roots international No. 1, 2022

Cover / Editorial / Content / ROOTS SUMMIT special / Automatic assistance: Freedom to navigate root canals / Digital technology in endodontics - Use of dynamic navigation to access and shape canals in teeth with pulp canal obliteration after trauma / Root canal therapy of necrotic primary molars—using a single-file reciprocating system / High-end technology for simplicity / The golden era of root canal shaping / Laser protocol for peri-implantitis treatment - An interview with Dr Michał Nawrocki / “The correct choice of an animal model is vital” - An interview with Dr Alexis Gaudin / The key role of vitamin D in immune health and regeneration - The evidence for supplementation / US-based Seiler Instrument came from humble origins / Meetings / Submission guidelines / Imprint

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Table of contents

issn 2193-4673 • Vol. 18 • Issue 1/2022

roots

international magazine of endodontics

including

special

interview

ROOTS SUMMIT “is not to be missed”

case report

Automatic assistance:
Freedom to navigate root canals

technique

High-end technology
for simplicity

1/22

[2] =>

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[3] =>

editorial

Steve Jones
Co-chairman
ROOTS SUMMIT

ROOTS SUMMIT 2020 2021 2022!
“Third time’s the charm” is our rallying cry as we
close in on this year’s ROOTS SUMMIT. When the world
entered a pandemic two months before the originally
scheduled dates, we thought we would reschedule the
event for a couple of months later. Who knew it would
be a couple of years?
After this extremely stressful, upsetting and isolating
time for all, many of our participants are suddenly affected by war on their border. Let’s hope that the madness of this war in Ukraine will soon end. During this
heartless and brutal time, it is more important than ever
that we get together as friends, learning and improving
our skills together.
The ROOTS Facebook group of around 30,000 members and ROOTS SUMMIT represent the camaraderie,
fellowship and mutual interest endodontists around the
world share. We do it every day online, but the strength
of our online community over the last 20 or so years
has been greatly enhanced by meeting on a semi-annual
basis. Those who were in Berlin in Germany in 2018 had
the experience of sharing their passion and profession
with friends from around the planet, and many signed up
immediately for the next ROOTS SUMMIT. At last count,
we had people coming to join us from over 30 countries.

To appreciate the global appeal of ROOTS SUMMIT,
you need look no further than our speakers list, which
includes dentists from the Czech Republic, Egypt, France,
Guatemala, India, Israel, Italy, Lebanon, Portugal, Romania,
Spain, Switzerland, Syria and the US.
We are extremely appreciative of the fact that all our
lecturers have stuck with us, as have the 40 sponsoring
companies and a couple of hundred participants. The
sponsors should be especially thanked, as they come to
ROOTS SUMMIT because that is where research findings are translated into clinical practice better than any
other meeting. They do not come to ROOTS SUMMIT
because they have purchased a spot on the podium.
They come because of the quality of the speakers and
the enthusiasm and passion the participants have for
endodontics! We all thank them for this open and ethical
approach.
We are accepting registrations up to and including
26–29 May, and we hope that you will consider joining
us in the beautiful city of Prague in the Czech Republic
for the best and most inclusive meeting in endodontics.
Steve Jones
Co-chairman of ROOTS SUMMIT

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| content
editorial
ROOTS SUMMIT 2020 2021 2022!

03

Steve Jones

ROOTS SUMMIT special
ROOTS SUMMIT “is not to be missed”

06

An interview with Dr Gianluca Plotino
page 08

ROOTS SUMMIT 2022—
“I can’t wait to experience the best endo meeting again”

07

An interview with Dr Jenner Argueta

ROOTS SUMMIT means “practical lectures,
enough time for the topics, no need to skip anything”

08

Lecture programme, abstracts and speaker information

10

An interview with Dr Daniel Černý

case report
Automatic assistance: Freedom to navigate root canals
page 24

20

Prof. Eugenio Pedullà

Digital technology in endodontics

24

Dr Bartlomiej Karaś

Root canal therapy of necrotic primary molars—
using a single-file reciprocating system

30

Drs Benjamín Rodríguez & Jenner Argueta

technique
High-end technology for simplicity

36

Adj Prof. Philippe Sleiman
page 30

The golden era of root canal shaping

38

Dr Ahmed Shawky

interview
Laser protocol for peri-implantitis treatment

42

An interview with Dr Michał Nawrocki

“The correct choice of an animal model is vital”

46

An interview with Dr Alexis Gaudin
Cover image courtesy of
FKG (www.fkg.ch).
1/22

issn 2193-4673 • Vol. 18 • Issue 1/2022

roots

international magazine of endodontics

including

research
The key role of vitamin D in immune health and regeneration

48

Prof. Shahram Ghanaati, Dr Karl Ulrich Volz & Dr Sarah Al-Maawi

manufacturer news

54

meetings

special

International events

56

about the publisher

interview

ROOTS SUMMIT “is not to be missed”

case report

Automatic assistance:
Freedom to navigate root canals

submission guidelines

57

international imprint

58

technique

High-end technology
for simplicity

04

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[5] =>

LITY

SW I S

S Q UA

FKG
RECIPROCATION

THE SAFES
SAF ST.
T
SIMPLY.

*

Smooth to use, minimally invasive.
Why choose anything else?

Come to visit us at our booth FW09
*Based on cyclic fatigue internal tests, compared with equivalent competitors' instruments.

[6] =>

| ROOTS SUMMIT special

ROOTS SUMMIT “is not to be missed”
An interview with Dr Gianluca Plotino
By Franziska Beier, Dental Tribune International

For your hands-on course, which will focus on how
to use different files for root canal anatomy, you
encourage participants to bring well-preserved extracted teeth to practise on. What instruments and
clinical techniques will participants get to know
during your workshop?
During my workshop, the clinical procedures for
treating root canals having various difficulties will be
explained and demonstrated on resin teeth in order
to show the standard clinical techniques and the use
of various instruments. I encourage all participants to
bring natural teeth because trying the instruments on
extracted teeth that have open access cavities will
give them a better overview of the performance of the
tools. I will show them how to integrate the reciprocating instruments R-PILOT (VDW) and RECIPROC blue
(VDW) and the VDW.ROTATE rotary files into their
practices.

PRAGUE
26–29 May 2022

4

DAYS OF ENDODONTICS

12

14

Could you briefly summarise your lecture on minimally invasive approaches in endodontic procedures
and tell us what the take-home message for attendees will be?
Following the trend of minimally invasive dentistry, the
concept of minimally invasive endodontics emerged.
However, I prefer to call it anatomically invasive
endodontics as all endodontic procedures must be
guided by the original root canal anatomy. In my
lecture, I will describe how to find a good balance
between maximising the preservation of the tooth
structure and keeping endodontic procedures safe and
efficient.

LECTURES

HANDS-ON-COURSES

register at www.roots-summit.com

Dr Gianluca Plotino

ROOTS SUMMIT, one of the most exciting endodontic
events of this year, will kick off in May in Prague in the
Czech Republic. One of the speakers will be Dr Gianluca
Plotino, who will contribute to the rich programme with
a hands-on course and a lecture. In this interview,
Dr Plotino, who maintains a private practice specialising
in endodontics and restorative dentistry in Rome in Italy,
gives a preview of his congress topics and explains
why endodontists should attend the event.
Dr Plotino, you will be very busy at this year’s ROOTS
SUMMIT, as you will present two different topics.
What do you find most rewarding about teaching?
I love it when people thank me and tell me that my suggestions, tips and tricks have changed their professional
lives! That is a priceless experience!

What are you personally looking forward to at the
upcoming ROOTS SUMMIT?
All lectures given by my colleagues and friends deserve
to be followed with the utmost attention, and I will be
there to learn. In addition, I will be happy to see so many
friends in person after such a long time!
Can you name three reasons why everyone interested and involved in endodontics should come to
the event?
It’s one of the most important endodontic events of the
year, one of the first to take place as an in-person event
after a long time, and it has a great scientific, cultural and
social offering. It is not to be missed!

Tribune Group GmbH is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or
endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Tribune Group GmbH designates this activity for 18.5 continuing education credits. This continuing education activity has been planned
and implemented in accordance with the standards of the ADA Continuing Education Recognition Program (ADA CERP) through joint efforts between Tribune Group GmbH and Dental Tribune International GmbH.

06

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ROOTS SUMMIT special

ROOTS SUMMIT 2022—
“I can’t wait to experience the
best endo meeting again”
An interview with Dr Jenner Argueta
By Franziska Beier, Dental Tribune International

Dr Jenner Argueta from Guatemala is a speaker at
ROOTS SUMMIT, which is hold from 26 to 29 May in
Prague in the Czech Republic. During his hands-on
course, the expert, who runs a practice that focuses
on micro-endodontics and micro-restorative dentistry,
will show attendees how to handle complex clinical
scenarios with the help of 3D magnification. Prior to the
event, Dr Argueta shared how this technology can benefit dental professionals and what he is most looking
forward to at the event.

PRAGUE
26–29 May 2022

Dr Argueta, what skills will participants learn in your
hands-on course and how are these going to benefit
them in treating patients?
As clinicians, we face complex clinical scenarios in everyday practice, such as root canals with ledges, radicular
resorptions, perforations and areas having difficult access
during surgery. The objective of my workshop is to show
attendees how to handle this type of situation in the most
comfortable and predictable manner by using novel materials, state-of-the-art equipment and 3D magnification.

DAYS OF ENDODONTICS

LECTURES

During your hands-on course participants will experience how to work with 3D magnification. What
are some of the advantages for dental professionals
of using such technology?
Having the possibility of moving the optical pod of the
3D microscope to any angle in order to focus on any area
of the oral cavity while maintaining the correct ergonomic
posture is a priceless advantage of 3D microscopic technology. This advantage is enhanced by high-definition
3D imaging with outstanding depth of field, which is
transmitted to a monitor that is perfectly positioned in
front of the clinician. These advantages make the clinical
workflow easier, more predictable and more enjoyable.

Is your course open to experienced endodontists
as well as to dental students?
Certainly! The goal is to show simplified techniques for
solving complex clinical situations, and these simplified
techniques will be applicable for both dental students

Dr Jenner Argueta

and trained endodontists. However, experienced endodontists will experience at first hand how 3D technology
can contribute to their clinical practice.
You have attended previous editions of the endodontic meeting. Looking back now, how would you
sum up these events and how excited are you that you
will be back at ROOTS SUMMIT in Prague soon?
I attended ROOTS SUMMIT 2016 in Dubai in the UAE
and ROOTS SUMMIT 2018 in Berlin in Germany. Both
were high quality events in terms of organisation, science,
lectures, camaraderie and friendship. I can’t wait to experience the best endo meeting again. It is time to get
the ROOTS family reunited in Prague!

Tribune Group GmbH is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or
endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Tribune Group GmbH designates this activity for 18.5 continuing education credits. This continuing education activity has been planned
and implemented in accordance with the standards of the ADA Continuing Education Recognition Program (ADA CERP) through joint efforts between Tribune Group GmbH and Dental Tribune International GmbH.

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[8] =>

| ROOTS SUMMIT special

ROOTS SUMMIT means “practical
lectures, enough time for the
topics, no need to skip anything”
An interview with Dr Daniel Černý
By Franziska Beier, Dental Tribune International

PRAGUE
26–29 May 2022

DAYS OF ENDODONTICS

LECTURES

HANDS-ON-COURSES

Dr Daniel Černý

Dr Daniel Černý, who has been the president of the Czech
Endodontic Society since 2015, is one of many renowned and
enthusiastic speakers at this year’s ROOTS SUMMIT. Ahead
of the event, Dental Tribune International spoke with Dr Černý
about what visitors can expect from the city of Prague and
from his lecture topic and asked him how he applies the
things he has learned at ROOTS SUMMIT in his daily practice.

But if you want to delve a little deeper, I recommend visiting
Prague Botanical Gardens on an early morning in May. From
there, you can climb up to the historic Vyšehrad Fortress to
sense a bit of early Prague history and enjoy the great views.
Afterwards you can casually stroll through the winding
streets of the Praha 1 district with its small shops, restaurants and cultural institutions.

Dr Černý, this year’s ROOTS SUMMIT will take place in your
home country. Can you tell us a bit about the event venue
and also about Prague itself? What are three city highlights
which international participants should not miss?
I am excited about ROOTS SUMMIT coming to Prague.
There are those highlights you can find in every guide, such
as Charles Bridge, the astronomical clock in Old Town
Square or Prague Castle, and they are certainly worth a visit.

The congress venue is quite new and technologically advanced, and I believe the ROOTS community will enjoy it
as much as I did last year when the annual meeting of the
Czech Endodontic Society was held there.
Together with Dr Radek Mounajjed, you will hold a lecture
on the advanced adhesive endodontic/restorative concept.
What can attendees expect to take away from it?

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[9] =>

ROOTS SUMMIT special

The concept is something we have been developing and practising for the last 16 years. Its main message is that you can
restore endodontically treated teeth with a high degree of predictability. It may not be simple or foolproof but following the
correct steps will take you safely to the desired result while
maintaining teeth with large structural damage. In this concept,
we combine knowledge from modern biology of endodontics,
adhesion to hard tissue, material science, biomechanics and
occlusion. We want to present the key ideas that define this
approach: reasonable structural savings, replacing the structure with similar material, adhesion and the fail-safe principle.
What are some of the highlights of this year’s ROOTS
SUMMIT that you are personally looking forward to?
I can imagine that the social events in Prague might be quite
epic. The scientific programme of the congress is classic
ROOTS SUMMIT: practical lectures, enough time for the topics, no need to skip anything. I am interested in Dr Catherine
Ricci’s lecture on large lesions and Dr Hugo Sousa Dias’s
lecture on the management of pulp canal obliteration. I also
want to learn more on bioceramics from Dr Meetu Ralli Kohli
and, of course, it is always nice to hear new thoughts from
Dr Stephen Buchanan.

Relatively easily. It is not that difficult since we all share
similar ideas, and my knowledge gain is often in the clinical
applications and from the tips on how to integrate new
ideas into the current knowledge. If I don’t apply what
I have learned directly, then at least I have understood
it and can subconsciously integrate it into my approach.
And for this reason, I think meetings like ROOTS SUMMIT
are better than hasty depersonalised scientific meetings
or just reading. We are social beings; we like to see and
hear one another.
This will be your second time at ROOTS SUMMIT. What
would you like to tell all the endodontists around the
world who have not booked their ticket yet? Why should
they attend this year’s edition?
I would give them three different reasons for booking their
ticket. Firstly, because of the ROOTS SUMMIT programme
and clinical approach as I described earlier. Secondly, because of the city of Prague in spring—beautiful, blossoming,
welcoming and friendly. And finally, because of the opportunity to meet old friends after having been locked up for
two years!

PRAGUE
26–29 May 2022

How do you translate the things that you pick up at
ROOTS Summit into your daily practice?

DAYS OF ENDODONTICS

With four years since the last event in Berlin, this has been
the longest break in ROOTS SUMMIT history. I think we
should all make the most of it right now. Carpe diem!

LECTURES

HANDS-ON-COURSES

[10] =>

| ROOTS SUMMIT special

Lecture programme
ROOTS SUMMIT 2022

Day 1: Thursday, 26 May 2022

Day 3: Saturday, 28 May 2022

8:30–16:30 The first day is designated
for hands-on coursework

8:30–10:00 Root to crown: Advanced adhesive
endodontic/restorative concept
Drs Daniel Černý & Radek Mounajjed

Day 2: Friday, 27 May 2022

13:30–15:00 Evidence-based treatment choices
in modern endodontic treatment
Dr Igor Tsesis

8:30–10:00 Digital planning in intentional
replantation and auto-transplantation
Dr Francesc Abella
10:45–12:30 Large lesions:
Endodontic or surgical treatment
Dr Catherine Ricci
13:30–15:00 Bioceramics in endodontics
Dr Meetu Ralli Kohli
15:45–17:15 Endodontic microsurgery:
Management of complex cases
Dr Jaime Silberman

15:30–17:00 Endodontic algorithms
in decision-making and clinical workflow
Dr Roberto Cristian Cristescu
17:15–18:45 Two-dimensional vs 3D endodontics
Prof. Gianluca Gambarini

Day 4: Sunday, 29 May 2022
8:30–10:00 Minimally invasive approaches
in endodontic procedures
Dr Gianluca Plotino
10:45–12:30 Irrigation and disinfection
of the root canal
Prof. Matthias Zehnder

Please visit www.roots-summit.com for the ROOTS SUMMIT 2022 programme.

10

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Prague © DaLiu/Shutterstock.com

13:30–15:30 The art of endodontics in the age of MIE
Dr Stephen Buchanan

[11] =>

[12] =>

| ROOTS SUMMIT special

Speakers
ROOTS SUMMIT 2022

Dr Francesc Abella
(Spain)
Dr Francesc Abella
graduated in 2005 in
dentistry from the
Universitat Internacional de Catalunya,
Barcelona, Spain. From
2005 to 2014, he completed his master’s degree
and PhD in endodontics at the same university. He
works in a private practice limited to endodontics
and restorative dentistry in Barcelona, and in clinical
endodontics, his areas of special interest include
CBCT in endodontics, microcomputed tomography, dental anatomy, dental traumatology, periapical
pathology, adhesive restoration and restoration of
endodontically treated teeth. Besides his work in
private practice, he is involved in endodontic research projects in the postgraduate endodontic
programme of the Universitat Internacional de
Catalunya.
Over the years, Dr Abella has given several lectures
and hands-on courses worldwide. He is the author
of several papers in peer-reviewed journals and part
of the expert committee convened by the European
Society of Endodontology on the use of CBCT.
Dr Abella is also an active member of the Asocia-

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cion Española de Endodoncia [Spanish association
of endodontics] and the secretary of the Sociedad
Española de Odontología Conservadora y Estética
[Spanish society of conservative and aesthetic
dentistry].

