Tạp chí nội nha EPUS tháng 3&4/2013 Vol6 No 2

Tạp chí nội nha EPUS tháng 3&4/2013 Vol6 No 2 Tạp Chí Endodontic Practice US Tháng 3 và tháng 4/2013Vol.6 No.2

an introduction

Dr Navid Saberi

P R O M O T I N G E X C E L L E N C E I N E N D O D O N T I C S

Corporate profile

Coltene: Growth helps fund innovation

PAYING SUBSCRIBERS EARN 24

CONTINUING EDUCATION CREDITS

Drs Peet van der Vyver

and Casper Jonker

March/April 2013 - Volume 6 Number 2

ASSOCIATE EDITORS

Julian Webber BDS, MS, DGDP, FICD

Pierre Machtou DDS, FICD

Richard Mounce DDS

Clifford J Ruddle DDS

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

Mali Schantz-Feld Email: mali@medmarkaz.com

Tel: (727) 515-5118 ASSISTANT EDITOR

Kay Harwell Fernández Email: kay@medmarkaz.com

PRODUCTION MANAGER/CLIENT RELATIONS

Kim Murphy Email: kmurphy@medmarkaz.com

NATIONAL SALES/MARKETING MANAGER

Drew Thornley Email: drew@medmarkaz.com

Tel: (619) 459-9595 NATIONAL SALES REPRESENTATIVE

Sharon Conti Email: sharon@medmarkaz.com

Tel: (724) 496-6820 E-MEDIA MANAGER/GRAPHIC DESIGN

Greg McGuire Email: greg@medmarkaz.com

PRODUCTION ASST./SUBSCRIPTION COORDINATOR

Lauren Peyton Email: lauren@medmarkaz.com

before any part of this publication may be reproduced in any form whatsoever,

including photocopies and information retrieval systems While every care

has been taken in the preparation of this magazine, the publisher cannot be

consequence arising from it The views expressed herein are those of the

author(s) and not necessarily the opinion of either Endodontic Practice or the

publisher.

Should endodontics remain a specialty?

Of course we endodontists would all reply with a resounding “Yes!” but it’s not quite that easy — in fact, we were almost decertified back in the late 1980s! As you probably know, every 10 years, the American Dental Association (ADA) requires that each dental specialty submits the reasons why the specialty is necessary Fortunately, we were recertified a couple of years ago due, in part, to the generous efforts of our AAE Foundation, which has funded research to expand the envelope of endodontic knowledge On a more personal level, what are we endodontists doing (or should be doing) to reaffirm the need for our specialty?

Our AAE appoints a committee to prepare a document that will be sent to the ADA highlighting the distinguishing practice guidelines that justify our specialty existence;

these guidelines have to reflect what all endodontists are capable of performing In fact, the AAE has position papers on the breadth and depth of what general dentists and the public should expect from a practicing endodontist With this introduction, I have a few questions for my endodontic colleagues:

Are we all using CBCT (cone beam) when periapical radiographic images are insufficient to make an accurate diagnosis? We don’t necessarily need to buy a CBCT (they are costly) because there are so many dental X-ray centers so nearby By employing CBCT, when appropriate, we can make more sophisticated and accurate diagnoses

After all, who but we endodontists are better trained to diagnose vertical root fractures? How about the more elusive (occult) incomplete vertical root fractures? But the subtext of this question about CBCT leads to another question: do we endodontists have sufficient training acquired either through a rigorous post-graduate endodontic program or through continuing education programs to interpret CBCT findings? In 2013, there is a reasonable expectation by general dentists and the patients we serve that endodontists should know when to employ and how to interpret CBCT

When it comes to a complex diagnosis (e.g., atypical facial pain) that presents ostensibly as “toothache,” our advanced training in history gathering and testing enables

us to recognize this uncommon entity We endodontists must reaffirm through our clinical diagnostic acumen that recognizing complex diagnostic entities is another area that distinguishes our specialty from general dentistry

Accurate diagnosis is part of the foundation of our specialty, and this in turn, leads

to accurate and appropriate treatment planning All of us have seen countless cases that were misdiagnosed which, of course, led to inappropriate treatment or even worse, mistreatment If an injured patient files a complaint against an endodontist alleging negligent treatment, it is quite likely Plaintiff’s counsel will inquire if the endodontist used CBCT leading to the diagnosis and treatment plan — and if not, why not? Of course, not every case we treat requires CBCT; however, if we fail to employ CBCT when it is indicated for diagnosis or treatment planning, we may expose ourselves to claims of negligent care

Pulp regeneration is not merely science fiction, it’s a science fact based on many fine studies published in our peer-reviewed endodontic journals Are we endodontists prepared to employ pulp regeneration when an appropriate case presents in our office? After all, our ability to stimulate pulp regeneration is another distinguishing feature that sets us apart from the general dentists’ skill-set When symptoms subside, patients may become dilatory about returning to their general dentist for a final restoration, or the general dentist may delay restoring the endodontically-treated tooth Thus, I would submit that we endodontists should also place final restorations in our access openings because

we know, through many papers published in endodontic journals, that there are countless failures due to coronal leakage around provisional restorations

Every day we are in practice, we must demonstrate our sophisticated Standard of Endodontic Excellence to justify endodontics as a specialty!

Stephen Cohen, MA, DDS, FICD, FACDDiplomate, American Board of Endodonticswww.cohenendodontics.com

TABLE OF CONTENTS

Clinical

Electronic root canal measurements using Endo-Eze Quill, Root ZX mini, Root

ZX II, and SybronEndo Mini apex locators — an in vitro comparison with actual canal length

Drs Carlos A Spironelli Ramos, Renato de Toledo Leonardo, Richard D Tuttle, and Bruno Shindi Hirata, study the location of the suitable apical file position 12

Long-term treatment of root fractures

Drs Jozef Mincík and Marián Tulenko discuss the long-term treatment of root fractures with Rebilda Post System 16

Endodontics in focus

Tip number 6 – Magnification and illumination

Dr Tony Druttman looks at the importance of magnification and illumination in the practice of endodontics 20

Dr John R Hughes: Privileged to serve

Dr John Hughes discusses restorative dentistry, the importance of sharing with

colleagues, and his fulfilling humanitarian efforts.

The COLTENE ENDO group offers a complete product lineup, ranging from

diagnostics, isolation, drying and filling products, to post and core build-up

materials.

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TABLE OF CONTENTS

Continuing

education

CBCT within endodontics: an

introduction

Dr Navid Saberi presents a guide to

cone beam computed tomography

24

New instruments for root canal negotiation and preparation Drs Peet van der Vyver and Casper Jonker introduce X-plorer canal navigation nickel-titanuim files for glide path preparation followed by Typhoon Infinite Flex nickel-titanium files for root canal preparation 32

Case study Preoperative risk assessment and endodontic treatment planning: examination of a complex clinical endodontic case Dr Rich Mounce looks at some common challenges in endodontic therapy 38

Product profile The TF Adaptive System The TF Adaptive System by Axis | SybronEndo is a new NiTi file system designed to work with the Elements motor which features Adaptive Motion Technology 42

PIPS™ Laser Endo PIPS™ Laser Endo harnesses the power of the Lightwalker Dual Wavelength Laser: improving clinical results and patient treatment acceptance 44

Vista SOLUTIONS Tested and proven for superior outcomes 46

Vari™-Tip Engineered Endodontics™ is revolutionizing the ultrasonic tip market with the Vari™-Tip, the first customizable, cost efficient, all-metal ultrasonic tip 48

Research Effect of repeated sterilization and simulated clinical use on the heating capacity of System B™ Heat Source pluggers Drs Steven W Black, Brian E Bergeron, Mark D Roberts, Jacob P Bitoun, Zezhang T Wen, Van T Himel, and Joseph L Hagan, MSPH, explore possible degradation and pathogens related to routine heat activation 50

Anatomy matters Root canal system anatomy only matters when it matters Dr John West explains the importance of educating referring dentists about endodontic diagnosis and technique 56

Diary 59

AAE Preview 60

Materials & equipment 63

Ruddle on the radar Thrill of the fill Avoiding apical and lateral blocks 64

Cone beam computed tomography

24

EndoPracAD2_2013F_Layout 1 2/6/13 10:14 AM Page 1

What can you tell us about your

background?

I was born in the back bedroom of the

church parsonage of the First Baptist

Church, Gene Autry, Oklahoma My father

was a minister, my mother was a full-time

mom, and both were the children of dirt

farmers in Oklahoma and Texas We were

poor as church mice, but I did not know it!

I was the second of four, a total nerd, and

moved to different locations every 4 to 5

years I took 18 to 21 hours per semester

at Oklahoma Baptist University where I

majored in chemistry and math with a

physics minor I applied to one dental

school at the end of my junior year and

graduated from The University of Missouri

at Kansas City 4 years later I married my

wife, Thompson, a designer for Hallmark

Cards, a month later Still married to the

same wonderful woman after 46 years! I

was a restorative dentist in Kansas City for

15 years and dealt with my mid-life crisis

by going to Boston University to study

endodontics under Dr Herb Schilder Two

years later, at the end of the residency,

we decided we didn’t want to be cold any

more We came to Tucson, Arizona, where

I started Southern Arizona Endodontics

(SAE) 30 years ago, a practice with 12

endodontists (one retired), four locations

and 55 of the best employees in southern

a good restorative dentist Great term success depends on the lab and patient attention to detail The greatest effort of the dentist is compromised by too many things outside of his control

long-Endodontics is certainly one of dentistry’s most predictable procedures and one that

is most dependent on operator excellence

How long have you been practicing, and what systems do you use?

