| case report | special | feature

ootsinternational magazine of endodontologyissn 1616-6345 Vol. 6 • Issue 4/20104 2010| case reportOpen-apex retreatmentunder the operating microscope| specialEndodontic success:The pursuit of our potential| featureAn interview with MICRO-MEGA

editorial _ roots IDear Reader,_Endodontics is fascinating. I will put aside the romantic view that endodontics is an art andassume that it is an ever-growing science that requires a great deal of study and training to reach ahigh-level clinical performance. I dare say that no other clinical discipline in dentistry requires such avast knowledge of and integration with so many other clinical and basic disciplines.As a clinical health-care discipline, endodontics is concerned with the promotion of oral health andprimarily deals with prevention and treatment of apical periodontitis. Every patient who enters our officeis confident that we are well prepared to apply the most effective treatment protocol available to reachthat goal. Unfortunately, this may not be true. Epidemiological studies reveal a very low success rate (40to 60%) of endodontic treatment in the general population. The majority of failed (or diseased) teethare poorly treated. The need for a complex background of knowledge and the technically demandingnature of endodontic procedures may help explain such an overall poor performance. However, the potentialfor success is very high (85 to 95%), as demonstrated by well-controlled, university-based studies.This rate is amongst the highest for any treatment in any health-care discipline. This keeps our hopeshigh. The challenge for the specialty now is to transfer this high success rate to the general population.Prof José F. Siqueira Jr.One of the possible solutions is to encourage the development of treatment procedures or protocolsthat are user-friendly and effective in order to allow more clinicians to be able to offer optimal outcomes.This would make endodontics more ‘democratic’ in terms of predictability. In a thoughtprovokingpaper by Morgan and Alexander published in roots 2/10, the authors discuss the issue ofapplying scientific knowledge to improve clinical practice. Dr Irving Naidorf had discussed this 40 yearsago and it is still significant today. Integrating scientific knowledge and clinical practice is certainlyrequired to maximise the success rate, but this approach might well also be used to develop alternativesto improve the quality (and consequently the outcome) of treatment in the overall population.In spite of the huge amount of scientific information about the aetiology and pathogenesis ofapical periodontitis generated over the last three decades, this knowledge has not been translated intoa significant improvement in endodontic treatment outcomes. This is because clinical technology andtreatment protocols have not been devised or even slightly modified on the basis of this boomingbiological know ledge. Science has provided a great deal of information on the nature of the problem, sothe time has come for this knowledge to be used by endodontic scientists and clinicians to find a better,affordable and less technically demanding approach that can still predictably treat our patients. In anideal world, there should be no dichotomy or dispute between research and clinical practice. In a clinicaldiscipline like endodontics, research should be mostly intended to find and test ways for the best treatmentand to improve the quality of life, while clinicians should use this scientific knowledge to improvetheir practices. Denying the importance and advances of the other is arrogant, nonsense, selfish andcounterproductive.In contrast to the many Doomsday prophets, we can foresee a bright future for endodontics.It’s up to us.Yours faithfully,Prof José F. Siqueira Jr.Professor and Chairperson, Department of Endodontics, Estácio de Sá UniversityRio de Janeiro, RJ, Brazilroots4_2010I03

I content _ rootspage 10 page 14 page 22I editorial03 Dear Reader| Prof José F. Siqueira Jr., Guest EditorI case report06 Open-apex retreatment underthe operating microscope| Dr Antonis Chaniotis10 Treating a calcified mandibular molar:A modern-day protocol| Dr Rafaël Michiels14 A cavernous sinus infection:A root-canal case| Dr Philippe SleimanI feature18 An interview withAudrey Stefani,Dr Stephan Gruner & Dr Khaled A. BaltoI special22 Endodontic success: The pursuit ofour potential| Dr Wyatt D. Simons30 Transparent teeth:A powerfuleducational tool| Dr Sergio RoslerI research32 CBCT applications in dental practice:A literature review| Dr Mohammed A. Alshehri et al.I industry news40 The RECIPROC system| VDWI meetings42 Greece inspired us once again| Dr Antonis Chaniotis44 A meeting of minds—Seeing is believing| Dr David English46 Endodontics:A central theme of IDS 201148 International EventsI about the publisher49 | submission guidelines50 | imprintCover image courtesy of Brown & Herbranson Imaging,www.eHuman.com.page 30 page 40 page 4404 I roots4_2010

