roots C.E. No. 2, 2012

Cover / Editorial / Content / Predictable apical microsurgery (Part II) / A logical basis to judge endodontic innovations / A case of diagnosis by access / ‘History & Heritage — Forging the Future’ AAE holds its annual session in Boston / The collaboration between endodontists and restorative doctors to preserve dentin … What’s next? / COLTENE ENDO launches CanalPro Irrigation System / PIPS Laser Endo harnesses the power of the Lightwalker / New Plasma light source from Seiler / Submissions / Imprint

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roots
issn 2161-6558

the international C.E. magazine of

2

2012

_C.E. article

Predictable apical
microsurgery (Part II)

_trends

A logical basis to judge
endodontic innovations

_case report

A case of diagnosis
by access

North America Edition • Vol. 2 • Issue 2/2012

endodontics

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editorial _ roots

Valuable summer
reading
It was a pleasure to see so many of you at the recent American Association of Endodontists Annual
Session in Boston. Each year, the meeting is a wonderful opportunity to connect with one another, to learn
about new products and to discover new techniques and innovations.
Now that summer is upon us, it’s also a good opportunity to catch up on some reading, and I hope that
you will find this issue of roots to be beneficial.
Presented within the pages of this publication, among many other articles, you will find an interesting
case report and an article about endodontic technology. You will also find our meeting coverage from AAE,
plus articles on some of the latest product offerings.
What makes roots even more beneficial is its C.E. component.
By reading the article on apical microsurgery by Dr. John Stropko, then taking a short online quiz about
this article at www.DTStudyClub.com, you will gain one ADA CERP-certified C.E. credit. Remember that
since roots is a quarterly magazine, you can actually chisel four C.E. credits per year out of your already
busy life without the lost revenue and time away from your practice.
To learn more about how you can take advantage of this C.E. opportunity, visit www.DTStudyClub.com.
Annual subscribers to the magazine ($50) need only register at the Dental Tribune Study Club website to
access these C.E. materials free of charge. Non-subscribers may take the C.E. quiz after registering on the
DT Study Club website and paying a nominal fee.
I hope that you will take the time to read all of the articles presented here in roots, and please send me
your feedback and ideas. I can be contacted at f.weinstein@dental-tribune.com.
Until we meet again at the fall meetings, I wish you the very best.

Fred Weinstein, DMD, MRCD(C),
FICD, FACD

Sincerely,

Fred Weinstein, DMD, MRCD(C), FICD, FACD
Editor in Chief

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I content _

page 8

page 18

page 24

I C.E. article
08	Predictable apical microsurgery
_John Stropko, DDS, PhD

I trends
18	A logical basis to judge endodontic innovations
_Barry Lee Musikant, DMD

I case report
24	A case of diagnosis by access
_L. Stephen Buchanan, DDS, FICD, FACD

I meetings
31	History & Heritage — Forging the Future: AAE
holds its annual session in Boston

I interview
34	The collaboration between endodontists and
restorative doctors to preserve dentin

I industry
38	COLTENE ENDO launches CanalPro
39	PIPS Laser Endo harnesses the power of the
Lightwalker
40	New Plasma light source from Seiler

I about the publisher
41
42

_submissions
_imprint

page 31

04 I roots
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I on the cover

Confocal imaging showing live E. faecalis in green (main image),
infiltration of the bacteria into the dentin tubules (upper right), post
treatment 30 seconds with Photon Induced Photoacoustic Streaming
(PIPS) showing no live bacteria (middle right) only dentin auto
fluorescence in red. The samples were then imaged via SEM, confirming
the effectiveness of PIPS application (lower right). Images courtesy
of Enrico DiVito, DDS, and Technology4Medicine.

page 34

page 39

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I C.E. article_apical microsurgery

Predictable apical
microsurgery (Part II)
Author_John Stropko, DDS

_c.e. credit

_The REB and REP

This article qualifies for C.E.
credit. To take the C.E. quiz,
log on to www.dtstudyclub.
com. The quiz will be available
on June 15, 2012.

_The amount, or degree, of the root-end bevel
(REB) is of utmost importance and should be precisely planned in advance after considering the overall
crown/root ratio, presence of posts or other obstacles,
the root anatomy and the periodontal status of the
tooth. According to previous research, 98 percent of
canal system ramifications occur in the apical 3 mm.1
If the bevel is long (traditionally 25 degrees to
45 degrees) an excessive amount of root structure
would have to be removed to include the apical 3
mm on the palatal, or lingual, part of the root’s apical
canal system (especially in roots with multi canals).
If the bevel is closer to 0 degrees, the lingual 3 mm
is easier to remove; more root structure can be conserved, improving the crown/root ratio. With a long
bevel, there is also an increased risk of completely
missing some important palatal, or lingual, anatomy,
especially if the operator is in any measure trying to
be conservative in order to preserve as much crown/
root ratio as possible (Fig. 1).
The long bevel creates a spatial problem that is
generally impossible for the operator to overcome
while trying to visualize the true long axis of the
canal system (Fig. 2). The longer the bevel, the greater
the tendency is for the operator to leave more of the

palatal, or lingual, aspect of the root intact. Because
it is difficult to visualize the long axis of the tooth,
the resultant retroprep is not as likely to be within the
long axis of the canal.
This concept is of utmost importance and is the
primary reason that, on occasion, the retroprep
unintentionally perforates to the lingual or palatal
(Figs. 3a, 3b).
Another important consideration is, with a bevel
as close to 0 degrees as possible, the cavo-surface
marginal dimensions (bet you haven’t heard that
term in a while!) of the root end preparation will be
considerably decreased. Therefore, the restoration
will be easier to place and have less chance of leakage.
The root anatomy is especially important when
there are more than two canals in one root. This occurs
most commonly in maxillary bicuspids and in the mesial roots of nearly all molars. It has been shown that
as many as 93 percent of the MB roots of the maxillary
first molars have a second (MB2) canal.2 However, the
operator has to be constantly aware that multiple
canals can occur in any root, no matter what tooth
is being operated on. If there is an isthmus present, it
can usually be seen with the OM if the root has been
adequately beveled and stained with methylene blue.
The refinement of the bevel is best accomplished
with a surgical length 1171 carbide-tapered fissure

Fig. 1

Fig. 2

Fig. 1_Illustration of the effect that
different bevel angles have on root
length, including the missing of
potential lingual anatomy. (Photos/
Provided by Dr. John Stropko, unless
otherwise noted.)
Fig. 2_Long bevel with round bur
preps, demonstrating angulation and
orientation problems, courtesy of
Dr. Gary Carr.

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C.E. article_apical microsurgery

Figs. 3a, 3b_Inadequate and acute
45-degree bevel clearly shows
how perforations can occur and
canals can be missed. Fig. 3a is the
surgeon’s view from the buccal. Fig.
3b is what actually occurred but was
completely missed by the operator.

Fig. 3a

bur (Brasseler) in a 45-degree handpiece (SybronDental). These handpieces have no air exiting from
the working end, which nearly eliminates the
possibility of an air emphysema, or air embolism,
beneath the flap.
A standard high-speed handpiece should never
be used for the above reason. On occasion, the
refinement of the bevel can cause additional
bleeding due to some enlargement of the crypt.
The operator should address any newly created
crypt management problem before proceeding
any further. Remember that it is of utmost importance to fully complete one step before proceeding to another!
After the REB is refined and crypt management is
completely under control, the apical surface is rinsed
and dried with a Stropko Irrigator (www.stropko.
com). The clean and dried surface is then stained
with methylene blue. It is important to allow the
methylene blue to remain on the tooth for just a short
period of time before gently rinsing and drying again
to enable inspection of the stained surface.
Normally, a fresh, white piece of Telfa is reinserted
for better lighting. If there are any fractures, presence of isthmus tissue or accessories present, the
staining will greatly enhance the operator’s ability
to visualize them. Also, the methylene blue will stain
the periodontal ligament and enable the operator to
be sure the apex has been completely resected (Fig.
4). If there is an accessory canal present, the easiest
answer is usually to bevel past it and restain. Or, on
occasion, the accessory can be “troughed out,” leaving the bevel as is.
When two canals are present in the same root, it
is necessary to prepare for an isthmus between the
two canals even if the staining didn’t reveal one. It
has been shown that in the mesiobuccal roots of
the maxillary first molars with two canals, the 4 mm
section displayed a partial or complete isthmus 100
percent of the time.3 This combined with the finding
in the same root in maxillary molars, that two canals
present clinically at least 93 percent of the time in
the mesiobuccal root of the maxillary first molar,

Fig. 3b

lends importance to always preparing isthmus area
of the REB.2
Although staining doesn’t always reveal the presence of an isthmus, it may lie just below the surface,
only to be exposed during the remodeling process of
the surface of the beveled root that normally takes
place during the healing process (Fig. 5). The rule is
to always prepare an isthmus when there are two
canals in one root.
The preparation of the root-end preparation
(REP) is best accomplished using ultrasonics. There
are many different ultrasonic units available. For the
most part, they are all dependable and have a good
service record. There are multitudes of ultrasonic
tips to choose from. The newer diamond coated
and vented tips (ProUltra Tips from DENTSPLY Tulsa
Dental or KIS Tips from Obtura/Spartan) are much
more efficient and especially good at removing
gutta-percha.
The most important consideration is not the brand
of the ultrasonic unit or type of tip but how the instrument is used. The tendency for the new operator
is to use the ultrasonic in the same manner (pressurewise) as the handpiece. The secret is to start at a low
power setting and use an extremely light touch! The
lighter the touch, the more efficient the action of the
tip will be.
The correct amount of coolant is also important.
If too much spray is used, visibility and cutting efficiency are both decreased. If too little spray is
used, the necessary amount of cooling will not be
available and overheating and/or micro cracks can
be the result.
The occasional left and right, variously angled
tips are necessary on occasion, but in most cases, the
anterior type tips will suffice. If the canal is large and/
or filled with gutta-percha, a larger, coated tip can be
used most efficiently. The key is to: 1) slow down; 2)
be gentle; 3) use a light, brushing movement; and 4)
carefully regulate the power setting of the ultrasonic
unit. The power setting will vary greatly depending
on the tip being used and nature of the preparation
task at hand.

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I C.E. article_apical microsurgery
Fig. 4_Staining allows the operator
to be sure of complete root resection,
and to see if there is an isthmus,
accessory or fracture present.
Fig. 5_An illustration of an isthmus,
lying just below the surface that
would not be evident, even after
staining with methylene blue
Fig. 6a_The series of ‘dots’ permit
easy and accurate preparation of an
isthmus in a root end that is very thin.
Fig. 6b_While still dry, the ‘dots’ are
connected until there is a shallow,
but definite ‘tracking groove.’
Fig. 7_A modified and pre-bent
needle is used to clean and dry the
REP for good vision.

