roots international No. 3, 2016
Cover
/ Editorial
/ Content
/ Treatment planning: Retention of the natural dentition and the replacement of missing teeth
/ Twisted files and adaptive motion technology: A winning combination for safe and predictable root canal shaping
/ From a distal
/ Long-term analysis of primary - non-surgical root canal treatments – A retrospective study
/ Products
/ Roots Summit 2016 - Premier global forum for endodontics takes place in Dubai
/ International Events
/ Submission guidelines
/ Imprint
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[1] =>
roots
issn 2193-4673
international magazine of
endodontics
3
2016
CE article
Treatment planning:
Retention of the natural dentition
and the replacement of missing teeth
technique
Twisted files and adaptive motion technology:
A winning combination
study
Vol. 12 • Issue 3/2016
Long-term analysis of primary,
non-surgical root canal treatments
[2] =>
[3] =>
editorial
|
Still looking for MB2:
Endodontic nirvana
Finding the Holy Grail. Grabbing the Brass Ring. Finding the MB2 canal in maxillary molars!
Pie in the sky? We think not!
With all the technological advances that have occurred in dentistry, certainly in endodontics,
the biologic objectives have remained the same, those being to eliminate and/or prevent apical
periodontitis. How does one do this? There is no magic wand nor is there a simple recipe to achieve
this objective. However, one thing is for sure, if a general practitioner embarks on root canal treatment, whether on a tooth with relatively simple or complex anatomy, he/she should be held to
the a standard that is expected of a specialist for the procedure being performed; thorough
debridement of the entirety of the canal anatomy, followed by three-dimensional obturation.
Dr Gary Glassman
To achieve endodontic success one must be skilled, understand the biologic system that one is
working in and understand the objectives of the treatment. One should also employ the correct
armamentarium, as long as he/she first has the tools. High magnification and the development
of ultrasonics for conventional endodontics have enabled many practitioners to treat complex
root canal anatomic variations more thoroughly.
Dental imaging has made leaps and bounds with the advent and use of the cone beam computed tomography (CBCT). Limited field of view images taken preoperatively will allow a three-dimensional rendering of the tooth to be treated. In essence, this will provide the practitioner with
a more precise ‘road map’ with respect to the anatomic makeup of the tooth to be treated. CBCT
has enlightened us to the complexity of the root canal system and thereby obliges us to 3-D disinfection and obturation.
Dr Ian Watson
An updated joint position statement of the American Association of Endodontists (AAE) and
the American Academy of Oral and Maxillofacial Radiology is intended to provide scientifically
based guidance to clinicians regarding the use of CBCT (available on AAE website).
In addition to the many recommendations that were given for the use of CBCT in endodontics,
the position paper stated that ‘limited FOV (Field Of View) CBCT should be considered the imaging
modality of choice for initial treatment of teeth with the potential for extra canals and suspected
complex morphology, such as mandibular anterior teeth, and maxillary and mandibular premolars and molars, and dental anomalies’. Why look for an MB2 canal when it doesn’t exist and risk
comprising the structural integrity of the tooth and risk perforation? After all, if it does exist then
the CBCT may reveal it. That being said, one should also take the CBCT results with somewhat of
a ‘pinch of salt’, as what often may appear as a lesion of endodontic origin may only be a variation
of normal. A proper systematic diagnostic protocol should always be followed by, which includes
but is not limited to, pulpal and periradicular testing of the tooth (teeth) in question.
So how do we reach this idyllic Endodontic Nirvana? Even with all the technological advances
that we have at our fingertips, we need to provide the patient with best possible care, and the only
way one can capitalise on these advances is plain old education, experience and practice, practice,
practice!
Drs. Gary Glassman & Ian Watson
(Guest Editors)
roots
3
2016
03
[4] =>
| content
page 6
| editorial
page 14
page 22
| study
03 Still looking for MB2: Endodontic nirvana
26 Long-term analysis of primary,
Drs. Gary Glassman & Ian Watson (Guest Editors)
non-surgical root canal treatments –
A retrospective study
Dr Robert Teeuwen
| CE article
06 Treatment planning:
Retention of the natural dentition
and the replacement of missing teeth
Dr Scott L. Doyle
| products
36 Latest technology and products information
| meetings
| technique
14 Twisted files and adaptive motion
technology: A winning combination for
safe and predictable root canal shaping
Dr Gary Glassman, Prof. Gianluca Gambarini &
Dr Sergio Rosler
| case report
22 From a distal
38 Roots Summit 2016—Premier global forum
for endodontics takes place in Dubai
40 International Events
| about the publisher
41 submission guidelines
42 imprint
Dr Sam Alborz
Cover image courtesy of FKG Dentaire (www.fkg.ch)
page 26
04 roots
3 2016
page 36
page 38
[5] =>
[6] =>
| CE article treatment planning
Treatment planning:
Retention of the natural dentition
and the replacement of missing teeth
Author: Dr Scott L. Doyle, USA
CE credit
Introduction
This article qualifies for CE credit.
To take the CE quiz, log on to www.
dtstudyclub.com. Click on ‘CE articles’ and search for this edition of
roots magazine. If you are not registered with the site, you will be
asked to do so before taking the
quiz. You may also access the quiz
by using the QR code above.
Preservation of the natural dentition is the primary
goal of dentistry. Published surveys indicate that patients generally value teeth and express a desire to
save their natural dentition in favour of extraction
whenever possible.1, 2 Significant technological and
biological improvements have been made in all disciplines of dentistry, making long-term retention of
natural teeth more attainable. Patients entrust dental
professionals to make appropriate recommendations
regarding the maintenance and restoration of their
oral health and function. It is essential to employ an
evidence-based, interdisciplinary approach that addresses the interests of the patient when determining
the best possible course of treatment.
In July 2014, the American Association of Endodontists, in collaboration with the American Col-
lege of Prosthodontists and the American Academy
of Periodontology, hosted a two-day Joint Symposium titled Teeth for a Lifetime: Interdisciplinary
Evidence for Clinical Success. Approximately 375
general dentists and specialists assembled in Chicago to focus on preserving the natural dentition.
The educational program included evidence-based
presentations on advanced regenerative techniques, improvements in technology, minimally
invasive restorative methods and best practices
for interdisciplinary treatment planning. Dr Alan
Gluskin, chair of the 2014 Joint Symposium Planning Committee, concluded that the current evidence directs clinicians to consider saving the natural dentition as the first option when developing
treatment plans.
Dental implants are one of the most significant
advancements in contemporary dentistry. This innovation has had profound effects on endodontic,
periodontic and prosthodontic treatment planning for the rehabilitation of edentulous spaces
and for teeth with an unfavorable prognosis.3 Implant-supported restorations minimize unnecessary preparation of intact abutment teeth and
allow fixed prosthodontic replacement when suitable abutments are absent. With appropriate usage and case selection, implant dentistry provides
a viable option for the replacement of missing
teeth.4, 5
There has been an increasing trend toward replacing diseased teeth with dental implants. Often,
an inadequate or inappropriate indication for tooth
extraction has resulted in the removal of teeth that
may have been salvageable.6 Teeth compromised by
pulpal or periodontal disease have value and should
not be extracted without thoroughly evaluating restorability and potential retention therapies.7
Fig. 1a
06 roots
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[7] =>
treatment planning CE article
Survival rates following initial nonsurgical root canal treatment
Author
Number of teeth
Follow-up (years)
Survival (percent)
Salehrabi and Rotstein (24)
1,463,936
8
97
Chen et al. (25)
1,557,547
5
93
Lazarski et al. (26)
44,613
3.5
94.4
A recent systematic review published in the Journal
of the American Dental Association highlights a key
question: “Is the long-term survival rate of dental implants comparable to that of periodontally compromised natural teeth that are adequately treated and
maintained?”8 Nineteen studies with a follow-up period of at least 15 years were included in the analysis.
The results show that implant survival rates do not
exceed those of compromised but adequately treated
and maintained teeth. These findings support other
studies comparing long-term survival of implants
and natural teeth,9, 10 providing an important message:
Periodontally compromised teeth can be retained
with quality treatment and appropriate maintenance.
Therefore, it may be advisable to postpone implant
consideration for the periodontitis-susceptible patient to fully utilize and extend the capacity of the
natural dentition.11
Treatment planning options
A key focus of the Joint Symposium involved treatment planning decisions regarding endodontic treatment and implant therapy. Should a tooth with pulpal disease be retained with root canal treatment and
restoration, or be extracted and replaced with an implant-supported restoration? This assessment involves a challenging and complex decision-making
process that must be customized to suit the patient’s
needs and desires.12–14 The topic has received considerable attention in the literature, the media and at
dental continuing education courses.
|
Table 1: Survival rates following initial
nonsurgical root canal treatment.
(Provided by American Association of
Endodontists)
Outcome assessment: Success and survival
Treatment outcomes play a key role in the assessment of different treatment options. Patients often
ask whether a procedure is going to be successful or
not. This question can be challenging for a clinician to
answer due to the variety of reported outcomes in
the literature.17 There are differences in the methodology and criteria used to evaluate the outcomes for
root canal treatment and implant prosthetics, which
makes comparisons between success rates difficult, if
not impossible.18 Endodontic studies have historically
used “success” and “failure” as outcome measures
and have focused on a strict combination of radiographic and clinical criteria.19 In contrast, the implant
literature has primarily reported “survival,”20, 21 i.e., the
implant is either present or absent. Therefore, implant
studies that solely evaluate survival as an outcome
measure will likely publish higher success rates than
endodontic studies that rely on biologic healing and
factors related to the entire restored tooth. To establish more valid and less biased comparisons, the
same outcome measures should be used. A more patient-centered measure is to compare the outcome
of survival, which is considered to be an asymptomatic tooth/implant that is present and functioning in
the patient’s mouth.22, 23
Fig. 1a: Pre-op image of tooth #19
with pulp necrosis and symptomatic
apical periodontitis. The patient is
interested in rehabilitation of the
edentulous space. (Images courtesy of
American Association of Endodontists)
Fig. 1b: Three-year recall image.
The patient has benefited from both
root canal treatment and implant
therapy. (Courtesy of Dr Tyler Peterson
and the University of Minnesota School
of Dentistry)
Endodontic treatment and implant therapy should
not be viewed as competing alternatives, rather as
complementary treatment options for the appropriate
patient situation (Figs. 1a & b). Root canal treatment is
indicated for restorable, periodontally sound teeth
with pulpal and/or apical pathosis. Endodontic treatment on teeth with nonrestorable crowns or teeth
with severe periodontal conditions is contraindicated,
and other options such as implant placement should
be considered.15 When making treatment decisions,
the clinician should consider factors including outcome assessment, local and systemic case-specific issues, costs, the patient’s desires and needs, aesthetics,
potential adverse outcomes and ethical factors.16
Fig. 1b
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| CE article treatment planning
Fig. 2a: Pre-op image of tooth #29.
Note lateral radiolucency and complex
canal anatomy.
Fig. 2b: Two-year recall image reveals
both excellent endodontic and
restorative treatment. Note healing of
lateral radiolucency.
(Courtesy of Dr Joe Petrino)
Fig. 2a
Fig. 3: A matched-case comparison of
survival rates after treatment with
either a restored endodontically
treated tooth (n = 196) or a restored
single-tooth implant (n = 196)
performed at the same institution
(J Endod 2006;31).
Multiple large-scale studies including millions of
teeth have used survival to assess the outcome following root canal treatment. An investigation using
an insurance database of more than 1.4 million root
canal-treated teeth demonstrated that 97 percent
were retained within an eight-year follow-up period.24 Other studies show similarly high survival rates
(Table 1).25, 26 An epidemiological approach allows for
the assessment of tooth retention from a large sample of patients experiencing actual care in private
practices. Systematic reviews27 and controlled studies
from academic settings complement the previous
findings. Two prospective trials each reported 95 percent survival rates at four years28 and four to six
years29 for teeth after initial root canal treatment.
Predictable tooth retention: Nonsurgical
root canal treatment and restoration
The majority of endodontic treatment is performed
by general dentists with a high degree of success.26 For
Fig. 2b
complex cases, referral to an endodontist with additional training and expertise may result in more favourable outcomes30 and positive patient experiences.31
Interdisciplinary care is important for the management of endodontically treated teeth. The restorative
dentist plays a significant role in the outcome by providing an appropriate and timely restoration.32 Root
canal treatment is not complete until the tooth is coronally sealed and restored to function. Multiple studies have confirmed that a definitive restoration has
a significant impact on survival,24, 25, 27, 28, 33 Therefore,
the likelihood of a favorable outcome increases with
both skillful endodontic care and prompt restorative
treatment (Figs. 2a & b).34
Advancements in technology aid in attaining high
levels of tooth retention. The dental operating microscope, nickel-titanium instruments, apex locators, enhanced irrigation protocols and dentin preservation
strategies are examples of improvements that allow
clinicians to predictably manage a greater range of
treatment options. Additionally, cone beam-computed tomography facilitates more accurate diagnosis and improved decision-making for the management of endodontic problems.35, 36
Comparative studies: Endodontically
treated teeth and single-tooth implants
Large-scale systematic reviews have addressed the
relative survival rates of endodontically treated teeth
and single-tooth implants. The Academy of Osseo
integration conducted a meta-analysis using 13 studies (approximately 23,000 teeth) on restored endodonticallytreatedteethand57studies(approximately
12,000 implants) on single-tooth implants. The outcome data demonstrated no difference between the
two groups during any of the observation periods.37
Another systematic review supported by the American Dental Association compared the outcomes of
endodontically treated teeth with those of a single-
Fig. 3
08 roots
3 2016
[9] =>
treatment planning CE article
Fig. 4a
tooth implant-restored crown, fixed partial denture,
and no treatment after extraction. At 97 percent, the
long-term survival rate was essentially the same for
implant and endodontic treatments. Both options
were superior to extraction and replacement of the
missing tooth with a fixed partial denture.38
Retrospective studies also have compared the outcomes for the two treatment options. A study conducted at the University of Minnesota compared the
outcomes of 196 restored endodontically treated
teeth with 196 matched single-tooth implants.39 Both
groups had 94 percent survival rates. The survival
curves for these two groups are provided in Figure 3.