I started restorative dentistry in 1966 and endodontics in 1983 Endodontics has seen many changes in that span The growth of new products and procedures has been almost exponential In our office,

we have all of the bells and whistles There

is probably nothing one of us has not tried There is a wide variety of the types

of rotary instruments we use We all end

up using vertical compaction of warm gutta percha for stuffing the root system While we have a lot of great systems at our disposal, most that are advertised to make the process easier also lend themselves to misuse Faster and easier rarely translate

to more predictable and better outcomes Regardless of the systems you use, they require knowledge of the root canal system you are invading, an understanding of the complexity of that system, and the determination to seal it well Ninety-nine percent of today’s graduates are well- informed and well-trained endodontists The systems they are most deficient in are the systems associated with the attraction and nurturing of referral sources That is an area that spells success or failure for many offices Failure to thrive with today’s high debt loads is not uncommon

What training have you undertaken?

I was fortunate to train under the firm control of Dr Herb Schilder I was fortunate to also study with a group of

33 exceptional residents; 11 in my class,

11 in the class before me, and 11 in the class behind The majority of my training came from the residents around me We

PRACTICE PROFILE

saw more, learned more, and experienced

more by the shear numbers of endodontic

procedures we were exposed to Some of

the best endodontists I have known came

out of those 33 people

I also was involved with a mastermind

group of 10 or 12 endodontists from all over

the United States for many years that met

every 6 months to compare successes,

frustrations, and challenges That really

shortened the learning curve for all of us

and exposed us to a lot of the movers and

shakers in the profession In addition, I

have been a student of business systems

and applications Part of our success has

been our attention to detail outside of the

root system

Henry Wadsworth Longfellow wrote:

The heights of great men, reached and

kept

Were not obtained by sudden flight,

But they, while their companions slept,

Were toiling upwards in the night.

Success or mastery is not a

9-to-5 endeavor Success favors those who

entertain the thoughts and wisdom of

others We all drink from wells others have

dug

Who has inspired you?

It would be impossible to be around Dr

Herb Schilder without being inspired His

commitment to the mastery of endodontics

was and is a frequent reflection The

rest of the dental list is rather long, but

includes Drs Pankey, West, Ruddle,

Pannkuk, Melnick, Stropko, Yu, and Sam

Marescalco, the best restorative dentist I

ever knew My wife, Thompson, is also a

source of great inspiration to me Though

visually impaired, her outlook on life, her

commitment to the joy of others, and her

love of her grandchildren bring a smile to

my mind

What is the most satisfying aspect

of your practice?

I would say the growth of those I work with

We have had dental assistants who have

decided to go back to school and on to

dental school Two of our staff leaders have

been with SAE for over 20 years, and many

have excelled with us for 10 years or more

The strength of our culture is the result of

the commitment our workforce has to treat

patients and each other with kindness,

courtesy, and respect I have never seen

a staff more aligned in the pursuit of

excellence both in and out of the tooth

Professionally, what are you most proud of?

For many years, we have maintained a relationship with over 350 different dentists who refer to our group We track our referrals very closely If we see a decline,

we are quick to see where we are failing them We are in the relationship business

The lengths we travel to maintain that connection and the service we perform for their patients consistently is the result

of systems we have had in place for many years We do good endo, but most offices

do good endo We really excel before and after treatment, from our followup to our commitment to see all patients who are in pain that same day

These may look like young fillies, but they are workhorses

I have worked with for a combined total of over 65 years!

What do you think is unique about your practice?

The quality of care we extend to our patients from the time of their contact with us to follow up after they leave our office We work hard to treat every one as

if he/she is a guest in our home; a special person we are privileged to serve

What has been your biggest challenge?

Early on, the biggest challenge was to control our growth to allow us to maintain quality of care in a caring environment

Once our systems were in place, developing

and maintaining our office culture became

a priority We are fortunate to have a rate administrator to manage our systems, culture, and priorities Michael Austin allows us to stay in the operatory with the confidence that outside the operatory, everything is under control

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

We are in the widget business If we are not making widgets, our income stream is threatened I would have been fascinated with the challenges of management/leadership of a company or service that allowed delegation of responsibilities without affecting the outcome I think an attorney with an MBA would allow for a great latitude of opportunities

What is the future of endodontics and dentistry?

I am excited about the challenges that lay before us When I look at where dentistry has come during my watch, I would hesitate to guess where it is going Just

15 years ago, implants were considered risky business Now, in the right hands, they are predictable I don’t see them replacing endodontics, but it has allowed

us an alternative to treating marginal teeth

We will continue to be faced with access

to care issues Products and solutions will continue to evolve I think success will always follow quality of care, especially in dentistry

What are your top tips for taining a successful practice?

main-You never get a second chance to make

a good first impression Always have your best telephone personality answering the phone There is no position in your practice for a person with a bad attitude A person with average skills and a great attitude always trumps a very skilled person with poor attitude We hire attitude and train skills You must be very intolerant of poor culture We work very closely with patients who are our guests at a challenging time in their life They do not need to be exposed to staff that is not harmonious and supportive

of each other Kindness, courtesy, and respect rules the day Your office requires management and leadership Managers focus on systems and structure, leaders on development Managers push; leaders pull Management involves efficiency; leadership involves effectiveness Peter Drucker once commented that “with the emergence

Dr Hughes and his colleagues at Southern Arizona Endodontics

Dentrix: We have over 75 work stations, 67 users, over four locations This software system gives us real time access to any chart in any location It also works seamlessly with DEXIS A great pairing.

Tulsa Dental: We are, I assume, one of Tulsa’s largest accounts and biggest fans! They seem

to always be there when the “next big thing” is introduced They have a large variety of rotary instruments that fit our group perfectly!

Roydent ™ Dental Products: We have used Roydent’s files and reamers forever.

Smart Practice ® : The best, most economical, suppliers of gloves Very service oriented.

A pro bono work in progress, we built in 3 1/2 days Getting ready to raise a home for another family Last project’s work crew

of the knowledge worker, the challenge

is not to manage people; the task is to

lead them.” That involves allowing staff to

contribute to the decision-making process

They work harder to implement ideas when

they are included in the process A staff

that is in alignment with decisions they help

develop, “buy in” to the success of the

office

What advice would you give to

budding endodontists?

First, join or start a mastermind group

It should be comprised of endodontists

outside of your geographic area Our group

met twice a year for many years We each

brought copies of all of the current printed

material in our office (such as referral pads,

letterheads, post-op correspondence)

and distributed them with the agreement

that we could mimic anything in our office

Sharing and discussing challenges and

solutions greatly reduces the learning

curve We spent Friday on tooth stuff and

Saturday on management, leadership, and

interface with referring offices

Second, know what your gift is, what

your strengths and weaknesses are Those

affect how you can best thrive There are

really just five or six ways you can practice

Each has pluses and minuses; some

attract specific personality types, or fill

specific needs and wishes of the dentist

Most practices are a combination of one or

two of the following

1) Government services: Veterans

Administration, Indian Health Service,

armed services, etc These involve

somewhat of an 8-to-5 group

involvement with retirement after a fixed

number of years

2) Education/Research, with an intermural

practice: Schools need endodontists

3) Develop products and/or systems,

lecture, become an “authority.”

4) Underserved area: These are becoming

SAE combines the last two We strive

to be able to say, “Send them right over!”

We know that frequently the patient isn’t hurting, the dentist is! We don’t judge whether he made a good decision in sending them; we are happy to triage the patient Rarely does the patient require immediate treatment If you are swamped, you medicate them You can say, “My, my,

my, I bet that hurts We are going to get you on some antibiotics that will make you feel better in a day or two In the meantime,

we will give you something for the pain

to get you some rest If we tried to do something today, I am afraid we would not

be friends afterward! We will first get the swelling down and get you comfortable.”

Or you can incise and drain or open the tooth None of that takes a long time Then, schedule them in the next week They will

be happy that you saw them

There are three great things about emergency patients; 1) They are thrilled to

be seen, 2) they are referred, not because

of the degree of difficulty, but because of the referring dentist’s lack of time, and 3) the dentist feels like he is a stud, and he can say, “they will see you today.”

Once they are in our office, it is our

chance It is our job to pamper them from

the moment they step in our office to the time they leave You can say it is not

necessary, I know it is not necessary! You

do it because you are building a practice that is exceptional People do not know good endo, but they know how they were treated, and how they felt when they left

When they think of your office, it should put

a smile on their face!

Third, don’t get too full of yourself

When was the last time you were impressed

by someone who introduced himself/

herself as “doctor?” Your patient knows that you are a doctor…your assistant can introduce you as doctor…but you, use your name “Hello, I am John Hughes.” That is much more powerful, whether in the office

or in social settings They will find out soon enough that you are a doctor Charles DeGaulle, former general and president of France, once said, “Graveyards are full of indispensable people.”

Keep your eye on possibilities!

You must be a rainmaker Referrals don’t just come; they must be earned What are your hobbies, and what

do you do in your spare time?