Fig. 4

For the preparation of an isthmus, an uncoated,
fine-pointed tip (CT-1 by SybronEndo) is inserted
into the ultrasonic and used to create a precise series
of multiple “dots” on the stained or “imaginary” line
between the two canals. For the DOT Technique, the
ultrasonic unit is set at a low power setting but inactivated, water spray is turned off, a CT-1 tip is placed
exactly where desired and the rheostat is “tapped”
for just an instant. The process is repeated again, and

Fig. 6a

Fig. 7

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Fig. 5

Fig. 6b

again, as many times as necessary, until there are a
series of “dots” (Fig. 6a). Then, while the water spray
is still off, the dots are gently connected to create the
initial, shallow but precise “tracking groove” (Fig. 6b).
The DOT Technique is of great value, especially
when there is concavity present and the width of the
beveled root is very thin mesial to distal. The resultant
groove serves as a definite guide for the completion
of the isthmus portion of the REP. Then with the water spray turned back on and the power increased
slightly, a pointed, coated tip can be used more
aggressively to deepen the tracking groove. In this
manner, accuracy is completely controlled and
there is no chance of “slipping off” while preparing
the isthmus in a very thin root. On occasion, if the
walls of the prep become too thin, further beveling
may be necessary.
Occasionally throughout the REP process, it
is important to use the Stropko Irrigator to rinse
and dry the REP to be sure it is kept within the long
axis of the canals and all debris is being removed
as planned. Various sizes of micro-mirrors, or an
endoscope, are used to periodically inspect the
preparation and confirm accuracy.
A pre-cut and pre-bent 25 gauge endodontic
irrigating needle (Monoject) works well for this
purpose. The notched end is removed by rapidly
bending the end one-third back-and-forth with a
Howe Pliers. The needle inserted into the Stropko
Irrigator is then bent similar to the ultrasonic tip
to be used for the REP (Fig. 7). Always keep in mind
that cleanliness and dryness are essential for good
visibility when using the OM.
Of particular interest is the buccal aspect of the
internal wall of the REP. Dr. Rubinstein was the first
to point out that often this area is not debrided due
to the angulation of the ultrasonic tip within the
canal system during the REP. If there is some guttapercha “streaming up” the side of the wall, and

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C.E. article_apical microsurgery

the preparation is finished, the best thing is to take a
small plugger and fold the gutta-percha coronally so
the wall is clean once more. It is usually futile to try to
“chase after” the gutta-percha with an ultrasonic tip.
The ideal REP should: 1) be within the long axis of
the canal system; 2) have parallel walls: 3) be at least
3 mm in depth (including the isthmus portion of the
preparation); 4) adequately extended to include any
buccal/lingual variations of the canal system; 5) be
clean (free of a smear layer) and 6) be dry and ready
to accept any type root-end filling material.
After completion of the REP, it should be rinsed
and dried once more with the Stropko Irrigator. The
REP is re-inspected, using micro-mirrors and the
varying powers of the OM and/or endoscope, to be
sure it is clean and within the long axis of the canal
system. At this time, the REP is etched with blue 35
percent phosphoric acid gel (Ultra-Etch by Ultradent)
to remove the smear layer. After 15 to 20 seconds, the
REP is thoroughly rinsed and dried with the Stropko
Irrigator and re-examined with the OM.
If all is as desired, a 15-second rinse with 2 percent
chlorhexidine will help eliminate any residual organisms present. One more gentle rinsing and drying
with the Stropko Irrigator and the REP is ready for the
root-end fill (REF).

_REF materials, techniques
The necessary steps and procedures have been
presented, enabling the operator to atraumatically
and predictably allow the root-end preparation (REP)
to be sealed using any accepted root-end fill (REF)
material.
The surgical crypt should be clean and dry so vision is clear and unobstructed. Remember, the steps
must be followed completely in order to achieve as
predictable a result as humanly possible. If, for some

Fig. 8a

reason, crypt management is not complete, or the
REP is not clean and finished, it is required to “go
back” and repeat a step, or two, to achieve the desired
result. The importance of having total control at this
point in the apical microsurgical procedure cannot be
over-emphasized.
The operator is now at a stage in the microsurgical
procedure where the tissues have been atraumatically retracted, the crypt is well-managed and the
acid etched; rinsed and dried REP is ready to fill.
Removing the smear layer barrier, exposing the
organic component (collagen fibrils) of the resected
cementum and dentin, has been shown to enhance
cementogenesis and is one of the keys to dentoalveolar healing.7
There are several materials that are currently
available as a retrofill: amalgam, IRM, Super EBA
“SEBA” (Bosworth, USA), bonded composites Optibond (SybronDental, United States), glass ionomers, such as Geristore (Den-Mat, United States)
and more recently, Mineral Trioxide Aggregate
“MTA” (DENTSPLY Tulsa).
The number of publications in literature about
research on the above materials is extensive, so only
a few of them will be mentioned due to space. The
author doesn’t want to recommend or disapprove
of any retrofill material (except amalgam), but will
generalize and relate his and others’ experience with
them and opinions about their applications.
Amalgam and IRM were used for many years
as the only commonly available retrofill materials.
However, in almost every “leakage” study published
during the past few years, amalgam has proved to be
the worst offender, exhibiting the most leakage.5,6
This fact, accompanied by the general controversy
about mercury in amalgam, strongly suggests that
there is no valid reason to continue its use as a retrofill
material. The only real advantage to amalgam is the

I

Fig. 8a_Amalgam is the most
radiopaque REF material, but its use
is highly controversial.
Fig. 8b_SEBA has a radiopacity
similar to that of gutta-percha.
Fig. 8c_The MTA has a radiopacity
just slightly better than gutta-percha.

Fig. 8b

Fig. 8c

		

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I C.E. article_apical microsurgery
Figs. 9a, 9b_Lee MTA Pellet Forming
Block.
Figs. 9c-9e_Using the Lee MTA
Pellet Forming Block system, it takes
fewer ‘passes’ with the instrument to
complete the fill of the REP with MTA.

Fig. 9c

Fig. 9a

Fig. 9b

favorable radiopacity (Fig 8a). In fact, of all REF materials commonly in use today, none of them compare
to the radiopacity of amalgam.
Since the advent of the anatomically correct, ultrasonic REP, one of the most popular and still-used
REF material is Super EBA (SEBA). A recent follow-up
study demonstrated a success rate of 91.5 percent
using SEBA.7 The author used SEBA routinely in
the early 1990s with full confidence of its sealing
capabilities.
To some, the major drawback of SEBA is its
technique sensitivity. The surgical assistant had to
mix it until it was thick enough to roll into a thin
tapered point with a dough-like consistency. For
even a well-trained assistant, this was often the most
stressful part of the microsurgical procedure. The
“dough-like” tapered end of the thin SEBA “roll” was
then segmented with an instrument, such as a small
Hollenbeck Carver.
The small cone-shaped endpiece was then inserted into the retroprep and gently compacted
coronally with the appropriate plugger. Two to five
of these small segments were usually necessary to
slightly overfill the retroprep.
Another problem experienced by many was that
SEBA was unpredictable as to its setting time —

sometimes setting too quickly and, at other times,
taking much too long for the tired surgeon.
At any rate, after the REF is complete, an instrument, and/or bur, is used to smooth the resected
surface, producing the final finish. A mild etchant
is then used to remove the “smear layer” produced
during the final finishing process. SEBA has a radiopacity comparable to that of gutta-percha, so it was
necessary to educate the new referring doctor that a
retrofill had indeed been performed (Fig. 8b). However, in some recent studies, SEBA has been shown
to have a better sealing ability that IRM, but not as
well as MTA.5,6
Bonding, using composite retrofill materials, is
now completely possible due to having total control
over the apical environment utilizing good crypt
management procedures. Many different materials
are available for use as a REF. Optibond (SybronDental) and Geristore (Den-Mat) are popular because of
their ease of use. They both have good flowability,
dual-cure properties and the ability to be bonded to
dentine. Geristore is supported by research demonstrating biocompatibility to the surrounding tissues.8
The usual etching, conditioning of the dentin,
insertion of the selected material, and curing by
chemical or light is accomplished in a routine manner

Fig. 9d

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Fig. 9e

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C.E. article_apical microsurgery

Fig. 10a_MTA should be carved
flush with the REB.
Fig. 10b_Blood supply
re-established to cover MTA.

Fig. 10a

Fig. 10b

when bonding into the retroprep. (Note: Because the
light source for the OM is so intense, it is mandatory
to obtain an orange filter to use while placing the
composite to prevent a premature set.) For most
microscopes, an orange filter is available that easily
and inexpensively replaces the “blood filter.” After
the composite is completely cured, the material is
finished with a high-speed finishing bur and the
resected root end is etched with a 35 percent blue gel
etchant (Ultradent, United States) for about 12 seconds to remove the “smear layer” and to demineralize
the surface.
Several studies showed no leakage with bonding
techniques and many operators use it as their technique of choice.
However, there is some controversy as to whether
the resected surface of the root should also be
coated with a thin layer of the bonding material. A
“cap” of material (usually Optibond) was placed with
the intention of sealing the exposed tubules on the
resected surface.
The operators who cover the resected surface
believe it necessary to ensure a good seal and the predictability would be better. On the other hand, there
are also operators who do not believe the exposed tubules are a factor concerning the predictability of the
healing process. They reason that nothing would heal
as well, or be more biocompatible, than the exposed
dentin of the apically resected surface.
The author did not cover the exposed apical surface and is convinced the jury is still out on this issue!
More recently, another material has become very
popular and is widely used by many. Mineral Trioxide
Aggregate (MTA) has attracted many converts. There
is so much research that has been done, and so many
publications presented, that just one reference would
be futile.
The evidence extolling the virtues of MTA, regarding its sealing capabilities and its biocompatibility
with the surrounding tissues, is overwhelming. The
author has talked to many respected endodontists,
and most are now using MTA as their routine retrofill

material. MTA is chemically similar to calcium sulfate,
forgiving to work with, and has a radiopacity slightly
better than gutta-percha (Fig. 8c).
The main advantage of MTA is its ease of use, much
like handling “Portland Cement.” One of the secrets to
using MTA is to keep it dry enough so it doesn’t flow
too readily (like wet sand), but yet is moist enough
to permit manipulation and maintain a workable
consistency.
The desired “thickness” is easily accomplished
by using dry cotton pellets, or the MTA mix can be
gently dried with a dedicated, air-only Stropko Irrigator (www.stropko.com). If the MTA is too dry and
needs moisture added, that, too, is easily done with
a cotton pellet saturated with sterile water. Properly
mixed MTA can be extruded in pellets of various sizes
(depending on the size of the carrier used) using a
Dovgan Carrier (Quality Aspirators) and condensed
with an appropriate plugger.
More recently, a simple method for delivery of the
MTA into the REP was introduced (Fig. 9a). The Lee
MTA Pellet Forming Block has several differently sized
grooves to create the desired aliquot of MTA. The MTA
adheres to the instrument, allowing for easy and efficient placement into the REP (Figs 9c-9e).
For a denser and stronger consistency, the assistant can touch the non-working end of the plugger, or
explorer, with an ultrasonic tip during the condensation process. The flow is increased and a much denser
fill is achieved. As a result, “ultrasonic densification”
also increases the radiodensity of the MTA’s appearance in the post-op radiograph, but it is still similar
to gutta-percha (Fig. 8c).
MTA has approximately an hour of working time,
which is more than adequate for apical microsurgery
and takes much “time pressure” out of the surgical
procedure. Finishing the MTA is simply a matter of
carving away the excess material to the level of the
resected root end (Fig. 10a). The moisture necessary
for the final set is derived from the blood, which fills
the crypt after surgery. The MTA is very hydrophilic
and depends on moisture for the final set, so it is im-

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I C.E. article_apical microsurgery
perative that there is enough bleeding re-established
after crypt management to ensure the crypt is filled. If
any material, such as ferric sulfate, has been used for
crypt management, it must be judiciously removed to
restore blood supply to the crypt.
This can be considered the final step in “crypt
management” and is especially important when MTA
is used for the REF. If the size of the lesion indicates
the use of guided bone regeneration, good blood supply is indicated anyway, so allow the blood to cover
the MTA before placing the GBR material of choice.
In a large lesion, it is sometimes difficult, even after
curettage, to restore bleeding into the crypt (perhaps
the crypt management was a little too effective), and
it may be necessary to use a small round bur in the
surgical handpiece to make several small holes in the
surface of the crypt to aid in the re-establishment of
the desired flow of blood.
Based on current studies, the operator can choose
any one of the above mentioned REF materials and
be comfortable that, if the proper protocol is followed, the apical seal will be predictable and healing
uneventful.

