roots international No. 2, 2023
Cover
/ Editorial
/ Content
/ Combined treatment potentiates anti-biofilm and anti-cariogenic efficacy
/ Good oral health associated with improved survival among head and neck cancer patients
/ Prominent endodontist shares expertise on treating patients undergoing radiotherapy - An interview with Dr Josiane Almeida
/ How to handle complex endodontic cases - An interview with Dr Ruth Pérez-Alfayate
/ Comparative evaluation of apical debris extrusion associated with using reciprocating and rotary systems with variable tapers including single- and multiple-file sequences, and the influence of the glide path
/ On the pulse of endodontics—the key role of new technologies in root canal therapy
/ The piston technique—a novel approach to canal obturation
/ Broken file management with Er:YAG laser and SWEEPS technology—a case series
/ Chairside fabrication of a nano-ceramic hybrid composite endocrown for a severely damaged molar after endodontic treatment
/ Manufacturer news
/ Research examines burn-out during COVID-19, offers strategies for resilience
/ ROOTS SUMMIT 2024: Athens gears up to host premier endodontic meeting
/ Meetings
/ Submission guidelines
/ Imprint
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[1] =>
issn 2193-4673 • Vol. 19 • Issue 2/2023
roots
international magazine of endodontics
interview
How to handle complex endodontic cases
case report
Broken file management with Er:YAG laser
and SWEEPS technology
meetings
ROOTS SUMMIT 2024: Athens gears up
to host premier endodontic meeting
2/23
[2] =>
than a conventional competitor
1
to perform retreatment procedures
removal of remaining
2
root filling material than PUI
XP-endo® Rise Shaper
Finisher R
2x faster
AlOmari T, Mustafa R, Al-Fodeh R, El-Farraj H, Khaled W, Jamleh A. Debris Extrusion Using Reciproc Blue and XP Endo Shaper Systems in Root Canal Retreatment. Int J Dent. 2021 Mar 24;2021:6697587. doi:10.1155/2021/6697587
De-Deus G, Belladonna FG, Zuolo AS, et al. XP-endo Finisher R instrument optimizes the removal of root filling remnants in oval-shaped canals. Int Endod J. 2019;52(6):899907. doi:10.1111/iej.13077
www.fkg.ch/xp-endo-rise
2x more
2
© Dr. Klaus Lauterbach (Germany), All rights reserved
1
Retreatment
Simplify Your
Retreatment Protocol
[3] =>
editorial
|
Steve Jones
Co-chairman
ROOTS SUMMIT
Welcome to the autumn issue of
roots magazine
A cohesive international community is a rare thing
but eminently achievable when the community is a group
of like-minded individuals with a clear goal. That has
been the basis for the original and most established online
endodontic study group, ROOTS (www.facebook.com/
groups/rootsendo), for its entire existence. Sharing
endodontic knowledge, articles, studies, tips and advice
online free of politics and without hierarchy is something
that has stayed at the core of the ROOTS group from its
beginnings in the 1990s.
There are many events in both the dental and endodontic
worlds, but we had noticed that there were scientific
events and commercial events but no event that focused
on how leading-edge scientific findings could be rapidly
translated to practice for the benefit of patients. This is
how ROOTS SUMMIT, now well into its third decade,
was born.
Our community is well represented in this issue of
roots magazine. In addition to the interviews with
Drs Josiane Almeida and Ruth Pérez-Alfayate, we have
contributions from Dr Gregori M. Kurtzman, who has been
a member of ROOTS since it was an e-mail list, and two
of his co-authors, Drs Tanvi Paliwal and Lanka Mahesh.
Another member of ROOTS, Dr Andreea Oana Cristescu
Roșu has a timely and interesting article regarding new
technologies.
There are also two contributions to this issue from
Dr Bartłomiej Karaś, a long-time member of ROOTS and
winner of the best case presentation at ROOTS SUMMIT 2022
in Prague. Dr Karaś is one of the more recent of the
numerous clinicians and speakers who have come
into prominence in part due to their involvement with
the ROOTS group. One of the main ROOTS SUMMIT
programme speakers next year in Athens will be
Dr Rajiv Patel, for example, and of course Dr Antonis
Chaniotis is another. When going through back issues of
roots m
agazine, I could not find an issue that did not
have at least one article written by a member of the
ROOTS alumni.
Perhaps this is something that you are interested in
pursuing? You could do this by writing an article or by
giving a case presentation at ROOTS SUMMIT. If either
one of those interests you, there will be multiple posts
on the ROOTS Facebook group regarding this. I also
invite you to go to the ROOTS SUMMIT website
(www.roots-summit.com) for the information on how to
participate and article requirements. Free entry to
ROOTS SUMMIT is the prize for any articles accepted for
publication in our next issue.
We hope that you enjoy this issue, and whether you
wish to write an article or to read one, we hope that you
will join our ROOTS Facebook community and attend
ROOTS SUMMIT in Athens in May 2024.
Steve Jones
Co-chairman of ROOTS SUMMIT
roots
2 2023
03
[4] =>
| content
editorial
Welcome to the autumn issue of roots magazine
03
Steve Jones
news
Combined treatment potentiates anti-biofilm and anti-cariogenic efficacy
06
Iveta Ramonaite
Good oral health associated with improved survival among head and neck cancer patients 08
page 06
Anisha Hall Hoppe
interview
Prominent endodontist shares expertise on treating patients
undergoing radiotherapy
10
An interview with Dr Josiane Almeida
How to handle complex endodontic cases
12
An interview with Dr Ruth Pérez-Alfayate
research
page 10
Comparative evaluation of apical debris extrusion associated with using
reciprocating and rotary systems with variable tapers, including
14
single- and multiple-file sequences, and the influence of the glide path
Drs Tanvi Paliwal, Lanka Mahesh, Gregori M. Kurtzman & Rohit Paul
industry report
On the pulse of endodontics—the key role of new technologies in root canal therapy 18
Dr Andreea Oana Cristescu Roşu
case report
The piston technique—a novel approach to canal obturation
22
Drs Grzegorz Witkowski & Bartłomiej Karaś
page 22
Broken file management with Er:YAG laser
and SWEEPS technology—a case series
28
Dr Bartłomiej Karaś
Chairside fabrication of a nano-ceramic hybrid composite endocrown
for a severely damaged molar after endodontic treatment
34
Drs Alejandro Bertoldi Hepburn & Matías Scazzola
manufacturer news
Cover image courtesy of DIRECTEndodontics
(www.directendo.com).
2/23
issn 2193-4673 • Vol. 19 • Issue 2/2023
roots
international magazine of endodontics
42
features
Research examines burn-out during COVID-19, offers strategies for resilience 44
Iveta Ramonaite
ROOTS SUMMIT calls for submissions and launches roots magazine contest
45
meetings
ROOTS SUMMIT 2024: Athens gears up to host premier endodontic meeting 46
Franziska Beier
International events
about the publisher
interview
How to handle complex endodontic cases
case report
submission guidelines
international imprint
Broken file management with Er:YAG laser
and SWEEPS technology
meetings
ROOTS SUMMIT 2024: Athens gears up
to host premier endodontic meeting
04
48
roots
2 2023
49
50
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© Marko Aliaksandr/Shutterstock.com
| news
Combined treatment
potentiates anti-biofilm and
anti-cariogenic efficacy
By Iveta Ramonaite, Dental Tribune International
According to research, dental caries is the most prevalent
and costly biofilm-induced oral disease. Fluoride as the primary anti-cariogenic agent cannot both sufficiently control
biofilm and prevent enamel demineralisation and can lead
to risks associated with overexposure to fluoride, especially
in children. However, a recent study has shown that using
a combination of an iron oxide nanoparticle (ferumoxytol,
Fer) approved by the US Food and Drug Administration and
stannous fluoride (SnF2), even at lower concentrations, can
help inhibit both biofilm accumulation and enamel damage.
The study has the potential to prevent dental caries and to
reduce fluoride exposure in patients.
“Traditional treatments often come short in managing the
complex biofilm environment in the mouth,” senior researcher
Dr Hyun (Michel) Koo, a co-founding director of the Center for
Innovation and Precision Dentistry and a professor in the
Department of Orthodontics at the University of Pennsylvania,
said in a press release. “Our combined treatment not only
amplifies the effectiveness of each agent but does so with a
lower dosage, hinting at a potentially revolutionary method for
caries prevention in high-risk individuals,” he continued.
The researchers found that Fer can stabilise SnF2 and
that it shows increased catalytic activity when combined
with SnF2. Additionally, they discovered that fluoride, iron
and tin form a protective film on tooth enamel to protect
it against further demineralisation. It was also reported
that the combined therapy did not disrupt the ecological
06
roots
2 2023
balance of the oral microbiota and showed no side
effects on the surrounding host tissue.
Senior author Dr David Cormode, an associate professor
of radiology at the university, commented: “What excites
us most about these findings is the multifaceted approach to caries prevention. It’s not just about inhibiting
bacterial growth or protecting the enamel; it’s a holistic
method that targets both the biological and physicochemical aspects of dental caries.”
“While we are happy with these initial findings, we still aim to
dig deeper in understanding the intricate ways Fer and SnF2
synergise to boost the therapeutic effects,” Dr Koo added.
Since both Fer and SnF2 are commercially available, the
research findings could quickly be translated into clinical
practice. However, further research is needed to closely
examine the mechanisms of interaction between SnF2
and Fer, the process of reactive oxygen species generation and the formation and efficacy of the protective
enamel film. “There’s potential here not just in dental care
but in exploring how this combination can be targeted
against other biofilms,” Dr Cormode said.
Editorial note: The study, titled “Iron oxide nanozymes
stabilize stannous fluoride for targeted biofilm killing and
synergistic oral disease prevention”, was published online
on 29 September 2023 in Nature Communications.
[7] =>
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[8] =>
| news
Good oral health associated
with improved survival among
head and neck cancer patients
By Anisha Hall Hoppe, Dental Tribune International
International Head and Neck Cancer Epidemiology
Consortium, representing the largest analysis of its kind
to date.
This comprehensive analysis included 10,042 HNSCC
patients from various geographic regions and focused
on demographics, clinical factors, oral health, treatment
and survival. The majority of patients were male, and the
participants had a mean age of 59.8 years. Most had latestage cancer and received surgery-based treatments.
© Mark_Kostich/Shutterstock.com
Head and neck squamous cell carcinoma (HNSCC) is
a global health concern, ranking as the sixth most common malignancy worldwide. Poor oral health has emerged
as an independent risk factor for HNSCC. Various aspects of poor oral health, such as tooth loss, periodontal
disease, infrequent toothbrushing and lack of dental
visits, have been associated with a moderate increase
in HNSCC risk. However, limited data exists on how oral
health has an impact on HNSCC survival. A recent study
aimed to address this gap by analysing data from the
Retention of natural dentition and frequency of dental visits have been identified as factors in head and neck squamous cell carcinoma survival.
08
roots
2 2023
[9] =>
news
Regarding oral health, the majority had more than 20 natural teeth, brushed their teeth less than once daily, used
mouthwash and had visited the dentist one to five times
in the past decade. The study revealed that HNSCC patients with more than ten natural teeth had better survival
compared with those with no teeth, and those with a history of more than five dental visits in the past decade had
better survival compared with those with no dental visits.
These associations were particularly pronounced in
patients with hypopharyngeal, laryngeal and unspecified
HNSCC. Other oral health factors like gingival bleeding,
toothbrushing frequency and mouthwash use showed
smaller survival differences.
These findings highlight the significance of natural dentition and frequency of dental visits as independent prognostic factors in HNSCC. Frequent dental visits were associated with early-stage HNSCC diagnosis, indicating
the potential for early disease detection and improved
survival. Geographic region was also found to be relevant
to survival, patients in South America and Europe experiencing better outcomes than those in North America.
Despite its strengths, the study had limitations. There
were variations in the definition and measurement of oral
health parameters across studies and a lack of infor
|
mation on post-treatment oral hygiene and alcohol consumption for some participants. Nevertheless, these results emphasise the importance of maintaining oral health
in HNSCC patients not only to prevent treatment-related
complications, but also to potentially improve survival.
Further prospective studies are needed to confirm and
expand upon these findings and to explore the underlying
mechanisms. Although the exact mechanisms linking
oral health to cancer remain unclear, hypotheses include
chronic trauma, oral inflammation and alterations in the
oral microbiome.
In 2020, there were 878,348 newly diagnosed cases and
444,347 reported deaths associated with this cancer.
There are regional variations reflecting differences in
the distribution of known risk factors, including smoking,
alcohol consumption, human papillomavirus infection
and socio-economic status.
Editorial note: The study, titled “Poor oral health influences
head and neck cancer patient survival: An International
Head and Neck Cancer Epidemiology Consortium
pooled analysis”, was published online on 19 September
2023 in the Journal of the National Cancer Institute,
ahead of inclusion in an issue.