Another investigation from the University of Alabama
provided similar results.40
Based upon similar survival rates, the decision to
treat a compromised tooth endodontically or replace
it with an implant must be based on factors other than
treatment outcome.37, 41 Several factors influence the
decision-making process.42–44 The following lists provide an overview of case-specific factors that should
be considered in making this treatment decision.
Systemic factors
·· The list of potential risk factors for peri-implantitis
or implant failure is extensive. It includes systemic
disease, genetic traits, chronic drug or alcohol consumption, smoking, periodontal disease, radiation
therapy, diabetes, osteoporosis, dental plaque and
poor oral hygiene.45
·· There are few medical conditions that directly affect
endodontic treatment outcomes. Risk factors that
may be associated with decreased survival of root
canal-treated teeth include smoking,46 diabetes,28, 46
systemic steroid therapy28 and hypertension.47
·· Patients taking antiangiogenic or antiresorptive
(i.e., bisphosphonates) medications may have an
increased risk for developing medication-related
osteonecrosis of the jaw. This may affect treatment
planning for both implant and endodontic treatment.
·· It is generally recommended to wait for the completion of dental and skeletal growth prior to implant placement.48
Local factors
·· Accurate diagnosis.
·· Restorability assessment: removal of caries/restorations; adequate ferrule.
·· Strategic nature of the tooth as it fits into the comprehensive restorative plan.
·· Caries risk and oral hygiene.
·· Periodontal assessment: tissue biotype, adequate
biologic width.
·· Presence of crack(s), root fracture(s), resorption.
·· Occlusion and parafunction.
·· Teeth with less than two proximal contacts and
those serving as fixed partial denture abutments
may have lower survival.27
·· Need for adjunctive treatment (crown lengthening,
orthodontic extrusion, sinus lift, bone graft, etc.),
which may impact financial cost and time to function.
·· Quantity and quality of bone.
·· Proximity to anatomical structures (maxillary sinus,
inferior alveolar nerve, etc.).
·· Implant esthetics in the anterior region may be
challenging.49
|
Fig. 4b
Fig. 4a: Pre-op image of tooth #30
with previous endodontic treatment
and persistent apical periodontitis.
A dentist initially recommended
extraction and replacement of this
tooth with an implant. The patient
requested a second opinion from an
endodontist who determined the tooth
to be treatable.
Fig. 4b: Four-year recall image
demonstrates apical healing following
nonsurgical retreatment. Accurate
diagnosis prevented the unnecessary
treatment of tooth #31.
(Courtesy of Dr Martin Rogers)
In addition to systemic and local factors, it is critical
to include the patient’s concerns during treatment
planning. Common patient-centered factors include
costs, treatment duration, satisfaction with treatment and the potential for adverse outcomes.
Financial considerations can influence a patient’s
decision when weighing treatment options. The
availability of dental insurance may also impact
choices.50 Endodontic treatment and restoration offer
considerable economic advantages to the patient.51–53
roots
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[10] =>
| CE article treatment planning
demonstrate that patients report a high degree of
satisfaction with the overall experience following
both procedures.2, 15
Fig. 5a
Fig. 5b
Fig. 5a: Pre-op image of tooth #19
with pulp necrosis and chronic apical
abscess.
Fig. 5b: Two-year recall image demonstrates excellent endodontic treatment
and healing of apical periodontitis.
(Courtesy of Dr Deb Knaup)
Fig. 6a: Pre-op image. Tooth #14 was
determined to have a vertical root
fracture of the MB root. The patient
expressed a strong desire to retain the
natural dentition but also to rehabilitate
the edentulous space.
Fig. 6b: Two-year recall image. Tooth
#14 had retreatment and resective
surgery on the MB root. Two dental
implants have restored the edentulous
space. (Courtesy of Dr. Brian Barsness
and the University of Minnesota School
of Dentistry)
10 roots
3 2016
A benefit of root canal treatment is the short time
frame required to completely restore both dental
function and aesthetics. In one study of about 400 patients, the restored single-tooth implant showed a
longer average and median time to function than
similarly restored endodontically treated teeth. Additionally, the implant group had a higher incidence of
post-treatment complications requiring subsequent
treatment interventions.39 This increased post-operative care can impact patients in terms of additional
visits, lost wages and unforeseen costs.
Despite high survival rates, both endodontically
treated teeth and implants are susceptible to complications. Non-restorable caries, prosthetic failures,
periodontal disease, crown/root fractures and specific endodontic factors are examples of complications following root canal treatment.57 Complications
associated with implants and related prostheses include: surgical, implant loss, bone loss, peri-implant
soft-tissue, mechanical and aesthetic/phonetic.58
A retrospective study directly compared the rates of
additional interventions related to complications.
Implant cases had a substantially higher need for subsequent intervention and maintenance visits than
endodontically treated teeth.40 However, a more recent prospective study suggests that patients from
both groups have minimal complications at one-year
follow-up.15
Endodontic retreatment options
The consequences of failure and subsequent treatment differ between endodontics and implants. Endodontic failure can usually be addressed successfully
by retreatment, microsurgery, or by extraction and
potential implant placement. Intervention after implant failure may vary from minimal restorative repairs to multiple corrective surgeries and/or the use
of a different prosthesis.59
Clinicians should consider the patient’s preferences, which are often related to function, comfort
and aesthetics. Tooth loss is associated with an impaired quality of life,54 and surveyed patients express
a clear desire to save their natural dentition whenever
possible.2 Large-scale surveys of post-endodontic patients have demonstrated that endodontic treatment
not only preserves the natural tooth, but also significantly improves patients’ quality of life.55 More than
97 percent of patients report being satisfied with their
endodontic treatment.31 If an implant is used to restore an edentulous space, a similarly high percentage of patients have a positive experience with implant therapy.56 Furthermore, comparative studies
Nonsurgical retreatment, or revision, is often the
first choice to address post-treatment apical periodontitis,60, 61 provided that the tooth is suitable for
further restoration and that the restoration will have
a good long-term prognosis (Figs. 4a & b).62 Current
best evidence indicates that the survival of nonsurgical retreatment is similar to that of primary treatment, and that the two treatments share similar prognostic factors.63 Two studies specifically evaluated
survival following retreatment. An epidemiological
study using an insurance database of 4,744 retreated
Fig. 6a
Fig. 6b
[11] =>
treatment planning CE article
teeth reported an 89 percent survival rate at five
years64 and a prospective trial of 858 retreated teeth
reported a 95 percent survival at four years.28
Modern techniques and rationale contribute to
excellent potential outcomes for retreatment. An
important factor when considering retreatment is
the ability to identify and address the aetiology of
post-treatment disease.63 Primary sources of nonhealing are persistent intracanal microorganisms
or ingress of microorganisms following treatment. If
the aetiology of the problem is deemed correctable
via an orthograde approach, retreatment is often the
first choice. If not, a surgical approach may be the
more predictable option.65
Contemporary endodontic microsurgery has undergone significant technological and procedural
advancements.66, 67 Recently performed studies suggest that microsurgical techniques using biocompatible root-end filling materials provide significant improvements over traditional methods. A meta-analysis showed contemporary microsurgical techniques
to have a significantly improved outcome (94 percent) compared to older techniques and instruments
(59 percent).68 A recent systematic review investigating current microsurgery found survival rates of
94 percent at two to four years and 88 percent at four
to six years, indicating that teeth treated with endodontic microsurgery tended to be lost at low rates
over the time studied.69 Microsurgery, with appropriate case selection, is a predictable procedure for teeth
that may have been considered for extraction in the
past.
Ethics and interdisciplinary consultation
Clinicians are ethically bound to inform patients of
all reasonable treatment options, explain the risks and
benefits involved with the available treatment options, and obtain informed consent before initiating
treatment. This information should be conveyed in an
impartial manner.1 Patients value participation in the
decision-making process and should be encouraged
|
to exercise autonomy by communicating their preferences.70 Clinical treatment decisions regarding either
endodontic treatment or tooth extraction with implant therapy must always be made in the best interest
of the patient using the best, most current evidence.
Should it be necessary, experts from the dental
team may need to be called upon to assist the clinician
in rendering the highest quality of care (Figs. 5a & b).
The standard of care must be applied equally to all
clinicians, generalists and specialists alike. The AAE’s
Endodontic Case Difficulty Assessment Form and
Guidelines provides valuable information to aid the
clinician in case selection and determining whether
to treat or refer. Patients are deserving of the best possible outcome for each case. Interdisciplinary communication and collaboration during treatment planning maximizes this likelihood.
Specialists and restorative dentists should be
viewed as partners in the treatment planning team.
Endodontists are uniquely positioned to evaluate the
restorability and prognostic longevity of teeth and
recommend whether to attempt natural tooth preservation or consider extraction and replacement with
an implant.71 Likewise, the endodontist should be wellversed in implant treatment planning to assist patients and referring colleagues in making an informed
choice regarding all replacement options.72, 73
If a tooth has a questionable prognosis, the endodontic specialist becomes an indispensable part of the treatment planning team. The endodontist has experience
with various treatment options that have potential to
preserve the natural dentition. Consultation regarding
a questionable tooth is often in the patient’s best interest prior to considering extraction. If the prognosis of
a restorable tooth is categorized as questionable or unfavourable in multiple areas of evaluation, extraction
should be considered after appropriate consultation
with all relevant specialists. Only then is the decision to
extract an informed choice. Extraction is an irreversible
treatment, but if necessary, dental implants provide an
excellent option to replace missing teeth (Figs. 6a & b).
Fig. 7: Pre-op image.
Fig. 8: Root-end filling with MTA.
Fig. 7
Fig. 8
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[12] =>
| CE article treatment planning
Fig. 9: Post-op image.
Fig. 10: Seven-month recall image.
Fig. 9
Fig. 10
Case report
heal following endodontic treatment. Clinicians are
advised to explore all options before recommending
extraction. Referral to an endodontist can aid in the
retention of a compromised tooth.
This case report demonstrates an alternative treatment option for a patient to save their natural tooth.
A 70-year-old female presented to an endodontist’s
office with a complaint of persistent pain to biting.
Tooth #31 had a history of root canal treatment and
coronal restoration. A thorough examination, including CBCT, led to the diagnosis of previously treated
tooth #31 with symptomatic apical periodontitis.
A detailed explanation of the risks and benefits associated with all treatment options was presented. The
patient expressed a strong desire to save her tooth and
consented to intentional replantation. Tooth #31 was
atraumatically extracted and continuously hydrated
with Hanks’ Balanced Salt Solution. No cracks or fractures were visible. Apical microsurgery was performed
extraorally. The root end was resected, ultrasonically
prepared and filled with mineral trioxide aggregate.
The tooth was replanted. The patient remains asymptomatic and very satisfied with her treatment.
A recent systematic review and meta-analysis revealed a mean survival rate of 88 percent for intentional replantation.* With careful case selection, intentional replantation may allow for a reasonable,
cost-effective treatment option for teeth that do not
about
Dr Scott Doyle was raised in Eau Claire, Wis. He received his BS
from the University of Wisconsin-Madison in 1995 and his DDS from
the University of Minnesota in 1999. After graduation from dental
school, Doyle served in the United States Air Force for seven years.
His first assignment was at Eglin Air Force Base, Florida, where he
completed an advanced education in general dentistry residency.
He practiced as a general dentist for two years at Altus Air Force
Base, Oklahoma, prior to his acceptance into an endodontic
residency. Doyle obtained both his MS and certificate in endodontics
from the University of Minnesota in 2004. He is a diplomate of the American Board of
Endodontics, attaining board certification in 2011. He currently serves as an associate clinical
professor for the Division of Endodontics at the University of Minnesota. He is a member of the
American Dental Association, the Minnesota Dental Association, the Minnesota Association of
Endodontists and the American Association of Endodontists, as well as a variety of study clubs.
He is currently president of the Minnesota Association of Endodontists.
12 roots
3 2016
Conclusion
Patients are living longer; therefore, preservation
of the natural dentition is more important than ever.
Helping patients maintain their “Teeth for a Lifetime”
is the fundamental goal of dentistry and often aligns
with the desires of the patient. A wide range of endodontic procedures result in a high level of tooth retention and patient satisfaction. Large-scale studies
provide strong support that the restored endodontically treated tooth offers a highly predictable, long
term approach to preserving “nature’s implant”—a
tooth with an intact periodontal ligament.
Thus, excellent endodontic treatment followed by
an immediate restoration of equal quality promises to
give patients service and function while maintaining
their esthetics for years. The results of multiple studies indicate that the high survival rates for the natural
tooth are similar to those reported for the restored
single-tooth implant.