Dr Stephen
Buchanan
(US)
Dr Buchanan received his dental
degree in 1978 from
the University of the
Pacific Arthur A. Dugoni
School of Dentistry in
San Francisco, US. In 1980,
he completed the endodontic graduate programme
at Temple University in Philadelphia, US. He began
pursuing 3D anatomy research early in his career.
In 1989, he established Dental Education Laboratories, a state-of-the-art training facility devoted to
hands-on instruction where he still teaches endodontic treatment, retreatment and segmented file
retrieval. Early in his career, Dr Buchanan identified
the power of video and film media in training and
produced the award-winning video series, The art
of endodontics. Dr Buchanan also holds a number
of patents for dental instruments and techniques.
Most notably, he was the first dentist to introduce

Please visit www.roots-summit.com for the ROOTS SUMMIT 2022 programme.

[13] =>

ROOTS SUMMIT special

Dr Daniel Černý
(Czech Republic)

Dr Daniel Černý received his dental degree from the Charles
University’s Faculty of
Medicine in Hradec
Králové, Czech Republic, in 1998. Between
1998 and 2007, he worked as
an assistant professor at the same faculty. He completed his doctoral degree with a focus on adhesive
post-endodontic treatment at Palacký University
Olomouc in the Czech Republic in 2018 and has
been a part-time faculty member at the university
since 2019. Since 2001, he has maintained a private
practice limited to adhesive dentistry and endodontics in Hradec Králové. Černý has been the President
of the Czech Endodontic Society since 2015. He was
the co-founder and first President of the Česká
akademie dentální estetiky [Czech academy of dental
aesthetics] from 2007 to 2009. From 2009 to 2013,
he served on the editorial board of LKS—Časopis
České stomatologické komory [journal of the Czech
Dental Chamber]. He is also the co-founder of the
Dental Summit congress in Prague, Czech Republic.
He has been the co-owner and director of the HDVI
continuing education institute since 2010. Dr Černý
has contributed four chapters to dental books and
lectures both nationally and internationally.

Dr Roberto Cristian
Cristescu
(Romania)
Dr Roberto Cristian
Cristescu began his
dental education in
1998 in Bucharest,
Romania, where he
studied dental medicine

at the Carol Davila University of Medicine and
Pharmacy. In 2004, he pursued a master’s degree in biomaterials science at the University
POLITEHNICA of Bucharest, from which he graduated in 2006.
Moving on to Amsterdam, Netherlands, from 2008
to 2011, Dr Cristescu took part in an endodontic
postgraduate programme at the Academic Centre
for Dentistry Amsterdam. During his studies and
in between his years of education, Dr Cristescu
was able to attain a great deal of clinical experience while working as a general dentist at the
Dan Theodorescu university hospital in Bucharest
(2004–2005) and two practices limited to endodontics both in his hometown of Bucharest and
his home of choice in Amsterdam.
In addition, he has held teaching positions in the
UK and Portugal and is an active member of
the Nederlandse Vereniging voor Endodontologie,
European Society of Endodontology and American
Association of Endodontists.

Prof. Gianluca
Gambarini
(Italy)
Prof. Gianluca Gambarini is head of endodontics and restorative dentistry at the
Sapienza University of
Rome, Italy, and director
of the dental school’s master
of endodontics programme. He maintains a private
practice limited to endodontics in Rome, where
his focus is on endodontic materials and clinical
endodontics.
As an international lecturer and researcher, Prof.
Gambarini has held more than 500 presentations at
world’s most renowned international congresses
and universities. He has also received several awards
and led research projects funded by national and international grants. In addition to that, Prof. Gambarini
is an active consultant in the development of new
technologies, surgical procedures and materials for
root canal therapy.
Furthermore, he holds patents concerning endodontic technologies he has developed. Currently,
Prof. Gambarini serves as Chairman of the Clinical
Practice Committee of the European Society of
Endodontology.

Please visit www.roots-summit.com for the ROOTS SUMMIT 2022 programme.

Prague © DaLiu/Shutterstock.com

variable-tapered instruments in endodontic therapy
and pioneered a system-based approach to treating
root canals. Dr Buchanan is a diplomate of the
American Board of Endodontics and a fellow of
the International and American College of Dentists.
He currently serves as a clinical guest professor at
the Herman Ostrow School of Dentistry of the University of California and the University of California
Los Angeles School of Dentistry and as a guest
lecturer at Loma Linda University School of Dentistry. He maintains a full-time private practice limited
to endodontics and implantology in Santa Barbara,
California.

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[14] =>

| ROOTS SUMMIT special

Dr Meetu Ralli Kohli
(India/US)
Dr Meetu Ralli Kohli
earned her BDS from
the Government Dental
College and Research
Institute, Bangalore,
India, and pursued her
DMD and specialty training in endodontics at the
University of Pennsylvania, Philadelphia, US. During
the course of her training, she received the esteemed
Louis I. Grossman Award, Samuel R. Rossman
Scholarship and Sherrill Ann Siegel award and
scholarship for demonstrating excellence in patient
care, clinical skills and research. She is Clinical
Associate Professor of Endodontics and the Director
of the Continuing Education and International Programme
at the Department of Endodontics of the University
of Pennsylvania School of Dental Medicine. She
also maintains a part-time private practice limited to
endodontics in Pennsylvania.
Dr Kohli has published in national and international
peer-reviewed journals and has contributed to books
on microsurgical retreatment. Her publications have
been recognised as best clinical research papers by
the Journal of Endodontics. She is on the scientific
advisory board as a reviewer for the Journal of
Endodontics, International Endodontic Journal and
Quintessence International, and is the associate
editor of the Color Atlas of Microsurgery in Endodontics.
Dr Kohli has served on the American Association of
Endodontists Constitution and Bylaws Committee
and currently serves on its Research and Scientific
Affairs Committee. She is a diplomate of the American
Board of Endodontics and an examiner for the Indian
Board of Endodontics.

Dr Radek
Mounajjed
(Czech Republic)
Dr Radek Mounajjed
graduated from the
Damascus University
Faculty of Dentistry,
Syria, in 1994. He then
completed his residency in
general dentistry in 1997 and
in prosthodontics in 2000, respectively. He completed his PhD in 2004 at the Charles University
Faculty of Medicine, Hradec Králové, Czech Republic.
Dr Mounajjed has been working at the multidisci-

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plinary D.C.M clinic in Hradec Králové as a full-time
prosthodontist since 2001, and at Palacký University
Olomouc, Czech Republic, as an external teacher since 2012.
Dr Mounajjed is the author of many publications
and book chapters. He has presented more than
150 talks, both nationally and internationally, and
has been invited to speak at Harvard University
and Mayo Clinic, both US.
On top of that, Dr Mounajjed is the co-founder of
HDVI, an accredited dental continuing education
centre in the Czech Republic. He is also a fellow
of the Academy of Prosthodontics in the US and
International College of Prosthodontists. Outside
of dentistry, he enjoys building and flying radiocontrolled model airplanes.

Dr Gianluca
Plotino
(Italy)
Dr Gianluca Plotino
graduated in dentistry
from the Università
Cattolica del Sacro
Cuore, Rome, Italy, in
2002. He obtained his PhD
there in 2009 and received
certification as first and second level professor in
2018. Dr Plotino works in his own private practice
limited to endodontics and restorative dentistry in Rome.
He has received several international prizes, published
more than 90 articles in scientific peer-reviewed journals on various endodontic and restorative topics, and
contributed numerous chapters to textbooks. Plotino
is an associate editor of the European Endodontic
Journal and the Giornale Italiano di Endodonzia and
serves on the editorial board of several other journals.
He is a certified member of the European Society
of Endodontology, an international member of the
American Association of Endodontists, and an active
member of the Italian Academy of Endodontics and
the Italian Society of Conservative Dentistry.

Dr Catherine Ricci
(France)
Dr Catherine Ricci graduated from the Université Paris Diderot (Paris 7)
in France in 1983. In
the same year, she became a certified member
of the Société Française

Please visit www.roots-summit.com for the ROOTS SUMMIT 2022 programme.

[15] =>

ROOTS SUMMIT special

d’Endodontie [French society of endodontics]. Also, at
Paris 7, she completed her postgraduate studies six
years later while working as an assistant professor from
1986 to 1990. During this period, Dr Ricci decided on
specialising in endodontics only. From 2001 to 2010,
she represented Europe as regent director on the board
for the International Federation of Endodontic Associations World Endodontic Congress. Today, Dr Ricci has
among her achievements authoring work in various
publications, lecturing nationally and internationally,
and co-directing the postgraduate programme at the
Université Nice Sophia Antipolis in France.

Dr Jaime Silberman
(US)
Dr Jaime Silberman is
a graduate of the
Universidad Peruana
Cayetano Heredia,
Lima, Peru, where he
completed his dental
education. He then received an MSc and a certificate in operative dentistry from the University of Iowa,
Iowa City, US. Dr Silberman continued his postdoctoral education at Columbia University in the City of
New York, US, where he received his specialty training certificate in endodontics and his DDS. Before
settling in Palm Beach County, Florida, US, Silberman
served as a full-time assistant professor in the Division
of Endodontics at Columbia University for five years.
Since 1997, he has been working in a private practice
limited to endodontics in the New York/New Jersey
area and later in Florida. Currently, Dr Silberman is
a faculty member of the endodontic postgraduate
programmes at Nova Southeastern University, Davie,
Florida, US, and Columbia University. He has been
invited to give lectures in New York, locally in the
US and internationally in South America. In addition,
Dr Silberman is a board-certified endodontist and
a member of the American Association of Endodontists, American Dental Association and Florida
Dental Association.

Dr Igor Tsesis

graduate endodontic programme at the School of
Dental Medicine of Tel Aviv University in Israel. Currently, he serves as an associate professor and
director of graduate endodontics at this university.
In addition, he is editor of the book Complications in
Endodontic Surgery (Springer, 2014) and co-editor
of the books Vertical Root Fractures in Dentistry
(Springer, 2015) and Evidence-Based Decision
Making in Dentistry (Springer, 2017). Dr Tsesis’ research concerns the diagnosis and treatment of
complications after root canal therapy and endodontic surgery. Most of his research has been published in internationally leading endodontic journals.
Dr Tsesis is a past President of the Israeli Endodontic
Society and a member of the Scientific Council of the
Israeli Dental Association. He also serves on the scientific advisory board of the Journal of Endodontics and is
an editor-in-chief of the Evidence-Based Endodontics.

Prof. Matthias
Zehnder
(Switzerland)
Prof. Matthias Zehnder
graduated from the
University of Bern
School of Dental Medicine in Switzerland in
1994, where he received
his doctoral degree in dentistry in 1996. Subsequently, he worked in private
practice and part time as a postdoctoral research
fellow at the Department of Oral Cell Biology of the
same dental school. Between 1998 and 1999, he
was employed at the Department of Oral Biology and
Periodontology of Boston University Henry M. Goldman School of Dental Medicine, Massachusetts, US.
He then pursued specialist training in endodontics at
Columbia University in the City of New York, US, from
which he graduated in 2001. In addition, Prof. Zehnder
completed his PhD at Turku University in Finland in
2005 and received the title of “docent” from the University of Zurich in Switzerland in 2007. Currently, he
is the tenured Head of the Division of Endodontology
at the Clinic of Preventive Dentistry, Periodontology
and Cariology at the university.

(Israel)
Zehnder’s main research interests are the development
of dental biomaterials, diagnosis of pulpal disease using
molecular markers and improvement of approaches to
disinfection of dental hard tissue. He is a former associate editor of the International Endodontic Journal,
current editor-in-chief of the Swiss Dental Journal, and
on the editorial board of other scientific journals.

Please visit www.roots-summit.com for the ROOTS SUMMIT 2022 programme.

Prague © DaLiu/Shutterstock.com

Dr Igor Tsesis received
his DDM from the
then Moscow Medical
Stomatological Institute in Russia in 1990.
In 2003, he graduated
cum laude from the post-

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[16] =>

| ROOTS SUMMIT special

Lecture abstracts
ROOTS SUMMIT 2022

Day 1: Friday, 27 May 2022
8:30–10:00

Digital planning in intentional replantation
and auto-transplantation
Dr Francesc Abella
In recent years, primary endodontic treatment,
nonsurgical retreatment and microscopical surgery
have achieved success rates of around 90%. However, there are situations in which the tooth cannot
be saved using these techniques. The first part of
this lecture will discuss intentional replantation. This
is an accepted endodontic treatment procedure in
which a tooth is extracted and treated outside the
oral cavity and then reinserted into its socket to correct an obvious radiographic or clinical endodontic
failure. It should not be considered a last-resort
treatment prescribed only for “hopeless” teeth as
proposed by Grossman. Although intentional replantation is not a frequently performed procedure,
it yields a tooth survival rate of 88% according to a
recent meta-analysis. In addition, the new advances
in computer-aided rapid prototyping (CARP) models
(tooth replicas) and 3D-printed guiding templates
allow us to apply this technique in a much more
predictable way.
In situations where the tooth cannot be saved,
there is the option of performing an auto-transplant
(both open and closed apex). The complications
observed in the past can be overcome thanks to
advances in diagnostic and surgical techniques,

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particularly CARP models and 3D-printed guiding
templates. The digital planning not only allows for
selection of the most suitable donor tooth according
to tooth morphology, but also shows the ideal 3D
position and the required dimensions of the alveolus
during surgery. Moreover, the use of tooth replicas
can reduce the additional socket time and possible
donor tooth injury during the procedure. Through
the results of two in vivo investigations, as well as
clinical cases and videos, we will teach the digital
step by step to plan all types of cases.
After this lecture, participants should:
1) know the main indications for intentional replantation, as well as how to digitally plan the whole
process;
2) know the advantages and possible complications
of tooth auto-transplantation; and
3) know the indications for the different types of
auto-transplantation: fresh extraction sockets, early
extraction sockets with soft-tissue healing, early
extraction sockets with partial bone healing, and
surgically created sockets.
10:45–12:30

Large lesions:
Endodontic or surgical treatment
Dr Catherine Ricci
Lesions are the result of the evolution of apical
periodontitis and are due to bacterial proliferation.
Sometimes, root canal disinfection allows, with

Please visit www.roots-summit.com for the ROOTS SUMMIT 2022 programme.

[17] =>

ROOTS SUMMIT special

But could we consider that a simple endodontic
treatment can solve this problem, without any surgery? In fact, faced with this situation, the first step
is a precise diagnosis to determine the origin of the
lesion and ensure that it is a lesion of endodontic
origin, in order to avoid treating endodontically vital
teeth or performing unnecessary surgery. Different
tests will be necessary (vitality tests, CBCT and clinical examination) and the analysis of the results and
their comparison with the patient’s perception will
allow us to make this diagnosis and to determine our
therapeutic choice between an endodontic or surgical treatment or both. Throughout this presentation,
the participants will learn to diagnose and treat large
periapical lesions on the basis of many clinical
cases.
After this lecture, participants should:
1) know how to make a differential diagnosis of large
lesions;
2) know how to choose the right treatment planning;
and
3) know how to decide on the use of bone tissue
regeneration.
13:30–15:00

Bioceramics in endodontics
Dr Meetu Ralli Kohli
The advent of MTA two decades ago brought about
a significant change in the clinical practice of endodontics: a material that suited our workspace and
the periradicular tissue perfectly. It has been extensively investigated in in vitro, animal and clinical
studies. It has been used from the coronal-most
application in the tooth as a pulp capping material
to the apical end as a root end filling material. With
due diligence in the literature, the material has our
academic and investigative endorsement. However,
there are limitations to the use of MTA, for example
the inability to use it for routine obturation, its handling properties and its tendency to cause discoloration. Materials scientists in recent years have
introduced several new and improved versions of
bioceramics to the field. The lecture will provide an

overview of the current research in the literature
on bioceramics. Clinical cases will be presented,
demonstrating application, advantages and disadvantages in various aspects of endodontics.
After this lecture, participants should be:
1) able to understand the concept of bioactivity
especially as an obturation material;
2) aware of key literature on bioceramics pertaining
to use in endodontics; and
3) able to recognise various clinical scenarios where
the material can be used effectively.
15:45–17:15

Endodontic microsurgery:
Management of complex cases
Dr Jaime Silberman
Literature has shown that there is a tendency in the
endodontic community to avoid challenging conditions owing to factors associated with a lack of
surgical training and practice, the perception of the
surgical endodontic procedures by our referrals
and other specialists, and financial aspects. Over
the last 20 years, the practice of endodontic surgery
has changed dramatically. The development of
microsurgical procedures, the capability of diagnosing, treatment planning and assessing our surgical
cases with the use of computed tomography, the
constant development of guided tissue/osseous
regeneration techniques, and the use of 3D-printed
surgical guides have allowed us, as clinicians, to
confront the most challenging cases. The purpose
of this lecture is to provide a clinical discussion
of multiple challenging conditions faced during the
daily practice of surgical endodontics based on
a solid literature review.
After this lecture, participants should be able to:
1) evaluate and discuss the impact of microsurgical
endodontics in challenging cases such as mandibular second molars, anatomically complex
mandibular premolars and palatal roots of maxillary molars;
2) evaluate the significance of CBCT as a tool for
the surgical endodontic management of complex
cases, from diagnosis and treatment planning
to the final outcome; and
3) describe and discuss multiple GTR and GBR
techniques associated with surgical endodontic
complex cases (allografts with membranes, PRF,
Emdogain).

Please visit www.roots-summit.com for the ROOTS SUMMIT 2022 programme.

