Tạp chí Nội Nha tháng 10 2013 Vol 6 No5

Tạp chí Nội Nha tháng 10 2013 Vol 6 No5 Một tài liệu hay và quý cho các bạn yêu thích bộ môn nội nha trong chuyên ngành răng hàm mặt. Một tài liệu hay và quý cho các bạn yêu thích bộ môn nội nha trong chuyên ngành răng hàm mặt. Một tài liệu hay và quý cho các bạn yêu thích bộ môn nội nha trong chuyên ngành răng hàm mặt.

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October 2013 - Volume 6 Number 5

ASSOCIATE EDITORS

Julian Webber BDS, MS, DGDP, FICD

Pierre Machtou DDS, FICD

Richard Mounce DDS

Clifford J Ruddle DDS

John West DDS, MSD

EDITORIAL ADVISORS

Paul Abbott BDSc, MDS, FRACDS, FPFA, FADI, FIVCD

Professor Michael A Baumann

Garry Nervo BDSc, LDS, MDSc, FRACDS, FICD, FPFA

Wilhelm Pertot DCSD, DEA, PhD

Julian English BA (Hons), editorial director FMC

Dr Paul Langmaid CBE, BDS, ex chief dental officer to the Government

for Wales

Dr Ellis Paul BDS, LDS, FFGDP (UK), FICD, editor-in-chief Private

Dentistry

Dr Chris Potts BDS, DGDP (UK), business advisor and ex-head of

Boots Dental, BUPA Dentalcover, Virgin

Dr Harry Shiers BDS, MSc (implant surgery), MGDS, MFDS, Harley St

referral implant surgeon

PUBLISHER | Lisa Moler

Email: lmoler@medmarkaz.com Tel: (480) 403-1505

MANAGING EDITOR | Mali Schantz-Feld

Email: mali@medmarkaz.com Tel: (727) 515-5118

ASSISTANT EDITOR | Kay Harwell Fernández

Email: kay@medmarkaz.com Tel: (386) 212-0413

EDITORIAL ASSISTANT | Mandi Gross

Email: mandi@medmarkaz.com Tel: (727) 393-3394

DIRECTOR OF SALES | Michelle Manning

Email: michelle@medmarkaz.com Tel: (480) 621-8955

NATIONAL SALES/MARKETING MANAGER

Drew Thornley

Email: drew@medmarkaz.com Tel: (619) 459-9595

PRODUCTION ASST./SUBSCRIPTION COORD

photocopies and information retrieval systems While every care has been taken in the preparation

of this magazine, the publisher cannot be held responsible for the accuracy of the information

printed herein, or in any consequence arising from it The views expressed herein are those of the

You are an endodontist: “how do you measure up?”

Does your endodontics leave the footprints you want? Does your endodontics distinguish who you are? Do your clinical endodontic skills set you apart? Are you the endodontist that you would want to go to? What are your “measurables?”

In today’s marketplace, it’s not good enough to be good enough, to have convenient hours, or to send referring doctors staff lunches In order to earn the transfer of referral trust, we have to do something different We have to deliver something that exceeds expectation How is this done? Listed below are 10 measurables that influence the endodontic referral and create endodontic value:

1 Quality The first step in becoming a masterful endodontic clinician is to slow down

When we slow down, we do better endodontic finishes, and we create more value

to our patients and referring doctors With greater value, we are worth more to the community, and a higher fee has been earned If your fees are justifiably higher, you have a choice to slow down The successful cycle then continues Slowing down and skillful endodontic mechanics have been the focus and hallmark of my current

Endodontic Practice US series entitled Anatomy Matters What is your finishing

checklist? What matters to you?

2 Only start what you can finish well Most of us attempt to finish everything we

start This is the risk of the growth phase of endodontics We have no time to finish anything well Our quality and standards go down, and what once set us apart has been lost

3 Be your dentists’ advocate/ally Let them know they can be safe with you no

matter how bad they may have had technical difficulties Tell them their success is your job You have their back

4 Transfer of trust Your referring dentists and their patients have granted you trust

Now you have to earn it

5 Be accountable for your results Referring dentists want an endodontist who has

no excuses Take full responsibility for a successful patient experience and treatment outcome

6 Present alternate treatment plans Sometimes endodontists have tunnel vision

or diagnose based on their own needs Dentists need the security and confidence that you will tell them and their patients WWIDIIWM (What would I do if it were me?) Learn the parts of the endodontic interdisciplinary mind: biology, structure, function, and esthetics Know these domains as well as, if not better, than your referring dentists

7 Practice team endodontics Discover what it is in your day that you enjoy the

most, and do more of that and less of what you don’t enjoy For me, I am lost in the moment or in the Flow when I am Cleaning, Shaping, Packing, or in Surgery (Flow,

Mihaly Csikszentmihalyi, 1991 by Harper Perennial) Delegate tasks that you enjoy less to trained and skilled hands

8 Exceed your referring doctors’ and patients’ expectations Perform at a level

of competence, consistency, and confidence that exceeds the expectations of the dentist and patients

9 Mentor an Endodontic Study Club This study club should be designed to

collaboratively learn knowledge and to make consensus diagnoses and treatment plans It should not be about “getting referrals.”

10 Lead Leaders take people where they have never gone before Leaders keep their

focus on the outcome they want in spite of pressure to do otherwise They start with the answer

Case study

Management of root resorptive lesions in maxillary incisors using computed tomography and MTA: 1-year follow-up

Drs Anil Dhingra and Marisha Bhandari delve into the advantages

of MTA and CBCT imaging 18

Endodontics in focus

Top ten tips: Tip number 9 - Preparation techniques

Continuing his series on endodontics, Dr Tony Druttman shows the importance of preparation 24

simple, adaptable endodontic solutions

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TABLE OF CONTENTS

Continuing

education

Endodontic treatment of curved

root canal systems

Dr John Bogle offers some cases

to treatment plan success for tooth

retention 28

Root canal preparation: the path

to success

Dr Omar Ikram explains the principles

of taper and apical preparation and

how they relate to clinical practice

32

Endo essentials

The big debate

Drs Michael Norton and Julian

Webber discuss — implants or

Apply current tax laws to improve patient care

Bob Creamer explains Section 179 and Bonus Depreciation 46

Practice management

Growing the money tree

William H Black, Jr discusses the financial advantages of having a good plan in place 48

Endospective

One clinician’s means of obtaining patency and preparing the glide path

Dr Rich Mounce discusses a method for obtaining patency and preparing the glide path with hand files 50

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Orthodontists

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frac-my treatment process is a lot less stressful My patients benefit from the technology and frac-my

referrals appreciate the value.” ~ Dr Kathryn Stuart, Endodontist - Fishers, Indiana

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What can you tell us about your

background?

I grew up in a small town on the Allegheny

River in Western Pennsylvania just 20

miles outside of Pittsburgh I attended the

University of Pittsburgh for college and

dental school Because it was during the

Vietnam War, I had been deferred from

military service, and so I entered the U.S

Army after I graduated from dental school

I was fortunate to have a very good dental

internship at Fort Bragg in North Carolina

and then spent 2 additional years as a

Captain in the U.S Army Dental Corps

doing general dentistry at Fort McNair in

Washington DC

Why did you decide to focus on

endodontics?

Because of extensive exposure to oral

surgery in the military, I originally thought

of specializing in oral surgery However, as

I approached the end of my Army service,

I began to think about endodontics as I

enjoyed saving teeth over extracting them

I visited what was then the School of

Graduate Dentistry at Boston University

(BU) and met Dr Harold Levin He

eventually became a mentor and my

partner in practice We first met by chance

when I walked into the school, and he was

kind enough to take considerable time

to explain the school and the specialty

of endodontics to me I left that meeting

with tremendous excitement about the

possibility of having a career in endodontics

and training at BU Not long after that, I

was fortunate to have an interview with Dr

Herb Schilder That led to a residency at

BU, training under Dr Schilder and many

other talented and dedicated endodontists

who were teaching there at the time

What training have you

undertaken?

I received a Certificate in Endodontics

and a Masters of Science and served as

Associate Clinical Professor at the school

for many years I am a Diplomate of the

American Board of Endodontics (AAE)

I have served two terms as a Trustee to

the American Association of Endodontics

and am currently serving as a Trustee to

the American Association of Endodontics Foundation I am currently the managing partner of North Shore Endodontics and Brookline Endodontics in Boston and suburbs

It is my association with the AAE Foundation that has been a real eye opener

to me on the real world of endodontics I have seen that there is a tremendous need for endodontic teachers in all of the dental schools and an equally important need for research to further our understanding

of the biological and technical processes that affect the outcome of the care we deliver This revelation has only been topped by the fact that the Foundation funding to date has been a result of a tremendous outpouring of support from endodontists and from corporate partners who see the commitment our endodontist members make and value their judgment

The Foundation is the only organization exclusively dedicated to supporting endodontic research and education It provides support to every endodontic residency program in the U.S and Canada The Foundation provides over 1 million dollars yearly to support research and faculty positions in endodontics

Who has inspired you?