Therefore, clinicians must consider additional factors when making treatment planning decisions, all of
which must be in the best interest of the patient. Endodontic treatment and implant therapy should not be
viewed as competing alternatives, rather as complementary treatment options for the appropriate patient situation._
Editorial Note: This article originally appeared in ENDODONTICS: Colleagues for Excellence, Spring 2015. Reprinted with
permission from the American Association of Endodontists,
©2015. The AAE clinical newsletter together with a complete
list of references are available at www.aae.org/colleagues.
Case report contributed by Dr Robert S. Roda.
* Torabinejad M et al. Survival of intentionally replanted
teeth and implant-supported single crowns: a systematic
review. J Endod 2015 (in press).
[13] =>
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Tribune Group GmbH is an ADA CERP provider. ADA CERP is a service of
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approve or endorse individual courses or instructors, nor does it imply
acceptance of credit hours by boards of dentistry.
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Tribune Group GmbH is designated as an Approved PACE Program Provider by the Academy
of General Dentistry. The formal continuing dental education programs of this program
provider are accepted by AGD for Fellowship, Mastership and membership maintenance
credit. Approval does not imply acceptance by a state or province board of dentistry or AGD
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[14] =>
| technique canal shaping
Twisted files and adaptive
motion technology:
A winning combination for safe and
predictable root canal shaping
Authors: Dr Gary Glassman, Canada; Prof. Gianluca Gambarini, Italy & Dr Sergio Rosler, Argentine
The ultimate goal of endodontic treatment is the
prevention and/or treatment of apical periodontitis,
such that there is complete healing and absence of
infection1 while the overall long-term goal is the
placement of a definitive, clinically successful restoration and preservation of the tooth.2
remnants of pulp tissue, debris generated during instrumentation, the smear layer, micro-organisms,
and micro-toxins from the root-canal system.5
Successful endodontic treatment depends on a
number of factors, including proper instrumentation,
successful irrigation and decontamination of the
root-canal system right to the apical terminus in addition to hard to reach areas such as isthmuses, and
lateral and accessory canals3, 4 (Fig. 1a & 1b).
It has been accepted that even with the use of rotary
instrumentation, the nickel-titanium instruments
currently available only act on the central body of the
root canal, resulting in a reliance on irrigation to clean
beyond what may be achieved by these instruments.6
‘Shaping canals creates sufficient space to hold an effective reservoir of irrigant that, upon activation, can
penetrate, circulate and digest tissue from the uninstrumentable portions of the root canal system’.7, 8
The challenge for successful endodontic treatment
has always been the removal of vital and necrotic
Several challenges often arise during root canal
preparation. Some of the most common ones are an-
Figs. 1a & b: The complexity of root
canal anatomy is demonstrated by
these cleared samples of maxillary
molars.
Fig. 1a
14 roots
3 2016
Fig. 1b
[15] =>
canal shaping technique
atomic factors that may prevent negotiation to the
apical termini, as well as ledge formation, perforation
and file separation.
The introduction of Nickel-Titanium (NiTi) alloy in
endodontics presented a significant improvement,
allowing good results in terms of cleaning and shaping of root canals, while reducing operative time and
minimising iatrogenic errors.9, 10
Fig. 2
Thanks to the superior mechanical properties of the
NiTi alloy, it was possible to use endodontic instruments of greater tapers in continuous rotation, increasing the effectiveness and rapidity of the cutting.
However, several studies reported a significant risk of
intracanal separation of NiTi rotary instruments.11–14
In fact, file separation via torsional and cyclic fatigue
has created the biggest fear and risk for dentists using
rotary NiTi files for root canal treatment.11, 12, 15
Although multiple factors contribute to file separation, cyclic fatigue has been shown as one of the
leading causes.16 Fatigue failure usually occurs by the
formation of microcracks at the surface of the file
that starts from surface irregularities often caused by
the grinding process during the manufacturing.
During each loading cycle microcracks develop,
propagating getting deeper in the material, until
complete separation of the file occurs.17 All endodontic files show some irregularities on the surface, and
inner defect, as a consequence of the manufacturing
process, and distribution of these defects influence
fracture strength of the endodontic instruments.18, 19
Since the introduction of NiTi in 198820, varied
instrument designs with claims of superior cyclic
fatigue resistance have been propagated. However,
there were no major changes in the manufacturing
process/raw materials until the introduction of
the second generation of NiTi files, ie,
M-Wire (DENTSPLY Tulsa Dental Specialties) in 2007 and Twisted File (TF, Kerr
Endodontics Formerly Axis/SybronEndo) in
2008.
TF instruments are manufactured using a proprietary heat treatment technology that changes the
crystalline structure completely so the triangular
cross section NiTi file blank can be twisted while maintaining the natural grain structure. More precisely,
TF instruments are created by taking a raw NiTi wire
in the austenite crystalline structure phase and transforming it into a different phase of crystalline structure (R-phase) by a process of heating and cooling. In
the R-phase, NiTi cannot be ground but it can be
twisted. Once twisted, the file is heated and cooled
again to maintain its new shape and
convert it back into the austenite
crystalline structure, which is super
elastic once stressed. The manufacturing process aims at respecting
the grain structure for maximum
strength as grinding creates microfracture points during the manufacturing of the instruments. Because TF files are twisted and not
ground, no surface microfractures occur on their surface and therefore do not need be polished away;
thereby not dulling the cutting edges and retaining
their efficient cutting ability.21–23
|
Fig. 2: Colour-Coded File Identification.
An intuitive, colour-coded system
designed for efficiency and ease of
use. Just like a traffic light – start with
green and stop with red.
Because of the increased flexibility, the TFs maintains the original canal shape better, minimises canal
transportation and stays centred even in severely
curved root canals.24, 25
In addition to the development of heat treated
TF technology to improve the performance and safety
of NiTi instruments, the file design has also been
changed with respect file dimensions, tip configuration, cross-section and flute design. More recently,
a third factor has become important in this search
for stronger and better instruments: Movement Kinematics, the branch of motion in
which the objects move.26
Fig. 3: ElementsTM Motor. Settings for
For more than a decade, NiTi instruments
have been traditionally used with a continuous
TFTM Adaptive, TFTM, K3, Lightspeed,
M4 Safety Handpiece and custom
settings for personal preference.
Fig. 3
roots
3
2016
15
[16] =>
| technique canal shaping
Fig. 4: The motion of TFTM Adaptive
instrument changes from rotary into
reciprocation mode, with specifically
designed CW and CCW angles which
may vary from 600–0° to 370–50°.
Fig. 4
rotary motion, but more recently a new approach to
the use of NiTi instruments in a reciprocating movement had been introduced by Yared.11 The clockwise
(CW) and the counterclockwise (CCW) rotations used
by Yared were four-tenths and two-tenths of a circle
respectively and the rotational speed utilised was
400 rpm. The concept of using a single NiTi instrument
to prepare the entire root canal was made possible
due to the fact that a reciprocating motion is thought
to reduce instrumentation stress.
Fig. 5: File size reference chart.
Recent literature data shows that a reciprocating
motion can extend cyclic fatigue resistance of NiTi
instruments when compared to continuous rotation,27, 28 mainly because it reduces instrument stress.
As the instrument rotates in one direction (usually the
larger angle) it cuts and becomes engaged into the
canal then it disengages in the opposite direction
(usually with the smaller angle) and the stresses are
therefore reduced. Following these concepts new
instruments have been recently commercialised;
Reciproc (VDW) and WaveOne (DENTSPLY Maillefer),
which uses specifically developed motors that produce a specific reciprocating movement (using approximately 150 to 30°angles).
This reduction of instrumentation stress (both torsional and bending stress) is the main advantage of
reciprocating movements. It has been shown that a
lot of different reciprocating movements can be used,
each one affecting the performance and the safety
of the NiTi instruments. Therefore, when discussing
the advantages and disadvantages of reciprocation,
the exact motion should also be mentioned, since
the actual angle of reciprocation can have substantial
influence on both the clinical and experimental behaviour of NiTi instruments.15
Another possible advantage of reciprocation could
be better maintenance of original canal trajectory,
mainly related to lower instrumentation stress and
consequently its elastic return. However, it must be
underlined that reciprocation does not affect the inherent rigidity of the instruments. If a quite rigid Niti
instrument of greater taper is slightly forced into a
curved canal, it will create more canal transportation
than a more flexible one, due to its inherent tendency
to straighten. Moreover, tip design could strongly influence canal transportation, with a cutting tip being
more dangerous that a non-cutting pilot tip.
While reciprocation with NiTi instruments have become very popular in recent years, with a significant
number of published articles, some of these studies
have shown that there is also inherent disadvantages
in the reciprocating movements.
It is well known that a small inadvertent extrusion
of debris and irrigants into the periapical tissues is
a frequent complication during the cleaning and
shaping procedures, both with manual stainless
steel and nickel-titanium rotary instrumentation
Fig. 5
16 roots
3 2016
[17] =>
canal shaping technique
techniques.29, 30 However, recent studies have shown
that commercially available reciprocating instrumentation techniques seem to significantly increase
the amount of debris extruded beyond the apex31, 32
and, consequently, the risk of postoperative pain.
A clinical study comparing Reciproc and NiTi rotary
instruments has also confirmed these findings.33
while in TF Adaptive setting (Fig. 3). When the TF Adaptive instrument is not (or very lightly) stressed in the
canal, the movement can be described as a continuous rotation, allowing better cutting efficiency and
removal of debris. The cross-sectional and flute design are meant to perform at their best in a clockwise
motion.
Since reciprocation movement is formed by a wider
cutting angle and a smaller releasing angle, while rotating in the releasing angle, the flutes will not remove debris but push them apically. Reciproc and
WaveOne motions are very similar (even if not precisely disclosed by manufacturers), and this fact could
also explain the higher incidence and intensity of
postoperative pain that has been found in recent research studies.33, 34
More precisely, it is an interrupted motion with the
following CW-CCW angles: 600–0°. This interrupted
motion is as effective as continuous rotation in lateral
cutting, allowing optimal brushing or circumferential
filing for better debris removal in oval canals. This
interrupted motion also minimises iatrogenic errors
by reducing the tendency of ‘screwing in’ (aka pull
down), that is commonly seen with NiTi instruments
of great taper that are used in continuous rotation.
Moreover, both WaveOne and Reciproc techniques
use a quite rigid, large single-file of increased taper
(usually 08 taper, size 25), which is directed to reach
the apex. In many cases, in order to reach the apical
working length, reciprocating instruments are used
with apically directed pressure, which produces an
effective piston to propel debris through a patent
apical foramen, and possibly directing debris laterally, making canal debridement more difficult. Since
instruments are commonly used without first performing preliminary coronal enlargement, this may
result in a greater engagement of the file flutes and
consequently may produce more torque and/or applied pressure on the file. Moreover, the cutting ability of a reciprocating file is decreased when compared to continuous rotation. Debris removal is also
less, thus increasing the frictional stress and torque
demand on the file, due to entrapment of debris
within the flutes. To reduce this tendency some authors have advocated the use of NiTi rotary glide path
instruments, before using a WaveOne or Reciproc instruments, but in this case the overall technique is no
longer a single file technique but a more complex and
more costly technique which utilises two different
types of Niti instruments, glide path instruments and
then shapers.35, 15
TF Adaptive
The TF Adaptive technique has been proposed in order to maximise the advantages of reciprocation, while
minimising its disadvantages. By using a unique, patented motion, the innovative TF Adaptive Motion
technology, together with an original three-file technique, most clinical cases can be treated effectively
and safely (Fig. 2).
TF Adaptive employs a patented unique motion
technology, which automatically adapts to instrumentation stress, when used in the Elements Motor
|
Fig. 6
On the contrary, while negotiating the canal, due to
increased instrumentation stress and metal fatigue,
the motion of the TF Adaptive instrument changes
into a reciprocation mode, with specifically designed
CW and CCW angles that may vary from 600–0° to
370–50° (Fig. 4). These angles are not constant, but
vary depending on the anatomical complexities and
the intracanal stresses placed on the instrument. This
‘adaptive’ motion is therefore meant to reduce the risk
of intracanal failure, without affecting performance,
due to the fact that the best movement for each
different clinical situation is automatically selected
by the Adaptive motor. It is quite interesting that the
clinician will hardly perceive the differences in the
changing motion, due to a very sophisticated algorithm, which permits a smooth transition between
the changing angles.
Fig. 6: Deep shaping. The clinical use
of a second instrument (06/35) after
the 08/25 significantly increases the
preparation in the apical one third,
improving the quality of canal shaping
and allowing room for enhanced
irrigation. This will also allow the use of
the apical negative pressure devices
such as the EndoVac to safely deliver
abundant quantities of sodium
hypochlorite to the apex without the
risk of apical extrusion.
As far as disadvantages of reciprocation are concerned, TF Adaptive motion is a reciprocating motion
roots
3
2016
17
[18] =>
| technique canal shaping
Fig. 7
Fig. 7: M4 Safety Handpiece.
with cutting angles (CW angles) much greater than
WaveOne/Reciproc movements. This results in the TF
Adaptive instrument is working for a longer time with
a CW angle, which allows better cutting efficiency
and removal of debris (and less tendency to push
debris apically and laterally), because the flutes
are designed to remove debris in a CW rotation.