AD
THE GLOBAL DENTAL CE COMMUNITY
REGISTER FOR FREE
www.dtstudyclub.com
DT Study Club – e-learning community
@DTStudyClub
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.
[10] =>
| interview
Prominent endodontist shares
expertise on treating patients
undergoing radiotherapy
An interview with Dr Josiane Almeida
By Franziska Beier, Dental Tribune International
The number of patients treated with radiation
therapy is growing as a result of improvements in
surgery and radiotherapy techniques. This means
more endodontists will be required to be part of a
team providing multidisciplinary treatment. Based
on your experience, what should clinicians know
about endodontic treatments before and after
radiotherapy in order to manage the oral health of
a patient?
Head and neck cancer poses a significant health chal
lenge on a global scale. Although radiation therapy is
highly recommended for cancer treatment, it may pro
duce adverse effects on the patient’s oral condition.
The high risk of osteoradionecrosis after radiotherapy
limits tooth extraction. Therefore, endodontic treatment
is a feasible option for managing oral health. Although
an effective root canal treatment avoids serious com
plications to the patient’s oral health, it is necessary to
know how to perform it and the ideal moment to choose,
taking into consideration all the concerns that arise as
a result of irradiation.
Dr Josiane Almeida
As cancer treatments evolve, clinicians of all disci
plines must also adapt their approaches to medical
and dental treatments in order to best compensate
for the powerful side effects of more robust treatment
options. Dr Josiane Almeida, researcher and lecturer
in the Department of Endodontics at the University
of Southern Santa Catarina and Federal University of
Santa Catarina in Brazil, will explain to attendees at the
2024 ROOTS SUMMIT how they can best adapt their
approaches for patients who have undergone head
and neck radiotherapy.
10
roots
2 2023
What are some of the specific implications of radiotherapy on endodontic treatment? Do endodontists have to change their treatment procedures in
order to treat previously irradiated areas?
The dental structure most affected by radiotherapy is
dentine, owing to its high organic content. Some of the
alterations are caused by a process called radiolysis,
leading to dehydration of the substrate, breakdown of
the odontoblastic extensions and collagen fibrils, and
cracks and fissures around the dentinal tubules. These
alterations make the dental structure more susceptible
to fracture and increase the dentinal roughness, which
in turn affects the interaction between the substrate
and microorganisms. Therefore, microbial colonisation,
followed by the establishment of a more complex and
structured biofilm, may occur. Bearing this in mind, en
dodontists need to redirect their treatment procedures
[11] =>
|
Athens © Nancy Pauwels/Shutterstock.com
interview
regarding patients who have undergone radiotherapy
in order to achieve endodontic success and restore
oral health.
There seems to be a debate about whether root canal
therapy or tooth extraction is the preferred option
for patients after radiotherapy. From your clinical
experience, what is your opinion on this topic?
The ideal course of action for treating a patient who has
been exposed to radiation should involve a collabora
tive effort between medical and dental professionals.
The treatment plan should be well thought out, taking
into account all potential risks to the patient. It is clear
that tooth extraction in radiation-exposed patients may
lead to osteonecrosis and other complications that
might harm the patient’s health. For this reason, end
odontic treatment is often the preferred option. None
theless, the top priority should always be the patient’s
overall well-being.
In your presentation, you will speak about future
treatment options for patients after radiotherapy.
Could you give a preview of what this will entail?
There is limited literature available on the combination
of endodontics and radiotherapy. We will not focus on
new treatment techniques, as in this sense endodontics
itself is already quite advanced, but rather on the damage
and structural changes that radiotherapy causes to the
dental structures. Additional topics include the way in
which such damage can be overcome and the ideal
time frame in which to perform endodontics in order to
obtain a more effective endodontic treatment with a
greater chance of success.
What will be the three main learning objectives of
your session at ROOTS SUMMIT 2024?
The objectives will be to address the alterations to dental
structures caused by irradiation, to examine irradiation’s
impact on endodontic therapy and to discuss appropriate
treatment approaches for the affected teeth.
What are you personally looking forward to at next
year’s ROOTS SUMMIT?
The event has been successful since its inception.
Although I have never before attended in person, I have
followed the entire event—speakers, topics covered
and excellent organisation—online. I am excited about
participating actively this time in Athens and joining the
team of speakers. I am confident that the event will pro
vide valuable knowledge for all attendees, as well as an
opportunity to network and share experiences.
Editorial note: The lecture by Dr Josiane Almeida, titled
“Effect of radiotherapy on dental structures: Current
clinic and future treatment perspectives” will be held
on 11 May 2024 from 11:00 a.m. to 12:30 p.m. More
information on the programme and registration can be
found at www.roots-summit.com.
roots
2 2023
11
[12] =>
© Saga Photo and Video/Shutterstock.com
| interview
How to handle complex
endodontic cases
An interview with Dr Ruth Pérez-Alfayate
By Franziska Beier, Dental Tribune International
Registration for ROOTS SUMMIT 2024 is open, and
the organisers would like to introduce some of the great
speakers and their lecture topics for next year’s event.
One of them is Dr Ruth Pérez-Alfayate, an associate professor at the Faculty of Biomedical and Health Sciences
at Universidad Europea in Madrid in Spain. In this interview, she introduces her lecture, titled “Complex diagnosis
in endodontics”, and explains why she decided to speak
at the congress.
Dr Pérez-Alfayate, in some of the more complex
endodontic cases, dental professionals have to use
invasive tests in order to be able to make a clear
diagnosis. For which cases are these invasive tests
appropriate, and how do dental professionals keep
a balance between invasive treatment measures and
the desire to keep the treatment minimally invasive?
These tests might be appropriate when there is doubt
about a vertical root fracture, when there is severe
pulpitis, when more than one tooth is suspected of this
pathology and is radiated, or when pulp necrosis needs
to be identified in a patient presenting with a low pain
threshold.
Dr Ruth Pérez-Alfayate
12
roots
2 2023
The balance, in my opinion, can be found when we
understand the expectations of our patients in the first
instance. Patient safety, the concept of “do no harm”
and minimally invasive treatment should prevail and must
[13] =>
|
interview
Are there any future developments in endodontic
diagnostics that you can tell us about?
Some researchers are working on various devices,
such as pulse oximeters, real-time ultrasound and ways
to evaluate the actual pulp status before conducting
treatment.
What will be the main learning objectives of your
lecture at ROOTS SUMMIT 2024?
I will describe a diagnostic protocol for endodontists
to enable them to understand which clinical situations
require a complex diagnosis, and I will propose how they
should act in these specific situations.
In some cases, even after the use of diagnostic tests,
the dental professional can be left with a high level of
doubt. What is the reason for this?
The reality is that currently we do not have any test that
is 100% objective. This means that one or two tests are
not sufficient. We need to find a diagnostic protocol that
gives us as much information as possible.
What are some of the endodontic diagnostic tests for
complex cases, and why can they be challenging?
The diagnostic tests include exploratory surgery, selective anaesthesia and cavity testing. Deciding when or
when not to use them is the challenge.
I know I will learn a great deal from the best and humblest
endodontists in the world. I am sure this will be a great
congress, and I hope to see as many people as possible
there. Do not miss it!
Editorial note: The lecture by Dr Pérez-Alfayate, titled
“Complex diagnosis in endodontics”, will be held on
10 May 2024 from 11:00 a.m. to 12:30 p.m. More information on the programme and registration can be found at
www.roots-summit.com.
© f11photo/Shutterstock.com
be a priority for us. All of these concepts can still be applied
even when we need to use invasive tests for diagnosis.
What made you decide to participate in the upcoming
ROOTS SUMMIT?
I have attended this congress many times, and I have
to say it is one of my favourites. Also, the organisers of
ROOTS SUMMIT are three people whom I admire greatly,
and when they ask you to come to their congress, it is
impossible to say no—it is an immense privilege.
roots
2 2023
13
[14] =>
| research
Comparative evaluation of apical
debris extrusion associated
with using reciprocating and rotary
systems with variable tapers
including single- and multiple-file sequences,
and the influence of the glide path
Drs Tanvi Paliwal, Lanka Mahesh, Gregori M. Kurtzman & Rohit Paul, India & USA
Introduction
The attainment of successful root canal cleaning and
shaping is dependent on the glide path and specific biological and mechanical objectives, which were beautifully
described by Herbert Schilder in 1974.1 To reduce the risk
of instrument fracture, root canal aberrations and transportation, it is recommended to create a glide path,
a smooth, possibly narrow passage from the coronal
orifice to the radiographic or electronically determined
terminus that allows instrumentation without resistance
for 3D cleaning and shaping without altering the canal
morphology.2, 3
Nowadays, most nickel–titanium (NiTi) instruments work
on torque control modes and employ different file designs and instrumentation techniques. Advancements in
designs include modifications to the tip, alterations of the
cutting edge, variations of the taper, changes in pitch
length, and heat and surface treatments, which enhance
efficacy and safety.4 These advancements allow better
control of root canal shaping, facilitating better irrigation
and obturation.
New-generation files also offer single-file or multiple-file
sequences, have offset or centred mass of rotation and
employ principles of rotary or reciprocating motion,
the clockwise and anticlockwise angles of which may
be equal or unequal. Offset-designed files produce a
mechanical wave of motion along the active length to
remove debris as well as offer flexibility.5
Instruments using reciprocating motion are beneficial in
narrow and more curved canals because of reduced
binding to the dentinal walls, reducing torsional stress.5
14
roots
2 2023
An example of such a system is WaveOne Gold
(Dentsply Sirona), which is a combination of second- and
third-
generation file systems and is made of M-Wire,
a special heat-treated NiTi alloy with gold technology to
increase flexibility and cyclic fatigue resistance.6 This is
a variable taper system.
File systems with continuous motion require less inward
pressure and fewer cycles and offer improved quality of
augering debris out of a canal. Such a file system with a
variable taper is One Shape (MicroMega), which has a
triangular cutting edge, asymmetrical cross sections over
the entire blade and a long pitch design that changes
progressively from three to two cutting edges between
the apical and coronal parts for cutting action. Additional
cutting edges are present in the apical and coronal parts.
One Shape is a single-file system. Also designed to
continuously rotate clockwise, the Mtwo instrument (VDW)
has an S-shaped cross section with two active cutting
surfaces and a constant taper. Another rotary system,
the HyFlex EDM file (COLTENE) has controlled memory
and is manufactured using electrical discharge machining.
This file has a quadratic cross section apically, trape
zoidal cross section in the middle and triangular cross
section coronally.7, 8
In this study, the influence of a glide path on apical debris
extrusion was investigated with reference to single- and
multiple-file sequences employing rotary HyFlex EDM a
single file system, One Shape, Neoendo [Orikam Healthcare],
Mtwo) and reciprocating systems (WaveOne Gold) with
different tapers. Quantification of apical debris was done
to deduce the effect of the instrumentation kinematics and
techniques. No previous single study has evaluated the
effect of glide path creation taking into consideration file
[15] =>
research
|
Table 1: Descriptive statistics of extruded debris for each group.
Group no.
n
Mean
SD
SE
Minimum
Maximum
IA
20
0.0248
0.02373
0.00531
0.0137
0.0359
0.00
0.10
IB
20
0.0372
0.03618
0.00809
0.0203
0.0541
0.01
0.13
IIAa
20
0.0162
0.02364
0.00529
0.0051
0.0272
0.00
0.11
IIAb
20
0.0008
0.00096
0.00022
0.0004
0.0013
0.00
0.00
IIAc
20
0.0293
0.01381
0.00309
0.0228
0.0357
0.01
0.06
IIAd
20
0.0035
0.00244
0.00055
0.0024
0.0047
0.00
0.01
IIBa
20
0.0214
0.04764
0.01065
–0.0009
0.0437
0.00
0.18
IIBb
20
0.0019
0.00103
0.00023
0.0014
0.0024
0.00
0.00
IIBc
20
0.0532
0.05456
0.01220
0.0277
0.0787
0.00
0.20
IIBd
20
0.0229
0.03160
0.00707
0.0081
0.0377
0.00
0.11
Total
200
0.0211
0.03313
0.00234
0.0165
0.0257
0.00
0.20
Materials and methods
Two hundred and twenty freshly extracted, single-rooted
human mandibular premolars with canals with mature
apices (25–30° curvature, according to
Schneider)
were selected and cleaned with an ultrasonic device.
The radii of curvature were 4–9 mm, and the apical
diameters corresponded to a #15 K-file, as observed
under a dental operating microscope at 25× magnifi
cation (Sanma Medineers Vision). Carious, fractured or
previously restored teeth or teeth with calcified canals
were excluded. The crown of each tooth was flattened
with a high-speed bur to obtain standardised tooth
lengths of 19 mm. Disinfection was done by immersing
the teeth in 0.1% thymol for 24 hours, and then the teeth
were stored in normal saline at room temperature until
required.
