roots international No. 4, 2018
Cover
/ Editorial
/ Content
/ 3-D endodontic instrumentation: Revision of a historical protocol
/ Hand files are heroes in complex anatomies—A mandibular molar with seven root canals
/ Strategies for the treatment of extremely curved root canals
/ Endodontic reboot: Adaptive core debridement and disinfective finishing
/ Diode laser-assisted vital pulp therapy in pulp polyp treatment
/ Novel applications of a bioactive resin in perforations, root resorption and endodontic-periodontic lesions
/ Management of referred pain
/ Successful communication in your daily practice - Part V: Bad online reviews
/ “We gain a better outcome for endodontic treatment”
/ Manufacturer news
/ International Events
/ Submission Guidelines
/ Imprint
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[1] =>
4/18
issn 2193-4673 • Vol. 14 • Issue 4/2018
roots
international magazine of
opinion
3-D endodontic instrumentation:
Revision of a historical protocol
industry report
Strategies for the treatment of
extremely curved root canals
case report
Management of referred pain
endodontics
[2] =>
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[3] =>
editorial
|
Dr Kenneth S. Serota
Guest Editor
E=mc : Endodontics is equal to
the third power of many changes
3
Revolutionary protocols and materials science demonstrate the evolving sophistication of modern era root
canal therapy. The technological advances of the past
three decades have enabled greater debridement and
disinfection of the labyrinthine root canal space. Iterations
of apex locators, enhanced magnification and illumination,
new file designs and metallurgy provide for bio-minimalism and diminished fracture potential. The development
of bio-active adherent sealers has enhanced the biologic
potential of root filling. However, the sum of these innovations has not as yet produced a substantive increase
in treatment outcome percentages. For years, clinicians
have accepted on faith the purported marketing claims of
company-supported in vitro testing. Fortunately, scientific
determination of the metrics of success of productneutral studies has replaced the possibility of experimental bias.
The most profound change in endodontics is the
recognition that root canal therapy is a restoratively driven
discipline. Bio-smart materials used in the root and crown
do not require egregious removal of tooth structure
as dictated by classical protocols. Clinicians blinded by
the optics of the “artistry” of radiographic results are
recognizing that this does not represent the totality of the
biologic requirements of success.
The “look” academically disenfranchised the clinician
from the understanding of the biomechanical dynamics
of dentine and its impact on the potential for fracture. The
excessive removal of tooth structure to enable treatment
needs was counterintuitive to long term success and is
fortunately a protocol of the past. As well, the overlooked
impact of both light and heavy parafunctional loading on
endodontically treated teeth is now recognized as the
most important tipping point in the configuration of the
restoration required.
The rigid restorative mandate of posts and cores had
the propensity to cause catastrophic failure. Fortunately,
reduced taper, new irrigation products have reduced the
retention of greater volumes of tooth structure and the
costs of new equipment. Overprepared tooth structure is
not necessary in the adhesion era.
The dogma of the protocol of cleaning shaping,
irrigation and “monobloc obturation” is axiomatic folly.
The pendulum swings of new equipment and treatments
are not necessarily best practices. The primary disease
vector of pulpal and peri-radicular is biofilms and to date,
the mechanism for their removal remains elusive. The
work of Kishen and Shrestha on biofilm disruption by
nanoparticles shows the greatest hope for elimination
of recrudescent disease as a consequence of biofilm
resistance intractability.
The ebbs and flows of endodontic growth, even if
measured in dollops, has always have been part of the
tenets of interdisciplinary dental therapeutics. The recognition that endodontics is an equal member at the
table of disciplines is now assured as it has chosen to
extend its involvement beyond the orifice. Endodontics
is a foundational component of the state of oral health.
Its outreach is now extended to a point commensurate
with its potential.
Dr Kenneth S. Serota
Guest Editor
roots
4 2018
03
[4] =>
| content
editorial
E=mc3 : Endodontics is equal to the third power of many changes
03
Dr Kenneth S. Serota (Guest Editor)
opinion
3-D endodontic instrumentation:
Revision of a historical protocol
page 16
06
Dr Kenneth S. Serota
industry report
Hand files are heroes in complex anatomies—
A mandibular molar with seven root canals
12
Dr Hugo Sousa Dias
Strategies for the treatment of extremely curved root canals
16
Dr Bernard Bengs
page 38
Endodontic reboot: Adaptive core debridement
and disinfective finishing
22
Drs Gilberto Debelian, Martin Trope & Kenneth S. Serota
case report
Diode laser-assisted vital pulp therapy in pulp polyp treatment
28
Drs Maziar Mir, Masoud Mojahedi,
Jan Tunér & Masoud Shabani
Novel applications of a bioactive resin in perforations,
root resorption and endodontic-periodontic lesions
page 42
© Victoruler
oruler/Shutterstock.com
/Shutterstock.com
32
Dr Marta Maciak
Management of referred pain
38
Drs Chady Torbay, Sara Salloum, Claudia Dib,
Edgard Jabbour & Philippe Sleiman
practice management
Successful communication in your daily practice
Part V: Bad online reviews
42
Dr Anna Maria Yiannikos
interview
Cover image courtesy of VDW
(www.vdw-dental.com)
international magazine of
44
manufacturer news
46
4/18
issn 2193-4673 • Vol. 14 • Issue 4/2018
roots
“We gain a better outcome for endodontic treatment”
endodontics
meetings
International Events
48
about the publisher
opinion
3-D endodontic instrumentation:
Revision of a historical protocol
industry report
Strategies for the treatment of
extremely curved root canals
case report
Management of referred pain
04
roots
4 2018
submission guidelines
49
international imprint
50
[5] =>
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Simple steps, easily done.
Contact MANI for more information:
www.mani.co.jp/en
dental.exp@ms.mani.co.jp
FOR ADVANCED TREATMENT
[6] =>
| opinion
3-D endodontic instrumentation:
Revision of a historical protocol
Dr Kenneth S. Serota, USA
Fig. 1
Fig. 2
Fig. 3
Fig. 1: The envelope of motion, as described by Dr Schilder, is generated by pre-curving a reamer and rotating and withdrawing the instrument during the working
cycle. All the work is done on the outstroke, obviating the potential for ledge creation. Fig. 2: An axial view (cross section) of the mesial root of a mandibular molar
demonstrates that the geometry of the canal space is irregular, elliptic/ovoid, but not round. (Unknown source) Fig. 3: The root shape mimics the canal shape. As
such, making a round shape using the largest diameter file is clinically impractical. Using a preset taper greater than 0.04 jeopardises the integrity of the root structure.
The past
The goal of the instrumentation phase of root canal
therapy is to debride, disinfect and shape the root canal
space prior to root filling while retaining an optimal amount
of tooth structure. This is of paramount importance in the
regions of peri-cervical dentine and isthmus/furcal anatomy.1 Historically, the significant flaws of stainless-steel
Fig. 4
files and reamers were their cutting geometry and rigidity.
The technical protocol for these instruments, even Dr
Schilder’s innovative envelope of motion,2 failed to correct
debridement inadequacies. The root canal does not natively present in the round; Dr Schilder’s approach, while
an improvement, failed to address the instrument design
and technique changes required to optimise shaping and
cleaning of the canal space (Figs. 1 & 2). The root shape
Fig. 5
Fig. 4: CBCT provides a z-axis image that demonstrates the number of canals present. As evident in the clinical case, the thinness of the dental isthmus housing
the second mesiobuccal canal could readily have been compromised with a round file of the predetermined taper, a serious concern if only the flat film was
relied upon. (Courtesy of Dr Martin Trope) Fig. 5: Micro-CT shows green (untreated canal) and red (treated portion of the canal after the use of a round file of
minimum diameter). Less than 50 % of the interfacial dentine was touched and debrided. (Courtesy of Dr Frank Paqué)
06
roots
4 2018
[7] =>
opinion
|
mimics the canal shape.3 Therefore, it is impossible to adequately sculpt the interfacial dentine of the canal unless
the file chosen corresponds to the largest diameter of the
non-round canal (Fig. 3), which can lead to weakening
or perforation of the root structure. Studies assessing the
planes of geometry of the root canal repeatedly demonstrate that the buccolingual diameter is greater than the
mesiodistal diameter—canals are predominantly ovoid
throughout the dentition, not round.4
Until recently, our reliance upon flat film radiography to
assess the spatial dimensions of root filling furthered the
lack of appreciation for file taper sizes and flexibility fundamentals. The z-axis was hidden from view in flat film
periapical radiographs; only the narrower mesial–distal
dimensions of the root canal space were evidenced (Fig. 4).
Faux 3-D imagery could be produced in theory by combining of angled mesial, distal and central ray radiographic
projections. In 2-D, cleaning to the narrowest diameter appears adequate in post-treatment radiographs. The introduction of microcomputed tomography (µCT) and cone
beam computed tomography (CBCT) has changed our
understanding of the planes of geometry produced by
our current treatment protocols. Mapping of the root canal space by µCT after instrumentation demonstrates that
barely 50 % of the canal is cleaned (Fig. 5).5, 6 The idiom,
“you can’t put a square peg into a round hole” suggests an
endodontic idiom: you can’t put a round file into an ovoid
canal and achieve the desired result.
The most under-appreciated sequela of round files is
the creation of significant amounts of dentinal debris.
Traditionally, the focus has been on the debris pushed
through the apex during instrumentation to avoid posttreatment pain caused by periapical inflammation. The
assumption that residual debris moves coronally and is
flushed from the canal by irrigants is questionable. In fact,
Fig. 7
Fig. 8
Fig. 6
Fig. 6: An irregular canal space is shown after instrumentation with a file
(round core). Note the existing debris accumulation in the canal irregularities
resultant from instrumentation. (Courtesy of Dr Gustavo De-Deus)
debris is pushed into the non-round parts of the canal,
blocking these areas from further cleaning and disinfection by irrigation solutions and adjunctive technologies.7, 8
Additionally, when irregularities are compacted with
detritus, increased pressure is exerted within the canal space with the attendant possibility of microfractures
(Fig. 6). This is of critical concern with the new generation
of nickel-titanium (NiTi) files, but not a factor with use of the
XP-3D Shaper (Brasseler USA).9 The trend towards fewer
files and larger tapers exacerbates this potential fracture
problem.
Cognitive dissonance
The introduction of NiTi files fostered a transition to instruments that would potentially obviate the flaws inherent in the use of carbon and stainless-steel files. NiTi files
are super-elastic and self-centring, and avoid ellipticisation
of the apical terminus. With appropriate taper selection,
Fig. 9
Fig. 7: The majority of the root canal space is ovoid. As demonstrated by the canal shape at successive levels from the apex, round files, in spite of selfcentring, can weaken the root structure with a typical 0.06-tapered instrument and will NOT debride the canal in its entirety. (Courtesy of Dr Gustavo De-Deus)
Fig. 8: There are approximately 157 file systems available globally. Most are made from round blanks; canals, however, are not “made” in the round.
Fig. 9: The Booster Tip has no cutting flutes on the first 0.25 mm. The next 0.25 mm section has six cutting flutes, which alters the apical extent of the canal
to a size 30.02 (size/taper) instrument. The tip design of traditional NiTi instruments enables the instrument to follow the glide path rather than actively cutting
and risk ledging or torsional failure if the tip inadvertently catches in an irregularity in the canal wall. (Courtesy of Dr Sebastián Ortolani Seltenerich)
roots
4 2018
07
[8] =>
| opinion
packing debris into untouched
areas. The XP-3D Finisher
(Brasseler USA) has a reach of
at least 3 mm, thereby touching even the widest canal
diameters while not changing
the original shape of the canal.10
Booster Tip
Fig. 10
The Booster Tip (BT) lead
section fits into the preFig. 11
established glide path, ensuring
Fig. 10: The file dimensions of the XP-3D Shaper are shown in its martensitic phase and in its austenitic phase.
precise guidance and centring
Fig. 11: The tooth shapes the canal, not the file, as evidenced in the cross-sectional images at 1, 3, 5 and 7 mm
of the instrument. A traditional
from the apex. (Courtesy of Dr Gustavo De-Deus)
glide path instrument produces
a 15.02 or 10.04 size/taper.
NiTi instruments should prevent thinning of the coronal
There are no cutting flutes on the lead section of the BT,
and middle thirds of the root minimising thus preventing
ensuring precise guidance and centring of the instrument.
wall weakening or strip perforation. However, each generThe XP-3D Shaper has a BT, which enables the instruation of NiTi files, whether ground, twisted or heat-treated,
ment to follow the glide path into the apical component
shaped and cleaned far less debris than expected from
to a depth of 0.25 mm. The next 0.25 mm section of the BT
the root canal space. Unfortunately, while a few sysis configured with six cutting flutes. Rotation of these flutes
tems included 0.04 tapers, the vast majority of single- or
sizes the next 0.25 mm of the canal space from a 15.02
multi-tapered files have 0.06, 0.07 and 0.08 tapers. Some
to a 30.02 (size/taper) instrument; thus, the apical size
of the latest systems use asymmetrical rotary motion, conchosen for the XP-3D Shaper is size 30 (Fig. 9).
forming S-shaping and reciprocal motion. Unfortunately,
separation of an NiTi instrument due to taper lock, cyclic
XP-3D Shaper
fatigue and torsional resistance remains an omnipresent
concern. The advantages of super-elasticity and self-cenTo better explain the unique properties of the file, the
tring were incalculable; however, the improvements were
physical characteristics of the MaxWire technology must
be understood. At room temperature, the XP-3D Shaper is
compromised by the persistence of round-core manufacin the martensitic phase, enabling it to be bent and more
turing (Figs. 7 & 8). The flaw in every iteration of NiTi files
readily placed in the canal. No more than three to five easy
remains the same: the cutting geometry produces a round
up-and-down strokes (swaths) of the serpentine XP-3D
shape.