This results in TF Adaptive taking advantage of
the use of a motion that is more similar to
continuous rotation for optimal debris removal. There are obviously some changes
in the angles depending on canal anatomy
(the more complex, the smaller the CW angle), but they do not seem to significantly
influence the overall result. On the contrary, these changes influence resistance
to metal fatigue, since TF instruments used
with Adaptive motion were found to have
superior resistance to cyclic fatigue when
compared to the same TF instruments used
in continuous rotation.36
As mentioned before, flexibility is a fundamental property to minimise iatrogenic
errors while negotiating canals, both in
reciprocation and in continuous rotation.
The use of a reciprocating movement,
therefore, does not significantly help a
NiTi instrument of greater taper to negotiate curved
canals with no iatrogenic errors. It mainly helps to reduce instrumentation stress and the risk of intracanal
failure. In addition, a study aimed to compare the frequency of dentinal microcracks after root canal shaping with two reciprocating (Reciproc and WaveOne)
and one combined continuous reciprocating motion
Fig. 8: TFTM Adaptive Technique Card.
Size and Sequence Determination.
Fig. 8
18 roots
3 2016
Twisted Files Adaptive (TFA) rotary
system. Ninety molars were chosen
and divided into three groups of 30 each.
Root canal preparation was achieved by using Reciproc R25, Primary WaveOne and TFA
systems. All the roots were horizontally sectioned at 15, 9 and 3 mm from the apex. The
slices were then viewed each under a microscope at x 25 magnification to determine the
presence of cracks. The absence/presence of
cracks was recorded, and the data were analysed
with a Chi‑square test. The significance level
was set at P < 0.05. The results found that instrumentation with Reciproc produced significantly more complete cracks than WaveOne
and TFA (P = 0.032). The TFA system produced
significantly less cracks then the Reciproc and
WaveOne systems apically (P = 0.004). The study
concluded that within the limits of this study,
the TFA system caused less cracks then the full
reciprocating system (Reciproc and WaveOne).
Single‑file reciprocating files produced significantly more incomplete dentinal cracks than
full‑sequence adaptive rotary motion.39
The TF Adaptive technique is basically a
three file technique, designed to treat the majority of cases encountered in clinical practice. Available are two sets of three file systems, one
for small, calcifying and severely curved canals and one
system for more ‘standard’ and larger canals, allowing
adequate taper and increased apical preparation in
both scenarios. The number of instruments within each
sequence can also vary and adapt to canal anatomy,
with the last instrument of the sequence used only
[19] =>
canal shaping technique
|
when a greater apical enlargement is needed due to
larger original canal dimensions and/or enhanced final irrigation techniques. The sequences are also different in their shaping concepts. Each file of the sequence being used is taken to full working length in a
‘crown down’ manner so that the root canal wall is internally sculpted incrementally, allowing dentin debris
and tissue to be evacuated coronally rather than to be
pushed apically. This may reduce the risk of canal blockage and the extrusion of debris into the apical tissues.
The SM 1 file (single colour band green, 04 taper 20 tip
size) is an excellent flexible Glide Path file which may be
used with either sequence to pre-enlarge the canal
thereby decreasing instrument stress for the next
larger size file in sequence. This also allows better maintenance of the original canal trajectory (Figs. 2 & 5).
The final apical enlargement with a size #35 file
is not only meant to allow the use of the Endovac
(EndoVac Kerr Endodontics, Orange, CA) irrigation
technique, but to improve canal shaping by touching more canal walls. Figure 6 clearly shows how
improved and deeper the apical one-third shape is
when a 06 taper 35 tip instrument follows a 08 taper
25 tip instrument. This is why in the majority of cases
two instruments are much better than a single file
technique, provided that the second instrument is
a flexible one. The superior flexibility allowed by the
use of TF technology permits TF Adaptive to follow
these criteria, and safely enlarge canals with minimal risk of iatrogenic errors like tooth weakening
and canal/apical transportation. The use of a more
rigid alloy would have not made this possible, especially in curved canals.”15
TF Adaptive technique
Fig. 9
Canal size and file sequence determination
(Figs. 5 & 8)
Small Canals (SM)
Using tactile feel, if you struggle to get a #15 K-File
to working length (WL) then the canal size is deemed
to be ‘small’. Use the Small Pack (one colour band) and
its instrument sequence. The small sequence may also
be used in severely curved canals as well as roots that
may be very thin and the risk of strip perforation is a
possibility.
Medium/Large Canals (ML)
TF Adaptive is an intuitive, color-coded system deUsing tactile feel, if a #15 K-File feels loose at worksigned for efficiency and ease of use. The colour- ing length then the canal size is deemed to be ‘mecoded system is based on a traffic light. The first in- dium/large’. Use the Medium/Large Pack (two colour
strument in sequence is green. The second instrument bands) and its instrument sequence.
in sequence is yellow and the third instrument in
sequence, if required, is red. Green means go. Yellow Establish working length
means continue or stop. Red means stop (Fig. 2).
Working length should be established with a reliable apex locator. A radiograph may help the clinician
Coronal access and glide path
as well.
1. Place rubber dam.
2. Obtain straight line coronal access with slightly
diverging axial walls adhering to the concept of
Minmimally Invasive Endodontics.37
3. Achieve apical patency and establish an apical glide
path using #8 hand file, follow that with a #10 hand
file and continue at least with a #15 hand file. Glide
path may be facilitated with the M4 Safety Handpiece (Kerr Endodontics, Orange, CA) (Fig. 7). The
pulp chamber should be filled brimful with NaOCl
(Sodium Hypochlorite).
Fig. 9: EndoVac Apical Negative
Pressure Irrigation System. The Master
Delivery Tip (MDT) accommodates
different sizes of syringes filled with
irrigant, the macro cannula is attached
to the autoclavable aluminum hand
piece and the micro cannula is
attached to an autoclavable aluminum
finger piece. The macro cannula, the
micro cannula and the MDT are
connected via clear plastic tubing.
The tubes are connected to the high
volume suction of the dental chair via
the Multi-Port Adaptor.
TF Adaptive canal shaping technique
1. Use the ‘TF Adaptive’ setting on your Elements
Motor. Figure #3
2. Ensure the pulp chamber is flooded with NaOCl or
EDTA and make sure the file is rotating as you enter
the canal.
3. Slowly advance the green (SM1 or ML1) with a single controlled motion until the file engages dentin
then completely withdraw the file from the canal.
Do not force apically. Do not peck.
roots
3
2016
19
[20] =>
| technique canal shaping
Irrigate and dry
When irrigating with EndoVac (apical negative
pressure irrigation system),2 in small canals, you
must take SM3 to working length. In medium/large
canals, you must take at least ML2 to working
length. Note that the Microcannula is .32 mm in
diameter (Fig. 9). TF Adaptive matching Paper
Points may be used to dry the canals.
Obturation
TF Adaptive matching Gutta Percha in combination with the Elements Free Cordless Obturation
system37 may be used to obturate the root canal
system. Alternatively, TF Adaptive carriers may be
used.
Fig. 10
Fig. 10: CBCT (Cone Beam
Computerised Tomography) three
dimensional visualisation of TFA
preparation (SM sequence) in a
complex molar, showing proper shape,
tapered preparation and excellent
maintenance of canal trajectories.
(Courtesy of Dr Lucila Piasecki, Brazil
and Prof. Gianluca Gambarini, Italy)
4. Wipe off the flutes. Deliver irrigant to the pulp
chamber and confirm canal patency with a #15
handfile K-File.
5. Repeat steps 3 and 4 using the file you started with
until working length is achieved.
6. Repeat steps 3 and 4 with the yellow SM2 or ML2
until the file reaches working length. If the desired
apical size is achieved the sequence is complete.
For larger apical sizes, repeat steps 3 and 4 with the
red SM3 or ML3 until the file reaches working length.
Note: All TFA files may be used in a brushing manner
directed towards the external surface of the root away
from the canal curvature when retrieving the file from
the canals.
authors
Dr Gary Glassman is the author of numerous publications. He lectures globally on
endodontics, is on staff at the University of Toronto, Faculty of Dentistry in the graduate department of endodontics, and is Adjunct Professor of Dentistry and Director of Endodontic
Programming for the University of Technology, Kingston, Jamaica. Gary is a fellow of the Royal
College of Dentists of Canada, Fellow of the American College of Dentists and the endodontic
editor for Oral Health dental journal. He maintains a private practice, Endodontic Specialists in
Toronto, Ontario, Canada. His website is www.drgaryglassman.com and his office website is
www.rootcanals.ca. He can be reached at drg@drgaryglassman.com.
Gianluca Gambarini is a full-time Professor of Endodontics, University of Rome, La Sapienza,
Dental School. He is head of the Endodontic Department International lecturer and researcher.
He is author of more than 450 scientific articles, three books and chapters in other books. He
has lectured all over the world (more than 350 presentations) and has been invited as a main
speaker in the most important international (AAE, IFEA, ESE) and national endodontic
congresses in Europe, North and South America, Asia, Middle East, Australia and South Africa.
Prof. Gianluca Gambarini still maintains a private practice limited to Endodontics in Rome, Italy.
Dr Sergio A. Rosler has been the Assistant Clinical Teacher in numerous graduate and
post-graduate Endodontic Programs and was Clinical Fellow Teacher at Warwick Dentistry
University in the United Kingdom. Dr Rosler has lectured at conferences and several
universities around the world. He maintains a private practice limited to Endodontics in
Buenos Aires, Argentine and can be reached at sergiorosler@gmail.com.
20 roots
3 2016
Conclusions
TFA employs Twisted File technology and
Adaptive Motion Technology. The TF Adaptive file
design is based on clinically proven Twisted File
technology, which means the file is twisted to
shape for improved file durability, features R-
Phase Technology to improve file flexibility and
strength while maintaining the original canal
curvature minimizing canal and apical transportation (Fig. 10).
Adaptive Motion Technology is based on a patented, smart algorithm designed to work with
the TF Adaptive file system. The authors have also
found that Adaptive Motion Technology works
well with other ground file rotary systems making
their use safer especially in smaller and curved canals. This technology allows the TF Adaptive file to
adjust to intra-canal torsional forces depending
on the amount of pressure placed on the file. This
means the file is in either a rotary or reciprocation
motion depending on the situation and adjusts
appropriately.
This winning combination results in exceptional
debris removal with the tried and trusted classic
rotary Twisted File design and less chance of file
pull down and debris extrusion with Adaptive
Motion Technology._
Editorial Note: A complete list of references is available
from the publisher.
This article originally appeared in Oral Health dental journal
MAY 2016.
Disclaimer:
Drs. Gambarini and Glassman are the inventors of Adaptive Motion
and receive a nominal royalty from Kerr.
[21] =>
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HyFlex™ EDM
• Up to 700% higher fracture resistance
• Specially hardened surface
• Less filing required for treatment success
ORIFICE
OPENER
(optional)
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10 / .05
HyFlex™
OneFile
25 / ~
FINISHING
FILES
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40 / .04
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60 / .02
002382
www.coltene.com
[22] =>
| case report canal preparation
From a distal
Author: Dr Sam Alborz, USA
Introduction
Limited workspace is a common problem in endodontic treatments. Before the arrival of pre-bendable NiTi files, a lot of RCT’s seemed to be almost inexecutable due to severe constraints in the access area.
The following three cases illustrate how modern endodontic instruments help specialists to enter a new
era of canal preparation, particularly if the apex is
comparatively hard to reach.
Case 1 (Figs. 1–7)
Fig. 1: Initial situation.
Fig. 2: EDM File surface under the
microscope.
Standard endodontic treatment begins with placement of a dental dam to isolate the working environment, access to the canal via opening of the pulp
chamber, and gauging the correct working length using a state-of-the-art electronic apex locator. However, root canals often come in extraordinary shapes:
an unusually curvy anatomy with hidden accessory
canals or horizontal branches might pose a real challenge to the most experienced of endodontic experts.
If the tooth is in a remote position or craniomandibular problems are added to the picture, the task is even
more difficult. Thankfully modern endodontics offers
practitioners a whole range of clever instruments and
dental materials that ensure an effective and reliable
preparation and filling of the canal system. This is
good news to endo-specialists given that not all cases
allow standard procedures – or following the words
of the old Bette Midler song: sometimes the world
looks different ‘from a distal’.
Case presentation
Necrosis in S-shaped canals
In our first case, a 23-year-old male patient was
referred to our dental practice with chief complaint
of pain in the lower left mandible. The radiograph
showed deep caries approaching the pulp chamber
and clinical testing revealed a diagnosis of irreversible pulpitis with symptomatic apical periodontitis
(Fig. 1). Further review of the radiographs showed
that tooth 18 had a very complex anatomy of the mesial roots: the canal system was almost S-shaped
and the apex therefore would be difficult to reach. In
addition to the distinct mesial-distal curvature there
was a significant faciolingual curvature associated
with the mesial roots which was discovered during
hand intrumentations. Yet, the difficult anatomy of
the root canal system itself was not the only constraining factor that considerably narrowed work
space. To make things even more challenging, the
patient had a severe class II skeletal relationship. Together with the posterior position of the offending
tooth, this combination limited access to the canal
openings even further.