Prague © DaLiu/Shutterstock.com

endodontic treatment only, healing with a suspension of clinical signs and complete tissue regeneration. However, when a large periapical lesion is
diagnosed radiographically, most of the time, the
first idea is to ask how to eliminate it and then who
can remove it surgically: the general practitioner, the
oral surgeon or possibly the endodontist.

|

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[18] =>

| ROOTS
Xxxxxx SUMMIT special

Day 2: Saturday, 28 May 2022
8:30–10:00

Root to crown: Advanced adhesive
endodontic/restorative concept

Drs Daniel Černý & Radek Mounajjed
Long-term data show that survival of nonvital teeth
has always been a challenge. Both endodontic and
restorative dentistry contribute critically to the treatment outcome. The presented concept of care has
been developed by both endodontists and prosthodontists over 18 years of cooperation. It is based on
four main ideas common to both fields: tissue preservation (unnecessary hard dental tissue loss should
be prevented); replacement with similar materials
(lost tissue should be replaced with material of similar physical properties); adhesion (all components
of reconstruction should adhere to each other)
and safety (when failure occurs, it should not be
catastrophic).
Over the years, the protocol has been extended
from nonvital teeth only to teeth with compromised
integrity and challenged vitality. The endodontist
delivers a ready-to-use abutment tooth free of
pathology for the final reconstruction regardless of
the tooth vitality. In this lecture, the decision-making
process, material selection, complete workflow and
long-term outcomes will be presented.
After this lecture, participants should be able to:
1) identify clinically relevant factors for reconstruction of nonvital teeth and teeth with challenged
vitality;
2) indicate the need for different adhesive tools to
construct the build-up of the abutment tooth with
fibre posts and various resin composites; and
3) describe critical details of ideal final restoration
of nonvital teeth.
13:30–15:00

Evidence-based treatment choices
in modern endodontic treatment
Dr Igor Tsesis
The treatment alternatives for apical periodontitis
include nonsurgical endodontic retreatment, surgical endodontic treatment, or tooth extraction, and
in certain cases, a follow-up protocol may be considered. The long-term prognosis, the alternatives
in case of treatment failure, post-treatment quality
of life, and patient’s preferences should all be recognised and incorporated in the treatment choice

18

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considerations. A decision on intervention for an
endodontically treated tooth with a periapical radiolucency should be based on the technical feasibility of the treatment, systemic factors and patient
values.
This presentation will discuss a patient-focused clinical decision-making process regarding the management and preservation of natural teeth based on the
principles of evidence-based medicine.
After this lecture, participants should be able to:
1) identify the main reasons for the persistence of
endodontic disease and possible treatment alternatives;
2) recognise the possibilities and limitations of
modern endodontic treatment; and
3) incorporate an evidence-based approach in the
decision-making process on treatment choice.
15:30–17:00

Endodontic algorithms in decision-making
and clinical workflow
Dr Roberto Cristian Cristescu
This lecture will focus on some decision-making
steps during endodontic clinical procedures in the
dental office. The current standard of care requires
dentists to base their actions on scientific evidence
and to be able to put that evidence into clinical
practice while keeping in focus the patient’s quality
of life during the treatment. We will follow some
important guidelines for clinical endodontics and
will exemplify them with clinical cases that reflect
the diagnosis and treatment spectrum of a general
dental office.
After this lecture, participants should:
1) have a clearer decision-making algorithm for their
clinical work;
2) be able to understand how to start making their
own clinical decision flowcharts for different
endodontic procedures; and
3) have a better understanding of the possible
outcomes of different treatment paths.
17:15–18:45

Two-dimensional vs 3D endodontics
Prof. Gianluca Gambarini
This lecture will address the use of CBCT in endodontics for diagnosis, the treatment plan, access
cavity design, working length determination, man-

Please visit www.roots-summit.com for the ROOTS SUMMIT 2022 programme.

[19] =>

ROOTS SUMMIT special
Xxxxxx

After this lecture, participants should:
1) understand the advantages of CBCT in all the
phases of endodontic treatment;
2) know how CBCT can be associated with endodontic and static/dynamic navigation software;
and
3) be able to evaluate the possible use of dynamic
navigation systems in surgical and nonsurgical
endodontic treatment.

Day 3: Sunday, 29 May 2022
8:30–10:00

Minimally invasive approaches
in endodontic procedures
Dr Gianluca Plotino
Clinical studies demonstrate that long-term prognosis of root filled teeth is influenced by the quality
of the restoration, as well as by the quality of the root
canal therapy itself. The most recent trends in the
restoration of endodontically treated teeth follow the
concept of minimally invasive dentistry, proposing
more conservative, less expensive and bioeconomic
restorations, based mostly on adhesive dentistry
and the introduction of new materials and technologies.
Following these trends, access procedures in endodontics and root canal preparation are changing
in a conservative way, sometimes drastically if
compared with the traditional concepts of cavity
outline opening and coronal straight-line access to
reach the apical region. The endodontic literature
appears to be poor on demonstrating how these
minimally invasive access procedures can influence the quality and prognosis of root canal therapy. This lecture will analyse the technical procedures of minimally invasive access and preparation
in different clinical situations and the possible
mechanical improvements derived from these.

clinicians should be in order to ensure gold standard endodontic treatments.
After this lecture, participants should:
1) understand the basic concepts of minimally invasive endodontic procedures;
2) be able to apply new strategies to optimise minimally invasive endodontic procedures; and
3) be able to evaluate critically the advantages and
disadvantages of present technologies, instruments and techniques.
10:45–12:30

Irrigation and disinfection
of the root canal
Prof. Matthias Zehnder
This lecture will discuss what we need to do to obtain adequate disinfection of the root canal system
with subsequent healing of periapical lesions. The
most important aspect in this context is neither
new tools nor special disinfectants, but a thorough
understanding of the actual case we are treating.
It will be shown that not all endodontic cases are
equal and how we can address the more difficult
cases by choosing our approach wisely. One core
issue is timing.
How much time are we prepared to spend on
a case, and what is best for our patient? In this
context, the effectiveness and compatibility of
the means we use to debride and disinfect are
key. The other core issue is anatomy. While
many clinicians are aware of the macroanatomy
of root canal systems, fewer consider microanatomy.
After this lecture, participants should be able to:
1) appreciate the importance of diagnostics and
anatomy in current and future treatment concepts;
2) understand the efficacy versus the effectiveness
of different protocols under different conditions;
and
3) understand the core characteristics and interactions of the main chemical agents used in root
canal cleansing.
Prague © DaLiu/Shutterstock.com

agement of complex cases, obturation, restoration,
follow-up and surgery. The various steps of the dental treatment will analyse the differences between
2D and 3D radiographs to demonstrate the benefits
of routine use of CBCT technology. There will also
be a focus on the use of clinical software for case
assessment and navigation systems using 3D CBCT
images.

13:30–15:30

The art of endodontics in the age of MIE
Moreover, the limits of these procedures will be
critically analysed to define how minimally invasive

Dr Stephen Buchanan
No Abstract Available

Please visit www.roots-summit.com for the ROOTS SUMMIT 2022 programme.

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[20] =>

| case report

Automatic assistance:
Freedom to navigate root canals
Prof. Eugenio Pedullà, Italy

Introduction
Mechanical root canal preparation with nickel–titanium (NiTi)
instruments activated by endodontic motors has made root
canal preparation more predictable in the clinical setting, as
well as significantly reduced working time and stress on the
practitioner. Since the introduction in the late 1980s of centric continuous rotary motion for NiTi files, new mechanised
techniques have been proposed with the aim of minimising
the risk of fracture of endodontic instruments by exploiting
the benefits of different kinematics in endodontic therapy.
Thus, trans-axial, eccentric and reciprocating motion
were introduced for the activation of NiTi instruments
to shape root canals. In particular, reciprocating motion
(better classified as partial reciprocation with rotational
effect) has asymmetrical angles of rotation in the anticlockwise and clockwise directions.
Continuous rotation and reciprocation have advantages but
also disadvantages. Indeed, the former allows easy progres-

1
Fig. 1: The fully automatic CanalPro Jeni endodontic motor (COLTENE).

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sion in root canals, but it does not protect the NiTi files from
the risk of torsional fracture. Reciprocation increases file
fracture resistance, reducing the screw-in effect but increasing the possibility of apical debris accumulation or extrusion.
Therefore, hybrid motions have been designed to combine rotary and reciprocating movements, taking advantage of each. Hybrid endodontic motors have just two
movements, changing the angle during activation, passing from a complete (360°) rotation to a single asymmetrical reciprocation with fixed and asymmetrical angles
(clockwise differing from anticlockwise) depending on
the torsional stress applied to the NiTi file.
However, digital technology can facilitate continuous
control of the file movement. The CanalPro Jeni endodontic motor (COLTENE; Fig. 1) allows fully automatic
assistance in the shaping of root canals using different
rotary motion, angle, speed and torque, automatically
changed by the complex and patented algorithms
of the motor. Rotary movement, speed and torque are

[21] =>

case report

2
Fig. 2: Apex reached as signalled by the integrated apex locator on the touch screen monitor of CanalPro Jeni.

continuously adapted to the prevailing conditions in the
root canal. The file movement of Jeni motion is adapted
to the changing pressure exerted on the instrument.
Light pressure is applied steadily from coronal to apical.
The reaction time of CanalPro Jeni is in the millisecond
range and thus significantly faster than that of humans. This
means greater safety, because of the reduced risk of NiTi
file fracture and decreased subjectivity of treatment because the advancement of the files is always automatically
controlled by the motor. With CanalPro Jeni, the dentist just
holds the contra-angle handpiece and the motor does the
rest, adjusting to the root canal anatomy and thereby increasing the efficiency and reducing treatment errors.
CanalPro Jeni not only changes the file movements, but
also continuously indicates the position of the file in the
root canal with its integrated apex locator (Fig. 2) and
suggests rinsing with irrigants when file progression is
compromised. This can guide the clinician to irrigate for
longer in complex cases.
The functionalities of CanalPro Jeni provide many advantages
to dentists. The motor starts in continuous rotation; however, if
the file is stopped and blocked in the root canal for any reason,
the dentist will be safe and will be able to continue his or her
work easily because the motor will activate the file with movements employing more reverse action until the file is unblocked.
Safety is also increased by the signal to rinse. When progression of the file is not allowed (such as in the case of
debris accumulation), the clinician could exert greater

pressure on the file in order to obtain instrument advancement. However, CanalPro Jeni will intercept this
and immediately advise the dentist with a long beep and
by activating reverse rotation to suggest the need to stop,
remove the file and irrigate rather.
Efficiency is ensured with CanalPro Jeni because the
movement by the motor always ensures some degree
of file advancement and cutting action. Therefore, it is
possible to advance into the root canal without the need
to perform the up and down motion controlled by the
subjective tactile feedback of the clinician. Moreover,
brushing motion with lateral cutting action on root canal
walls to favour the progression of the file is also allowed
by all the different movements effected by the motor.
This consistent forward motion can ultimately save time
during mechanical preparation. Root canal therapy and
retreatment can be performed safely and efficiently.
Different file systems can be selected in the control program via the touch screen. Presently, the HyFlex EDM,
HyFlex CM, MicroMega One Curve, MicroMega 2Shape
and Remover for HyFlex and MicroMega file systems (all
COLTENE) are already pre-installed in the software. In addition, the Doctor’s Choice program gives the clinician the
freedom to choose even different movements, like twist off
(continuous rotation), twist on (continuous rotation with an
alternative movement automatically activated when the set
torque is surpassed), and reciprocating motion with settable milliseconds in order to decide how much and in which
direction the NiTi instruments should be moved and the
anticlockwise motion that is helpful when the tip is blocked.

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[22] =>

| case report

Fig. 3: Pre-op radiograph of tooth #35. Incomplete endodontic obturation and a metal post were visible. A radiolucent periradicular lesion was detectable
laterally on the distal aspect of the root. Fig. 4: Final radiograph of the endodontic retreatment (with the dental dam still on the tooth) showing complete and
compact filling of the endodontic space, including the filling of a lateral canal and a little extrusion of sealer though it in the site of the lateral radiolucent lesion.
Fig. 5: Follow-up radiograph at one year of the endodontic retreatment of tooth #35. Healing of the lateral radiolucent lesion confirmed the success of the
endodontic retreatment performed with HyFlex Remover and EDM files activated by CanalPro Jeni.

Case 1
In this first case, periapical periodontitis of tooth #35 is presented. The 44-year-old patient was first diagnosed with
acute pulpitis of a mandibular premolar in 2017. Tooth #35
received root canal therapy and was then obturated with
gutta-percha and sealer and restored with a metal post
and composite materials. Unfortunately, the success of the
treatment was not long-lasting. In 2020, the patient presented at our practice with acute pain symptoms and pain
on percussion or biting. The preoperative periapical radiograph showed periapical periodontitis even laterally on the
distal aspect of the root of tooth #35 (Fig. 3). The patient
finally agreed to the necessary endodontic retreatment.
The first step in retreatment is the complete removal of
inadequate or aged gutta-percha filling. Therefore, after
the removal of the composite and metal post with ultrasonic tips, the 30/.07 HyFlex Remover file (COLTENE),
activated by the automatic Jeni motion of CanalPro Jeni,
was used for the gutta-percha disassembling procedure.
The fast and continuous changes of the movement performed by the automatic Jeni motion, combined with the
efficiency of the heat-treated HyFlex Remover file, allowed fast and safe removal of the previous obturation
material. In a recent paper, it was reported that the use of
the innovative CanalPro Jeni kinematics accelerates the
time for removal of root filling materials.1 Indeed, within
seconds, clean access to the apical third was achieved.
Subsequently, when the untreated part of the root
canal was reached, scouting was done with a #10 and

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15 K-type file. After determination of the working length
(WL), the HyFlex EDM file system, activated by the fully
automatic Jeni motion of CanalPro Jeni, was used in the
single-length technique. Thus, after the 20/.05 HyFlex
EDM file reached the WL, the 25/~ HyFlex EDM OneFile
and then the 40/.04 file were used to WL. Jeni motion allowed the files to reach the WL just by guiding the files in
the apical direction and removing the files from the root
canal and irrigating on the sounding of the long beep.
After this, the reinsertion of the file into the root canal
was deeper than the previous depth of insertion, and
this procedure was repeated until the WL was reached.
In this case, the 20/.05 file reached the WL in one pass,
the OneFile in two passes and the 40/.04 file in one pass
of the instrument. The 50/.03 HyFlex EDM finishing file
was then used to 1 mm from the WL in order to create a
stop for the 50/.02 master cone used for the micro-seal
thermoplasticised obturation technique.
The postoperative periapical radiograph showed perfect
adaption of the obturation material used and filling of a
large lateral distal canal that probably was the cause of
the periapical lesion and symptoms of the tooth (Fig. 4).
The one-year follow-up radiograph showed the healing
of the periapical lesion, and the patient reported no
symptoms during that time (Fig. 5).

Case 2
A 32-year-old male patient presented at our practice, having
been referred to us by his dentist for further endodontic
evaluation of pain in the left side of his maxilla. During the

[23] =>

case report

Fig. 6: Pre-op radiograph of tooth #26 showing decay under a previous composite restoration close to the pulp chamber that caused the patient pain. Irreversible pulpitis was the diagnosis. Fig. 7: Periapical radiograph of tooth #26, the beam angulated mesially to verify the correct obturation of the separate
mesiobuccal canal after endodontic treatment with the HyFlex EDM file system and CanalPro Jeni. Fig. 8: Post-op periapical radiograph of the endodontic
treatment of tooth #26.

initial examination, the patient experienced pain when a
gentle jet of cold air was blown between teeth #26 and 27.
The preoperative periapical radiograph confirmed the suspected decay of the distal root of tooth #26 under its previous composite restoration (Fig. 6). The patient was informed
about the situation, and he agreed to endodontic therapy
in order to obtain a predictable result of the treatment.
The entire treatment was performed exclusively under
the microscope. This allowed optimisation of the view of
the work field.
Full preparation was performed with a sequence of flexible NiTi files using CanalPro Jeni. After placement of a
dental dam, the access cavity was prepared, and coronal
flaring was obtained with the HyFlex EDM orifice opener.
In addition, to the composite in the canal entrance, the
extreme curvature of the root canals, especially in the
apical third of the distal one, presented a challenge.
In the mesiobuccal, independent second mesiobuccal
and distal buccal root canals, the 15/.03 HyFlex EDM file
was followed by the next size files, 10/.05 and 20/.05. The
palatal root canal was prepared with the same sequence,
plus the use of the 25/~ HyFlex EDM OneFile and 40/.04
HyFlex EDM file. CanalPro Jeni suggested irrigation for
the progression of the files with a long beep. This happened more in the second mesiobuccal and distal root
canals, where the preparation was more difficult because
of the narrow and curved anatomy. After a final rinse
and drying procedure with dedicated paper points, the
carrier-based thermoplasticised gutta-percha obturation
technique was used to fill the root canals (Figs. 7 & 8).

Conclusion
Digital endodontic assistance systems such as CanalPro
Jeni navigate the dentist step by step through mechanical
and chemical preparation by adjusting the variables of file
movement. The instantaneous control of CanalPro Jeni
improves the safety and efficiency of root canal therapy,
reducing the subjectivity of tactile feedback control
and possible errors during endodontic treatment and
retreatment.

contact
Prof. Eugenio Pedullà graduated
in dentistry and dental prosthetics
from the University of Catania in Italy
in 2003. He obtained his PhD at the
same university in 2007. From 2009
to 2014, he was a research fellow
at the University of Catania, where he
is now associate professor of conservative
dentistry and endodontics.
Prof. Pedullà carries out his clinical and research activities
mainly in the field of endodontics and conservative dentistry.
Prof. Pedullà is an active member of the Italian Academy of
Endodontics and Società Italiana di Odontoiatria Conservatrice
(Italian society of conservative dentistry), an ordinary member
of the Italian Society of Endodontics, an international
member of the American Association of Endodontists and
a member of the European Society of Endodontology.
He can be contacted at eugeniopedulla@gmail.com.

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[24] =>

| case report

Digital technology in endodontics
Use of dynamic navigation to access and shape canals
in teeth with pulp canal obliteration after trauma
Dr Bartlomiej Karaś, Poland

Fig. 1: Intra-oral view of the initial situation. Visible discoloration of the right central incisor. Figs. 2a & b: CBCT scan, sagittal (a) and coronal planes (b).
Visible pulp canal obliteration and periapical lesion.