Shaper with the BT should result in an apical terminus
Inevitability of bio-minimal adaptive shaping shaped to a size 30 file and a canal taper of 0.02 (Figs. 10 & 11).
The choice of a 0.3 mm diameter enables a 31-gauge irrigating needle to approximate the working length, preventA new generation of adaptive/virtual core files, the XP-3D
ing vapour lock. Maximum irrigation efficiency is ensured.
system, has dramatically changed the landscape of endAdditionally, a shelf for seating the gutta-percha point
odontic instrumentation. The XP-3D Shaper was designed
prior to root filling is created. With an increasing number
to adapt to the anatomical shape of the canal while respectof strokes, the file has the capacity to expand from tapers
ing the native framework of the root canal space without
Fig. 12
Fig. 13
Fig. 12: In small (mesial) canals, the XP-3D Shaper file will first reach a 0.3 mm diameter and in time increase the canal taper subject to the resistance of
the dentine. The virtual/adaptive core prevents packing of debris in irregularities. Fig. 13: The µCT image to the left shows the packing of the debris into the
isthmus by a reciprocating file. The image on the right shows the canal after preparation with the XP-3D Shaper. Increased resistance due to packing of debris
is a common flaw in round NiTi files and can result in fracture.
08
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4 2018
[9] =>
opinion
|
Fig. 14
Fig. 15
Fig. 14: The image shows the comparison of the mechanism of cutting by a file made from a round blank and by the XP-3D Shaper. No matter how much
relief is provided by reducing the taper along a file with an apical third taper of 0.06/0.07/0.08, enhanced resistance is created and irrigation turbulence
is not enhanced. The OPPOSITE is true of the Shaper. Fig. 15: Photoelastic stress analysis using a monochromatic light source and plastic models
demonstrates that a reciprocating file (A) creates high stress in the apical third, a rotational file (B) shows strong stress in the apical third and the XP-3D Shaper
file (C) shows no stress in the apical third.
of 0.01 to 0.02/0.04/0.06/0.08 while maintaining the
flexibility of the original 0.01 taper. At body temperatures,
the file attains its austenitic characteristics and attempts
to achieve its potential of an 0.08 taper, a maximum that is
needed in only the most unique cases.
As much healthy tissue as possible must be maintained;
therefore, it is recommended that when the working
length has been achieved in the first three to five strokes,
an additional ten long strokes will achieve a 0.04 taper,
which is sufficient to adequately disinfect the root canal
space in very tight canals. In larger canals, the file will
easily create larger tapers, as lesser dentinal resistance
is met. As a function of its serpentine shape, light brushing
and up to 30 long strokes will result in over 90 % of the
walls being touched in these larger non-complex canals
(Figs. 12 & 13).
To summarise: the file is adaptive to the original shape of
the canal; thus, the tooth shapes the canal space, in contrast to round NiTi files, where the file shapes the tooth.
As shown in Figure 10, the file has a sinusoidal/serpentine shape. The space available for this shape in motion
Fig. 16
enables a light brushing technique to adapt and debride
90 % or more of the walls in larger non-complex canals,
which contrasts dramatically with the debris removal with
round NiTi files. As previously discussed, round files will
pack debris into the canal irregularities, a major drawback
in sufficiently cleaning a canal. The serpentine shape, virtual core and 0.01 taper of the XP-3D Shaper enable it
to adapt to the canals and ensure that debris remains in
turbulent solution, ensuring its optimal removal from the
canal (Fig. 14). This enables the irrigants to work maximally
as the canal is shaped. Tests using photoelastic models
have shown that apical pressure is not built up using the
XP-3D Shaper, obviating concerns regarding microcracks.
Round-core files should significant generation of apical
pressure (Fig. 15).
Recently, new and costly irrigation devices have been
introduced in the endodontic armamentarium as adjuncts
to the traditional side-vented needle and passive ultrasonic irrigation. The EndoActivator (Dentsply Sirona), the
EndoSafe Plus (Vista Dental), the Endovac Pure (apical
negative pressure irrigation; Kerr) and the GentleWave
(Sonendo) are all relatively new.11 The GentleWave sys-
Fig. 17
Fig. 16: The dimensions of the XP-3D Finisher are shown in the martensitic and austenitic phases. At body temperature, the last 10 mm of the instrument during
rotation achieves a sickle shape with a diameter of 3 mm. Pressure on the bulb can further enhance the tip diameter. Fig. 17: The anatomy of the canal will cause
the XP-3D Finisher to expand or contract and enter small irregularities in the canal walls with an up-and-down motion. No other file can reach these indentations.
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4 2018
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[10] =>
| opinion
Fig. 18
Fig. 19
Fig. 18: The natural expansion and contraction of the XP-3D Finisher contacts the irregularities of the canal walls. It is insufficiently sturdy to alter the original
shape created by the XP-3D Shaper. Fig. 19: The XP-3D Finisher creates a robust turbulence within the irrigating solutions. Studies have shown it to remove
microflora to a depth of 40 µ.
tem claims to be capable of removing residual tissue, the
smear layer, biofilm and bacteria from the tubules.12 Further
scientific assessment of this device remains to be done.
enhanced inhibition or eradication of microflora presence
from the root canal space (Figs. 18 & 19).
Retreatment
The XP-3D Finisher file has been modified for retreatment. The core is 0.03 mm in diameter with an 0.00 taper.
This provides a more robust adaptation to the interfacial
dentine, enhancing the removal of residual gutta-percha
and debris from the irregularities (Fig. 20).
Conclusion
Fig. 20
Fig. 20: A study by Alves et al. demonstrated that the reduction of residual
debris in the canal space using the XP-3D retreatment Finisher was 69 %
greater by comparison to standard round files.15
XP-3D Finisher
The XP-3D Finisher is used adjunctively to the XP-3D
Shaper. The Finisher’s design allows it to access and
scrape untouched components of the canal walls without
altering the canal shape created by the XP-3D Shaper.
The file has a tip diameter of 0.25 mm with an 0.00 taper.
It is extremely flexible and thus has tremendous resistance
to cyclic fatigue. The spoon-shaped design of this file is
created in a mould in the austenitic phase. At room temperature, the martensitic phase can be manipulated to any
shape. Upon insertion into the canal, the file is heated to
body temperature (35 °C), and the material seeks to revert
to the austenitic phase (Fig. 17). In the austenitic phase,
it forms a uniquely shaped cleaning instrument. At body
temperature, the apical 10.0 mm of the file transforms into
a bulb/sickle shape, while retaining a depth of 1.5 mm.
Without squeezing the bulb, rotation of the file produces
a tip size of 3 mm. However, if the bulb is squeezed, the tip
will expand to a maximum of 6 mm. The instrument cannot cut; thus, its only impact is scraping, which removes
microbes up to 40 µ up the tubules (commensurate with
root planing in periodontal therapy).13, 14 As it is moved up
and down in the canal, a vigorous agitation of the irrigants
(sodium hypochlorite and EDTA) occurs, which adds to an
10
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4 2018
Preliminary studies of XP-3D files have shown remarkable removal of soft tissue, fewer residual dentinal chips
in an isthmus, and bio-minimalistic shapes of the root
canal space (optimal taper of 0.04), resulting in lower dentinal stress (fewer microcracks). An efficient debridement
and disinfection of the apical third area is achieved by the
BT and the serpentine design of the Shaper. Have we
achieved the ideal fusion of technology and biology for
long-term positive patient-centred treatment outcomes?
Perhaps. What has been achieved is a redress of a
design flaw that has persisted for much too long. This
design change will bring endodontics closer to the desired
objective of bio-minimal shaping that is tooth-directed.
This will protect the native anatomy of the root, minimising
functional stress and fracture potential.
Editorial note: A list of references is available from the publisher.
about
Dr Kenneth Serota graduated with
a DDS from the University of Toronto
Faculty of Dentistry in Canada in 1973
and received his Certificate
in Endodontics and Master of Medical
Sciences from the Harvard–Forsyth
Dental Center in Boston in Massachusetts
in the US. Active in online education
since 1998, he is the founder of the
ROOTS endodontic forum and the NEXUS interdisciplinary
forum. Dr Serota is an adjunct clinical instructor in the
University of Toronto postdoctoral endodontics department.
[11] =>
My choice?
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Find the VDW
endo motor
that matches
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VDW.GOLD®RECIPROC®
Comprehensive endo motor
with integrated apex locator
RECIPROC® blue
one file endo
vdw-dental.com/motor
[12] =>
| industry report
Hand files are heroes in complex
anatomies—A mandibular molar
with seven root canals
Dr Hugo Sousa Dias, Portugal
In general, mandibular first molars have
two roots, a mesial and distal, and usually three root canals.3 The aim of this
clinical case report is to present and
describe the unusual presence of seven
root canals in a mandibular first molar, detected during routine endodontic therapy,
and demonstrate the importance of obtaining patency.
Blocked, calcified, curved and transported canals challenge clinicians on a
daily basis, and the use of hand files is
crucial. It is important for the clinician to
find a stiff and safe hand file that allows
him or her to deal with such challenging
situations.
Fig. 1
Many of the difficulties in root canal therapy are due to
variations in root canal morphology. A thorough knowledge of the basic root canal anatomy and its variations
is necessary for successful completion of endodontic
treatment.1, 2 These differences in root canal morphology
influence the success of endodontic treatment and the
long-term prognosis of the tooth.
Fig. 2
12
Fig. 3
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4 2018
Fig. 4
Case report
A 35-year-old Caucasian female, with a non-contributory medical history, was referred for endodontic treatment of the mandibular right first molar with the chief
complaint of severe pain for three days. The tooth was
very sensitive to percussion, non-responsive to thermal
[13] =>
industry report
Fig. 5
Fig. 6
Fig. 7
Fig. 8
and electrical pulp tests, and showed no mobility, and
periodontal probing around it was within physiological
limits.
was removed and two more canal orifices were detected in the mesial root and one more in the distal root
(Fig. 2).
The initial radiograph showed a pulp stone in the pulp
chamber and no signs of periapical pathology were
observed (Fig. 1). Based on the results of clinical and
radiographic examination, a diagnosis of necrotic pulp
with symptomatic periapical periodontitis was made and
root canal therapy recommended.
Initial negotiation and scouting of the root canals were
carried out with size 8 and 10 K-type-file (MANI). The
working length was verified using the Apex ID apex
locator (Kerr Endodontics) and confirmed radiographically (Fig. 3). All of the canals were instrumented with a
size 8, 10, 12 and 15 D Finder (MANI) to obtain a manual
glide path using the NSK ER10 reciprocating handpiece
(Fig. 4).
Local anaesthesia was performed, the tooth was isolated by rubber dam, the access cavity prepared and
ultrasonic tip used to remove the pulp stone. Inspection
of the pulp chamber revealed two mesial and two distal
canal orifices. After using a DG16 endodontic explorer
and surgical microscope, calcified tissue was observed
between two mesial root canals and two distal root
canals. With an ultrasonic tip, the overlying dentine
Fig. 9
|
Cleaning and shaping were performed with rotary files
up to size 25.04 in all of the root canals. Irrigation was
performed throughout with 5.25 % sodium hypochlorite.
A final irrigation protocol was done with 17 % EDTA and
5.25 % sodium hypochlorite, and irrigant was activated
with a manual dynamic activation technique. The canals
Fig. 10
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4 2018
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[14] =>
| industry report
Fig. 11
Fig. 12
were thoroughly dried and obturation performed using
4 % gutta-percha cones (Fig. 5) and AH Plus (Dentsply
Maillefer), employing the continuous wave of condensation technique with the Elements Obturation Unit
(Kerr Endodontics; Figs. 6 & 7).
The pulp chamber was sealed with Ionoseal (VOCO)
and a temporary restoration was performed. The patient was referred to her dentist for the permanent
coronal restoration. At a follow-up visit after six months,
she was asymptomatic (Fig. 8) and a post-treatment
CBCT scan was performed using Veraviewepocs 3D
R100 (Morita) that showed four portals of exit in the
mesial root and two portals of exit in the distal root
(Figs. 9–12).
Technical points
In order to deal with these kinds of anatomical variations and avoid procedural errors, the practitioner should
observe the following points:
– An accurate inspection of the pulp floor yields important information, and the practitioner needs to be
attentive when removing the pulp stone (the use of
ultrasonic tips is safer).