®AN EASY TO USE & SAFE SOLUTIONTO ACTIVATE YOUR IRRIGATIONDesigned byClifford J. Ruddle DDS,Robert H. Sharp DDS,Pierre Machtou DDSMULTIPLE BENEFITSSAFE• Strong, flexible medical grade polymer tips• Single patient use• Uncoated & Non Cutting tipsEFFECTIVE• Creates fluid hydrodynamics• Improves debridement and the disruptionof the smear layer and biofilmSIMPLE• Very simple clinical technique• Intuitive Device• Ideal in practice when portability is requiredwww.dentsplymaillefer.com

I case report _ open-apex retreatmentOpen-apex retreatmentunder the operatingmicroscopeAuthor_ Dr Antonis Chaniotis, Greece_Owing to the lack of apical constriction, rootcanaltreatment of permanent teeth with open apicesposes great challenges. When it comes to the endo -dontic treatment of such teeth, debridement andobturation of the canal space create a significantproblem. The wide-open canal and thin dentinal wallsare difficult to clean and shape, and it is even moredifficult to obtain an acceptable conventional apicalseal. For many years, apexification was the treatmentof choice. The main goal of this procedure is to controlthe bacterial infection and establish a suitableenvironment for the induction of calcified tissue intothe apical area. Calcium hydroxide—Ca(OH) 2 —hasremained the most acceptable intra-canal medicamentused for apexification. 1However, this procedure is associated with a numberof clinical problems, such as prolonged treatmenttime, unpredictability of apical closure, difficulty inpatient follow-up and susceptibility to fracture.Moreover, long-term use of Ca(OH) 2 as an intra-canalmedicament can weaken the thin dentinal walls of animmature root to a greater extent. 2In order to override the disadvantages of the apexificationtechnique, many alternatives have beensuggested that aimed mainly at the development ofa one-step procedure (one-visit apexification). Someof these potential alternatives were abandoned dueto limitation in the availability and bio-compatibilityof the materials. 3,4Fig. 1_Pre-op radiograph of rightmaxillary central incisor.Mineral trioxide aggregate (MTA) has been proposedas a material suitable for one-visit apexification.It combines bio-compatibility and bacteriostaticaction with favourable sealing ability when used incontact with bone tissue. 5–8 MTA offers an acceptablebarrier at the end of root canals in teeth with necroticpulps and open apices. This apical plug provides safebio-compatible constriction that permits verticalcondensation of warm gutta-percha in the remainderof the wide canal. For some, the intra-canal deliverytechnique is crucial for the adaptation and the qualityof the apical MTA plug. 9 Moreover, the use of anoperating microscope may allow better control of theplacement of the MTA apical plug. 9Fig. 1Following, the microscopic retreatment of anopen-apex central incisor is described. Extrudedthrough the open-apex, gutta-percha cones were retrievedsuccessfully under magnification and completionof the treatment was achieved with the placementof an MTA apical barrier. Clinical tips for the procedureare provided and the predictability of the technique isconsidered.06 Iroots4_2010

