

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[3] =>

[4] =>

News

Endo Tribune U.S. Edition | October 2012

Specialists to discuss traumatic injuries

linicians and scientists recognized
throughout the international
endodontic and pediatric dental
communities will speak at a multidisciplinary joint symposium on traumatic
dental injuries. The American Association
of Endodontists (AAE) and the American
Academy of Pediatric Dentistry (AAPD) will
hold their second joint symposium on traumatic injuries Nov. 9 and 10 at the Westin
Kierland Resort & Spa in Scottsdale, Ariz.
The meeting, Contemporary Management of Traumatic Injuries to the Permanent Dentition, is composed of two full
days of programming where attendees can
earn 13 continuing education credits. Topics include treatment options and diagnosis of several traumatic injuries, as well as
a panel discussion on treatment planning
and collaboration between specialists. After attending the meeting, participants
will have gained the knowledge to identify
different types of traumatic injuries, understand the methods to prevent damage
to permanent teeth, discuss diagnostic
methods and outcomes of previously traumatized permanent teeth and much more.
“The AAE and AAPD have chosen to
join forces in an effort to identify the best
course to take while handling traumatic
dental injuries,” said AAE President Dr.
James C. Kulild. “Both associations encourage partnership in the dental community
AD

to offer patients the best care possible.”
“We are pleased to align with the AAE in
presenting a program that showcases the
best dental practices and emerging treatment concepts by deploying an evidencebased approach,” said AAPD President Dr.
Joel H. Berg. “Collaboration is key when
providing a unique educational opportunity such as this one to our respective
members, and we’re very excited about the
invaluable knowledge that will be attained
at the conclusion of this symposium.”
Well-established endodontic and pediatric dentistry speakers include Dr. Leif
K. Bakland, Dr. Kenneth M. Hargreaves,
Dr. Dennis J. McTigue, Dr. Ove A. Peters
and Dr. William F. Vann Jr. Following the
meeting, both associations will release
special edition journals that will include
speaker manuscripts and meeting proceedings, including relevant findings.
The AAPD is the recognized authority
on children’s oral health. As advocates
for children’s oral health, the AAPD promotes evidence-based policies and clinical guidelines; educates and informs policymakers, parents and guardians and
other health care professionals; fosters
research; and provides continuing professional education for pediatric dentists
and general dentists who treat children.
Founded in 1947, the AAPD is a notfor-profit professional membership as-

‘The AAE and AAPD have chosen to join forces in an effort to identify the best course to take
while handling traumatic dental injuries,’ says AAE President James C. Kulild. The associations
will hold a joint session Nov. 9 and 10 in Scottsdale, Ariz. Photo/Provided by www.sxc.hu

sociation representing the specialty of
pediatric dentistry. Its 8,400 members
provide care for infants, children, adolescents and individuals with special
health care needs.

More information about the joint AAEAAPD meeting is available at www.aae.
org/traumameeting.
(Source: AAE)

[5] =>

[6] =>

Interview

Endo Tribune U.S. Edition | October 2012

Starting fresh in the Black Hills
Rich Mounce steps up his game with a new practice and new tools in his armamentarium
By Fred Michmershuizen, Managing Editor