Dr Schilder was the best teacher I have

ever encountered He was exceptionally smart, very demanding, and capable of explaining complex concepts in a clear way His educational protocol allowed for little deviation from his prescribed technique I have realized the tremendous value of this approach on countless occasions in my career when faced with difficult diagnostic and treatment cases Herb knew that the oddities of anatomy and biology were looming out there By giving his residents a solid understanding

of diagnosis and disciplined treatment objectives, he equipped us for the real world of endodontic practice Herb trained clinicians in an era when the specialty of endodontics was just beginning to grow

Dr Schilder’s legacy continues at BU through the BU Endo Alumni Association, which provides a forum for all BU trained endodontists to collaborate

Tell us about your practice.

My career in practice began when I joined Dr Harold Levin and Dr Robert Rosenkranz Over many years together, we grew the practice to a multi-office, multi-doctor practice Both of those doctors have retired from practice, and I am now fortunate to have Dr Yuri Shamritsky and

Dr Fiza Singh as partners Together we have continued to grow the practice, which

Dr Peter A Morgan

PRACTICE PROFILE

Hard work and attention to detail lead to smooth sailing in endodontics

In sailboat racing and in practice, all members of the crew need to focus on every detail to get a good outcome

PRACTICE PROFILE

now includes six offices

Dr Yuri Shamritsky began his dental

career with a Doctor of Dental Science

from the University of Moscow In the

U.S., he continued his dental education

at Boston University Goldman School

of Dental Medicine where he received

a DMD and a Certificate of Advanced

Graduate Studies He served for over 10

years as Associate Clinical Professor and

Director of the Microendodontic Surgical

Program Yuri has inspired many students

by his dedication to precise microsurgical

techniques, and he has applied his skills to

resolve many problems for his patients in

our practice

Dr Singh received her Doctorate of

Dental Surgery from New York University

College of Dentistry She holds a Certificate

in Endodontics, a 3-year specialty

fellowship from The Harvard School of

Dental Medicine, and Masters of Medical

Sciences from Harvard Medical School,

including 2 years of research at The

Forsyth Institute Her specialized training

includes Oral Implantology and Oro-Facial

Musculoskeletal Pain/TMD Disorders

from the New York University College of

Dentistry Dr Singh is also board certified

in Endodontics in Canada, where she is

a member of the Royal College of Dental

Surgeons

We are also fortunate to have the

following doctors in our practice:

Dr Paul Talkov, who completed his

dental school at Tufts University and endo

residency at Boston University Goldman

School of Dental Medicine

Dr Andrea Shah, who completed her

dental school at Harvard University and

endo residency at Tufts University While a

resident, she was recipient of a Research

Grant from the AAE Foundation

Dr Andrew Bradley, who completed

his dental school at Tufts University and

endo residency at Boston University

Goldman School of Dental Medicine

We are very proud to have Dr Schilder

and Dr Joe William’s former practice,

Brookline Endodontics, as a part of our

current practice Many of the doctors in our

practice had the benefit of Dr Schilder’s

teaching during their training Continuing

his treatment philosophy in the office where

he practiced has been very professionally

rewarding for us

What is the most satisfying aspect

of your practice?

There are many aspects of Endodontic

practice that I find satisfying The most rewarding feeling by far is the satisfaction of meeting a patient with significant symptoms that are life-interrupting and reversing those symptoms quickly and painlessly Every endodontist experiences this, and I hope they all realize what a unique service it is

in the health care world It is very common

in our offices for an emergency patient to

be seen very soon after we get the call from his/her dentist Not long after that,

we complete the emergency treatment

At a subsequent appointment, the patient returns with gratitude for having had his/

her very significant problem resolved painlessly Patients benefit greatly from the skill of their endodontist, and the model of how we move patients between offices in response to patient need is a model that should be more frequently found in health care

Professionally, what are you most proud of?

I am very proud of our practice While I know that group practice is not for everyone, it has been a very favorable format for my partners and me Because we have a group of doctors, we have the opportunity

to share ideas and to collaborate on cases

Because we are bigger, we have more staff, and they also bring new ideas and capabilities to the table The biggest gains

in our business management have come about as a result of empowering our staff

members to take responsible roles in the practice We have a great team, and I am very proud of them

The leader of our staff team is our Practice Manager, Michele Whitley Michele and other staff members have taken an active role in continuing education

by presenting courses at the AAE Annual Session and at other CE venues Holly LeBlanc, another staff member, has served as a consultant to EndoVision

This involvement in the larger world of endodontics outside our practice walls empowers our staff to bring back to our practice innovative ideas they develop

in collaboration with colleagues at these educational sessions As AAE Annual Session chair some years ago, I stressed

Dr Andrew Bradley

Dr Morgan and two of his key team members, Cheryl Bennet-Delong and Jennifer Hamlett

Dr Andrea Chung Shah

Partners: Dr Yuri Shamritsky, Dr Fixa Singh, and

Dr Peter Morgan Dr Paul Talkov

PRACTICE PROFILE

the need to incorporate more staff

educational courses in our programs to

fulfill this objective

What is unique about your

practice?

I believe our practice is unique It was

started in Lynn, Massachusetts in 1962

by Dr Harold Levin At that time he was

the only endodontist between Boston and

Montreal, Canada That has changed of

course, and now there is competition for

almost every endodontist no matter where

they practice What makes us unique is our

multi-office format Because of this, while

we do face competition, we stay busy

in many locations The key to business

success is having a full appointment book

This is our way of helping that to be true

What systems do you use?

I have been fortunate to practice in the

time of the evolution of technology in

endodontics We all appreciate the teaching

and patient education advantage of digital

X-ray However, to really appreciate it, you

have to have worked for years with film As

I tell my patients, in the past I would look at

the little X-ray films and tell the patients that

they needed a root canal Now I enter the

room and the image is already on the big

monitor, and the patient often says to me,

“I guess I need a root canal.”

We started with Schick digital X-ray

in 1998 We made a big commitment to

equip all of our locations at that time It

was immediately very helpful clinically and

provided a “WOW factor” for patients as

they had never seen such a thing before

Dr Morgan and his team taking a break at the EndoVision booth, from presenting at the AAE Annual Session

in San Antonio

Our relationship with Schick continues today and has led us to an equally rewarding relationship with Sirona We followed the integration of digital X-ray with conversion to EndoVision and an Electronic Health Record (EHR) EHR is certainly the current standard for records, and we find it

to be essential for a multi-location practice

Because we have multiple doctors, we have loyalties to both Global and Zeiss operating microscopes, and surprisingly

we have all become comfortable with both More recently, we have opened our eyes even wider with the incorporation

of the Sirona XG3D CT scan machine

This technology has provided exceptional value to our patients by giving us more information than ever before from which

to make treatment decisions The XG3D

by Sirona provides a remarkably clear

5 cm X 5 cm focused field which is truly the current “WOW!” in 3D imaging The availability of this technology has enhanced our relationship with referring dentists because they repeatedly see the value of the informed treatment decisions we can make in retreatment, surgical, resorption, and unusual anatomy cases

My partner, Dr Shamritsky and I recently had the opportunity to attend a Sirona/Sicat opinion leaders conference in Bonn, Germany I was very impressed with the application of the XG3D CT technology

to the creation of surgical guides This has the potential for application in endodontics

as well as in implant placement and the creation of precision prostheses

Another recent addition to our practice

is a marketing tool, the Endofone App

This is essentially an electronic business card that uses smart phone technology

to inform our patients about our practice Accessed via a QR code, patients can instantly learn about us and get all of the essential information about us on their smart phone without having to go to the web site

These technologies help us, but I believe it is more important than ever for all endodontists to focus on true clinical skills There is a saying, “It is a poor carpenter who blames his tools.” Herb Schilder and many of the great early endodontists did not use a microscope or digital X-ray Yet they were instrumental in establishing many of the treatment methods we still use today They showed cases then that would rival any case done today with enhanced vision and rotary instrumentation I believe the future of endodontics will depend

on endodontists defining the value of consistent predictably successful cases for their patients If endodontics is defined

by equipment and technology, it will allow anyone with that equipment and technology to claim the high ground

What has been your biggest challenge?