The apparatus used in Myers and Montgomery was
modified for debris and irrigant collection.9 Eppendorf
tubes and vials were pre-weighed with 10–5 g
precision on an electronic microbalance (SI-234,
Denver Instrument). The mean of three consecutive
readings was taken.
Access cavity preparation was done with a high-speed
round carbide bur (DIATECH, COLTENE) in all teeth.
A barbed broach (VDW) was used to remove the remnants
of pulp. The working length (WL) was 0.5 mm short of the
standardised tooth length. The crown-down technique
was used for biomechanical preparation.
The samples (N = 200) were divided into groups according
to instrumentation as follows:
– Group A (n = 100) for instrumentation with a glide path:
· Subgroup IA (n = 20): WaveOne Gold; and
· Subgroup IIA (n = 20 in each group): (a) Sub-subgroup
IIAa: HyFlex EDM; (b) Sub-subgroup IIAb: One Shape;
(c) Sub-subgroup IIAc: Mtwo; and (d) Sub-subgroup
IIAd: Neoendo.
– Group B (n = 100) for instrumentation without a glide
path:
· Subgroup IB (n = 20): WaveOne Gold; and
· Subgroup IIB (n = 20 in each group): (a) Sub-subgroup
IIBa: HyFlex EDM; (b) Sub-subgroup IIBb:
One Shape; (c) Sub-subgroup IIBc: Mtwo; and
(d) Sub-subgroup IIBd: Neoendo.
For Group A, the 19/.02 Neoendo glide path file was used
to create a glide path, using a brushing motion. For Groups A
and B, the canals were prepared in the same manner.
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2 2023
© Natali _ Mis/Shutterstock.com
design and taper and the number of files used regarding
apical debris extrusion.
95% confidence interval
of the mean
Lower bound
Upper bound
15
[16] =>
| research
Table 2: ANOVA test values.
Total sum of the square
df
Mean square
F
Significance
Between groups
0.050
9
0.006
6.230
0.000
Within groups
0.169
190
0.001
Total
0.218
199
The 25/0.06 WaveOne Gold file were used with a slow
in and out pecking motion, the 25/.12 and variable taper
25/~ HyFlex EDM files were used, the 25/.06 One Shape
file were used without pressure and with an in and out
motion, the Mtwo files were used in the sequence of
10/.04, 15/.05, 20/.06 and 25/.06, and the variable taper
Neoendo files were used in the sequence of 15/.02,
20/.04, 25/.04 and 25/.06 according to the manufacturers’ instructions. During instrumentation, each file was
removed after three pecking motions and cleaned with
gauze. Distilled water was used to irrigate the canals
using a 29-gauge side-vented irrigation needle. The
procedure was repeated until the file reached the WL:
as verified with an apex locator (Endo-Eze FIND Apex Locator,
Ultradent). A single operator performed all the pro
cedures to avoid any inter-operator variability.
The roots were rinsed with 1 ml distilled water to remove
debris adherent to the external surface of the roots
and collected in the Eppendorf tubes. The tubes were
incubated at 70 °C for five days to evaporate the irrigant.
The dry debris was weighed, and the mean of three
consecutive readings was recorded. The amount of
debris was calculated by subtracting the weight of the
pre-weighed empty Eppendorf tubes from the tubes
with debris after instrumentation.
Statistical analysis and results
Statistical analysis was performed utilising SPSS software (Version 16, IBM). A one-way analysis of variance
(ANOVA) and Tukey’s post hoc test were used to analyse
the data for multiple comparisons. The level of significance was taken as P < 0.05.
The results showed that the instruments tested caused
a measurable amount of debris extrusion apically.
The highest amount of debris extrusion was seen in
Sub-subgroup IIBc, and Sub-subgroup IIAb showed the
least amount of debris extrusion apically (Tables 1 & 2).
Discussion
This study highlights the role of root canal preparation
techniques, kinematics, the number of files used, file
16
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cross section, design, taper and motion, and glide path
on apical debris extrusion. During root canal preparation, even if the WL is controlled, the risk of extrusion
of fragments of pulpal tissue, dentine chips, necrotic
debris, microorganisms and intracanal irrigants beyond
the apical foramen is present. This can trigger an inflammatory reaction and thus result in postoperative com
plications. However, apical debris extrusion may differ
according to the instrumentation technique and the file
design.10, 11
Factors that could affect the extrusion of debris are
(a) natural physical factors, such as the anatomy of the
apical constriction, hardness of root dentine, quantity,
pressure and flow of the irrigation, and position of the
tooth; (b) mechanical factors, such as the final instrument, apical size, instrumentation technique, pitch
design, degree of rotation of the file (full rotation versus
reciprocation), speed, number of files used and
operator’s skill.12–14
Crown-down preparations with a file with a short pitch
design is advised, which results in less debris extrusion.15 Caviedes-Bucheli et al. suggest that instrument
design is the most influential factor rather than the number of files used and type of file motion.16 Side-vented
needles were used to reduce periapical extrusion of
debris and irrigant compared with open-ended needles.
The One Shape file system has a modified triangular
design with three sharp cutting edges in the apical and
middle parts as well as an S-shaped design with the
two cutting edges near the shaft, explaining the reduced
debris extrusion. However, the value for Sub-subgroup
IIAa was not significant compared with the values for
Sub-subgroups IIAb and IIBb. This may be because of
HyFlex EDM being a single-file system with controlled
memory and a variable cross-section design.17–19
In this study, the rotary file systems showed the least
debris extrusion, and efficiency was increased by using
glide path files. Improved coronal transportation of dentine
chips and debris was seen with continuous movement,
whereas reciprocating motion enhanced debris transportation towards the apex.20 Bergmans et al. advocate
the use of hand instruments before the use of rotary
[17] =>
research
Subgroup IA extruded less debris than did Subgroup IB
and Sub-subgroups IIAc and IIBc. To cut the dentine
forwards, WaveOne Gold uses anticlockwise rotation
and progressively shorter clockwise rotation to prevent
flexural fatigue of the file and to prevent locking into the
canal walls, reducing cyclic fatigue. The file’s reverse
cutting helix, distinct cross sections (parallelogram with
two cutting edges and one point contact) along the
length of the active portions, and tip diameters provide
greater flexibility of the file. The reduced debris extrusion
in Subgroup IA in comparison with Sub-subgroups IIAc
and IIBc may be because of WaveOne Gold having
a fixed taper at D1–D3 but a progressively decreasing
taper at D4–D16. The cross sections with changing
pitch and helical angle along the active portions serves
to preserve dentine. Fewer pecking motions were needed
to reach full WL with WaveOne Gold when a glide path
was created as was found in the study reported in this
article and supported by other studies.23, 24
With regard to kinematics, reciprocal motion appears to
increase the transportation of debris towards the apex,
whereas continuous rotation provides the coronal
transportation of dentine. Topçuoğlu et al. report that no
significant difference was seen regarding the type of
motion if a glide path was created beforehand.25 In this
study too, no significant difference was seen between
Subgroup IA and Subgroup IB. The same was found by
Gunes and Yesildal Yeter.26 Less debris extrusion was
seen with the reciprocating file system compared with
full-sequence rotary instrumentation, which is also
supported by this study.
Debris extrusion was less for file systems with variable
tapers. A variable taper ensures a deep shape and
predictable apical resistance. Whereas, file systems
utilizing a constant taper tend to force more debris out
apically.
Sub-subgroup IIAd had significantly less debris extrusion than did Subgroups IA and IB, and Sub-subgroups,
IIBc and IIAc, but this difference was not significant for
Sub-subgroups IIBb, IIAb, IIAa and IIBa. Neoendo files
undergo a proprietary heat treatment method which
does not cause the flutes to open as a result of stress.
Surface treatments of files result in superior cutting efficiency
of the files. Moreover, heat-treated file systems have improved flexibility and greater cyclic fatigue resistance.
It should be considered that there are no guidelines for
calculating the optimal final canal size preparation clinically.
The Scandinavian approach encourages larger apical
preparations, whereas the Peters approach advocates
more conservative apical enlargement. An increase in
apical diameter promotes debris extrusion.28
Limitations
The extruded debris was collected by a modified M
yers
and Montgomery method to make it simple, practical
and affordable. An extremely low amount of debris was
collected, requiring care to be taken by the operator,
avoiding contact with moist or greasy fingertips. Simulation
of periapical tissue was not done. Thus, different results
may be seen clinically. A difference in microhardness values of dentine may also have affected the study results.
The lack of vital pulp tissue or necrotic tissue that may be
present within
lateral canals and apical ramifications
could be another limitation.
Conclusion
Root canal instrumentation requires thorough biological
knowledge. In the present study, single-file systems with
variable tapers caused less extrusion of debris than did
multiple-file system with variable tapers. The reciprocating
file systems with a variable taper caused more debris
extrusion than did rotary file systems with variable tapers
but less debris compared with the rotary file system with
a constant taper. The creation of a glide path led to a
decrease in debris extrusion with both reciprocating and
rotary file systems. It is hoped that these study results
will help clinicians to take advantage of each particular
system to reach the goal of endodontics without com
promising the structural integrity of the tooth.
Editorial Note: Please scan this QR code
for the list of references.
about
Dr Tanvi Paliwal, MDS, is in private implant
practice in Delhi in India. She can be contacted at
tanvipaliwal1988@gmail.com.
Dr Lanka Mahesh BDS, MBA, is in private
implant practice in Delhi in India. He can be contacted
at drlanka.mahesh@gmail.com.
Dr Gregori M. Kurtzman, DDS, is in private practice
in Silver Spring in Maryland in the US.
He can be contacted at drimplants@aol.com.
© Natali _ Mis/Shutterstock.com
instruments, which also implies glide path preparation.21
Berutti et al. determined the role of a glide path for safely
shaping the canal before any instrumentation using
reciprocating motion.22
|
Dr Rohit Paul, MDS, is a lecturer in the Department
of Conservative Dentistry and Endodontics at the Faculty of
Dental Sciences of PDM University in Bahadurgarh in India.
He can be contacted at drrohitpaul@yahoo.com.
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2 2023
17
[18] =>
| industry report
On the pulse of endodontics
—the key role of new technologies
in root canal therapy
Dr Andreea Oana Cristescu Roşu, Romania
1
Fig. 1: Pre-op panoramic radiograph.
“Faster, higher, stronger”—this motto certainly no
longer applies only to the Olympic Games. How can
certain tasks be performed even more precisely,
even better, even more smoothly? Where can one
save precious minutes? And which techniques and
technologies can be of assistance here? What is in
Fig. 2: Dr Andreea Oana Cristescu Roşu at the microscope during treatment.
2
18
vogue in endodontics right now? What are the research and development teams in the dental industry
working on? What is the role of new technologies
in root canal therapy and its simplification, improvement and acceleration? These are the topics of this
article.
[19] =>
industry report
|
Using the correct files: The advantages of
electrical discharge machining technology
In some aspects, dentistry and Formula One are actually
not that dissimilar: if you do not expect the root canal
to make an abrupt turn during a treatment session, you
can quickly end up in the crash barriers here too. Even
a seemingly easy case can lead to complications—
fractured instruments, edges and ledges in the root
canal, tooth loss—which is precisely what one wishes
to avoid, particularly in endodontics.
Files manufactured using electrical discharge machining
(EDM) can prove helpful here. Manufactured using a
special EDM process, the HyFlex EDM files (COLTENE)
mainly differ from conventional files in that they are extremely flexible and exceptionally resistant to breakage.
Like the proven HyFlex CM files, the HyFlex EDM system
also features the controlled memory (CM) effect. For
this reason, HyFlex nickel–titanium (NiTi) files can follow
the anatomy of the root canal with great precision, thus
reducing the risk of ledge formation, apex transportation or
even perforation. Furthermore, the files can be prebent.
4a
4b
3
Fig. 3: Canal profile under the microscope.
This is particularly advantageous in root canals with
abrupt curvatures.
Owing to the special anatomy of the patient case presented next, flexible, pre-bendable and fracture-proof
files together with the appropriate technique were very
4c
Figs. 4a–c: HyFlex NiTi file system used during the treatment. 15/.04 HyFlex CM (a). 20/.04 HyFlex CM (b). 25/~ HyFlex EDM (c).
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2 2023
19
[20] =>
| industry report
This was due to a special dental anatomy that had not
been identified. In the middle of the root, about 13–14 mm
from the cusps, the root canal splitted into two different
canals (Vertucci Type V or deep split). This was easy to
see on the initial panoramic radiograph (Fig. 1), which is
why I decided to prepare the canals with HyFlex CM and
HyFlex EDM files and under magnification (Figs. 2 & 3).