case report _ open-apex retreatment IFig. 2a Fig. 2b Fig. 2cFig. 2d_Case reportA 32-year-old male patient was referred to ourpractice for evaluation of the maxillary left centraland lateral incisor. Medical history was non-contributory.There was a history of trauma at the age of 10.Clinical evaluation revealed no signs of infection inthe area of the maxillary left incisor. Probing waswithin normal limits, and cold and electric vitalitytests of the lateral incisor were positive. The centralincisor was protected by a full coverage crown. Radiographicexamination (Fig. 1) revealed a previouslytreated open-apex central incisor associated with alarge radiolucent area at the end of the root-canalsystem of both the central and lateral incisors. Guttaperchacones were extended far beyond the open apexinside the lumen of the peri-radicular lesion. It wasevident that the previous dentist attempted to obturatethe wide canal using the wrong technique andwithout previous apexification. The result was theextrusion of the obturation material far beyond theapex. The patient was informed of the possibility ofperforming surgery to resolve the problem followingthe orthograde attempt to retreat the wide-opencanal.After crown removal, a prefabricated post wasrevealed. The post was easily removed by ultrasonicvibration, and access was achieved. Retrieval of theoverextended gutta-percha cones was achieved withISO size 45 Hedstrom Files (DENTSPLY Maillefer). Nosolvents or Gates-Glidden burs were used in order toavoid cutting or softening of the overextended material.With the help of a microscope (Global Surgical),an ISO size 45 file was inserted between the dentinalwall and the under-condensed material. Withdrawalof the Hedstrom File in one stroke retrieved the majorityof the gutta-percha cones from the wide canal,leaving only the overextended ones (Fig. 2a). For theretrieval of the extruded cones, the file was bent at thetip using the Endo-Bender (SybronEndo; Fig. 2b). Carewas taken not to push the remaining cones out of theopen apex, and the whole procedure was accomplishedunder x16 magnification. Figures 2c and dshow the radiographs of the successful procedure.Length was radiographically assessed using anISO size 110 Hedstrom File (Fig. 3). After retrieval ofthe gutta-percha cones, the wide-open canal wascleaned using ultrasonic irrigation with 4.8% NaOCl(Irrisafe, Satelec). The canal was then dried and filledwith Ca(OH) 2 (UltraCal, Ultradent). One week later,access was regained and Ca(OH) 2 was removed byultrasonic irrigation with 4.8% NaOCl. A 17% solutionof EDTA (SmearClear, SybronEndo) was left in thecanal for one minute, and the final rinse was achievedusing syringe irrigation with 4.8% NaOCl.The canal was dried and an absorbable gelatinehaemostatic sponge (SPONGOSTAN, Ethicon) was cutto fit the width of the canal (Fig. 4a). The sponge wasFig. 3aFigs. 2a–d_Radiographicassessment of gutta-percha conesretrieval (a, c & d), Hedstrom tipmodification using Endo-Bender (b).Figs. 3a & b_Length determinationradiograph.Fig. 3broots4_2010I07

I case report _ open-apex retreatmentFig. 4a_Gelatine sponge cutto fit the canal.Fig. 4b_Gelatine sponge in place.Fig. 4aFig. 4bguided through the wide canal to the open apex withpre-fitted pluggers, creating a platform for the safeadaptation of the MTA plug (Fig. 4b).White MTA (DENTSPLY Maillefer) was mixed withsterile water until a thick consistency was achieved.MTA material was carried inside the root canal withan appropriate amalgam carrier used as MTA carrier(Fig. 5a). Pre-fitted pluggers were used with slightapical pressure to push the MTA material to the apexuntil the material was adapted to the apical anatomyof the open apex that was plugged with the absorbablesponge (Fig. 5b). Adaptation of the materialwas assessed visually under x16 magnification andradiographically until the plug filled the apical 5mmof the wide canal (Figs. 6a & b). After the completion ofthe procedure, a wet cotton pellet was placed in contactwith the MTA, and temporarisation was achievedwith Cavit G (3M ESPE). The patient was referred backto his general practitioner for appropriate restorationand came back to our practice for a follow-up examinationafter six months (Figs. 6c & d)._DiscussionA major problem in performing endodontics inimmature teeth with necrotic pulp and wide-openapices is obtaining an optimal seal of the root-canalsystem. For more than 40 years, such cases were approachedclinically with apexification. 1 The initial aimof the procedure was to limit the bacterial infectionand create an environment conductive to the productionof a mineralised tissue barrier or root-endformation at the immature root apex. Ca(OH) 2 wascommonly used for this purpose. Despite the popularityof this technique, inherent disadvantagesexist. Variability of treatment time, unpredictability ofapical closure, difficulty in patient follow-up, susceptibilityto fracture and reinfection are the main disadvantagesof the procedure. All these disadvantageslead us to continue the search for procedures andmaterials that may allow for continued apical closurein teeth with immature apices. Although research onthe revascularisation procedures of the necrotic openapex is promising, 10 the MTA apical plug technique isconsidered a good alternative treatment procedure.Figs. 5a & b_MTA carried inside thecanal (a), and condensed to length (b).Fig. 5aFig. 5b08 IIts physical and chemical properties make MTA agood potential apical barrier, including its sealing andantimicrobial ability, marginal adaptation and biocompatibility.6 However, the material manipulationand delivery technique of the procedure pose greatclinical challenges. The aim of the present article wasto describe the MTA apical plug technique systematically,and to provide tips and hints for the successfulmanagement of challenging open-apex retreatmentcases. Although extruded beyond the apex materials,which may indicate surgical treatment planning, anorthograde retreatment procedure was followed inthe present case. Extruded materials were successroots4_2010