Fig. 1
The insufficient interocclusal space did not allow a
common NiTi 21 mm rotary instrument to fit into the
canal. For this reason, a special NiTi file system by
Swiss dental specialist COLTENE was used for canal
preparation. The HyFlex EDM is a modular designed
nickel titanium file system: in close cooperation with
Fig. 2
22 roots
3 2016
[23] =>
canal preparation case report
|
leading universities and international endo-specialists, the renowned research department of the
company developed an extremely versatile concept
which meets various demands. The abbreviation
‘EDM’ stands for a specific manufacturing process
named ‘Electrical Discharge Machining’, which produces a unique surface (Fig. 2). The spark erosion
employed improves cutting performance, as the
created structure can be compared with the serrated edge of a knife you use for cutting bread at
home. Due to its special material properties, the file
is virtually unbreakable and predestined for dentists
who require fast and reliable results using a reduced
file sequence.
To create a suitable glide path, both mesiobuccal
and mesiolingual canals were handfiled to a size 15
file. All pulpal tissue was removed after opening the
pulp chamber and canal clearance was checked thoroughly. For the actual preparation, the use of a universal EDM file in ISO size 25 totally sufficed (Fig. 5).
With the flexible file we were able to instrument the
mesial canals to a working length of 22 mm. Keeping
its pre-bent shape, the instrument permitted to
work without any stress and when the apex was
gauged in the distal canal, a size 30 hand file seemed
to fit in quite comfortably. Consequently, a 40/0.04
HyFlex EDM finishing file was used to enlarge the
apical aspect of the two distal canals. It is important
to point out that thorough irrigation was perIn the case described we benefitted first and
formed with sodium hypochlorite between every
foremost from the so-called ‘Controlled Memofile. At the end of the procedure the canals were irry’-effect (CM): similar to classical stainless steel
rigated with NaOCI, EDTA and CHX under acoustic
files, HyFlex files can be pre-bent and considstreaming. The canals were then dried via mierably help in preparation of distal molars
crosuction followed by the insertion of the cor(Fig. 3, 4). At the same time they do not bounce
responding paper points. In the end, the canals
back like classic NiTi files, which means that they
were obturated with the help of the traditional
move in an optimal way in the centre of the canal.
warm vertical compaction technique (Fig. 6).The
During autoclaving, reusable CM-treated files
pulpal floor was sealed with a layer of glass ionoreturn to their initial shape because they are not
mer, sponge pellet (to act as a spacer) and a dual-
plastically deformed. Due to the special situacured temporary filling material consisting of zinc
tion of the patient the pre-bent EDM files were
oxide and zinc sulphate over the top. A post-op
the only files that would fit in the limited work
radiograph was obtained (Fig. 7) and after the
space. Interestingly, the 25 mm EDM file fit in a
successful endodontic treatment the patient was
space that would not allow a 21 mm traditional
subsequently referred to his general dentist for
rotary NiTi.
Fig. 5 the definitive restoration of the tooth.
Fig. 3: Pre-bendable EDM File 60/.02.
Fig. 4: Pre-bent EDM File 60/.02.
Fig. 5: HyFlex EDM One File.
Fig. 6: Post-op (clinical) situation.
Fig. 7: Post-op situation.
Fig. 3
Fig. 4
Fig. 6
Fig. 7
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[24] =>
| case report canal preparation
lowing sequence all files were pre-bent beginning
with HyFlex EDM 10/0.05 (Fig. 9), followed by the
EDM OneFile size 25 in a soft pecking motion. Thorough irrigation throughout the treatment helped
clear the canals of any debris and necrotic tissue.
Gauging the apices revealed ample enough room
for a size 30 hand file, indicating that apical enlargement was warranted. The decision was made to utilise EDM 40/0.04 finishing file on the distal canals.
Due to the abrupt canal curvature, the mesial canals
were shaped using a HyFlex CM 35/0.04. After copious irrigation with NaOCI, EDTA and CHX under
acoustic streaming the canals were dried and obturated using the warm vertical compaction technique. Thanks to the flexible, fracture resistant
files we were able to shape the canals very effective and efficiently. The access was closed in the
same manner as in case 1 (see Fig. 10, 11). Without
pre-bendable NiTi files, we would probably have
been unable to perform root canal treatment on
this tooth.
Fig. 9
Fig. 8
Case 2 (Figs. 8–11)
Fig. 8: Initial situation.
Fig. 9: HyFlex EDM Glidepath file.
Fig. 10: Post-op (clinical) situation.
Fig. 11: Post-op situation.
Abrupt canal curvature
Our second case proved to be equally challenging:
a 24-year-old female patient entered our referral
practice with a necrotic pulp in tooth 18. The opening
was limited and once again, the tooth was positioned
very distal with only limited space for instrumentation. The root canals were highly curved with sudden
sharp dilacerations (Fig. 8). After consultation, the
patient agreed to root canal treatment.
The dental dam was used to isolate the tooth
and the canals were accessed with a round diamond
bur. The previous composite resin restoration was
removed to facilitate the identification of possible
cracks. The dentin appeared to be intact, we then
proceeded to shape the canals. We started to
handfile all canals to a size 15 hand instrument to
create a suitable mechanical glide path. In the fol-
Fig. 10
Fig. 11
24 roots
3 2016
Size 60 finishing files
In our last case, a 37-year-old female patient
presented with a necrotic pulp in the upper right
central incisor with an evident vestibular swelling
(Fig. 12). The pulp chamber was accessed using a
surgical length friction grip size 2 round bur. Once
working length was obtained the canal was hand
filed to a size 15 hand instrument. Additionally, the HyFlex EDM Orifice Opener 25/0.12
was used to enlarge the coronal aspect of
the canal. The apex was gauged, showing that
a size 50 hand file was snug. As the canal was
already very large coronally, we decided to use
a size 60/0.02 EDM finishing file to shape the
remainder of the canal and accomplish apical
enlargement (cp. Fig. 13). Even the large size 60
EDM file proved its astonishing fracture-resis-
[25] =>
canal preparation case report
tant quality throughout this case (Fig. 14).
The canal was irrigated with NaOCl, dried,
calcium hydroxide applied, and sealed
with a provisional restoration. To alleviate
vestibular swelling incision and drainage
was performed.
Case 3 (Figs. 12–15)
Fig. 12: Initial situation.
Fig. 13: HyFlex EDM File 60/.02.
Fig. 14: Pre-bent EDM File 60/.02
entering the canal.
Fig. 15: Post-op situation.
Three weeks later the patient returned
for her follow-up visit. The swelling and I &
D site had fully resolved. The root canal system was irrigated, obturated, and sealed as
described in the previuos cases and the patient was referred back to her general practitioner (Fig. 15). With the aid of the HyFlex
EDM files we were able to complete the
entire treatment using only two rotary instruments. With this effective system we
were able to stay conservative coronally yet
enlarge apically. With the right equipment
both root canal specialists and general
practitioners can create convincing results
in a short period of time, without making
any concessions to the natural anatomy of
the root canal.
Summary
|
Fig. 14
Fig. 13
Modular designed NiTi systems demonstrate their
full versatility in root canal profiles that are difficult
to access or have an unusually abrupt curvature. Flexible files like the HyFlex EDM or HyFlex CM can be prebent, which helps dentists to operate both confidently and safely, even under challenging conditions.
Depending on the clinical situation endo-specialists
can choose between fast instrumentation with only
a few files or high-precision shaping of the canal with
a clever combination of a more refined file sequence.
Fig. 15
Thanks to their intuitive way of handling even newcomers to endodontics can achieve reliable results in
next to no time – with an astonishing ‘distal effect’._
contact
Dr Sam Alborz completed
dental school at the University of
Texas Health Science Center in
San Antonio, graduating with
highest honors (Magna Cum
Laude). He then worked as a
general dentist before entering
the Endodontic residency
program at Boston University.
He has given numerous presentations both nationally and
internationally and is currently in private practice in
Knoxville, Tennessee. Dr Alborz is a member of the
American Association of Endodontists, American Dental
Association, Tennessee Dental Association, Second
District Dental Society and Blount County Dental Society.
Fig. 12
Dr Sam Alborz, DDS
109 Land Oak Road
Knoxville, TN 37922
alborzdds@hotmail.com
www.tnmicroendo.com
roots
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[26] =>
| study non-surgical treatment
Long-term analysis
of primary, non-surgical
root canal treatments–
A retrospective study
Author: Dr Robert Teeuwen, Germany
Abstract
After 20 years, 82.3 % were not subject to failure
and 51.5 % were saved from extraction.
Ng et al.4 evaluated 76 studies from 1922–2002 in
a systematic review. Various studies showed an average success of 74.7 % based on strict criteria, and a
success rate of 85.2 % based on loose criteria. When
using strict criteria, the success rate increased with
duration of follow-up period—from 67.3 % after
24 months to 85.4 % after 48 months. In a follow-up
publication based on 63 studies5, the authors analysed parameters regarding their influence on the success of the root canal treatment (RCT). Using strict
criteria, they determined four main factors: apical
periodontitis (AP), quality of root canal filling (RF) homogeneous versus nonhomogeneous, length of RF,
and quality of restoration. They ascribed a success
of 82.5 % to vital teeth, and a success of 73.1 % to
non-vital teeth. The lowest success rates could be observed in mandible molars, patient age > 50. In a systematic review of 14 survival studies Ng et al.6 showed
that survival rates concerning extractions showed
better results than success rates. The study of Lee et
al.7 features a clear comparison of the evaluated comparison parameters success/survival.
Introduction
Materials and methods
Studies feature the evaluation of factors with the
treatment aim of healing and retention in a symptom-free environment. Evaluation of success/failure
is partly based on X-rays only, and partly on X-rays
plus clinical situation. According to Schmalz1, X-rays
are not an absolutely reliable parameter. Furthermore,
studies2, 3 show that the bias of the reviewer influences the interpretation of the X-ray. Finally, various
improbabilities affect evaluation.
The author, who started as a dental practitioner in
1969, used the 9,988 non-surgical endodontic treatment cases registered in his patient files from 1985 to
1999. Of these, X-rays were no longer available in 518
cases. Five teeth were extracted immediately upon
noticing of via falsa. Eight hundred and twenty-one
cases had not returned to the practice after RCT, however they were included in the dropout rate without
further analysis. Thus, 8,644 cases of vital and non-vi-
The aim of this study was to exam more than 8,000
primary, non-surgical root canal treatments in the
author’s general practice during 1985–1999 and followed-up for 25 years.
Factors that have influence on failure and extraction
rate were evaluated. Statistically, the data were analysed by log-rank test and Cox regression. The estimated
survival rates were shown in Kaplan-Meier curves.
With regard to the multivariat Cox regression the
significant factors were: overfilled root canal, poor
root filling quality, restoration, and fractured canal
instrument, via falsa. Further on failure was influenced by the operator and the preoperative status of
the pulp. Insurance conditions, patient age and type
of tooth influenced the extraction risk.
26 roots
3 2016
[27] =>
non-surgical treatment study
Variable
Sub-group
Operator
Operator
Gender
Gender
Age
Age
Age
Health-insurance
Health-insurance
Health-insurance
Tooth-type
Tooth-type
Tooth-type
Visits
Visits
Sympt. preoperative
Sympt. preoperative
Pulp preoperative
Pulp preoperative
Periapex preoperative
Periapex preoperative
RC-filling length
RC-filling length
RC-filling length
RC-filling quality
RC-filling quality
Restoration
Restoration
Restoration
Restoration
Breakage RC-instrum.
Breakage RC-instrum.
Via falsa
Via falsa
T
A
Male
Female
< 30
30 - 50
> 50
RVO (worker)
VDAK (employer)
Private patients
Front
Premolars
Molars
1
>1
yes
no
vital
non-vital
lesion
no lesion
short
flush
long
homogen
inhomogen
filling
crown
crown+post
filling+post
yes
no
yes
no
Origin
Teeth
n (%)
Followup
Year
at Risk
n
5071 (58,7)
3573 (41,3)
4440 (51,4)
4204 (48,6)
3370 (39,0)
3355 (38,8)
1919 (22,2)
5100 (60,0)
2300 (27,1)
1093 (12,9)
2736 (31,6)
3275 (37,9)
2633 (30,5)
289 (52,9)
257 (47,1)
79 (22,4)
273 (77,6)
8098 (93,7)
546 (6,3)
256 (46,9)
290 (53,1)
4553 (52,7)
3326 (38,5)
765 (8,85)
5788 (67,0)
2856 (33,0)
5576 (64,5)
2482 (28,7)
529 (6,1)
57 (0,7)
382 (4,4)
8262 (95,6)
32 (0,37)
8612 (99,6)
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
1648
1011
1397
1262
809
1217
633
1465
818
352
856
1069
734
79
67
28
71
2513
146
63
83
1438
1008
213
1803
856
1199
1157
290
13
100
2559
7
2652
tal teeth at 3,951 patients remained for analysis. The
non-vital cases had been applied to a former study8
with shorter follow-up-time, exclusion of molars and
X-ray-rating of three reviewers. The observation period ended in September 2006. A recall of the patients
did not take place. Considering extractions and remaining cases after 5, 10, 15 and 20 years, drop-out
rates amounted to 40.6, 58.5, 72.2 and 81.7 %.