All steps have been meticulously followed, the REF
has been placed, the crypt has refilled nicely, the final
radiograph has been approved, and it is time to suture
the flap into position.
Sadly, most operators now push the microscope
aside and suture without it. To do this robs the operators of an opportunity to demonstrate to themselves
and their patients the amazing capabilities of the OM.
The doctors must make a commitment to master the
suturing technique using the OM.
It will never be accomplished with the OM
pushed aside at this critical step in the apical
microsurgical procedure. The following will be
based largely on the author’s own experiences during nearly 20 years of doing, teaching and writing
about apical microsurgery.
Dr. John Harrison has published some of the most
clearly written and comprehensive work on wound
healing associated with periapical surgery.

There are five publications that are a “must read”
for the endodontic surgeon. These publications can
be found in the Journal of Endodontics: 1991, Vol. 17,
pp. 401-408, 425-435, 544-552; 1992, Vol. 18, pp.
76-81; and 1993, Vol. 19, pp. 339-347.
After reading these articles, the microsurgical
protocol developed by Drs. Gary Carr, Richard Rubinstein and others becomes clearer and is more easily
understood. The word “atraumatic” is an important
factor to achieve predictable wound healing.
When the surgical site is ready for closure, the flap
should be gently massaged to close approximation
with the attached tissue. But, keep in mind, the flap
has probably lost dimension, or “shrunk” slightly, due
to the mere act of retraction over a period of time
and has endured a slight decrease of blood flow to it.
Fortunately, this is usually not a problem. If the initial
incision was planned with this final step in mind, the
tissues should re-approximate with minimal manipulation. Now is when the operator will appreciate
nice “scalloping” and a sharp scalpel when making
the incision in the beginning of the surgery (Fig. 11).
Remember the old saying, “Hindsight is always
20/20”? The smooth side of a small #2 mouth mirror can be used to hold the tissue in position while
the second surgical assistant (on the same side of
the chair as the doctor) hands the doctor the needle
holder with the needle positioned properly in the
beaks so the sutures can be easily and accurately
placed.
All suturing is accomplished using 6-0 black
monofilament nylon (Supramid, S. Jackson). Some
microsurgeons are using 8-0 and, even 10-0 sutures;
but the 6-0 is easy to use, doesn’t tear through the
tissue as readily and the results are no different
than with the more technique-demanding, thinner
sutures. Keep in mind, the sutures will be removed in
24 hours so it is really a moot point as to whether the
suture is 6-0, 8-0 or 10-0.
The results achieved with 6-0 suture seem to
be well suited to apical microsurgery. The black silk
suture, traditionally used in surgery, is a detriment
to the rapid healing we are trying to achieve. Not
only does bacterial plaque more readily accumulate
on it than monofilament but, also, the braiding

Fig. 11

Fig. 12

_Sutures, suturing techniques

Fig. 11_If the incision is planned
well, re-approximation of the flap is
uneventful.
Fig. 12_Sutures immediately
post-operation.

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[15] =>

C.E. article_apical microsurgery

I

Fig. 13_Twenty-four hours postoperation; before sutures are
removed.
Fig. 14_Appearance of the tissue
immediately after the 24-hour suture
removal.

Fig. 13

Fig. 14

Fig. 15_Two weeks post-operative,
the healing is proceeding as
expected.
Fig. 16_At six months postoperative, nothing is seen except the
scar from a previous apical surgery
done 10 years ago.

Fig. 15

Fig. 16

acts as a wick for the migration of bacteria into the
wound. This can result in an increased inflammatory
response and compromised healing.
The type of needle used depends on the type of
flap to be sutured. For the Oshenbein-Leubke Flap,
a taper point needle (TPN), 3/8 circle (Supramid, S.
Jackson, code MEA-60B) is used.
The TPN is far superior to the reverse cutting type
needle (RCN) because there isn’t the tendency to cut,
or tear, the flap edges. Also, the TPN require less effort to exit at a point in the attached tissue where the
operator intends, not where the needle wants to exit.
In other words, it is easier to guide a TPN to the
desired point of exit in the attached tissue than it
is an RCN. They just seem to cooperate more when
suturing this type of flap! One of the nicest things
about using this flap design is the ability to easily see
the healing taking place (Figs. 12–16).
For the Sulcular Flap, a reverse cutting needle
(RCN), 3/8 circle (Supramid, S. Jackson, code MPR60B) is used. This needle is used because the larger
size facilitates passing it through the contacts when
doing a sling suture. The sling, or mattress type, suture is routinely used to save time on closure, rather
than doing individual buccal to lingual sutures. On
many occasions, the TPN (see above paragraph) is
also used to suture the attached gingival area of the
flap at the coronal aspect of the releasing incision.
A technique for suturing using the SOM: While the
scope assistant holds the retractor in place, the second assistant uses a small Castro-Viejo type needle
holder. The beaks of the holder must grasp the needle

approximately 3/4 of the distance from the pointed
end to where the suture is attached to the needle.
Special attention, by the second assistant, must be
taken to keep the beaks of the holder away from
either end of the needle, as these are the areas of the
needle’s greatest weakness and can be inadvertently
bent or broken (Fig. 17).
Care is taken so the needle is firmly grasped perpendicular to the beaks of the holder. This allows the
operator more definite control and a better “feel” of
the needle during the suturing process.
The second assistant now passes the needle holder
into the doctor’s normal working hand (Hand A). The
doctor then begins the suturing process by inserting
the needle through both sides of the incision. When
the needle is completely through both sides of the incision, the needle is then grasped between the thumb
and index finger of the opposite hand (Hand B).
While the doctor is doing this, the second assistant is holding the end of the suture so it won’t inadvertently be pulled through the tissues. The doctor
proceeds to make the three loose “loops” around the
beaks of the needle holder to start the first knot.
While the doctor is making these initial “loops,”
the second surgical assistant is placing the end of the
suture into the doctor’s visual field of the microscope,
so the end of the suture can be easily grasped in the
beaks of the needle holder by the doctor.
The second assistant can be sure the end of the
suture is within the doctor’s field of vision by looking into a monitor that has been placed so it is easily
seen (Fig. 18).

		

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[16] =>

I C.E. article_apical microsurgery
Fig. 17_The needle must be placed
into the beaks of the needle holder
correctly.
Fig. 18_The second assistant
presents the end of the suture so the
doctor can control it.

16 I roots
2_ 2012

Fig. 17

Fig. 18

The “loops” around the beaks of the needle
holder create enough friction so there is a controllable tension between the doctor’s Hand B and the
beaks of the needle holder in Hand A. Care must
always be taken that the tension is only between
Hand B and the needle holder in Hand A, so no
undesirable tension is exerted on the tissue during
the suturing process.
The purpose of maintaining some tension is to
give the doctor a positive tactile sense while taking up the excess suture material in Hand B. As the
suture is drawn through the tissue by Hand B, Hand
A is lowered to prevent exerting too much tension
on the tissue.
The tension on the suture is regulated by the
looseness, or tightness, of the “loops” which control
the amount of friction for the suture to overcome as
it is gathered. Hand B continues gathering as Hand
A yields the suture with a “descending” motion while
still maintaining the desired tension, and the beaks of
the holder have the end of the suture firmly secured.
When the end of the suture is at the desired length
relative to the incision, the “loops” are allowed to
slip off the beaks for the initial knot. Then, using the
same basic rhythm of movements, the “securing”
and “locking” knots are placed. It is an alternating
rhythm of movement that is difficult to describe in
writing, but is actually very easy for the beginning
microsurgeon to learn.
The doctor now allows the second surgical assistant to take the needle holder from Hand A and
simultaneously be handed the micro-scissors so the
suture can be cut close to the knot.
After the second assistant takes the scissors and
the suture, the doctor is handed a micro-forceps to
gently move the knot between the point of insertion
and the incision, helping to prevent plaque buildup
over the incision itself (Fig. 19).
Note: When moving the knot with the microforceps, it is important that the knot be “pushed” to
place, not “pulled” to place. This ensures the suture’s
original tension and integrity is maintained.
One of the most common mistakes made when

suturing is to make the suture too tight. It is better to
make the suture a little too loose than to make it too
tight. When the suture is too tight, it causes ischemia
and thus compromises rapid healing. When making
a sling suture in a sulcular flap, it is easy to be too
aggressive when tying the knot, causing the rest of
the suture to get too tight. The doctor should always
recheck the tension over the entire length of the suture before completing the securing knots.
The releasing incision is usually an integral part of
every flap and is considered differently from the rest
of the incision. Normally, the releasing incision is not
sutured, but if it is, the suture should be looser than
the other sutures. It has been shown that epithelial
creep, or streaming, occurs rapidly, or at a rate of
about 1 mm per side per 24 hours.
In other words, a wound whose edges were
separated 2 mm would be expected to come together
within a 24-hour period. In hundreds of surgeries during the past 12 years, there were only a few
cases where the releasing incision wasn’t completely
closed.
Of those few that didn’t close within 24 hours,
they all closed within 48 hours. To repeat: If the operator prefers to suture the releasing incision, it must
be sutured loosely (Fig. 20). Another consideration
is to be sure to suture “like tissues to like tissues.”
Never suture attached gingival tissue to unattached
gingival tissue. If one side of the suture “tears out,” it
will be the attached gingival side.
When using the OM to suture, the incision can be
closed accurately with extremely good approximation. It is because of well-planned and nicely scalloped incisions; atraumatic flap elevation procedures; and the very close repositioning of the flap
with thin, hair-like sutures (6-0) that we can plan on
routinely removing sutures in 24 hours (see Figs. 16
and 17).
The sutures have completed their task after 24
hours, and in fact, have now become foreign bodies
that can cause irritation, excessive inflammation,
be a source of infection and, ultimately, result in a
retardation of the healing process.14

[17] =>

C.E. article_apical microsurgery

Fig. 19_The suture knot is ‘pushed’
into the proper position, not ‘pulled.’
Fig. 20_If the vertical releasing
incision is sutured, it must be kept
very loose.