ich Mounce, DDS, recently relocated his endodontic practice from Vancouver, Wash., to
Rapid City, S.D. In an interview,
he discusses the move, a new business
venture he has launched, plus some of
the differences in practicing in the Black
Hills of South Dakota vs. the Pacific
Northwest.
You moved your practice to Rapid City,
S.D., from Vsncouver, Wash., in 2011. How
did that come about?
I was born and raised in Portland, Ore., and
practiced in the area as an endodontist
from 1991 to the end of 2010. I was ready
for a new challenge and a lifestyle change.
From 2002 to 2010, I presented several
hundred C.E. programs nationally and internationally, and I wrote a similar number of trade magazine features. Having
achieved almost everything I set out to
do having a presence outside my practice, it was a natural place to make a break
when I did. In April 2011, I opened my new
endodontic practice in Rapid City.
Laura, my wife, has family in the area.
We now live in the Black Hills, about 12
miles from Mount Rushmore. We simplified our lives considerably by the move.
The Black Hills are sacred to the Lakota
Sioux, and I can see why. It’s a spectacular
place to live.
Was it tough moving your practice and beginning again?
I would not say tough, but moving presented many choices — what aspects of
my previous practice I wanted to keep
and what needed changing. Endodontic
practice is not a one-size-fits-all experience. From office design and esthetics to
management software, there were many
decisions to make. The design features
and other aspects of the build-out were
all custom, and I am very pleased with
the results.
Does practicing in South Dakota differ
much from the Pacific Northwest?
In some ways, yes. South Dakota does
not have large group practices owned by
non-dentists, and the economy in the Dakotas is robust. These two factors account
for much of the difference I experience
in the delivery of dentistry. For a host of
reasons that are beyond the scope of your
question, I am not a fan of large groups
owned by non-dentists. Despite what advocates would say, this model of delivery
care does not ultimately favor optimal
patient care.
We have a very high standard of practice in my area, provided by a dedicated
group of private-practice clinicians. The
turnstile-type “dental mill” present in
some locations in other states is simply
not present.
In setting up your new practice in South
Dakota, what did you do differently than
with your practice in Washington state?
Lots of things. I trained and got an IV
sedation permit. I bought a cone-beam

Rich Mounce, DDS, is now practicing endodontics in Rapid City, S.D. Photos/Provided by Rich Mounce, DDS

machine, and I started using new, selfgenerated internal systems for practice
management.
The IV permit has given me an option
with phobic patients that I obviously
would not otherwise have. I favor IV sedation relative to oral sedation because
with titration of IV drugs, our level of
control is more predictable and, I believe,
safer.
Cone-beam technology has helped add
the third dimension to understanding
what two-dimensional images are missing. It’s provided diagnostic information
missing from conventional films. While
not a panacea, guesswork on early vertical fracture presentations, atypical root
forms, resorption and missed canals, for
example, are all things of the past.
My new internal systems mean checklists for every vital function in the practice. For example, among many things,
there is a checklist for every item needed
to treat a patient, track inventory and
determine whether patients have been
called the day before. This level of monitoring every practice function helps
prevent things from falling through the
cracks. It also allows new employees to
slot into their roles faster.
How is it going so far?
We’ve been blessed; the new practice has
gotten off to a solid start.
Do you have any other projects in the
works?
I am glad you asked. Laura and I are very
excited about the launch of our new
company, MounceEndo. Starting Nov.
1, we will be selling American-made rotary nickel titanium files in a controlled
memory (CM©) form and a standard nickel titanium (SNT) form, the MounceFile.
We will also sell stainless-steel hand files
and burs made by Mani of Japan — one of
the premium global sources of hand files
and burs — and reciprocating handpiece
attachments from W&H of Austria.
We will stock staple items, including assorted packs of NiTi files, K-files, H-files
and reamers in common sizes along with

Mounce’s operatory is designed as a mini surgery suite to provide IV sedation.

reciprocating handpiece attachments.
Other items are ordered in bulk. With a
little bit of advanced planning, this represents a huge win for the doctor. Our prices
and selection will be very tough to beat.
Aside from the basic items we stock,
our sales are primarily bulk purchases
requiring a minimum order and are fulfilled in four to eight weeks. We will not
be all things to all people. If you want
great prices and can wait for the products, we are a fantastic option. If you
can’t wait, we are not the best option.
For example, take a pack of K-files that
may be available elsewhere for $7.50 at
a bulk sale price. At this time, initially,
we will sell the same pack of K-files for
between $3.25 and $4.50 per pack, depending on the quantity purchased and
whether we stock the item. Our CM NiTi
will sell for as little as $35 a pack for a 50pack sale. Standard NiTi will sell for as little as $25 a pack, again for a 50-pack sale.
The competition we bring to the big players in the market is a good thing for clinicians. With all due respect, the big players in the market are not clinicians; they
are marketers and business people. I am
more tuned to the needs and frustrations

of doctors in the chair because I am one.
This translates to our customers as more
responsive service, volume discounts, selling materials that I use every single working day, and specializing in one basic line
of products — shaping root canal systems.
And there is one other added advantage to dealing with our company: We
don’t have a sales force that needs to hit
quarterly targets. We want to create customers for life, not for the most recent
sales cycle.
What makes the MounceFile different
than what is already out there?
I’ll tell you. As you and your readers know,
I did advocate the Twisted File before,
which is an excellent product. But there
are many valid ways to shape root canal
systems. Just as there are many popular
car models for different tastes, there are
many different tastes for endodontic
file systems, and all of them work to one
degree or another. It would be cheeky of
me to tell you that my new file is “better”
than someone else’s. That said, I put my
name on the MounceFile because so far
I have not fractured one clinically. These
files are smooth and fluid in their tactile