This allowed me to follow the respective canal profiles
and preserve the root canals as far as possible through
optimal and centred preparation in each canal.
5
6
Fig. 5: Radiograph after the first treatment session. Fig. 6: Final radiograph
after obturation.
important. I therefore, decided to use the modular
HyFlex NiTi file system for preparation purposes.
The patient case: Vertucci Type V
When the 40-year-old male patient was referred to our
practice in the spring of 2018 with persistent complaints
regarding the mandibular left second premolar, he was
already rather frustrated. He had previously undergone
several endodontic treatments at another practice, unfortunately without success. He was suffering from an acute
periapical abscess and was in severe pain.
7a
7b
The treatment was performed in two appointments.
The first appointment involved preparation, cleaning
and interim medication with calcium hydroxide. After applying the dental dam to isolate the working field, the
25/.12 HyFlex EDM Orifice Opener and the 10/.05 HyFlex
EDM Glidepath files were initially used to open the canal
and create the glide path. The actual preparation was
performed with 15/.04 and 20/.04 HyFlex CM files followed by the 25/~ HyFlex EDM OneFile (Fig. 4). During
treatment, the canals were rinsed extensively with
CanalPro sodium hypochlorite and EDTA and dried with
the corresponding HyFlex paper points and the practical,
flexible Surgitip endodontic aspirator tips (COLTENE) before application of the calcium hydroxide dressing (Fig. 5).
Ultrasonic activation was also used to enhance the effect
of the irrigation solutions.
Root canal obturation and final restoration with a fibre post
were performed at the second appointment. The radiograph
confirmed that I had been able to treat both root canals
along the entire length of the tooth (approximately 23 mm)
with minimal loss of tooth structure and in the most
conservative manner possible (Fig. 6).
7c
Figs. 7a–c: Radiographic follow-up. Radiograph after three months (a). Radiograph after one year (b). Radiograph after three years. The patient attended
for professional dental cleaning, and some calculus can be seen on the image (c).
20
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[21] =>
industry report
7d
|
7e
Figs. 7d & e: Periapical radiograph after five years.
The follow-up appointments observed complete healing
of the treated tooth (Fig. 7). Together with the patient,
we decided that a crown was not necessary for the
moment.
The easy-to-remember sequence
can be recalled intuitively
Root canal therapy in a premolar may appear to be a fairly
straightforward procedure at first glance, but as the present case illustrates, even a supposedly simple treatment
can lead to complications and persistent pain without
careful analysis of the tooth anatomy. Therefore, it is
extremely important to pay the necessary attention to
the specific canal profile from the beginning and to use
appropriate instruments and techniques for further treatment. In cases of a deep split or other complex anatomies,
particularly flexible and fracture-proof files should be
used. In my experience, the files with CM effect from the
modular HyFlex file system are very helpful.
The present patient case furthermore illustrates that
treatment should never be rushed. This also contributes
to the patient being given the necessary attention for
successful dental treatment.
Next to choosing the correct files, employing the latest
technology simplifies treatment immensely. For example,
the CanalPro Jeni motor (COLTENE) can be used to
automate preparation and at the same time even determine the working length. Similar to a navigation system,
the motor reliably guides the user through the respective
root canal anatomy, and a preprogrammed sequence of
NiTi files can be easily selected via the touch screen.
Newcomers in particular benefit from the intuitive operation and software-supported analysis of the canal profile
by the fully automated endodontic motor.
With COLTENE’s new HyFlex EDM OGSF (Opener, Glider,
Shaper, Finisher) sequence, which was first announced at
this year’s International Dental Show in Cologne in Germany,
endodontic procedures will become even easier. Owing
to the defined, easy-to-remember sequence, learning
to use these files is relatively quick, and being intuitive,
the sequence is easily recalled and repeated.
Conclusion
New technologies in endodontics ensure that daily routines in the dental practice are continuously improved,
individual work steps are accelerated and treatment is
made more pleasant for everyone involved—the dentists,
assistants and patients.
about
Dr Andreea Oana Cristescu Roşu
is an assistant professor at
Titu Maiorescu University in Bucharest
in Romania. She graduated in dentistry
from the Victor Babeș University
of Medicine and Pharmacy in
Timişoara in Romania in 2007
and received her PhD in dentistry
(prosthodontics) in 2015. In 2014,
she founded the Nord Vest Dental private clinic in Bucharest.
With great passion, Dr Roşu shares her many years of
experience in the dental field and as a university lecturer with
other dentists, dental assistants, doctors and dental students
through various research groups. She has been involved as a
consultant and member of the Colegiul Medicilor Stomatologi
din Bucureşti (Bucharest college of dentists) since 2017 and
is an active member of the Asociația Română de Endodonție
(Romanian association of endodontics).
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21
[22] =>
| case report
The piston technique—a novel
approach to canal obturation
Drs Grzegorz Witkowski & Bartłomiej Karaś, Poland
1
Introduction
Up to now, the gold standard of obturation has been the
continuous wave compaction technique.1, 2 However, this
technique is difficult to perform and needs additional
expensive equipment. Another option is a newly re
invented technique of single-cone obturation with calcium
silicate-based sealers (CSBSs).3 Their properties are well
known. In general, these materials are biocompatible,
2
3
22
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2 2023
non-toxic, non-shrinking and chemically stable within
the biological environment.4–7 They also have the ability
to form hydroxyapatite during the setting process and to
create a bond between dentine and the filling material.3, 4
However, there is a lack of articles on this technique,
and research has focused on cone-less obturation
techniques with CSBSs.8
In this article, we would like to present a new approach
to obturation, the piston obturation technique, and share
our clinical experience with it, recommending it for most
clinical situations. The main benefit of this technique is that
one achieves a 3D seal with no gutta-percha points. This
is beneficial in cases of deep canal splits, ledges at apical
areas, broken instruments in the apical third, and canal
blockages and difficult anatomies in the apical zone.
The piston technique is simple and predictable. Once
the final preparation and irrigation protocol has been
performed, owing to the specific properties of CSBSs, the
canal should not be overdried. A small amount of moisture
should remain in the canal space as the catalyst for the
setting reaction of the sealer. With the application needle
[23] =>
case report
4a
4b
5a
5b
5c
6a
6b
6c
6d
introduced to the maximum level of the insertion, gently
eject the material from the syringe directly into the canal
space. To avoid extrusion, try not to block the needle in the
canal. After seeing the material in the canal space, remove
the needle and use a hot gutta-percha extruder to create
a plug in the coronal part. Next, push the coronal part of
the gutta-percha with the cold plugger towards the apical
zone. Do not push more than 1–2 mm (Fig. 1).
Case 1
The patient was referred to Dr Witkowski’s dental office
for endodontic treatment of teeth #31 and 41 (Fig. 2). After
examination, endodontic treatment was performed (Fig. 3).
6e
7
|
In tooth #41, the access cavity was done by the referring
dentist (Fig. 4a). In tooth #31, the access cavity was de
signed and performed (Fig. 4b). After this step, preparation
of the canal space was done, in tooth #41 up to 25/.04
and in tooth #31 up to 20/.04 with V
DW.ROTATE (VDW;
Figs. 5a–c). The next step was the irrigation protocol,
which was performed with an Er,Cr:YSGG laser (BIOLASE)
at 1.5 W and 100 Hz in both teeth. The canals were prepared
for obturation. In tooth #41, obturation was done with a single
point and CSBS, and in tooth #31, the piston technique
was performed (Figs. 6a–e). A control radiograph was
taken immediately after the treatment (Fig. 7). Healing of
the lesion was visible on the follow-up radiograph per
formed six months after the treatment (Fig. 8).
8
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23
[24] =>
| case report
24
9
10a
10b
10c
10d
10e
10f
11a
11b
Case 2
Case 3
The patient was referred to Dr Witkowski’s dental
office for removal of a broken file in the mesial canal
and the final endodontic procedure (Fig. 9). Owing to
difficulties and the risk of perforation, bypassing of the
file was suggested to the patient and she agreed.
Proper instrumentation was performed in both the
mesial and distal aspects using the R25 RECIPROC blue
(VDW; Figs. 10a–f). After this step, extensive irrigation
protocol was performed with sonic agitation and con
tinuous irrigation (Figs. 11a–d). The root canal system
was then prepared for obturation and obturated using
the piston technique (Figs. 12a–c). This technique is
capable of obturating even not mechanically instru
mented spaces and is very easy to use, especially
when there is an obstacle in the canal space such as
a broken file (Fig. 13).
A deep split in the canal is always challenging, especially
in situations where there is compromised access or limited
space. The patient came to Dr Witkowski’s dental office for
a routine procedure of caries removal and restoration (Fig. 14).
An initial radiograph was performed (Fig. 15). Initial removal
of caries was performed, and a gingivectomy was also
done owing to a deep carious lesion in the subgingival
area mesially (Figs. 16a–d). After isolation, restoration of
the mesial wall was performed according to the standard
protocol. After this, the access cavity was reshaped with
ultrasonic tips (Figs. 17a–d). Instrumentation was then per
formed with the R25 RECIPROC blue up to the level of the
split, and the split was prepared with the 12.5/.04 R-PILOT
(VDW; Figs. 18a & b). The final irrigation protocol was per
formed with copious amount of fluids (sodium hypochlorite
and citric acid with a final rinse of distilled water; Figs. 19a & b).
11c
11d
12a
12b
12c
13
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2 2023
[25] =>
case report
14
15
16a
16b
16c
16d
17a
17b
17c
17d
18a
18b
19a
19b
20a
20b
20c
20d
Obturation was performed with the piston technique, and the
restoration was done with composite material (Figs. 20a–d).
The patient was referred to the prosthodontist for final
21a
21b
|
restoration. On the final CBCT scan, it was clearly visible
that the piston technique had helped to obturate the deep
split in the apical area (Figs. 21a–d).
21c
21d
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2 2023
25
[26] =>
but the shape of the root canal was not clear (Fig. 22). The
examination was extended by CBCT imaging. The CBCT
scan revealed internal resorption in the mesiobuccal canal
and an isthmus and apical inflammatory root resorption in
the apical area of the mesial root (Figs. 23a & b). A cast post
and prosthetic crown were also noted.
22
Two treatment plans were presented to the patient, non-surgical
root canal retreatment and surgical root canal retreatment. After
intra-oral examination, the quality of the prosthodontic treatment
was found to doubtful (Fig. 24). The decision was made to
remove the crown and perform non-surgical retreatment.
23a
23b
Case 4
The patient was referred to Dr Karaś’s office for non-surgical
root canal retreatment of tooth #46. The tooth was symptomatic,
and the radiographic examination revealed a periapical lesion
around the mesial root. The periapical lesion was clearly visible,
After local anaesthesia, the crown was cut with a high-speed
handpiece (Fig. 25). The post was exposed and removed
(Figs. 26 & 27). The pulp chamber and root canal orifices were
examined for cracks. After inspection, a gingivectomy was per
formed (Fig. 28) and a dental dam (Kerr Dental) was placed (Fig. 29).
The dental dam was sealed with a temporary flowable material
(Fig. 30). After sealing the dental dam, the full adhesion protocol
with a sixth-generation self-adhesive primer and bonding agent
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
26
[27] =>
case report
was performed, and the pre-endodontic build-up was created
(Fig. 31). Residues of the cement and root canal filling materials were removed with a diamond-coated ultrasonic tip
(Woodpecker; Fig. 32). Patency was easily established with
hand files (VDW), and the canals were shaped with rotary mar
tensitic files (Poldent) up to 40/.04. Each step of instrumentation
was performed with lubricating cream containing EDTA (VDW;
Fig. 33). After each instrument, the canals were flushed with
5.25% sodium hypochlorite (Cerkamed). After reaching the final
sizes of the root canals, the irrigation protocol was performed:
three sequences of 5.25% sodium hypochlorite and 40.00%
citric acid (CERKAMED) activated with an ultrasonic file (MANI),
followed by 5.25% sodium hypochlorite activated with the ultra
sonic file for approximately 10 minutes (Figs. 34 & 35). The flow
of the liquid between both mesial canals was visible.
At this stage, one of the most important decisions had to be made
regarding the resorption and isthmus present in the mesial root.
On the one hand, in the case of non-penetrating internal resorp
tion, the material of choice is gutta-percha with a sealer. On the
other hand, in the case of apical inflammatory root resorption, it
is recommended to use mineral trioxide aggregate (MTA) or putty
materials. There is no problem with using these two materials in
the same root in most cases, but in this case, the canals were too
narrow to use the MTA comfortably and the quality of filling of the
isthmus that could be achieved was questionable.
From this point of view, a novel approach of placing a tricalcium
silicate-based sealer was a promising idea. The sealer was
placed in the previously described manner. The premixed
sealer in the plastic syringe (META BIOMED) was placed in the
mesiobuccal canal and the syringe depressed until it filled
the mesiolingual canal. The distal canal was filled separately.