Fig. 19

For those who doubt the 24-hour Suture Removal
Theory, an easy exercise is this:
1) At the next surgery, be sure to place at least
five sutures.
2) After 24 hours, have the patient come in and
remove the worst-looking suture, the one you think
isn’t healing as well as the others.
3) Then, the next day, remove the next worstlooking suture.
4) The next day, do the same, and so on. At the end
of the fifth day, the worst-looking suture will be the one
remaining! If that doesn’t convince you, nothing will.
Post-operatively, the usual result is little, or no, pain
or swelling. The post-operative instructions are ice
packs 15 minutes on and then 15 minutes off for the
first six hours only, gentle rinsing with Peridex for the
next 24 hours, and have sutures removed the next day.
Experience has demonstrated that prescribing Ibuprofen 600mg every six hours, along with on to two tabs of
Tylenol OTC (taken between the doses of Ibuprofen), has
a very effective anti-inflammatory effect.
It is the exception, rather than the rule, that a
patient requires a stronger medication for post operative pain. Antibiotics are not usually prescribed.
If everything is within normal limits, the patient
is instructed to begin gentle cleaning of the area on
the third day post-op, using a wash cloth over his or
her index finger, and to begin gentle brushing, with a
soft brush, on day five. The patient is scheduled for a
follow-up visit two weeks after surgery.
At the two-week visit, normally the incision is barely
visible, and on most occasions, can hardly be detected.
A word of caution: Not all patients respond to
treatment as well as others. Don’t be in a hurry to treat
a problem that may not exist. On a few occasions,
patients may be slower than normal in response to
treatment, sometimes taking several weeks to heal as
well as other patients have or do in just days.
If there is any doubt, place the patient on antibiotics and an anti-inflammatory for a week as a
precaution, but what is really desired is more time for
delayed healing to occur.
The apical microsurgical technique described in

Fig. 20

the previous six parts has become the standard of
care in endodontic treatment and raises endodontic
apical surgery to a new and exciting level.
For the first time, apical surgery can be performed
with predictable results. But these results can only
be achieved if the proper protocol is followed meticulously.
The steps must be followed without compromise.
Much more could be written, but hopefully enough
of an overview has been given to stimulate just one
more doctor to begin using the OM. It is the finest tool
our profession has ever been given.
Apical microsurgery can be an enjoyable part of
the daily regimen, for both the doctor and the newly
involved dental team._
Editorial note: Part I of this article appeared in
roots, the international magazine of endodontics,
Vol. 1, No. 1, 2011. A complete list of references is
available from the publisher.

_about the author

roots

John J. Stropko received his
DDS from Indiana University
in 1964, and he practiced
restorative dentistry for 24
years. In 1989, he received
a certificate for endodontics
from Boston University and
recently retired from the
private practice of endodontics in Scottsdale, Ariz.
Stropko is an internationally recognized authority on
micro-endodontics. He is the inventor of the Stropko Irrigator, has published in several journals and textbooks and is
an internationally known speaker. He is the co-founder of
Clinical Endodontic Seminars and and was an instructor
of microsurgery for the endodontic courses presented at
the Scottsdale Center for Dentistry. Stropko and his wife,
Barbara, currently reside in Prescott, Ariz. You may contact
him at docstropko@gmail.com.

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[18] =>

I trends_technology

A logical basis to judge
endodontic innovations
Author_Barry Lee Musikant, DMD

_The introduction of new technology has as
its goal to improve a process that was unable
to be achieved, poorly achieved by other means
or achieving the same or superior results in a
more time and cost-efficient manner. Using these
criteria as the justification for the introduction of
rotary NiTi, the burden of proof is on demonstrat-

ing that at least some of these conditions previously existed.
Certainly prior to the introduction of rotary NiTi,
dentists were shaping canals in many cases quite
well. One simply has to observe the work of Dr. Herb
Schilder to recognize excellence before the implementation of rotary NiTi.1

Fig. 1

Fig. 3

Fig. 1_Photo of a K-File. Note the
high number of horizontally oriented
flutes. (Photos/Provided by Dr. Barry
Lee Musikant)
Fig. 2_Photo of a relieved reamer.
Note the patented flat side and the
decreases number of vertically
oriented flutes.
Fig. 3_Photo of a relieved reamer
that negotiated easily to the apex in a
highly curved canal.

18 I roots
2_ 2012

Fig. 2

[19] =>

[20] =>

I trends_technology

Fig. 4_Illustration of a relieved
reamer in a reciprocating handpice.

Fig. 4

20 I roots
2_ 2012

Yet, most dentists would admit that achieving
that level of perfection is quite challenging using
the tools Schilder had to work with. So, while it was
possible to attain perfection with what previously
existed, the incorporation of rotary NiTi made it possible for more dentists to achieve results approaching
the excellence of Schilder.
The justification for the implementation of rotary
NiTi is that it produces superior results more simply
and in less time than conventional endodontics. Yet
to make this an accurate comparison, we have to
settle on just what conventional endodontics means.
For most dentists, conventional endodontics
means the shaping of canals with a series of K-files
used in a stepback manner. Yet, this was not the
technique Schilder used to shape canals.2
Rather, he used reamers, instruments whose
design includes fewer and more vertically oriented
flutes than K-files, instruments that are used conventionally, but not nearly as well known as K-files.
If one considers the use of K-files as the only
option if one doesn’t adopt rotary NiTi, one also has
to admit that the adaptation of rotary NiTi does not
eliminate the use of K-files since they are a requirement for glide path creation, a necessity before rotary
NiTi can be safely used. Therefore, at best, rotary NiTi
implies the reduction in the use of K-files without re-

‘For most dentists,
conventional endodontics
means the shaping of canals
with a series of K-files used
in a stepback manner.
Yet, this was not the
technique Schilder used
to shape canals.’
placing them completely. All the problems associated
with K-files in their creating the initial canal shaping
are still present. It is only the latter part of canal shaping for which the rotary NiTi are responsible.
With the notable improvements that rotary NiTi
bring to canal shaping, is it not reasonable to assume
that these same improvements would exist whether
or not K-files or K-reamers unrelieved and relieved
were used?
To make this judgment, one would have to appreciate the beneficial effects of a reamer design in
comparison to a K-file.
Certainly, Schilder did have that appreciation. He
noted in his papers that reamers engaged less along
length reducing the resistance to apical negotiation.
He noted the superior tactile perception, their greater
flexibility and the increased ability to shave dentin
from the canal walls.
Yet are these improvements sufficient to eliminate
the need for rotary NiTi? It has been stated many times
that 02 tapered stainless steel instruments tend to
distort transport canal walls to the outside curve as
progressively larger tipped sized instruments become
stiffer and stiffer. Equating K-files with K-reamers
one would conclude that this is a distinct possibility
with either design and the more flexible rotary NiTi
instruments would shape these canals to greater
dimensions with less chance of distortion.
This progression of thought is undermined by the
fact that K-reamers are significantly less stiff than
comparably sized K-files; that by incorporating a
flat along the K-reamers working length, the cross
sectional area is reduced making the instruments
even more flexible; that the reduced engagement
along length allows the instruments to adapt to the
canal walls, more readily taking advantage of stainless steel’s property of recording curves rather than
snapping back to the straight position, a unique NiTi
property and detrimental to our goal of distortionfree shaping.

[21] =>

trends_technology

As we can see, the concept of conventional shaping versus the new world of rotary NiTi is a bit more
complex than one might originally think. We can
state categorically that K-reamers that are relieved
are significantly more flexible than comparably sized
K-files, and that they engage far less along length and
provide for a superior tactile perception, giving the
dentist the ability to know when the reamer is either
hitting a solid wall, in a tight, but patent canal or in a
canal that is so curved that it requires prebending to
negotiate around without distortion. Providing this
superior tactile perception sets the relieved reamers
apart from K-files.
While acceding to the superior usage of relieved
reamers over K-files, wouldn’t the incorporation of
rotary NiTi after glide path creation make the procedure even more efficient and effective? As its name
implies, NiTi instruments are used most effectively
in rotation. Yet, using NiTi in rotation increases the
chances of instrument separation, a product of either
torsional stress or cyclic fatigue or some combination of both.3 In contrast, the relieved reamers are
used with either a tight watch-winding stroke or
in a 30-degree reciprocating handpiece, virtually
eliminating the two factors that make rotary NiTi
vulnerable to breakage.4
The K-reamers, routinely shape canals to a minimum of 35, one mm back to a 40 with a 25/06 overlaid

Fig. 5a

Fig. 5b

Fig. 6

Fig. 7

taper. After the canal is shaped to a 20, a tapered
peeso is used to straighten any coronal curve that
may exist generally to within 6 mm of the apex. The
relieved reamers 25 thru 40 are mostly limited to
shaping the apical 6 mm of the canal. Even highly
curved canals are not susceptible to distortion via
these thicker relieved reamers because they are still
far more flexible than comparably sized K-files, their
motion is confined to a short arc that keeps them
centered within the canal and the tactile perception
clearly tells the dentist if the tip of the instrument is
hitting a wall or negotiating a highly curved canal
from the straight position.
With resistance mainly defined by what lies ahead
of the tip of the instrument, be it from a solid wall or
an abruptly curved canal, the dentist knows when to
remove the instrument, bend it at the tip and manually negotiate around the curve prior to reattaching
it to the reciprocating handpiece followed by rapid
negotiation to the apex.
All the rotary NiTi systems make sense if the
premise for their use is based on the K-file, an instrument Schilder clearly understood to be a poor design
for the function asked of it. None of the rotary NiTi
systems make sense, if the better designed reamers
— both unrelieved and relieved — are utilized with a
short arc of motion either generated manually or in
the reciprocating handpiece. Rotary NiTi addresses

Figs. 5a, 5b_Radiographs showing
endodontic case performed with
relieved reamers in a reciprocating
handpiece.
Figs. 6, 7_Radiographs showing two
more endodontic cases performed
with relieved reamers in
a reciprocating handpiece.

roots
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I 21

[22] =>

I trends_technology
‘Once the relieved reamer tactile perception of what the tip of the reamer is
encountering that knowing when to remove the
reamer, bend it at the tip and manually negotirecords the curve, it is in
ate around the impediment is obvious making it
effect a passive instrument unlikely that distortions will result.
Schilder knew what he was doing when he
with the blades shaving the chose K-reamers over K-files. He never needed
rotary NiTi to create a standard of shaping
dentin along the length of the that rotary NiTi does not measure up to. You
can achieve that standard in a thoroughly safe
canal walls on the downstroke manner by using relieved reamers, instruments
Schilder would have noticed negotiate
and removing dentin on the that
through the canal with even less resistance
than non-relieved reamers and in using them
upstroke wherever the
with either a tight watch-winding motion or
reciprocating handpiece they are being
dentist directs the length of inusedthewith
the tight arc of motion that Schilder
would have approved of (Figs. 5a, 5b)._
the instrument to contact
_References
the canal walls.’
1.

the challenge of shaping curved canals without distortion better than K-files. They are far more flexible
than K-files and somewhat more than K-reamers,
but lose their luster for non-distortion because of
their rebound effect in curved canals. Always seeking
out the straight position, as their tip size and taper
increase there is a greater and greater tendency to
shape to the outside wall of curved canals. Most dentists know this and with the added concern for breakage are generally satisfied in shaping curved canals
to a maximum of 25/06 and often a 20/04, a degree
of shaping that will minimize breakage and distortion, but also often prove inadequate from the point
of view of full debridement and effective irrigation.
An instrument need not be as flexible as NiTi if is
capable of combining the flexibility it does have with
the ability to record curves rather than snap back to
the straight position. Once the relieved reamer records
the curve, it is in effect a passive instrument with the
blades shaving the dentin along the length of the canal walls on the downstroke and removing dentin on
the upstroke wherever the dentist directs the length
of the instrument to contact the canal walls.
In this way a uniform layer of dentin is removed
circumferentially retaining the original canal shape
and not undermining the thinner walls of oval canals the way it would occur if rotary NiTi was used
instead5.
That is not to say that relieved reamers could not
distort a canal wall. All one would have to do is hit
a wall, know you hit the wall and continue to peck
aggressively despite all the apical resistance encountered. Distortion would inevitably follow.
However, the relieved reamers offer such superior

22 I roots
2_ 2012

2.
3.