[7] =>

Endo Tribune U.S. Edition | October 2012

feel and come in a vast array of tapers, tip
sizes and lengths. I’ll use Mani hand files
and MounceFiles in my private practice
going forward. Also, the research that has
been published on the CM NiTi has been
favorable.
And while cost is not the only issue in
selecting a file system, cost is a concern.
With six files in a pack, at $25 a pack for
standard NiTi and $35 a pack for CM with
minimum 50-pack orders, it’s tough to
argue for paying significantly more for
other files that come three in a pack, or
even other brands with six files in a pack
for significantly more money.
Can you offer some additional details
about the MounceFile?
The MounceFile is square in cross section,
has four cutting edges and cuts efficiently. Any electric torque-controlled endodontic motor can be used. Rotational
speed is a matter of personal preference,
anywhere from 350 to 900 rpm. I run
them on the higher end, but many clinicians will use 500 rpm. Torque control
and auto reverse are a matter of personal
preference. They can be used step-back or
crown-down. While the MounceFile assorted pack has six instruments, it is possible to use less than six files in anatomy
that will allow it.
How are you going to run a practice plus
your own endodontic supply company at
the same time?
I will practice full-time moving forward. Hard work does not frighten me,
and being in practice and overseeing
MounceEndo is certainly doable. Laura is
my secret weapon. She is an immensely
capable partner in this endeavor.
We’ll also have more than adequate
support staff to take care of our customers. It’s critical to me that we serve our
customers at a higher level than the competition.
Changing subjects, what advice do you
have for young endodontists to enhance
their practices?
In short, take the “long view.” What ultimately matters to a practice is patients
coming out of the operatory feeling well
cared for. It’s a bit like the tortoise and the
hare. While some might want to always
focus on profitability, giving people a reason to want to come back over and over
is a much more powerful long-term strategy for practice growth and satisfaction.
While there are a multitude of strategies for optimizing production and running the non-clinical aspects of the business, if the clinician does not connect
with his or her patient, have the right
human touch, compassion and a “patient
first” mantra, financial success as one

Rich Mounce, DDS,
is in full-time private
endodontic practice
in Rapid City, S.D., and
is

the

owner

MounceEndo, a supplier

American-

made rotary nickel
titanium files marketed as the MounceFile

Controlled

Memory (CM) and standard NiTi forms, Mani
stainless-steel hand files and burs, and W&H reciprocating handpieces. He can be contacted at
RichardMounce@MounceEndo.com or MounceEndo.
com.

interview

measure of practice success is going to
suffer. The converse is true.
Having the right staff and the management systems is also critical to create an
environment where great treatment can
be provided. MounceFiles or not, if the
clinician is running late, the staff is apathetic, informed consent is not provided,
among a myriad of possible challenges,
it’s very tough, if not impossible, to end up
with a happy patient leaving your office.
One final question: There are now multiple file systems, a wide variety of sources,
claims and counter claims in the marketplace. How do general practitioners optimally learn and progress in their technique
in the midst of so many alternatives?
This is difficult for the endodontist, and
it’s even tougher for the GP. The GP has to
be passionate to sort the wheat from the
chaff on endodontic instrumentation
and obturation methods. As a start, GPs
need to decide which cases they want to

A case treated with the MounceFile CM
instruments.