RCTs were carried out according to the N2method of Sargenti.9 This method includes the use
of the paraformaldehyde-containing zinc oxide root
canal cement N2 and canal preparation without canal rinsing. Canal preparation was solely done manually by reamer: using step-back technique in vital
teeth, crown-down technique in non-vital teeth. The
creamy N2 composition was applied to the root canal
by lentulo instruments. A gutta percha point was
added in wide canals only. The RF-sitting were always
finished by a definite filling as well as a provisional
crown, if needed. The adequate length of the RF was
considered to end in the area of the radiological apex
up to –2 mm, an RF level of < –2 was determined as
underfilling, an RF level of > 0 as overfilling. RF-quality was judged according to its homogeneity. X-rays
were taken and diagnostics were performed by the
author himself. Follow-up X-rays were only evaluated
Extraction
Survival
% (CI)
73,9 (80,7-72,3)
72,2 (70,2-74,3)
71,7 (69,9-73,4)
75,1 (73,3-76,9)
81,2 (79,1-82,2)
73,5 (71,6-75,5)
62,9 (60,2-65,6)
69,5 (67,7-71,2)
78,2 (76,0-80,4)
79,0 (75,9-82,1)
74,3 (72,2-76,6)
73,6 (71,6-75,6)
71,6 (69,3-74,0)
69,3 (62,6-76,6)
73,8 (66,9-81,4)
80,8 (70,7-92,4)
69,7 (62,7-77,4)
73,4 (72,1-74,7)
71,4 (66,6-76,6)
65,5 (58,1-73,8)
76,3 (70,1-83,0)
71,3 (69,6-73,1)
76,2 (74,3-78,2)
72,3 (68,0-76,8)
75,4 (73,9-76,9)
68,9 (66,7-71,2)
63,8 (62,0-65,7)
86,8 (85,2-88,5)
86,6 (83,2-90,1)
56,5 (41,2-77,7)
64,2 (58,3-70,7)
73,7 (72,4-75,0)
26,2 (12,6-54,4)
73,4 (72,2-74,7)
p
0.927
0.927
0.0015
0.0015
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
0.0314
0.0314
0.0314
0.0672
0.0672
0.116
0.116
0.186
0.186
0.0577
0.0577
0.0001
0.0001
0.0001
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
at Risk
n
Failure
Survival
% (CI)
p
1558
952
1332
1188
754
1143
613
1384
774
330
807
1007
696
62
53
22
54
2395
115
56
69
1354
972
184
1723
787
1134
1111
265
90,0 (88,9-91,1)
86,4 (84,8-87,9)
88,9 (87,6-90,1)
88,3 (86,9-89,6)
86,2 (84,4-87,9)
89,1 (87,8-90,5)
90,8 (89,1-92,5)
88,5 (87,3-89,7)
88,8 (87,2-90,5)
88,5 (86,0-91,1)
91.9 (90,5-93,2)
91,2 (89,9-92,5)
81,8 (79,8-83,8)
69,0 (62,6-76,0)
73,7 (66,6-81,5)
71,4 (60,2-84,6)
66,9 (59,7-74,9)
89,7 (88,8-90,7)
71,3 (66,5-76,4)
65,1 (58,2-72,9)
76,6 (70,3-83,5)
86,7 (85,3-88,0)
93,4 (92,3-94,5)
79,5 (75,8-83,3)
92,1 (91,2-93,0)
81,5 (79,5-83,5)
84,9 (83,5-86,3)
94,4 (93,3-95,5)
89,8 (86,7-92,9)
<0.0001
<0.0001
0.417
0.417
0.0007
0.0007
0.0007
0.629
0.629
0.629
<0.0001
<0.0001
<0.0001
0.0496
0.0496
0.575
0.575
<0.001
<0.001
0.0028
0.0028
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
93
2417
2
2508
74,2 (68,6-80,2)
89,2 (88,3-90,2)
8,25 (1,30-52,3)
88,9 (88,0-89,8)
<0.0001
<0.0001
<0.0001
<0.0001
one year or more after RCT. According to the European
Society of Endodontology (ESE) quality guidelines10,
the ‘follow-up’ diagnoses were classified into three
criteria:
·· Diagnosis 1 (success): Regular periodontal gap in
X-ray, no symptoms, no fistula, no swelling;
·· Diagnosis 2 (uncertain result): AP after < 4 years,
incomplete healing, not to be evaluated, scar tissue,
remaining shadow around overfilled root-canal;
·· Diagnosis 3 (failure): AP still existing > 4 years,
newly developed AP, clinical symptoms.
|
Table 1: Survival probability related to
extraction and failure with confident
intervals (CI).
In multi-canal teeth, the root canal with the poorest prognosis was selected as being relevant for the
analysis. The present study contains an analysis of
success/failure and survival of root-filled teeth with
reference to re-intervention: extraction, retreatment
(RTR), root-end-resection (RER), trephination (TR),
hemisection (HEM). Failures were divided into:
·· Clinical failure: no follow-up X-ray accompanying
acute exacerbation, pain, swelling, fistula;
·· Failure with follow-up X-ray.
The statistic evaluation was executed with program R: R Core Team.11 The survival rates were estimated by nonparametric estimation according to
Kaplan & Meier.12 Group comparison was done by
roots
3
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[28] =>
| study non-surgical treatment
Table 2: Cox-Regression based on
univariat significant factors.
Variable
Operator
Insurance
Age
Tooth-type
Pulp preop.
r.c. filling
length
r.c. filling
quality
Restoration
Failure
Breakage
canal instr.
Via falsa
Sub-Group
(RVO reference)
VDAK
Private
( <30 reference)
30-50
>50
(front reference)
premolar
molar
(short reference)
flush
long
(filling reference)
crown
crown+ post
p-Value
Extraction
HR
<0.001
<0.001
0.767
0.759
0.69-0.85
0.65-0.88
<0.001
<0.001
1,874
3,123
1.66-2.11
2.75-3.55
0.001
<0.001
0.815
0.731
0.73-0.91
0.64-0.84
CI
p-Value
0.013
Failure
HR
CI
1,210
1.041-1.41
<0.001
0.309
0.25-0.38
0.099
0.026
0.004
0.914
0.818
1,160
0.82-1.02
0.69-0.96
1.05-1.28
<0.001
<0.001
<0.001
0.636
1,758
2,081
0.52-0.77
1.41-2.20
1.78-2.43
<0.001
<0.001
<0.001
0.006
0.310
0.316
2,794
1,324
0.20-0.35
0.26-0,39
2.49-3.14
1.08-1.62
<0.001
0.030
0.428
0.720
0.35-0.52
0.53-097
<0.001
2,179
1.70-2.79
<0.001
2,533
1.60-4.01
<0.001
8,370
5.05-13.88
CI = Confidence Interval
Factors are compared with the reference group based on value 1.
Hazard Ratio >1: the evaluated factor has a greater risk of a negative result
Hazard Ratio <1: the evatuated facto factor is lress prone to a negative result
Fig. 1: Related to failure survival
probability: length of root-canal filling.
Fig. 2: Survival probability (extraction):
quality of root-canal filling.
Fig. 1
28 roots
3 2016
Log Rank test. A p-value of < 0.05 was judged as being significant statistically. Survival publications depending on 14 influence factors (Table 1) in reference
to failure and extraction were determined with the
help of the multiple Cox regression (Table 2). This include the findings which were relevant in vital and
non-vital cases.
Fig. 2
Results
The observation period of the 8,644 analysed teeth
lasted up to 25 years after the RCT (median 6 years).
8,098 (93.7 %) were attributed to vital extirpations
(VitE) and 546 (6.3 %) to conservative initial treatment of non-vital teeth. During the observation pe-
[29] =>
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[30] =>
| study non-surgical treatment
Fig. 3
Fig. 3: Survival probability (extraction):
restoration.
Fig. 4: Survival probability: extraction,
re-intervention, clinical failure,
radiographic failure.
Fig. 4
riod, an average of 5,295 cases attained a minimum
of one follow-up X-ray after 7.14 years: 4,886 (60.3 %)
in vital teeth, 409 (74.9 %) in non-vital teeth. The follow-up X-ray diagnoses are shown in Table 3.
(sex, insurance condition, preoperative symptoms)
did not have a significant influence to failure.
Of the RCTs, 58.7 % were carried out by the author
himself, and 41.3 % by his assistant doctors. Cox regression showed a higher failure risk for the assistant
cases versus the author: however, there was no higher
extraction risk.
X-ray diagnosis < 4 years after RCT (n = 1,482) revealed a radiographical failure of 9.9 %. This radiographical failure rate decreased to 8.3 % when diagnosis was made > 4 years after the RCT.
Out of the entity of 713 failures (8.2 % of all RCTs),
514 (5.9 % of all RCTs) were incorporated with X-ray.
In doing so, the failure of 465 cases (90.5 %) was
proved radiographically; 49 failures (9.5 %) were
not substantiated in the X-ray. Another 199 cases
(2.3 % of all RCTs) in form of acute exacerbations
had to be judged as clinical failures without follow-up X-ray: 139 (1.72 %) in vital, 60 (10.98 %) in
non-vital teeth. Fifty-five failures remained without
therapy. In 13 cases, therapy was limited to a non-
contact grinding. Four hundred and twelve failures
(57.8 %) were extracted, failures increased extraction rate to the 2.8-fold.
Fourteen factors had been evaluated (Table 1)
regarding extraction and failure rate. Five of these
factors (operator, vitality status prior to RCT, preoperative AP, preoperative symptoms, number of appointments) did not have a significant influence to
the extractions statistically, whereas three factors
Diagnosis
Success
Uncertain
Failure
Table 3: Follow-up X-ray-diagnosis.
30 roots
3 2016
The clientele consisted of 51.4 % male and 48.6 %
female patients. Regarding failures and extractions, a
significant statistic difference between the sexes
could not have been observed in the multivariate
analysis (p = 0.417).
With regards to insurance, 59 % of the patients
were insured by the RVO health insurances (legal
health insurance for workers), 26.6 % by insurances
for employees, 12.6 % had private health insurance,
and 1.7 % were insured elsewhere. The failure analysis
revealed no difference between the individual insurances (p = 0.629). Cox regression showed a lesser (approx. 24 %) extraction risk in employees and privately
insured patients.
The average age of the patients amounted to
36.7 years (6–84). Regarding age, the highest failure rate was observed in patients < 30 years, however, they had the lowest extraction rate. According to Cox regression, the middle age group of
Total
n
4474
356
465
5295
Vital
%
84.5
6.7
8.8
n
4171
304
411
4886
Non-vital
%
85.4
6.2
8.4
n
303
52
54
409
%
74.1
12.7
13.2
[31] =>
non-surgical treatment study
Teeth
12,11,21,22
13.23
14,15,24,25
16,17,18,26,27,28
32,31,41,42
33.43
34,35,44,45
36,37,38,46,47,48
36.46
37.47
Extraction
Survival (CI)
%
81,9 (78,9-85,1)
71,8 (67,7-76,2)
72,3 (69,3-75,4)
72,3 (69,1-75,7)
63,1 (55,6-71,5)
69,3 (64,8-74,1)
74,6 (72,0-77,4)
70.9 (67,7-74,4)
72,2 (67,6-77,0)
69,7 (64,7-75,0)
At Risk
n
346
242
478
372
68
200
591
362
174
163
30–50 years had nearly 2-fold and the age group
of over 50 years a 3.1-fold higher extraction risk
versus the patients under the age of 30.
Analysis revealed significant differences (< 0.0001)
regarding failures connected with the kind of tooth:
molars 18.2 %, premolars 8.8 %, front teeth 8.1 %. Extraction rate of upper incisors was the lowest, extraction rate of the lower incisors the highest. Details
can be seen in Table 4. According to univariate analysis, age and kind of tooth were not relevant regarding
failure. Considering all analysed influence factors,
premolars had a lower extraction risk of 81.5 % versus
front teeth, molars a lower extraction risk of 73.1 %.
P
<0.0001
0.547
0.8100
0.0584
0.0131
0.0066
0.8100
0.134
0.813
0.197
At Risk
n
321
205
445
355
59
190
562
341
160
157
Failure
Survival (CI)
%
90,9 (88,6-93,2)
93,6 (91,2-96,1)
90,1 (88,0-92,2)
85,4 (82,8-88,0)
82,5 (76,5-89,1)
93,6 (91,2-96,1)
92,2 (90,5-93,9)
78,3 (75,3-81,5)
72,7 (68,2-77,5)
84,7 (80,7-88,9)
Aside from 19 teeth (0.23 %), all vital teeth were
treated in one appointment. The multi-appointment
of non-vital teeth in 257 cases (47 %) led to more failures (p = 0.0496).
Significant failure rate differences could be observed regarding pulp vitality prior to RCT (p < 0.001).
Cox regression showed the significantly lower failure
risk for vital teeth, which amounted to 30.9 % of
non-vital teeth.
Two hundred and fifty-six (46.9 %) of the non-vital
teeth featured an apical lesion when starting RCT.
These were diagnosed with a failure rate of 34.9 %
P
0.0115
<0.0001
0.0356
<0.0001
0.0081
0.0058
<0.0001
<0.0001
<0.0001
0.0175
Table 4: Survival probability of
teeth-groups 10 years after
root-canal-treatment (p-value
compared to the totality of all other
teeth).
Case 1
Figs. 5a & b: Pre-op X-ray (a). Post-op
X-ray with fistulation drill (b).
Figs. 6a & b: Fistulation drill in situ (a).
Post fistulation (b).
Fig. 7: Control X-ray – 5 years after
treatment.
Fig. 5a
Fig. 6a
|
Fig. 5b
Fig. 6b
Fig. 7
roots
3
2016
31
[32] =>
| study non-surgical treatment
Table 5: Re-intervention of all RCT and
failure of re-intervention.