Introduction
Pulp canal obliteration (PCO) is one of the complications
which may occur in dental pulp after tooth trauma. It is also
one of the mechanisms of pulp healing after trauma; however, pulp necrosis too may occur as a result of trauma. PCO
can be recognised clinically as early as three to 12 months
after trauma. PCO is an effect of the deposition of hard tissue, such as sclerotic or reparative dentine; however, the
underlying mechanisms of PCO are still unclear. Oginni et
al. report that partial obliteration was present in 56.9% and
total obliteration in 43.1% of 276 cases of teeth after trauma,
and they suspect that the mechanism of formation of obliteration is related to damage to the neurovascular supply.1
The types of injuries mostly responsible for PCO have also been
investigated. It was revealed that luxation, subluxation, intrusion and concussion are the most frequent causes of trauma.
In the case of concussion, teeth with developing apices have
a better prognosis and a lower likelihood of developing PCO.

Figs. 3a–c: Planning of the virtual guide in Navident software (ClaroNav).
The axis and depth of the preparation are shown.

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Jacobsen and Kerekes report that, although PCO necrosis
and periapical disease are rare, they can occur after many
years after the trauma. Bastos and Cortes emphasise that
crown discoloration can be present in many cases and can
be a first visible factor of PCO. Usually, the colour changes
to dark yellow or even grey.
Management of PCO owing to a lack of patency can be very
challenging for clinicians. Creating a proper access cavity
(one that will not sacrifice too much tooth structure) and locating the root canal orifice in the calcified tooth requires
experience and additional equipment, like a dental operating microscope. According to Carvalho and Zuolo, using
the dental operating microscope increases the probability
of finding all the orifices located in the pulp chamber floor.
Boveda and Kishen state that creating a constricted access
cavity should be very valuable in terms of a long-term prognosis, but can require an additional diagnostic protocol, for
example capturing a CBCT scan before the treatment.

Dynamic navigation
Nowadays, thanks to the development of modern technologies, it has become possible to perform treatment more
conservatively and more predictably. The Navident dynamic
navigation system (ClaroNav) is to a clinician what a GPS
is to a driver. Navident uses a stereoscopic camera and
marker (or reference) spheres so that the camera can track
the movement of the operator. Also the system requires a
CBCT scan of the patient and a digital guide, which is designed in the Navident software. After designing the guide,
the clinician needs to register the patient’s teeth to calibrate
the CBCT scan with a special tool (the wand). After registration of the patient’s teeth, the clinician needs to calibrate
the drill and the handpiece with dedicated markers. With

[25] =>

PROFESSIONAL PRECISE RELIABLE
ENDODONTIC SOLUTIONS

www.fanta-dental.com

[26] =>

| case report

Fig. 4: Calibration of the Navident device. The tracers and camera are shown. Fig. 5: Intra-op view of the software.

the combination of the prepared guide, tracking markers
and dynamic tracking of the camera, the dentist can see
the actual position of the drill and its angulation with a lag of
0.3–0.5 seconds on the computer screen. According to available data, the accuracy of the equipment is 0.1 mm and 1°,
which is significantly better than CAD/CAM-fabricated guides
for endodontic treatment. It must be considered that the accuracy of the procedure may differ depending on the clinician.

Case 1
A 36-year-old female patient came to the dental office with
discoloration and pain of the maxillary right first incisor (Fig. 1).
In the medical history taking, she reported a trauma approximately 15 years earlier. During the radiographic examination
in the office of her general dentist, PCO was revealed. She
was referred for a CBCT scan and endodontic treatment.
During the consultation, the CBCT scan was performed
with the 9000 C 3D with a voxel size of 0.1 mm (Carestream).
The CBCT scan revealed a highly calcified pulp chamber

and an almost invisible trace of the root canal (Fig. 2). The
patient was informed about the new, beneficial technology which can help to preserve additional tooth structure
during treatment.
Before the treatment, the CBCT scan was uploaded to
the software and the virtual guide was planned (Fig. 3).
This is one of the most important parts of the protocol
because during the treatment the Navident software tracks
the handpiece and shows the correlation between the
clinician’s work and the already planned guide. If the depth
or direction is missed on the guide, there is a very high risk
of root perforation.
During the clinical procedure, the jaw tracker was placed
on the patient’s teeth and fixed with impression material.
Registration of the patient’s tooth position and calibration
of the CBCT scan was performed with the help of the wand
tool. The drill tag was attached to the handpiece, and the
calibration of the handpiece and drill was performed with
the calibration tool (Fig. 4). After all the registration and

Figs. 6a & b: First stage of the access cavity creation (a). CBCT check, sagittal plane (b). The axis of the access cavity was visible. Figs. 7a & b: Hand file
scouting of the canal orifice. Figs. 8a & b: Final preparation (a). The size of the access cavity and of the root canal orifice was checked with the #80 hand
plugger (b). Figs. 9a & b: Drying the canal before obturation.

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| case report

10a

10b

11a

Figs. 10a & b: Obturation with gutta-percha (a) and the control radiograph (b).
Figs. 11a & b: Occlusal check (a) and the control radiograph of the composite seal (b). Fig. 12: CBCT check, sagittal plane. Measurement of the
root thickness confirmed the size of the preparation. Healing of the
periapical tissue was observed. Fig. 13: CBCT check, sagittal plane. The long
axis of the root and the axis of the access cavity and root canal preparation
were visible.

calibration procedures, the patient, tooth and guide were prepared for the access cavity creation. The access cavity was
created with the EndoGuide bur (SS White Dental) with the
aid of the Navident software. The greatest challenge of the
procedure for the clinician is to work simultaneously with the
fast-speed handpiece in the tooth and trace the position and
angulation of the drill on the computer screen, potentially leading to trouble with coordination in the first procedures (Fig. 5).
After reaching the depth of drilling on the prepared guide,
another CBCT scan was performed to check the accuracy of the access cavity (Fig. 6). According to the image,
the angulation of the access cavity had changed slightly to
the palatal side and the root canal was reached with the
#10 K-file (Kendo, VDW; Fig. 7). Shaping of the root canal was performed with Endostar E3 Azure (Poldent) up
to size 30/.04. After the shaping protocol, the size of the
root canal orifice was checked with the #80 hand plugger,

15a

16a

16b

11b

16c

17a

and it was indicated that the size was larger than #80 but
smaller than #100 (Fig. 8). The irrigation protocol was performed with 5.25% sodium hypochlorite and 40.0% citric
acid. Both solutions were activated with EDDY sonic tips
(VDW), and sodium hypochlorite was additionally activated
with elements free (Kerr) for intra-canal heating. The canal was dried with paper points (Fig. 9) and obturated with
warm gutta-percha using the continuous wave technique,
and a control radiograph was performed (Fig. 10). The
access cavity was sealed with a composite material, and
another radiograph was performed (Fig. 11).
The recall appointment took place four months after treatment. Healing of the periapical tissue was observed.
Despite the limitations of the CBCT imaging related to the
voxel size (0.1 mm), the size of the access cavity was found
to be 1.1 mm ± 0.2 mm, confirming the measurement performed during treatment (Fig. 12). Moreover, we could also

15b

15c

17b

17c

Fig. 14: Intra-oral view of the initial situation. Visible discoloration of the right central incisor. Figs. 15a–c: CBCT scan, sagittal (a & b) and coronal planes (c).
Pulp canal obliteration was visible in both teeth, and a periapical lesion was present around the left incisor. Internal resorption in the right incisor was suspected.
Figs. 16a–c: Planning of the virtual guide for the right incisor. The axis and depth of the preparation are shown. Figs. 17a–c: Planning of the virtual guide
for the left incisor. The axis and depth of the preparation are shown.

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case report

18a

20a

18b

20b

19a

20c

19b

21a

21b

Figs. 18a & b: CBCT check, sagittal plane. The axis of the access cavity was visible for both teeth. Figs. 19a & b: Drying the canal before obturation (a).
The final shape of the access cavity (b). Figs. 20a–c: Obturation with gutta-percha (a & b) and the control radiograph (c). Figs. 21a & b: Occlusal check (a)
and the control radiograph of the composite seal (b).

confirm that the access cavity and the root canal preparation had the same angulation, parallel to the long axis of
the root, and remained in the centre of the root (Fig. 13).

Case 2
A 30-year-old female patient presented to the dental clinic
complaining of constant pain of the left central incisor.
Moreover, the patient was unhappy with the aesthetics of
both incisors and had a history of trauma (Fig. 14). CBCT
examination was performed with the 9000 C 3D (Fig. 15).
The CBCT scan revealed a periapical lesion around the left
central incisor and PCO for 12 mm from the incisal edge.
The root of the left incisor was approximately 5 mm shorter
than the root of the right incisor, which could indicate apical inflammatory root resorption. Moreover, PCO was present in the right central incisor up to 12 mm from the incisal
edge, and an irregular shadow in the central area of the root
was present. This image could indicate internal resorption.
There was no lesion in the periapical area. In both teeth,
the size of the canals in the periapical area were narrower
than the typical size of the canals in the central incisors.
Before the treatment, the CBCT scan was uploaded to the
software and the virtual guide was planned (Figs. 16 & 17).
All the registration and calibration procedures were performed in the same manner as the previous case.
The access cavity was performed with the EndoGuide bur
with the aid of the software. After reaching the depth of
drilling on the prepared guide, another CBCT scan was
performed to check the accuracy of the access cavity
(Fig. 18). The CBCT scan revealed that the angulation of the
access cavity was suitable but that the depth was insufficient. The EndoGuide drill and Navident were used one
more time to reshape the access cavity. After gaining patency in the canal, the #10 K-file was used to establish the
working length. The canal in the right incisor was shaped

with Endostar E3 Azure up to size 40/.04, and the canal
in the left incisor was shaped up to size 45/.04. In both
canals, the irrigation protocol was performed with 5.25%
sodium hypochlorite and 40.0% citric acid. Both solutions
were activated with EDDY sonic tips, and sodium hypochlorite was additionally activated with elements free for intracanal heating. The canals were dried with paper points
(Fig. 19) and obturated with warm gutta-percha using the
continuous wave technique, and a control radiograph was
performed (Fig. 20). Finally, the composite sealing was
performed and the occlusal check was done (Fig. 21).

Conclusion
Although dynamic navigation in endodontics is a very new
and uncharted technology, the three teeth with massive PCO
in these case reports proved that it offers very promising
utility for endodontists. This technology requires further investigation, but it appears that it could help many clinicians
to treat teeth with PCO and perform non-surgical retreatment with a better outcome. Moreover, using this technology
in preparing constricted access cavities appears to be very
promising in terms of the survival of the treated teeth thanks
to preserved tooth structure such as peri-cervical dentine.
Therefore, digital solutions like Navident should be used more
often in endodontics to gather more data and create a new
standard for treating teeth with PCO in the future.

contact
Dr Bartlomiej Karaś
MAXDENT
Ul. Hallera 53/2
53–325 Wrocław
Poland
kontakt@bkaras.com

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| case report

Root canal therapy of necrotic
primary molars—using a
single-file reciprocating system
Drs Benjamín Rodríguez & Jenner Argueta, Guatemala

Introduction
Pulpectomy is a root canal procedure for pulp tissue that is
irreversibly infected or necrotic owing to caries or trauma.
The root canal pulp tissue is removed, and the canal is
commonly shaped with hand or rotary files.1 This procedure is the standard of care when normal shedding
coupled with the eruption of the permanent successor or
long-term tooth retention is the priority goal and evidences
a good healing outcome.2
Like in permanent teeth, it is crucial to achieve adequate
disinfection in the root canal system of primary teeth.3
Premature extraction of necrotic primary molars leads to
space loss, an important oral health concern in children
because of the consequent improper arch length and
altered successor eruption.3 Therefore, pulpectomy of
primary teeth with severe pulp involvement should be
considered the treatment of choice when indicated.3, 4
However, it represents a challenge because of the morphological complexities of the root canal system, presenting
multiple roots, uneven apical resorption, fused roots,
two mesiobuccal canals and two distobuccal canals in
maxillary molars, as well as fins and isthmuses, among
others.2 The disinfection protocol involves biomechanical
preparation with hand or rotary instruments and mainly
employs 0.5–5.5% sodium hypochlorite (NaClO) and
17% EDTA.5 Additionally children are more prone to anxiety and stress during dental treatment,4, 5 which may
require, in addition to well-established paediatric behaviour
management, techniques inherent to the endodontic field
that help to make the procedure simpler and less
time-consuming.6, 7
Stainless-steel hand files have been traditionally and, to
some degree, successfully used for pulpectomy procedures in primary molars.7 Despite this, when they are used
exclusively, they have multiple drawbacks because of their
rigidity, making it difficult to negotiate the canals properly
and to avoid procedural errors like ledge formation and
perforation.8 Rotary instrumentation was later introduced
and has proved to be very beneficial in the practice of

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paediatric endodontics.8, 9 It takes less time, is less skill
dependent and reduces the probability of errors that
arise with hand files. Consequently, rotary instrumentation
facilitates the creation of better conical space for a superior
obturation protocol.10 However, these systems almost always require a long sequence, and may become fatigued,
owing to the rotational movement, increasing the probability
of file fracture or distortion.11, 12
Continuous advances in the field of endodontics have
resulted in reciprocating instruments that have been applied in root canal therapy of permanent teeth. The clockwise and anticlockwise movement produces less binding
of the instrument to the dentine wall, resulting in a decrease
in cyclic fatigue and instrument fracture.13 Reciprocating
instruments advocate the use of a single file for the entire
root canal preparation. Being less time-consuming, it
allows for a longer irrigation protocol. The technique used
involves a cycle of instrumentation of in and out pecking
motions of 2–3 mm in amplitude with slight apical pressure. Each cycle requires irrigation of the root canal with
the irrigating solution and cleaning the file flutes of all
dentine remnants, debris and pulp tissue between each
cycle.12, 13
In the research on primary molar pulpectomies, the results
of the use of reciprocating instruments have been encouraging so far, demonstrating good cleaning and shaping
properties and shortened instrumentation time, thus being
beneficial for the preparation of primary teeth.14–17 However,
we found no in vivo studies or clinical reports on the use
of the R25 file (RECIPROC, VDW) in primary molar pulpectomy. In this article, we present a case series of primary
molar pulpectomy using R25 in RECIPROC ALL motion in
five primary molars with a diagnosis of pulp necrosis and
periapical disease.

Pulpectomy procedure
All the patients’ parents (or legal guardians) were informed
about the procedure protocol and prognosis and signed
a written consent. The pulpectomy procedures were performed by the same operator, an endodontist with ten

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case report

years of experience in primary molar pulp therapy. All the
cases were non-vital teeth with a diagnosis of pulp necrosis. Radiography confirmed bone loss in the apical or furcal
area, severe decay compromising the pulp chamber and
at least two-thirds remaining of the root surface. All the
children were cooperative and did not have systemic disease or special care needs. Follow-up time ranged from
14 months to 36 months.
The treatment protocol was performed in the following steps:
– Local anaesthetic (1 carpule of 2 cm3 of 2% lidocaine
hydrochloride with 1:100,000 adrenaline) was slowly
injected and negative aspiration confirmed.
– Under complete isolation with a clamp and dental dam,
the access cavity was performed with a high-speed #4
round bur under the operating microscope (OM-100,
Ecleris), and the access was redefined with a diamond
bur.
– The canals were searched with the aid of the DG16
endodontic explorer (Hu-Friedy) and negotiated with
10/.02 K-type files (SybronEndo; Kerr).

– The final irrigation protocol per root was 2 cm3 of alcohol
and 1 cm3 of 17% EDTA for 1 minute, followed by 2 cm3
of alcohol, 5 cm3 of 2.5% NaClO and 3 cm3 of saline,
and then paper points (Meta Biomed) were inserted to
ensure canal dryness.
– A mixture of zinc oxide eugenol (ZOE) in a powder–liquid
form (Proquident) was delivered into the canals on a
40/.04 gutta-percha cone (Meta Biomed). Owing to its
diameter at the tip, the cone was intended to fall short
of the apical working length to avoid over-extrusion of
the material.
– An intermediate radiograph was taken to visualise the
quality of obturation. If further condensation was required, more ZOE paste of a harder consistency was
gently plugged with a sterile cotton pellet.
– Intermediate obturation was performed in the cavity
above the ZOE using a glass ionomer luting cement
(Ketac Cem Easymix, 3M ESPE).
– At a second appointment, 15 days later, upon confirming
the absence of signs or symptoms of disease, a stainlesssteel crown was adapted and cemented with glass
ionomer in a powder–liquid form (Ketac Cem Easymix).

Case 1—Fig. 1: Initial situation. Fig. 2: Deep cavity and bone loss in the furcal area. Fig. 3: Three canals, lateral canal filling. Fig. 4: Fifteen-month control
showing bone deposition in the furcal area.

– The canal length was determined with an electronic apex
locator (Root Zx II, Morita) and confirmed with a periapical radiograph. From the measure obtained, 1 mm
was subtracted to calculate the working length.
– The irrigation was realised with 2.5% NaClO delivered
passively 2 mm short of the working length in 27 gauge,
3 cm3 Luer lock endodontic syringes (PlastCare).
– The root canal preparation was performed with a 21 mm
long R25 file according to the manufacturer’s recommendations in reciprocating motion (VDW.SILVER
RECIPROC, VDW) in the RECIPROC ALL mode, without
apical pressure, using in and out movements of 2–3 mm
in amplitude, allowing the instrument to advance in the
canal in a safe way until it reached the working length.
– No lateral pressure against or brushing of the canal walls
was done, in order to reduce the risk of weakening the
thin tooth structure.

Case 1 (Figs. 1–4)
This female patient was 4 years and 7 months old and presented with pain that had lasted for several days affecting
the mandibular right second primary molar. On clinical
examination, a buccal gingival swelling and facial initial
oedema were noted, and the tooth was found to have deep
occlusal decay. Pulp necrosis and a symptomatic apical
abscess were diagnosed. The patient was prescribed
medication to control acute infection and rescheduled after
the antibiotic treatment. At the second appointment, no
pain was reported and the buccal abscess had partially
receded. A decision was made to perform pulpectomy and
restoration. Over-extrusion of the obturation material was
observed. The 15-month re-evaluation confirmed no clinical or radiological signs of disease, and bone deposition
was evident in the furcal area.