The new MounceFile CM will be available
from MounceEndo beginning Nov. 1.

treat, how much risk they will take — in
essence, what their “comfort level” is
for cases potentially going pear shaped.
In essence, all clinicians need to decide
what is in the patient’s best interest as
they “do unto others.”
My suggestions would be to talk with and
learn from their endodontists, subscribe to
the Journal of Endodontics, attend every

class possible from every manufacturer
offered at regional and national meetings, and practice extensively on extracted
teeth until they are very confident.
And one final note, for both endodontists and general dentists: It is important
to be patient with mistakes. We learn a
lot more from things that go wrong than
those that go right.
AD

[8] =>

clinical

C8
“ RESECTION, Page C1
bone block was stored in Ringer’s solution
to facilitate subsequent repositioning (Fig.
2). The root apices were then exposed and
ultrasonically removed (Fig. 3).
After apical resection, our protocol
called for thorough removal of all soft
tissue using instruments, followed by
complete decontamination of the cyst
lumen using a diode laser.
Care had to be taken to ensure that the
laser tip did not make direct contact with
the bone. Retrograde preparation of the
root canals was also performed ultrasonically, which only takes a few seconds
when using the Piezotome 2.
Following chlorhexidine-digluconate
and sodium-hypochlorite rinses, the retro-prepared root canals were dried with
paper points. In our clinic, we have had
excellent success with the MAP (MicroApical Placement) retro system (PDSA),
which has been on the market for many
years (Fig. 4). The system comes in a sterilizable metal container (Fig. 5).
The triple-angled endo tips (Fig. 6)
greatly simplify the uptake and application of the material, with the syringe
facilitating “injection” (retrograde obturation) of the root canal to a depth of
several millimeters. This well-targeted
application of the restorative material
keeps the surgical field open (Fig. 7).
On application of ProRoot MTA (DENTSPLY Maillefer), the material was allowed to
set, the cross-section surface of the resected
area was smoothed and polished, the resec-

Endo Tribune U.S. Edition | October 2012

tion lumen was filled with a quick-hardening bone cement (VitalOs, PDSA), and the
bone block was returned to its place (Fig. 8).
The post-operative radiograph shows
the site following apical resection and
retrograde root filling (Fig. 9).
The patient was prescribed Amoxicillin 750 mg and Ibuprofen 600 mg postoperatively, as well as Arnica C30 to prevent swelling. Post-operative healing was
uncomplicated and the sutures could be
removed after eight days. Swelling was
minimal, and the patient reported virtually no post-operative pain.

Case No. 2
A 65-year-old female patient presented with
an apical resection on tooth #14 that had
been performed alio loco five years before.
The patient was looking for help because
the site had become infected again. She reported pain at tooth #14 on occlusal contact
and percussion. A local digital radiograph
clearly showed the area of apical resection,
the two root-canal fillings, and a cystic periapical radiolucency (Fig. 10).
Because this was a surgical re-entry case,
the same incision technique was used as
chosen by the primary treatment provider,
i.e. a crescent-shaped incision as described
by Pichler (Fig. 11). The procedure was otherwise the same as in Case No. 1. Following
retrograde ultrasonic preparation (Fig. 12),
ProRoot MTA was mixed to a working consistency and applied using the MAP System
(Figs. 13, 14). This clean and efficient application mode and controlled handling shortened the surgical procedure and reduced

Fig. 9: Post-op OPG detail following apical
resection of tooth #36.

Fig. 10: Base-line status of tooth #14 following
apical resection alio loco and reinfection.

Fig. 11: Surgical site #14 following the
semilunar incision.

Fig. 12: Retrograde ultrasonic preparation
(Piezotome 2).

Fig. 13: Mixed ProRoot MTA prior to
application.

Fig. 14: Applying the MTA using the MAP
System.

Fig. 15: Resected and retro-filled tooth #14.

Fig. 16: Outcome for tooth #14.

post-operative complaints (Fig. 15). The postoperative radiograph (Fig. 16) shows an efficient retrograde filling of both root canals
following revision of tooth #14. Owing to a
projection artifact, the restorative appeared
beside the canals, when it was in fact clinically located exactly within.

ing at these treatment methods; rather,
apical resection is a complimentary treatment mode and an attempt to preserve
teeth over the longer term that would
otherwise be considered lost.