– The use of magnification and powerful illumination is
considered to be of key importance in this stage because it allows the practitioner to see all colour changes
in the pulp floor.
– The initial root canal exploration should be performed
with pre-curved small files (size 8 and 10) without any
apical pressure.
– Before using any rotary file, it is important to create
a manual glide path with hand instruments.
– During glide path creation, it is important to use
intermediate size files (size 12) in order to reduce
the percentual increase of tip size between 10 and
15 hand files.
14
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4 2018
– The practitioner must never push, peck or force any file
inward and must provide constant irrigation between
each file.
The reciprocating handpiece allows the practitioner to
achieve an effective manual glide path with D Finder files.
First of all, the hand files are always used until patency is
achieved, and only after that are they connected to the
reciprocating handpiece and used in an up-and-down
motion (1 mm) until the file feels loose in the root canal.
To preserve the root canal anatomy, avoid root canal
transportation, strip perforation or another error, we
decided to finish our preparation with a 4 % taper.
Editorial note: A list of references is available from the
publisher.
about
Dr Hugo Sousa Dias graduated with
a DDS from University Fernando Pessoa
in Porto in Portugal in 2008 and
completed the postgraduate programme
in endodontics at the University of
Lisbon in Portugal in 2015. Besides
running a practice limited to endodontics
in Porto, he is Director of the Master in
Endodontics clinical residency programme
at Foramen Dental Education in Porto. Dr Dias is the founder of
the Portuguese Group for Endodontic Study (study club) and
a member of the European Society of Endodontology and the
Sociedade Portuguesa de Endodontologia [Portuguese endodontic
society]. He has given more than 20 lectures around
the world and is co-author of a chapter in the book
The Root Canal Anatomy in Permanent Dentition (Springer, 2018).
[15] =>
THE NEW NiTi FILE GENERATION
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Step 1 (direct protection)
Step 2 (sleeping protection)
Protection already at filling, e.g.
with bioactivity due to possible
residual moisture in the root canal
Regenerative protection against
possible moisture ingress, e.g.
by cracks
[16] =>
| industry report
Strategies for the treatment of
extremely curved root canals
Dr Bernard Bengs, Germany
Fig. 1
Fig. 2
Fig. 3
Fig. 1: Pre-op radiograph of tooth #25. Fig. 2: Trepanation. Fig. 3: The untwisted PathFile after use in the canal.
One of the major challenges in endodontics is the
enormous complexity of root canals. Among other things,
a large number of difficulties must be overcome in terms
of the number, position, possible branches and curvatures of the canals. Case studies are used to demonstrate how predictable treatment results can be achieved
in adverse anatomies too.
The aim of root canal preparation is the complete removal of all vital and necrotic tissue, infected canal wall
dentine, foreign matter and root filling material. Adequate
chemical disinfection should be made possible and
Fig. 4
Fig. 5
Fig. 4: Radiographic measurement. Fig. 5: The HyFlex CM file sequence.
16
roots
4 2018
shaping should allow wall-to-wall obturation of the canal system. As early as 1974, Herbert Schilder published
guidelines on this topic, which have virtually remained
unchanged, including the creation of a continuously
conical canal shape from the access cavity to the apex,
respecting the course of the root canal and maintaining
the position of the apical foramen at a size as small as
practicable.1
In the presence of very pronounced curvatures, especially abrupt or even S-shaped (i.e. double) curvatures,
it can prove extremely difficult to implement these
[17] =>
industry report
|
guidelines. The angle of curvature is not the only factor here; the length of the distance after the curvature
is also decisive for the demands on the instruments.
As the degree of difficulty increases, the risk of step formation, splinting and instrument fracture quite naturally
increases.
Treatment planning
Initial information is provided by the preoperative radiographic image. In complex anatomies, such as those that
often occur in the posterior region, a CBCT scan provides
valuable information on 3-D curvatures and the confluence of canals.2 This information is extremely important
for treatment planning, as it allows the clinician to determine a strategy regarding the instruments to be used and
canal preparation in advance. For example, very narrow,
strongly curved roots should, if applicable, be prepared
with a smaller ISO size or a slimmer taper, since even
very flexible nickel-titanium (NiTi) file systems become
significantly stiffer with increasing dimensions, which entails unwanted transportation or even strip perforations
as risks. Each case should be considered individually to
allow sufficient removal of infected tissue without risking
unwanted excessive removal of dentine.
In vital cases, the size of the preparation may be more
moderate than in cases of pulp necroses or revisions, as
less removal of dentine will be required here. Ultimately,
of course, the treatment size should be determined by apical gauging (apical measurement). As this is only practicable to a limited extent in the case of very extreme, even
opposing curvatures, even more attention should be paid
to tactile feedback during instrumental canal preparation.
Sufficient preparation is always required for root canal
irrigation and subsequent obturation so that a shape of
at least size 30.04, or better of size 30.06 or 35.06 (rarely
larger in the case of strong curvatures), which is usually
required in extreme cases, must be prepared manually
Fig. 7
Fig. 6
Fig. 6: The master point image.
using the step-back technique. Otherwise, it will not be
possible to achieve sufficient disinfection and filling of the
root canal.
Notes on preparation
The preparation of an optimal primary and secondary
access cavity is extremely important, particularly in the
case of strong curvatures. Therefore, a most straightline access to the canal system is very important, as
otherwise steps or blockages are created right at the
beginning of treatment that can only be corrected with
great difficulty.
First, the course of the canal should be probed with an
ISO size 6, 8 or 10 scouting file, if necessary, after coronal
pre-flaring with an orifice shaper or Gates–Glidden drill.
Irrespective of the file system used, the preparation of
a glide path is essential for safe canal preparation.
Particularly in the case of strongly curved, narrow canals,
the use of rotary NiTi glide path files is not only less prone
to complications than with manual instruments, but also
Fig. 8
Figs. 7 & 8: Root canal filling and check of tooth #25.
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4 2018
17
[18] =>
| industry report
Fig. 9
Fig. 10
Fig. 11
Figs. 9–11: Pin check and post-op check after one year and 4.5 years, respectively.
more comfortable. The gliding space created allows a
significantly lower-risk use of the following rotary NiTi files
for canal preparation.3
The point of confluence of canals represents a special case of curvature, as this often occurs particularly
abruptly. It, therefore, makes sense, for example in the
case of two canals in the mesial root of a mandibular
first molar, to initially prepare only one canal fully to its
working length. This will often be the mesiolingual canal. To determine the confluence, a gutta-percha point
is then positioned in the prepared canal and a Kerr file is
inserted into the other canal. The marking of the instrument tip in the gutta-percha point determines the length
up to which the second canal must now be prepared.
This avoids risky stressing of the instruments, as well
as the unnecessary removal of dentine. Furthermore,
the chemical preparation of the canal system is an indispensable part of the preparation, since only part of
the canal wall surface is addressed during mechanical
preparation.
Fig. 12
Fig. 12: Preoperative radiograph of tooth #37. Fig. 13: The opened pulp.
18
roots
4 2018
Case 1: Pulp necrosis in an S-shaped canal
In November 2013, a 46-year-old emergency patient
with acute symptoms of tooth #25 presented. The tooth
had been restored with a ceramic inlay, the sensitivity
test for cold was negative, and the tooth was sensitive
to percussion and pressure. The preoperative radiograph revealed periapical periodontitis (Fig. 1). The diagnosis was pulp necrosis after a previous preparation
close to the pulp. The inlay was removed and an adhesive
pre-endodontic build-up was fabricated from composite. During trepanation, pus drained from the canal entrances. Working length was then determined, followed
by initial preparation with Kerr files up to only ISO size 8,
for time reasons, together with intermittent irrigation with
heated 6% sodium hypochlorite (NaOCl). Subsequently,
a drug deposit was inserted by rotating in Ledermix.
Owing to the small preparation size, the use of calcium hydroxide would only have been possible to a limited extent.
Root canal therapy was continued approximately six
weeks later: after anaesthesia and placement of a rub-
Fig. 13
[19] =>
industry report
|
ber dam, tooth #25 was trepanned under the microscope
(Fig. 2). The glide path was first prepared manually with
C+ Files of ISO sizes 6 and 8 (Dentsply Maillefer), then
mechanically with PathFiles of size 13, 16 and 19 (Dentsply
Maillefer). The more flexible HyFlex Glidepath files (COLTENE)
were not yet available at the time of treatment. A detailed
image of the brand-new PathFile illustrated how extremely the S-shaped canal configuration had stressed
the rotary NiTi instruments after a single use (Fig. 3). It
depicted the plastic deformation of the instrument, a clear
indication that this instrument could only withstand the
requirements with good fortune. A fractured instrument
would certainly have been within the realms of possibility.
After radiographic confirmation of the working length,
the canals were prepared with the HyFlex CM (controlled
memory) NiTi files (COLTENE; Figs. 4 & 5). The following
sequence was used: 15.04, 20.04, 20.06, 25.04, 25.06,
30.04 and 30.06. Intermittent irrigation was again performed with heated 6 % NaOCl.
After apical gauging, the final preparation was performed
in steps of 0.5 mm from ISO size 35 to ISO size 60 using manual NiTi Kerr files in the step-back technique for safety reasons. Thus, a cone of ten was created in the apical region.
Although possible in principle, the use of a 35.06 HyFlex CM
was deliberately abstained from, as while these instruments
offer high flexibility in general, the stiffness might still have
been too great for the S-shaped course of the canals. Finally,
irrigation was performed with a 17 % EDTA solution and
6 % NaOCl, activating the irrigation liquids by ultrasound.
Fig. 14
Fig. 14: Removal of the coronal pulp.
Case 2: Pulpitis aperta of tooth #37
A 46-year-old patient presented with pulpitis complaints regarding tooth #37 in October 2013. The tooth
had been restored with a partial gold crown, and the
marginal seal was incomplete (Fig. 12). After local anaesthesia, the restoration and the cement build-up were removed. Underneath was the opening of the pulp chamber (Fig. 13). The diagnosis was pulpitis aperta. First, an
adhesive, pre-endodontic composite abutment was created under rubber dam isolation. At the same time, the
coronal pulp was removed during trepanation of the pulp
chamber (Fig. 14). As pain treatment, Ledermix was applied as a drug owing to the time limitation, and the tooth
was closed adhesively with composite.
After the master point try-in with configured gutta-percha points, warm vertical root canal filling was performed
using the modified Schilder technique (Figs. 6–8). The
tooth was sealed adhesively with composite and a glassfibre pin (Fig. 9). Postoperative radiographs after one year
and 4.5 years, respectively, showed the complete healing
of the extensive osteolysis (Figs. 10 & 11).
Further treatment was performed in one visit in December 2013. After local anaesthesia, the drug was removed
and the course of the canal was probed with C+ Files
of ISO sizes 6, 8 and 10 under control of an endodontic motor. The radiographic confirmation of the working length showed a pronounced, abrupt curvature of
Fig. 15
Fig. 16
Figs. 15 & 16: Radiographic measurement and master point image.
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4 2018
19
[20] =>
| industry report
Fig. 17
Fig. 18
Figs. 17 & 18: Root canal filling and check of tooth #37.
the canals in the apical third of the mesial root (Fig. 15).
The glide path was prepared with PathFiles of sizes 13,
16 and 19, then expanded with ProTaper hand files S1
and S2 (Dentsply Maillefer), which were prebent with the
Endo-Bender (Kerr). Rotary preparation was performed
with the HyFlex CM.
In this case, the following sequence was used with
ascending sizes and tapers: 15.04, 20.04, 20.06, 25.06,
30.04, 30.06 and 35.06. The path of the canal was manually expanded intermittently with prebent ProTaper hand
instruments F1 to F3 and then perfectly shaped with the
corresponding rotary HyFlex files, as the instruments were
stopped in the mesial root by the speed limiter of the endodontic motor owing to the extreme curvature. The entire
preparation was performed under intensive irrigation with
heated 6 % NaOCl. In addition, an ultrasound-activated
final irrigation with 17 % EDTA and NaOCl was performed
three times for 20 seconds. After the master point try-in,
the root canal was obturated vertically with warm guttapercha using the modified Schilder technique (Figs. 16–18).
Tooth #37 was sealed adhesively with a glass-fibre pin
and composite (Fig. 19). Postoperative radiographic control after one year and approximately 4.5 years showed
continued uneventful apical conditions (Figs. 20 & 21).
Discussion
These cases demonstrate that the safe preparation of
even extreme curvatures is predictable owing to the use
of highly flexible instruments such as the HyFlex CM.4
Fig. 19
Fig. 20
Fig. 21
Figs. 19–21: Pin check and post-op check after one year and 4.5 years, respectively.