I really enjoy pro bono construction in Mexico When I retire, I hope to build

a home every month or so I now build every March with a group of students from Westmont College during their spring break It greatly changes the lives of the givers and the receivers EP

Lateral Canals and Isthmuses

Better

Than Needle Irrigation

235 Ascot Parkway | Cuyahoga Falls, OH 44223

Tel USA & Canada 800.221.3046 | 330.916.8800 | coltene.com

See us at AAE booth # 711

PATENT PENDING

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• Ratcheting syringe permits controlled delivery

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Benefits of Continuous Ultrasonic Irrigation:

• Removes significantly more debris from narrow isthmuses better than conventional needle irrigation*

• Significantly increases the penetration of irrigation solutions into lateral canals**

Ultrasonic Irrigator

*Adcock et al, J.Endod 2011; 37 (4) **Castelo-Baz et al, J Endod 2012; 38 (5)

In May 2011, the COLTENE ENDO group

formed to consolidate some of the most

widely known endodontic brands under

one umbrella, allowing clinicians simplified

access to product information Bringing

many widely known brands under one

umbrella enables greater focus The

COLTENE ENDO group is comprised

of three sites: Altstatten, Switzerland,

Langenau, Germany, and Cuyahoga

Falls, USA The American headquarters in

Cuyahoga Falls, Ohio is one of the main

manufacturing locations for several of the

products and the home site for divisional

management Operating as an international

team allows the COLTENE ENDO group

to cross-pollinate ideas, making products

more relevant and uncompromising based

on feedback from a broad, multinational

group of dentists, universities, and opinion

leaders

The COLTENE ENDO group has

brought together products from four

product lines; Alpen®, ROEKO, Hygenic®

and Whaledent Alpen®, a complete line

of diamond and carbide burs, offers endo

access products to gain entry into the canal

Celebrating its 100th birthday, ROEKO

products like ROEKOSeal continue to be

used by a wide dental audience Another

brand of products that performs day in and

day out is Hygenic® Endo-Ice®, paper and

gutta-percha points

Helping to ensure better isolation

with latex and non-latex choices are the

industry’s gold standards, Hygenic® Dental

Dams and Clamps For the past 50 years,

the ParaPost® and ParaCore have been

used in millions of post and core

build-ups Within the COLTENE ENDO product

portfolio are everyday endo products used

for a wide range of therapies The merger of

brands into one globally managed portfolio

allows greater focus on the endodontic

field, thereby enhancing customer service

and expediting innovation forces

Endodontic products continue to

grow

The focus of COLTENE ENDO, to

concentrate on bringing together all the

products needed to perform endodontic

treatment, is helping fuel the overall growth

of the entire company The COLTENE

ENDO group has tapped into an ongoing

trend within dental — patients are living longer, thereby necessitating more treatment In general, older patients have more money, resulting in geriatric dental patients being treated for endodontic ailments like root canals Moreover, the mission of the COLTENE ENDO group is

to focus on filling out their portfolio to offer

a wide selection of endodontic products

The Strategic Dental Marketing group agrees that endo product sales are on the rise Richard Fishbane, Vice President

of Strategic Dental Marketing states, “In

2012, the endodontic category of products saw a growth rate that was substantially higher than the overall growth rate for dental products in the U.S Coltene’s Endo

Division was a major factor in that growth and posted the strongest annualized sales growth of any major endodontic manufacturer in the U.S.” The success of Coltene in 2012 was aided by the strong performance of the endo division

Investment in R&DEven during the economic downturn of

2008 and 2009, Coltene funded research and development projects, keeping the pipeline full The COLTENE ENDO group’s development process is collaborative gathering cross-functional input from Asia, Europe, and the Americas The process starts with investigation of market needs and trends Customer input enters the

Growth helps fund innovation

CORPORATE PROFILE

Coltene North American headquarters, Cuyahoga Falls, Ohio

History of COLTENE ENDO firsts

First high volume casting and metal post manufacturer First to introduce a silicone endo sealerFirst cold flowable root canal sealerFirst core build-up material and post cement (ParaCore) to be

indicated as a crown cement

CORPORATE PROFILE

Operating as an international team allows the COLTENE ENDO group to cross-pollinate

ideas, making products more relevant and uncompromising based on feedback from a

broad, multinational group of dentists, universities, and opinion leaders.

development process through opinion

leaders, universities, R&D staff, and sales

and marketing personnel Winning ideas

are formulated and tested following a

rigorous process that ensures new key

benefits are included Validation occurs by

testing the product’s properties through

internal and external means that also

includes giving products to universities and

key opinion leaders to test

Coming out of the COLTENE ENDO

group are three market-focused products

helping the endodontist and general

practice dentist drive successful clinical

outcomes The Coltene Hyflex® CM™

NiTi files offer clinicians up to 300% more

resistance to cyclical fatigue, helping reduce

the incidence of file separation HyFlex® CM

NiTi files have been manufactured utilizing a

unique process that controls the material’s

memory, making the files extremely flexible

but without the shape memory of other NiTi

files This gives the file the ability to follow

the anatomy of the canal very closely,

reducing the risk of ledging, transportation,

or perforation

CanalPro™ is another new complete

grouping of products introduced by the COLTENE ENDO team The complete system of color-coded syringes provides an easy way to organize and identify different types of irrigants and solutions, helping to increase safety and minimize the chance of syringe swap The CanalPro™ line offers a complete selection of endodontic irrigation tips

CanalPro™ endodontic solutions are engineered to optimize the time spent

on irrigation, giving the clinician the best approach for cleansing canals and achieving the best outcomes CanalPro™

irrigation solutions come in four formulas:

CanalPro™ NaOCl EXTRA, NaOCl, EDTA and CHX-Ultra CanalPro™ helps complete the COLTENE ENDO lineup, allowing the practitioner four separate products to help cleanse the canal and eliminate debris

Newly introduced GuttaFlow®2 is the second generation of the first cold flowable root canal filling system that combines gutta percha with a sealer The delivery system is an industry standard 5ml syringe making dispensing convenient and simple

GutttaFlow®2 requires no heating, no

condensation, and no plastic carriers to transport material into the canal

The COLTENE ENDO group offers

a complete product lineup, ranging from diagnostics, isolation, drying and filling products, to post and core build-up materials What makes the mission of the newly formed COLTENE ENDO group more relevant than ever, is discovery

of new techniques and products to solve everyday problems New product innovation that saves valuable chair time while driving improved patient outcomes

is what matters most Successful and-true products are being surrounded with incremental product innovations to make the endodontist and general practice dentist’s job faster to complete, freeing up valuable time for everyone

Coltene/Whaledent, Inc

235 Ascot ParkwayCuyahoga Falls, OH 44223800-221-3046

This information was provided by ColTene endo.

EP

Summary

The purpose of this study was to determine

the ability of four apex locator devices to

1) indicate precisely the foramen exit

position correctly, 2) provide fundamental

data for working length determination,

and 3) indicate intermediate points Thirty

extracted maxillary central incisors were

used in this study Measurements were

taken using the new Endo-Eze® Quill

(Ultradent, USA), Root ZX® mini (J Morita,

Japan), Root ZX® II (J Morita, Japan),

and SybronEndo Mini (Sybron Dental

Specialties, USA) apex locators An analysis

of variance (ANOVA) was used to evaluate

the measurements, and no statistically

significant differences were found between

the electronic measurements of the devices

and the actual canal length at the foramen

point This study also showed that none

of the devices demonstrated accurate

measurements at intermediate points

Introduction

The establishment of the correct apical limit

of instrumentation is accepted as one of

the most important operative procedures

in endodontics Determination of accurate working length has a profound influence on ideal canal cleaning and shaping, microbial disinfection, and appropriate sealing of the root canal system The location of the suitable apical file position has constituted a persistent challenge in clinical endodontics

Radiographs are commonly used to determine the working length However, radiographic assessments of the working length may prove inaccurate, depending

on the direction and the extent of the root curvature, and the position of the apical foramen in association with the anatomic apex

By measuring the electrical properties

of the apical third of the root canal, such

as capacitance and impedance, it should

be possible to detect the canal terminus

The root canal system is surrounded by dentin and cementum, which are insulators

to electrical current At the apical foramen, there is a small orifice in which conductive materials within the canal space (e.g., tissue and fluid) are electrically connected

to the periodontal ligament that is itself a conductor of electric current

Thus, dentin, along with the tissue and fluid inside the canal, forms a resistor, the value of which depends on their dimensions and inherent resistivity When

an endodontic file penetrates inside the canal and approaches the apical foramen, the resistance between the endodontic file and the foramen decreases because the effective length of the resistive material (dentin, tissue, and fluid) decreases Along with resistive properties, the structure of the tooth root has capacitive characteristics

Therefore, various electronic methods have been developed that use a variety of methods to detect the canal terminus While the simplest devices measure resistance, other devices measure impedance using one high frequency, two frequencies, or more than two frequencies In addition,

some systems use low frequency oscillation and/or a voltage gradient method to detect the canal terminus

Many new electronic foramen locators have become available, resulting in the need to have their accuracies ascertained and compared Some techniques for determining the endodontic working length have been described and verified scientifically, including the digital tactile sensibility, methods based in radiographic analysis, and electronic methods The third generation of apex locators are based on analysis of relative impedance changes over frequency, and preliminary published studies indicated reliable and accurate measurements of the position of apical foramen Despite being based on the same third generation method of operation, the different models to be tested differ as to the number of frequencies used to calculate the impedance variation The current study’s aim is to determine if the new Endo-Eze Quill, Root ZX II, Root ZX mini, and SybronEndo Mini present accurate measurements of foramen position (canal length) and intermediate positions to calculate working length

Electronic root canal measurements using Endo-Eze Quill, Root ZX mini, Root ZX II, and SybronEndo Mini apex locators — an in vitro comparison with actual canal length

CLINICAL

Drs Carlos A Spironelli Ramos, Renato de Toledo Leonardo, Richard D Tuttle, and Bruno Shindi Hirata, study the location of the suitable apical file position

Carlos A Spironelli Ramos, DDS, MSc, PhD, is

a specialist in Endodontics; Professor, Roseman

University of Health Sciences, College of Dental

Medicine, South Jordan, Utah; and Master and PhD in

Endodontics, University of São Paulo, and Ultradent

R&D Endodontic Segment Manager.

Renato de Toledo Leonardo, DDS, MSc, PhD, is a

specialist in Endodontics; former Head and Chairman,

Department of Restorative Dentistry, Araraquara

Dental School-UNESP; Master in Endodontics, PhD in

Pathology, University of São Paulo; Visiting Professor,

University of Texas at San Antonio, Texas; and Invited

Professor, Universitat Internacional de Catalunya,

Spain.

Richard D Tuttle, DDS, is Col USAF Ret., R&D Clinical

Division Manager, and Clinical Applications Advisor.

Bruno Shindi Hirata, DDS, MSc, is a specialist in

Endodontics and Master in Endodontics, State

University of Londrina, Brazil.