Conclusion
Apical resection is a routine procedure in
our clinic. Thanks to the use of ultrasonic
surgery, the surgical laser and the MAP
System, this procedure is reliable, predictable and simple, and we have preserved
the natural teeth of many patients. Being
an oral implantologist myself, I do not
perceive anything contradictory in look-

Editorial note: This article first appeared
in roots, the international magazine of
endodontology, Vol. 7, No. 3, 2011.
A complete list of references is available
from the publisher.
Prof. Marcel Wainwright, DMD
Dental Specialists and White Lounge Kaiserswerth
Kaiserswerther Markt 25–27
40489 Düsseldorf, Germany
www.dentalspecialists.de

[9] =>

Endo Tribune U.S. Edition | October 2012

industry

The Jordco System

ounded by two practicing dentists in 1979, Jordco has developed products that help dentists
deliver optimum care, simplify
the delivery of care, improve staff safety
and reduce cross contamination. Today,
Jordco continues to set the standard for
utility, infection control, innovation and
innovative dental product design.
Jordco continues to refine its product
line and has recently introduced the
Jordco System. The system works on the
premise that Jordco products complement each other and work in concert
from diagnosis through all phases of
treatment.
Treatment products include:
• Endoring II — Hand-held Endodontic
Assistant
• EndoGel — Endodontic Lubricating
Gel
• e-Ruler — Endodontic File Measuring
Instrument
• Jordco Mixing Sticks — Cement and
Composite Mixing Tools
• Pure Bond Dispensers — Bonding
Agent and Composite Dispenser
Diagnosis products include:
• e-Dx—Dual Diagnotic Instrument
Organizing and storage products include:
• Endoring II Color Editions–Hand-held
• Endodontic Assistants
• Jordco e-Foam — Endodontic Foam
• FileCaddy — Bulk File Storage System
• Endoring Marking Tabs — Endodontic
Organizing Tool

ProUltra Piezo
Ultrasonic
Driven by SmartPowerTM Technology,
the ProUltra Piezo Ultrasonic is designed
to generate dependable and constant
power for all ultrasonic procedures.
SmartPower automatically locks on to the
optimum working frequency for the ultrasonic tip being used, eliminating the need
to constantly adjust the power setting.
According to DENTSPLY Tulsa Dental
Specialties, it’s ideal for endodontic applications such as locating hidden canals,
removing obstructions, performing periapical surgery and canal irrigation.
More information is available from
DENTSPLY Tulsa Dental Specialties, www.
tulsadentalspecialties.com, (800) 662-1202.
(Source: DENTSPLY Tulsa)

Photo/Provided by DENTSPLY Tulsa Dental
Specialties

Safety and convenience products include:
• Pure Floss Dispenser — Sanitary Dual
Floss Dispensing System
• Pure Buff — Polishing Wheel System
During its 32-year history, Jordco has
evolved into a world-class dental products innovator and manufacturer by
embracing the latest science, production
technology and commitment to quality.
Twenty years ago, the founders assumed
all domestic and international marketing responsibility for their entire product line while further expanding their
research and development program.
This consolidation allowed Jordco to
open an FDA-registered assembly and
distribution center located in Beaverton,
Ore. All of Jordco’s products are devel-

Photo/Provided by Jordco

oped and manufactured in the United
States. All of Jordco’s manufacturing
partners are located in the United States
and all share a common dedication to
quality in every Jordco part produced.
Consolidation also allowed Jordco to es-

C9
tablish a quality system compliant with
the international standard ISO 13485 for
medical devices. The Jordco Quality System is used to comply with biannual FDA
inspections, FDA Premarket Notification
510 (k) approvals and CE mark acceptance.
The Jordco Quality System is the driving
force behind the company’s determination to develop, manufacture, package
and distribute world-class products to
the dental profession. The Jordco team
of employees work passionately to fulfill
the goal spelled out in the Jordco quality
system: Jordco’s vision is to provide the
dental community with quality products
that will simplify the delivery of care.
New Jordco endodontic and dental
products are under development.
To learn more about Jordco and its
other products that are soon to be introduced, visit the company’s website at
www.jordco.com or call (800)752-2812.
(Source: Jordco)
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[cover] => Endo Tribune U.S. No. 9, 2012

[toc] => Array ( [0] => Array ( [title] => Designing endodontic instruments for success [page] => 01 ) [1] => Array ( [title] => Efficient and ergonomic apical resection using the Kaiserswerth algorithm [page] => 01 ) [2] => Array ( [title] => Specialists to discuss traumatic injuries [page] => 04 ) [3] => Array ( [title] => Interview: Starting fresh in the Black Hills [page] => 06 ) [4] => Array ( [title] => Industry [page] => 09 ) ) [toc_html] =>

Table of contents

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