20
roots
4 2018
[21] =>
industry report
|
Meanwhile, additional instruments have become available
in sizes 15.01, 15.02 and 20.02, as has HyFlex EDM size
10.05, which are superior to the files used at the time in
terms of material properties and thus offer greater safety
in difficult cases (Figs. 22 & 23).5 Furthermore, it can be
seen that hybridisation with manual instruments can be
helpful or even necessary to minimise the risk of fracture
and to control abrupt curvatures. The file sequences used
are of course material-intensive, especially since the files
were discarded after use in each patient case. This procedure is costly, but offers the best possible safety to
avoid cross-contamination and instrument fracture.
Conclusion
The postoperative radiographic checks after several
years proved that even very complex anatomies can
nowadays be treated safely, predictably and sustainably
with suitable instruments. For the patient, this implies the
long-term preservation of the natural dentition, even in
challenging cases.
Editorial note: A list of references is available from the author.
contact
Dr Bernard Bengs is a specialist
in endodontics certified by the
German Society of Endodontology
and Traumatology.
Voxstraße 1, 10785 Berlin, Germany
dr.bengs@gmx.de
Fig. 22
Fig. 23
Figs. 22 & 23: HyFlex Glidepath files and HyFlex EDM 10.05 Glidepath file.
AD
Dental Tribune International
ESSENTIAL
DENTAL MEDIA
www.dental-tribune.com
[22] =>
| industry report
Endodontic reboot: Adaptive core
debridement and disinfective finishing
Drs Gilberto Debelian, Norway; Martin Trope & Kenneth Serota, USA
Fig. 1a
Fig. 1b
Fig. 2a
Fig. 2b
Fig. 1a: This axial view of a mandibular molar demonstrates the ovoid eccentricity of the canals and existence of an isthmus connection between the mesiobuccal and mesiolingual canals consistent with findings of numerous studies.8, 9 Fig. 1b: The root canal space is an arborizational, anastomotic, labyrinthine
complexity, morphologically comparable to the pathways of a maze. While primary canals exist, the tributaries, accessory branches and lumina of the dentinal
tubules harbor extensive tissue and microflora. The existence of these vast, capacious passages has been demonstrated throughout the past century, beginning
with the work of Hess and continues to this day with the use of microcomputed tomography.17 Figs. 2a & b: The axial view of the obturation (microstructural
replication) demonstrates the flaw in flat field film interpretation. Significant areas of the buccolingual dimensions of the root canal space remained uncleaned
despite the illusory appearance in the radiograph.
Fifty years ago, Dr Herbert B. Schilder introduced two
legacy concepts to the science of endodontics: the constricted envelope of motion for instrumentation and the
Fig. 4
Fig. 3
22
Fig. 3: Dr Herbert B. Schilder’s principles included a continuously tapering shape, maintenance of the original anatomy, an
apex as small as practical, and conservation of tooth structure.
A continuously tapering space was acquired using precurved
hand instruments, which imposed discontinuous contact with
the canal walls and created an envelope of motion. Transactionally, Schilder created a virtual core. Fig. 4: The ideal file would produce
an apical size that three-dimensionally cleaned the minor apical foramen.
The SAF is a hollow file designed as an elastically compressible, thin-walled
pointed cylinder that is composed of a NiTi lattice. Its hollow shape allows for
the continuous flow of irrigant through its lumen. It was a beginning in the
paradigm shift toward minimally invasive 3-D debridement and disinfection.
roots
4 2018
use of hydraulics to enhance the rheology of the obturation material used to seal the root canal space and
optimize its gravitometrics. These were radical innovations for their time and despite technological and biological shortcomings of the armamentarium available,
these innovations should have been technology-iterated
and shortcomings in material and manufacturing evolution obviated; however, until recently that has not proved
to be the case in toto. In order to truly understand the
inherent flaws, the clinician must recognise the totality of
what is necessary to engender predictable clinical success in endodontics.
Studies assessing the diametric dimensions of apical
anatomy have repeatedly demonstrated that the buccolingual diameter is greater than the mesiodistal diameter;
canals are predominantly ovoid throughout, not round
(Figs. 1a & b).1–4 The technical flaw most inherent, the
use of a round file of any design conformation to clean
an ovoid canal configuration, manifests as the failure to
debride a substantial amount of the canal contents. A recent study showed that the mean (± standard deviation)
untreated areas ranged from 59.6% (± 14.9%) to 79.9%
(± 10.3%) for the total canal length and 65.2% (18.7%)
to 74.7% (17.2%) for the apical canal portion, respectively
(Figs. 2a & b).5
[23] =>
industry report
The evolution of nickel-titanium (NiTi) instrumentation
manufacture has persisted with a round core blank, regardless of whether it was ground, twisted, nanocoated,
heated or metallurgically reformulated. NiTi files are superelastic and able to self-center, avoid apical ellipticisation and, with appropriate taper selection, prevent thinning of the coronal and middle thirds of the root, resulting
in weakening or strip perforation. They are, however, unable to cleanse most of the intracanal space effectively
(Fig. 3). Moreover, regardless of design configurations
with a variable tip or variable taper or multiple tapers
on a single file, they were unable to adequately cleanse
the isthmus confluence of many canals.6 A revolutionary
design in file configuration, the Self-Adjusting File (SAF)
System (ReDent NOVA) was introduced to correct this
deficiency by including a virtual core (Fig. 4). It showed
significant promise in terms of the degree of debris removal
in complicated intracanal anatomy such as the isthmus
when compared with the widely accepted ProTaper system (Dentsply Maillefer, Switzerland); however, it failed
to take hold as a true replacement for traditional “round”
rotary instrumentation systems.7–9
The manipulation of the metallurgical properties of NiTi
by thermomechanical processing treatments has led to
significant improvement on the clinical performance of
the endodontic rotary files. The transition from the martensitic phase (soft phase) to the austenitic phase (stiff
phase) is dependent on temperature and metal stress.
The reversible transition between these two phases
increase the safety and performance of these files during
rotation. Unfortunately, fracture still occurs due to cyclic
fatigue and torsional failure when the elastic limit is
exceeded (Fig. 5a).
The new generation of NiTi alloys have transformation
temperatures much higher than those of conventional
austenitic materials used in previous generations of
rotary instruments and will transform at close to body
temperature. A recent study of ProTaper Universal,
HyFlex CM, TRUShape and Vortex Blue showed that a
temperature increase to 37 °C, simulating body tempera-
Fig. 7a
|
Fig. 5a
Fig. 5b
Fig. 6
Fig. 5a: The revolution in endodontic instrumentation imparted by the first
generation of NiTi instruments related to their shape memory and superelasticity.
Despite the advantages, these files were susceptible to fracture due to fatigue and
torsional failure. Fig. 5b: Heat treatment (thermal processing) is one of the most
fundamental approaches to adjusting the transition temperatures of NiTi alloys
and affecting the fatigue resistance of NiTi endodontic files. Newer alloys (e.g.,
MaxWire) transforming close to body temperature have demonstrated superior
resistance to cyclic fatigue and torsional failure. Fig. 6: An overview of the unique
features of the XP-endo Shaper are demonstrated. The discontinuous adaptive
debridement motion kinesis mimics Schilder’s envelope of motion exactly.
Fig. 7b
Fig. 7a: A traditional NiTi file from a round blank is represented in red and XP-endo Shaper in blue. The sinusoidal motion of the XP-endo Shaper in contrast to
the round file, which augers, demonstrates the benefit of adaptive debridement. In conjunction with the XP-endo Finisher, unprecedented levels of debris removal
and disinfection are possible. Fig. 7b: Minimally invasive endodontics, preservation of coronal dentinal girth and optimal apical size. (Courtesy of Dr. G. Debelian)
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4 2018
23
[24] =>
| industry report
Fig. 8a
Fig. 8b
Fig. 8a: Photoelasticity is an experimental technique for stress and strain analysis useful for conditions of complicated geometry or loading. As evidenced by
the accompanying images, the XP-endo Shaper demonstrates the least stress in the apical third. Fig. 8b: ProTaper NEXT was the first example of an attempt
to migrate away from the augering peck and pull motion of most NiTi files. Its swaggering motion was an improvement with regard to emulating the constricted
envelope of motion; however, its foundation remained a round blank with all the attendant issues related to cyclic fatigue and torsional failure.
ture, substantially decreased the fracture resistance of
all instruments tested.10 MaxWire (Martensite-Austenite
electropolish-fleX), while not included in this study, is
analogous to Vortex Blue. The temperature effect on the
latest generation of NiTi files is shown in Figure 5b.
Fig. 9a
Fig. 9a: The apical 10 mm of the file transforms into a bulb more coronally
and a tip in the last few millimetres. When rotating at canal temperature, the
XP-endo Finisher exhibits a total expansion of 3 mm. Fig. 9b: The XP-endo
Finisher is placed in the canal in the martensitic phase. When in the canal,
body temperature transforms it to the austenitic phase. Moved up and down in
7–8 mm increments, the natural shape of the canal expands or constricts the
tip or the bulb and disrupts debris, tissue or biofilm, which is removed by the
turbulence of the irrigant.
Fig. 9b
24
A new generation of adaptive/virtual core files, the
XP-endo system (FKG Dentaire, Switzerland) has dramatically changed the view of endodontic instrumentation.
In the absence of a solid core, this system allows the
tooth to dictate the canal configuration achievable and
allows cleaning of the canal with a degree of thoroughness that is unprecedented. Figure 7 details various features of the XP-endo Shaper. The Booster Tip lead section
fits into the pre-established glide path, ensuring precise
guidance and centering of the instrument. A traditional
glide path instrument is used consistent with a #15/0.02
(size/taper) instrument. There are no cutting flutes on the
lead section of the Booster Tip, and the XP-endo Shaper
instrument slips into the prepared apical component of
the glide path to a depth of 0.25 mm. The next 0.25 mm
section of the Booster Tip is configured with six cutting
flutes. Rotation of these flutes sizes the next 0.25 mm of
the canal space anywhere from a #25/0.02 to #60/0.02
(size/taper) instrument; however, the apical size chosen
for the XP-endo Shaper is #30. The taper of the XP-endo
Shaper is 0.01; however, the MaxWire alloy of the Shaper
enables the martensitic shape at room temperature to
realise the memorised shape as illustrated at body temperature (Fig. 6). By repeated swaths (a motion analogous to whittling in contrast to pecking) of the file, the
taper created ranges anywhere from 0.02 to 0.08. The
ideal intracanal taper throughout is 0.04, which preserves
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4 2018
[25] =>
industry report
|
dentinal girth in the coronal third and sustains maximal
dentinal retention in any root curvature. Figure 7a demonstrates the difference between the ability of a standard
round NiTi file to clear a less than ideal volume of intracanal debris in contrast to the more significant maximal
debridement achieved by the XP-endo Shaper’s adaptive discontinuous contact of the canal walls. The desired
minimally invasive shape achieved with this unique instrument is shown in Figure 7b.
The distinctions of greatest importance between the
XP-endo Shaper and conventional NiTi instruments are
as follows: The Shaper does not compact debris on the
flutes, resulting in increased frictional resistance, as it provides substantial space in the lumen or the virtual core;
nor does it force the debris apically as evidenced in instruments used with reciprocating motion.11 As the points of
contact on the dentinal walls are discontinuous, less stress
is applied and thus less cyclic fatigue created than with
conventional instruments,12 which can be readily demonstrated in photoelastic testing models (Fig. 8a). Figure 8b
demonstrates that efforts have been made with other file
systems to emulate the uniqueness of the adaptive core
design of the XP-endo Shaper; however, regardless of the
design alterations, a solid round core remains.
Inhibition or eradication of microflora presence from
the root canal spaces is a multifactorial conundrum. The
bulk of the microbes reside in the primary canal in a planktonic/loose form; however, there is a vast network of labyrinthine irregularities acting as a microbial reservoir that
communicate with the primary canal. While irrigation with
disinfectants may be very effective against planktonic microbes, it is not sufficiently effective when the microbes
are in biofilm form or in canal irregularities. The ability of
organisms within the residual biofilms to create an adaptive mechanism to the environmental changes resulting
from the treatment protocol can result in recrudescence
of the pathosis.13 The biofilm must be eliminated before
the disinfectants will work. This is analogous to scaling
and root planning in periodontal therapy.
Fig. 10
Fig. 10: The image reflects the distal views of 3-D reconstructions of the
mesial root canal systems of four mandibular molars prior to (green) and
after (red) canal preparation with reciprocating instruments. Final irrigation
was done with conventional irrigation, passive ultrasonic irrigation, the SAF
and the XP-endo Finisher. The figures demonstrate the effectiveness of the
Finisher in the apical region.
resistance to cyclic fatigue. Its primary action within the
root canal is to scrape the walls that it contacts rather
than debride and sculpt a shape into the wall of the canal.
When the file is cooled below 35 °C, it is in the martensitic phase. It can be bent to any other shape when in
this phase. When the file is heated to body temperature
(37 °C), it will change to the austenitic phase. When the
file is rotated in the austenitic phase, it creates a uniquely
As already mentioned, most files produce a final round
shape on any given canal cross section and as such the
practitioner is limited in the capacity to scrape the walls
of the nonround root canal space; at best, a round file
can brush the walls to facilitate an enhanced disinfection.