case report _ open-apex retreatment Ifully retrieved through the wide-open apex with theindispensable aid of a surgical microscope. ModifiedHedstrom Files proved very useful for the purpose.Cleaning of the wide-open canal was enhanced byultrasonic irrigation, while Ca(OH) 2 was placed as anintra-canal medicament. The effectiveness of Ca(OH) 2as an antimicrobial agent is well documented, 11although its use is still controversial. Hachmeister etal. 12 demonstrated that the remains of Ca(OH) 2 oncanal walls has no significant effect on MTA leakageor displacement resistance. On the other hand, it wassuggested by Porkaew et al. 13 that remnants ofCa(OH) 2 on the dentinal walls may interfere with theapical seal produced. However, in a recent paper byHam et al., 14 it was suggested that the combinationof MTA and Ca(OH) 2 in apexification procedures mayresult in more favourable regeneration of the periapicaltissues. In the present case, Ca(OH) 2 wasremoved as effectively as possible from the dentinalwalls using ultrasonic irrigation with 4.8% NaOCl and17% EDTA for one minute.Fig. 6aFig. 6bFor proper and safe adaptation of the MTA apicalbarrier, an absorbable gelatine sponge was condensedat the apex, creating a scaffold against which the MTAmaterial could be seated. SPONGOSTAN is consideredto be fully absorbed within four to six weeks (instructionfor the material use), while in the orthopaedicliterature it is referred to as a possible 3-D scaffold fora chondrocyte matrix. 15 Concerns have been raisedabout delayed healing patterns and painful reactionto SPONGOSTAN when packed to sockets after surgicalremoval of third molars. 16 In the case of an openapex and MTA plugs combined with the use of absorbablegelatine sponges, I have never encounteredan experience of painful post-operative reaction orhealing impairment attributed to the use of the gelatinesponge. Further research is needed on the subject.For the insertion of the material inside the wide canal,a small amalgam carrier was used in conjunction withappropriate Schilder pluggers under magnification.Concerns have been raised about the MTA placementtechnique. Lawley et al. 17 found that ultrasonic condensationled to significantly less bacterial penetrationcompared to hand condensation, after 45 daysbut not in the 90-day interval. On the contrary,Aminoshariae et al. 9 found better adaptation and lessradiographic voids with hand condensation than withultrasonics. More research is required to find the idealplacement technique.Appropriate adaptation of the material wasassessed visually under microscopic inspection andradiologically. Concerns have been raised about theappropriate MTA plug thickness. It has been postulatedby some authors that the thickness of the apicalplug may influence its leakage patterns. De Leimburget al. 18 reported in a recent paper that orthograde useof MTA provided an adequate seal against bacterialinfiltration, regardless of the thickness of the apicalplug. Hachmeister et al. 12 underlined in their paperthat the thickness of the apical plug may have asignificant impact only on displacement resistance.In the present case, we obtained a sufficient apicalplug of 5mm, leaving 12mm space for resin post andcore restoration.Orthograde delivery of MTA in open apices is considereda very sensitive technique and the clinicianshould practise his/her skills before going in vivo. Thiscase presentation was designed to guide the clinicianstep-by-step to the successful management of challengingopen-apex cases._Editorial note: A list of references is available from thepublisher._about the authorFig. 6cFig. 6dFigs. 6a & b_Post-op radiograph andmicroscopic appearance of the MTAplug (x16, Global Entrée Plus).Figs. 6c & d_Gutta-fishing at6 months.rootsDr Antonis Chaniotis graduated from the University of AthensDental School in 1998. He completed a three-year postgraduateprogramme in Endodontics at the University of Athens DentalSchool in 2003. He is a clinical instructor in the undergraduateand postgraduate programmes in the Department of Endodonticsof the University of Athens Dental School. Since 2003, hehas practised in a private practice in Athens that specialises inEndodontics. Dr Chaniotis can be contacted at antch@otenet.gror via his website www.endotreatment.gr.roots4_2010I09