I think the most successful practices are those that know how to change to meet the challenge of the changing market for our services The model used by my partner,

Dr Levin, when he started the practice, may not be the model for success today The single practitioner then had more patients than the doctor could manage They were often begging the endo department chairs to send them their next graduate Today’s single practitioners had better find an area in need of an endodontist,

or they will not have a busy schedule In addition, starting a practice today requires

Michele Whitley, practice manager and Dr Peter Morgan, managing partner

“The ASI Endodontic carts are a great convenience This space

saving design allows me to be organized and efficient with only one

foot control and without all of the cords draped over my counters.”

– Dr Kelly Jones

The Cart, With Only One Foot Control

The versatility of ASI’s custom integrated cart system

allows for infinite positioning of the cart

to easily maneuver within close reach

during procedures and then out of patient

view after procedures Adding a monitor

mount creates an intimate environment for

both patient education and clinical use.

Side Delivery

An ASI cart positioned at the doctor’s

dominant side requires the least amount of

tasking movements during a procedure and

works efficiently with microscope dentistry

Foot Control Placement

The foot control tubing of an ASI system can

be run underneath the floor through a conduit

from the junction box to the patient dental

chair The end result creates easy access to

the foot control without tubing running

across the floor

The Junction Box

In addition to attractively concealing the standard

connections of compressed air, suction and electricity,

ASI’s unique in-wall junction box allows computer

connections such as video, USB, network and other

IT connections throughout the office to be easily

organized and safely hidden from view.

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Achieve the Optimal Treatment Room with ASI

PRACTICE PROFILE

a much larger capital investment than

before the days of high-powered software

and technology This increases the risk of

a practice venture, and as a result, many

endodontists choose to avoid this risk and

work in the offices of general dentists, or

for corporate dental centers Naturally, this

puts more competitive pressure on the

more traditionally situated endodontist

Changing to meet these market realities

is challenging It requires constantly

adapting to meet the needs of the referring

dentists and their patients Having younger

endodontists in the practice helps us

adapt, as they have a closer understanding

of the needs and wishes of their peers

What advice would you give to

budding endodontists?

I have had the advantage of working with

young endodontists in our practice over the

years They have all taught me more than

I have taught them However, in general, I

would advise the young graduate to find a

mentor to reach out to when needed Also,

in challenging diagnostic cases, I would

advise remembering that you can almost

always wait a day to make a treatment

decision rather than making a decision

immediately that you may regret later

In talks to endo resident groups,

I always stress that success for any

endodontist requires you to make yourself

indispensable to the practice By this I

mean that it is essential to commit to an

“all in” approach The residents I see

who achieve the greatest success begin

by working hard in their training and in

their practice to continually improve their

clinical skills Then they must also learn

to integrate successfully into the group of

individuals they work with This is extremely

important as the daily challenge of practice

necessitates a team approach to be

successful Also, new doctors in a practice

need to recognize the absolute requirement

to grow the practice This means you,

the new person, need to become the

recognized established person in the

practice ASAP In addition, every doctor

in a practice must accept responsibility for

special projects This means recognizing

that there is more to being a successful

endodontist than just doing good cases

What are some tips for maintaining

a successful practice?

To help associates succeed, the partners

in a practice also need to work hard to

give them every opportunity to succeed In

our group, we schedule new doctors in a way to allow for them to meet patients and referring doctors at a reasonable pace We

do not require that all partners’ schedules are filled before associates get patients

on their schedule We invest a lot of time and energy in the process of selecting an associate and integrating him/her into the practice The new associates make a big commitment also Our goal is to give this combined effort the best possible chance for success

What would you have become if you had not become a dentist?

When I was making the final decision to

go on to dental school, I briefly considered going to law school I had minored in Political Science and had some good friends going on to law school In the end,

I decided that dentistry was right for me, and it has turned out to be a very satisfying career

Tell us some more about yourself

What are your hobbies, and what

do you do in your spare time?

When I came to Boston, in addition to finding Boston University and an area to practice, I also met my wife, Jessie Morgan

Jessie is an accomplished painter with a studio near our home Her abstract works can be seen in contemporary galleries, and

on her website Her paintings are held in corporate and private collections nationally and internationally I love that her abstract work is so different from what I do

I have come to love New England I am fortunate to live in a New England coastal community with a beautiful natural harbor

I became interested in sailboat racing and have spent many years competing

in one-design sailboat racing in this area

I learned that developing a competitive

Our practice continually strives to incorporate advanced technology, such

as the Sirona XG3D Cone-Beam CT machine shown above

team in sailboat racing has many parallels

to developing a successful practice team Both require dedicated talented individuals who are willing to work hard to achieve success And in both, others are trying to win too So, in order to win, you must pay attention to every detail

I often say to our doctors and staff at the office, “We want our patients to realize that they have been referred to the right place for endodontic care.” To accomplish this, we apply the same rule that I have used with my racing crew to prepare for a sailboat race Every detail is important and essential to give us the best opportunity for a good outcome In our offices, this

means that we will always strive to have everything from doctor and staff continuing education to incorporating the appropriate technology up to a very high standard And

it means that every contact with patients and every detail about our offices reflect our commitment to the highest standard of care By putting our patients first, we are

in essence putting our referring doctors first as well It is a simple but powerful philosophy

We appreciate the trust referring doctors put in our practice every time they refer a patient Our doctors and staff members work hard to exceed expectations so that the patients return with respect for their dentists for having referred them to us

• Endovision: Henry Schein Leading the way with practice management software for multi- office locations.

• Brasseler: Great products for endodontists.

• Endofone: An innovative new way to inform referred patients and referring dentists.

EP

This EHR Module is 2011 compliant and has been certified by an ONCDATCB in accordance with the applicable certification criteria adopted by the Secretary of Health and

Human Services This certification does not represent an endorsement by the U.S Department of Health and Human Services or guarantee the receipt of incentive payments.

You might have the slickest looking offi ce in town, but is your software still from the Stone Ages? At TDO,

we believe you deserve a software system that helps your practice grow, not one that gets in your way.

TDO Software allows you to provide the best possible patient care Only TDO enables your staff to be their

best by eliminating time-wasting ineffi ciencies in the offi ce TDO makes it easy to keep current with the

latest technology, terminology, materials and techniques With TDO

you can create professional-looking referral and CBCT reports and

print, email or publish them on your website with just one click.

Take your practice out of the museum and into the

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ARE YOU A DINODONTIST?

With roots that can be traced back to

the 19th century, Carestream Dental

certainly has a long history of innovation

when it comes to dental specialties —

including endodontics This legacy carries

on still, as the company continues to

develop imaging systems and software

and enter new markets It’s because of

this proud tradition that more than 800

million images are captured each year on

products from the company’s imaging

portfolio Today, Carestream Dental is

focused on providing endodontists with the

products they need to facilitate treatment

planning and improve patient care

History of Carestream Dental

The Carestream Dental of today was

built on the shoulders of major industry

leaders of the past — starting in 1896

when Eastman Kodak introduced the first

photographic paper designed specifically

for dental X-rays As technology improved

and became more digitalized, Trophy

Radiologie filed a patent for the world’s

first digital intraoral sensor in 1983 Already

known for producing intraoral X-ray

generators, the digital intraoral sensor

earned Trophy a reputation as the world’s

leader in dental digital radiography

In 2000, PracticeWorks emerged as a

dominant dental software company when it

acquired several other software companies

PracticeWorks went on to acquire Trophy

Radiologie in 2002, and was purchased

the next year by Eastman Kodak to expand

their presence in the dental business With

the integration of PracticeWorks/Trophy,

Eastman Kodak built the industry’s leading

portfolio of film, digital imaging systems,

and practice management software Then,

in 2007, Onex Corporation purchased

Kodak’s Health Group, and Carestream

Dental was born

The Carestream Dental Factor

“We exist to make your practice better,”

said Marc Gordon, Carestream Dental’s

General Manager, U.S Equipment and

Software “Our number one goal is to make

user-friendly, yet sophisticated, technology

to put our customers’ practices at the forefront.”