Alternative methods must be applied to remove toxins
unreachable by traditional files.
The XP-endo Finisher was designed to be adjunctive
to the XP-endo Shaper. The Finisher has many properties that allow it to gain access and scrape untouched
components of the canal walls, and the turbulence it
produces in the canal irrigant enhances its antimicrobial
properties. The file has a #25 tip diameter with a 0.00
taper. It is extremely flexible and thus has tremendous
Fig. 11
Fig. 11: The pre-op periapical radiograph shows a mesiodistal resorptive
defect. The cone beam computed tomography images show that this was
internal resorption and that it extended buccolingually as well. The post-op
radiograph shows that, at the second visit, the canal was filled completely,
which is an indication that the tissue and debris had been removed. Also,
and just as importantly, the original shape of the canal was maintained so
that the tooth was not further weakened by the cleaning procedure.
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4 2018
25
[26] =>
| industry report
Figure 11 is an example of the unique action of the Finisher. The irregularity in the canal is in the mesiodistal
dimension owing to internal resorption. The Finisher enabled removal of debris and tissue in the irregularity while
retaining the original shape of the canal and preventing
further weakening of the root.
Fig. 12
Fig. 12: Microcomputed tomography (µCT) images of representative specimens subjected to retreatment procedures. Only the apical segment of roots
was reconstructed. Left: The initial µCT scan taken after root canal filling.
Middle: A post-preparation µCT scan taken after retreatment procedures
with both systems: left canals with RECIPROC and right canals with Mtwo.
Right: The final µCT scan after using the XP-endo Finisher.16
shaped cleaning instrument: The apical 10 mm of the
file transforms into a bulb shape coronally while retaining a tip in the last few millimetres. Since the depth of the
spoon is 1.5 mm, the total diameter of the bulb and tip is
3.0 mm. However, if the bulb is squeezed, the tip will expand to a maximum of 6 mm; if the tip is squeezed, the
bulb will likewise expand to a #300 file (Fig. 9a); however,
since the instrument cannot cut, the only impact on the
dentine is optimised scraping. Therefore, if moved up and
down in the canal, the bulb and tip will expand or contract in concert with the natural 3-D diameter of the canal.
Maximum loss of length when transforming from straight
to full austenitic phase is 1 mm.
The small core diameter of the file maintains its flexibility and cyclic fatigue resistance, causing it to scrape, not
shape, the dentinal walls. This, plus the turbulence that
is created in the irrigant, results in a large surface area of
the canal being touched by the file and removal of biofilm
that would never be removed by round files.
Figure 9b shows the action of the XP-endo Finisher. In
the martensitic phase, the Finisher is placed in the canal
before it changes to full austenitic phase. The middle illustration demonstrates full austenitic phase at canal temperature; the file will expand to the extent that is determined by the canal anatomy. By moving the Finisher up
and down in a 7–8 mm swath, it expands and contracts
according to the anatomy of the canal. A recent study
demonstrated the efficacy of the Finisher in comparison
with traditional modes regarding hard-tissue debris removal;14 the results are reflected in Figure 10. A more
recent study showed that the Finisher had the greatest
bacterial reduction compared with standard needle irrigation, sonic agitation with the EndoActivator and PIPS
(photon induced photoacoustic streaming).15
26
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4 2018
There is a third file in the XP-endo system, the
XP-endo Finisher R designed for retreatments. This file
is a #30/0.00 making it slightly stiffer and more efficient
in removing root filling material adhering to the canal
walls, especially in the curvature or oval areas. The residual amount of filling material when a tooth is retreated is
difficult to calculate; however, studies using histological
evaluation of teeth with post-treatment periapical periodontitis show evidence that bacterial colonisation is associated with the canal remnants. A new supplementary
strategy using a finishing instrument was evaluated for its
ability to improve filling material removal in a recent study,
and the results showed substantial reduction in residual
contents when the Mtwo system and RECIPROC system
were used for retreatment. The results using the XP-endo
Finisher R instrument were encouraging because the
remaining filling volume showed a 69% reduction in
volume contents. In canals with residual filling material,
an adjunctive approach with the XP-endo Finisher R
instrument significantly enhanced removal (Fig. 12).16
Conclusion
Preliminary studies on XP-endo files have shown remarkable removal of soft tissue, fewer dentinal chips
residual in the isthmus and canal walls after instrumentation, and low dentinal stress (fewer microcracks). The
minimally invasive conservative instrumentation engenders a low amount of dentine removal coronally and efficient debridement and disinfection of the apical third
area. Have we achieved the ideal fusion of technology
and biology for long-term positive treatment outcomes?
Perhaps. What has been achieved is a redress of a design flaw that has persisted for much too long.
Editorial note: This article first appeared in May 2017 in
the Dentaltown magazine.
A list of references is available from the publisher.
about
Dr Gilberto Debelian is an adjunct
visiting professor in the postgraduate
programme in endodontics at the
University of Pennsylvania, US.
In addition, he maintains a private
specialist endodontic practice
in Bekkestua, Norway.
[27] =>
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[28] =>
| case report
Diode laser-assisted vital pulp
therapy in pulp polyp treatment
Drs Maziar Mir, Germany; Masoud Mojahedi, Germany; Jan Tunér, Sweden & Masoud Shabani, Iran
A pulp polyp or hyperplastic pulpitis is inflammation
of the exposed dental pulp owing to an open cavitated carious lesion, tooth fracture after trauma or longstanding fractured restoration.1 Type I hypersensitivity
reactions may also have a role in pathogenesis of pulp
polyps because of the higher concentration of histamine,
immunoglobulin E and interleukin in primary or permanent teeth.2 Removal of the polyp, pulpectomy and root
canal therapy are considered for treatment of this disease.1, 3
Clinical findings
In the oral examination process, the exophytic mass
was found to interfere with eating and occlusion, causing
intermittent pain and simultaneous bleeding.
Internal root resorption and a periapical lesion (apical
periodontitis) can often be seen in a tooth affected by
a pulp polyp. The former indicates chronic inflammation
with odontoclastic activity, and the latter expresses
severely inflamed pulps, for example irreversible pulpitis
or an infected root canal system.4, 5 A pulp polyp is referred to as asymptomatic irreversible pulpitis.
Diagnosis
The radiographic examination showed internal root resorption at the middle third and a periapical lesion at the
end of the mesial root of the first molar, as well as large
dental carious lesions in the first and second right molars
of the mandible (Fig. 2). The patient was thus diagnosed
with a pulp polyp.
Recently, vital pulp therapy (VPT) has proven to be a
successful treatment for molars with irreversible pulpitis associated with apical periodontitis. Based on many
effective diode laser properties, diode laser-assisted
VPT has shown to be a powerful method for VPT.6–9
Laser-assisted VPT in the treatment of a pulp polyp
After the patient had completed the consent form,
the operation area was anaesthetised through blocking of the inferior mandibular alveolar nerve with 2 %
lidocaine (1:80,000 adrenaline; 1.8 ml; Darou Pakhsh
Pharmaceutical).
This article aims to present successful results obtained
by diode laser-assisted VPT in a case of pulp polyp disease, applied in permanent mandibular molars using
calcium-enriched mixture (CEM) cement. One tooth also
showed internal root resorption and periapical periodontitis and the other was not.
Case presentation
A 17-year-old male patient with complaints of deep caries and an exophytic mass at a right mandibular permanent
molar was referred to us for treatment (Figs. 1a & b).
Medical history
The patient’s medical history showed no systemic
medical problems, no allergic reaction, no use of medications or recreational drugs and no history of past surgical
procedures. Thus, the patient did not need to be referred
for medical consultation.
28
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4 2018
Dental history
Oral and maxillofacial examination of the patient revealed no temporomandibular joint disorder or myofascial disturbances, no functional or parafunctional habits,
a Class I occlusion and poor oral hygiene.
In the next step, the controlled area was defined and
laser warning signs were properly placed in order to secure the operating room. The eye protection of the patient,
the patient’s guardian and the assistant were checked.
After reviewing the patient’s information (examination
sheet and radiograph, consent form, etc.), mouth rinsing
was done with a 0.2 % chlorhexidine oral rinse (Shahre
Daru Laboratories) for about one minute.
The pulp polyp was removed with a high-power diode
laser (Gigaa Laser) and the canal orifices were cleaned
with a cotton pellet soaked in normal saline for five minutes, followed by low-level diode laser irradiation.
The laser parameters applied for the pulp polyp removal were as follows: wavelength of 980 nm, power of
1.2 W, fibre of 400 µ, initiated fibre, continuous wave and
[29] =>
case report
contact mode. After completing this procedure,
Low Level Laser Therapy (LLLT) was performed
(Figs. 3a & b). The laser parameters for biomodulation intentions were the following: wavelength of 980 nm, output power of 300 mW, irradiation time of 10 s and energy of 3 J. The size
of the laser aperture was 7 mm2 and irradiation
was performed in a rotational mode at a distance
of 5 mm. The area of the canal orifice was
13 mm2.
Fig. 1a
|
Fig. 1b
After this procedure, the CEM cement dress- Figs. 1a & b: Clinical appearance of the pulp polyp disease in the first and second right
ing was placed (Fig. 4a). The CEM cement dress- molars of the mandible.
ing was done on a base of 2 mm of CEM cement
paste (Biunique Dent) prepared according to the
manufacturer’s instructions using a sterile plastic instruPost-procedural education
ment. A dry sterile cotton pellet was used to achieve
The patient was advised to respect oral hygiene acbetter adaptation of the CEM cement to the cavity wall
cording to the Caries Management by Risk Assessment
at the exposure site.
requirements, and the next visit was scheduled for two
days after the VPT procedure.
Interim restorative treatment with a glass ionomer
cement (Fuji IX, GC Europe) was applied according to the
Final result
manufacturer’s instructions without finger pressure after
Excellent pulp polyp removal was achieved and the
CEM cement placement (Fig. 4b). We decided to place
VPT was carried out with no bleeding, carbonisation
the permanent filling after one month.
or char. The patient did not experience any discom-
Fig. 2
Fig. 2: Radiographic examination showing large cavities in the first and second right molars, a radiolucent lesion in the periapical area and internal root
resorption of the first molar mesial root.
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4 2018
29
[30] =>
| case report
Fig. 5
Fig. 3a
Fig. 3b
Fig. 4a
Fig. 4b
Fig. 6
Figs. 3a & b: Situation immediately after pulp polyp removal and achievement of good coagulation with the diode laser and subsequent LLLT. Figs. 4a & b: Situation
immediately after CEM cement placement and interim restorative treatment with a glass ionomer cement. Fig. 5: Radiographic examination immediately after VPT of
the teeth affected by the pulp polyp disease. Fig. 6: Radiographic examination at approximately seven months after VPT: successful situation after treatment.
fort and was satisfied with the result. Radiographic examination was performed in order to monitor the result
of the laser-assisted pulpotomy based on radiographic
changes (Fig. 5).
Follow-up
The first visit after treatment was scheduled for two
days after the procedure. No pain was experienced and
the second LLLT was performed with the same setting,
but in contact mode at the coronal part, the mid-root
part and the apical part of each root of the two affected
molars in order to promote the healing process. The next
visit was again scheduled for two days later in order to
perform the third LLLT.
30
The precise molecular mechanisms for LLLT are not entirely clear, but its clinical effects on pain control, inflammation reduction and wound healing are well investigated.16–18
Gupta et al. reported that laser pulpotomy with high-power
diode lasers showed better clinical and radiographic
results in human primary molars than did electrosurgery and ferric sulphate pulpotomy in order to achieve
good coagulation.19 Uloopi et al. have applied low-level
diode lasers in pulpotomy and they noted that Low Level
Laser Therapy can be considered for pulpotomy in primary teeth, its success being comparable to mineral
trioxide aggregate pulpotomy technique.20
Conclusion
Finally, at the follow-up appointment at seven months,
a successful treatment outcome was observed clinically and the patient experienced no pain. The good
results were also evident in the radiographic examination (Fig. 6). A successful treatment outcome could be
observed, the periapical radiolucency had disappeared
and the internal root resorption of the mesial root of the
first molar had stopped.
It is clear that the aim of diode laser application in pulpotomy can be very different. In this case, a high-power diode
laser was applied for pulp polyp removal and good coagulation, and LLLT was used to promote the healing process.
Based on the laser protocol applied in this study, diode
lasers can be successfully used for VPT of pulp polyps.
Discussion
contact
Diode lasers are used extensively in many dental
practices.10 Laser–tissue interaction with a high-power
diode laser is based on photothermal effects and in
LLLT is not photothermal, but works based on a photochemical mechanism.11, 12 Since LLLT is dose-dependent,13
the laser parameters have to be respected carefully.14, 15
Dr Masoud Shabani
Department of Community Dentistry
School of Dentistry
Ardabil University of Medical Sciences
Ardabil, Iran
m.shabani@arums.ac.ir
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4 2018
Editorial note: A list of references is available from the publisher.