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Case 2—Fig. 5: Initial condition. Severe decay and buccal abscess. Fig. 6: Four long root canals were detected. Fig. 7: Obturation and temporary restoration.
Fig. 8: Fourteen-month control showing the successor eruption process advancing normally. Fig. 9: Clinical aspect at final evaluation showing healthy gingival tissue.

Case 2 (Figs. 5–9)
This male patient was 6 years and 7 months old and presented
with severe tooth decay on the mandibular left first primary
molar without any symptoms of pain. He experienced slight
discomfort to percussion and palpation of the buccal gingiva.
A buccal abscess and no mobility were observed. The radiograph showed a large area of interradicular bone loss. The
tooth was diagnosed with pulp necrosis and asymptomatic
apical abscess. Pulpectomy was performed, and at a second
appointment, a stainless-steel crown was placed upon confirming absence of signs or symptoms of disease. At the
14-month recall, no clinical pathology was detected and a normal eruptive process of the permanent premolars was observed in spite of the extrusion of the obturation material.

Case 3 (Figs. 10–13)
This male patient was 7 years old and presented with mild pain
that had lasted for several days. An extensive and deep cavity

in the mandibular left first primary molar was observed. There
was no swelling of the gingiva, but the tooth was painful on
percussion. The radiograph showed the severity of the decay
but no consistent changes to the surrounding bone. Pulpectomy was the treatment of choice. The diagnosis of pulp necrosis was confirmed once the access cavity had been performed, and three canals were located and fully negotiated.
At a second appointment, 15 days later, the tooth was totally
asymptomatic and the decision was made to restore with
a stainless-steel crown. The 36-month control showed the
tooth to be in normal function and completely healthy.

Case 4 (Figs. 14–18)
This male patient was 4 years and 6 months old and presented with constant and spontaneous pain of the mandibular left first primary molar that had lasted for several days
but no facial oedema or buccal gingival swelling. Deep decay was observed but no mobility or deep probing depths.
On the radiograph, the carious lesion could be seen to be

Case 3—Fig. 10: Initial radiograph. Fig. 11: Obturation and final restoration. Fig. 12: Control at 36 months showing the normal eruption process despite
the slow resorption of the zinc oxide eugenol. Fig. 13: Clinical aspect at final evaluation showing healthy gingival tissue.

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case report

Case 4—Fig. 14: Severe decay. Fig. 15: Initial radiograph showing compromised pulp chamber. Fig. 16: Obturation of four root canals. Fig. 17: Thirty-month
control. Fig. 18: Clinical aspect at final evaluation showing healthy gingival tissue.

compromising the pulp chamber and initial bone damage
was observed in the furcal area. Pulpectomy was the treatment of choice. In the removal of the carious lesion, the
pulp was exposed and no bleeding was observed. Pulp
necrosis was diagnosed. Two mesial and two distal canals
were located, and the tooth was obturated. At a second
appointment, the tooth was asymptomatic and was restored with a stainless-steel crown. At the 30-month control,
the tooth presented no symptoms and a normal eruptive
process was observed on the radiograph.

Case 5 (Figs. 19–23)

This male patient was 5 years and 8 months old and presented with distal deep interproximal caries on a maxillary
left first primary molar and an associated buccal sinus tract.
The patient was asymptomatic and without a history of pain.
Pulp necrosis with suppurative periapical periodontitis was
diagnosed. Three canals were located and prepared for obturation. Apical over-extrusion with the ZOE was observed.
Fifteen days later, the patient was asymptomatic and the sinus

Case 5—Fig. 19: Initial condition. Interproximal decay. Fig. 20: Initial radiograph showing apical bone loss. Fig. 21: Obturation of three root canals and
final restoration. Fig. 22: Thirty-month control showing bone healing around the mesial root and distal root tissue. Fig. 23: Clinical aspect at final
evaluation showing healthy gingival tissue.

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| case report
tract had resolved, so the decision was made to restore the
tooth with a stainless-steel crown. Follow-up after 30 months
showed periapical healing of mesial apical area of previous
radiolucency and no signs or symptoms of disease or pain.

Discussion
Dental caries is a pathology of wide prevalence in the
world, and it affects the dentition in the early stages of life,
being most common in susceptible populations because
of a lack of dental education and limited access to quality
healthcare services.18 It is well known that it is essential to
avoid space loss during childhood in order to preserve the
natural dentition. Loss of proper space can lead to malposition of permanent teeth and compromises nutrition,
speech ability and self-confidence, among others.19 Primary
molar pulpectomy is the treatment of choice to preserve
primary natural dentition in teeth affected at the pulp–
dentine complex and periodontally diseased as a result
of bacterial invasion of the root canal system.20
Anxiety and stress regarding dental treatment in general
are common, but must especially be taken into consideration
when it comes to performing paediatric endodontic treatment.21 The search for and implementation of efficient endodontic techniques requires proper understanding of the
root canal system anatomy, root canal instrumentation, disinfection and obturation techniques, and the importance of
coronal restoration.20, 22 When it comes to root canal instrumentation, hand file techniques have been widely used in
endodontics, but they are time-consuming, uncomfortable at
some point and susceptible to procedural errors, especially
if performed by clinicians with limited clinical experience.22, 23
Mechanically driven instrumentation came to change the way
we shape canals, providing a faster way to enlarge the root
canal system in a convenient geometry to allow the appropriate movement of the irrigating solutions inside the root canal
system.23, 24 Instrument design, nickel–titanium alloys and the
type of movement are factors to take into consideration, because they will directly influence the instrument performance.

Ramazani et al. in their in vitro study compared two rotary systems
and RECIPROC in mesiobuccal canals of primary molars.28
They confirmed the RECIPROC system’s fast and good cleaning and shaping ability. These were the first studies to advocate
the use of the RECIPROC system in the primary dentition.
Moraes et al. conducted an in vitro study employing a
3D-printed prototype of a maxillary primary central incisor.14
They concluded that the R40 file of the RECIPROC system
was effective for instrumenting their 3D-printed model.
Tyagi et al. in their in vivo study compared the use of a rotary
system and the RECIPROC system for primary molar pulpectomy and evaluated the possible influence of the file system
on child behaviour, among other factors.29 Their results regarding clinical performance were in accordance with those of
previous research. Nonetheless, they stated that the choice
of file system did not significantly alter child behaviour.
Dalzell et al. conducted a micro-CT study in which they
evaluated the instrumentation efficacy of manual, Mtwo
and RECIPROC blue files (VDW) in non-fused and fused
primary molar roots and found significant differences in
cleaning and shaping effectiveness in both fused and
non-fused teeth.30 Additionally, they found more procedural errors when the reciprocating instruments were used.
This last finding is contrary to those of previous research
and our clinical experience so far. Although we have not
seen the clinical performance of the RECIPROC blue system,
it shares the geometrical design and motion of RECIPROC.
Barasuol et al. compared the shaping ability of hand, rotary
and reciprocating files in primary teeth in a micro-CT in vitro
study.25 Their results showed more canal transportation in
the middle third of the root canal with the R25 file. They also
found a shorter instrumentation time with the RECIPROC
system compared with manual instrumentation.

In paediatric dentistry, chair time is a factor to consider: the
shorter, the better for the patient to manage anxiety and
feel comfortable. Single-file reciprocating instrument systems can be beneficial for paediatric endodontic treatment
because they properly enlarge the geometry of the root
canals, facilitate good shaping to enable proper distribution
of irrigating solutions all along the working length and
are less time-consuming than rotary and manual instrumentation sequences.23, 25, 26 However, to the best of our
knowledge, there is a lack of in vivo research on the use of
reciprocating instruments in primary molar pulpectomy.

To the best of our knowledge, ours is the first clinical report
of the use of the R25 file in an in vivo scenario for primary
molar pulpectomy. The long period of follow-up showed good
results overall. These five cases were restored with complete
stainless-steel crowns, and the time of their cementation was
appropriate, avoiding recontamination of the root canal system.
Our clinical experience over the years exceeds the cases reported here; however, these cases were presented because
of their longer follow-up and proper stainless-steel restoration. The therapeutic success of our unreported cases
follows the trend shown in this case series. Stainless-steel
crowns are the preferred restoration for children at high risk
of caries and teeth that have undergone pulp therapy. This
may have contributed to the long-term success of treatment.

Moghaddam et al. in their experimental study compared the
cleaning efficacy and instrumentation time of RECIPROC and
Mtwo (VDW) in primary molars.27 They concluded that using
systems such as RECIPROC for pulpectomy is beneficial.

The use of the operating microscope, coupled with the experience of the operator in microscopic endodontics, may also have
contributed to these results. The dental microscope is underestimated and under-used in paediatric dentistry; however, its

RE
DT

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ibune Gr
s, nor do
ibune Gr

[35] =>

case report

about
Dr Benjamín Rodríguez earned
his degree in dentistry from the
Universidad Francisco Marroquín
and his MSc in endodontics from
the Universidad de San Carlos de
Guatemala, both in Guatemala City
in Guatemala. In 2019, after six years
of endodontic clinical practice,
he earned a postgraduate degree
in oral and maxillofacial radiology from UIC Barcelona in Spain.

advantages in locating canals in primary molars are clear, and
its use is likely to become the standard of practice in dentistry.
The improved ergonomics also allows longer working times
without repetitive muscle strain and prevents postural issues.”
More research is needed with longer follow-up and more
cases and future investigations should focus on randomised
clinical trials. Newer reciprocating instruments like RECIPROC
blue could possess designs and metallurgical characteristics
that are beneficial for use in primary molar pulpectomy and
should therefore be investigated.

Dr Jenner Argueta earned his
degree in dentistry and master’s
degree in endodontics from the
Universidad de San Carlos de Guatemala
in Guatemala City in Guatemala.
He is a certified researcher at the
Guatemalan national council for science
and technology and teaches endodontics
at the Universidad Mariano Gálvez
de Guatemala in Guatemala City. He obtained the Certificate of
Proficiency in Endodontics from UB School of Dental Medicine
at the University of Buffalo in Buffalo, New York, in United
States. Dr Argueta also runs a clinical practice focused
on micro-endodontics and micro-restorative dentistry.
He was president of the Academia de Endodoncia de Guatemala
(endodontic academy of Guatemala) from 2016 to 2020.
Dr Argueta can be contacted at jennerargueta@gmail.com.

Editorial note: A list of references is available from the
publisher.
AD

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Tribune Group is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry.This continuing education activity has been planned and implemented in accordance with the standards of the ADA Continuing Education Recognition Program (ADA CERP) through joint efforts between
Tribune Group and Dental Tribune Int. GmbH.

[36] =>

| technique

High-end technology for simplicity
Adj Prof. Philippe Sleiman, Lebanon

use a rather simplified approach for treating the complex
root canal anatomy. In this article, I will demonstrate this
approach with reference to several cases.
The orifice opening is done with the 25/.08 Traverse file,
which has a maximum flute diameter of 1 mm. This is a file
that I use in almost all of my cases. In straight canals,
it goes as deep as it can and, in curved canals, is limited
to working above the curve.
1

Since nickel–titanium (NiTi) files were introduced into root
canal therapy, engineers have been seeking the perfect
design and combination for optimal root canal therapy. Heat
treatment and twisting of NiTi was a major breakthrough in
this field. It opened up the era of heat treatment for rotary files,
and now almost all files in the market are heat-treated, creating
great flexibility, but putting aside cutting efficiency, cutting
being the major task for rotary files in shaping root canals.
The Traverse and now ZenFlex file systems (both Kerr) are
produced using a novel heat treatment that combines cutting efficiency and flexibility in one file and in the necessary
places. This new technology in heat treatment adds value
to our daily work, as ultimately what matters is the treatment that we offer to our patients. Safety and cutting efficiency are apparent when using these files, allowing me to

In straight canals, ZenFlex offers a wide range of sizes, from
20 to 55, in both .04 taper and .06 taper. After using the
ZenFlex for some time, the dentist can evaluate the size that
he or she likes to use according to his or her experience and
preferences and can use one ZenFlex file to finish the shaping.
In this first example, the patient was referred for treatment
of a sinus tract of the anterior maxilla (Fig. 1). A gutta-percha
cone was placed inside the fistula, showing the way to the
infection site. This was a straightforward case, prepared
using the 25/.08 Traverse file in the upper part of the root
canal, followed by a 10 K-File (Kerr) to determine the working length and then a 40/.06 Traverse file taken to working
length. Naturally, treatment involved complete chemical
preparation and 3D sealing of the root canal space (Fig. 2).
The next example was also a straightforward case. This
was a maxillary lateral incisor with a necrotic pulp and a
slightly resorbed apex. A 55/.06 ZenFlex file was used in a
single-file technique to treat this canal (Fig. 3).
In molars and narrow canals, a simple sequence is required
in order to perform shaping. It can start with the 25/.08
Traverse file, taken to just above the curve, especially in
mesial canals. Using a K-File, the dentist can determine the
working length using an apex locator and use this length
for preparation with rotary files. The K-File is also used to
achieve patency. The second rotary file is the 13/.06 Traverse
file, taken to working length, followed by the 20/.06 and
25/.06 ZenFlex files, also taken to working length. If the
dentist is following an apical enlargement regime, a 30/.04
ZenFlex file can be used for the apical area (Fig. 4).

4
Fig. 4: Technical card for small to medium canals.

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Maxillary second molars are in my opinion one of the most
challenging teeth to treat because of their position and
unpredictable anatomy. In this example case, the patient
was referred for irreversible pulpitis (Fig. 5). Looking at the
preoperative radiograph, we can see the curvature of especially the mesial and palatal root canals. The sequence used
was as described before, starting with the 25/.08 Traverse

[37] =>

technique

orifice opener as deep as it goes and just above the curve,
followed by a 8 K-File for working length determination and
the 13/.06 Traverse file used to working length in all canals.
During the use of the 13/.06 Traverse file, I did not feel much
resistance, so I decided to go ahead with the .06 taper
sequence. The next file was the 20/.06 ZenFlex, followed by
the 25/.06 ZenFlex file. Personally, I believe in apical enlargement, and for that reason, I used the 30/.04 ZenFlex file as
the final enlargement file in this case. I used a medium cone
as the master cone and achieved 3D sealing of the system
(Fig. 6). Of course, I performed complete chemical preparation, according to my sequence, during the procedure.
In very narrow canals, the .06 taper ZenFlex file will be replaced by the .04 taper one, in order to reduce taper lock,
which occurs when a large file is trapped inside a single or a
double canal curve. This can create a great deal of torsional
stress and bending stress on the same spot, leading to severe
damage of the file and even to file separation. The sequence
is use of the 25/.08 Traverse file in the straight part of the
canal, followed by 8 and 10 K-Files, taken to working length.
The 13/.06 Traverse file opens the way for the 20/.04 ZenFlex
file, which is followed by the 25/.04 ZenFlex file and additionally
the 30/.04 ZenFlex file for apical enlargement (Fig. 7). A medium
or fine-medium cone can be adapted as the master cone.
In this example case, the patient was referred by his treating dentist, who had penetrated deep into the roots in
trying to find the canals and was not successful, but fortunately no perforation had occurred (Fig. 8). Under the
microscope and using ultrasonic tips, the canals were
made accessible. On the radiograph, we can see that the
canals, especially the mesial ones, are narrow and have
small curves, particularly apically. The real challenge in this
case was maintaining the original shape of the canal. For
those reasons, the sequence with the .04 taper was chosen. Treatment was initiated with the 25/.08 Traverse orifice
opener, followed by a 8 K-File for working length determination. The 13/.06 Traverse file was used all the way
to the end of the working length, followed by the 20/.04

7
Fig. 7: Technical card for narrow canals.

and 25/.04 ZenFlex files, both taken to working length. For
apical enlargement, the 30/.04 ZenFlex file was used.
A medium cone was used as the master cone in the distal
root, and fine-medium cones were used in the mesial root.
A full sequence of irrigation was used during the treatment,
and the system, which included a deep isthmus between
the mesial roots, was filled in multiple levels from the middle
to the apex, achieving beautiful 3D obturation (Fig. 9).

contact
Adj Prof. Philippe Sleiman is an
assistant professor at the Faculty of
Dental Medicine of the Lebanese University
in Beirut in Lebanon and Adj Prof. at the
UNC Adams School of Dentistry at the
University of North Carolina in Chapel Hill,
North Carolina, in United States. He can
be contacted at profsleiman@gmail.com.

37
8

[38] =>

| technique

The golden era of root canal shaping
Dr Ahmed Shawky, Egypt

After access preparation and location of anatomy, the next
challenge facing the endodontic clinician is to select the proper
file alloy and sequence for the shaping procedure in order to
be able to shape the anatomy safely and predictably and without any procedural errors. This article will show the advantages of the MG3 instruments (Shenzhen Perfect Medical
Instruments) and how we can customise the sequence of these
files according the anatomy encountered and case difficulty
for predictable root canal shaping with a high safety margin.

Files
First, I will go through the components of the basic
assortment of the MG3 Gold file system (Fig. 1). The main
advantage of this file system is the presence of different
designs and cross sections in the same instrument kit,
a smart thing for dealing with different anatomies.
The MG3 Gold files are machined with a variable pitch
and helix (Fig. 2), allowing efficient coronal evacuation
of debris and preventing a screw-in tendency. This also
reduces the torsional load on the instrument that would
otherwise occur because of debris accumulation or
excessive friction with the root canal walls.