Carestream Dental’s dedication to advancing endodontics can be summed

up by the Carestream Dental Factor; three pillars on which the company bases all of its products and services Incorporating the key elements at the heart of Carestream Dental’s philosophy, the company’s main focus is on delivering workflow integration, humanized technology, and diagnostic excellence

Workflow integration: Administrative

tasks cut into time that can be better spent communicating with and treating patients

For this reason, Carestream Dental designs systems and software to enhance treatment planning and fit seamlessly into busy endodontic practices Ensuring that every link in the chain fits and contributes to the workflow as a whole allows endodontists

to increase productivity and efficiency

Intuitive technology and software are the hallmarks of Carestream Dental

By developing imaging systems that can

be quickly utilized by practitioners — and easily integrated with leading third-party endodontic practice management software, such as TDO — users can eliminate time that would have been spent troubleshooting problems and instead focus on patients

Humanized technology: Patients are an

integral part of every endodontic practice,

so Carestream Dental is committed

to providing solutions that facilitate communication between the endodontist and patient When communication is optimized, patients are happier and healthier — allowing them to make better, more informed decisions regarding their proposed treatment plan and, in turn, increasing case acceptance

Diagnostic excellence: When evaluating

canal morphology and endodontic pathology, details are everything To facilitate faster, more reliable treatment planning, Carestream Dental has created

a number of cutting-edge diagnostic tools that enable endodontists to capture sharp, high-quality images quickly From industry-leading 3D imaging systems to high-resolution intraoral sensors, Carestream Dental offers a range of solutions that allow endodontists to identify areas of concern and determine the best course of action

Technology developed for cians, by clinicians

clini-The Carestream Dental Factor isn’t the only thing driving user-focused and innovative products and services — the clinicians at the heart of the company also play a large role Through meetings and forums with doctors in the field, Carestream Dental

CORPORATE PROFILE

A history of proven technology, a future dedicated to innovation

Endodontic clinical image captured with an RVG 6100 sensor

RVG 6100 sensor

CORPORATE PROFILE

is better able to understand the needs of endodontists in order to develop — and modify — products In fact, the voice of the customer (VOC) is critical throughout the development process

To ensure quality, Carestream Dental also manages every aspect of the products they develop “By controlling each step

in the process — from development and manufacturing all the way to support — we make it easier for endodontists to deliver better patient outcomes,” said Mr Gordon

Innovative products to facilitate endodontic treatment planning

Endodontists require high-resolution images to evaluate the morphology of the dental pulp and view the most intricate details of canals — something that Carestream Dental certainly delivers The following is just a sample of the imaging products Carestream Dental has designed

to meet the specific needs of endodontic practices:

CS 3D Imaging Software: Included

with Carestream Dental’s CBCT imaging units, CS 3D Imaging software allows practitioners to view images slice by slice

in axial, coronal, sagittal, cross-sectional, and oblique views to enhance diagnostic interpretation In addition, the images can

be saved to a CD/DVD or USB drive with

a complimentary copy of the software to share with the referring doctor — improving the colleague collaboration process

RVG 6100: With greater than 20 lp/

mm resolution per image, Carestream Dental’s RVG 6100 sensors deliver the highest image resolution in the industry

Each sensor undergoes rigorous testing to provide maximum durability and flexibility, and the RVG 6100 features a rear-entry cable, three different sizes, and rounded corners to improve comfort for patients and make positioning easier for users

Comprehensive education

When endodontists understand how to fully maximize their imaging capabilities, they are better able to get the most of out of their equipment For this reason, Carestream Dental is committed to providing thorough training and education

to ensure their customers have the skill and knowledge necessary to use their imaging products and software

In addition to providing web-based and in-person training, Carestream Dental holds 3D symposiums, where practitioners can learn how to use 3D imaging equipment in their daily practice This event

features leaders in the industry who share advice and insights, as well as information

on the latest industry trends in 3D, to make participants’ practices more efficient and successful

Next steps

With the launch of CS Solutions, a appointment CAD/CAM restoration system, Carestream Dental will once again enter an entirely new market — and it certainly will not be the last As an integrated, open-architecture system, practitioners can scan

one-an impression with a CBCT unit or scone-an the patient’s mouth directly with the CS 3500 intraoral scanner, design the crown, inlay,

or onlay using the CS Restore software, and mill the crown in-office with the CS

3000 milling machine For doctors who would rather send the design or milling off to the lab, they can easily submit the information electronically to their dental lab

Mr Gordon

To learn more about Carestream Dental’s portfolio of imaging products and software for endodontic practices, please call 800-944-6365 or visit carestreamdental.com today

This information was provided by Carestream Dental.

Root resorption image as seen on Carestream Dental’s 3D Imaging software

EP

CS 9000 3D

RVG 6100 sensor

As early as 1995, the study conducted

by Ray and Trope confirmed the

relevance of a good post-endodontic

restoration for the successful preservation

of teeth where the root canals have been

treated In today’s age of adhesive dentistry,

considerable importance is awarded to

preventing “leakage” and, accordingly, the

risk of reinfection of the canal system (Fox,

Gutteridge, 1997) The post-endodontic,

adhesive core build-up with simultaneous

glass fiber post luting satisfies both of

these indispensable requirements for a

certain long-term prognosis of severely

damaged teeth

The Rebilda Post system from

Voco offers a user-friendly concept in an

optimally coordinated set, featuring all the

necessary components

Up-to-date post treatments

The consensus today is that a root post

is used to retain the coronal build-up

and, consequently, for creating sufficient

retention The degree of coronal dental

hard tissue loss and the expected loads

on the tooth determine the type of

post-endodontic treatment on a case-by-case

basis

In cases of low to medium levels of

destruction, treatment with a plastically

processed composite without

post-retained build-up is usually indicated If the

clinical crown displays severe substance

loss, a post construction system should

be employed to guarantee secure retention

(taken from the shared scientific opinion

of the German Academic Association

of Dentistry, the German Association of

Prosthodontics and Dental Materials, and

the German Association of Dentists in

‘Aufbau endodontisch behandelter Zähne’

(2003) [English translation: Build-up of endodontically treated teeth])

A dentin margin of no less than 2 mm width is later prepared apical to the build-

up in the so-called “ferrule design” in order

to increase fracture resistance (Hemmings,

et al., 1990; Torbjörner, Karlsson, Ödman, 1995) Root canal posts affixed with adhesives allow consistently minimally invasive preservation of intact dental hard tissue, whereby retentive areas in the region of the build-up can also be used as additional retentive surfaces

In contrast to metal, zirconium and carbon posts, glass fiber-reinforced composite root posts display biomechanical behavior similar to that of dentin Thanks to their dentin-like elasticity, arising forces can be distributed over the surrounding tooth substance without the development of punctiform force peaks

in the root as in the alternatives named above The physiological distribution of the forces, to apical and coronal, of the total adhesive composite of glass fiber, build-up composite, and preserved tooth substance reduces the risk of fractures

Systematic adhesive core build-up

CLINICAL

Dr Ludwig Hermeler presents a clinical case using the Rebilda Post system

Figure 1: The Rebilda Post system (Voco) in its practical drawer insert

Ludwig Hermeler, Dr med dent, established

his practice in Rheine, Germany, in 1991 He

is licenced to practice medicine and gained

his doctorate in 1988 at the Westfälische

Wilhelms-Universität Münster He has

national and international publications in the fields

of endodontics, esthetic dentistry, bleaching, and

implantology He is a member of the German Association

for Oral Implantology (DGOI) and International Congress

of Oral Implantologists (ICOI).

Figure 2: X-ray taken prior to removal of telescopic tooth LR4

The Rebilda Post system

The Rebilda Post system fits in dental

cabinets as a complete drawer insert

(Figure 1) and contains all the necessary

components for stable, coronal build-ups –

with or without a root post – in a maximum

of five steps: dual-curing Rebilda® DC

as a luting and build-up composite;

Futurabond® DC as a dual-curing

self-etch bond; Rebilda Post, the glass

fiber-reinforced composite root post with the

precisely coordinated pilot and root canal

drills, and Ceramic Bond, a coupling silane

that strengthens the bond between Rebilda

DC and Rebilda Post

Voco has complemented the existing

post sizes of 1.2 mm, 1.5 mm, and 2.0

mm diameters with the new 1.0 mm post

size As a result, the available range is now

perfectly suited to treating all anatomical

root canal sizes safely and with minimal

substance loss

Clinical case

The patient is a 75-year-old male The

telescopic tooth LR4 (Figure 2) was

extracted and a curved clip placed on

tooth LR3 (Figure 3) as an interim solution

Following adequate healing of the wound,

the terminal tooth LR3 should be furnished

with a telescopic crown and the existing

restoration suitably reproduced on the

right-hand side Tooth LR3 is extensively

filled on all sides, and its loading as a

terminal abutment tooth is not insignificant

Consequently, it is equipped with a glass

fiber post for the fixation of the adhesive

build-up After application of a rubber dam,

removal of the fillings and a check with

Caries Marker (Voco), it becomes evident

that the remaining healthy substance

requires an adhesive, preprosthetic

restoration (Figure 4)

Tooth LR3 was treated with a root

canal filling in 2001, subjected to regular

X-ray controls ever since, and has not

displayed any symptoms at all over the

whole period Following removal of the

root canal filling using a Gates-Glidden bur

to achieve the planned depth, precision

drilling is performed with the drill from the

system corresponding to the respective

post size (Figure 5)

The X-ray image for measurement

is performed with the Rebilda Post drill

with a diameter of 2 mm (Figure 6) The

image displays the correct fit with apical

preservation of the root canal filling of

approximately 5 mm Optimal drilling

performance is ensured by intermediate

Figure 3: Initial clinical situation following extraction of telescopic tooth LR4 with already accordingly expanded partial prosthesis