[31] =>
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[32] =>
| case report
Novel applications of a bioactive
resin in perforations, root resorption
and endodontic-periodontic lesions
Dr Marta Maciak, Poland
There are already several commercially available
dental materials that can be defined as bioactive. For
instance, any fluoride-releasing material, calcium silicateand calcium aluminate-based cements, and calciumbased or calcium-containing materials. Biomaterial scientists in the field of implantology have adopted the
word “bioactive” to mean materials that are bound to each
other through a biomineralised interface. There appears
to be confusion within the dental profession, including
among scientists, clinicians and industry persons, to
what extent biomineralisation can be achieved with dental materials and which materials can be appropriately
termed “bioactive” or “biomineralising”.1
Fig. 1
Introduction
During the last decade, a considerable amount of
attention has been directed towards the development
of so-called bioactive materials. To understand this phenomenon better and to avoid misinterpretation, a condensed review of the literature and an assessment of
various definitions need to be considered.
Fig. 2
Fig. 3
32
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4 2018
Fig. 4
Bioactivity has been defined and can be interpreted in
various ways. A broad definition that has several meanings is the following: a material that is able to have a biological effect or a material that is biologically active and
forms a bond between the tissue and the material.2 In the
field of tissue engineering, the term “bioactivity” is related
to the cellular effects induced by the release of biologically active substances and ions from the biomaterial, for
example from bioactive glasses both in soft- and hardtissue engineering applications.3, 4 In addition, its activity
.6
[33] =>
case report
Fig. 4
Fig. 5
has been demonstrated in pulp capping experiments in
non-human primates.5
Thus, in medicine, bioactivity covers all interaction
of materials with living cells and tissue, including the
effects of pharmaceuticals. In biomaterial science, with
bioceramics and bioactive glasses, bioactivity of a
material usually denotes that the material is capable of
forming hydroxyapatite minerals on its surface in vitro
and in vivo.6
The following theoretical question should be asked:
can a material that releases ions for biomineralisation
be considered bioactive or is the substrate on which the
biomineralisation occurs bioactive? Thus, bioactivity of
dental materials relates to their potential to induce specific and intentional mineral attachment to the dentine
substrate.7
Another definition has been presented in an article by
Lööf et al.: “Bioactivity of a ceramic material is a surface
Fig. 6
|
property that provides a bond between the material
and living tissues without fibrous encapsulation.”8 In yet
another definition, bioactivity is described as follows:
“A bioactive material is one that forms a surface layer of
an apatite-like material in the presence of an inorganic
phosphate solution.”9
ACTIVA BioACTIVE-RESTORATIVE and ACTIVA
BioACTIVE-BASE/LINER (Pulpdent) have been shown to
exhibit bioactive properties based on this last definition.
ACTIVA BioACTIVE products are the first dental resins
with a bioactive ionic resin matrix. They have a shockabsorbing rubberised resin component and reactive ionomer glass fillers that mimic the physical and chemical
properties of natural teeth. These bioactive materials
actively participate in the cycles of ion exchange that
regulate the natural chemistry of the teeth and saliva and
contribute to the maintenance of tooth structure and oral
health. ACTIVA has the strength, aesthetics and physical
properties of resin composites and is more bioactive than
glass ionomer cements.10 ACTIVA seals teeth against mi-
Fig. 7
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4 2018
33
[34] =>
| case report
Fig. 8
. 10
Fig. 9
croleakage11, 12 and its continuous release and recharge
of significant amounts of calcium, phosphate and fluoride
ions provide patients with long-term benefits.
In the US, the bioactivity claim for ACTIVA, being the
first bioactive resin material, has been accepted. Based
on its strength and durability due to a patented rubberised resin molecule that absorbs stress and resists
fracture, the author has used ACTIVA BioACTIVERESTORATIVE and ACTIVA BioACTIVE-BASE/LINER in
lieu of mineral trioxide aggregate (MTA) and Biodentine
(Septodont) for selected endodontic and other procedures.
34
Upon removal of the temporary filling, a large amount
of purulent exudate filled the pulp chamber and was
evacuated. After the MTA had been removed, the furcation was flushed with metronidazole (liquid; Polpharma)
and 2 % chlorhexidine (Cerkamed). The borders of the
perforation were refreshed with a carbide bur, and then
the pulp chamber was etched with 37 % orthophosphoric acid for 10 seconds, followed by a thorough rinse.
Through the perforation, a collagen sponge (ANTEMA,
Molteni Dental) was applied to support the ACTIVA BioACTIVE-BASE/LINER and to protect the underlying bone
defect. The sponge was not visible on the radiograph.
The canal orifices were protected with cotton pellets and the
entire pulp chamber was treated with a dentine bonding
agent (DenTASTIC UNO, Pulpdent), which was light-cured,
and then covered with ACTIVA BioACTIVE-BASE/LINER,
covering the floor of the pulp chamber (Fig. 2).
The cases presented here are off-label treatments
using ACTIVA BioACTIVE-BASE/LINER in cases with a
poor prognosis and in which extraction (and an implant)
may have seemed a more obvious choice of therapy.
These procedures are not listed in the company’s indications for use and were carried out by the author after
explaining the possible potential benefits, as well as the
risks to the patient. All of the patients agreed to the treatment and signed an informed consent form for endodontic treatment.
The tooth was closed with GIZ glass ionomer (Ihde
Dental) as a temporary filling. The patient was painfree within two days. A follow-up radiograph taken on
3 November 2015 (14 days postoperatively) showed the
beginning of the healing of the bone in the furcation area
(Fig. 3).
Case 1
A 28-year-old female patient was referred and presented with pain of tooth #46. The referral letter stated
that endodontic retreatment was needed and the perforation had been closed with MTA. The patient was in
considerable pain when eating and when closing her
mouth. Her medical history did not present any contraindications to dental treatment.
Case 2
A 16-year-old patient was referred with root resorption
of tooth #21. A CBCT scan and radiograph (Figs. 4 & 5)
taken on 30 March 2017 clearly demonstrated the root
resorption. Note the temporary filling in the pulp chamber. The patient’s medical history was non-contributory.
The diagnosis was mixed internal and external root
resorption.
The clinical examination showed a temporary filling
in tooth #46. A radiograph taken on 20 October 2015
showed extrusion of MTA into the furcation, as well as a
bony defect (Fig. 1). Perforation of the floor of the pulp
chamber was diagnosed.
After removal of the temporary filling, inflamed granulation tissue was seen inside the canal. In spite of the
fact that the apical portion of the canal was calcified, it
was located. The canal was shaped and cleaned with
the Self-Adjusting File (SAF) System (ReDent NOVA) and
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4 2018
[35] =>
case report
Fig. 10
|
Fig. 11
XP-endo Finisher (FKG Dentaire), and flushed with 5.25 %
sodium hypochlorite (NaClO), 17 % EDTA (Cerkamed) and
metronidazole (Polpharma). As a first temporary canal filing, Dexadent (Chema-Elektromet) was applied for one
week to treat the inflammatory tissue in the canal. During
subsequent visits, the canal was rinsed with 40% citric
acid (Cerkamed) and 2 % chlorhexidine (Cerkamed) using
the SAF System and XP-endo Finisher. A temporary filling of Multi-Cal (Pulpdent) mixed with 2 % chlorhexidine
(liquid) was inserted into the canal. Initially, the temporary dressing was replaced every two weeks to accomplish removal of granulation tissue and to stimulate bone
regeneration. Over the course of about seven months, a
reduction of the bone lesion was observed, as evidenced
by radiographs (Fig. 6) and CBCT and under high magnification.
The final treatment after approximately 11 months
(Fig. 7) consisted of cleaning the canal with the XP-endo
Finisher and EDTA and 2% chlorhexidine irrigation. The
resorption area was plugged with a collagen sponge
(Antema) to provide support for ACTIVA BioACTIVE
CEMENT and to prevent it from flowing beyond the root
structure. A dentine bonding agent (All-Bond Universal,
Bisco) was applied to the canal space, but not polymerised, just slightly air-dried, and the root was filled from the
apex to the pulp chamber with ACTIVA BioACTIVE-BASE/
LINER. A fibre post (Cytec blanco, Hahnenkratt) was immediately placed, following which the pulp chamber was
filled with ACTIVA. After 20 seconds, the restoration was
light-cured from three different directions for 20 seconds
each.
The final result can be seen on a radiograph from
13 February 2018. Complete bone healing adjacent to
the resorption area was observed (Fig. 8). While the radiograph shows the fibre post, the collagen sponge and
ACTIVA BioACTIVE CEMENT do not possess sufficient
radiopacity to be seen on a radiograph.
Case 3
A 63-year-old female patient presented for dental
treatment. A panoramic radiograph (Fig. 9) revealed a
heavily restored dentition with single crowns, a three-unit
bridge and multiple missing teeth in both arches. She
complained of pain in the mandibular right premolar area.
Her medical history did not present any contra-indications
to dental treatment.
When the patient was informed that tooth #45 would
have to be extracted, she objected and asked if anything
could be done to save it, even if only on a temporary basis, as she was reluctant to commit to wearing a removable partial denture. She thus consented to a treatment
that offered no guarantee of success.
Clinical examination showed third-stage luxation and
pus in the gingival pocket. A radiograph showed a
three-wall infrabony pocket (Fig. 10A) reaching the apex
of the root. The diagnosis was periapical periodontitis
with purulent exudate and root caries on the mesial
aspect. The treatment consisted of endodontic and
periodontal treatment after a panoramic radiograph and
realtime polymerase chain reaction (PET test, PET Plus,
MIP Pharma) were performed.
Endodontic treatment was performed on 2 July 2014
with a HyFlex file of size 25.04 (COLTENE) and the
SAF System. The pus was evacuated from the root
canal and the canal was flushed with 5.25% NaClO and
metronidazole, and Dexadent ointment was applied
and left for one week. To avoid extra expenses, no bone
grafting material was used; only a deep curettage was
performed.
An occlusal cavity was prepared and filled with
ACTIVA BioACTIVE-RESTORATIVE, and the tooth was
splinted to the adjacent premolar with fibreglass and
ACTIVA (Fig. 10B). The purpose of the splint was to lend
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4 2018
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[36] =>
| case report
Fig. 12
Fig. 13
support to the tooth, which presented with a Class III
mobility, thus promoting healing. After a few days, the
patient reported being free of pain, and no exudate in
the canal was observed.
On 10 July 2014, the canal dressing was changed
to Multi-Cal mixed with 2 % chlorhexidine and left for a
period of two weeks. Two weeks later, the Multi-Cal was
removed with the SAF System using 40 % citric acid and
distilled water. Then the canal was rinsed with 2 % chlorhexidine and dried with suction. GuttaFlow (COLTENE)
was used as a sealer, and a master cone was softened
in chloroform and placed in the canal. Vertical hot condensation was carried out in the apical part. The remainder of the root canal was filled with a continuous wave
of gutta-percha. The period until the next appointment
determined whether the treatment would be successful
or not. Healing of the infrabony lesion continued during
this period (Fig. 11).
Three months later, the gutta-percha was partially removed from the canal, which was etched and rinsed,
followed by application of the dentine bonding agent
(All-Bond Universal). The canal was filled with ACTIVA
CEMENT and a fibre post was placed, and after 20 seconds, it was light-cured (Fig. 12). After three years, a radiograph showed complete bone healing and periodontal
attachment (Fig. 13).
Conclusion
Based on the available published research and after
early favourable results had established the effectiveness
of ACTIVA BioACTIVE materials, and based on the pH,
release of calcium and phosphate ions and apatite formation in the presence of saliva, the decision was made
to expand the number of suitable cases. Although a
favourable outcome could not be guaranteed, clinical
cases followed over a period of three and more years
36
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4 2018
presented with positive results and provided evidence
that the bioactive properties of ACTIVA BioACTIVE materials through their ability to stimulate apatite formation
and osteoblasts provided a viable treatment option. The
evidence has been presented here with radiographs and
CBCT scans showing new bone formation. Although histopathological evidence has not been provided, a periodontal evaluation demonstrated periodontal attachment
in the cases presented here.
Editorial note: A list of references is available from the
publisher.
contact
Dr Marta Maciak, PhD,
graduated with a DDS from the
Medical University of Białystok in
Poland in 1999. In 2007, she
graduated with a specialty in
conservative dentistry and
endodontics from the university’s
Department of Restorative Dentistry.
From 2004 to 2009, she was an
assistant in the same department. In 2009, she received a
PhD in medical sciences in dermatology. She is a member of
the Polish Dental Association and Polish Endodontic Association.
She has authored many publications, and since 2005,
she has lectured in Poland and numerous other countries,
in addition to presenting practical training in the fields
of endodontics and aesthetic dentistry. Her main interests
are aesthetic dentistry, endodontics and prosthetics.
She can be contacted at martamaciak2012@gmail.com.