Figure 1: Endo EZE Quill Apex locator, Ultradent, USA

Materials and methods

Selection of extracted teeth

This study was performed in accordance

with the guidelines issued by the

Department of Health, State of Paraná,

Brazil, and after approval by the State

University of Londrina’s Ethics in Research

Committee

Figure 2: A digital caliper (Mitutoyo, Japan) showing a

value corresponding to the actual length of the canal and

the electronic measurements of the canal The

measure-ments were taken from the top of the rubber stopper to

the base of the handle

Figure 3: Cross section showing the placement of the file

in the specimen during the measurements and the tance measured (line AB) from the base of the file handle

dis-to the dis-top of the rubber sdis-top

Recently extracted human maxillary central incisors stored in 2.5% glutaralde-hyde solution were used in this study

After evaluating the canal shape with mesiodistal and buccolingual radiograph films, teeth with previous endodontic treatment, complicated anatomy, external root resorption, immature root, and apical

foramen diameter up to 4.0X10-2 mm were excluded, leaving 30 teeth to be used for this study The selected teeth were immersed in 5.25% sodium hypochlorite solution for 15 minutes Calculus and soft tissue debris were removed with a scaler, and the teeth were washed thoroughly with tap water The teeth were then stored in 100% humidity at a temperature of 36ºC until the tests were conducted

All teeth specimens were cut horizontally at the cemento-enamel junction with a diamond disc (Extec® 12205, Extec Corp.) mounted in a precision saw (IsoMet®

1000, Buehler Ltd) The canal orifice at the cemento-enamel junction cut was used as the reference point for all measurements

Visual determination of the actual canal length

In order to determine a value corresponding

to actual canal length of the specimens, a

No 10 K-File (Maillefer, Switzerland) was introduced into the canal until the tip of the file reached an imaginary line connecting the edges of the foramen exit The silicon stop was lowered to the cemento-enamel

Table 3: Mean of the distances between the intermediate points measured (0.5, 1.0, 1.5, 2.0, 2.5, and 3.0) NS means with no statistical difference between the compared values (ANOVA, p<0.05)

SS means statistical difference between groups There were no differences among the devices studied at 0.0, 0.5, and 1.0 At points 1.5 and 2.0, SybronEndo Mini showed statistical different results comparing with the others

junction cut position Using a digital caliper

(Mitutoyo, Japan), measurements were

made from the silicon stop to the base of

the handle (Figures 2 and 3) The same

methodology was used to determine the

electronic measurement’s values

Electronic determination of the canal

length

After locating the canal opening

using an endodontic probe, the initial

instrumentation was made with a No

10 or 15 K-File (Maillefer, Switzerland),

stopping approximately 3 mm short of the

temporary working length In all cases,

instrumentation was made using the

crown-down technique All specimens

were irrigated abundantly with 2.5%

sodium hypochlorite, and the excess liquid

was evacuated from the canal before any

electronic measurements were taken,

according to the device manufacturer’s

instructions

Alginate (Alginplus®, Major,

Torino, Italy) was mixed following the

manufacturer’s instructions, and all of the

specimens were individually embedded in

alginate Before electronic measurements

were taken, the teeth were removed from

the alginate to verify the regularity of the

reproduction and the absence of bubbles

Within 2 hours after alginate preparation,

the root canal electronic measurements

were taken Each specimen was tested

with the four devices by the same operator,

and the measurements were recorded

The four devices: Endo-Eze Quill

(serial number F1, Figure 1); Root ZX mini,

(serial number ZJ062); Root ZX II (serial

number VA8025); and SybronEndo Mini,

(serial number SC3456) were set up with

the contrary electrode in the alginate and

the file electrode attached to the file to

be introduced into the canal The devices

would determine the canal length from the

reference point to the “0” mark (foramen

position, 0.5, 1.0, 1.5, 2.0, 2.5, and 3.0), as

indicated on the devices Although some

devices were designed to measure canal

lengths at varying distances from the apical

foramen, measurements to the “foramen”

mark were taken first and compared with

the actual length’s relative value in order

to standardize the procedure for the four

devices

For the electronic measurements, a

K-File sized for the foramen’s anatomical

diameter was introduced gently towards

the radicular apical third, until the

Endo-Eze Quill showed the green LED indication

(0.0), the Root ZX mini and Root ZX

II showed the last green mark before

“APEX,” and the SybronEndo Mini showed the green LED indication “APEX.” The same procedure was performed two times for each device After the foramen position measurements were taken, intermediate point measurements were taken with the four devices Using a digital caliper (Mitutoyo, Japan), measurements were made between the silicon stop and the base of the handle (Figures 2 and 3)

From these measurements, calculations were made of the differences between the relative values corresponding

to the actual canal lengths and the electronic device’s measurements of the canal lengths at the foramen position (0.0), and the other positions of (0.5), (1.0), (1.5),

(2.0), (2.5), and (3.0) The statistical analysis for each device was made from this data.Results

Because the specimen sample size was greater than 20, the Kolmogorov-Smirnov nonparametric test was used to compare the sample distribution It was found that the significance was 0.200, showing a normal distribution of the results

As the distribution was normal, the ANOVA parametric test was used, analyzing the data from the four devices The significance was 0.066, (p<0.05), showing that there was no statistical difference between the values found comparing electronic measurements at the point 0.0 (foramen positions) and canal’s actual length Intermediate points, from

2 Rambo MV, Gamba HR, Ratzke AS, Schneider

FK, Maia JM, Ramos CA In vivo determination

of the frequency response of the tooth root canal impedance versus distance from the apical foramen

Conf Proc IEEE Eng Med Biol Soc 2007;570-573.

3 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.

4 Ricucci D Apical limit of root canal instrumentation and obturation, part 1 Literature

review Int Endod J 1998;31(6):384-393.

5 Stein TJ, Corcoran JF Radiographic “working

length” revisited Oral Surg Oral Med Oral Pathol

1992;74(6):796-800.

6 Nekoofar MH, Ghandi MM, Hayes SJ, Dummer

PM The fundamental operating principles of

electronic root canal length measurement devices Int

Endod J 2006;39(8):595–609.

7 Carneiro E, Bramante CM, Picoli F, Letra

A, da Silva Neto UX, Menezes R Accuracy of root length determination using Tri Auto ZX and

ProTaper instruments: an in vitro study J Endod

2006;32(2):142-144.

8 Welk AR, Baumgartner JC, Marshall JG An in vivo comparison of two frequency-based electronic

apex locators J Endod 2003;29(8):497–500.

9 Ponce EH, Vilar Fernández JA The dentino-canal junction, the apical foramen, and the apical constriction: evaluation by optical microscopy

cemento-J Endod 2003;29(3):214–219.

10 Herrera M, Abalos C, Planas AJ, Llamas R Influence of apical constriction diameter on Root ZX

apex locator precision J Endod 2007;33(8):995–998.

11 Olson DG, Roberts S, Joyce AP, Collins DE, McPherson JC III Unevenness of the apical

constriction in human maxillary central incisors J

13 Venturi M, Breschi L A comparison between two

electronic apex locators: an ex vivo investigation Int

Endod J 2007;40(5):362-373.

14 Ounsi HF, Naaman A In vitro evaluation of the

reliability of the Root ZX electronic apex locator Int

Endod J 1999;32(2):120-123.

0.5 to 3.0, showed statistical differences

between electronically measured points

and actual corresponding points in all

devices studied

Table 1 shows the mean and standard

deviation of the distances between the

electronic measurement at point 0.0 of

each device and the actual length

Table 2 shows the mean of the

distances between all points measured

(point 0.0, 0.5, 1.0, 1.5, 2.0, 2.5, and 3.0)

and relative actual length values There

was no difference between all device’s

electronic measurements at point 0.0

and the actual root canal length (p<0.05)

Statistical analysis showed differences

(p<0.05) between all the intermediate

points electronically measured by all

devices tested and the actual intermediate

values

Table 3 shows the mean of the

distances between intermediate points

measured using the tested devices (point

0.5, 1.0, 1.5, 2.0, 2.5, and 3.0) Comparing

results among the intermediate electronic

measurements of Endo-Eze Quill, Root ZX

mini, and Root ZX II showed there were

no statistical differences between the

results Nevertheless, at points 1.5 and

2.0, SybronEndo Mini showed statistically

different results when compared with the

other devices

Conclusion

It was observed that no electronic

measurement of any of the devices used in

this study was beyond the real position of

the apical foramen, maintaining the apical

biological limit parameters The results are

in agreement with studies that used similar

third-generation apex locators

Comparing the electronic

measure-ments at the foramen positions, indicated

by the four apex locators studied

(Endo-Eze Quill, Root ZX mini, Root ZX II, and

SybronEndo Mini) with the actual root

canal’s lengths found no statistically

significant differences

The intermediate points do not

appear to be accurate because they

showed statistically significant differences

as compared to the actual intermediate

points These results are in agreement with

the Rambo, et al., study, which showed

that electronic apex locators are accurate

when used at the foramen reference point

only.EP

Others claim a closed tip, but a microscope may reveal a much different story

The RINN Max-i-Probe tip is welded closed to protect your patient from fluids expressing past the apex

“ the Max-i-Probe removed significantlymore bacteria the unique side vent ofthese safety-ended needles producesupward turbulence that enhances complete cleaning of root canals.“

— Journal of Endodontics, Vol.33, No 6, June 2007

ENDODONTIC/PERIODONTAL IRRIGATION PROBES

‘Closed-end’

generic probe Max-i-Probe

The irrigating probe confirmed

THE BEST

in the Journal of Endodontics.