Starter file (orifice modifier, 20/.10)
This file has a short working segment (9 mm) and 19 mm
length. This improves accessibility in restricted areas (Fig. 3).
It is used for mechanical pre-flaring or orifice modification
for elimination of coronal dentine resistance. It has a convex
triangular cross section, which increases the blade strength,
giving the instrument a high cutting efficiency. With this
cross section, the instrument is subjected to excessive torsional load; therefore, this instrument must be used in brushing
motion towards the outer walls and not pecking motion.
Gliders (16/.02 and 19/.02)
Another advantage of this system is that it has two glide
path files (Fig. 4). They can be used sequentially, depending on case difficulty. Sometimes, only one is used. The
rectangular cross section provides four blades for better
centring ability, avoiding transportation, and for high cutting efficiency for reproducible glide path preparation.
The small size and taper of these files make them
extremely flexible for negotiating mechanically difficult
curvatures. Owing to the small size of the gliders, it is
recommended to use them with brushing motion ahead
of pecking motion to avoid torsional failure.

Pitch

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[39] =>

Cross-Section Designs

“The MG3 Gold with low shape memory and high cutting
efficiency allows (...) to manage different cases
with an excellent margin of safety and predictability.”
Shaping files 20/.04 and 25/.06
The cross section of these shaping files is triangular
(Fig. 5). This design provides sharp blades for enhanced
cutting efficiency and reduces the metal core of the instrument, as the size is increased to maintain flexibility.

The off-centre design also makes the instrument move
in swaggering motion for better canal tracing and for
avoiding transportation. The 35/.04 file is an optional file
for increasing the preparation size in large root canals.
It is used in zone pecking motion.

The heat treatment imparts a wear-resistant surface with
superior cutting behaviour and enhances cyclic fatigue
resistance.

Additional information

The 25/.04 file can be used in body shaping and can
be used as a finishing file in cases with anatomical limitations, such as severely curved canals. The 25/.06 file
can be used for pressureless pre-flaring and as a shaping
or finishing file.
Shaping file 35/.04
The cross section of this shaping file is off-centre rectangular (Fig. 6). This design provides sharp blades for enhanced cutting efficiency and reduces the contact points
of the instrument with the root canal walls.
This reduces the torsional load on this larger size and
provides better clearance of debris.

Non-assorted refills of all sizes are available for the
clinician to customise his or her treatment sequence
up to ISO tip size 50. All files are available in lengths of
21, 25 and 31 mm (except the starter file, being of 19 mm
in length).
The recommended operation speed is 300–350 rpm, and
the recommended torque is 2 Ncm for the glide path and
shaping files and 3 Ncm for the starter file. Markings indicate
taper: one marking for 2%, two for 4% and three for 6%.
Precisely calibrated working length markings are engraved on each instrument shank at 18, 19, 20 and
22 mm for easy reproduction of the recorded working
lengths in each canal, especially in multi-rooted teeth of
different lengths.

Cross-Section Designs

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[40] =>

ration, only one large mesial orifice was identified. Ultrasonic modification revealed the presence of two mesial
canals originating from a single mesial orifice (sub-pulpal
bifurcation).

7

How to use the MG3 Gold instruments
Case 1 (Fig. 7)
The patient presented to the clinic and was diagnosed
with symptomatic irreversible pulpitis and apical periodontitis of a mandibular third molar. After access prepa-

8

40
9

Mechanical pre-flaring with the 25/.06 MG3 Gold file,
followed by mechanical body shaping with the 25/.04 file,
created a smooth glide path down the two separate
mesial canals despite coronal restriction. Following the
reproducible glide path, shaping with the 20/.04, 25/.04
and 25/.06 files was not a difficult task.
Case 2 (Figs. 8 & 9)
A patient with a mandibular third molar diagnosed with
irreversible pulpitis and symptomatic apical periodontitis
was referred to my practice. Under high magnification,
the canal entrances were negotiated using medium-

[41] =>

technique

11a

11b

power ultrasonic instruments and D-perfect C Files
(Shenzhen Perfect Medical Instruments). Special care
was given to the coronal portion of the root canal, especially to the mesiobuccal canal, owing to the scouted
double curvatures. Pressureless mechanical pre-flaring
was done to reduce the coronal interferences (cervical
dentinal triangle—red triangle), which can place huge
stress on the shaping files, leading to procedural errors
such as instrument separation and transportation, thereby
increasing the difficulty of an initially straightforward case.
Mechanical pre-flaring in such a case can be done using
either the starter file (20/.10) or the apical 3–4 mm of the
25/.06 shaping file or even both. The mode of action of
these files is brushing motion towards the outer walls.
Case 3 (Figs. 10 & 11)
The patient presented with a mandibular first molar with
advanced symptomatic pulpitis and apical periodontitis.
Taking into consideration the constricted appearance of
the root canals on the digital radiograph, MG3 Gold was
the best suited for the situation owing to the high cutting
efficiency. Mechanical pre-flaring with the 25/.06 file was
done to facilitate body shaping using the 25/.04 file and
a secured mechanical glide path to a final size of 30/.04
in the five-canaled molar.

11c

Conclusion
When dealing with anatomy, variability is the rule. This is
the reason that the endodontic practitioner must be able
to modify the sequence of the instruments and treatment
approach according to the anatomy.
The introduction of new file systems like MG3 Gold with
low shape memory and high cutting efficiency allows the
clinician to manage different cases with an excellent
margin of safety and predictability.

about
Dr Ahmed Shawky, BDS, MSc, PhD,
is a senior lecturer in endodontics
at the Faculty of Dentistry of Cairo
University in Egypt, and his field of
research is regenerative endodontics.
He is a consultant in micro-endodontics
and has conducted more than
25 certified continuing education
endodontic training courses both
nationally and internationally. He is an opinion leader
for Dentsply Sirona Middle East and North Africa.

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[42] =>

| interview

Laser protocol for peri-implantitis
treatment
An interview with Dr Michał Nawrocki
By Dental Tribune International

insufficient for me, and to be honest my knowledge of
lasers, physics, indications and procedures was incomplete at the time. Then in January 2016, I invited Dr Ilay
Maden to my clinic to conduct a course and teach my
colleagues and me about various Er:YAG and Nd:YAG
procedures with the LightWalker laser. A few months
later, I decided to extend my knowledge about lasers by
attending the Master of Science in Lasers in Dentistry
presented by Prof. Norbert Gutknecht in Aachen. Now,
I cannot imagine continuing my daily practice and treatments without having LightWalker. Sometimes, I use it
as an additional tool during certain procedures, but very
often it’s a crucial and necessary tool for me to use to
conduct a particular procedure.
What procedures do you perform with laser?
Laser can be used in all fields of dentistry; however,
I am mainly focused on implantology and surgery, as well
as prosthodontics. In prosthodontics, it can be used for
sulcus conditioning, preparation for veneers and removal
of complete ceramic crowns, as well as during more challenging procedures like crown lengthening before tooth
preparation. We can use it in gingivectomy (Nd:YAG laser)
and bone recontouring (Er:YAG laser).

Dr Michał Nawrocki

Laser is becoming essential for every modern dental
practice. Moreover, from an educational standpoint,
there are many benefits in terms of the personal and professional development of the practitioner. In this interview, Dr Michał Nawrocki explains how laser dentistry
has helped to advance his practice and career and why
dental laser, and Fotona’s LightWalker in particular, has
become an essential part of his daily practice.
Dr Nawrocki, you have been using laser technology
since 2016. Looking back at your journey as a laser
dentist, how has LightWalker impacted your everyday practice?
I started my great adventure with Fotona’s LightWalker
in 2016. Before that I had used a diode laser, but it was

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All my surgery cases are finished with photo-biomodulation
using the Nd:YAG Genova handpiece. I have observed
that wound healing is much faster and better in such
cases owing to pain reduction, disinfection, reduction of
oedema and the laser’s analgesic function. Sometimes,
I have to conduct an endodontic treatment during the
procedure (which is quite rare and normally done by my
colleagues), in which case I really appreciate the deep
disinfection with Nd:YAG, which offers the highest bacterial reduction in comparison with other wavelengths,
and the Er:YAG SWEEPS (shock wave-enhanced emission
photoacoustic streaming) procedure, which provides the
most effective cleaning and disinfection. With surgical
treatments, I use both wavelengths in almost all cases.
Even when performing an easy and fast tooth extraction,
I can use Er:YAG for granulation tissue removal, followed
by Nd:YAG for disinfection, clot stabilisation and finally
photo-biomodulation. Of course, I use laser before implant insertion, as well as when complications appear.

[43] =>

interview

One of your main fields of specialisation is implantology. Where does the laser fit in this field?
We can use LightWalker for all implantology cases. Sometimes, it’s only needed for better and faster wound healing
(photo-biomodulation with the Nd:YAG laser), but very often
it is necessary to conduct the treatment. For me, it’s the
most important device during immediate implantation with
immediate loading, especially when the bone must be very
precisely cleaned of granulation soft tissue and disinfected.
In the meantime, we can also provoke bleeding of the bone
using the Er:YAG laser for superficial bone ablation. I also
really appreciate the use of laser during bone grafting with
the Khoury method. Sometimes, I combine this technique
with immediate implantation, especially in the aesthetic
zone. Then, after bone shield fixation, I can use the laser for
bone recontouring. With the Er:YAG laser, it’s done very
precisely—I remove sharp edges and create an emergence
profile for the crown—and most importantly, everything is
safe for the shield (almost no vibration, so we don’t lose
stability) and the implant (no thermal effect).
Of course, we can also use the Er:YAG laser for more
common and “easy” procedures—like implant uncovering
(Er:YAG). The healing is faster and we avoid suturing, but of
course, even with the thin chisel tip, some amount of soft
tissue is vapourised—so it cannot be conducted in all cases.
In 2018, you defended your master’s thesis at RWTH
Aachen University titled Comparison of Two Methods of
Periimplantitis Treatment with the Use of Nd:YAG and
Er:YAG Laser. Can you tell us more about that research?
Owing to the increasing number of implants being placed,
the development of peri-implantitis is a growing concern
and one of the primary challenges in present-day dentistry.

In cases of inflammation, it is necessary to implement
treatment, or risk implant loss. However, until now, no
uniform protocol or procedure has been defined which
could be considered the best and the most effective
solution. Different methods of treatment of tissue inflammation around the implant are used, depending on the
extent of inflammation, method availability, type of defect,
and skills and experience of the dental surgeon.
We know that laser can be used for the treatment of
inflammation in soft and hard tissue around implants,
such as mucositis and peri-implantitis. I wanted to investigate what kind of procedure would be the most effective
and minimally invasive—so the question was whether we
could use a minimally invasive, flapless procedure for
proper treatment and solve the problem of inflammation.

“I really appreciate the deep
disinfection with Nd:YAG,
which offers the highest
bacterial reduction [...]”
The procedures were conducted with Er:YAG and Nd:YAG
lasers. In the first group of patients, a mucoperiosteal flap
was elevated in order to gain better access to the operative
area, while the second group of patients was treated using a
more minimally invasive procedure without the flap method.
The assessment of treatment effectiveness involved clinical
and radiographic examination before the surgical procedures
and three months after the laser procedures. After conducting the intra-oral examination and defining plaque, probing
depth and bleeding on probing indices, photographic documentation of a given area was performed, bitewing and
occlusal surface radiographs were taken, and professional
scaling and root planing were subsequently carried out.
Based on my research, we know that non-surgical treatment
of peri-implantitis is effective and very often reduces inflammation. Of course, when we have severe defects, it’s impossible
to avoid a surgical procedure to elevate a flap to get proper
access to the defect. In such cases too, we should use a nonsurgical procedure as a first step to decrease the inflammation
and, after two to three weeks, perform the flap procedure.
Can you describe your standard laser protocol for
peri-implantitis treatment?
Firstly, we have to distinguish mucositis from peri-implantitis
with a radiovisiograph and with the use of a periodontal
probe. If possible, I remove the prosthetic restoration to get
better access for the treatment. In our surgical protocol,
we have five steps: (1) removal of granulation tissue with the
use of the Er:YAG laser (cylindrical tip); (2) decontamination

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In your opinion, what are the main benefits of choosing a laser system that includes two complementary
wavelengths, such as Er:YAG and Nd:YAG, especially
in the field of oral surgery?
Very often, we combine these two wavelengths to conduct
treatment in a fast, safe and predictable way. For me, it’s
crucial to use these two complementary wavelengths—
the interaction between the tissue and laser beam is quite
different, and owing to these differences in absorption,
transmission and scattering, we obtain different actions.
For example, during root apicectomy, after flap elevation,
I remove granulation soft tissue with the Er:YAG laser using
the H14 handpiece with a cylindrical tip (or when I want to
be more precise—a Varian tip) and the apicectomy is done
with the H02 non-contact handpiece. As the next step,
I conduct deep disinfection with the Nd:YAG laser (transmission in hydroxyapatite and absorption in pigmented
bacteria) before bone augmentation. Finally, I finish the
treatment with photo-biomodulation using the Nd:YAG laser.
As you can see from this example, I need both of these
two complementary wavelengths to achieve final success
with fast healing and proper bone regeneration.

[44] =>

| interview

Fig. 1: Initial situation. Fig. 2: Pocket depth measurements. Fig. 3: Bleeding on probing. Figs. 4 & 5: Use of the Er:YAG laser Varian tip for granulation tissue
removal, implant surface decontamination and surface ablation of infected bone. Fig. 6: Photo-biomodulation with the Nd:YAG laser. Fig. 7: Final results
after three months. No sign of inflammation.

of the implant surface with Er:YAG; (3) surface ablation of
infected bone with Er:YAG; (4) reduction of bacteria in the
bone with the Nd:YAG laser; and (5) photo-biomodulation
with the Nd:YAG laser (after flap closure).
In our non-surgical procedure, there are only four steps—I skip
deep disinfection with the Nd:YAG laser owing to the 1,064 nm
wavelength’s high absorption in titanium (it’s not possible
without elevating a flap to disinfect only the bone and not
harm the implant surface). As I mentioned, the flapless procedure is most often my first option, and when the defect is
severe, I decide on a surgical procedure as the second stage.
After the procedure, the same restoration is generally
placed in the mouth (after corrections if necessary). Some-

times, depending on the type of bone defect, I decide to
conduct bone regeneration with the use of bone substitute
and collagen membranes. In such cases, I have to remove
the restoration and, after peri-implantitis treatment with the
use of laser and bone augmentation, close the flap with
cover screws, leaving the patient with no restoration (posteriorly), not even a temporary one, for two to three months.
What are the benefits of LightWalker for the treatment
of peri-implantitis in your everyday practice?
As I mentioned, the treatment of peri-implantitis is a huge
challenge nowadays; statistically, in 20% of cases periimplantitis develops and in 40% of cases mucositis develops
around inserted implants. Treatment with the use of Er:YAG
and Nd:YAG lasers is very effective, fast and comfortable

Fig. 8: Initial situation. Fig. 9: Granulation tissue visible after flap elevation. Fig. 10: Granulation tissue removal with Er:YAG laser. Fig. 11: Bone augmentation.
Fig. 12: Final results with restoration two years post-op.

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[45] =>

interview

Fig. 13: Initial situation. Visible fistula one year after loading. Fig. 14: Bone defect of 9.27 mm in diameter. Fig. 15: Flap elevation. Fig. 16: Granulation tissue
removal with Er:YAG. Fig. 17: Implant resection. Fig. 18: CBCT scan on the day of surgery. No bone augmentation. Fig. 19: CBCT scan 1.5 years post-op.
Visible bone regeneration. Fig. 20: Situation 1.5 years post-op. No sign of inflammation.

for both patients and practitioners. We can use a minimally
invasive, non-surgical treatment, which very often is highly
effective, and thus avoid a surgical procedure. However,
it’s very important that we use our lasers with proper parameters to protect the soft and hard tissue and not alter
the implant surface. We can thoroughly remove bacterial
biofilm from the implant surface without altering it, and
we have the possibility of re-osseointegration. Of course,
we have to be aware of risk factors and aim to avoid them,
understand what the reason for the disease was and solve
the underlying problem. Sometimes, it’s only improper oral
hygiene, while other times, we must change or correct
the restoration. Each case is individually treated.
Could you share with us some of your more challenging cases of peri-implantitis and explain how the
treatment was performed?
Case 1 was a patient who presented with deep pockets
(9 mm), bleeding on probing and visible purulent effusion
(Figs. 1–7) and was treated with a non-surgical protocol.
In Case 2, the patient preferred a surgical procedure with
bone augmentation, as a consequence of bone graft
complication and graft exposure (Figs. 8–12).

The implant apicectomy in Case 3 shows that one year
after the immediate implantation with immediate loading
there was inflammation around the implant apex. The rest
was properly integrated (Figs. 13–20).
What advice would you give to your dental colleagues
who may be considering whether to incorporate laser
technology into their practice?
I can only advise them to use laser; there is no reason to
hesitate. Laser technology really changes dental practice.
Laser use provides new possibilities, new treatment
protocols and many advantages in dental procedures.
Our treatments are more comfortable, less painful (sometimes even painless) and very often less invasive and
more predictable. We have a great advantage of selective
tissue removal based on the chosen laser wavelength
and settings. Last but not least, it is better for our marketing, and patients now expect newer technologies.

Editorial note: A shortened version of this interview was
published in implants—international magazine of oral
implantology, vol. 23, issue 1/2022.

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[46] =>

| interview

“The correct choice of an animal
model is vital”
An interview with Dr Alexis Gaudin
By Iveta Ramonaite, Dental Tribune International

As in other medical fields, both dental research and
the pharmaceutical industry aim to identify therapeutic
strategies that can decrease pain, that can make dental therapeutics more efficient, faster and more comfortable, and that can make more predictable results
possible. The use of animal models can accurately
replicate many oral diseases and dental issues. Their
use makes it possible for scientists to conduct research into the effect of new drugs and therapeutic
proposals.