Schilder H. Filling root canal in three dimensions. Dent Clin
North Am 1967;11:723–44.
Schilder H. Cleaning and shaping the root canal. Dent Clin
North Amer 1974;18:269–296.
Li UM, Lee BS, Shih CT, Lan WH, Lin CP. Cyclic fatigue of
endodontic nickel titanium rotary instruments: static and
dynamic tests. J Endod. 2002 Jun;28(6):448–51.
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 May;109(5):e82–5.
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.

_about the author

roots

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). 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. He may be contacted at info@
edsdental.com.

[23] =>

[24] =>

I case report_endodontic zone

A case of diagnosis
by access
Author_L. Stephen Buchanan, DDS, FICD, FACD

Fig. 1

Fig. 2

Fig. 1_Pre-op radiograph showing a
well-performed root-canal therapy
on tooth #19 (conservative access
preparation and coronal shapes,
dense fills to each canal terminus).
Tooth #20 was treatment planned for
root-canal therapy after the patient’s
pain had not been alleviated by
treatment of #19. (Photos/Provided
by Dr. L. Stephen Buchanan)
Fig. 2_Pre-op radiograph of the
maxillary arch, showing relatively
large pulp horns in the chambers
of teeth #13, 14 and 15, with
restorations near each of them.

24 I roots
2_ 2012

_She was related to my practice neighbor, a
good friend and a very talented oral surgeon (OS),
and was visiting him in Santa Barbara for the holidays. She was experiencing intractable pain in her
left facial region. Could I see her today?
Two weeks before, her general dentist had
referred her to an endodontist, who treated
the root canal in tooth #19. However, the pain
continued to escalate thereafter and endodontic
treatment of tooth #20 was his secondary treatment plan. Fortunately, she left before that tooth
was invaded.
When I met her at my front desk, I questioned
her about her chief complaint — the chronology,
eliciting factors and the pain referral pattern of her
symptoms. She stated that the pain had been intensifying for the last two weeks, was spontaneous in
onset and, for the most part, she was not aware of
thermal sensitivity.
The patient felt pain in her upper and lower left
teeth and down her neck. I immediately thought

that this might be a classic case of myofascial pain
masquerading as an endodontic problem. While
dying pulp will refer pain indiscriminately to both
upper and lower jaws, it never refers pain below the
lower border of the mandible or above the patient’s
cheekbone. I call it the endodontic zone (EZ). When
asked whether she had any history of myofascial
or joint pain, the patient informed me that her
temporomandibular joint clicked and that she had
an occlusal night guard, which she had not been
wearing lately.
So, not reactive to thermal stimulus, pain
referred outside the EZ and a history of temporomandibular dysfunction — interesting. I thought
that I had diagnosed this case in my reception area
and that I had the wonderful opportunity to tell the
patient that she did not need another root-canal
treatment.
My assistant took the patient back to an operatory, took conventional X-ray (Figs. 1, 2) and
CBCT images, and gathered clinical findings and

[25] =>

[26] =>

I case report_endodontic zone

Fig. 3

Fig. 4

Fig. 3_CT axial view, showing the MB
root of tooth #14 with two canals.
Fig. 4_CT sagittal view, of the MB root
from the mesial direction. Note the
common orifice of the MB1 and MB2
canals that immediately bifurcate and
are apically confluent where the canal
terminates in a severe curve in the
hidden palatal plane.

Fig. 5_CT sagittal view of the DB
root from the mesial direction. Note
the multiplanar curvatures ending in
an apical bend to the hidden buccal
direction.
Fig. 6_CT sagittal view of the palatal
root, showing nearly perfect tapered
canal shape.

Fig. 5

pulp testing data. No peri-radicular pathosis was
seen in any of the X-rays, cold tests of all teeth
on the left side of the patient’s face were within
normal limits (WNL), and I was itching to find the
myofascial trigger-point that had been making
her miserable. I had her open half-way — as per
Dr. Janet Travel — then palpated her left masseter
and temporalis muscles, but they were stellar —
surprising!
I then felt like I was in the “Twilight Zone” instead
of the EZ. The patient had not reported thermal sensitivity and had pain referred beyond where dying
pulp refers. But I was unable to reproduce the pain
by palpating her muscles of mastication.
At this point, I had no option but to turn to my
standard process of pulp testing to rule pulpitis
out as the etiology of her symptoms (although the
previous endodontist had ruled out tooth #19). I did
cold testing (with an H2O ice pencil formed in an
autoclaved empty anaesthetic carpule) on all of her
teeth on the upper and lower left side of her face, and
while they all responded WNL, teeth #18, 14 and 15
responded sharply, but transiently — not definitive
by any means.
The possibility of more than one tooth being irreversibly inflamed was virtually zero. I still did not
know what was going on, although tooth #14 was
very slightly sensitive to biting pressure and percus-

Fig. 6

26 I roots
2_ 2012

sion. It had been restored recently with composite
and was nearly in crossbite and therefore more likely
to be affected by bruxism.
Therefore, I was left to my best next move in these
kinds of situations. I heat tested all of the upper and
lower teeth (except #19 of course) with my System
B Heat Source (SybronEndo). SybronEndo sells a special heat-testing tip for Touch ’n Heat and System B
Heat Source that allows users to apply a sustainable
heat stimulus to both quadrants of teeth in under a
minute, with gutta-percha on the tip and the sources
set to 200 degrees C.
In my experience, using sustainable sources of
thermal stimuli to test pulp is the sine qua non of endodontic diagnosis. With transient sources of thermal stimuli — spray refrigerants and flame-heated
gutta-percha — the temperature is never the same,
which adds another variable to an already subjective data point. Additionally, it sometimes takes a bit
of time to elicit a response when insulating acrylic,
porcelain or calcification of the pulp chamber delays
the response of a tooth with a relatively healthy pulp.
I tested teeth #18, 20, 21, 12 and 13 and achieved
WNL responses (little or no response to heat is
normal). However, when I heated #14, I reproduced
the patient’s chief complaint exactly and it had
a prolonged effect. This was a huge relief and far
better than having to say “I just don’t know what is
making your sister-in-law miserable.” We scheduled
the patient for an emergency appointment the next
day, as her pain was at a manageable level when she
had taken an adequate dose of ibuprofen and as my
schedule was already full, with three other emergency appointments.
My OS buddy called me the next morning to
inform me that his sister-in-law was nervous about
another possible misdiagnosis and erroneous treatment plan. In my mind, this concern qualified her
as passing the IQ test. I repeated the thermal testing just to be certain that I was not going to be the
second endodontist that would perform a needless
root-canal treatment on a dentist’s relative, while
failing to resolve her chief complaint. Cold testing
gave the same vanilla responses, but heat testing on
the mesiobuccal (MB) line angle of #14 reproduced
her pain, and it was also a bit more sensitive to percussion and bite.
I felt even more confident in my diagnosis when
the patient’s pain was totally alleviated by infiltration with 1.5 carpules of 2 percent lidocaine 1/100k
epinephrine on the buccal side of tooth #14 and 0.5
carpule on the palatal side — given comfortably with
extremely slow administration of the anaesthetic
using the STA Anesthesia Delivery System (Milestone
Scientific) — in this very tight tissue.
As an aside: I really do not trust local anesthesia
as a diagnostic procedure. It is not specific enough

[27] =>

case report_endodontic zone

Fig. 7

to rule out a single tooth, it may mask adjacent
myofascial aetiology and, after giving any local anesthesia, further diagnostic work is not possible. As
a confirmation of our definitive pulp testing results,
however, the elimination of her symptoms after
anesthesia was good to see.
After anesthesia had been confirmed by heat
testing and percussion, tooth #14 was isolated with
a rubber dam and an access cavity into the pulp
chamber was cut. As was expected from the tooth’s
sensitivity to heat stimulus, the pulp was partially
necrotic — the MB and distobuccal (DB) canals having fully degenerated tissue and the palatal canal
pulp virtually intact (Fig. 7).
The volumetric images gathered with my Accuitomo (J. Morita) revealed that the MB root held
two canals that diverged from a single orifice and
then joined again in the apical third, where it appeared to have a severe palatal curve (Figs. 3–6). As
I had learned from my friend and colleague Dr. John
Khademi, I cut a shallow MB2 groove in the mesial
access wall to facilitate treatment of the only canal
in the upper molars that does not have an access line
angle dropping into it (Fig. 8).
All canals were negotiated with rotary NiTi instruments — first with a Vortex (DENTSPLY Tulsa) 15/.06
file to mid-root, followed by a Vortex 15/.04 to length
in each canal except the MB1 and MB2, which required the more flexible PathFiles (DENTSPLY Tulsa)
to reach the terminus owing to their abrupt apical
curves. Rotary negotiation (in most cases without
using hand files beforehand) has been a gratifying
procedural upgrade in my practice. While I have not
found the PathFiles to be dependable as first instruments in tight canals, Vortex files accomplish this
in a way that is counter-intuitive to my previous
paradigm (using # 8, 10 and then 15 K-files to length
in the presence of a lubricant). By a fluke I found
that in all but the most severely curved canals (of
course those with impediments as well) these small

Vortex instruments usually cut to length in less than
a half-minute.
I am not exactly certain why Vortex files work so
well for handpiece-driven negotiation, but my best
guess is that their triangular cross-sectional geometry has enough space between the three cutting
flutes to auger, rather than compact, vital pulp tissue
from the apical thirds of small canals.
I have yet to block a canal with these instruments,
although I am very careful to stop using them at the
slightest hint of apical resistance. If the 15/.06 meets
resistance, I use the 15/.04. If the 15/.04 becomes
stuck, I bring in hand files in sizes 08 and 10 C-files to
length, and then I use the # 1, 2 and 3 rotary PathFiles
to length (all 0.02 tapered with tip diameters of 0.13,
0.16 and 0.19 mm).
I used the Root ZX II (J. Morita) with all initial files
taken to length, thereby knowing at all times when
I had reached the termini, and obviating the need
for a length determination X-ray. As usual, I used
the straight apex locator probe instead of the test
clip version. Even with hand files, I dislike the spring
clip file probe, as it interferes with my tactile sense
and it gets in the way of the rubber dam field. With
rotary negotiation, the straight probe with its v-cut
tip makes it very easy to pick up as estimated length
is approached with the rotary negotiating file, and
its tip notch rides smoothly on the rotating file. The
final reason I prefer this probe set is because it is
thinner and fits more easily between the stop and
handle and it is very effective at positioning the stop
exactly at the reference point once length has been
indicated. An additional advantage of doing the
initial negotiation procedure with Vortex 15/.06 and
15/.04 files is that with these tapers being greater
than the typical 0.02 tapered hand files, there is less
change in curved canal lengths during the shaping
procedures to follow.
I never do initial negotiation procedures with
NaOCl irrigant in the access cavity. While all the cur-

Fig. 8
Fig. 7_Dental pulp extirpated from
the palatal canal. A bent #25 broach
was rotated as it was carefully
inserted into the canal, after which
it was gently and slowly removed
with the intact pulp wrapped around
it. Bending a #25 broach causes its
mid-portion to sweep around the
periphery of the canal wall of medium
and large canals regardless of their
size and taper, obviating the need for
other sizes.
Fig. 8_Access cavity in tooth #14,
showing the preparation limited
to the mesial half of the occlusal
surface. Note the Khademi Groove
cut into the mesial wall for easier
treatment of the MB2 canal — the
only canal in the upper molars
without an access line angle to guide
instruments and materials. The small
amount of time needed to cut this
groove pays dividends throughout
the procedure, especially during
negotiation when lubricant is filling
the access cavity.