Root fractures must be regarded as a

form of complex trauma because they

affect both the dental hard tissue, and the

periodontal and pulpal tissue They result

from powerful forces with compression

zones acting in the root region The

consequence of fractures is that the

tooth is split into a coronal and an apical

fragment

In regards to the level at which the

fracture occurs, a distinction is made

between fractures in the apical, middle,

and cervical third of the root It is known

that young patients, in whom root growth is

not yet complete, have the best prospects

of the fracture healing

Other factors that are favorable to

the healing process include a positive

sensitivity test at the time of the accident,

no dislocation, and no pronounced mobility

of the coronal fragment In the absence of

dislocation, there is a danger of the fracture

not being detected, and therefore, imaging

at two levels is necessary for the purpose

of diagnosis (von Arx, Chappuis, Hänni,

2007)

The recommendation that a root

fracture should be treated with rigid

splinting for several months has long since

become obsolete No positive effect on the

healing pattern in the region of the fracture

gap was demonstrated with splinting for

longer than 4 weeks (Cvek, Andreasen,

Borum, 2001)

The factors determining the choice of

treatment are the location of the fracture,

the nature and degree of dislocation of the coronal fragment, and the stage of root growth In the case of root fractures located entirely in the intra-alveolar region, the outcome is often favorable With a root fracture, only the coronal fragment

is treated as a rule because the apical portion generally remains vital (Andreasen, Hjorting-Hansen, 1967)

The specific case

In 1999, an 11-year-old patient came to our practice after a bicycle accident During the intraoral examination, we found greatly increased mobility of the upper right lateral incisor (UR2) and less pronounced mobility

of the maxillary central incisors (UR1, UL1)

without dislocation The teeth were treated with a wire splint, which was adhesively bonded to the labial surfaces Two weeks after the initial treatment, the percussion test on the upper right lateral incisor (UR2) was negative At the same time, sensitivity

to percussion was detected Following trepanation and pulp extirpation, the tooth was filled with calcium hydroxide (Figure 1).Two months after the trepanation, a permanent root canal filling was placed

in the upper right lateral incisor (UR2) Incipient obliteration in the apical region,

a symptom that often accompanies root fractures, prevented the apex being reached (Figure 2)

At the patient’s regular visits to our

Long-term treatment of root fractures

Dr Jozef Mincík studied dentistry at the University of

Košice in Slovakia, and from 1980 to 1989 assisted

in the Department of Conservative Dentistry at the

1st Department of Stomatology Clinic of the Košice

University Hospital He has had his own dental practice

in Košice since 1990, and has been head of the

Conservative Dentistry section of the Slovakian Dental

Association since 2000 His key areas of expertise

include esthetic-restorative dentistry, endodontics,

and dental traumatology He is the author of numerous

publications and presentations on these subjects.

Dr Marián Tulenko studied dentistry at the University

of Košice and has worked at Dr Mincík’s practice

since 2008 He is a member of the Young Dentists

section of the Slovakian Dental Association, and in his

publications and presentations he specializes in the

areas of esthetic-restorative dentistry, endodontics, and

dental traumatology.

Figure 2: Permanent root canal filling

of the upper right lateral incisor (UR2) The maxillary central incisors (UR1, UR2) are vital No resorption is recognizable at the fracture lines

Figure 3: External root resorption of the coronal fragment of the upper left central incisor (UL1) in the fracture line

Figure 4: The permanent endodontic treatment of the upper left central incisor (UL1) External resorption

in the fracture line was diagnosed, while the apical region was found to

be normal

Figure 5: Considerable healing of the resorption of the fracture gap on the upper left central incisor (UL1) 2 years after endodontic treatment External resorption of the upper right central incisor (UR1)

Figure 6: The radiograph taken after the root canal filling on the upper right central incisor (UR1)

Figures 7A-7C: The coronal fragment of the upper right lateral incisor (UR2) is adhesively luted to the apical fragment with the aid of the composite post Rebilda Post (Voco)

Figure 8A: Resection of the apical fragment of the upper right lateral incisor (UR2) and restoration of the bone defect with bone substitute material Figure 8B: Situation after resection of the upper right lateral incisor (UR2)

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practice, the clinical and radiographic

check-ups revealed no pathological

changes up to 2008 However, 9 years after

the accident, the pulp test on the upper

left central incisor (UL1) was negative The

radiograph shows an external inflammatory

root resorption of this tooth in the fracture

line (Figure 3)

Following a temporary calcium

hydrox-ide dressing, a permanent restoration was

placed in the affected upper left central

incisor (UL1) The restoration extended

as far as the fracture line because the

apical region displayed no changes, and

therefore, was most probably vital, as is

typical with root fractures (Figure 4)

The next check-up was 2 years later

The patient complained of discomfort at

the upper right central incisor (UR1) The

radiograph showed considerable healing

of the external resorption of the fracture

gap on the upper left central incisor (UL1);

however, on the other hand, we diagnosed

external resorption on the upper right

central incisor (UR1), similar to the upper

left central incisor (UL1) [Figure 5]

The upper right central incisor (UR1)

received endodontic treatment similar to

the upper left central incisor (UL1) The root

canal filling extended as far as the fracture

gap (Figure 6)

This check-up revealed a periapical

process on the upper right lateral incisor

(UR2), which was not filled up to the apex

because of an obliteration In our opinion, the infection extended to the periapex, and therefore to the fracture line via the gingival sulcus Consequently, we decided

to secure both fragments of the tooth with the aid of the glass fiber-reinforced composite post Rebilda Post (Voco) and to seal the gap with composite In this way, it was possible to save the tooth We use the fiber-reinforced composite (FRC) Rebilda Post because this system has proven very successful in our experience One

of the benefits of this post is that it has a modulus of elasticity similar to that of the tooth In this particular case, securing the fragments assists the treatment of the root fracture, and the adhesive luting creates a barrier against ingress of bacteria into the periodontium (Figures 7A-C)

Subsequently, we treated the periapical process surgically by performing

a resection and retrograde restoration

We restored the bone defect with bone substitute material (Figures 8A and 8B)

The latest check-up in June 2011, 12 years after the accident, shows formation

of new bone in both fracture lines following the endodontic treatment Furthermore, the radiograph confirms that the periapical process of the upper right lateral incisor (UR2) has healed following the resection (Figure 9)

Thanks to this treatment, the teeth are fully functional in spite of root fractures

With the exception of the discoloration on the upper right lateral and upper left central incisors (UR2, UL1), the patient has been free of all symptoms for 12 years after the accident (Figures 10 and 11)

ConclusionOur experience confirms that the prognosis for root fractures is very good in most cases This may be linked to the fact that,

in comparison with apical interruption of the blood supply, the revascularization area is large, and the distances to be bridged are small

As mentioned at the beginning, the treatment is determined by the location

of the fracture, the nature and degree of dislocation of the coronal fragment, and the stage of root growth

REfEREncEs

Andreasen JO, Hjorting-Hansen E Intraalveolar root fractures: radiographic and histologic Study of 50

cases J Oral Surg 1967;25:414-426.

von Arx T, Chappuis V, Hänni S Verletzungen der bleibenden zähne - teil 3: therapie der

wurzelfrakturen Schweiz Monatsschr Zahnmed

on the maxillary central incisors (UR1, UL2) have become filled with hard tissue The periapical process of the upper right lateral incisor (UR2) has healed fully

Figure 10: Palatal view of the affected teeth 12 years after

This article is part of a series that

appears in 10 consecutive issues and

is designed to offer practical advice on

some of the most common challenges

that we face in endodontics The purpose

is to make the practice of endodontics

easier Some of the information will give

you a better understanding of what you

are dealing with; some will make it easier

to avoid pitfalls; some will show you how

to improve the quality of your work; and

some will advise what to do in difficult

situations Although each article covers a

specific topic, they interrelate, and some of

the questions that arise may be answered

in other articles By nature it cannot be

comprehensive, otherwise it would be a

textbook, but hopefully, it will give you

valuable practical information

Available technology

One of the primary purposes of root canal

treatment is the elimination of bacteria from

the root canal system, which as I have

described in the first article of this series,

is often very complex (Figure 1) When I

qualified just over 30 years ago, the practice

of endodontics was very different We relied

on 20/20 vision and nothing else Once

the canal entrances had been identified,

everything was done pretty much just by

feel Now with the technologies available

to us, while the importance of tactile sense

cannot be underestimated, it is possible to

overcome obstacles that are visible right

into the depth of the canals

Magnification in dentistry starts with

operating loupes, which will increase the

image size from 2x to about 5x (Figure

2) After 5x, the loupes start to become

very heavy, and magnification is better

provided by the operating microscope,

which magnifies the image from about 5x to 20x (Figure 3) Illumination with the loupes comes in the form of a headlight, which obviates the need for a separate operating light As it is mounted on the loupe frame or a headband, no shadow is produced The light source in the operating microscope is integral within the scope itself, so that light passes down the canal walls In straight canals, the apex can be clearly seen, as well as isthmuses, fins, and secondary canals Both have their advantages and disadvantages Loupes are considerably more versatile, and many dental procedures can be carried out at these low magnifications However one pair

of loupes only give one magnification, so the tendency is to have just one pair Over the years, I have progressed from 2x to 3.25x to 4.25x There are many situations, particularly in endodontics, where the tooth needs to be seen in much greater detail, and while I do change the magnification from time to time, most of my work is done

at 10x The greater the magnification, the narrower the width of field, and the lower the depth of field The better we can see what we are doing, the more control

we have The more control we have, the greater the chances are for a successful result Not all endodontic procedures require the use of the microscope, but at the very least, it is useful for checking canal cleanliness prior to obturation

DiagnosisThe microscope has proven itself to be an invaluable tool for confirming the presence

of cracks both in the natural crowns of teeth and in the roots of teeth restored with post crowns External root resorption can also be confirmed with careful examination

of the gingival margins under magnification The marginal fit of restorations and the presence of caries can also be checked (Figure 4)

Canal location

As discussed in last month’s article, finding the canals can be infinitely more difficult than cleaning and shaping them The pulp chamber and even the canals themselves may be sclerosed A very careful technique is required to preserve tooth structure, and this requires a good knowledge of canal anatomy, experience,