MADE IN THE U.S.A

Figure 4: Healthy remaining substance of tooth LR3 prior

to adhesive build-up Figure 5: Preparation of post canal with the drills of the Rebilda Post system

cleaning of the canal and the drill by rinsing

away dentin remnants

The Rebilda Post is cleaned with

alcohol before the trial insertion During the

position check in the mouth, the root post

fills the canal precisely without becoming

wedged (Figure 7) The post is shortened

to the required length extraorally using a

fine-grain diamond (not forceps or scissors

due to the risk of delamination) The glass

fiber post is cleaned again with alcohol,

dried, and silanized for 60 seconds with

the Ceramic Bond included in the system

(Figure 8) before being dried with oil-free air

again Prior to the adhesive luting, the root

canal is rinsed out with water and dried

using paper points

Futurabond DC is activated by

pressing on the marked area of the Single

Dose and then mixed by piercing the film

and making circular movements with the Single Tim (Figure 9)

The self-etch bond is rubbed into the canal with the fine Endo Tim (Figure 10) and over the rest of the tooth surface with the Single Tim for 20 seconds, the solvent dried with oil-free air for seconds, and any excess liquid in the channel removed using paper points A shiny bonding layer

is created, which is not light-cured

Rebilda DC is introduced directly into the root canal using the thin, pliable application tip of the Quickmix syringe (Figure 11), starting apically and keeping the cannula tip emerged in the luting composite throughout the application

The Rebilda Post is inserted with a rotary movement, with small amounts of excess material being forced out in the process

Light-curing is performed for 40 seconds to

fix the post (Figure 13), and then additional Rebilda layers are applied The core build-

up can then be light-cured for a further 40 seconds per layer; the chemical curing takes 5 minutes

Thanks to its consistency, Rebilda

DC is easy to apply, and Voco also offers shaping aids for designing the build-up, which can be individually cut to size for the tooth shape using scissors The build-up is also easy to process thanks to the dentin-like hardness of Rebilda DC Figure 14 shows the prepared tooth; the preparation employs the ferrule effect in order to stabilize the abutment tooth and the subsequent restoration The high radiopacity of Rebilda Post impresses in the X-ray image, and it is clear that the post and build-up composite form a homogeneous, adhesive build-up block (Figure 15) The functionality of the

Figure 6: X-ray image for measurement with Rebilda Post

Figure 11: Introduction of composite Rebilda DC (Voco)

with the pliable application tip of the Quickmix syringe Figure 12: Introduced Rebilda Post with excess composite forced out in the process Figure 13: Fixation of the post via primary light-curing for 40 seconds

telescopic restoration, expanded with the telescopic LR3 and then rebased, and the familiar wearing comfort are restored for the patient (Figure 16 and 17)

Conclusion

Modern composites and adhesive systems are of decisive importance for long-term tooth conservation in the post-endodontic treatment of severely damaged teeth

Voco’s Rebilda Post system is a sophisticated, optimally coordinated, and complete set with materials that satisfy the high requirements for a stress-free, coronal build-up with a root post

Figure 14: Finished, prepared tooth with Rebilda Post and

Rebilda DC build-up

Figure 15: X-ray image of the homogeneous adhesive

build-up block

Figure 16: Inserted telescopic crown tooth LR3

Figure 17: The restored telescopic restoration

REfEREncEs

Fox K, Gutteridge DL An in vitro study

of coronal microleakage in treated teeth restored by the post and core

root-canal-technique Int Endod J 1997;30(6):361-368.

Hemmings KW, King PA, Setchell DJ

Resistance to torsional forces of various

post and core designs J Prosthet Dent

1991;66(3):325-329

Ray HA, Trope M Periapical status of endodontically treated teeth in relation to the technical quality of the root filling and the

coronal restoration Int Endod J 1995;28(1):

This case presented with periapical

radiolucencies and external root resorptions

in maxillary incisors, tooth Nos 11, 12, 21,

22 (FDI) To determine the exact extent

of the lesions, as periapical radiographs

tend to underestimate the size of the

resorptive lesions, cone beam computed

tomography (CBCT) was performed

Revision of root canals was performed and

nonsurgical management initiated using

mineral trioxide aggregrate (MTA) [Dentsply

Maillefer Ballaigues, Switzerland] and

thermoplasticized gutta percha (Obtura,

Obtura Spartan® Endodontics)

Follow-up radiographs after regular intervals

showed healing of the periradicular tissues,

demonstrating the effectiveness of MTA as

a clinical filling material of choice

Introduction

The management of endodontic problems

is reliant on radiographs to assess the

anatomy of the tooth and its surrounding

anatomy Such radiographic images have

inherent limitations, the major limitation

being the lack of the three-dimensional

nature of the radiographs and masking

of areas of interest by overlying anatomic

(anatomic noise), which are of relevance

in endodontics (S Patel, 2009)

Resorptive defects are challenging

to diagnose correctly, which may result in

inappropriate treatment being carried out

(Chapnick L,1989) Cone beam computed

tomography reconstructed images have been successfully used in diagnosis and

management of resorptive lesions (Maini A, Durning P, Drage N, Resorption 2008) It

is able to reveal the true nature and exact location of the lesion, determine the “portal

of entry” of the resorptive lesion, and also reveal previously undetected resorptive lesions (Cohenca N, Simon JH, Marthur

A, Malfaz JM, 2007) Root resorption is inhibited by the protective unmineralized innermost pre-dentin and outermost pre-cementum surfaces of the root (Lindskog S, Blomlof L, Hammarstrom

L, 1983) Channels extend into dentin and interconnect within the periodontal ligament As the lesion advances, bone-like material (replacement resorption) might also become deposited within the lesion and also in direct contact with the adjacent dentin; this indicates that the lesion is not destructive but attempting to repair itself (Shanon Patel, Shalini Kanagasingam, Thomas Pitt Ford, 2005) Few studies have determined the ability of cone beam computed tomography to improve diagnosis of root resorptive lesions

Management of root resorptive lesions in maxillary

incisors using computed tomography and MTA:

Anil Dhingra, BDS, MDS, FAGE, is a Professor in the

Department of Conservative Dentistry & Endodontics,

Subharti Dental College, Subharti University, Meerut,

India Dr Dhingra can be reached at anildhingra5000@

yahoo.co.in

Marisha Bhandari, BDS, is from the Post Graduate

Department of Conservative Dentistry and Endodontics,

Subharti Dental College, Subharti University, Meerut,

India

Figure 3 Figure 4

Figure 5

Case report

A 30-year-old male patient reported to

the Department of Conservative Dentistry

and Endodontics, Subharti Dental College,

Meerut, Uttar Pradesh, India with the

chief complaint of pain and mobility in the

upper anterior tooth region for the past

12 months The patient’s medical history

was noncontributory The patient reported

trauma to his upper anterior teeth more

than 15 years ago, for which root canal

treatment was performed On examination,

it was observed that tooth Nos 11, 12, 21,

22 (FDI) were tender on percussion, with

Grade II mobility in relation to tooth Nos

11 and 21 (FDI) with no discoloration

Radiographic examination revealed

incomplete root canal treated teeth with

overextended obturation and multiple

periradicular lesions in relation to tooth

Nos 11, 12, 21, 22 (FDI) [Figure 1]

In order to determine the extent and

depth of the lesion in three spatial levels, we

decided to opt for CBCT imaging in relation

to the maxillary anterior tooth region

Based on the CBCT images and

three-dimensional reconstruction, a diagnosis of severe external root resorption in relation to tooth Nos 11, 12 and periradicular lesions

in relation to tooth Nos 11, 12, 21, 22 (FDI) was determined (Figures 2 and 3)

The patient was informed of the diagnosis, treatment plan alternatives, and prognosis of the case An informed consent was obtained from the patient, and nonsurgical root canal therapy was initiated

On the basis of tomography findings, revision of root canal was carried out using ProTaper® Retreatment files D1, D2, D3 (Dentsply Maillefer, Ballaigues, Switzerland) [Figures 4, 5, 6, 7] The root canals were cleaned and shaped using the ProTaper system (Dentsply Maillefer, Ballaigues, Switzerland) Tooth Nos 11 and 12 (FDI) were cleaned and shaped

up to a F5 ProTaper (Dentsply Maillefer, Ballaigues, Switzerland) Tooth Nos 12 and 22 were cleaned and shaped up to F3 ProTaper (Dentsply Maillefer, Ballaigues, Switzerland) Intracanal irrigation was performed with 1ml 1.25% sodium

Figure 6

hypochlorite in between every instrument, and two final irrigations of 1ml 17% EDTA, followed by 1.25% NaOCl were performed before drying the canal with paper point (Dentsply Maillefer Ballaigues, Switzerland).The canals were obturated