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I 27

[28] =>

I case report_endodontic zone

Fig. 9

Fig. 10

Fig. 9_Rotary GTX File with variablewidth lands — thinner at the tip and
shank, thicker in its middle region.
This geometry optimizes the radial
lands to cut much more efficiently
than rotary files with consistentwidth lands, while maintaining
identical fidelity to canal curvatures.
Fig. 10_Paper point used to dry the
palatal canal, showing blood mark
only on its middle region.

28 I roots
2_ 2012

rent apex locators work in the presence of conductive
fluids, none of them work as well as when relatively
non-conductive lubricants are used instead. NaOCl
short-circuits the apex locator to metallic restorations and even without metal nearby, the readings
in the presence of this irrigant are much less stable.
A note of caution: while non-landed shaping instruments are safe in the smallest sizes, I would not
recommend using them for shaping canals. To prevent apical damage, I use only radial-landed rotary
files (Fig. 9) to cut final shapes after initial negotiation. Final shapes were cut in the palatal canal with
a single 30/.08 GTX File, with a 20/.06 and a 30/.06
GTX File in the DB canal, and three instruments in
the apically curved MB canals. I cut a crown-down
shape in these canals with first a 20/.06 and then a
20/.04 GTX File.
After confirming that there was apical continuity
of taper in each canal, by using NiTi K-files as radial
feeler gauges — this is done in the presence of 17
percent EDTA (to remove the smear layer) — my efforts turned to cleaning the root-canal system with
pre-heated 6 percent NaOCl. I began by ultrasonically vibrating the irrigant with a #10 K-file taken 1
mm beyond the terminus — this prevents the microledging that occurs when the vibrated file tip is held
inside the apical third — for a couple of minutes in
each canal, and then switched to active irrigation
with the negative pressure EndoVac System (Discus
Dental).
Despite heating the solution, using ultrasonication and a state-of-the-art delivery method, in an
inflamed vital case like this I still feel that the NaOCl
needs additional time to digest any tissue that may
remain in lateral and accessory canals. Failure to
clean the lateral aspects of root-canal systems containing severely inflamed pulp remnants adequately
is what causes some of these patients to complain
of persistent pain to biting and percussion despite
apparently ideal root-canal treatment results evidencing no peri-radicular pathosis.

Obturation was accomplished after cleaning
with the System B/Elements Obturation Unit (SybronEndo) using the Continuous Wave of Obturation
Technique. Interestingly, when I was drying the
palatal canal in preparation for cementing the prefit master cone of gutta-percha, the paper points
were coming out soaked in blood. While this may be
disconcerting to clinicians, it does not mean anything has necessarily gone awry, it just means that
the bleeding must be stopped.
I soaked a paper point in 30 percent ferric
sulphate (known by the brand name Cutrol or the
pharmaceutical name Monsel’s Solution), placed
it to the end of the canal and a bit beyond, and
after 10 or 15 seconds removed it, irrigated with
NaOCl, gained patency with a K-file that could
be passively placed beyond the terminus, and
resumed drying the canal. Sometimes this must
be done two or three times to staunch bleeding,
but I have never seen it fail. In this case, while the
paper point stopped absorbing blood at its tip, it
continued to show a spot of blood in the middle
of the cone (Fig. 10). The post-operative X-ray images revealed a lateral canal filled in the middle of
the palatal canal (Figs. 11, 12).
A piece of sponge and Cavit (3M ESPE) were
placed in the access cavity and the patient was
dismissed after post-operative images had been
taken and instructions given. As usual, the
patient also received enough Aleve to last four
days at two tablets BID and instructions about
managing her pain of myofascial origin (finally
located as emanating from her left sternocleidomastoid muscle).
A phone call four days later confirmed that she
had no spontaneous pain referral, just the expected
soreness to biting pressure.
So, looking back at this case, why the misdirection
and wrong turns?
Firstly, my initial hypothesis about the etiology of
her chief complaint was misdirected by the lack of

[29] =>

[30] =>

I case report_endodontic zone

Fig. 11

Fig. 12

Fig. 11_Post-op radiograph,
revealing — to a limited degree —
the multiplanar curvature of the DB
canal and the apparently straight MB
canal form. Note the conservative,
mesially angulated access cavity
preparation and the filling material
in the distal pulp horn, which was
intentionally left unroofed to preserve
coronal tooth structure.
Fig. 12_Shallow, distally angulated
post-op radiograph, revealing the
severe apical curvature of the MB
canal system and the mid-root
lateral canal in the palatal canal that
spotted the middle of the paper point
in Figure 10 with blood.

30 I roots
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thermal sensitivity and by the pain she described in
her neck region. Ironically, the patient did not relate
thermal sensitivity because she does not care for
really hot or cold foods or beverages and therefore
had not thermally challenged tooth #14. As to the
muscle tenderness outside the EZ, when I heard her
describe this referral of pain below her mandible, I
assumed she also had trigger-point myopathy in her
masseter and temporalis muscles, the muscles that
commonly refer pain into the EZ.
Regarding the first endodontist needlessly treating tooth #19 and failing to resolve the original etiology of the patient’s pain syndrome, it is a profound
truth that endodontic disease becomes less obscure
and easier to diagnose with time. Therefore, being
the second one in on the case undoubtedly was an
advantage at some level. With that said, a pulpal
status like this one (partial necrosis) will return a
WNL cold test response, albeit a delayed and vague
one, virtually every time.
Interpreting sharp but transient responses to
cold testing as indicative of irreversible pulpitis
is a very common mistake. Until sharp, prolonged
responses are seen — ideally with identical reproduction of the patient’s pain — clinicians must
obtain further pulp testing results outside of normal limits before they start diving into pulp chambers. In this case, every tooth — except #19 (no
response) and 14 (delayed, vague) — responded
in a very sharp but transient manner. I had no
doubt that #19 responded the same way before
it was treated, as evidenced by the endodontist’s
secondary treatment plan of accessing #20, a
perfectly healthy tooth.
Partially necrotic pulp is nearly impossible to
diagnose without using a sustainable source of
heat. Classically, partially necrotic pulp responds
to cold tests WNL, although sometimes cooling the
tooth will alleviate the pain. Unless a heat stimulus

is applied, thereby increasing the pressure inside the
dead space, patients will be left in pain until the remaining pulp dies and clinicians will feel inclined to
cut access cavities until the patient’s pain is relieved.
We can and must do better than diagnosis by
access._
Please visit www.endobuchanan.com for video
clips of this case.
Note: An earlier version of this article appeared
in roots, the international magazine of endodontics,
Vol. 7, No. 2, 2011.

_about the author

roots

L. Stephen Buchanan, DDS,
FICD, FACD, was valedictorian of his class at the
University of the Pacific
School of Dentistry, and he
completed the endodontic
graduate program at Temple
University in Philadelphia in
1980. He began pursuing
3-D anatomy research early
in his career, and in 1986
he became the first person in dentistry to use micro
CT technology to show the intricacies of root structure.
In 1989 he established Dental Education Laboratories, through which he has lectured and conducted
participation courses around the world. Buchanan
holds a number of patents for dental instruments
and techniques, including variably tapered shaping
instruments for use in endodontics. He pioneered a
system-based approach to treating root canals. He is
a diplomate of the American Board of Endodontics.
He maintains a private practice limited to endodontics
and implant surgery in Santa Barbara, Calif. Contact
him at 1515 State St., Suite 16, Santa Barbara, Calif.
93101, (800) 528-1590 or (805) 899-4529, info@
endobuchanan.com, www.endobuchanan.com.

[31] =>

meetings_AAE

‘History & Heritage —
Forging the Future’
AAE holds its annual session in Boston

Fig. 1

Author_Fred Michmershuizen, Managing Editor
_The American Association of Endodontists
held its 2012 Annual Session April 18-21 at the
Hynes Convention Center in Boston. The meeting
offered endodontists, general dentists and other
specialists the opportunity to participate in a
large selection of endodontic courses as well as
learn about the rich history of the specialty in the
United States.
During the four-day event, meeting attendees
could receive continuing education credit from eight
different educational tracks, three of which were
new this year: Exploring the Future, Evidence BasedEndodontics and Orofacial Pain, Oral Pathology and
Trauma. The sessions were offered in a variety of
learning formats.
The popular Master Clinician Series showcased
live, state-of-the-art surgeries, including implant
placement, regenerative endodontic therapy, molar
endodontic microsurgery, the use of cone beam
computed tomography and more.
This year’s master clinicians included Dr. Paul D.
Eleazer, Dr. Shepard S. Goldstein, Dr. Mani Moulaza-

deh, Dr. Richard A. Rubinstein, Dr. Wyatt D. Simons
and Dr. John D. West.
On the exhibit hall floor, companies showcased
their products and services.
Roydent Dental Products offered its popular
C-Files in new sizes — 12.5, 15 and assorted packs
06-10, all in 21 mm and 25 mm lengths. The new 12.5
is an exclusive size to Roydent and allows doctors
to make a half step when instrumentating between
sizes 10 and 15.
Nancy Connor, Roydent’s sales and marketing manager, said the C-Files provide an ideal and
extremely effective way to instrument calcified
canals. They are also ideal for locating canals and
instrumenting narrow canals. Their non-cutting tip
allows doctors to break through calcification safely
and efficiently.
SS White, which had an expanded booth presence
this year, introduced a full line of endodontic products
driven around the company’s passion for conservation
and efficiency. The offerings included the redevelopment
of the V Taper file and many other instruments.

Fig. 1_Dr. Richard A. Rubinstein
performs atypical molar
microsurgery during a theaterin-the-round educational
presentation at the 2012 AAE Annual
Session in Boston. (Photos/Fred
Michmershuizen)

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I 31

[32] =>

I meetings_AAE

Fig. 2

Fig. 3

Fig. 2_Dane Carlson of Seiler
Precision Microscopes
Fig. 3_Companies offer
their products and services in
the exhibit hall.