In each canal, pistons from the previously heated gutta-
percha extruder were placed and the warm gutta-percha was
slightly compacted with stainless-steel hand condensers.
A periapical radiograph was taken to evaluate the quality of
the obturation. The bioceramic sealer was slightly extruded
through the resorbed apex into the periapical area (Fig. 36).
After the obturation, the chamber and orifices were cleaned
(Fig. 37). A resin core with fibre posts was placed, and the
temporary pink material was removed. The patient was
referred to the prosthodontist for final restoration.
|
Editorial note: Please scan this QR code for
the list of references.
about
Dr Grzegorz Witkowski graduated
from the Medical University of Warsaw
in Poland in 2003. Since 2004,
he has run a private practice in Olsztyn
in Poland focused on endodontics,
CAD/CAM and aesthetic dentistry.
He is a recognised international
speaker and the author of numerous
articles on advanced endodontics
and the use of CBCT, CAD/CAM, laser-assisted endodontics
and the microscope in everyday practice. He is author of the
book Procedury Endodontyczne (Wydawnictwo Kwintestencja,
Poland, 2022), in which he explains protocols for everyday
endodontics. He is a member of the European Society of
Endodontology and Polskie Towarzystwo Endodontyczne
(Polish association of endodontics). Dr Witkowski can be
contacted at grzegorzwitkowski@me.com.
contact
Dr Grzegorz Witkowski
Witkowscy Dental Clinic
Ul. Kazimierza Jaroszyka 8, 10-762 Olsztyn, Poland
grzegorzwitkowski@me.com
www.dentalkursy.pl
about
The recall appointment was performed after three years. The
periapical radiograph and CBCT scan revealed healing of the
periapical tissue and no resorption of the bioceramic sealer
(Fig. 38). The tooth remained asymptomatic.
Dr Bartłomiej Karaś graduated
in dentistry from Wrocław Medical
University in Poland in 2009. He is an
educator and the author of numerous
publications focusing on minimally
invasive endodontics. He is a vice
president of the endodontics section of
the Polskie Towarzystwo Stomatologiczne
(Polish dental association) and
a fellow of the European Society of Endodontology and the
World Federation for Laser Dentistry. Dr Karaś runs a private
dental practice limited to endodontics in Wrocław.
Conclusion
contact
The piston technique suggested in this article is a predictable
and efficient method of obturation of the canal space. It re
quires further research and discussion; however, it appears
to be especially promising in compromised cases with diffi
culties such as complex anatomy, foreign objects or pro
cedural errors during initial treatment.
Dr Bartłomiej Karaś
MAXDENT
Ul. Hallera 53/2, 53-325 Wrocław, Poland
karasdentysta@gmail.com
www.bkaras.com
roots
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[28] =>
| case report
Broken file management
with Er:YAG laser and
SWEEPS technology—a case series
Dr Bartłomiej Karaś, Poland
1
2
3
Case 1—Fig. 1: Pre-op radiograph. Periapical lesion and broken file visible. Fig. 2: Pre-op CBCT scan. Broken file far beyond the canal curvature.
Fig. 3: Pre-op CBCT scan. Tip of the broken file located below the junction of the mesiobuccal and mesiolingual canals.
Introduction
trieval and decide whether is it worth removing the broken
file, leaving it in place or trying to bypass it.1
Broken file management is one of the most challenging
parts of endodontic treatment. Regardless of whether the
clinician is faced with a retreatment involving retrieval of
the broken file or with a file breaking during the primary root
canal preparation, the situation usually affects the success
rate of treatment.
As is well known, one of the most important factors in root
canal treatment is the eradication of the biofilm. The broken
file is not a problem per se, but it is an obstacle to proper
disinfection. In some cases, removing the broken file
requires sacrificing a large amount of very precious peri-
cervical dentine. Therefore, in every case, the clinician has
to consider all the benefits and disadvantages of the re-
4
5
The advantages of SWEEPS technology
As mentioned, one of the most important factors of endodontic treatment is root canal disinfection. Usually around
the broken file, there is a great deal of accumulated hard-
tissue debris, and if the broken file is located in the middle
part of the root, the disinfection of the apical part of the
canal may be insufficient.
The novel SWEEPS (shock wave enhanced emission photoacoustic streaming) irrigation technique offers the clinician an
easier and more predictable means of managing broken
files. The basic principle of the technology is the delivery of
6
Fig. 4: Treated tooth after dental dam isolation. Damaged temporary restoration. Fig. 5: Tooth after removal of the temporary restoration. Fig. 6: Tooth after
removal of the caries and sealing of the chamber with flowable composite and dental dam.
28
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2 2023
[29] =>
case report
synchronised pairs of ultra-short pulses, which create primary
cavitation in the vicinity of the fibre tip, followed by secondary
cavitation in the remote, difficult-to-reach apical areas. This
phenomenon creates shock waves that spread in all directions at a speed of up to 10 m/s—so the impulse reaches
10 mm in depth in just 0.001 seconds.2 Moreover, the available data shows that the removal of accumulated hard-tissue
debris with the Er:YAG laser is very efficient3 and three times
more efficient than passive ultrasonic irrigation.4
Case 1
The patient was referred to the office after failure to retrieve
a broken file. After enlarging the canal and attempting to
remove the file, the previous operator gave up the treatment.
The tooth was symptomatic, so the patient wanted to proceed with the file retrieval and root canal treatment.
|
7
Fig. 7: Fotona 300/20 laser tip.
lenging. Thanks to SWEEPS technology and a bioceramic
sealer, an alternative approach could be taken.
The periapical radiograph and the CBCT scan revealed that
the file had broken far beyond the curvature in the mesiobuccal canal and below the junction with the mesiolingual
canal. Also, a periapical lesion was visible around the apices of the mesial and distal roots (Figs. 1–3). The length of
the file was approximately 5 mm. Bypassing the file through
the mesiolingual canal would have been a risky procedure
because it may have caused the fracture of the second instrument and the obturation may also have been very chal-
After performing anaesthesia and placing a dental dam, the
temporary restoration was removed (Figs. 4 & 5). The pulp
chamber was rinsed with 5.25% sodium hypochlorite and
the irrigant activated with ultrasonics. After cleaning the
chamber of the tooth, the dental dam and clamp were
rinsed with water and dried and flowable dental dam was
placed to seal the tooth and enlarge the space in the pulp
chamber for the laser-activated irrigation (Fig. 6). Activation
was performed with the SkyPulse laser (Fotona). The
AutoSWEEPS mode was chosen. The power of activation
was set to 1 W. The flat SWEEPS 300/20 fibre tip was used
(Fig. 7). The tip was placed slightly below the orifice of the
mesiobuccal canal for the majority of the irrigation with
sodium hypochlorite. After 120 seconds of activation with
sodium hypochlorite, the tip was placed in the pulp chamber
8
9
10
11
Fig. 8: Pulp chamber after the irrigation protocol. Fig. 9: Pulp chamber after obturation with the piston technique. Fig. 10: Post-op radiograph. Puffs of the
sealer visible. Fig. 11: Mesially shifted post-op radiograph.
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[30] =>
| case report
12
13
Case 2—Fig. 12: Pre-op CBCT scan. Periapical lesion visible. Fig. 13: Pre-op radiograph. Two pieces of the broken file visible.
to activate the sodium hypochlorite in all the canals simultaneously for 30 seconds. This procedure was continued
for 30 minutes. Only the distal canal was shaped with rotary
files, up to size 40/.04. Both mesial canals remained the
same size as they were before the file broke during the
primary treatment. Finally, the canals were flushed with
EDTA activated with AutoSWEEPS at a power of 0.4 W, and
sodium hypochlorite was activated for three cycles with
14
15
16
17
18
19
Fig. 14: Treated tooth after dental dam isolation. Fig. 15: Tooth after removal of the composite restoration. Fig. 16: Tooth after removal of the restoration.
Fig. 17: Tooth after removal of the caries and sealing of the chamber with flowable composite and dental dam. Fig. 18: First removed piece of the broken file.
Fig. 19: Second removed piece of the broken file.
30
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[31] =>
case report
|
utoSWEEPS at a power of 0.6 W and with a 30-second
A
break for the resting phase. The irrigant flow between the
mesiobuccal and mesiolingual canals was rapid, indicating
that obturation could be performed.
The canals and chamber were dried with micro-suction and
paper points (Fig. 8). A bioceramic sealer (CeraSeal, META BIOMED)
was used in the piston technique. The sealer was injected in
all canals and covered with flowable gutta-percha in the
orifices (Fig. 9). Periapical radiographs were performed, and
they revealed that the root canals had been filled correctly,
showing puffs of sealer in the periapical area (Figs. 10 & 11).
20
21
22
23
Case 2
The patient came to the office because of moderate pain
connected with the mandibular right first molar. A periapical
radiograph and CBCT scan were performed. The images
revealed radiolucency around the mesial root of the molar.
Also, two pieces of a broken instrument were visible, one in
the middle part of the root, before the curvature, and the
other slightly below the curvature (Figs. 12 & 13).
After performing anaesthesia and placing a dental dam, the
composite restoration was removed, and a temporary restoration with flowable composite and flowable dental dam for the
root canal treatment was performed (Figs. 14–17). After removing the filling material from the mesiolingual and distal canals,
access to the broken file was performed. The first piece of the
instrument was removed with the ultrasonic tip (Fig. 18), and the
tip of the second piece of the file then became visible. Unfortunately, the removed file piece broke in the middle and only the
coronal part could be retrieved (Fig. 19). Because the apical part
of the broken file was invisible and did not emerge from the
canal during the irrigation and activation, an attempt at bypassing
it was made. Analysis of the CBCT scan did not reveal a clear
answer as to whether there was one apical foramen, so during
the bypass procedure through the mesiolingual canal, a periapical radiograph was performed. The radiograph indicated
that either there was a ledge in the apical area or there were
two separate apical foramina (Fig. 20). For the irrigation protocol, the AutoSWEEPS mode was used at 1.2 W power with the
flat SWEEPS 300/20 fibre tip. The tips of both mesial canals
were placed below the orifice. The Less-Prep Endo protocol
was performed twice in the manner described elsewhere.5 After
the irrigation, irrigant flow between both canals was rapid.
The canals were dried with paper points and micro-suction
(Fig. 21). After the irrigation protocol, there was still a lack of
patency and tugback was achieved only in the mesiolingual
canal. The mesiobuccal and distal canals were filled with an
epoxy resin sealer and warm gutta-percha (squirting technique), and the mesiolingual canal was filled with a 30/.04
gutta-percha cone with the continuous wave of condensation technique (Fig. 22). A distally shifted periapical radiograph was performed (Fig. 23). The radiograph revealed a
puff of sealer in the periapical area of the mesial root and
Fig. 20: Intra-op radiograph confirming lack of bypass and of patency.
Fig. 21: Pulp chamber after the irrigation protocol. Fig. 22: Pulp chamber
after obturation. Fig. 23: Post-op radiograph. Puff of the sealer visible.
the isthmus filled with the sealing material. A composite
material was placed into the access cavity, and the patient
was scheduled for the control appointment.
At six months and 12 months, CBCT scans were performed
(Figs. 24 & 25). The images found no signs of inflammation
in the periapical area, and the tooth was asymptomatic.
24
25
Figs. 24: CBCT scan at the six-month follow-up. Fig. 25: CBCT scan at the
12-month follow-up.
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31
[32] =>
| case report
26
27
Case 3—Fig. 26: Pre-op CBCT scan. Two apical lesions visible. Fig. 27: Pre-op radiograph. Broken files visible.
28
29
30
31
32
33
Fig. 28: Treated tooth after dental dam isolation. Fig. 29: Tooth after removal of the caries and sealing of the chamber with flowable composite and dental dam.
Fig. 30: Removal of the gutta-percha. Fig. 31: Apparent over-instrumentation of the root canal orifice, probably performed with ultrasonics during a previous
attempt at broken file removal. Fig. 32: Root canal orifice sealed with flowable composite. Fig. 33: View of the two broken files together in the mesiobuccal canal.
Case 3
The patient was referred to the office for root canal retreatment of three teeth before prosthodontic treatment.
One of these teeth was the mandibular left first molar. The
CBCT scan revealed two radiolucent spaces around
both roots (Fig. 26). Moreover, the periapical radiograph
showed a broken file in the mesiobuccal canal (Fig. 27).
34
35
32
roots
2 2023
After performing anaesthesia and placing a dental dam,
the old restorations were removed, a temporary composite build-up was performed, and the tooth was sealed
with flowable dental dam (Figs. 28 & 29). The old gutta-
percha cones were removed from all the canals (Fig. 30).