Top ten tips:

Tip number 6 – Magnification and illumination

ENDODONTICS IN FOCUS

Dr Tony Druttman looks at the importance of magnification and illumination in the practice of endodontics

Figure 1: Complex root canal anatomy in a lower molar tooth

Tony Druttman, MSc, BChD, BSc, has

extensive expertise in treating dental root

canals, resolving difficult endodontic cases,

and saving teeth from being extracted His

two London practices, one in the West End

and the other in the City of London, are

restricted to endodontic treatment.

www.londonendo.co.uk

Figure 2: Working with magnifying loupes

Figure 3: Working with the operating microscope Figure 4: Caries detected using the microscope

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and the use of the microscope Second

mesiobuccal canals in upper molars can

often only be found at high magnification

(Figure 5) Other teeth can sometimes have

more than the expected number of canals

(Figure 6), and failed endodontic treatment

is often caused by missed canals As I have

discussed in previous articles in this series,

a good quality preoperative radiograph

will often indicate the presence of a canal

that divides along its length (Figure 7), but

the exact position can only be detected

by careful visual examination under high

magnification (Figures 8A and 8B) Similarly

the presence of a second canal in the distal

root, or a third canal in the mesial root of

a lower molar, can only be detected by

careful clinical examination

Canal preparation

Because of the complexity of the root

canal system, canal preparation cannot

necessarily be considered to be complete

just because a rotary instrument of a

certain size and taper has been taken to

a predetermined length, even with the

accompanying irrigation regimes The

cross-sectional shape of canals may vary

along their length They may be circular at

the apex and become oval more coronally,

or have a teardrop shape They may be

joined to another canal or another branch

via an isthmus, as is often the case with

lower incisors and the distal canals of lower

molars C-shaped lower second molars can

often present a considerable challenge in

preparation Only careful examination of the

ENDODONTICS IN FOCUS

Figure 7: In tooth 45, the canal divides

on the middle third

Figure 8A: Mesiobuccal canal divides in the apical third of the root of upper molar

Figure 8B: Both branches of the canal are clearly seen using the microscope and can therefore be instrumented

Figure 9: Fractured instrument in the MB1 canal viewed under the magnification of the operating microscope

Figure 10A: Fractured spiral filler in the

mesial root of a lower molar Figure 10B: Fractured instrument removed and the tooth retreated

prepared canals using the microscope will identify (some of) those areas of the canal system that have remained unprepared

Seeing around a curve, however, is not an option with the microscope

Endodontic retreatmentAnother major area of endodontics where the microscope has proved its worth is in endodontic retreatment, both surgical and nonsurgical The predominant cause of endodontic failure is due to the presence

of bacteria, and retreatment involves removing obstructions that prevent access

to the site of bacterial contamination This may involve removing root-filling materials,

or bypassing or removing ledges and blockages such as fractured instruments (Figure 9) I will be discussing retreatment

in greater detail in the final article of this series Instruments have been adapted and invented for use in conjunction with the microscope, particularly in the field of ultrasonics Fractured instruments can often be removed using fine ultrasonic tips

to trough around the instrument, removing minimal amounts of dentin (Figures 10A and 10B) This can only be done with the aid of the microscope This has led

to an increase in the success rates of nonsurgical retreatment approaching that

of primary treatment The success rate of surgical endodontics has also increased significantly with the use of microsurgical techniques Soft tissue management, root end cavity preparation, and suturing techniques have all changed radically since

Figure 11: Common working position leading to musculo-skeletal problems

the introduction of the microscope into surgical endodontics

ErgonomicsAnother significant benefit from the use of both magnifying loupes and the operating microscope is in the field of ergonomics The practice of dentistry over many years, especially endodontics, when the operator tends to sit in one position for a considerable length of time, can take its toll

on the operator Back, shoulder, and neck problems are not uncommon because

of incorrect posture (Figure 11) By using

an increased working distance, operating loupes allow the back to be held straighter than when working without magnification (Figure 12) The microscope allows for the neck, shoulders, and back to be in a comfortable neutral position, especially when used with an operating stool with arm supports (Figure 13)

In conclusion, the introduction of increased magnification and improved illumination of the operating field has many benefits, both for the operator and the patient, and nowhere more so than

in endodontics The ability to work with a high level of accuracy and control improves the quality of treatment, reduces treatment time, and reduces operator fatigue I am convinced that the use of magnification should be an integral part of undergraduate teaching of operative dentistry, particularly

in the field of endodontics

Next issue: Determining length

Figure 12: Improved posture using magnifying loupes Figure 13: Comfortable neutral posture using the

operating microscope

EP

Figure 5: A very small MB2

canal detected after

obtura-tion of MB1 due to bubble

formation seen with the aid

of the microscope

Figure 6: Palatal root has two canals in this upper first molar

Cone beam computed

tomogra-phy (CBCT)

Since their discovery in 1895 and first

application in dentistry in the same year,

X-rays have been an invaluable aid in

the practice of dentistry (Cruse, Bellizzi,

1980) Clinicians still depend greatly

on dental radiography for obtaining

diagnostic information, including the field of

endodontics and in relation to the diagnosis

of periradicular disease (PRD)

One major shortcoming of classic

dental radiography, however, is a

two-dimensional reproduction of a

three-dimensional entity (Patel, et al., 2009) In

medicine, this problem was overcome

in 1972 by the invention of computed

tomography (CT) scanning (Beckmann,

2006) However, due to high radiation

exposure, the use of CT scanning in

dentistry could not be justified (Patel, et al,

2009) This dilemma has been addressed

by the introduction of three-dimensional

cone beam CT scanning (CBCT), and

since the late 1990s, CBCT scanning has

been given serious consideration within

maxillofacial diagnostic radiology (Patel,

2009; Farman, et al, 1997)

CBCT versus conventional CT

Cone beam CT scanning (CBCT), which is

also referred to as cone beam volumetric

imaging (CBVI) and cone beam volumetric

tomography (CBVT), is an extraoral

radiographic method of producing

three-dimensional digital radiographic

information (Patel, et al., 2009; Patel,

2009; Miles, 2008; McNamara, Kapila,

2006; Horner, Drage, Brettle, 2008; Patel,

et al., 2007) In conventional CT scanning

machines, the X-ray source and detector

rotate 360 degrees around the patient

at about the rate of 60 times per minute,

with a thin fan-shaped beam of X-rays

directed through the patient The thickness

of each image slice is determined by the

CBCT within endodontics: an introduction

CONTINUING EDUCATION

Dr Navid Saberi presents a guide to cone beam computed tomography

distance the patient is moved through the inside of the CT scanning machine during this synchronized rotation This creates multiple sectional images that are then processed by a computer to create a three-dimensional image of the patient’s region of interest (Beckmann, 2006, Miles, 2008; Horner, Drage, Brettle, 2008; Patel,

et al., 2007)

In cone beam CT scanning devices, unlike conventional CT scanning, a narrow cone-shaped beam, as opposed to a fan-shaped beam, rotates between 180 to 360 degrees (depending on the model) around the patient’s region of interest, capturing

a volume of the patient, as opposed to a

Navid Saberi, BDS, MFDSRCS(Ed), MSc(Glas),

maintains a practice limited to endodontics in London,

England He is also honorary secretary of the Scottish

Endodontic Study Group For more information about

that study club, please visit www.sesg.org.uk.

Figure 1: Diagram showing the basic concept of CBCT CBCT scanner uses a cone beam source to acquire the entire area of interest

Educational aims and objectives The purpose of this article is to look at the uses and benefits of using cone beam computed tomography (CBCT) in dentistry.

Expected outcomes Correctly answering the questions on page 36, worth 2 hours of CE, will demonstrate you understand how using CBCT for endodontic treatment can benefit the clinician and patient.

slice in conventional CT scanners Cone beam CT scanning also allows the desired image to be produced in a single rotation without the need for moving the scanner

or the patient (Figure 1) [Patel, et al, 2009; Patel, 2009; Miles, 2008; Horner, Drage, Brettle, 2008; Patel, et al, 2007; Patel, Kanagasingam, Mannocci, 2010; Cotti, 2010; Scarfe, Farman, 2008]

The X-ray field can also be collimated

to include the region of interest only This quick cone beam production and volumetric image capturing is capable of reducing the exposure by over 50 times

in some cases (Patel, 2009; Miles, 2008; McNamara, Kapila, 2006; Horner, Drage,

CONTINUING EDUCATION

Brettle, 2008; Patel, et al., 2007; Patel,

Kanagasingam, Mannocci, 2010; Cotti,

2010; Scarfe, Farman, 2008) CBCT is

capable of producing high contrast images

with good resolution in a short period

of time However, soft tissue contrast is

relatively poor in these devices (Horner,

Drage, Brettle, 2008; Patel, Kanagasingam,

Mannocci, 2010; Scarfe, Farman, 2008)

As explained above, the effective

dose of CBCT is much less than that

for conventional CT, although the dose

is dependent on the volume of tissue

irradiated, and also the other imaging

parameters that are selected (Horner,

Drage, Brettle, 2008; Patel, et al., 2007;

Scarfe, Farman, 2008) CBCT scanners are

also significantly cheaper than conventional

CT scanners A full list of advantages and

disadvantages of CBCT and conventional

CT can be found in Table 1

Pixel versus voxel

A pixel is a two-dimensional picture element

that is a square that measures between 20

and 60 micrometers in size (Miles, 2008;

McNamara, Kapila, 2006) A voxel, on the

other hand, is a three-dimensional volume

element and is a cube, which may or

may not be isometric (Patel, 2009; Miles,

2008; McNamara, Kapila, 2006) This is

the building block of the volume of the

image that has been captured by cone

beam CT scanning and then processed

and digitized by computer software (Figure

2) The computer software also allows

viewing of the image volumes and further

image management, manipulation and

interactions (Patel, 2009; Miles, 2008;