[37] =>
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[38] =>
| case report
Management of referred pain
Drs Chady Torbay, Sara Salloum, Claudia Dib, Edgard Jabbour & Philippe Sleiman, Lebanon
Referred pain can make diagnosis difficult and can
result in off-target or wholly unnecessary root canal
therapies, tooth extractions or surgeries. The incidence
of dental-related pain during an acute myocardial infarction is a serious example of referred pain.7
Therefore, listening to the patient, obtaining a detailed
dental history and collecting comprehensive diagnostic data are factors that improve the diagnosis of the
problem before treatment initiation.8 The most favourable therapy for referred pain is treatment of the cause of
the symptom; this involves identification of the site of the
primary disease, which may not be simple in all circumstances.9 If the origin site cannot be identified, therapy is
only symptomatic, with generally administered analgesic
drugs. Certainly, adequate pain management is a compelling and universal requirement in healthcare.10 For this
reason, collaboration between the departments of dentistry, pharmacology and physiology might be needed.11
Fig. 1
Introduction
Referred orofacial pain, which is pain sensed at a site
apart from the site of origin, is very frequent in dental
clinics.1, 2 As endodontists, the diagnosis of pain and
successful pain management are our primary tasks. Pain
referral undeniably has a neural basis. Specific passages
and neural couplings in the brain and in the body are
believed to lead to the probability of pain referral.3, 4 As
an illustration, some of the most enervating pain conditions that manifest initially as dental pain arise from the
structures innervated by a common nerve network, the
trigeminal system.5, 6
Fig. 2
38
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4 2018
In this report, we describe two cases of misdiagnosis
and a delay of appropriate treatment, resulting in the excessive and ineffective use of drugs. In these, several oral
healthcare professionals failed to diagnose the cause of
persistent facial pain because of the inability to conduct
a comprehensive dental examination. Furthermore, they
failed to use new technology to aid diagnosis.
Case 1
A patient suffering from what looked like facial myalgia was referred for consultation. He was a manager at a
well-known medical hospital and had for several weeks
suffered from extreme pain. His doctors thought that it
Fig. 3
[39] =>
case report
Fig. 4
Fig. 5
was inflammation of the trigeminal nerve, and since analgesics and anti-inflammatories had had almost no effect,
the patient was put on Tegretol. A friend advised him to
seek a dental consultation just in case. A CBCT scan was
taken to obtain adequate visualisation for diagnosis and a
clinical examination was performed. Nothing specific was
found, but the image around the third molar (Fig. 1) was
suspicious. The surgeon thus suggested that it be extracted, but once the anaesthetic had worn off, the pain
was still the same. I asked for a copy of the CBCT scan
and was carefully looking over each tooth in the evening
when something caught my eye under the second molar. From the axial views (Figs. 2 & 3) and the multiplanar
reformatted (MPR) view (Fig. 4), it looked like a migrating infection from the molar going around the mandibular
nerve and that may have been the cause of the pain, as
the inflammation can exert pressure on the nerve, causing
pain. I immediately called the patient and asked to see him
as soon as possible in the morning. On his arrival, the first
thing I did was to check the vitality of the tooth in question, as well as the rest of the dentition, both maxillary and
mandibular. The mandibular second molar did not show
any sign of vitality in response to heat, cold or electronic
stimulus and was almost negative on percussion, which
was curious. I explained the situation to the patient, and
he agreed that we do the drilling test, and it did not react
at all. I opened the access cavity, and as soon as I began
testing the permeability on the distal canal, the patient
began experiencing severe throbbing pain that radiated
to the left of his face. A few seconds later, inflammatory
liquid started draining from the distal canal, and I used
the MacroCannula of the EndoVac (Kerr) to help it drain
faster. The drainage lasted almost 15 minutes. Once it
had stopped, the patient felt some relief, but he asked for
a pause in treatment, as the pain was intense. We agreed
not to finish the treatment in the same day and that I would
see him the following day, and he promised to keep me
posted during the day. After taking a long-deserved nap,
he called me and told me that he felt like a normal person again. All medications were stopped—he was feeling
peculiar from the Tegretol— and the next day I finished
the root canal therapy (Fig. 5) using TF Adaptive (Kerr) and
the Sleiman sequence of irrigation with the EndoVac, followed by warm 3-D obturation of the root canal system,
and later a crown was placed.
Case 2
The patient was referred to the clinic suffering from
pressure on a mandibular molar. She also described a
burning sensation on her lower lip. A radiograph was
Fig. 6
Fig. 7
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4 2018
|
39
[40] =>
| case report
Fig. 8
Fig. 9
taken (Fig. 6), and it showed an incomplete root canal
therapy with a radiolucency in the apical area. I informed
the patient that a CBCT scan would be essential in order
to determine exactly what was going on. From the axial
view (Fig. 7), we could see clearly the amount of bone
destruction under the mesial roots in particular. Additionally, I noted that the bone covering the mandibular nerve
had resorbed in certain areas, which could put the nerve
in contact with the inflammatory liquid, causing what the
patient described as a burning sensation. On the sagittal
slices (Fig. 8), we could see the volume of the lesion and
the intimate relation with the mandibular nerve. The 3-D
reconstruction using Anatomage software revealed the
volume of the lesion (Fig. 9). The lesion did not look cystic,
as it was confined to the spongy bone, with no damage
to the cortical bone lingually or buccally, and no defined
borders. I advised the patient that we would need to put
her on antibiotics 24 hours prior to the treatment as a precaution in order to try to minimise any flare-up, as such an
occurrence would place more pressure on the nerve. The
following day, the root canal therapy was performed using
TF Adaptive and the Sleiman sequence of irrigation with
the EndoVac, followed by warm 3-D obturation of the root
canal system. During the use of negative pressure, a great
deal of drainage continued for almost 10 minutes from the
mesial canals. Root canal therapy was performed in a single session (Fig. 10). Antibiotics were continued for seven
days. Figure 11 shows a comparison between five weeks
and immediately postoperatively. Figure 12 shows a comparison between five months and demonstrating that the
healing process was proceeding well. Taken at the oneyear follow-up, Figure 13 shows the beautiful healing and
complete closure of the bone surrounding the mandibular
canal. Figure 14 provides a comparison between the initial
situation and the progress after one year.
Fig. 10
40
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4 2018
Discussion
Orofacial pain has been associated with many neurological diseases, as well as some cardiac problems.12
In this paper, we discovered a low prevalence of referred
dental pain, from the origin site of pain origin, evaluated
through a tomographic scanner, to the other sites.13, 14
The extended illness in the patient (case 1) was caused
by a slip-up on the part of the treating dentist. Medical
misinterpretations can have tragic effects on the lives
of patients. Therefore, a standard and logical protocol
should be followed in the hope that a correct diagnosis of
pain can be made and the appropriate therapy directed
to the source of pain and not the site of pain.15
Fig. 11
[41] =>
case report
Fig. 12
Fig. 13
Actively listening to patients is vital for both diagnosis
and pain management. It is only through effective communication between both parties that dentists and patients
can produce the best treatment plan. Equally important
are a good knowledge of the facial anatomy, a carefully recorded medical history and a clinical examination including
pulp tests and advanced radiographic techniques.16 Likewise, shedding light on some factors that could play role in
the occurrence of the referred pain might be beneficial.17, 18
for a consultation or for more accurate diagnostic details, whether concerning equipment or experience,
might be embarrassing and self-devaluing.29 Moreover,
professional custom often runs against obtaining second
opinions, standing in the way of the best therapy.30
Nevertheless, physicians should always prioritise the
patient’s welfare and ask for help if needed.31
|
Editorial note: A list of references is available from the publisher.
Recurrent dental pain occurs the most in women, and
this is in accordance with some reports indicating that
women have a higher rate of some painful facial conditions.19, 20 Recent medical evidence suggests that the
trigeminal and vagus nerves are frequently viewed as pain
mediations to the facial region.21–23 Moreover, the differences in pain perception and the presence of proprioceptors in the periodontal tissue increases the probability of
referred pain accompanying periapical lesions over the
probability of such pain with periodontal lesions.24
Additionally, when suspecting referred pain of any
unknown origin, it is the dentist’s responsibility to refer
the patient to the appropriate physician, providing a detailed report of the tests performed.25 As the diversity of
referred pain becomes more complicated across a wide
range of situations, and the necessity to coordinate interaction among multiple disciplines becomes ever more
important, combining well-functioning teams is a critical target throughout the healthcare system, especially
when odontogenic causes of pain have been ruled out
and non-odontogenic causes need to be considered.
An interdisciplinary team is a one in which the team
members include all kinds of medical specialists, not just
dental ones.26, 27 Researchers have suggested that working together decreases the potentiality of medical errors.
Effective teams disintegrate hierarchy and concentrate
the power of healthcare systems.28
Fig. 14
contact
Dr Philippe Sleiman is an assistant
professor at the Faculty of Dentistry
of the Lebanese University in Beirut
in Lebanon. He can be contacted at
profsleiman@gmail.com.
However, under the mantra “the doctor knows best”,
a physician may be hypnotised into thinking that asking
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4 2018
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[42] =>
| practice management
Successful communication
in your daily practice
Part V: Bad online reviews
Dr Anna Maria Yiannikos, Germany & Cyprus
Hi! I am Dr Anna Maria Yiannikos and I am in the happy
position to present you the 5th part of this new loved series filled with communication protocols. This series includes the most popular and challenging scenarios that
might occur in your dental practice. I will show you how
to deal with them so that your patients always leave your
practice feeling: “My dentist is THE BEST!”
Each individual article of this series will teach you a new
specialised protocol that you can easily use, customise
and adapt from the same day to your own dental clinic’s
requirements and needs.
Let’s start with today’s challenging topic which is…
how to deal with a bad online review from a stranger.
Imagine receiving a negative review at your Facebook
page from someone who is not even a patient—maybe,
because he just wants to be mean, or maybe he just
wants to hurt you.
5 fantastic tips
Let’s not focus on that though! Our goal is to change
the negative incidence into a positive one. Isn’t that
correct? You might ask: “Dr Anna, how can I do that?
This guy, who gave me the bad review, is not even a
patient.” Let’s discover 5 fantastic tips that I have for you
today. You will just love them!
1. Do not take it personally
Take a deep breath. The first rule of dealing with
negative reviews is to not take them personally! That’s
because as your business grows, you will have to
face more and more of them. Do not get into the bad
reviewer’s trap responding to what he says.
For example, you should not get defensive and list
all of the reasons why the potential patient is wrong.
He is, quite frankly, a jerk that loves making a personal
©V
i c to
r ule
r/ Sh
u t te
om
4 2018
c k .c
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r s to
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[43] =>
practice management
|
© Trueffelpix/Shutterstock.com
attack. Avoid joining the conversation—it is absolutely
wrong!
2. Don’t try to remove it
Even if you try to remove the negative review from that
online site, you might not be able to! Most important,
remember that most people who frequent review sites
and look for your business on social media, know that
not all of your reviews are perfect. Don’t sweat if you have
received one bad review.
3. Ask for positive reviews
What would be wise to do is to focus on getting more
positive reviews from friends and loyal patients!
After all, every positive review takes the sting out of a
negative one. Ten positive reviews and one negative
might give pause for thought; but 100 positive
reviews and one negative review isn’t for sure
a big deal.
Send the request immediately to your friends
to rate your clinic asap! What will be the result?
You will receive so many positive reviews that
the bad review will be at the bottom of the list,
and now who will see it? Most probably no one!
4. Move on
Enjoy all the great things that your friends
say about your practice! The reality is that
you have to deal with bad reviews, you
can’t ignore them!
5. Don’t allow posts on your
Facebook page
If you cannot handle the bad
feeling of someone being mean
to you, turn off the feature that
allows anybody to post on your page. Remember that
you’re only turning off original posts—not comments.
If they’re negative, you can respond in the comment
section or let other visitors comment on your posts.
Make the best of it!
I know that you feel bad about this unfair situation
but you can transform it easily and quickly in to a positive
one. I have done that myself! Things like that can happen. Grab the opportunity to make it positive by using the
above troubleshooting guide that I offer you!
In the next issue of roots magazine, I will present to you
the sixth part of this unique new series of communication
concepts that will teach you… how to deal with economic
crisis! I will help you to discover 5 effective ideas that will
increase your income immediately!
Until then, remember that you are not only the dentist
of your clinic, but also the manager and the leader. You
can always send me your questions and request for more
information and guidance at dba@yiannikosdental.com
or via our website www.dbamastership.com. Looking
forward to our next trip of business growth and educational development!
contact
Dr Anna Maria Yiannikos
Adjunct Faculty Member of AALZ
at RWTH Aachen
University Campus, Germany
DDS, LSO, MSc, MBA
dba@yiannikosdental.com
www.dbamastership.com
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4 2018
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[44] =>
| interview
“We gain a better outcome
for endodontic treatment”
By DTI
The activation of the fluid is so effective that I quickly
adopted it.
How does it work?
EDDY is not an ultrasonic device, but a sonic one.
Because of the frequency it uses, which is between 5,000
and 6,000 Hz, it is tremendously effective. It works like
an ultrasonic device in many ways, but seems to activate
the irrigant more effectively, especially in curved canals,
which in turn enhances the procedure. The activation is
3-D, which means that EDDY moves the fluid in a 3-D
direction into all lateral canals, isthmuses and other
anatomical complexities.