After the removal of the gutta-percha and cleaning of the
root canals, it was apparent that a large amount of the
dentine had been removed from the orifice of the mesiobuccal canal (Fig. 31). Most probably, this had occurred
during an attempt at removing the broken file in the previous treatment. Fortunately, there were no visible signs
of perforation in the orifice. The damaged wall was
Fig. 34: One of the retrieved file pieces in the lasso tool. Fig. 35: Intra-op
radiograph. All pieces of the broken files had been removed.
[33] =>
case report
36
38
|
37
39a
39b
Fig. 36: Pulp chamber after the irrigation protocol. Fig. 37: Pulp chamber after obturation. Fig. 38: Post-op radiograph. Figs. 39a & b: CBCT scan at the
12-month follow-up.
sealed with composite resin (Fig. 32). Irrigation of the
mesiobuccal canal with the AutoSWEEPS mode and
sodium hypochlorite and inspection under 16× magnification revealed two pieces of the broken instruments
(Fig. 33), complicating treatment. The tips of both files
were visible, but both were also jammed. An attempt
at removal with an ultrasonic file was ineffective, so the
flat SWEEPS 300/20 fibre tip was used with the
AutoSWEEPS mode at a power of 1.2 W. After a few minutes of irrigation with sodium hypochlorite and EDTA,
both file pieces started to move a little, indicating that
both were removable. Both pieces were retrieved with a
lasso loop tool (BTR Pen, CERKAMED; Fig. 34). A periapical radiograph was performed to confirm that there
were no more broken file pieces (Fig. 35).
vative treatment in many cases. In some cases, we can
loosen the file without using ultrasonic tips, allowing us
to be more conservative. Moreover, thanks to the much
more effective reduction of accumulated hard-tissue
debris, we can clean the space around the broken file
to avoid removing the file (for example, if the file broke behind the curvature) and still have successful treatments
with less risk of creating perforations in the classic
approach to file retrieval.
After the file retrieval, all the canals were shaped with
rotary files, and the final irrigation protocol was performed
with the SSP (super-short pulse) mode. After the irrigation
protocol, irrigant flow between the mesiobuccal and
mesiolingual canals was rapid. The canals were dried.
We could clearly see that the orifices of the mesial canals
were of very similar ISO size, indicating that the file retrieval had been very conservative (Fig. 36). The canals
were filled with an epoxy resin sealer and gutta-percha
with the continuous wave technique (Fig. 37). A distally
shifted periapical radiograph was performed, and on it,
we could see in the mesial root that two parts of the
isthmus had been filled with the sealer (Fig. 38). The tooth
was restored with a fibre post and referred to the
prosthodontist for indirect restoration.
about
After 12 months, a CBCT scan was performed (Fig. 39).
The image found no signs of inflammation in the peri
apical area, and the tooth was asymptomatic.
Conclusion
Incorporating the Er:YAG laser into challenging endodontic treatments gives clinicians new possibilities, allowing
them to achieve more effective, predictable and conser-
Editorial Note: Please scan this QR code for
the list of references.
Dr Bartłomiej Karaś graduated
in dentistry from Wrocław Medical
University in Poland in 2009. He is an
educator and the author of numerous
publications focusing on minimally
invasive endodontics. He is a vice
president of the endodontics section of
the Polskie Towarzystwo Stomatologiczne
(Polish dental association) and
a fellow of the European Society of Endodontology and the
World Federation for Laser Dentistry. Dr Karaś runs a private
dental practice limited to endodontics in Wrocław.
contact
Dr Bartłomiej Karaś
MAXDENT
Ul. Hallera 53/2
53-325 Wrocław
Poland
karasdentysta@gmail.com
www.bkaras.com
roots
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[34] =>
| case report
Chairside fabrication of a
nano-ceramic hybrid composite
endocrown for a severely damaged
molar after endodontic treatment
Drs Alejandro Bertoldi Hepburn & Matías Scazzola, Argentina
Introduction
Many authors recommend not using endodontic posts
in the reconstruction of endodontically treated molars,
as they are not necessary for the retention of the restoration or for a better mechanical prognosis.1, 2 For the
restoration of severely damaged endodontically treated
molars, endocrowns made of highly filled nano-hybrid
composites are a valid alternative to conventional
post build-ups and fixed dentures. Compared with
conventional methods, endocrowns offer good aesthetics, better mechanical performance, lower costs
and less clinical time for their fabrication, among other
advantages.3, 4
Endocrown restorations are luted by adhesive cementation using the enlarged pulp chamber and the remaining coronal structure as the most effective retention area.5 This minimally invasive treatment concept
has shown the following advantages in comparison
with the classical post and core approach: preservation of healthy tooth hard tissue, reduced risk of catastrophic failures such as root fractures or perforation
while preparing the post space, lower contamination
of the endodontic system, fewer failures in creating the
necessary adhesive interfaces, no need for excessive
interocclusal space, fewer clinical appointments and
lower costs of treatment.
The longevity of these restorations is similar or even
better than that of conventional restorations on glass
fibre-reinforced composite posts.6, 7 Compared with
the insertion of posts, endocrowns are considered
a more conservative approach that allows easier reintervention and access to root canals and that has
reduced technical steps during fabrication (avoiding
34
roots
2 2023
cementation of the post, creating a core build-up, producing a provisional crown, etc.), reducing treatment
time and costs and the risk of endodontic reinfection.8
This article presents the endodontic retreatment and
coronal restoration of a badly damaged mandibular
molar using a nano-ceramic hybrid composite block for
the fabrication of an endocrown by means of a CAD/CAM
technique.
Case, diagnosis and treatment planning
A 40-year-old male patient came to our endodontics
department at the University of Buenos Aires’ School
of Dentistry in Argentina due to toothache. At the intra-
oral examination, the restoration on tooth #46 presented with a mesial fracture. The preparation margins
showed a clear marginal gap all around the restoration,
indicating possible microleakage. The massive loss of
dental hard tissue was particularly evident on the lingual side, and on the buccal side, the enamel margin
was discoloured from grey to brown. The interproximal
contact points between tooth #46 and neighbouring
teeth had been lost. Teeth #47 and 45 appeared to be
tipped towards the first molar.
The reason for the spontaneous pain was the endodontically treated tooth #46, which had been previously restored with an amalgam filling. There was also
inflammation in the apical area of the molar evident
from the intra-oral palpation.
In the radiographic examination, the amalgam restoration showed open margins, especially on the mesial
side (Fig. 1). The endodontic treatment was defective:
the root canal preparation appeared to have been inadequate, and both the 3D seal and the working length
[35] =>
case report
1
2a
2b
|
3
Fig. 1: Radiograph of the pre-op situation showing insufficient endodontic treatment of tooth #46. Additionally, an amalgam coronal restoration with
microleakage was detected. There were also apical lesions evident around both roots. Both neighbouring teeth had migrated towards tooth #46 and closed
the interproximal spaces. Figs. 2a & b: Radiographs of the endodontic treatment. Working length control (a). Check of the extension of the Master gutta-percha
points (b). Fig. 3: Post-op results of the endodontic treatment. A proper 3D seal had been achieved. The working length and sealing had been corrected.
The extra distal root canal had been found, treated and sealed.
were insufficient. A canal in the distal root seemed not
to have undergone any endodontic treatment. Irregular root morphology compatible with hypercementosis
was observed in the apical half of the roots of tooth #46,
showing an increase of volume of a round shape.
A widening of the periodontal space over almost all of
its extent could also be observed. A significant apical
lesion of the distal root and a smaller one of the mesial
root were revealed as well.
The patient was diagnosed with a defective amalgam restoration on endodontically treated tooth #46
with microleakage, acute periapical periodontitis with
spontaneous pain, and a ball-shaped morphology of
both roots (hypercementosis). The tooth required endodontic retreatment and a new coronal restoration.
Endodontic retreatment and immediate fabrication
and insertion of the definitive coronal restoration were
planned to be carried out in the same clinical session.
The clinical situation and the intended therapy were
explained to the patient, and the patient accepted the
therapy recommended.
Timeline of treatment steps
The first step was the endodontic reintervention. After
local anaesthesia, the operative field was isolated with
a dental dam, and a dental dam clamp was placed
around tooth #46. The old amalgam was removed,
taking care to preserve sound tissue. Once the endodontic filling had been reached, remnants of amalgam and cement were carefully removed. The endodontic filling was removed with rotary instruments
for canal shaping and retreatment (ProTaper Universal
retreatment files, Dentsply Sirona). The coronal third
was treated with the D1 file (30/.09), the medium third
with the D2 file (25/.08) and the apical third with the
D3 file (20/.07). An entirely mechanical removal proce-
dure was performed to avoid the use of endodontic
solvents. The non-treated root canal in the distal root
was located and manually prepared with size 15, 20
and 25 K-files. The same files were used for the radiographic check of the working length, which was measured with an apex locator (Fig. 2a).
Once the working length had been determined, the root
canals were prepared and cleaned with the ProTaper
Next system (Dentsply Sirona). This system has three
main files, X1, X2 and X3, with a variable taper. Before
moving to the next file in the sequence, the root canals
were irrigated with a 2.5% sodium hypochlorite solution
(EndoActivator, Dentsply Sirona).
After shaping, irrigation with a 17% EDTA solution was
performed for 1 minute in the root canals, this anti
bacterial solution being indicated for removal of the
smear layer. Final irrigation was done with a 2.5% sodium hypochlorite solution. The root canals were finally
dried with sterile paper points.
ProTaper Next Conform Fit gutta-percha points
(Dentsply Sirona), matched to the size of the canals prepared with ProTaper Next files, were inserted in each
root canal and checked with an intra-oral radiograph
(Fig. 2b). The root canals were then filled by means of a
lateral condensation technique with cold gutta-percha
and manual spreaders. Accessory gutta-percha points
and an endodontic sealer (ADSEAL, Meta Biomed)
were used as well.
Once completed, the gutta-percha points were cut
manually with a hot instrument. After cleaning the
dentine surface of the pulp chamber floor, a radiographic control was carried out (Fig. 3). The results
were promising. The radiograph showed properly prepared, well-filled root canals, including the canal in the
roots
2 2023
35
[36] =>
| case report
4
5
Fig. 4: Situation immediately after root canal filling. Gutta-percha needed to be cut properly. Poor condition of the residual dentine. No longer any enamel on
the distal area. Fig. 5: Large volume of the enlarged pulp chamber. There were undercuts over the lingual wall. The remaining tissue was thin.
critical distal root. In all four root canals, the working
and filling lengths were now well established.
adhesion to the floor of the pulp chamber; hence, this
was done under the microscope (Fig. 6).
After the endodontic retreatment, a great loss of tissue was observed in the coronal part of the molar,
including the loss of enamel in the distal and lingual
sides of the tooth crown, and the residual dentine was
thin and strongly discoloured (Fig. 4). Nevertheless,
the area that would serve for adhesive bonding to
the planned endocrown was large and voluminous.
This space, an enlarged pulp chamber, consisted of
the original pulp chamber augmented by the access
cavity, endodontic instrumentation and iatrogenic
tissue removal (Fig. 5).
Since some excess material had accidentally been left
behind, 1–2 mm of gutta-percha inside each root canal
was removed using the tip of an ultrasonic device
without water cooling and with manual excavators.
Removing excess gutta-percha and cleaning away the
endodontic sealer are important steps for enhancing
The next step was the covering of the floor of the enlarged pulp chamber and its walls with a flowable
composite material in order to close the access to the
root canals, to fill the undercuts and to shape the final
preparation. Pretreatment with total etching using 37%
phosphoric acid of enamel and dentine was carried
out over the enlarged pulp chamber for 15 seconds,
the phosphoric acid was aspirated and the conditioned
surface rinsed for 20 seconds (Fig. 7a). Afterwards,
a universal dual-polymerising adhesive (Futurabond U,
VOCO) was applied to the conditioned surface, which
had been dried off according to the instructions for
use (Fig. 7b). The adhesive was rubbed carefully for
20 seconds and dried for at least 5 seconds with a gentle air
stream for the evaporation of the solvent and remaining
water. Light polymerisation of the adhesive was then
performed for 10 seconds with a high-power LED curing
light (Celalux 3, VOCO).
6a
7a
6b
7b
Figs. 6a & b: Gutta-percha cut by 1–2 mm inside each root canal with an ultrasonic tip and manual excavators. Figs. 7a & b: Etching of the dentine and enamel
with phosphoric acid (a). Application of a universal adhesive after rinsing and drying (b).
36
roots
2 2023
[37] =>
case report
8
9
|
10
Fig. 8: Floor of the cavity and undercuts covered and sealed with Rebilda DC. Fig. 9: Polymerising of the core build-up composite with the Celalux 3.
Fig. 10: Cavity shaped, excess material removed and margins smoothed.