I case report _ calcified mandibular molarTreating a calcifiedmandibular molar:A modern-day protocolAuthor_ Dr Rafaël Michiels, Belgium_Treatment and discussionFig. 2A diagnostic radiograph (Fig. 1), which is essentialin determining the treatment strategy, was taken tovisualise the extent of the lesion and the anatomy ofthe roots. The patient was then anesthetised by a loweralveolar nerve block with 4% articaine, 0.01mg/mlepinephrine (Septanest Special, Septodont).The temporary filling and cotton pellet wereremoved, exposing a large carious lesion. In order tofacilitate the temporary restoration after treatment,an AutoMatrix (DENTSPLY Caulk) was placed. Thisalso enabled better isolation. The tooth was then isolatedwith a rubber dam (Coltène/Whaledent; Fig. 2).Fig. 1 Fig. 3Fig. 1_Diagnostic radiograph.Fig. 2_Placement of rubber damand AutoMatrix.Fig. 3_Calcified tissue inthe pulp chamber._Endodontics has evolved enormously over thelast few decades. However, the basic principles fromthe past still apply today. The following case reportgives an example of the manner in which the old principlesare applied with newer techniques, devices andmaterials._History and diagnosisA 37-year-old female patient was referred to ourpractice for a problem with her lower right secondmandibular molar (tooth #31). She had no health issues,and was given an ASA score of 1. The referringdentist opened the tooth because of an acute pulpitisdue to an extensive carious lesion disto-lingually. Shehad difficulty locating the mesial canals because thepulp chamber was heavily calcified. She had placedcalcium hydroxide upon the orifices of the canals andsealed the tooth with a cotton pellet and a temporaryrestoration. The patient had no clinical symptomswhen she presented to our office for treatment.Isolation, which is one of the fundamental prin -ciples in endodontics, is more than 100 years old. In1864 already, Sanford C. Barnum developed the rubberdam, which was generally accepted as a necessityin achieving good isolation and better prognosis. 1The first step in the treatment of a tooth […] is theadjustment of rubber dam over the diseased tooth topreclude the possibility of the entrance of germs in theoral secretions into the pulp chamber. This should bethe invariable rule. 2However, a recent survey found that only 3.4% ofgeneral dental practitioners use the rubber dam intheir endodontic routine. 3Visualisation and magnification can help cliniciansgreatly in cases like the one presented here.Without the use of a surgical operating microscope(OM), it is very difficult to locate canals in the presenceof a great deal of calcification. “You cannot treat whatyou cannot see” is a quote that is regularly heard andthat hits the nail right on the head.10 Iroots4_2010

case report _ calcified mandibular molar IIn this case, visualisation and magnification wereobtained through the OM (OPMI pico, Carl Zeiss).Photographs were taken with a Canon PowerShotA650 IS (Canon) mounted on the FlexioStill adapter(Carl Zeiss).I removed the carious dentine with LN burs(DENTSPLY Maillefer). There was a great deal of cal -cified tissue in the pulp chamber (Fig. 3), which I alsoremoved with LN burs. The calcium hydroxide waseasily removed with 10% citric acid.After a clean opening cavity had been created, theactual root-canal treatment was begun. Two mesialcanals were located and coronally pre-flared withProTaper SX (DENTSPLY Maillefer; Fig. 4). Workinglength was determined with an ISO size 10 K-file(DENTSPLY Maillefer; Table I) and the Root ZX miniapex locator (J. Morita Europe). A glide path was thenestablished with K-Flexofiles sizes 15 and 20.Cleaning was performed with 3% NaOCl, whichwas ultrasonically activated with an Irrisafe tip (Sa -telec) several times throughout the procedure. Theultrasonic activation of the irrigating solution resultsin more effective removal of organic tissue, debris andplanktonic bacteria. 4 It is a very easy and inexpensiveprocedure and should be incorporated in every endo -dontic routine.Shaping was done with ProTaper files S1, S2 and F1in the mesial canals and ProTaper file F2 in the distalSize in mm Working length MAF Reference pointOral D 21.5 mm 35 DB cuspcanal, giving the canal sufficient taper but a small apicaldiameter. Many controversies exist about shapingthe apical diameter. I prefer an apical diameter of atFig. 4MB 21.5 mm 30 MB cuspML 22.5 mm 30 ML cusp Table IFig. 4_Locating the mesial canals.Table I_Working lengths and apicaldiameters of the canals.Fig. 5_Fractured Irrisafe tip.Fig. 6_Removed Irrisafe tip.Fig. 7_Confirmation radiograph.Fig. 5Fig. 6 Fig. 7roots4_2010I11