Maillefer, Ballaigues, Switzerland), to obtain an apical stop of 5-6 mm with some extrusion of the material apically The apical stop method involved size 50 MAF with 5/7 endodontic pluggers After drying the coronal aspect of the MTA plug with paper points, the canals were further obturated with thermoplasticized gutta percha, Obtura (Obtura Spartan Endodontics) and the sealer

Ballaigues, Switzerland) was restored with composite An X-ray film was recorded, which showed that the resorptive defects were filled with MTA (Dentsply Maillefer, Ballaigues, Switzerland) [Figures 8, 9,

10, 11] An occlusal radiographic film recorded after a 2-month, 6-month, and 12-month interval showed the teeth had

CASE STUDY

remained completely asymptomatic, and

the periapical lesion showed healing or

healing in progress of the lesion present at

the beginning of the treatment procedure

(Figures 12-18)

Discussion

Root resorption in this case may have

been produced by the trauma to the

teeth reported by the patient during his

childhood and due to incomplete root canal

therapy Root resorption is the loss of hard

tissue (i.e., cementum and dentin) as a

result of odontoclastic action Cone beam

computed tomography appears to be a

promising diagnostic tool for confirming the

presence, appreciating the true nature, and

managing external root resorption (Shanon

Patel, Shalini Kanagasingam, Thomas

Pitt Ford, 2005) As with CBCT, a

three-dimensional volume of data is acquired

in the course of a single sweep of the

scanner, using a simple, direct relationship

between the sensor and source, which

rotates synchronously 180-360 degrees

around the patient’s head The X-ray

beam is cone-shaped (hence the name of

the technique) and captures a cylindrical

or spherical volume of data This has an

advantage of reducing the patient radiation

dose The radiographic outcome of root

canal treatment is more successful when teeth are treated and obvious radiographic signs of periapical disease are detected (S Patel, 2009) Thus, earlier identification

of periradicular radiolucent changes with CBCT may result in earlier diagnosis and more effective management of endodontic disease (Cotton TP, Geisler TM, Holden

DT, et al., 2007) In situations where patients have poorly localized symptoms associated with an untreated or previously root treated tooth and clinical and periapical examination show no evidence

of disease, CBCT may reveal the presence

of previously undiagnosed pathosis

CBCT images are geometrically accurate (Murmulla R, Wortche R, Muhling J, et al., 2005) and the problem

of anatomical noise seen with periapical eliminated Serial sets of linear and volumetric measurements obtained with CBCT technology could therefore be used

to provide a more objective and accurate representation of osseous changes (healing) over time (Pinky HM, Dyda A, et al., 2006) Future research may show that periapical tissues, which appear to have

“healed” on conventional radiographs, may still have signs of periapical diseases when imaged using CBCT (S Patel, 2009)

Figure 11 Figure 12 Figure 13

Figure 14 Figure 15 Figure 16

Figure 17

Figure 18

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© 2013 Obtura Spartan Endodontics The 3 free tips included with a purchase of the Spartan Wave are the BUC 1, BUC 3, and CPR 4 and will be shipped with the unit See instructions for use Rx Only Products may not be available in all areas Please contact your Obtura Spartan Endodontics Sales Representative for availability and

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CASE STUDY

Mineral trioxide aggregrate has

emerged as a reliable bioactive material

with extended applications in endodontics

that include the obturation of the root

canal space It provides an effective seal

against dentin and cementum, and also

promotes biologic repair and regeneration

of the periodontal ligament The chemical

composition of MTA was determined by

Torabinejad, et al The material consisted

of fine hydrophilic particles, and the main

components were tricalcium silicate,

tricalcium aluminate, tricalcium oxide, and

silicate oxides Bismuth oxide acts as a

radiopacifier They declared that calcium

and phosphorus were the main ions in

MTA (Hashem Ahmed Adel Rahman, et al.,

2008) It appears that teeth obturated with

MTA might not only increase their fracture

resistance with time, but bacteria might

be effectively entombed and neutralized

in severely infected teeth Unsuccessful

root canal treatments compromised by

microleakage, large periapical lesions,

perforations, and inadequate cleaning

and shaping can demonstrate superior

healing rates when this osteoinductive and

cementogenic material is used to restore

the root canal system

MTA provides an effective seal against

dentin and cementum and also promotes

biologic repair and regeneration of the

periodontal ligament It not only fulfills the

ideal requirement of being baceriostatic,

but might have potential bactericidal

properties The release of hydroxyl

ions, a sustained high pH for extended periods, and the formation of a mineralized interstitial layer might provide a challenging environment for bacterial survival The cured cement creates a potentially impervious seal that might be difficult for microorganisms to penetrate This unique sealing property, combined with an initially high pH that increases to 12.5 after curing, might provide a suitable mechanism for bacterial entombment, neutralization, and inhibition within the canal system These factors are important when considering nonsurgical patients with large periapical lesions associated with initial root canal treatment or in cases presenting with refractory endodontic disease diagnosed for retreatment (George Bogen, et al., 2009) There are many factors involved

in the healing of periapical lesions, such as the apical limit of root canal instrumentation and obturation (Riccuci D, Langeland K, 2005) and follow-up time (Leonardo MR, Barnett F, Debelian G, et al., 2007) It is necessary to perform further recall in this case to confirm total healing of the lesion

Estrela, et al., tested the reliability of

a periapical X-ray film, and the images obtained by CBCT to detect periapical lesions; they found that the best results were obtained with the CBCT group

In the clinical case presented here,

we observed that the extent of resorption could not be detected in conventional X-ray film, hence, the need for the use of CBCT

Conclusion

Cone beam computed tomography technology is improving at a rapid pace It overcomes most of limitations of intraoral radiography The increased diagnostic data should result in more accurate diagnosis and monitoring, and therefore, improved decision making for the management

of complex endodontic problems It is a desirable addition to the endodontist’s armamentarium When indicated, three-dimensional CBCT scans may supplement conventional two-dimensional radiographic techniques, which at present have higher resolution than CBCT images In this way, the benefits of each system may be harnessed

In this case, the patient tried to save his teeth and accepted the treatment accordingly Twelve months after treatment, the teeth were asymptomatic, there was no periapical radiolucency, and the conventional X-ray film showed healing

or healing in progress of the periapical lesion present at the beginning of the treatment procedure

Acknowledgement

The authors thank Dr Shibani Grover, Professor and Head of the Department, Department of Conservative Dentistry and Endodontics, Subharti Dental College, Meerut, India for her eminent support and guidance

REfEREncEs

Patel S New dimensions in endodontic imaging: Part

2 Cone beam computed tomography Int Endod J

2009;42(6):463-475.

Chapnick L External root resorption: an experimental

radiographic evaluation Oral Surg Oral Med Oral

Pathol 1989;67(5):578-582.

Maini A, Durning P, Drage N Resorption: within

or without? The benefit of cone-beam computed

tomography when diagnosing a case of an internal/

external resorption defect Br Dent J

2008;204(3):135-137.

Cohenca N, Simon JH, Mathur A, Malfaz JM Clinical

indications for digital imaging in dento-alveolar trauma

Part 2: root resorption Dent Traumatol

2007;23(2):105-113.

Lindskog S, Blomlöf L, Hammarström L Repair

of periodontal tissues in vivo and in vitro J Clin

Periodontol 1983;10(2):188-205.

Patel S, Kanagasingam S, Pitt Ford T External cervical

resorption: a review J Endod 2009;35(5):616-625.

Cotton TP, Geisler TM, Holden DT, Schwartz SA,

Schindler WG Endodontic applications of cone-beam

volumetric tomography J Endod 2007;33:1121-1132.

Marmulla R, Wörtche R, Mühling J, Hassfeld S

Geometric accuracy of the NewTom 9000 Cone Beam

CT Dentomaxillofac Radiol 2005;34(1):28-31.

Pinsky HM, Dyda S, Pinsky RW, Misch KA, Sarment

DP Accuracy of three-dimensional measurements

using cone-beam CT Dentomaxillofac Radiol

2006;35(6):410-416.

Patel S New dimensions in endodontic imaging: Part

2 Cone beam computed tomography Int Endod J

Bogen G, Kuttler S Mineral trioxide aggregate

obturation: a review and case series J Endod

2009;35(6):777-790.

Estrela C, Bueno MR, Leles CR, Azevedo B, Azevedo

JR Accuracy of cone beam computed tomography and panoramic and periapical radiography for detection of

apical periodontitis J Endod 2008;34(3):273-279.