If the clinician already uses ultrasonic activation, why
should he or she switch to EDDY?
As I said, I was sceptical about changing from ultrasonic to sonic. I continue to use ultrasonic tips in my
practice, for example to remove some remnants of the
Dr Grzegorz Witkowski is a member of the European Society of Endodontics,
Polish Association of Endodontics and Polish Academy of Aesthetic Dentistry.
Since 2004 he runs a private practice in Olsztyn (Poland) focused on
endodontics, CAD/CAM and aesthetic dentistry.
A main cause of endodontic failure is the recolonisation of the poorly treated root canal system with microorganisms. The primary goal of endodontic treatment
has always been to effectively irrigate the canal and prevent reinfection of the periapical tissue. As a means to
achieve greater success, longevity and reliability in modern endodontics, proper irrigation has been enhanced
through the activation of the irrigant. In contrast to ultrasonic activation, the flexible EDDY tip, launched by VDW
in 2015, uses sonic activation of the fluid. We spoke to
Dr Grzegorz Witkowski, a leading Polish endodontist,
about his daily experience with sonic activation and his
irrigation protocol.
How long have you been using EDDY?
I started using EDDY more than two years ago. Before EDDY, I was an ultrasonic system user—and I still
continue to use ultrasonic tips for some uses. Therefore,
I was sceptical about the tip at the beginning. As soon
as I saw how it worked, it changed a lot in my practice.
44
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4 2018
Fig. 1: EDDY polyamide tip in oscillating motion.
[45] =>
interview
Fig. 2
|
Fig. 3
Figs. 2 & 3: Sodium hypochlorite activated with EDDY.
material in retreatment. For most endodontic cases, however, it is easier to use sonic activation. It works just like
ultrasonic activation, as it activates the fluid and spreads
it with the proper amount of power into every part of the
canal.
For regular treatment and even retreatment, I would
say EDDY is a faster and safer means of activation. In
particular, general dentists will appreciate the flexible
and elastic tip. One does not have to worry about the
preparation of the wall, which is really important, as this
instrument will not damage the canal walls. There is
no transportation of the canal, which many dentists
know is a common procedural accident. For EDDY, one
just irrigates and activates. What an effective method!
Without canal transportation, with the proper preparation and a proper irrigation protocol, we gain a better
outcome for endodontic treatment.
What is your irrigation protocol?
My own protocol is quite complex. As an endodontist, I mostly deal with difficult cases. In my workshops,
however, I always recommend the same protocol.
I start with the main fluid, sodium hypochlorite, usually
5.25 per cent. I use 20 to 40 ml per canal, which is quite
a lot. I also use citric acid to remove the smear layer.
After that, I continue to use sodium hypochlorite. To
neutralise the pH, I use distilled water. At the end, I use
chlorhexidine for a prolonged antibacterial effect and
stabilising effect of the collagen matrix. I do not dry the
canal with alcohol.
I learnt that EDDY is more effective when one places
a syringe with additional sodium hypochlorite into the
canal and administers it continuously. EDDY will rinse
everything thoroughly.
When do you know that you have cleaned the canal
properly?
First of all, it is important to understand that one never
knows. If you ask 100 endodontists what irrigation protocol they would recommend, they would not be able
to reach a consensus. Every endodontist may agree
in general, but regarding specifics, everybody will say
something different. My focus is on understanding the
fluid interactions and easy ways to activate it. The sodium
hypochlorite does not work at all levels, so one needs to
use different fluids.
It is commonly understood in endodontics that the process of chemical irrigation should take longer than mechanical preparation. A molar with four canals takes me
60 minutes to treat and I spend approximately 40 minutes
of that on irrigation. Preparation nowadays is easy, but we
do preparation for proper irrigation. With the advances in
root canal preparation, we now have to focus on proper
irrigation. In particular, we have to rinse at every level;
during preparation, we should already establish a clean
system. All files push some debris to the apex. Proper
irrigation is the main means of preventing that.
How important is it to have a flexible tip?
The flexibility of the EDDY tip is a big advantage,
especially for S-shaped canals and other complicated
anatomies. EDDY can easily be applied into the canal.
With an ultrasonic tip, one touches the walls, which may
lead to transportation of the canal. This is something to
be avoided. With the flexible EDDY tip, one can easily
follow the preparation path. General practitioners who
do not activate the fluid and then use EDDY will notice a
difference, especially on the postoperative radiograph.
Thank you very much for the interview.
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[46] =>
| manufacturer news
Three different types of 3-D imaging
Imaging with Planmeca CBCT units
All Planmeca’s CBCT units support
three different types of 3-D imaging, as well as extraoral bitewing, cephalometric and digital panoramic imaging.
This flexibility to switch between 2-D and 3-D allows clinicians
to optimise their imaging and select the techniques that work
best with each case. With proprietary features for imaging with
ultra-low radiation doses and patient movement correction also
available, Planmeca provides a completely unique dental imaging
experience.
The Planmeca Ultra Low Dose protocol is the best method for
acquiring CBCT images at low radiation doses, according to the
company. It can be used with all voxel sizes and in all imaging
modes and allows clinicians to gather more information than from
standard 2-D panoramic images at an equivalent or even lower
dose. All this is possible without a statistical reduction in image
quality.1
Whereas Planmeca
Ultra Low Dose protects patients from
unnecessarily high doses, the new Planmeca
CALM imaging protocol helps avoid retakes by compensating for movement. According to studies,2 patient movement
may occur in up to 40% of cases, meaning that image quality is not
optimal in a significant portion of CBCT scans. Planmeca CALM
corrects artefacts caused by movement, resulting in sharper final
images. The algorithm can be applied before the image is captured, as well as after the scan has been completed.
When purchasing a new CBCT unit, clinicians should ensure they
request all the necessary information on the product. This would
include accurate information on patient radiation doses and
comparison of the differences in image quality between standard and low-dose images, as well as images with and without
artefact correction. Making the right choice will lead to improved
diagnostics, saved time, reduced costs and lower radiation
exposure for patients.
www.planmeca.com
References
1. Ludlow JB, Koivisto J. Dosimetry of orthodontic diagnostic FOVs using low dose
CBCT protocol. Poster session presented
at: 93rd General Session & Exhibition of
the International Association for Dental
Research; 2015 Mar 11–14; Boston, MA.
2. Spin-Neto R, Wenzel A. Patient movement and motion artefacts in cone beam
computed tomography of the dentomaxillofacial region: a systematic literature
review. Oral Surg Oral Med Oral Pathol
Oral Radiol. 2016 Apr;121(4):425–33.
46
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4 2018
[47] =>
manufacturer news
|
Strengthened composition and rounded cross section
The Meta Biomed GL153 series: Stay true to form
An unavoidable truth of endodontics is that the root canal is a
complex space to work in. Shaping root canals helps to make navigation easier, but the files used in this process can be prone to
fracture as a result of cyclic or torsional fatigue. META BIOMED’s
new GL153 series is a set of instruments with exceptional
resistance to fatigue, allowing you to navigate and clean long,
tapered and complex canals more easily than ever before.
The GL153 files undergo a proprietary thermomechanical treatment that gives them a much greater resistance to fatigue. The
controlled memory wire used in their manufacture has been
verified by an independent scientific study to significantly increase
the number of cycles before failure compared with other files on
the market.
The strengthened composition and rounded cross section of the
GL153 work to create a smooth, efficient path, shaping the root
canal and preserving the surrounding tooth structure without risk
of file separation.
META BIOMED’s standing as one of the dental industry’s primary
innovators ensures that the GL153 is optimally designed for the
practitioner’s and patient’s safety
and comfort. The flute design of
the files reduces the screw effect,
greatly decreasing the likelihood
of over-instrumentation. In addition,
no elastic limits are exceeded, and
there is no risk of taper lock when
used in the recommended reciprocating motion with a constant
downwards pressure.
Torsional fracture often occurs
when a file tip becomes stuck in
a canal and the shank continues
to turn. With a flute length of
just 10 mm, the GL153 series
promises that the apex of the tooth
can be reached safely and that
ideal root canal preparation is more
achievable than ever.
“With its unlimited flexibility and
excellent resistance to fracture, the
GL153 Safe10 series represents
our commitment to providing highquality solutions for everyday
dental procedures at a low cost,”
said Ian Yun, Managing Director at
META BIOMED.
www.meta-biomed.com
AD
[48] =>
| meetings
International Events
The largest Annual Dental
EVENT IN THE WORLD!
GNYDM
IDS 2019
25–28 November 2018
New York, USA
www.gnydm.com
12–16 March 2019
Cologne, Germany
www.ids-cologne.de
ADF
AAE Annual Meeting
27 November – 1 December 2018
Paris, France
www.adfcongres.com
10–13 April 2019
Montréal, Canada
www.aae.org
CIOSP
KRAKDENT
30 January – 2 February 2019
São Paulo, Brazil
www.ciosp.com.br
10–13 April 2019
Krakow, Poland
www.krakdent.pl
Waiting for
you in 2019!
Organizer:
Support:
Information:
Exhibit Inquiry:
48
roots
4 2018
International Media:
AEEDC
Dental Salon
5–7 February 2019
Dubai, UAE
www.aeedc.com
22–25 April 2019
Moscow, Russia
www.dental-expo.com/dental-salon
CDS Midwinter Meeting
APDC & SIDEX
21–23 February 2019
Chicago, USA
www.cds.org
8–12 May 2019
Seoul, Korea
www.apdc2019.org
[49] =>
© 32 pixels/Shutterstock.com
submission guidelines
|
How to send us your work?
Please note that all the textual components of your submission must be combined into one MS Word document.
Please do not submit multiple files for
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In addition, images must not be embedded into the MS Word document. All
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We can run an unusually long article in
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In short, we do not want to limit you in
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Larger image files are always better,
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Also, please remember that images
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You may submit images via e-mail, via
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Please also send us a head shot of
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An abstract of your article is not required.
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or less).
Questions?
Magda Wojtkiewicz
(Managing Editor)
m.wojtkiewicz@dental-tribune.com
roots
4 2018
49
[50] =>
| international imprint
Imprint
Publisher/President/CEO
Torsten R. Oemus
t.oemus@dental-tribune.com
Managing Editor
Magda Wojtkiewicz
m.wojtkiewicz@dental-tribune.com
Designer
Franziska Schmid
Copy Editors
Sabrina Raaff
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Editorial Board
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Benjamin Briseno, Germany
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Gary Cheung, Hong Kong
Asgeir Sigurdsson, Iceland
Adam Stabholz, Israel
Jorge Vera, Mexico
Unni Endal, Norway
Esteban Brau, Spain
José Pumarola, Spain
Kishor Gulabivala, United Kingdom
William P. Saunders, United Kingdom
Fred Barnett, USA
L. Stephan Buchanan, USA
James Gutmann, USA
Ben Johnson, USA
Kenneth Koch, USA
Sergio Kuttler, USA
John Nusstein, USA
Ove Peters, USA
International Administration
Chief Financial Officer
Dan Wunderlich
Director of Content
Claudia Duschek
Clinical Editors
Nathalie Schüller
Magda Wojtkiewicz
Editors
Monique Mehler
Brendan Day
Kasper Mussche
Franziska Beier
Executive Producer
Gernot Meyer
Advertising Disposition
Marius Mezger
International Office/Headquarters
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
Business Development & Marketing Manager
Alyson Buchenau
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Printed by
Löhnert Druck
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04420 Markranstädt, Germany
Copyright Regulations
roots international magazine of endodontics is published by Dental Tribune International (DTI) and appears in 2018 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
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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.
50
roots
4 2018
[51] =>
Adapted to Nature
Single-file system
Shape memory alloy
Adaptive Core
Preserves dentine,
easy and safe
ENDO DONE !
www.fkg.ch
[52] =>
Easy and convenient cordless obturator
with innovative cartridge
Innovative solutions
for successful root
canal treatment.
The new EQ-V system by Meta Biomed
for the most reliable, convenient and precise
root canal obturation.
Warm
Gutta Percha
Obturation
Meta Biomed Co., Ltd — Head Office
270 Osongsaengmyeong1-ro,
Osong-eup
Heungdeok-gu, Cheongju-si,
Chungbuk, Korea
Phone: +82 43 218 1981
info@meta-biomed.com
www.meta-biomed.com
Meta Biomed Europe GmbH
Wiesenstraße 35
45473 Mülheim an der Ruhr
Tel +49 208 309 9190
Fax +49 208 30 991 999
europe@meta-europe.com
www.meta-europe.com
)
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/ Endodontic reboot: Adaptive core debridement and disinfective finishing
/ Diode laser-assisted vital pulp therapy in pulp polyp treatment
/ Novel applications of a bioactive resin in perforations, root resorption and endodontic-periodontic lesions
/ Management of referred pain
/ Successful communication in your daily practice - Part V: Bad online reviews
/ “We gain a better outcome for endodontic treatment”
/ Manufacturer news
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