32 I roots
2_ 2012

“The V Taper really is unique because it has a patented variable taper that at the top of the file is much
more conservative and allows for the preservation
of cervical dentin to a higher degree than any other
file system on the market,” said Tom Gallop, CEO of
SS White. “As we are starting to learn, and as the
endodontic and restorative community is starting to
see, the value of that cervical dentin in terms of the
long life creation of successful restorations is a vital

element, so we feel that with that patented feature in
V Taper files and a lot of the research pointing to the
need to preserve that cervical dentin as much as possible that we are on the path to creating longer lasting
endodontic procedures and restorative procedures.”
Other product highlights included the introduction of SafeSiders instruments from EDS in a new
31 mm size; a new, high-density foam for cleaning
instruments, available from Jordco; new X-treme

[33] =>

meetings_AAE

Fig. 4

endodontic instruments from JS Dental Mfg.; a new
Marwan Abou-Rass (MAR) microsurgical endodontic
instrument line from Hu-Friedy; the Impact Air 45
high-speed, air-powered handpiece from Palisades
Dental; and the introduction of a new Plasma light
source for Seiler microscopes.
The AAE recognized six individuals with the organization’s highest honors and awards.
Dr. Jerome V. Pisano received the AAE’s highest
honor, the Edgar D. Coolidge Award, given for leadership and exemplary dedication to dentistry and endodontics. Dr. Ronald I. Deblinger received the Presi-

Fig. 5

dent’s Award, which has been bestowed only eight
times in the award’s history. Dr. Ove A. Peters received
the Louis I. Grossman Award. Dr. Richard E. Walton
received the I. B. Bender Lifetime Educator Award. Dr.
George A. Bruder III was honored with the Edward M.
Osetek Educator Award. Dr. John W. Gillan received
the Spirit of Service Lifetime Award for his impact on
dental communities in Third World countries.
The theme of the 2012 meeting was “History
& Heritage — Forging the Future.” Next year’s AAE
Annual Session is scheduled for April 17–20 in
Honolulu._

I

Fig. 6
Fig. 4_Brant Miles of SS White
Fig. 5_James Johnsen of Jordco
Fig. 6_Meeting attendees take part
in a lecture.

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I 33

[34] =>

I interview_Tom Gallop

The collaboration between
endodontists and restorative
doctors to preserve dentin …
What’s next?
Author_Fred Michmershuizen, Managing Editor
_In an interview conducted at the recent
American Association of Endodontists Annual
Session in Boston, Tom Gallop, CEO of SS White,
discussed the collaboration between endodontists
and restorative dentists to preserve dentin and therefore improve outcomes for patients.

Fig. 1_SS White looks to bring greater
collaboration between the endodontic
community and the restorative dental
community, says Tom Gallop, CEO
of SS White. The preservation of
dentin is one element that benefits
clinician and patient alike, and can
be a bridge to connect these two
respected practices. (Photo/Fred
Michmershuizen)

34 I roots
2_ 2012

Fig. 1

Your company is making a big splash here at AAE
with a new, expanded booth and presence. What are
you trying to accomplish?
To me, with a “me-too” idea, you need to play it lowkey to be authentic, but with an ability to execute on a
big idea, having a major presence is more appropriate.

[35] =>

[36] =>

I interview_Tom Gallop
So, what’s the big idea?
Doctors tell us that what we do is help them to
preserve the maximum amount of healthy tissue, in
a very efficient manner that increases the life of the
restoration and allows for more endodontic treatments. Increasing the collaborative effort between
the restorative dentist and the endodontist is one key
byproduct we have seen as a result.
In some ways we have had the endodontist looking at the lower apical third and the keys to achieving
great clinical outcomes there, and the restorative
dentist has been looking at the pericervical dentin
and how can they create a long-life crown. We
worked with each group to look at both facets. That
is the big idea.
What’s new and exciting for endodontists?
SS White has always been known within the
endodontic community for very specific products,
like Great White Burs for faster endodontic access
through metal, Great White Z Diamonds for access
through zirconia and recently EndoGuide Burs for
more precise endodontic access.
This year we are introducing a full line of endodontic products driven around our passion toward
conservation and efficiency. Those products include
the redevelopment of the very popular V-Taper File
System, V-Glide Path File, V-Fill Obturation system
and other unique endodontic instruments that are
all designed to create more conservative and more
efficient endodontic procedures.
What sets the V-Taper file apart from other, similar files?
V-Taper is unique because of the variable taper
design, which allows for the preservation of cervical
dentin to a higher degree than any other file system
on the market. It also allows less instrumentation
than most systems and more efficiency
Most endodontists want an 06 taper down at the
apex to allow them to get better irrigation, better obturation, better three-dimensional fill. But when they
have to negotiate around tight curves, often times
they have to compromise and use an 04 tapered file.
So they are either compromising by not getting the
shape they want at the apex, or they are compromising by having to remove too much structure to get the
06 taper down to the apex. With the unique design
of the V-Taper system, it allows for the endodontist
to have the best of both worlds: get that 06 taper
but with much more ease in negotiating those tight
curved canals, so they can get the best results.
SS White has traditionally been known as a restorative dental company. How does that enhance
your ability to add endodontic instruments to your
offerings?

36 I roots
2_ 2012

SS White is in a unique position in that we are looking at the tooth as a whole. I think that perspective
is different from most other endodontic companies,
who mainly focus on the endodontic side of the procedure and do not take into account the needs of the
restorative dentist.
What about access techniques to preserve more
of the dentin?
SS White originally developed the standard round
carbide bur, which unfortunately has not been the
ideal instrument for use during endodontic access
procedures. When we developed the round bur, it
was intended for use in cutting cavity preparations.
To effectively cut a cavity preparation, you need a bur
that cuts both laterally and vertically. Up until the
launch of the EndoGuide Burs, no other manufacturer listened to the endodontist and general dentist
on their need to design an access-specific bur that
would allow for greater precision in gaining access
to the root canal. Rather, the manufacturer said this
is what we have on the shelf already available for you
to use for your access preparations.
At SS White, we asked clinicians: How can we
design a product specific to procedure challenges
and anatomy? We focused on the conical shape and
small tip diameter as two of the defining features that
create more precise access and control. Doctors tell
us EndoGuide Burs are better than existing products
when they are contending with calcified canals or
troughing. They also indicate that the product helps
them reduce perforations and conserve vital pericervical dentin. EndoGuide Burs were developed with
our team of endodontic and restorative specialists,
which include Dr. David Clark, Dr. John Khademi and
Dr. Eric Herbranson.
EndoGuide is the first truly endodontic-accessspecific-designed product that has been developed
with collaboration and input from the manufacturer,
endodontist and restorative dentist, allowing for a
more precise, efficient and conservative pathway for
gaining proper endodontic access.
The dental market worldwide has given EndoGuide
Burs a very warm welcome. Key opinion leaders and
leading universities in such diverse markets as Mexico,
the Netherlands, Italy, Germany, Russia and India, to
name a few, have implemented the use of EndoGuide
in their teaching, training and other forms of education. The drive and passion that has been put forth
worldwide in creating more conservative endodontic
access has truly been astonishing.
What came next?
The next challenge SS White undertook after the
launch of EndoGuide Burs was that of creating more
refined and conservative root canal shaping procedures. The shaping of the root canal procedure has

[37] =>

interview_Tom Gallop

The SS White sales and marketing
team shows off its new booth during
the recent CDA Presents The Art
and Science of Dentistry meeting
in Aneheim, Calif. (Photo by Robert
Selleck, Dental Tribune)

significant value to the quality of the final restoration.
Research has shown that preserving dentin has a direct
correlation to creating longer lasting restorations. Our
challenge was to develop a system that will shape the
root canal without eliminating key segments of dentin
at the same time, such as the dentin triangle, which is
vital to the strength of the tooth. One school of thought
is that the dentin triangle should be removed to create
proper visibility and to effectively irrigate and obturate
the canal. Following this philosophy causes the removal
of dentin that could strengthen the tooth if left intact.
The system that had the most appeal to us to accomplish our goal of effective shaping, while preserving
dentin when possible, was the V-Taper 2 NiTi File System, which has been redeveloped and relaunched here
at the AAE meeting in Boston.
Can you talk more about how endodontists and
GPs can collaborate to preserve tissue?
The industry has done a remarkable job in the
development of more efficient file systems that allow

for greater numbers of patients to gain treatment.
This has been a step in the right direction. Advances in
diagnostics have also taken a major step forward over
the past 10 years as well. We have seen a rapid adoption of microscopes, cone-beam and digital X-ray. The
combination of increased visibility, better diagnostics
and the preservation of dentin is now in place, with the
goal of creating better patient outcomes. As a result,
the patient benefits from the developmental and collaborative effort with longer life and stronger teeth.
In closing, what would you like to say to both endodontists and restorative dentists?
Thank you for bringing your thoughts and ideas
to us. We will continue to listen and develop more effective instrumentation. With what we have done already, we are confident that both the restorative doctor and the endodontist can achieve faster, stronger
and longer-life restorations. When this happens, we
have seen the relationship and collaborative effort
between GPs and endodontists continue to grow._

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I 37

[38] =>

I industry_COLTENE ENDO

COLTENE ENDO
launches CanalPro
Irrigation System

CanalPro Irrigator
(Photo/Provided by
COLTENE®ENDO)

38 I roots
2_ 2012

_COLTENE®ENDO, the recently formed endodontic business unit of Coltene/Whaledent, is
pleased to announce the launch of its CanalPro™ Endodontic Irrigation Line. The convenient, color-coded
system offers highly efficacious solutions and innovative delivery instruments for root-canal therapy.
COLTENE®ENDO solutions are engineered to optimize
the time spent on irrigation, giving the clinician the best
approach to cleansing canals and the best outcomes.
CanalPro™ EXTRA, used for irrigation and debridement
of root canals, is two times wetter than standard sodium
hypochlorite, enabling it to penetrate into lateral canals
and isthmuses and reach more hard-to-reach surfaces
within the canal. CanalPro NaOCl EXTRA is two times
more digestive than standard sodium hypochlorite,
resulting in faster tissue dissolution.
CanalPro™ EDTA offers the optimal 8.5pH for
smear layer removal, allowing disinfection solutions
to penetrate further and for better adhesion of sealers and obturation materials.
The CanalPro™ Syringe Station is a handy device that
is always ready to fill syringes within seconds. No more
filling a beaker with solutions and leaving them out in
the air, light and heat, then disposing of the excess. The
Syringe Station provides a neat, no drip/no splatter way
to fill the system’s color-coded syringes. When filling
even the messiest solutions, such as sodium hypochlorite, the Syringe Station helps prevent counter, carpet

and scrub damage. The low-level indicator light provides
a visual signal when the bottle should be replaced. The
unit can be wall-mounted, and multiple units can be
joined together with the dovetails on the side to create a
dedicated syringe filling area for all solutions used in the
dental office. Color-coded syringes provide an easy way
to organize and identify syringes for irrigants and solutions, helping to increase safety and minimize the chance
of syringe swap.
A simple, disposable negative pressure simultaneous irrigation and evacuation device, the CanalPro™
Irrigator is designed for easy, one-hand use. The
ratcheting syringe allows for a tactile and audible
signal for every 0.2 ml delivered, and the bellows
design enables adjustment to working length for
controlled apical third placement. The evacuation of
fluid flows from apical to coronal region to virtually
eliminate clogging. The CanalPro™ Irrigator provides
safe, cost-effective apical irrigation and evacuation.
Unsurpassed vision with precise rinsing and drying
is as essential to a successful endodontic procedure as
proper shaping and cleaning. Precise control of air and
water in dental procedures requiring a gentle and effective stream of water or air for superior and efficient
cleaning or drying of any surface or working area is
exactly what the CanalPro™ AirWater Irrigator offers
the clinician. The AirWater Irrigator fits most air/water
syringes and can be used with virtually any luer lock tip.
The CanalPro™ line offers a complete selection
of endodontic irrigation tips. Flexibility and superior
canal tracking are two benefits that the CanalPro™
NiTi Irrigating Tip offers. The 30ga nickel titanium tip
with adjustable needle angle is autoclavable for costeffective repeated use, resulting in a long life cycle
with minimal clogging. CanalPro™ Flex-Tips offer excellent canal tracking in a unique non-kink polyamide
tip. This single-use tip is available in 25ga and 30ga.
Steel irrigating tips are available in 27ga and 30ga in
slotted-end and side-port configurations.
For more information, call Coltène/Whaledent at
(330) 916-8800 or visit coltene.com._

[39] =>

industry_Technology4Medicine

PIPS Laser Endo
harnesses the power
of the Lightwalker
Dual wavelength, all-tissue Er:YAG & Nd:YAG laser cleanses canals
_PIPS™ harnesses the power of the proprietary Lightwalker Er:YAG laser, both exclusively available from Technology4Medicine
(www.T4Med.com), to create photoacoustic
shock waves within the cleaning and debriding
solutions in the canal.
The containment of the shockwaves thoroughly streams these solutions three-dimensionally through the entire canal system,
enhancing their effectiveness. The canals and
subcanals are left clean and the dentinal tubules are free of smear layer.
It is a well-established fact that different dental procedures require different
laser wavelengths. Wavelength is important to clinical outcomes because specific
body tissues interact in different ways
depending on the particular laser source.
The Lightwalker is a true dual wavelength
system.
With the choice of two complementary
wavelengths, LightWalker is the “universal”
laser. Practically all laser-assisted dental
treatments can be performed with either
the most highly absorbed Er:YAG laser
wavelength or the selectively absorbed,
deeper penetrating Nd:YAG laser wavelength.