Ricucci D, Langeland K Apical limit of root canal instrumentation and obturation, part 2 A histological

study Int Endod J 1998;31(6):394-409

Holland R, Mazuqueli L, de Souza V, Murata SS, Dezan Júnior E, Suzuki P Influence of the type of vehicle and limit of obturation on apical and periapical tissue response in dogs’ teeth after root canal filling with

mineral trioxide aggregrate J Endod

2007;33(6):693-697

Leonardo MR, Barnett F, Debelian GJ, de Pontes Lima RK, Bezerra da Silva LA Root canal adhesive fillings in dogs’ teeth with or without coronal

restoration: a histopathological evaluation J Endod

2007;33(11):1299-1303

American Association of Endodontists Appropriateness

of care and quality assurance guidelines of the American Association of Endodontists Chicago, IL:

1994.

Holland R, Sant’Anna Júnior A, Souza Vd, Dezan Junior

E, Otoboni Filho JA, Bernabé PF, Nery MJ, Murata

SS Influence of apical patency and filling material on healing process of dogs’ teeth with vital pulp after root

canal therapy Braz Dent J 2005;16(1):9-16

EP

DENTSPLY MAILLEFER / T: 1-800-924-7393 / F: 1-800-924-7389 / MAILLEFER.DENTSPLY.COM

©2013 DENTSPLY International, Inc., DENTSPLY Maillefer MAIADDAL06/13

Sharpen Your Root Canal Visibility

Introducing the new Detect™ Apex Locator from Maillefer.

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• Latest multi-frequency technology enables location of the apex in most types of canal conditions

This is the article that brings the previous

eight together, starting with knowledge

of the anatomy of the root canal system

The primary purpose of root canal

preparation is the removal of all vital and

necrotic tissue, microorganisms and their

by-products from the root canal system

This involves opening up the canal or

canals to allow irrigants to reach as much

of the root canal system as possible It

also permits shaping of the canal(s) to

facilitate obturation (Figure 1) Many of the

problems that clinicians experience with

obturation are in fact due to incorrect canal

preparation

Canal preparation is the area of

endodontics that has gone through the

most significant change in the last 20

years The nickel-titanium revolution has

made canal preparation so much easier,

faster, and more predictable Since the

introduction of the first rotary files, there

have been many developments that have

reduced the number of files required and

made the process more efficient Two of

the latest rotary file systems Reciproc®

(VDW, Munich, Germany) and WaveOne®

(Dentsply Tulsa Dental Specialties) claim

that canals can be prepared with just one

rotary file, and the Reciproc technique even

claims that the use of hand files to prepare

a glide path is not necessary Another, the

Self Adjusting File (ReDent Nova, Ra’anana,

Israel) prepares the canal wall by adjusting

itself to the contours of the canal This is an

interesting concept, and recent research

shows encouraging results.1

Like with everything else in life that

claims that one-size-fits-all, there are those

situations where the claims can be borne

out, and those where they cannot, and it

is important to understand the difference

Root canals come in all shapes and sizes,

from the immature central incisor with an

open apex to the severely curved canal, to the sclerosed canal that is only apparent

in the middle third of the root They all require a different approach, and this is what makes endodontics so challenging

Hand instrumentation is as important as

it ever was, although nowadays instead

of being used to prepare the whole canal, hand instruments are used predominately

at the beginning to create a glide path and towards the end of preparation to gauge the size of the apical preparation

The cleaning and shaping objectives are as follows:

• maintain the position of the foramen

practicable

Creation of a glide path

This is one of the most critical parts

of the preparation sequence With large canals, it is not a challenge, but with curved and sclerosed canals, blockages and ledges are either naturally present,

or can all too easily be created even with the first instruments introduced into the canal Once the canal entrance has been identified, a small K file (my preference is for a size 10 Maillefer FlexoFiles®) should

be introduced through a well of sodium hypochlorite and gently advanced into the canal to about two-thirds of the estimated length If any resistance is encountered, then smaller files, size 08 or even 06, should be used, and once these files move freely, then the size 10 is reintroduced

There are many techniques associated with different rotary file systems, and the recommended sequence of instrumentation should always be followed

In an article of this nature, it is impossible

to give precise advice for every situation that may be encountered, however, there are some basic principles that should be followed

Top ten tips:

Tip number 9 - Preparation techniques

ENDODONTICS IN FOCUS

Continuing his series on endodontics, Dr Tony Druttman shows the importance of preparation

Tony Druttman, MSc, BChD, BSc, is an

endodontist working in central London He

is also a part-time teacher at the Eastman

Dental Institute, University of London, and

lectures in the UK and abroad.

Figure 1: Ideal preparation shape

Figure 2: Creation of a zip by incorrect preparation techniques

Figure 3: Patency filing

Hand instruments should be used

delicately The tactile sense in the fingers

is very refined, and with practice, it should

be possible to read the canal Placing a

gentle curve at the tip of the file will often

overcome a ledge Excessive force is likely

to ledge the canal further In curved canals,

an apical zip, or even a perforation, can

be created as successively larger files are

“screwed” into the canal in an attempt to maintain working length (Figure 2) The balanced force technique should be used

This requires the following sequence:

• Place the file into the canal and turn it 90 degrees clockwise, using light pressure

• Turn the file 120 degrees counterclockwise using firm apical pressure – this advances the file into the

Figure 4: Apical delta obturated

because patency filing was used

in the preparation

Figure 5: Mtwo® (VDW, Munich, Germany) nickel-titanium files 10/04-25/06

canal and cuts the dentin

• Turn the file clockwise in the canal without pressure to clean the canal

Patency filing

This technique is predicated on the concept that the apex of the canal should be kept open to allow irrigants to reach the apex

of the root, rather than creating an apical

Figure 7: Although the distal canals of this lower molar have been cleaned, the isthmus has not

Figure 6: Preparation of curved canals using the Mtwo rotary system

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files adapt perfectly to the canal path These balanced

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the canal dramatically reduce ledging and

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ENDODONTICS IN FOCUS

stop and blocking the terminus with dentin

chips (infected or otherwise) [Figures 3

and 4] The patency file (size 10) should be

introduced no further than 1 mm beyond

the working length and should be used at

intervals in the preparation sequence to

ensure that the apical constriction has not

been blocked with debris

Apical gauging

The question, “What is the ideal size of

the preparation?” is one that will be hotly

debated for a long time to come Some

of the literature recommends larger apical

sizes with a less tapered preparation,2 while

other papers recommend smaller apical

sizes and greater tapers.3 The decision

will often depend on a variety of factors

including the canal geometry, not only the

dimensions, but the angle and radius of

curvature Another factor is the irrigant and

irrigation technique I have recommended

in the previous article on irrigation, that it

is important that the irrigant penetrates as

far as possible into the root canal system

Once the canal has been prepared to a

considered optimal size, for example with

a size 25 rotary file with an 06 taper to the

working length, a size 30 hand file (with an

02 taper) is placed gently into the canal If

resistance is met approximately 1 mm from

the working length, then it should not be

necessary to prepare the canal to a larger

size If it reaches the working length without

resistance, then the master apical file size

(the final size of file that is used to working

length) should be increased

Which rotary file system is best?

There is no best system for everyone This

is like asking which is the best car — we all

have our favorites (Figures 5 and 6) In my

opinion, the best file system should have

the following features:

• Cut efficiently

REfEREncEs

1 De-Deus G, Souza EM, Barino B, Maia J, Zamolyi

RQ, Reis C, Kfir A The self-adjusting file optimizes

debridement quality in oval-shaped root canals J

Endod 2011;37(5):701-705.

2 Usman N, Baumgartner JC, Marshall JG Influence

of instrument size on root canal debridement J

4 Wu MK, R’oris A, Barkis D, Wesselink PR

Prevalence and extent of long oval canals in the

apical third Oral Surg Oral Med Oral Pathol Oral

Radiol Endod 2000;89(6):739-743.