Extraction
RER
RTR/RER
RTR/TR
RTR
TR
HEM
Re-intervention
n
%
1883
21.78
82
0.95
47
0.54
12
0.14
90
1.04
58
0.67
10
0.11
2182
25.24
Failure
n
412
79
43
11
35
58
7
645
%
21.87
96.34
91.48
91.66
38.88
100.00
70.00
29.56
RER = root-end resection
RTR = retreatment
TR = trephination
HEM = hemisection
after 10 years. The difference with/without AP was
significant (p = 0.0028 %).
Cox regression by finding a 32 % higher extraction
risk (Fig. 3).
Also RF-degree (Fig. 1), RF-quality and restoration
had a significant influence on the failure rates. The
highest failure frequency could have been observed
after overfilling. Adequately filled teeth had a risk of
failure of 63.6 % versus underfilled teeth; overfilled
teeth had a 1.8-fold higher risk in comparison to underfilled teeth. Extraction rates of adequately and underfilled teeth featured nearly the same extraction
frequency, whereas overfilled teeth showed an extraction risk of 18 % less. 25 % of all front teeth and
premolar RFs as well as 52.6 % of all molar RFs showed
a poor RF-quality which ended in a twofold failure risk
versus a good RF quality and thus a 16 % higher risk
of extraction (Fig. 2).
The process-related accident of a via falsa with
perforation increased failure risk (75.2 % failure-rate
after 8 years) to the 8.4-fold, extraction risk to the
2.5-fold.
Root-filled teeth provided with one filling only had
a higher tendency to failures and extractions. Cox
regression proved a failure rate of 28 % less after
crowning with build-up pins versus filling therapy.
Without build-up pin insertion, crown provision was
the reason for a 57 % lower failure rate. Crowning reduced the extraction risk to 31 % of teeth provided
with a filling.
Three hundred and eighty-two (4.4 %) of fractured canal instruments were registered—1.83 % in
front teeth and premolars, 10.29 % in molars. A failure was diagnosed in 72 cases (18.8 %) resulting in
a 2.2-fold higher failure risk for teeth with fractured canal instrument. During observation period,
108 (23.8 %) teeth were extracted with a fractured
canal instrument. The statistic relevance determined by the log-rank test was confirmed in the
32 roots
3 2016
Extractions represented the main contingent of
re-interventions with another 299 treatments (RER,
RTR, TR, HEM). Nearly 30 % of re-interventions were
needed due to failure. The relation of re-intervention
and failure can be learned from Table 5. Table 6 gives
a survey about reasons for extraction and their relation to failures. Figure 4 shows the chance of survival
of cases which were not subject to extraction, further
re-interventions or failure (clinically, radiologically)
in a survival curve according to Kaplan Meier.12 After
20 years, 82.3 % (CI 80.5–84.2) of RCTs were not affected by radiological and/or clinical failure with n =
381 remaining under risk. Within the first year after
RCT the incidents were: 183 of the 199 (92 %) acute
exacerbations, 22 of the 514 (4.3 %) failures with follow-up X-ray, 159 of the 1,883 (8.4 %) extractions and
140 of the 299 (46.8 %) further re-interventions.
Discussion
‘Presence or absence of the tooth is not subject to
interpretation as would be subjective measurement
of radiographic change, clinical signs and symptoms,
patient history, etc’. With this statement, Alley et al.13
pointed out the advantages of survival studies,
whereas Torabinejad et al.14 limited these advantages
by calling survival studies as being ‘less biased’ as well
as less informative. They further noted that endodon-
[33] =>
non-surgical treatment study
|
Case 2
Fig. 8: Initial situation X-ray (1987).
Fig. 9: Control X-ray (2002).
Fig. 10: Permatex-Anker inserted with
N2 (2002).
Fig. 11: Control X-ray (2011).
Fig. 8
Fig. 9
Fig. 10
Fig. 11
tic studies come up with another variability making
comparability more complicated.
The present study includes a drop-out rate of
40.6 % after 5 years, of 58.5 % after 10 years. As a
recall never took place it can be supposed that the
drop-out rates would have been more favorable in
case of recall management.
The cases of the present study were treated in the authors office and evaluated by the author himself.
Whereas extraction and thus the relevant survival represent a hard, non-discussible fact, success/failure evaluations are subject to bias. According to literature6, 7 the
survival rate regarding tooth extractions is higher than
the failure rate. Analysis of the practice data showed the
opposite: after 20 years, 51.5 % of the teeth were still
in situ and 82 % were still saved from failure.
Comparison with some studies can partly not be
made, as survival data refer to the initial case numbers
and are not in reference to the remaining cases getting less over the years. So the survival dates referring
to extractions gained from the insurance registers
have to be seen critically. Lazarski et al.15 indicated
that 94.4 % remained in the mouth functionally after
an average of 3.5 years. Salehrabi and Rotstein16 calculated a remaining in situ of 97.1 % after 8 years
and Chen et al.17 a remaining in situ of 93.3 % after
5 years. Drop-outs are not mentioned in these studies. The fact is that only data known to the insurance
are evaluated in those studies, which is rather unlikely
in non-treated pathology, non-treated radiographical failure or goodwill treatments. In 914 cases, Stoll
et al.18 noticed 105 (11.5 %) losses (extractions, RER,
RTR) after 106 months, which can be interpreted as a
cumulative survival rate of 74 %. De Chevigny et al.19
report about 70–73 % of drop-outs. They judged the
remaining cases as being in function (95 %) and as
healed radiographically (86 %).
The long observation period of up to 25 years may
have supported the low failure rate. The later lower
failure rate can be led back to the fact that the radiographical failure diagnosis averaged from 9.9 % to
8.3 % after the fourth year. It has to be mentioned
that 9.5 % of the failures accompanied by X-ray
could not have been verified radiographically. This
may be due to the fact that the apical osteitis has not
yet rounded the corticalis with sufficient mineral
loss what is, according to Bender20, the pre-condition for a radiographical AP presentation. Also
anatomic features may superimpose an AP. The declining development of apical lesions over time
Extraction Reason
Caries, Fracture
Parodontopathy
Prosthetics
Endodontic Failure
Unknown Reason
Pain
Total
Extraction
n
%
866
441
167
222
78
109
1883
46
23.4
8.9
11.8
4.1
5.8
Table 6: Extraction reason and failure.
Failure
n
%
55
24
10
222
4
97
412
6.4
5.4
6
100
5.1
89
roots
3
2016
33
[34] =>
| study non-surgical treatment
Fig. 12
Fig. 13
Case 3
Fig. 12: Pre-op X-ray (1989).
Fig. 13: Post-op X-ray (1989).
Fig. 14: Control X-ray (2007).
conforms to literature data indicating a better RCT
success result4, 21 although Eckerbom et al.22 noted
an increase of apical lesions from 17.3 % to 21.4 %
within 20 years. The own, relatively high success
rate might be based on a bias with a too positive
evaluation of the cases or an over-representation
of the VitEs. It might also be due to the used RCT
method as observed in epidemiological studies23 in
countries with extensive application of formaldehyde-containing materials despite poor technical
RF-quality.
undergo therapy. The postoperative pain sensations
amounted to 1.7 % after vital, after completion of a
non-vital treatment to 11 %. A little more than a third
could be contributed to overfilling:
30.9 % after overfilling of vital and 41.7 % after overfilling of non-vital teeth. The Gesi et al.27 study on vitally extracted teeth mentions a pain rate of 13.3 %
within the first week after VitE. 30.7 % of the pain
arose in overfilled teeth. In the own study, 69 overfillings (34.2 %) were responsible for 199 postoperative
pain sensations.
Socially advantaged patients were represented
with approx. 40 % in the examined patient population. They carried a 24 % lower extraction risk than
social weak patients. A different failure risk did not
exist between the individual social statuses of the patients. According to Hujoel et al.24, decision for extraction is determined by sociodemographic factors.
A low income status and a low level of education favor
the decision for extraction. The authors Jafarian and
Etebarian25 concluded from an analysis of 2,620 extracted teeth that the level of education is of significant importance for tooth preservation. In a company
health insurance study26 representing the working
class, 8.3 % of the endodontic cases were extracted
within 2 years. After 5 years, 28 % of reinterventions
in the form of extractions and RTRs became necessary.
In my own practice, the cumulative survival quote of
all reinterventions increased to 16 % after 5 years.
Neither the sex, nor the preoperative pathology or
the number of appointments were decisive for extractions or failure. However, the failure risk of vital
teeth only amounted to 30.9 % of non-vital teeth.
The multivariate analysis emphasised the results of
the univariate analysis regarding the extraction risk
subject to age and kind of tooth. The two older age
classes attained higher extraction rates compared to
the age class of <30. With increasing age, tooth loss
rises even in non-root canal treated teeth by carious
destruction and periodontal diseases. According to
Eriksen et al.23, epidemiologic studies reflect the endodontic performance of general dentists with success rates of 60–75 %. In his own practice, the author
achieved a failure rate of 10.3 % in vital and 28.7 % in
non-vital teeth.
According to Lee et al.7, the median survival limit
regarding extraction had been reached after 21 years,
thus approximately corresponding to my own. The
median failure limit of Lee et al. was after 119 months
(about 10 years). It has to be added that the authors
scheduled their study 2 weeks after RCT only, so very
early extractions and failures might have been skipped
from the study.
Torabinejad et al.14 pointed out that in their study
they categorically assigned pain after RCT to the failures. The same principle is valid for the present study.
All acute exacerbations (clinical failures) were treated.
10.5 % of the failures accompanied by X-ray did not
34 roots
3 2016
Fig. 14
It is also to be expected that different levels of experience are responsible for different success rates.
The cases treated by assistant doctors had a statistically significantly higher failure rate compared to the
practice senior while the extraction rates of assistants
and practice senior were on the same level. Cox regression proved that RF-degree and RF-quality do
hardly play a role for the extraction risk the more
however for the failure risk. An RF with ‘voids’ and incomplete canal wall adhesion allows a bacterial augmentation/invasion, an overfilling at least a periapical irritation caused by canal content flowing over the
apex and root canal filling material.
According to Ng et al.6, the most significant criteria for survival were: crown, two proximal contacts,
[35] =>
non-surgical treatment study
Fig. 15
Fig. 17
no use as prosthetic post and non-molar. In their
studies, crowned teeth with or without build-up
pin showed the lowest extraction risk versus all
other researched variables, crowned teeth without
build-up pin simultaneously featured the lowest
failure risk. Crowns offer a high fracture protection
and are an expensive investment, where the patient
does not like to separate from. It has to be considered though that crowning of teeth is preceded by
an estimation of the survival prognosis6 and the
better case material will be considered first when it
comes to crowning.
Regarding the incidents of perforation and fractured canal instrument, the author found evidence
from Ng et al.28 in the survival literature, where 76
(4.7 %) of 1,617 cases were subject to perforation
and 105 cases (12.2 %) out of 858 secondary root
canal treatments subject to fracture of a canal instrument. The Cox regression proves a 3.7-fold extraction risk for perforations, for the cases with
fractured canal instrument a 3.1-fold extraction
risk. Marquis et al.29 added 11 fractured canal instruments and 18 perforations in 369 endodontic cases
to the intraoperative complications which affect
the success result. Their own study proved a 2.5-fold
extraction and a 8.4-fold failure risk for via falsa perforations. In case of fractured canal instruments
the risk of extraction increased 1.3 times and the
risk of failure to 2.2 times.
|
Fig. 16
Fig. 18
Conclusions
More than 8,000 endodontic primary cases had
been observed for up to 25 years. Quality and length of
RF, the type of restoration, the fracture of root canal
instruments and the incident of perforation were responsible for the failure and extraction risk. The position of the tooth, age and social status had an influence on extraction frequency, the pulp state and the
operator on the failure frequency. A symptom-free
tooth remaining in situ of 73.2 % after 10 years and
51.5 % after 20 years speaks for a successful endodontic treatment therapy under practice conditions._
Fig. 19
Case 4
Fig. 15: Pre-op X-ray (1992).
Fig. 16: Post-op X-ray (1992).
Fig. 17: Before RCT (15.06.1992):
fistula.
Fig. 18: After N2-RF (01.07.1992):
fistula diminished.
Fig. 19: Control X-ray (1998).
Acknowledgment: The author would like to thank Dr rer.
nat. Monika Kriner for performing the statistics.
Editorial note: A list of references is available from the
publisher.
contact
Dr Robert Teeuwen
Berliner Ring 100
52511 Geilenkirchen
Germany
robteeuwen@t-online.de
roots
3
2016
35
[36] =>
products
innovative instruments
FKG Dentaire SA expands its range of 3-D instruments with the introduction
of the XP-endo Finisher R
FKG Dentaire SA continues it’s marketing of innovative instruments, after the introduction of the
revolutionary XP-endo Finisher in 2015. The range
of instruments designed for 3-D cleaning of the
root canal is now enriched by the XP-endo Finisher
R (XP-FR), targeting the removal of filling material.
Made of a unique and highly flexible NiTi alloy that
can expand 100 fold compared to standard instruments, XP-FR reaches areas of the canal walls
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After initial filling material is removed, regardless
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material is always present particularly in curved
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dentists keen to enhance the long-term success
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The XP-FR is available in sizes 21 and 25 mm,
packed in a sterile blister of 3 instruments.
For more information please visit FKG website.
Fig. 1: XP-FR L21 – ISO 30 (M Phase).
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Fig. 3: XP-FR L25 – ISO 30 (M Phase).
Fig. 4: XP-FR L25 – ISO 30 (A Phase).