Subsequently, a layer of a dual-curing core build-up
composite (Rebilda DC, VOCO) was applied over
the cavity floor and the lingual wall where the
undercuts were present (Fig. 8). The build-up
material was light-cured immediately thereafter
(Fig. 9) and the cavity reshaped (Fig. 10), resulting in
a smooth floor and preparation margins and a voluminous enlarged pulp chamber. The residual tissue,
especially the enamel over the mesial side, could be
preserved.
Owing to the loss of interproximal contact points that
had occurred in the previous years, both teeth #47
and 45 had tipped towards tooth #46, bringing it into
contact with them subgingivally. After their separation
with a thin diamond bur, the appropriate space needed
was recreated to allow proper coronal restoration of
tooth #46. Finishing and polishing reciprocating tips
for the EVA system (KaVo Dental) were used afterwards to smooth and polish the reduced interproximal
surfaces. Immediately thereafter, the dental dam was
removed and retraction cord was placed around the
molar (Fig. 11). A digital impression was carried out
using the CEREC Omnicam (Dentsply Sirona; Fig. 12),
11
12a
capturing the preparation margins of the endocrown
cavity perfectly.
After general design of the restoration, the impression file was transferred to another design program
(exocad) in order to digitally generate the restoration
(Fig. 13). After completion of the digital design of the
endocrown, the file was returned to the CEREC system. Once this had been done, the restoration was
fabricated by milling a block of a highly filled nano-
ceramic hybrid material (Grandio blocs, VOCO; Fig. 14).
The processing of the composite block took about
10 minutes. Afterwards, a light-curing characterisation material (FinalTouch, VOCO) was applied
to pretreated furrows and fissures (Fig. 15), light-
cured and occlusally covered with a packable or
flowable composite (or a mixture) and light-cured.
The endocrown was polished with rubber points and
brushes (Figs. 16 & 17).
During the CAD/CAM of the restoration, the patient
remained in the clinic. Once the restoration had been
finished, it was taken to the clinic, disinfected in alcohol for 3 minutes and tried in the cavity. The fit was very
12b
Fig. 11: Final preparation prior to taking the digital impression, for which retraction cord had been placed. Figs. 12a & b: Margins and various details of
the cavity preparation well captured in the digital impression.
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| case report
13a
13c
13b
13d
Figs. 13a–d: Design performed in exocad (a & b). Restoration digitally placed inside the block to support the milling process (c & d).
precise and so was the occlusal relationship, so no
adjustments were done. The restoration covered the
remaining tissue, and the portion inserted in the enlarged pulp chamber was voluminous to guarantee the
retention of the endocrown and protect the residual
dental tissue.
After several try-in tests, the adhesive luting could take
place. For this purpose, the inner surface of the endocrown had been previously roughened through
sandblasting with 50 µm aluminium oxide particles at
100–200 kPa, cleaned using brushes and distilled
water and detergent, rinsed with water and dried with
air stream (Fig. 18a). Thereafter, a silane coupling agent
(Ceramic Bond, VOCO) was applied and let dry for
60 seconds (Fig. 18b). Once again, retraction cord
was placed in the gingival sulcus to displace the free
gingivae and prevent fluids from affecting the adhesive process, and Teflon tape was used to protect the
neighbouring teeth (Fig. 19).
The newly covered cavity was etched with 37% phosphoric acid, rinsed with water, dried and pretreated
with Futurabond U. A dual-curing cementation composite material (Bifix QM, VOCO) was applied to the
endocrown (Fig. 20) so that it could be luted in the
tooth. After application of continuous light pressure,
38
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it was fitted into place correctly. Excess cement was
removed with micro-brushes from the lingual and buccal sides and with dental floss from the interproximal
spaces. The material was then light-cured for 1 minute
from the lingual and buccal sides. The margins were
optimised with finishing diamond burs and polished
with rubber points and brushes. The interproximal
spaces were checked for excess material. The occlusion was checked, and no adjustments were needed
(Figs. 21 & 22).
Results
The endodontic retreatment and endocrown restoration of a badly damaged molar were carried out in
a single clinical session. Postoperative clinical photographs and radiographs verified the results of the treatment: the molar recovered its anatomical forms and
thus its function.
The endocrown restoration and the build-up material
occupied the enlarged pulp chamber completely;
the access to the root canals was thus closed hermetically. The margins of the endocrown also showed an
adequate seal. The tight seal of the restoration will play
a crucial role in the long-term results of the endodontic
treatment.
[39] =>
case report
14
|
15
Fig. 14: Milling of the block in the milling machine. Fig. 15: Application of white stains to characterise the colours of the restoration.
Regarding the endodontic retreatment, the preparation and seal of the root canals were appropriate,
a suitable 3D seal was achieved and the working
length was corrected. Also, the previously untreated
root canal in the distal root was properly prepared and
sealed (Fig. 23).
The microscope-assisted cleaning of the gutta-percha
and endodontic sealer are expected to enhance the
adhesion over the floor of the cavity.1 The quality of
the coronal restoration is at least as important for peri
apical health as the quality of the endodontic treatment
itself.9
Discussion
In one clinical session, the badly damaged tooth #46 was
endodontically retreated and restored with an endocrown
fabricated chairside by means of CAD/CAM technology.
This combination is both time- and money-saving.
In the case of endodontically treated teeth, several
advantages result from carrying out the definitive
coronal restoration in the same session as the post-
endodontic treatment of the root canals.10 It ensures a
better coronal seal and increases the success of the
endodontic treatment. Moreover, the time between
the root canal filling and the coronal restoration should
be as short as possible to avoid root canal recontamination.11 Better mechanical protection is provided to
residual tissue from the very beginning of the process if a definitive restoration is inserted in the same
session. In fact, the probability of dislodgement of the
definitive restoration is much lower compared with
that of a provisional one. The final function of the tooth
is restored from the very beginning of the process,
16
17
The radiographically diagnosed hypercementosis
of tooth #46 was a factor with no therapeutic con
sequences. This hyperplastic formation of radicular
cementum could have arisen from irritation of infected
root canals and/or by the hyperactivity or hypoactivity
of the tooth root due to dysfunctional occlusal forces
associated with the defective anatomy of the old
restoration.
Fig. 16: Occlusal surface of the finished endocrown. Fig. 17: Inner surface of the endocrown. Note the extensive portion for bonding in the enlarged pulp
chamber preparation of the molar.
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| case report
18a
18b
19
Figs. 18a & b: Inner surface of the endocrown after sandblasting with aluminium oxide particles, followed by cleaning of the surface with distilled water and
detergent (a). Application of Ceramic Bond (b). Fig. 19: Tooth ready for the adhesive pretreatment with Futurabond U. Teflon tape protecting the neighbouring
teeth and retraction cord placed.
subsequently offering greater comfort to the patient.
Patients normally appreciate having the process finished in just one clinical appointment although it is a
longer session.
The material of choice for this endocrown was a
prepolymerised highly filled nano-ceramic hybrid
composite. Together with lithium disilicate-reinforced
glass-ceramics, feldspathic ceramics and polymer-
infiltrated feldspathic ceramics (hybrid ceramics), highly
filled nano-hybrid composites are considered among
the most suitable for the fabrication of endocrowns.
Case reports and clinical studies have shown additional advantages of the fabrication of endocrowns with
nano-ceramic hybrid composite like the one used for this
case: the greater elasticity results in higher absorption
of mechanical stress and thus higher protection of
weakened tooth tissue.8, 12, 13
Compared with a conventional provisional indirect
restoration made of regular composite inserted and
20
21
polymerised over a plaster model, an industrially
polymerised highly filled nano-ceramic hybrid composite
such as Grandio blocs used in this case shows
better physical and mechanical properties13 and features a higher degree of polymerisation. The higher
degree of polymerisation reduces water absorption
and degradation in the oral environment. A restoration made from Grandio blocs is expected to have
a higher fracture resistance, no chipping fractures
and no deformation (because it is prepolymerised).
Compared with analogue procedures, the CAD/
CAM approach adds precision to the final restoration.12
The cavity preparation is also a sensitive aspect
when working with endocrowns. Butt joint occlusal margins are preferred, and axial reduction is not
recommended.2, 4 Some recent investigations have
suggested that butt joints implemented with 20° bevels
are more effective than flat butt joints.14 In this case,
no axial reduction was performed.
22
Fig. 20: Cementation of the restoration with Bifix QM after acid etching, rinsing and drying of the tissue and core build-up composite and application of Futurabond U.
Fig. 21: After placement of the restoration and removal of excess adhesive cement and polishing of the margins and the surface. Fig. 22: After polishing
of the occlusal surface. The gingivae had been injured and needed to heal.
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[41] =>
case report
|
Subgingival preparation margins must be accessible,
and this can be achieved, among other methods,
by placing retraction cord before taking conventional
or digital impressions. No contact should be present
between the cavity and the adjacent tooth. The occlusal space should be adequate as well and have been
carefully checked previously.12
According to various studies, the adhesion protocol
when cementing the restoration is also crucial.
The dentine of an endodontically treated tooth and
especially the dentine of the root canal and of the
floor of the pulp chamber might represent an altered
substrate, offering lower adhesive power.15 Clinically,
tooth #46 had become brown and translucent because
several years had passed since the tooth had lost its
vitality. Research indicates that dentine in this condition
might have modified collagen (lower density collagen
with short and cut fibres). This could negatively affect
the adhesive technique when depending exclusively
on the collagen fibre–adhesive–hybrid layer. Dentinal
tubules should be open in order to generate resin tags
and compensate for the loss of adhesion due to the
poor quality of the collagen.16
In this clinical situation, by the time the restoration
process had started, the dentinal tubules were open,
endodontic treatment having just been completed
and before the adhesive post-endodontic treatment.
Here, it was important not to use rotary instrumentation for removing the excess gutta-percha, as
this would have generated a secondary smear layer.
This is more difficult to dissolve, the usual smear layer
being associated with plasticised gutta-percha and
endodontic sealer.17 Thus, for such cases, the use of
ultrasonic tips and hand instrumentation is preferable for removing excess gutta-percha. Excess endo
dontic sealer should also be carefully removed with
alcohol or a detergent substance using micro-brushes
or sponges (e.g. Pele Tim, VOCO). Carrying out total-
etch conditioning using a 35–40% phosphoric
acid gel after removing gutta-percha and sealer
excess will also help keep the dentine clean and its
tubules open.
Conclusion
Performing the restoration immediately after endodontic
treatment ensures a better and immediate coronal
seal, ensures immediate protection of the sound tissue, saves time, and offers comfort and confidence
to the patient and the clinician. Endocrowns made of
the highly filled nano-ceramic hybrid composite G
randio
blocs represent a new alternative for treating badly
damaged teeth, especially molars, while freeing the
dentist from the use of root posts. In vitro and clinical
studies as well as clinical experience with this material
23a
23b
Figs. 23a & b: Radiographs before (a) and after (b) treatment, showing
dramatic differences. The endodontic treatment had been corrected and
the restoration was well adapted and shaped. The interproximal relationships
had been re-established through the anatomy of the endocrown. There were
no gaps between the restoration and the endodontic filling. The sealing of the
endodontic treatment was complete and tight.
are promising. These endocrowns represent a less
invasive and better mechanical option compared with
posts and crowns.
Editorial note: This article was first published in
digital—international magazine of digital dentistry, Vol. 4,
Issue 2/2023.
Please scan this QR code for the list of
references.
about
Dr Alejandro Bertoldi Hepburn
is an associate professor at the
endodontics department of the
University of Buenos Aires’ School of
Dentistry in Argentina and a lecturer
in postgraduate prosthodontics at the
Universidad Del Desarrollo’s dental
school in Concepción in Chile.
Dr Matías Scazzola
is an assistant professor
at the e ndodontics department
of the University of Buenos Aires’
School of Dentistry in Argentina.
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[42] =>
| manufacturer news
Technology-based company
DIRECTEndodontics—a modern company, for modern dentists
DIRECTEndodontics offers great European products at affordable
prices and free shipping without the hassle of dealing with distributors, sales representatives, call centres and shipping.
At DIRECTEndodontics, all products are only a click away. The
company offers:
– great European-crafted endodontic instruments
– replacements for the reciprocating and rotary nickel–titanium
instruments you currently use
– the opportunity to keep using your current techniques with our
products
– products at a fraction of the price you currently pay
– free shipping on all orders.*
DIRECTEndodontics sells all products directly to dental professionals. Online ordering is easy, and live chat customer support is
available 24 hours a day, seven days a week.
Register now to receive an additional 10% off all orders for the first
12 months. You receive a 100% money-back guarantee on all
unopened products for three years and a 100% refund on up to
two empty instrument packs per stock-keeping unit (SKU), so
you can even use all the files in two packs per SKU and still receive
a full refund!