Fig. 2

There are many advantages to using the
Lightwalker and PIPS™ for endodontic procedures:
• First is the entire root canal and subcanal system is more effectively cleaned
and debrided than with traditional instrument-only techniques, reducing the risk of
re-infection.
• The minimally invasive nature of PIPS™
preserves more tooth endoskeleton than traditional instrument techniques because filing
can be limited to as small as ISO #20, maintaining more postrestoration tooth strength.
• Sub-ablative power levels eliminate the
risks of thermal damage, ledging and demineralization inherent to other laser endodontic
methods.
• Because the PIPS™ tip is inserted only into
the coronal opening and not into the canal,
there is no risk of tip breakage from curved
canals or unwanted apical extrusion of chemical irrigants, as is possible with standard laser
endodontic methods.
• Less filing time and less soaking time
for chemical agents can significantly reduce
treatment time while being more effective.
The SEM images below demonstrate the
effectiveness of PIPS™._

Fig. 3

Fig. 1_ The Lightwalker dual wavelength, all
tissue Er:YAG & Nd:YAG laser. (Photos/Provided
by Technology4Medicine)
Fig. 2_Internal surface after conventional
instrumentation, without PIPS™
Fig. 3_Clean dentin surface achieved with the
PIPS root canal treatment.
Fig. 4_Higher magnification after PIPS. Collagen
fibers are intact, with no thermal damage.
Fig. 5_Clean dentinal tubules
after PIPS

Fig. 1

Fig. 4

Fig. 5

roots
2

_ 2012

I 39

[40] =>

I industry_Seiler

New Plasma light
source from Seiler
Latest advance is designed to offer clearer, crisper images

_Have you seen the light? Seiler’s new Plasma
light source, that is!
It’s even brighter than 180 W Xenon and
three times as bright as an LED, with over
100,000 LUX and it has a bulb life of more than
10,000 hours.
See clearer, crisper images through the use of
live video and/or a digital camera.
The Plasma can be retrofitted to an existing
scope or equipped on any new operating microscope.
Seiler continues to stay at the forefront
of fine optics and stands behind its products
with a lifetime warranty on the optics and
mechanics.
To experience the Seiler advantage, call
(800) 489-2282 to schedule a free demonstration, or visit www.seilermicro.com for more
information._

Fig. 1_Seiler has a new Plasma light source.
(Photos/Provided by Seiler)
Fig. 2_A close-up view.

Fig. 1

40 I roots
2_ 2012

Fig. 2

[41] =>

about the publisher _

I

submissions

formatting requirements
Please note that all the textual elements
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(tables, charts, photographs, etc.) must not
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If you are interested in submitting a C.E.
article, please contact us for additional instructions before you make your submission.
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Article lengths can vary greatly — from a
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you need more or less words to do the topic
justice, then please make the article as long or
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We can run an extra long article in multiple parts, but this is usually discussing a subject matter where each part can stand alone
because it contains so much information. In
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you in terms of article length, so please use
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_Questions? Comments?
Please do not hesitate to contact us for our
International C.E. Magazine Author Kit or if
you have other questions/comments about
the article submission process:
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r.goodman@dental-tribune.com
Roots Managing Editor Fred Michmershuizen
f.michmershuizen@dental-tribune.com
Managing Editor Sierra Rendon
s.rendon@dental-tribune.com

		

roots
I 41
2
_ 2012

[42] =>

I about the publisher _ imprint

roots

the international C.E. magazine of endodontics
U.S. Headquarters
Dental Tribune America
116 West 23rd Street, Ste. 500
New York, NY 10011
Tel.: (212) 244-7181
Fax: (212) 244-7185
feedback@dental-tribune.com
www.dental-tribune.com

Managing Editor
Fred Michmershuizen
f.michmershuizen@dentaltribune.com
Managing Editor
Sierra Rendon
s.rendon@dental-tribune.com

List Manager
Robert Spencer
database@dental-tribune.com
Product/Account Manager
Humberto Estrada
h.estrada@dental-tribune.com

Publisher
Torsten R. Oemus
t.oemus@dental-tribune.com

Designer
Kristine Colker
k.colker@dental-tribune.com

Product/Account Manager
Mara Zimmerman
m.zimmerman@dentaltribune.com

Chief Operating Officer
Eric Seid
e.seid@dental-tribune.com

C.E. Director
Christiane Ferret
c.ferret@dtstudyclub.com

Product/Account Manager
Will Kenyon
w.kenyon@dental-tribune.com

Product/Account Manager
Marketing Manager
Group Editor
& Interactive
Anna Wlodarczyk-Kataoka
Robin Goodman
r.goodman@dental-tribune.com a.wlodarczyk@dental-tribune.com Gina Davison
g.davison@dental-tribune.com
Marketing Assistant
Editor in Chief
International Account
Lorrie Young
Fred Weinstein,
Manager
l.young@dental-tribune.com
DMD, MRCD(C), FICD, FACD
Jan Agostaro
f.weinstein@dental-tribune.com
j.agostaro@dental-tribune.
Accounting
com
Melissa Chan
m.chan@dental-tribune.com

Editorial Board

Marcia Martins Marques, Leonardo
Silberman, Emina Ibrahimi, Igor Cernavin,
Daniel Heysselaer, Roeland de Moor, Julia
Kamenova, T. Dostalova, Christliebe Pasini,
Peter Steen Hansen, Aisha Sultan, Ahmed
A Hassan, Marita Luomanen, Patrick Maher,
Marie France Bertrand, Frederic Gaultier,
Antonis Kallis, Dimitris Strakas, Kenneth Luk,
Mukul Jain, Reza Fekrazad, Sharonit
Sahar-Helft, Lajos Gaspar, Paolo Vescovi,
Marina Vitale, Carlo Fornaini, Kenji Yoshida,
Hideaki Suda, Ki-Suk Kim, Liang Ling Seow,
Shaymant Singh Makhan, Enrique Trevino,
Ahmed Kabir, Blanca de Grande, José Correia
de Campos, Carmen Todea, Saleh Ghabban
Stephen Hsu, Antoni Espana Tost, Josep
Arnabat, Ahmed Abdullah, Boris Gaspirc,
Peter Fahlstedt, Claes Larsson, Michel Vock,
Hsin-Cheng Liu, Sajee Sattayut, Ferda Tasar,
Sevil Gurgan, Cem Sener, Christopher Mercer,
Valentin Preve, Ali Obeidi, Anna-Maria
Yannikou, Suchetan Pradhan, Ryan Seto, Joyce
Fong, Ingmar Ingenegeren, Peter Kleemann,
Iris Brader, Masoud Mojahedi, Gerd Volland,
Gabriele Schindler, Ralf Borchers, Stefan
Grümer, Joachim Schiffer, Detlef Klotz,
Herbert Deppe, Friedrich Lampert, Jörg
Meister, Rene Franzen, Andreas Braun, Sabine
Sennhenn-Kirchner, Siegfried Jänicke, Olaf
Oberhofer and Thorsten Kleinert

Dental Tribune America is the official media partner of:

roots_Copyright Regulations
_the international C.E. magazine of roots published by Dental Tribune America is printed quarterly. The magazine’s articles and illustrations are protected by copyright. Reprints of any kind, including digital mediums, without the prior consent of the publisher are inadmissible
and liable to prosecution. This also applies to duplicate copies, translations, microfilms and storage and processing in electronic systems.
Reproductions, including excerpts, may only be made with the permission of the publisher.
All submissions to the editorial department are understood to be the original work of the author, meaning that he or she is the sole copyright
holder and no other individual(s) or publisher(s) holds the copyright to the material. The editorial department reserves the right to review all
editorial submissions for factual errors and to make amendments if necessary.
Dental Tribune America does not accept the submission of unsolicited books and manuscripts in printed or electronic form and such items
will be disposed of unread should they be received.
Dental Tribune strives to maintain the utmost accuracy in its clinical articles. If you find a factual error or content that requires clarification, please contact Group Editor Robin Goodman at r.goodman@dental-tribune.com. Opinions expressed by authors are their own and
may not reflect those of Dental Tribune America and its employees.
Dental Tribune 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.
The responsibility for advertisements and other specially labeled items shall not be borne by the editorial department. Likewise, no responsibility shall be assumed for information published about associations, companies and commercial markets. All cases of consequential liability
arising from inaccurate or faulty representation are excluded. General terms and conditions apply, and the legal venue is New York, New York.

42 I roots
2_ 2012

[43] =>

[44] =>

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[cover] => roots C.E. No. 2, 2012

[toc] => Array ( [0] => Array ( [title] => Cover [page] => 01 ) [1] => Array ( [title] => Editorial [page] => 03 ) [2] => Array ( [title] => Content [page] => 04 ) [3] => Array ( [title] => Predictable apical microsurgery (Part II) [page] => 08 ) [4] => Array ( [title] => A logical basis to judge endodontic innovations [page] => 18 ) [5] => Array ( [title] => A case of diagnosis by access [page] => 24 ) [6] => Array ( [title] => ‘History & Heritage — Forging the Future’ AAE holds its annual session in Boston [page] => 31 ) [7] => Array ( [title] => The collaboration between endodontists and restorative doctors to preserve dentin … What’s next? [page] => 34 ) [8] => Array ( [title] => COLTENE ENDO launches CanalPro Irrigation System [page] => 38 ) [9] => Array ( [title] => PIPS Laser Endo harnesses the power of the Lightwalker [page] => 39 ) [10] => Array ( [title] => New Plasma light source from Seiler [page] => 40 ) [11] => Array ( [title] => Submissions [page] => 41 ) [12] => Array ( [title] => Imprint [page] => 42 ) ) [toc_html] =>

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