McNamara, Kapila, 2006; Patel, et al.,

2007; Patel, Kanagasingam, Mannocci,

2010)

Sensors

The type of sensor determines important

image volume characteristics such as the

size, shape, and spatial resolution of the

reconstructed volume (Patel, 2009; Miles,

2008; McNamara, Kapila, 2006; Patel, et

al., 2007; Patel, Kanagasingam, Mannocci,

2010; Scarfe, Farman, 2008) The sensor

options include an image intensifier that is

coupled to either a charged coupled device

(CCD) or complementary metal oxide

semiconductor (CMOS), a CCD chip or a

thin film transistor (TFT) flat panel type of

image receptor (Miles, 2008; McNamara,

Kapila, 2006; Scarfe, Farman, 2008)

One of the most important sensor

characteristics, which determines the

diagnostic superiority of the CBCT machine, is the signal-to-noise or signal-to-glare ratio This ratio varies between sensors CCD and flat panel sensors have a higher (better) signal-to-noise ratio than image intensifier systems This leads

to improved diagnostic accuracy when faced with scatter, which is produced by metallic elements and prostheses within the maxillofacial skeleton and teeth The smaller and more compact size of CCD and flat panel sensors also reduce the overall weight and size of the CBCT unit, and make them more ergonomic However, the compact CCD sensors produce smaller reconstructed image volumes, and

therefore a smaller anatomic field of view when compared to flat panel and image intensifier sensors Thereby, they are not suitable for full arch and full maxillofacial skeletal image reconstruction (Patel, 2009; McNamara, Kapila, 2006; Patel, et al, 2007; Scarfe, Farman, 2008) Overall, the image intensifier is an older technology and produces a lower quality of image The flat panel detectors and CCD sensors are the newest image receptors These offer less image distortion, wider contrast scale, and glare elimination when compared with the image intensifier receptors (McNamara, Kapila, 2006; Patel, et al., 2007; Scarfe, Farman, 2008)

Figure 2: The concept of a voxel The volume of images in CBCT is composed of voxels, which can be as small

• Short scanning time

• No superimposed tomographic blurring

• Multiplanar views and 3D reconstruction possible

• Uniform magnification

• Not technically demanding to perform

• Lower dose than conventional CT

• Multiplanar views and 3D reconstruction possible

• Uniform magnification

• Bone density measurements possible

• Soft tissue assessment possible

Disadvantages

• Imaging of entire jaw rather than site

of interest in the majority of scanners

• Not suitable for soft tissue assessment

• Imaging of entire jaw rather than the site of interest

CONTINUING EDUCATION

Lofthang-Hansen et al

(2007) Oral Surgery,

Oral Medicine, Oral

Pa-thology, Oral Radiology

Simon et al (2006)

Journal of Endodontics

Cross sectional NewTom 3G 17 large PRD cases

Granuloma vs cyst differentiation

CBCT reliable in diagnosing cysts and granuloma

Ex vivo trial NewTom 3G 18 teeth CBCT accuracy in detecting

PRD Highly accurate results in CBCT cases

Stavropoulos et al

(2007) Clinical Oral

Investigation

Animal ex vivo trial NewTom 3G 10 pig mandibles

CBCT vs digital vs PA accuracy CBCT was over 20% more accurate

CBCT vs PA for the diagnosis

CONTINUING EDUCATION

Ex vivo trial i-CAT 69 teeth Detection of transverse root #

CBCT with 0.125 voxel resolution was more accurate than 0.25 voxel or PSP system

Hassan et al (2010)

Journal of Endodontics Ex vivo trial 5 scanners 80 teeth

Detection of root # by different CBCT scanners i-CAT was the most accurate

Higher detection of PRD in CBCT cases

Özer (2010) Journal of

Endodontics Ex vivo trial i-CAT 80 teeth

Detection of root # with different thickness by CBCT and PA

CBCT was determined to be more accurate than PA

Patel and Dawood

CBCT vs OPG in detecting apical root resorption

CBCT was established to be superior

to OPG

Estrela et al (2009)

Journal of Endodontics

Cross sectional i-CAT

40 patients(48 scans) CBCT vs PA in detecting root resorption CBCT was 30% more accurate than PA

Liedke et al (2009)

Journal of Endodontics Ex vivo trial i-CAT 60 teeth

Evaluation of different voxel sizes of CBCT in detecting resorption

CBCT was determined to perform well especially with 0.3mm voxel size

CBCT performed much better than PA

La et al (2010) Journal

of Endodontics Case report Implagraphy 1 tooth

The use of CBCT in canal identification

Mid-mesial canal in a mandibular first molar was identified using CBCT

dimensional images that can be used for maxillofacial surgical treatment planning, assessing impacted teeth prior to surgical extractions, temporomandibular joint analysis, orthodontics, airway assessment, periodontics, bone level evaluation, implantology, endodontic assessment, diagnosis, and treatment planning

Clinical applications of cone beam

CT scanning within endodonticsCone beam computed tomography (CBCT) has been established to be superior

to conventional intraoral and extraoral radiography in diagnostic accuracy CBCT

is capable of producing high contrast images with good resolution in a short period of time

In endodontics, this particularly relates

to early diagnosis of periradicular disease

CONTINUING EDUCATION

Quality of reconstructed data

The quality of reconstructed image formats

and data is related primarily to the voxel

size, signal-to-noise ratio, and contrast, or

dynamic range

Most units these days produce a

dynamic range up to 65,536 shades of

gray (16 bits) The voxel size ranges from

0.08 to 0.6 mm3 Voxel size is inversely

proportional to improved anatomic feature

detection In image intensifier sensors, the

reduction of voxel size can only be achieved

by reducing the field of view However, due

to low (poor) signal-to-noise ratio in these

units, the quality of the reconstructed image

cannot be as high quality as CCD and flat

panel units Conversely, flat panel sensors

can create a small voxel size for any given

field of view (Miles, 2008; McNamara,

Kapila, 2006; Patel, et al., 2007; Scarfe,

Farman, 2008)

The image data in image intensifier CBCT units can be up to 1.5 gigabytes per scan when using a large field of view

Whereas, the size of the image data in flat panel CBCT units can be up to 400 megabytes, and in CCD, CBCT scanners can reach 100 megabytes Thus, storage, back-up, and transfer of data in CCD and flat panel CBCT scanners are also easier than in image intensifier CBCT scanners

However, all units require high local and/or regional data transfer network speed and capacity (McNamara, Kapila, 2006; Scarfe, Farman, 2008)

Clinical applications of cone beam CT scanning

Advances in CBCT imaging means these scanners can reconstruct three-

Moura et al (2009)

Journal of Endodontics

Cross sectional 3D Accuitomo 503 obturations

Influence of obturation length

on PRD

CBCT performed better than PA in the detection of PRD and checking obturation length

Matherne et al (2008)

Journal of Endodontics Ex vivo trial i-CAT 72 images

CBCT vs CCD vs PSP in diagnosing root canals

CBCT performed significantly better than intraoral radiography

Michetti et al (2010)

Journal of Endodontics Ex vivo trial Kodak 9000 3D 9 teeth

Accuracy of CBCT in root canal image reconstruction

CBCT images were similar to real histologic section

Ex vivo trial Accuitomo 2 teeth CBCT vs digital vs PA in void detection

Digital radiographs performed better than CBCT and PA in detecting small voids

Overall CBCT was determined to be superior to PA

Sanfelice et al (2010)

Journal of Endodontics Ex vivo trial i-CAT

32 extracted lower first molars

Canal enlargement monitoring using CBCT

Significant differences could be identified pre vs post instrumentation using CBCT

with greater accuracy of lesion size, extent,

nature, and position (Stavropoulos, Wenzel,

2007; Paula-Silva et al., 2009; Patel, et al.,

2009; Estrela, et al., 2008) Furthermore,

three-dimensional volume of information

captured by CBCT can also aid clinicians

in the diagnosis of root fractures, root

resorption, perforations, obturation voids

and defects, and root canal morphology

(Naito, Hosokawa, Yokota, 1998; Tyndall,

Rathore, 2008; Misch, Yi, Sarment, 2006;

Patel, Horner, 2009; Cotton, et al., 2007;

Pinsky, et al., 2006; Hassan, et al., 2009;

Huybrechts, et al., 2009)

Most CBCT studies have either been

performed ex vivo on cadavers or on

animals Conclusions drawn from these

studies should be carefully analyzed as

laboratory tests methodology may not

reflect the clinical situation Furthermore,

methods used by authors in CBCT studies

should also be critically evaluated in

terms of CBCT scanner settings This is

particularly important when two or more

machines are being compared as different

settings will inherently change the quality of

reconstructed three-dimensional images

Unfortunately, this important information

is not always provided by the authors

Nevertheless, almost all CBCT studies

have shown overwhelming superiority of

these imaging machines over conventional

radiography (Annex 1)

Another benefit of CBCT is its use

in evaluation of periradicular healing and

endodontic outcome assessment

Paula-Silva, et al., (2009) clearly demonstrated

that traditional intraoral radiographic

evaluation of periradicular healing is an

unsuitable and unreliable method for this

purpose In contrast, CBCT provides

acceptable diagnostic information in

relation to periradicular repair However,

histological analysis of the root periapex

remains the gold standard

In another study, Christiansen, et

al., (2009) confirmed that, on average,

periapical bone defects measured on

periapical radiographs are approximately

10% smaller than on CBCT images This is

a very important finding, and may influence

decision making and guidelines regarding

conventional radiographic outcome

assessment

Current ESE guidelines (2006) state

that root canal treatment has an uncertain

or an unfavorable outcome if:

• Radiographs reveal that a lesion has

remained the same size or has only

diminished in size

• A radiologically visible lesion has appeared subsequent to treatment, or a pre-existing lesion has increased in size