* Free shipping throughout Europe on all orders.
www.directendo.com
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[43] =>
manufacturer news
|
Root canal treatments from A to X
COLTENE expands its product range with the empowering
CanalPro X-Move endodontic motor
Tap-dancing or slow-waltzing, moving back and forth on the
dance floor or circling in rotating movements—tastes differ on
the dance floor. In the same way, dentists have their own preferences for reciprocating and continuously rotating systems in
endodontic treatment. The new CanalPro X-Move endodontic
motor from the international dental specialist COLTENE now
offers fans of both working motions an extremely practical
alternative—and adds to the company’s already extensive
product portfolio.
Full freedom of movement
The novel wireless X-Move endodontic motor is characterised above all by its simple handling and great flexibility.
Being wireless, the unit can be conveniently moved around
the chair or between different dental chair units. The “x” in
the name stands for the choice of practically x different
movement protocols and treatment methods. X-Move
works efficiently and reliably in both fully rotating and
reciprocating modes, in particular with the MicroMega
One RECI file. The movement patterns of other nickel–
titanium files from the COLTENE Group, such as the
HyFlex EDM and MicroMega One Curve mini files, and
the HyFlex REMOVER and MicroMega REMOVER
files for retreatments, are also stored. This
makes the X-Move particularly intuitive and
pleasant to use.
With a diameter of only 8 mm, the delicate
matt-black head of the contra-angle handpiece ensures a better view of the working
field and facilitates photographic documentation. The integrated
isolation of the handpiece eliminates the need for additional
sleeves. Equally practical is the integrated apex locator for
automatic length determination. With a speed of 2,500 rpm
and a torque of up to 5 Ncm, the flexible motor scores overall
with a good price–performance ratio.
Premiere at the International Dental Show in Germany
The CanalPro X-Move motor adds another versatile tool to
the COLTENE Group’s range of endodontic instruments.
COLTENE has always pursued the design and implemen
tation of practical solutions for dentists. To this end, the
company collaborates with international scientists, practice
owners, key opinion leaders and dental teams. Under the
slogan “Your Endo Guide”, the group has set itself the goal
of supporting general dentists and endodontic specialists
with experienced endodontic consultants, easy-to-use
and intuitive products, and international training programmes.
At this year’s International Dental Show in Cologne,
COLTENE presented its innovative motor to the
dental community for the first time, and international visitors had the opportunity to learn about
the many possible applications of the X-Move
and the matching COLTENE files.
www.coltene.com
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| features
Research examines burn-out
during COVID-19, offers strategies
for resilience
By Iveta Ramonaite, Dental Tribune International
Mental health support is now a great priority for many
employers who wish to show their commitment to promoting well-being in the workplace. However, burn-out
among healthcare staff continues to be a cause for concern and may lead to issues such as high employee turnover, absenteeism, depression and a greater likelihood of
medical errors, thus threatening patient safety. Putting
mental health in the spotlight, recent research examined
the levels of burn-out experienced during the COVID-19
pandemic by oral health providers at non-profit dental
facilities in the US serving low-income families or individuals.
It also highlighted contributing factors and strategies
used to increase workforce resilience.
The report, published by the Oral Health Workforce
Research Center at the University at Albany’s Center
for Health Workforce Studies, used data from the 2021
online survey by Health Choice Network that included information on clinicians working in 25 community health
centres across the US. The survey gathered information
on 588 respondents, including those working in primary
care, oral health, and mental and behavioural health settings. Oral health clinicians totalled 33 dentists, 12 dental
hygienists and 25 dental assistants.
It found that the prevalence of burn-out during the
COVID-19 pandemic was uniformly high across all clinician types. Namely, 79.3% of the oral health providers
reported burn-out, similarly to 80.1% of the surveyed primary care providers and 76.2% of mental and behavioural
health providers. Most of the oral health providers attributed their burn-out to a chaotic work environment and
a lack of effective teamwork in their organisation.
Seeking to better assess the environmental and personal
factors that contributed to burn-out among oral health
providers, the researchers then conducted in-depth
interviews with 26 people working in various positions
at non-profit dental organisations throughout the US in
2022. The goal of the interviews was to collect information about the impact of COVID-19-related stressors on
dental staff’s stress and anxiety levels and to determine
© Lightspring/Shutterstock.com
A recent report has examined the extent of burn-out encountered by oral health professionals and has outlined the approaches employed to enhance resilience in the workforce.
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features
|
ROOTS SUMMIT calls for submissions
and launches roots magazine contest
By Dental Tribune International
The ROOTS SUMMIT team is excited to invite dental professionals to submit their presentations for inclusion in the
dynamic scientific programme for the event set to take place
from 9 to 12 May in Athens. Contributions may be in the form
of either poster or oral presentations. The organisers have
also introduced the roots magazine contest, which will offer
the chance to win free tickets for the upcoming event.
The main presenting author is requested to submit an
abstract in English and may submit only one abstract.
Responsibility for the abstract’s content rests fully on
the presenting author, who must also confirm that all
co-authors agree with the content prior to submission.
For oral presentations, case reports can also be sub
mitted. Oral presentations will be 10 minutes long and
followed by 5 minutes for questions and answers.
Please note that presenting authors must register for the
congress should their abstract be accepted.
The detailed submission guidelines can be found at
www.roots-summit.com/en/p/about-us/case-presentationguidelines-for-roots-summit-2024.
Win free entry to ROOTS SUMMIT 2024
Dental Tribune International, who is co-organising the event,
would like to invite authors to contribute their endodontic
clinical cases to its print publication roots—international
magazine of endodontics. Authors whose submissions
fulfil the magazine’s publication criteria have the chance
to win free entry to the 2024 summit.
The deadline for the roots magazine contest is
29 February 2024. The case submission guidelines can
be found at www.dental-tribune.com/submission-guidelines.
Please use the subject line “roots magazine contest 2024”
when sending your clinical case via e-mail.
The deadline is 8 December 2023 for oral presentations and 26 April 2024 for poster presentations.
More information on the event can be found online at
www.roots-summit.com.
whether burn-out and stress affected employee re
cruitment and retention.
“It’s not only important to be aware of burn-out, but to
understand the reasons why health workers are experiencing it,” said Center for Health Workforce Studies
Director Dr Jean Moore. “Once specific stressors have
been identified, then strategies to address them at both
organisational and personal levels can be implemented
to reduce burn-out for these providers,” she continued.
Among the environmental factors that had an impact on
dental staff were the lack of uniformity in policies and
requirements and the uncertainty about infection pathways. Factors such as school and day care centre
closures, loss of jobs in families, illness and death from
COVID-19, and isolation from social interactions also
contributed to poor mental health.
At the organisational level, reported stressors were
mostly related to the difficulties with obtaining and financing
personal protective equipment, the changing guidelines
related to aerosol-generating procedures, the reassignment of clinicians to non-traditional roles, staff furloughs
and workforce shortages.
Finally, regarding individual-level stressors, nearly all the respondents suggested that the lack of day care and in-person
schools was a huge issue, especially for single parents and
women. It was also one of the main reasons that forced
dental assistants and hygienists to leave the profession.
To address the stressors, organisations implemented
various strategies to promote well-being and self-care
among workers. These included more vacation time, additional pay, more break time for staff and more flexible
work schedules for parents.
Further research is needed to assess the prevalence
of burn-out in dentistry and potential work- and family-
related factors associated with burn-out, using a nationally
representative sample of dentists, hygienists and assistants.
Editorial note: The report, which includes information on
both the survey and the interviews, is titled Identifying
Strategies to Improve Oral Health Workforce Resilience.
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| meetings
1
ROOTS SUMMIT 2024:
Athens gears up to host
premier endodontic meeting
By Franziska Beier, Dental Tribune International
After a successful event in Prague in the Czech Republic
in May 2022, which was attended by more than 400 people
from 42 countries, the organisers of ROOTS SUMMIT have
announced the dates and venue for next year’s edition. The
endodontic meeting will be held from 9 to 12 May 2024 at the
Eugenides Foundation in Athens in Greece. Attendees can look
forward to the usual high-calibre clinical practice and technique tips, intended for immediate incorporation into practice.
Speakers will include Prof. Matthias Zehnder from Switzerland,
Dr Josiane Almeida from Brazil, Dr Ruth Pérez Alfayate from
Spain and Dr Antonis Chaniotis from Greece. The endodontic
meeting will focus on topics such as irrigation and disinfection
of root canals, restoration of endodontically treated teeth, the
effect of radiotherapy on dental structures, root canal blockage management and the rationale for the management of
complex, borderline cases in endodontics.
“ROOTS SUMMIT 2024 will feature speakers from nine countries, each of whom will bring significant scientific credibility
and authority to the benefit of every participant’s clinical
practice. Our scientific director, Dr David E. Jaramillo, is well
known for putting together unrivalled scientific programmes,”
said ROOTS SUMMIT Co-Chairman Stephen Jones.
“One of our speakers will be Dr Mitsuhiro Tsukiboshi from
Japan. The American Association of Endodontists describes Dr Tsukiboshi as the ‘world’s leading authority on
auto-transplantation of teeth’ on its website. His lecture on
auto-transplantation of teeth as part of complex treatment
plans is not to be missed,” emphasised Jones.
2
3
46
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[47] =>
meetings
|
4
Fig. 1: The impressive main entrance area of the Eugenides Foundation building complex on Syggrou Avenue is an integral part of the original building. Fig. 2: The Eugenides
Foundation has been hosting scientific and technical education events for over 60 years in its purpose-built lecture theatre. Fig. 4: One of the first conference venues in Greece,
the Eugenides Foundation Auditorium has recently undergone renovation respectful of its original architectural features. Fig. 4: As part of the social programme, participants
will be able to visit the foundation’s new science and technology centre. Fig. 5: The ground-floor peristyle is at the heart of the activity of today’s Eugenides Foundation.
Fig. 6: The second-floor peristyle can host corporate or social events as part of conferences being held at the Eugenides Foundation complex. (All images: © Eugenides Foundation)
In addition to the lecture programme, attendees will have
the opportunity to participate in hands-on workshops,
connect with industry professionals and learn about new
equipment, procedures and protocols in endodontics.
Taking place in the Greek capital, the meeting will be
hosted in a city that offers a myriad of ancient monuments,
temples, ruins and churches. ROOTS SUMMIT 2024 is to
be held in the conference halls of the Eugenides Foundation,
a landmark building complex right next to the waterside,
but still close to the city centre. Two large lecture halls and
two floors for exhibition assure enough space to showcase,
get together and educate. A special highlight will be the
foundation’s planetarium, which ROOTS SUMMIT attendees
can visit during the conference days.
“The Eugenides Foundation has been hosting scientific
and technical education events for over 60 years in its
purpose-built lecture theatre. In the last 20 years alone, the
fully renovated conference and lecture rooms have hosted
over 1,400 Greek and international events and welcomed
470,000 participants,” commented Jones.
5
Early bird tickets available
The organisers are inviting endodontists, dental professionals
in other fields, dental students and industry representatives
to attend next year’s meeting. The early bird discount
(€695.00) will run until 31 December. The standard registration fee thereafter will be €795.00. A student rate
(€595.00) will be offered permanently. Hands-on courses
will be charged separately, and the rates for these will be
announced later.
History of ROOTS SUMMIT
ROOTS SUMMIT meetings have been enjoyed by participants for more than 20 years. The first meeting was held in
1999 in Toronto in Canada, and many events all over the
world followed, having taken place in the US, the Netherlands,
Mexico, Spain, Brazil, India, the UAE, Germany and the
Czech Republic.
More information on the programme and speakers can be
found at www.roots-summit.com.
6
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| meetings
48
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2 2023
GNYDM 2023
5th EAS Congress
24–29 November 2023
New York, USA
www.gnydm.com
29 February–2 March 2024
Valencia, Spain
www.eas-aligners.com
ADF 2023
AAE24 Annual Meeting
28 November – 2 December 2023
Paris, France
https://adfcongres.com
17–20 April 2024
Los Angeles, USA
www.aae.org
CIOSP 2024
ITI World Symposium 2024
24–27 January 2024
Sao Paulo, Brazil
www.ciosp.com.br/en
9–11 May 2024
Singapore
www.iti.org/start
AEEDC 2024
ROOTS SUMMIT
6–8 February 2024
Dubai, UAE
www.aeedc.com
9–12 May 2024
Athens, Greece
www.roots-summit.com
159th Chicago Dental Society
Midwinter Meeting
DDS.Berlin
22–24 February 2024
Chicago, USA
www.cds.org/midwinter-meeting
28–29 June 2024
Berlin, Germany
www.dds.berlin
© 06photo/Shutterstock.com
International events
[49] =>
|
© 32 pixels/Shutterstock.com
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roots
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49
[50] =>
| about the publisher
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50
roots
2 2023
[51] =>
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[52] =>
register at www.roots-summit.com
ROOTS SUMMIT IS
COMING TO ATHENS
THE GLOBAL DENTAL CE COMMUNITY
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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