PRAGUE
26–29 May 2022

“The correct choice
of an animal model
is vital in order to minimise
suffering and cost while
DAYS OF ENDODONTICS
LECTURES maximising
HANDS-ON-COURSES
efficiency
and the success
of the research.”
register at www.roots-summit.com

4

12

14

Dr Alexis Gaudin

Dr Alexis Gaudin believes that novel diagnostic tools, such as the use of
biological markers, could be an alternative to studying pulpitis on animal
models in the future. (Image: © Alexis Gaudin)

Dr Alexis Gaudin is an associate professor in the
Department of Endodontics at Nantes Université in
France. In 2021, together with five other researchers, he
published a review article that sought to provide a thorough understanding of the different animal models used
in dental research to study pulp inflammation. In this interview with Dental Tribune International, Dr Gaudin discusses the ideal animal model for studying pulpitis, talks
about the increasing popularity of non-animal methods in
dental research and considers the possibility of studying
artificially generated caries-inducing models in the future.

The correct choice of an animal model is vital in order to
minimise suffering and cost while maximising efficiency
and the success of the research. Scientific and practical
decisions govern the selection of the animal model.
For example, the animal model used must be as close
as possible to humans from an anatomical, biological
and physiological point of view. The operating conditions for inducing pulpitis, including accessibility and
dental dam installation, must be technically simple, and
the inflammatory conditions obtained must be equivalent to those found in humans.

Dr Gaudin, why is it important to choose the most
appropriate animal model in dental research, and
how would you describe the ideal animal model for
studying pulp inflammation?

The animal model should give the most precise and
scientifically interpretable results while presenting the
least serious biological risk for the research team. The
results should be reproducible, and the animal model

Tribune Group GmbH is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or
endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Tribune Group GmbH designates this activity for 18.5 continuing education credits. This continuing education activity has been planned
and implemented in accordance with the standards of the ADA Continuing Education Recognition Program (ADA CERP) through joint efforts between Tribune Group GmbH and Dental Tribune International GmbH.

46

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[47] =>

interview

should be available and have reasonable acquisition
and care costs. The choice should also be directed
towards the species requiring the fewest animals. Finally,
the research should be conducted on the minimum
number of animals to provide the maximum amount of
information.
What are some of the hurdles in choosing the correct
animal model to study dental pulp?
Among the animal kingdom, rodents, rabbits, ferrets,
swine, dogs and non-human primates have been used
to model human pulpitis. The diversity of animals found
in studies indicates the difficulty of choosing the correct
and most efficient model. Each animal model has its
own characteristics that may be either advantageous or
limiting, depending on the study parameters.
Non-human primate models have certain limitations
such as zoonotic risks, supply difficulties and a high cost
of purchase and maintenance.

What are some of the disadvantages of choosing
an animal approach to studying pulpitis?
The use of animal models in research is still debated
from an ethical point of view. There is not an ideal animal
model since they all have advantages and drawbacks.
How effective are in vitro experiments and other
experimental alternatives for studying pulpitis, and
are they gaining increasing popularity in dental
research?

“In the future, it might
be possible to consider
artificially generated
caries-inducing models.”

PRAGUE

It is generally accepted that the immune systems of rats
and mice are comparable; however, much more information is available for the mouse. Moreover, there are
differences between the results obtained in mice and
rats. For instance, several studies have shown that the
immune parameters in mice are more sensitive to the
effects of stress (as measured by corticosterone) compared with those in rats. Even if rodents are the mainstay
of in vivo immunological experimentation, it is important
to point out that the immune systems of mice/rats and
humans are quite similar but also present some differences, especially when it comes to development,
activation and response to aggression. It is, therefore,
necessary to consider the possibility that a given murine
model response may not occur in exactly the same way
in humans.

Alternative methods are gaining popularity since they
are becoming increasingly accurate. They involve
3D experiments and can combine new knowledge
to implement the experiment. The overall aim is to
limit animal suffering and to protect the welfare of
animals.

26–29 May 2022

DAYS OF ENDODONTICS

What changes do you see in dental research on
animals in terms of legislation, ethicality and the
validity of findings?
The rule of the three Rs was developed by Russel and
Burch in 1959 and forms the basis of the regulation and
the ethical foundation of the use of animals for scientific
purposes. It stands for replacement, refinement and
reduction (in the number of animals).

LECTURES

HANDS-ON-COURSES

More recently, a fourth R, responsibility, was added in
order to focus on the integrity and honesty of scientists
regarding the proper and reasonable use of laboratory
animals. However, legislation differs from country to
country.

There are higher costs involved with the use of larger
animals such as swine and dogs.

How is pulpitis typically induced in animal models?
There are three main dental pulp induction techniques
found in the literature, varying according to the causal
agent. The first technique consists of making cavities
with burs under water spray until pulp exposure.
The second method involves creating cavities under
the same conditions as previously described, with
or without pulp exposure. Once the cavity has been
made, an exogenous supply of toxins, such as lipopolysaccharide or human carious dentine, is placed
either directly in contact with the pulp or at the bottom
of the cavity so that the toxins diffuse through the
dentinal tubules.
The third induction technique consists of using transgenic animal models.

In your opinion, how will dental pulp be studied in
the future? Will there be novel methods that will help
researchers better understand the physiology of
dental pulp?
In the future, it might be possible to consider artificially
generated caries-inducing models that would represent
a more elegant and closer-to-reality alternative to
mechanical injury and lipopolysaccharide stimulation.
This would also help to avoid off-target effects of the
transgenic models.
Additionally, biological markers and other novel diagnostic tools could help to successfully visualise pulp
morphology, vitality and regeneration.

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1 2022

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| research

The key role of vitamin D in
immune health and regeneration
The evidence for supplementation
Prof. Shahram Ghanaati, Dr Karl Ulrich Volz & Dr Sarah Al-Maawi, Germany & Switzerland

A healthy immune system is the basis of general good
health and a good immune defence. It has been proved
that individual habits, nutrition and the environment have
an influence on our health.1 A balanced and healthy diet
in particular is the key to a healthy human body. An unbalanced diet can seriously impair the immune system
and increase the risk of chronic disease as a result.1 In the
last decade, chronic diseases such as diabetes mellitus,

Endogenous synthesis

Exogenous intake

7-dehydrocholesterol

Vitamin D3
cholecalciferol

Calcidiol
(25-hydroxycholecalciferol)

Calcitriol
(1,25-dihydroxycholecalciferol)
1
Fig. 1: Diagram for endogenous synthesis and exogenous vitamin D3 intake.

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1 2022

obesity and cardiovascular disease have surged sharply
in various countries. A major reason for this is an increasingly unhealthy living environment and increasingly
unhealthy lifestyle choices, especially in industrialised
countries.2 The role of food components and especially
vitamins has become increasingly important in various
areas. In 1928, the German biochemist Adolf Windaus
was awarded the Nobel Prize in Chemistry for his work
on the correlation between sterols and vitamins, which
sparked further research interest in vitamin D.3
Vitamin D can be produced in a physiological way in the
human body. Sunlight is essential for this endogenous
synthesis, which takes place primarily in the skin, where
7-dehydrocholesterol is converted into cholecalciferol
(vitamin D3) by UVB rays. In order to reach its biologically
active form, cholecalciferol undergoes further conversion
steps in the liver (calcidiol) and in the kidney (calcitriol). The
latter is the biologically active form of vitamin D and acts as
a transcription factor. After binding to the vitamin D receptor, calcitriol regulates the expression of various proteins
in the cell. The physiological mode of action of calcitriol
therefore resembles that of a hormone and not that of a
vitamin. That is why vitamin D, as a precursor of calcitriol,
should rather be regarded as a prohormone (Fig. 1).4, 5
The connection between vitamin D and parathyroid hormone was recognised shortly after its discovery. Within
this context, the regulatory effect of vitamin D on the mineral balance of the body and in particular the regulation
of calcium and phosphate levels was emphasised.6–8 Furthermore, it was established quite early on that vitamin D
plays an important role in mineralisation and bone formation. Consequently, many studies have focused on the influence of vitamin D on skeletal health and the treatment
of diseases such as osteoporosis. These findings have
contributed to vitamin D being primarily associated with
bone health in the public perception.
However, some studies have shown the positive effect of
vitamin D on the immune system too and thus on the general health of the body. Several studies have shown that
vitamin D has a preventive effect on chronic diseases such
as diabetes mellitus, hypertension and cardiovascular dis-

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research

p
an
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ease.9 Studies also report its potential anti-inflammatory
and antiviral effects.10 In this context, it has been shown
that vitamin D supplementation in pupils could reduce
the incidence rate of influenza virus infection.11 These
rather new findings and the immunomodulatory effects
of vitamin D demonstrate the importance of maintaining
healthy vitamin D levels in the body. Since endogenous
vitamin D synthesis is compromised by relatively short exposure to sunlight in most countries, the need for exogenous supply is becoming increasingly important. However,
the intake of vitamin D through food seems to be insufficient in the general population, which has contributed to
a global vitamin D deficiency pandemic.12 This pandemic
has already been documented and reported in numerous
studies in various countries.13 Nevertheless, its importance
is still mostly under-estimated in most countries.
The concept of supplementation with vitamin D preparations was first introduced in the 1940s. Today, 90 years
later, there are still no uniform recommendations regarding the dose to be taken. One of the reasons for this is the
historical development and the association of vitamin D
with bone health and the new knowledge about its further extensive capabilities. Although there is a growing
amount of data on the non-skeletal effects of vitamin D

and its preventive role in many chronic diseases, current
dose recommendations are still based solely on bone requirements. Another issue is the difficulty in standardising methods for the determination of serum vitamin D
levels. This review therefore focuses on the non-skeletal
effects of vitamin D and its supplementation dose based
on randomised controlled clinical trials. It provides an
overview of the new findings and treatment protocols.

Immune system booster in the case
of chronic and infectious disease
There is increasing interest in the study of the immune
system-supporting mechanisms of vitamin D. Interestingly,
the majority of body cells express vitamin D receptors on
their surfaces, which emphasises the multimodal action
of vitamin D. Owing to its regulatory effect, the active form
of vitamin D as a hormone can intervene in the synthesis of various cytokines and regulate them according to
their condition.14 It has been shown that vitamin D inhibits
the production of pro-inflammatory cytokines, whereas
it up-regulates the synthesis of anti-inflammatory signal
molecules.5 In this way, it exerts its immunomodulatory
effect and supports the differentiation of lymphocytes
into Th2 cells and regulatory T cells.14 This could explain

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1 2022

49

[50] =>

| research
its potential preventive influence in chronic and infectious
diseases. However, these mechanisms of action still remain largely unexplained for the respective indications.
The correlation between vitamin D levels and the prevalence of various chronic diseases has been shown in
several clinical studies. A meta-analysis of 25 prospective cohort studies has shown that low vitamin D levels
increase the risk of developing cardiovascular disease.
In about 10,000 patients, the risk of cardiovascular disease was about 44 % higher than in people with healthy
vitamin D levels.15 Another study showed a correlation
between vitamin D levels and the development of hypertension. It examined 8,155 patients suffering from hypertension and vitamin D deficiency. After the vitamin D
deficiency had been eliminated, 71 % of the patients no
longer showed any symptoms or had measurably high
blood pressure.16 A positive influence of vitamin D has
also been demonstrated in the development of Type 2
diabetes mellitus. It was shown that the number of patients in a prediabetic stage and with a vitamin D deficiency was significantly lower than in the untreated group,
once the vitamin D deficiency had been eliminated.17
Furthermore, the potential of an anti-infectious or antiviral effect of vitamin D has been increasingly investigated
in recent years. As a result, vitamin D has gained greater
significance as a preventive or adjuvant therapy.11, 18 A
systematic review has shown that a vitamin D deficiency
is associated with a higher viral load in hepatitis B patients.19 Furthermore, it was shown that vitamin D can inhibit a herpesvirus infection through its anti-inflammatory
and supportive defence effect.20 In addition, studies have
shown that vitamin D supplementation reduces the prevalence of influenza infections during influenza outbreaks.21
Another meta-analysis showed that the number of certain
vitamin D receptor polymorphisms involved in processing
of vitamin D correlates with an increased risk of a viral in-

Number of test persons

15
Vitamin D deficiency: 85.7 %
45.8 %

20.8 %

l
0–

l
–2
10

l
m
g/
0n
–3
20

2
Fig. 2: Distribution of vitamin D levels according to a pilot study conducted by the Clinic for Oral
and Maxillofacial Plastic Surgery at Goethe University Frankfurt am Main.

1 2022

Determination of vitamin D levels
and definition of hypovitaminosis
Vitamin D is a lipophilic molecule that is transported in the
blood by carrier proteins. Approximately 80 % of these
molecules are bound to the vitamin D binding protein in
this manner. A further 10–15 % are bound to albumin and
the rest circulates freely in the blood. The determination
of the vitamin D level as part of a routine examination
involves measuring the total concentration of all these
forms. The 25(OH)D serum concentration is widely recognised as a reliable marker of vitamin D levels.12 Similar
to other vitamins and blood components, the vitamin D
concentration is usually expressed in nanograms per millilitre (ng/ml) or in nanomoles per litre (nmol/l). Both units
are used, depending on the individual testing laboratory.
Here, it must be noted that 1 nmol/l equals 0.4 ng/ml. The
definition of a healthy vitamin D level and thus hypovitaminosis is a matter of much debate. In the literature, a
vitamin D level of less than 30 ng/ml (75 nmol/l) is considered a vitamin D deficiency (hypovitaminosis).13, 19, 23, 24
In various countries, studies have reported a general
vitamin D deficiency. Observational studies have documented that the prevalence of vitamin D levels of below
20 ng/ml (50 nmol/l) is as much as 24 % in the US, 37 %
in Canada and 40 % in Europe.13, 24 The German Robert
Koch Institute reported that 58 % of 18- to 79-year-olds in
Germany have a level of below 20 ng/ml (50 nmol/l).25 This
vitamin D deficiency pandemic was recognised as such
several years ago. However, not much has been done in
terms of supplementation and defining a sufficient dose.
A pilot study examined the vitamin D levels of medical
staff in the clinic for oral and maxillofacial plastic surgery
at Goethe University in Frankfurt am Main in Germany.
Out of 24 participants, 85.7 % had a vitamin D deficiency
with a value below 30 ng/ml, whereas 45.8 % even had
a value of below 10 ng/ml (Fig. 2). It is important to emphasise that a healthy vitamin D value is considered to be
between 40 ng/ml and 60 ng/ml.

Current guidelines for vitamin D
supplementation

12.5 %

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fection. Based on the vitamin D-mediated improved immune defence and its potential role as an antiviral agent,
its importance in the prevention of viral diseases is increasingly being investigated. Especially in the COVID-19
pandemic, vitamin D supplementation can play an important role in preventing and defeating infection.22

Given that, in most cases, endogenous synthesis of
vitamin D is insufficient owing to limited exposure to sunlight, the body’s vitamin D intake should also come from
food or dietary supplements. The amount of vitamin D
absorbed can be expressed in two units: micrograms
(µg) and international units (IU). One microgram equals
40 international units (1 µg equals 40 IU). These units

[51] =>

research

must be considered when administering vitamin D. Since
in most cases vitamin D intake via food is insufficient
for the body’s needs, supplementation with vitamin D
preparations is an utmost necessity. In the literature, the
current recommendations for doses to be administered
are largely inconsistent and are mainly based on the estimated requirements of maintaining optimal bone health.
The recommendations range from 400 IU/day to 4,000 IU/
day. The European Food Safety Authority recommends

a dose of 600 IU/day for healthy adults.22 A similar recommendation, a dose of 400 IU/day, has been published
by the Scientific Advisory Committee on Nutrition in the
UK.26 The Institute of Medicine Committee in the US recommends a dose of 600 IU/day for adults under 70 years
of age and a dose of 800 IU/day for those over that age.27
The American Association of Clinical Endocrinology recommends a dose of 1,000–4,000 IU/day.28 The recently
updated reference values of 2012 from the German

Category

Dose

Administration
duration

Initial
concentration

Targeted
concentration

Side effects

Prevention in pupils21

1,200 IU/day

12 months

Not specified

Not specified

None

Cancer, cardiovascular
disease30

2,000 IU/day

12 months

29.8 ng/ml

41.8 ng/ml

None

Diabetes mellitus17

4,000 IU/day

12 months

28.0 ng/ml

52.3 ng/ml

None

4,000 IU/day

24 months

28.0 ng/ml

54.3 ng/ml

None

50,000 IU/day

5 days

23.2 ng/ml

45.0 ± 20.0 ng/ml

None

100,000 IU/day

5 days

20.0 ng/ml

55.0 ± 14.0 ng/ml

None

25,000 IU/fortnight

2 months

7.6 ng/ml

19.0 ng/ml

None

25,000 IU/week

1.5 months

8.0 ng/ml

25.0 ng/ml

None

25,000 IU/week

2 months

8.4 ng/ml

35.6 ng/ml

None

1,000 IU/day

5 months

28.8 ng/ml

33.6 ng/ml

None

5,000 IU/day

27.0 ng/ml

64.0 ng/ml

None

10,000 IU/day

26.0 ng/ml

89.6 ng/ml

None

Ventilated patients in
intensive care31

Test persons with a
vitamin D deficiency32

Test persons with a
vitamin D deficiency33

|

Breast cancer patients
with bone metastasis34

7,000 IU/day

4 months

< 20.0 ng/ml

Not specified

None

Psychiatric clinic24, 35

5,000 IU/day

12 months

24.0 ng/ml

68.0 ng/ml

None

10,000 IU/day

12 months

25.0 ng/ml

96.0 ng/ml

None

Test persons with a
vitamin D deficiency36

100,000 IU/month
(3,000 IU/day)

36 months

24.4 ng/ml

54.0 ng/ml

None

Multiple sclerosis37

20,000 IU/day

12 months

21.6 ng/ml

44.0 ng/ml

None

Multiple sclerosis38

50,000 IU/week
(7,142 IU/day)

6 months

15.3 ng/ml

33.7 ng/ml

None

Asthma, rheumatic arthritis,
rickets, tuberculosis in the
1930s and 1940s24, 39

60,000–
600,000 IU/day

Not specified

Not specified

Not specified

Hypercalcaemia
as a result of
over-physiological
vitamin D concentrations

Table 1: Overview of the vitamin D doses administered in selected randomised clinical studies.