Figure 8: Pre-curved ultrasonic K file Figure 9: C-shaped canals in lower second molar requiring

ad-ditional ultrasonic preparation

Figure 10: C-shaped canal viewed from the pulp chamber after obturation

• Have great strength and flexibility

• Be safe to use

• Have enough instruments in the range to

be used in the majority of situations

• Have a safe cutting tip, so as not to over enlarge the apical preparation

• Be versatile enough so that the instrument can be used by hand when necessary

• Can be pre-curved to overcome ledges (when used by hand)

The best way to evaluate a system

is to read the literature about it, decide what features and benefits are important

to you, and then try the system It is important to follow the manufacturer’s recommendations and to use the appropriate type of motor and handpiece

As new instruments are being developed, re-evaluation is advisable

It is important to remember that because a canal has been prepared to a certain length, with a file of a certain size and taper, that does not mean that the canal system is clean (Figure 7) Many canals are irregular in cross section and may have areas such as an isthmus between canals that harbor necrotic tissue and bacteria.4 A variety of preparation and irrigation techniques and armamentaria have to be used to ensure optimal canal cleanliness My own preference is to use

an ultrasonically energized K file, which can

be adapted to the canal curvature (Figures 8-10) Areas of the canal system that have not been cleaned adequately with rotary instrumentation can be visually identified with the use of the operating microscope and addressed in a controlled manner with ultrasonics

During preparation and before the canals are obturated, the canal length should be checked This is particularly important with curved canals, because

as the size increases, the working length

may reduce This can be done either by rechecking working lengths electronically

or radiographically by cone fitting the percha points (Figure 11)

gutta-In conclusion, the careful use of both hand and rotary instrumentation will deal with many of the situations that we are faced with It is important to understand the anatomy of the canal system and to “read” both the canals and the instruments When canal preparation is done in a controlled and considered way, obturation is a relatively straightforward matter EP

Figure 11: Cone fit of gutta-percha cones to ensure that correct working length has been established

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The goal of quality endodontic therapy

has remained the same since its

inception Appropriate removal of pulpal

tissues with proper cleaning and shaping

followed by an obturation system and

coronal seal will satisfy both mechanical

and biological objectives.1 As clinicians we

need to appreciate each of these aspects

and know that our therapy’s success is

dictated by the weakest element of our

treatment One area that has the potential

for improvement is our ability to accurately

instrument root canal systems in a manner

that maintains the original path of curvature

in both significant and multiple curvature

systems Failing to realize canal curvature

before treatment can lead to preparation

errors (i.e., apical zips, perforations, canal

blockages, or instrument separation),

which can leave the canal unprepared and

lead to continued pathology compromising

the outcome of treatment.2

The question now becomes, “How do

we treat these excessively curved cases

appropriately?” The purpose of this paper

is to provide dentists with the available tools

and knowledge to treatment plan success

for tooth retention through endodontic

therapy on curved root canal systems

Cases will be provided to demonstrate a

sample treatment sequence

Step 1 – Strategize your approach

to success

The most logical approach to begin treating

these intricate root systems is to start with

a clear vision of what you are trying to

accomplish Understanding the anatomy

prior to the onset of treatment allows the

clinician to anticipate potential challenges

and work to prevent procedural errors

Several tools can be beneficial in this

regard, one of these being the American

Endodontic treatment of curved root canal systems

CONTINUING EDUCATION

Dr John Bogle offers some cases to treatment plan success for tooth retention

Association of Endodontists (AAE) case difficulty assessment form.3 In a checklist format, a dentist can use this form to select whether the patient falls into a minimal, moderate, or high difficulty ranging from radiographic analysis, canal calcification, and medical history to tooth access This document is readily available online and there to assist with treatment planning A key point within this form is “Canal and Root Morphology.” Justifiably, the degree of curvature or multiple curvatures increases the difficulty of the case from minimal to high levels of difficulty

The degree of curvature and number

of curves within the tooth can produce challenges for appropriate shaping of the canal system.4 Prior to initiation of treatment, the clinician should consider both the angle and radius of curvature, as this has been suggested as a more accurate resemblance of true canal anatomy.5 The greater the angle of curvature and the smaller the radius of curvature, the greater the complexity of the case (Figure 1)

Dr John Bogle, DMD, MS, FRCD(C), is an

endodontic specialist and maintains a private

practice limited to endodontics in Calgary,

Alberta He is a mentor in several local study

clubs and presents to multiple groups on

various endodontic topics Dr Bogle has no conflict of

interest related to this article.

Educational aims and objectives

This article aims to discuss the treatment of excessively curved root canal systems.

of three-dimensional radiography allows for accurate assessment of the root canal space in multiple planes.6 Three-dimensional imaging can allow the clinician

to view proximal views with a high degree

of accuracy This is beneficial because many teeth have curvatures that are only present in a proximal view.7 One example

of a cone beam CT machine is the Kodak

9000 3D It has been shown to accurately depict the relationship of the internal canal anatomy compared radiographically and histologically.8

Figure 1: Pruett’s method to calculate the radius of curvature5

CONTINUING EDUCATION

Step 2 – Have the tools necessary

to make this success a reality

In the treatment of curved canals, several

key products are instrumental in achieving

true success These include small stainless

steel hand files, nickel-titanium hand

files, and rotary nickel-titanium files First,

the stainless steel hand files are used to

assist with creating a glide path Passive

movement with a light touch is necessary

to debride pulpal tissues and negotiate

apical anatomy However, larger stainless

steel instruments can alter the internal

structure of the canal (i.e., increased canal

transportation) when compared to

nickel-titanium instruments.9 Nickel-titanium hand

files can be used to increase the diameter

of the glide path while maintaining the

canal anatomy Nickel–titanium rotary

files are flexible, but multiple curves or

significant curves can still put incredible

strain on these instruments Recently, a

new product, Typhoon Controlled Memory

(Clinician’s Choice), has been developed

that uses thermal treated NiTi alloy that

enhances the mechanical properties of

nickel-titanium.10 These files have been

shown to be more resistant to cyclic fatigue

than standard nickel-titanium files.11 These

three tools: small stainless steel hand files,

moderate-sized nickel-titanium hand files,

and rotary Controlled Memory or CM files,

are essential for treating the moderately to

severely curved canal systems predictably

Step 3 – Use the tools

appropriately

Each instrument has a specific function

and should be used in the correct manner

Endodontic files are designed to create

additional space within the root canal to

decrease contact with subsequent files

Endodontic files should have minimal

contact along the root canal Slow,

consistent enlargement of the canal can

decrease the forces applied to each file used during instrumentation, minimizing chances for instrument failure Hand files should be used in a watch-winding, or preferably, the balanced force technique.12Rotary instruments should never be forced apically to avoid unnecessary strains and possible failure/fracture of instruments.13Two types of failure occur with root canal instruments: torsional loading and cyclic fatigue Torsional loading occurs if a file binds within the canal and continues to rotate to the point of separation (torsional failure) Cyclic fatigue is the result of continued forces being placed on an instrument as it operates around curves

This results in repeated strain on the file resulting in eventual work hardening and fracture.14 In root canals with significant curves, cyclic fatigue is always a concern during treatment The literature has demonstrated two key points One, using CM files increases the resistance

to fracture versus non-treated NiTi rotary files Two, operating CM instruments in the presence of fluid increased resistance

to fracture versus use in a dry environment

by over 200%.15 Clinicians should always operate endodontic rotary instruments with canals flooded This increases contact time between the internal root surface and the disinfectant as well as decreases potential for instrument separation

Now that the steps to treat curved canal systems have been discussed, I would like to present a few cases that show the utilization of these steps and techniques

Case 1

A 17-year-old male with non-contributory medical history presented for evaluation

of Quadrant 1 Vitality tests confirmed

a diagnosis of irreversible pulpitis with acute apical periodontitis for tooth 1.6

Cone beam CT images (Kodak) confirm pronounced curve in MB canals and S curvature in DB canal Dental caries were removed, and aseptic treatment was maintained with a resin-modified glass ionomer cement (Fugi II, GC Corporation) Vital tissue in 5 (MB1/2/3, DB, and P) canals was confirmed upon pulp chamber access Initial coronal debridement with

a rotary Sx file (Dentsply Tulsa Dental Specialties) in conjunction with stainless steel hand files to remove pulpal tissues A glide path was created using a combination

of stainless steel hand files and NiTi hand files (Flex Files, Dentsply Tulsa Dental Specialties) After achieving repeatable patency measurements with the Elements Apex Locator (Sybron Endo) and 15 NTK®,

a 20/04 Typhoon (Clinician’s Choice) rotary file was introduced into each canal Passive movement into each canal allowed for appropriate cleaning and shaping of the canal system If the file appeared to stop moving apically while in the canal, the instrument was withdrawn, irrigation and recapitulation with a 15 NTK® hand file

In an apical enlargement approach, initial instrumentation with a 20 and 25 NTK® was used Subsequent 25/04 through 35/04 instruments were used in all buccal canals and a 45/04 for the palatal canal After disinfection was completed, obturation with master gutta-percha cones, Kerr EWT sealer (Sybron Endo) and Calamus® gutta percha (Dentsply Tulsa Dental Specialties) was completed The floor of the chamber was sealed with a resin-modified glass ionomer cement (Fugi IX, GC Corporation) and temporized with Cavit™ (3M)

Case 2

A 39-year-old female with non-contributory medical history presented for evaluation

of Quadrant 4 Vitality tests confirmed

a diagnosis of necrotic pulp with

Figure 2: Typhoon CM rotary files Figure 3: Tulsa Dentsply Flex NTK® hand files Figure 4: Preoperative CBCT image (S curve on DB root and

significant curve on MB root)