Fig. 1
Fig. 2
Fig. 3
Fig. 4
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Crêt-du-Locle 4
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info@fkg.ch
www.fkg.ch
use of composites
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Vista Dental Products is revolutionizing composite delivery with its new
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Therma-Flo Composite Warming Kit.
(Photo by Vista Dental Products)
36 roots
3 2016
Scientific research indicates heating composite material aids in the reduction of curing time and improves polymerization, which reduces voids
in the restoration, the company says. Heated composite material is much
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The Therma-Flo Warming Kit accepts most manufacturers’ composite capsules and composite guns, so dentists can continue to
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[37] =>
X V I . D EN TA L WO R L D
13-14-15 October 2016 – Budapest, Hungary
3 DAYS, 5 LEADING TOPICS
AESTHETICS, ENDODONTICS, MICROWORLD,
IMPLANTOLOGY, ORTHODONTICS
1 day - 60 E
ur
2 day - 110 Eur
Eur
0
5
1
y
a
3d
Dr. Claudio Cacaci
Dr. Ana Ferro
Dr. Antonis Chaniotis
Prof. dr. Asbjörn Hasund
Prof. dr. Florian Beuer
Dr. Gianfranco Politano
Dr. Gil Asafrana
Dr. Giuseppe Marchetti
Dr. Jason Smithson
Dr. Johan Karsten
Dr. Lars Christensen
Dr. Nazariy Mykhaylyuk
Dr. Oscar von Stetten
Dr. Roberto Cristescu
Dr. Ivan Vyuchnov
Dr. Maxim Belograd
Dr. Jan Hajtó
Milos Miladinov
Dr. Bogdan Acatrinei
Dr. Henriette Lerner
Platina sponsor:
D E N TA LWO R L D. H U
Venue: Hungexpo Budapest Fair Center
H-1101 Budapest, Albertirsai út 10.
HUNGEXPO
[38] =>
| meetings Roots Summit
Roots Summit 2016
Premier global forum for endodontics
takes place in Dubai
Dubai © In Green / Shutterstock.com
This year’s ROOTS SUMMIT, which has drawn dental
professionals to various locations all over the world in
the past decade, will take place from Nov. 30 to Dec. 3
at the Crowne Plaza Dubai hotel in the United Arab
Emirates. Aimed at updating participants about the
latest in endodontic treatment, an unparalleled series
of lectures and workshops will be held by global opinion leaders in the field.
siasts in the 1990s. After the establishment of a
dedicated Facebook group three years ago, membership increased from 1,000 to more than 20,000.
Today, the group is composed of members from over
100 countries.
Previous ROOTS SUMMITS have been held in Canada, the US, Mexico, Spain, the Netherlands, Brazil
and last year in India. These meetings have been
known for the strength of their scientific programs
and their relevancy to clinical practice. The lectures,
workshops and hands-on courses scheduled for
this year’s meeting will be no exception. More than
15 distinguished experts are presenting during the
conference.
For the summit in Dubai, the organisers have partnered with Dental Tribune International (DTI) and the
Dubai-based Centre for Advanced Professional Practices (CAPP) for the first time. With its international
network, composed of the leading publishers in dentistry, DTI reaches more than 650,000 dental professionals in 90 countries through its print, online and
educational channels, as well as a number of special
events.
Over the past decade, CAPP has been able to establish first-class standards for continuing dental
education programs not only in the UAE but also
across the Middle East. Since 2012, CAPP has been
affiliated with DTI as a strong local partner in the
Middle East.
Although the meeting will focus exclusively on the
latest techniques and technologies in endodontics,
the organisers have strongly encouraged not only
dentists specialising in the field to attend but all who
have an interest in endodontics, including general dentists and manufacturers and suppliers of endodontic
products. Overall, about 700 attendees are expected.
Over the past 15 years, the ROOTS SUMMIT has
grown significantly. The community originally started
as a mailing list of a large group of endodontic enthu-
38 roots
3 2016
Based on the successes of previous ROOTS
SUMMITS, the organisers anticipate a large turnout
for this year’s meeting. Various sponsorship opportunities are available, including booth space, as well
as sponsorships of workshops, hands-on courses,
meeting bags and social events.
Online registration for the ROOTS SUMMIT is now
open at www.roots-summit.com. Dental professionals are also invited to join the ROOTS Facebook group
and like the ROOTS SUMMIT 2016 Facebook page._
[39] =>
The Dental Tribune
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[40] =>
| meetings events
International Events
2016
FDI Annual World Dental Congress
7–10 September 2016
Poznan, Poland
www.fdi2016poznan.org
Canadian Academy of Endodontics –
52nd Annual General Meeting
14–17 September 2016
Winnipeg, Canada
www.caendo.ca/agm
Czech Endodontic Society –
8th Annual Congress of CES
24 September 2016
Czech Republic
German Society of Endodontology and
Traumatology (DGET) – Member Summit 2016
24 September 2016
Düsseldorf, Germany
www.oemus.com/events
Italian Academy of Endodontics (AIE) –
24th National Congress
6–8 October 2016
Pisa, Italy
www.accademiaitalianaendodonzia.it
3rd PanDental Conference and Exhibition 2016
11–12 November 2016
Birmingham, United Kingdom
www.pandental.co.uk
German Society of Endodontology and
Traumatology (DGET) Annual Meeting
17–19 November 2016
Frankfurt/Main, Germany
Greater New York Dental Meeting
25–30 November 2016
New York, USA
www.gnydm.com
ROOTS Summit
30 November–3 December 2016
Dubai, UAE
www.roots-summit.com
Austrian Society of
Endodontology Annual Meeting
2–3 December 2016
Vienna, Austria
www.oegendo.at
2017
Swiss Society for Endodontology –
Annual Conference
20–21 January 2017
Bern, Switzerland
www.endodontology.ch
Poznan – Fountain at the Wolnosci square. Photo: © Radoslaw Maciejewski / Shutterstock.com
40 roots
3 2016
American Association of Endodontists –
AAE17
26–29 April 2017
New Orleans, USA
www.aae.org
[41] =>
submission guidelines about the publisher
submission guidelines:
Please note that all the textual components of your submission
must be combined into one MS Word document. Please do not
submit multiple files for each of these items:
·· the complete article;
·· all the images (tables, charts, photographs, etc.) captions;
·· the complete list of sources consulted; and
·· the author or contact information (biographical sketch,
mailing address, e-mail address, etc.).
|
Image requirements
Please number images consecutively throughout the article
by using a new number for each image. If it is imperative that
certain images are grouped together, then use lowercase letters
to designate these in a group (for example, 2a, 2b, 2c).
Please place image references in your article wherever they
are appropriate, whether in the middle or at the end of a sentence.
If you do not directly refer to the image, place the reference
at the end of the sentence to which it relates enclosed within
brackets and before the period.
In addition, please note:
In addition, images must not be embedded into the MS Word
document. All images must be submitted separately, and details
about such submission follow below under image requirements.
·· We require images in TIF or JPEG format.
·· These images must be no smaller than 6 x 6 cm in size at 300 DPI.
·· These image files must be no smaller than 80 KB in size (or they
will print the size of a postage stamp!).
Text length
Article lengths can vary greatly—from 1,500 to 5,500 words—
depending on the subject matter. Our approach is that if you Larger image files are always better, and those approximately
need more or less words to do the topic justice, then please make the size of 1 MB are best. Thus, do not size large image files down
the article as long or as short as necessary.
to meet our requirements but send us the largest files available.
(The larger the starting image is in terms of bytes, the more leeWe can run an unusually long article in multiple parts, but this way the designer has for resizing the image in order to fill up more
usually entails a topic for which each part can stand alone be- space should there be room available.)
cause it contains so much information.
Also, please remember that images must not be embedded into
In short, we do not want to limit you in terms of article length, the body of the article submitted. Images must be submitted
so please use the word count above as a general guideline and if separately to the textual submission.
you have specific questions, please do not hesitate to contact us.
You may submit images via e-mail, via our FTP server or post
Text formatting
a CD containing your images directly to us (please contact us
We also ask that you forego any special formatting beyond the for the mailing address, as this will depend upon the country
use of italics and boldface. If you would like to emphasise certain from which you will be mailing).
words within the text, please only use italics (do not use underli
ning or a larger font size). Boldface is reserved for article headers. Please also send us a head shot of yourself that is in accordance
Please do not use underlining.
with the requirements stated above so that it can be printed
with your article.
Please use single spacing and make sure that the text is left justified. Please do not centre text on the page. Do not indent para- Abstracts
graphs, rather place a blank line between paragraphs. Please do An abstract of your article is not required.
not add tab stops.
Author or contact information
Should you require a special layout, please let the word processing The author’s contact information and a head shot of the author
programme you are using help you do this formatting automati are included at the end of every article. Please note the exact
cally. Similarly, should you need to make a list, or add footnotes information you would like to appear in this section and foror endnotes, please let the word processing programme do it for mat it according to the requirements stated above. A short
you automatically. There are menus in every programme that will biographical sketch may precede the contact information
enable you to do so. The fact is that no matter how carefully done, if you provide us with the necessary information (60 words
errors can creep in when you try to number footnotes yourself.
or less).
Any formatting contrary to stated above will require us to remove
such formatting before layout, which is very time-consuming.
Please consider this when formatting your document.
Questions?
Magda Wojtkiewicz (Managing Editor)
m.wojtkiewicz@dental-tribune.com
roots
3
2016
41
[42] =>
| about the publisher imprint
roots
international magazine of
endodontics
Publisher/President/CEO
Torsten R. Oemus
t.oemus@dental-tribune.com
Managing Editor
Magda Wojtkiewicz
m.wojtkiewicz@dental-tribune.com
Designer
Josephine Ritter
Copy Editors
Sabrina Raaff
Hans Motschmann
International Administration
Chief Financial Officer
Dan Wunderlich
Business Development Manager
Claudia Salwiczek-Majonek
Project Manager Online
Tom Carvalho
Accounting Services
Karen Hamatschek
Anja Maywald
Manuela Hunger
Media Sales Managers
Matthias Diessner (Key Accounts)
Melissa Brown (International)
Antje Kahnt (International)
Peter Witteczek (Asia Pacific)
Weridiana Mageswki (Latin America)
Maria Kaiser (North America)
Hélène Carpentier (Europe)
Barbora Solarova (Eastern Europe)
International Offices
Dental Tribune International
Holbeinstr. 29, 04229 Leipzig, Germany
Tel.: +49 341 48474-302
Fax: +49 341 48474-173
info@dental-tribune.com
www.dental-tribune.com
Dental Tribune Asia Pacific Ltd.
Event Manager
Room A, 20/F, Harvard Commercial Building,
Lars Hoffmann
105–111 Thomson Road, Wanchai, Hong Kong
Tel.: +852 3113 6177
International PR & Project Manager
Fax: +852 3113 6199
Marc Chalupsky
Tribune America, LLC
Marketing & Sales Services
116 West 23rd Street, Ste. 500,
Nicole Andrä
New York, NY 10011, USA
Tel.: +1 212 244 7181
Event Services
Fax: +1 212 244 7185
Esther Wodarski
Executive Producer
Gernot Meyer
Editorial Board
Fernando Goldberg, Argentina
Markus Haapasalo, Canada
Ken Serota, Canada
Clemens Bargholz, Germany
Michael Baumann, Germany
Benjamin Briseno, Germany
Asgeir Sigurdsson, Iceland
Adam Stabholz, Israel
Heike Steffen, Germany
Gary Cheung, Hong Kong
Unni Endal, Norway
Roman Borczyk, Poland
Bartosz Cerkaski, Poland
Esteban Brau, Spain
José Pumarola, Spain
Kishor Gulabivala, United Kingdom
William P. Saunders, United Kingdom
Fred Barnett, USA
L. Stephan Buchanan, USA
Jo Dovgan, USA
Vladimir Gorokhovsky, USA
James Gutmann, USA
Ben Johnson, USA
Kenneth Koch, USA
Sergio Kuttler, USA
John Nusstein, USA
Ove Peters, USA
Jorge Vera, Mexico
Printed by
Löhnert Druck
Handelsstraße 12
04420 Markranstädt, Germany
Copyright Regulations
roots international magazine of endodontics is published by Dental Tribune International (DTI) and appears in 2016 with four issues. The magazine and
all articles and illustrations therein are protected by copyright. Any utilisation without the prior consent of editor and publisher is inadmissible and liable to
prosecution. This applies in particular to duplicate copies, translations, microfilms, and storage and processing in electronic systems.
Reproductions, including extracts, may only be made with the permission of the publisher. Given no statement to the contrary, any submissions to the
editorial department are understood to be in agreement with a full or partial publishing of said submission. The editorial department reserves the right to
check all submitted articles for formal errors and factual authority, and to make amendments if necessary. No responsibility shall be taken for unsolicited
books and manuscripts. Articles bearing symbols other than that of the editorial department, or which are distinguished by the name of the author, represent
the opinion of the afore-mentioned, and do not have to comply with the views of DTI. Responsibility for such articles shall be borne by the author.
Responsibility for advertisements and other specially labeled items shall not be borne by the editorial department. Likewise, no responsibility shall be
assumed for information published about associations, companies and commercial markets. All cases of consequential liability arising from inaccurate or
faulty representation are excluded. General terms and conditions apply. Legal venue is Leipzig, Germany.
42 roots
3 2016
[43] =>
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[44] =>
3D agility_
The One to Shape your Success
FKG Dentaire SA
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