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1 2022

51

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| research
Authors’ dose recommendation
for healthy adults

Vitamin D test

< 40 ng/ml

≥ 40 ≤ 80 ng/ml

> 80 ng/ml

10,000 IU/day

5,000 IU/day

1,000 IU/day

Monitoring after three months

3
Fig. 3: Vitamin D3 dose recommendation of the authors for healthy adults.

Nutrition Society estimate the need at 400 IU/day for children and 800 IU/day for adults.25 The US research institute GrassrootsHealth collected data on the safety of a
dose of 10,000 IU/day and found no undesirable side effects.24, 29 The European Food Safety Authority also classifies a dose of 10,000 IU/day as safe, but recommends
no more than 4,000 IU/day.22

Clinical supplementation protocols in
randomised controlled clinical studies
As opposed to the recommendations of various authorities and institutions, relatively high doses of vitamin D
have been administered in randomised controlled clinical
trials, and these have in most cases led to the support
of therapy. Various clinical supplementation protocols
have been used with doses ranging from 1,000 IU/day to
100,000 IU/day. Two different strategies have been pursued: one option is to administer a relatively high dose,
such as 100,000 IU, once a month to raise and maintain
vitamin D levels; and the other option is to supplement
with an adequate daily dose (between 5,000 IU/day and
10,000 IU/day) to cover the body’s daily requirements.
Most studies have documented an observation period of
up to one year and have paid particular attention to the
analysis of the dreaded side effect of vitamin D intoxication. However, no vitamin D intoxication was observed in
any of these studies. A detailed overview of the respective studies is given in Table 1. Not long after the discovery of vitamin D and the recognition of its role in maintaining mineral balance, many diseases, such as asthma,
rickets and tuberculosis, were treated in the 1930s and
1940s with extremely high daily doses of vitamin D (between 60,000 IU/day and 600,000 IU/day). These studies
reported hypercalcaemia as a result of over-physiological
vitamin D concentrations, which led to growing concern
regarding vitamin D supplementation. It is important to
note that these studies were carried out with much higher
doses than the ones currently administered.

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1 2022

Today, the importance of vitamin D for the general health
of the body and the immune system is well documented. A
vitamin D value of between 40 ng/ml and 80 ng/ml should
be aimed for. In contrast to the doses recommended by
various associations, there is increasing evidence in current research that a relatively high daily dose is necessary to reach these values. However, there are no uniform
guidelines at this point. Based on the investigated data,
we recommend a daily dose that is adapted to the individual needs of the patient. In the case of a vitamin D deficiency (< 40 ng/ml), a dose of 10,000 IU/day should be
administered for three months to compensate for the deficiency. As a maintenance dose for a vitamin D level in the
range of 40–80 ng/ml, a dose of 5,000 IU/day is recommended. If the level is higher than 80 ng/ml, it is advisable
to reduce the dose to 1,000 IU/day. The vitamin D level
should be checked every three months in order to adjust the dose to the individual needs of the patient (Fig. 3).
When supplementing vitamin D, it is equally important to
take the patient’s medical history into consideration and,
in the case of compromised organ function or metabolic
disease, to individualise the dose accordingly.

Editorial note: A list of references is available from
the publisher. This article was first published in
implants—international magazine of oral implantology,
vol. 22, issue 1/2021.

about
Prof. Shahram Ghanaati
is a specialist in maxillofacial surgery
and oncology, based in Frankfurt am
Main, Germany. In 2013, he was
appointed Director of the University
Cancer Center of the Frankfurt
University Hospital. He is the Senior
Physician and Deputy Director of the
Department of Oral and Maxillofacial
Plastic Surgery of the Frankfurt University Hospital.
In addition, he is the Director of the research laboratory
FORM-Lab (Frankfurt Orofacial Regenerative Medicine).

contact
Prof. Shahram Ghanaati
Universitätsklinikum Frankfurt
Theodor-Stern-Kai 7
60590 Frankfurt am Main, Germany
+49 69 6301-3744
shahram.ghanaati@kgu.de

[53] =>

EDITION

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THE HYBR

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EXHIBITION AND CONFERENCE
IN ASIA PACIFIC
NEW DATES:

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[54] =>

| manufacturer news

Seiler Instrument celebrates its 77th anniversary this year

US-based Seiler Instrument came from humble origins
When Seiler Instrument launched in September 1945, the staff
included just its founders: husband and wife duo Eric H. and Dora
Seiler. Operations ran out of a small rented manufacturing and
office space located in downtown St Louis in Missouri. The company
has come a long way since. Today, Seiler Instrument has about
240 employees, does business around the globe and boasts a nearly
13,800 m2 headquarters in the Kirkwood suburb of St Louis.
Seiler Instrument was founded with a focus on repairing microscopes and surveying equipment. Eric H. Seiler, who was trained
in Germany as an instrument maker, came to the US in 1923. “He
was not only able to build instruments, but was also able to train
people. That was the double benefit from him. He was a master of
optics and able to train,” said his grandson Tom Seiler, executive
vice president of the company’s geospatial and medical divisions.
Even during its subsequent expansion, Seiler Instrument’s focus
on optical instruments has not wavered. The company operates
five major divisions: manufacturing, geospatial, medical, planetarium and design solutions. The company serves as a contract
manufacturer for precision machining and optical instrument assembly and sells surveying software and instruments, microscopes,
ZEISS planetarium equipment and theatre equipment for astrology
and related fields.
Key to the company’s long tenure has been a “strong family unit”,
according to Tom. The company is led by its third generation,

which includes Tom, his brother Eric (Rick) Seiler Jr, who is president
and CEO, and their sister Louise Schaper, director of compliance
and planetarium division manager. Of the second generation,
Eric P. Seiler remains chairman of the company and his wife, Hazel
Elaine, is a board member. Four members of the family’s fourth
generation are also involved in the company.
Perhaps the greatest challenge for Seiler Instrument since its
founding has been managing its growth and finances without
straying from the family-owned and closely held vision of the
company, said Tom. “We have benefited greatly from our strong
relationships and support from UMB Bank over 40 years,” he said.
Seiler Instrument celebrates its 77th anniversary this year, but
Tom said the family is not slowing down. It is targeting several
growth channels, including in its medical division, where executives see opportunity for long-term strategic growth with 3D microscopes. The company hopes to achieve that through existing
vendor relationships throughout the world.
According to Dane Carlson, medical division manager, “Dentistry
does not lend itself to good posture, causing injury. The dental
microscope is a wonderful ergonomic tool, but Seiler’s new
3D microscope provides an even better ergonomic opportunity
for the dentist. While using the 3D microscope, the dentist is not
in a static position, and the 3D microscope allows the end user to
manipulate the optical pod in a 360° rotation while the monitor
stays directly in front of the dentist. This is the first 3D dental
surgical microscope built with this unique design. This distinctive
design allows the end user to learn the microscope quicker and
be able to provide many direct vision angles not achievable with
the traditional microscope.”
While Seiler Instrument has grown significantly since its founding
in the 1940s, Tom said it has not strayed from its roots. A point of
pride for the company, he said, is a high number of first-generation
immigrant employees “working to achieve the American dream”.
“That’s exactly what our grandparents were. Our founder was
a first-generation immigrant,” said Tom.
www.seilerinst.com

[55] =>

manufacturer news

Removers and obturation material leave a lasting impression

European dentists test Remover files and obturation material—
a strong duo for revision work

Practicality in its ongoing product innovations is a top priority for
international dental specialist COLTENE. True to its motto “Upgrade
Dentistry”, the company has set itself the goal of continuously making the everyday work routines of dentists and their teams easier
and more efficient. In addition to the development of new working
aids and dental materials in collaboration with experts and research
institutions all over the world, extensive testing in dental practices
therefore plays a significant role.
Nearly 600 dentists from across Europe took part in a large-scale
practice experiment in which special attention was paid to the
handling of endodontic revision treatment. The specifically developed
Remover revision files manufactured by COLTENE were used in
combination with the GuttaFlow bioseal ceramic sealer.
Depending on their personal preferences, participants could choose
between the Remover for the HyFlex or MicroMega filing systems.
The revision files are available in size 30/.07 and in lengths of
19 and 23 mm. In next to no time, they remove insufficient guttapercha fillings or similar older endodontic restorations. Owing to
their intricate shape, they adapt to the natural contour of the canal
and efficiently loosen the existing dental material without requiring
any additional solvents. At the same time, the Remover files are
gentle on the surrounding tooth structure and their non-cutting tip
provides additional safety during preparation.
Accordingly, both endodontic experts and beginners alike had good
experiences in the practice experiment. The survey results confirm the
significant improvement in efficiency when switching from various
hand files as well as existing conventional preparation files and revision systems to revision with a single Remover nickel–titanium file:
42% of respondents rated the performance in removing obturation

material as excellent, and another 47% as good. In addition, more than
half of the participants reported noticeable time-savings compared
with their previous approach. This is all the more remarkable because
files from a wide variety of manufacturers and different methods
of filing had been stated for previous use. After the test, over 85%
indicated that they would continue to use the file in the future.
During subsequent filling and sealing of the root canal with the
GuttaFlow bioseal ceramic sealer, the rating of the properties respondents liked the most differed. Among other things, the obturation
material supports regeneration by raising the pH level in the root
canal. Hydroxyapatite crystals are formed on contact with bodily fluid.
These are natural components of bone and tooth tissue and thus support the healing process. The majority of respondents (60%) named
ease of handling as the most outstanding feature of the obturation
material. Rapid polymerisation in only 12–16 minutes, good radiopaque visibility and flowability were also rated positively. Over 72%
of the testers were very satisfied or satisfied with the overall result
of treatment, and 75% of the dentists said that they could imagine
continuing to use GuttaFlow bioseal in their practice in the future.
Quick answers to questions about application
For the optimal integration of the newly developed instruments and
dental materials, as well as for other application issues in endodontics, COLTENE regularly offers continuing education, practice workshops and webinars. At www.coltene.com or one of the innovation
leader’s social media channels, interested dentists can find out
about the latest trends and ideas from the dental world. This way,
even endodontic beginners will soon be able to achieve competent
and efficient preparation.
www.coltene.com

In a Europe-wide study conducted with about 600 dental professionals, the majority of testers of GuttaFlow bioseal ceramic from COLTENE were very
satisfied or satisfied with the overall result of treatment. (All images: © COLTENE)

[56] =>

| meetings

International events

ROOTS SUMMIT 2022

AAID Annual Conference 2022

26–29 May 2022
Prague, Czech Republic
www.roots-summit.com

21–24 September 2022
Dallas, USA
www.aaid.com

26–29 May 2022
Istanbul, Turkey
https://cnridex.com

13–15 October 2022
Budapest, Hungary
https://dentalworld.hu/
dental-world-2022-en

SIDEX Seoul International
Dental Exhibition &
Scientific Congress 2022

19th ESCD Annual Meeting

27–29 May 2022
Seoul, South Korea
https://eng.sidex.or.kr

13–15 October 2022
Rome, Italy
https://escdonline.eu

DENTAL BERN 2022
9–11 June 2022
Bern, Switzerland
https://dental2022.ch

56

roots
1 2022

Dental World Budapest 2022

Formnext 2022
15–18 November 2022
Frankfurt am Main, Germany
https://formnext.mesago.com/
events/en.html

EuroPerio10

IDS 2023

15–18 June 2022
Copenhagen, Denmark
www.efp.org/europerio

14–18 March 2023
Cologne, Germany
www.ids-cologne.de

© 06photo/Shutterstock.com

17 IDEX Istanbul 2022
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|
© 32 pixels/Shutterstock.com

submission guidelines

How to send us your work
Please note that all the textual components of your submission must be combined into one MS Word document.
Please do not submit multiple files for
each of these items:
· the complete article;
· all the image (tables, charts, photographs, etc.) captions;
· the complete list of sources consulted
and
· the author or contact information (biographical sketch, mailing address,
e-mail address, etc.).
In addition, images must not be embedded into the MS Word document. All images must be submitted separately, and
details about such submission follow below under image requirements.

Text length
Article lengths can vary greatly—from
1,500 to 5,500 words—depending on
the subject matter. Our approach is that
if you need more or fewer words to do the
topic justice, then please make the article
as long or as short as necessary.
We can run an unusually long article in
multiple parts, but this usually entails
a topic for which each part can stand
alone because it contains so much information.
In short, we do not want to limit you in
terms of article length, so please use the
word count above as a general guideline
and if you have specific questions, please
do not hesitate to contact us.

Text formatting

Please use single spacing and make sure
that the text is left justified. Please do not
centre text on the page. Do not indent
paragraphs, rather place a blank line between paragraphs. Please do not add tab
stops.
Should you require a special layout,
please let the word processing programme you are using help you do this
formatting automatically. Similarly, should
you need to make a list, or add footnotes
or endnotes, please let the word processing programme do it for you automatically.
There are menus in every programme that
will enable you to do so. The fact is that
no matter how carefully done, errors can
creep in when you try to number footnotes
yourself.

Larger image files are always better,
and those approximately the size of 1 MB
are best. Thus, do not size large image
files down to meet our requirements
but send us the largest files available.
(The larger the starting image is in terms
of bytes, the more leeway the designer
has for resizing the image in order to fill
up more space should there be room
available.)
Also, please remember that images
must not be embedded into the body of
the article submitted. Images must be
submitted separately to the textual submission.
You may submit images via e-mail
or share the files in our cloud storage
(please contact us for the link).

Any formatting contrary to stated above
will require us to remove such formatting
before layout, which is very time-consuming. Please consider this when formatting
your document.

Please also send us a head shot of yourself that is in accordance with the requirements stated above so that it can
be printed with your article.

Image requirements

Abstracts

Please number images consecutively
throughout the article by using a new
number for each image. If it is imperative
that certain images are grouped together,
then use lowercase letters to designate
these in a group (for example, 2a, 2b, 2c).

An abstract of your article is not required.

Please place image references in your
article wherever they are appropriate,
whether in the middle or at the end of a
sentence. If you do not directly refer to the
image, place the reference at the end of
the sentence to which it relates enclosed
within brackets and before the period.

Author or contact information
The author’s contact information and a
head shot of the author are included at
the end of every article. Please note the
exact information you would like to appear in this section and format it according to the requirements stated above.
A short biographical sketch may precede
the contact information if you provide us
with the necessary information (60 words
or less).

In addition, please note:
We also ask that you forego any special
formatting beyond the use of italics and
boldface. If you would like to emphasise
certain words within the text, please only
use italics (do not use underlining or a
larger font size). Boldface is reserved for
article headers. Please do not use underlining.

· We require images in TIF or JPEG format.
· These images must be no smaller than
6 x 6 cm in size at 300 DPI.
· These image files must be no smaller
than 80 KB in size (or they will print the
size of a postage stamp!).

Questions?
Magda Wojtkiewicz
(Managing Editor)
m.wojtkiewicz@dental-tribune.com

roots
1 2022

57

[58] =>

| about the publisher

Imprint
Publisher and
Chief Executive Officer
Torsten R. Oemus
t.oemus@dental-tribune.com

International Administration

International Headquarters

Chief Financial Officer
Dan Wunderlich

Managing Editor
Magda Wojtkiewicz
m.wojtkiewicz@dental-tribune.com

Chief Content Officer
Claudia Duschek

Dental Tribune International GmbH
Holbeinstr. 29, 04229 Leipzig, Germany
Tel.: +49 341 48474-302
Fax: +49 341 48474-173
General requests: info@dental-tribune.com
Sales requests: mediasales@dental-tribune.com
www.dental-tribune.com

Designers
Franziska Schmid
Copy Editors
Sabrina Raaff
Ann-Katrin Paulick
Editorial Board
Fernando Goldberg, Argentina
Markus Haapasalo, Canada
Clemens Bargholz, Germany
Michael Baumann, Germany
Benjamin Briseno, Germany
Heike Steffen, Germany
Gary Cheung, Hong Kong
Asgeir Sigurdsson, Iceland
Adam Stabholz, Israel
Philippe Sleiman, Lebanon
Jorge Vera, Mexico
Unni Endal, Norway
Esteban Brau, Spain
José Pumarola, Spain
Kishor Gulabivala, United Kingdom
William P. Saunders, United Kingdom
Fred Barnett, USA
L. Stephan Buchanan, USA
James Gutmann, USA
Ben Johnson, USA
Kenneth Koch, USA
Sergio Kuttler, USA
John Nusstein, USA
Ove Peters, USA

Clinical Editors
Nathalie Schüller
Magda Wojtkiewicz
Editors
Franziska Beier
Jeremy Booth
Brendan Day
Iveta Ramonaite

Printed by
Löhnert Druck
Handelsstraße 12
04420 Markranstädt, Germany

Executive Producer
Gernot Meyer
Advertising Disposition
Marius Mezger
Art Director
Alexander Jahn

Copyright Regulations
All rights reserved. © 2022 Dental Tribune International GmbH. Reproduction in any manner in any language, in whole or in part, without the prior written permission of Dental Tribune International
GmbH is expressly prohibited. Dental Tribune International GmbH makes every effort to report clinical information and manufacturers’ product news accurately but cannot assume responsibility for the
validity of product claims or for typographical errors. The publisher also does not assume responsibility for product names, claims or statements made by advertisers. Opinions expressed by authors
are their own and may not reflect those of Dental Tribune International GmbH.

58

roots
1 2022

[59] =>

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[60] =>

CanalPro Jeni
™

Digital assistance system for canal preparation

Jeni - ready - go!

• Digital assistance system for canal preparation
controls the file movement at millisecond
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• Movement profile of the file continuously
adapts to the individual root canal
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• Irrigation recommendation is indicated by
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• Due to the integrated apex locator and fully
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007076 10.21

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HyFlex™ CM

MicroMega One Curve

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[cover] => roots international No. 1, 2022

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Table of contents

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