However, the guideline fails to clarify what constitutes an acceptable radiographic assessment Now that better diagnostic equipment has become available with CBCT, potentially more cases could be classified as unsuccessful

in the future This is particularly important

in endodontic diagnostic radiology and the use of CBCT scanning in outcome assessment of endodontic treatment

In comparison, success and failure assessment criteria for a different treatment modality to endodontic treatment, such as dental implant placement, are generally less strict The differences between these criteria render the two treatment modalities incomparable Furthermore, success measures for dental implant longevity and survival have misleadingly led to the common belief that dental implant placement is more successful than endodontic therapy This belief could negatively influence patient decision making regarding the appropriate treatment

Therefore, radiographic outcome assessment in endodontics should be interpreted with caution (Friedman, Abitbol, Lawrence, 2003) to assist patients and clinicians in making an informed decision

in relation to endodontic or dental implant treatment planning

Wu, et al., (2009) argued that a re-duced periapical radiolucency on radiographs does not guarantee that the healing process has begun or is continuing

The authors reported that a high percentage

of cases that were confirmed healthy from periapical radiography presented with apical periodontitis in CBCT images It was recommended that the outcomes of root canal treatment should be re-evaluated in long-term longitudinal studies using CBCT and stricter than normal evaluation criteria

Furthermore, the authors recommended replacement of periapical radiography with CBCT in dental clinics because of the misleading results obtained from periapical radiography

This argument and debate raises a very crucial question – what constitutes endodontic success?

The aim of root canal treatment has been to treat periradicular disease

Therefore, the success of root canal treatment will only be achieved by complete resolution of the apical lesion (Ørstavik, Pitt Ford, 2008) However, how should

success be assessed? The gold standard assessment is by means of histological analysis of the root periapex (Simon, et al., 2006; Paula-Silva, et al., 2009) However, performing histological analysis of the apex of every asymptomatic root canal treated tooth is unjustifiable, unrealistic, and difficult to perform Furthermore, it may cause considerable morbidity, and therefore unethical to carry out

As explained above, success assessment can also be achieved by radiographic monitoring of the lesion But we now know that conventional radiography is not a reliable method for this assessment CBCT is shown to be a more accurate diagnostic tool However, even CBCT is not 100% accurate

in the diagnosis of periapical lesions (D’Addazio, et al., 2011) Unfortunately, those authorities who recommend routine assessment of endodontically treated teeth with CBCT fail to mention this fact

So, what is important for clinicians? Consideration should be given to patient-centered outcomes, including patient satisfaction and improved quality of life after root canal treatment as opposed to a paternalistic look at intervention and treat-ment outcome If we think CBCT is better than periapical radiography, and routine overexposure of patients to radiation is justifiable, why not perform apical surgery

in order to obtain a biopsy of every single PRD lesion to establish resolution? After all, histological examination is the proven gold standard and even CBCT cannot match its accuracy Where do we stop?

Dugas, et al., (2002) conducted an interesting study looking at the quality of life and satisfaction outcomes of endodontic treatment The authors interviewed individuals with known root canal treated teeth, asking them to complete

a questionnaire This questionnaire was

an endodontically-adapted quality-of-life instrument consisting of 17 questions Of the cohort, 97.1% reported satisfaction with the decision to have endodontic treatment Surprisingly, 96.4% individuals were found to have PRD associated with the root canal treated teeth The use of quality-of-life instruments and dental satisfaction scales in order to contemporize endodontic assessment was recommended The authors concluded that further development of endodontic-specific quality of life and satisfaction instruments that measure the impact of endodontic disease, and treatment on

CONTINUING EDUCATION

REfEREnCEs

Beckmann EC CT scanning the early days Br J Radiol

2006;79:5-8.

Christiansen R, Kirkevang LL, Gotfredsen E, Wenzel

A Periapical radiography and cone beam computed

tomography for assessment of the periapical bone

defect 1 week and 12 months after root-end resection

Dentomaxillofac Radiol 2009;38(8):531-536.

Cotti E Advanced techniques for detecting lesions in

bone Dent Clin North Am 2010;54(2):215-235.

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

Schindler WG Endodontic applications of cone-beam

volumetric tomography J Endod

2007;33(9):1121-1132.

Cruse WP, Bellizzi R A historic review of endodontics,

1689-1963, part 2 J Endod 1980;6(4):532-535

D’Addazio PS, Campos CN, Özcan M, Teixeira HG,

Passoni RM, Carvalho AC A comparative study

between cone-beam computed tomography and

periapical radiographs in the diagnosis of simulated

endodontic complications Int Endod J

2011;44(3):218-224.

Dugas NN, Lawrence HP, Teplitsky P, Friedman S

Quality of life and satisfaction outcomes of endodontic

treatment J Endod 2002;28(12):819-827.

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.

European Society of Endodontology Quality guidelines

for endodontic treatment: consensus report of the

European Society of Endodontology Int Endod J

2006;39(12):921-930.

Farman AG, Ruprecht A, Gibbs SJ, Scarfe WC

Advances in maxillofacial imaging Amsterdam: Elsevier;

1997.

Friedman S, Abitbol S, Lawrence HP Treatment

outcome in endodontics: the Toronto study Phase 1:

initial treatment J Endod 2003;29(12):787-793.

Hassan B, Metska ME, Ozok AR, van der Stelt P,

Wesselink PR Detection of vertical root fractures in

endodontically treated teeth by a cone beam computed

tomography scan J Endod 2009;35(5):719-722.

Horner K, Drage N, Brettle D 21st century imaging

London: Quintessence Publishing Co Inc.; 2008.

Huybrechts B, Bud M, Bergmans L, Lambrechts P, Jacobs R Void detection in root fillings using intraoral analogue, intraoral digital and cone beam CT images

Int Endod J 2009;42(8):675-685.

McNamara JA Jr, Kapila SD, eds Digital radiography

and three-dimensional imaging Monograph

43, Craniofacial Growth Series Department of Orthodontics and Pediatric Dentistry and Center for Human Growth and Development, The University of Michigan, Ann Arbor: Needham Press; 2006.

Miles DA Color atlas of cone beam volumetric imaging

for dental applications Hanover Park, IL: Quintessence

Orstavik D, Pitt Ford TR Essential endodontology 2nd

ed Oxford, UK: Blackwell Munksgaard; 2008.

Patel S New dimensions in endodontic imaging: Part

2 Cone beam computed tomography Int Endod J

Patel S, Dawood A, Mannocci F, Wilson R, Pitt Ford

T Detection of periapical bone defects in human jaws using cone beam computed tomography and intraoral

radiography Int Endod J 2009;42(6):507-515.

Patel S, Dawood A, Whaites E, Pitt Ford T New dimensions in endodontic imaging: part 1 Conventional

and alternative radiographic systems Int Endod J

2009;42(6):447-462.

Patel S, Horner K The use of cone beam

computed tomography in endodontics Int Endod J

2009;42(9):755-756.

Patel S, Kanagasingam S, Mannocci F Cone beam

computed tomography (CBCT) in endodontics Dent

Update 2010;37(6):373-379.

Garcia de Paula-Silva FW, Hassan B, Bezerra da Silva

LA, Leonardo MR, Wu MK Outcome of root canal treatment in dogs determined by periapical radiography

and cone-beam computed tomography scans J

Endod 2009;35(5):723-726.

de Paula-Silva FW, Santamaria M Jr, Leonardo MR, Consolaro A, da Silva LA Cone-beam computerized tomographic, radiographic, and histologic evaluation of periapical repair in dogs’ post-endodontic treatment

Oral Surg Oral Med Oral Pathol Oral Radiol Endod

2009;108(5):796-805.

de Paula-Silva FW, Wu MK, Leonardo MR, da Silva LA, Wesselink PR Accuracy of periapical radiography and cone-beam computed tomography scans in diagnosing apical periodontitis using histopathological findings as

a gold standard J Endod 2009;35(7):1009-1012.

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.

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how does it work? Dent Clin North Am

2008;52(4):707-730.

Simon JH, Enciso R, Malfaz JM, Roges R, Bailey-Perry

M, Patel A Differential diagnosis of large periapical lesions using cone-beam computed tomography

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Stavropoulos A, Wenzel A Accuracy of cone beam dental CT, intraoral digital and conventional film radiography for the detection of periapical lesions

An ex vivo study in pig jaws Clin Oral Investig

patients’ well being should take place This

new way of treatment evaluation will help

put patient-based outcomes at the center

of endodontic treatment assessment

Clinical endodontics has been defined

as the prevention and/or elimination of

periradicular disease (Ørstavik, Pitt Ford,

2008) This definition must be revised due

to the unreliability of diagnostic equipment

available to us Clinical endodontic

outcomes should be more patient focused

and concentrate more on the elimination

of the clinical signs and symptoms of

periradicular disease Indeed, even

periradicular disease may not always be the

primary factor in determining the outcome

of root canal treatment Moreover, the

term success should perhaps be replaced

by the term survival or functionality

This is especially important when direct comparison between endodontics and dental implant survival rates is being made

Furthermore, this will reduce patients being confused and misled over often reported higher survival rates of implants

ConclusionCBCT has been established to be superior

to conventional intraoral and panoramic radiography in its accuracy and sensitivity

in detecting endodontic related pathology

The use of CBCT significantly enhances the clinician’s ability to diagnose PRD and other endodontic complications, particularly when compared with conventional intraoral radiography Therefore, more endodontic

disease may be detected in the future However, strict selection criteria for CBCT use must be followed, and routine CBCT examination of patients should be avoided This will reduce unnecessary patient exposure to radiation, especially when the question for which radiographic exposure is required can often be answered by lower-dose conventional intraoral radiography In addition, routine post root canal treatment radiographic follow-up by means of CBCT in patients without clinical signs or symptoms of endodontic disease is not recommended EP

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