I case report _ calcified mandibular molarFig. 8Fig. 9 Fig. 10 Fig. 11Fig. 8_Obturation of the isthmus.Fig. 9_Pulp chamber after obturationand removal of excess sealer.Fig. 10_Final radiograph.Fig. 11_Final position._contactDr Rafaël MichielsParklaan 1192300 TurnhoutLeopoldplein 143500 HasseltBelgiumrootsrafael.michiels@gmail.comwww.ontzenuwen.beleast a size 30 because I rinse with a 30-gauge irri -gation needle. That way, the NaOCl comes into directcontact with the apical dentine. 5 This results in a significantlybetter removal of debris from the apicalpart of the root. 6 In order to achieve a bigger apicaldiameter, a ProFile size 30.06 (DENTSPLY Maillefer)was taken to working length in the mesial canals anda ProFile size 35.06 in the distal canal. Utilising an ISOsize 10 K-file, patency was maintained in all threecanals throughout the entire treatment.After the canals had been shaped, they were rinsedwith 10% citric acid, which was ultrasonically activatedthree times for 20 seconds with an Irrisafe tip.During the third activation, the tip fractured andbecame stuck in the isthmus between the mesialcanals. Cotton pellets were placed in the mesiolingualand distal canal to prevent the instrumentfrom falling into the canals during its retrieval(Fig. 5). Retrieval was done with another Irrisafe tip(Fig. 6). A final rinse was performed with 3% NaOCl,which was heated with a few bursts with System B(Sybron Endo). Finally, cone pumping was performedwith size 06 tapered gutta-percha cones. The lite -rature refers to cone pumping as manual dynamicirrigation that has proven to be more effective thanregular irrigation. 7A confirmation radiograph was then taken withgutta-percha master cones (DENTSPLY Maillefer) inplace (Fig. 7). The canals were dried with paper points(Roeko).Obturation was performed with a hybrid techniquein which cold lateral condensation was used to fill theapical 4mm. Thereafter, the System B needle wastaken 4mm short of working length into the canal.Backfill was performed with the Elements Extruder insmall increments of 2mm each time to reduce shrinkage.TopSeal (DENTSPLY Maillefer) was used as asealer. During the backfill, I could see the isthmusbeing obturated with gutta-percha (Fig. 8), which is adesirable result. Were tissue to have been left in theisthmus, it may have led to failure. After obturation,excess sealer in the pulp chamber was removed with96% alcohol (Fig. 9). A temporary restoration wasthen placed with Fuji IX GP Fast A2 (GC Europe).Final radiographs (Figs. 10 & 11) were taken and thepatient was sent home with instructions regardingpossible post-operative discomfort and a prescriptionfor 400 mg ibuprofen._ConclusionIn the past, there were several revolutions in thefield of endodontics, such as isolating with the rubberdam, cleaning with NaOCl and shaping with rotaryinstruments. Today, we still make use of these prin -ciples and are developing them further in order tomake treatment easier and safer and to gain morefavourable outcomes._Editorial note: A list of references is available from thepublisher.12 Iroots4_2010

CONCEPTNewNITI ROTARY SYSTEMA safe & efficient specific sequenceTO ACHIEVE REQUIREDBIOLOGICAL APICAL SIZESAS SIMPLE AS 0, 1, 2 , 3...Since root canal infection is the cause of apicalperiodontitis, the biological aim of endodontic treatmentis the prevention or elimination of root canal microbes.Consistent success in endodontics requires high technicalskill in order to achieve a biological aim. It is wellestablished that in order to remove enough microbesfrom the root canal to ensure predictable success, theapical third of the canal must be instrumented to certainminimum sizes.Most instrumentation systems require an additional stepto achieve minimum sizes in the apical third of the canal.This results in additional files, time and expense for thepractitioner.The BioRaCe sequence is unique, it has been especiallydesigned to achieve the required apical sizes withoutthe need for additional steps and additional files. If usedaccording to instructions, most canals can be effectivelycleaned with 5 NiTi files. Thus with the use of the uniqueBioRaCe system, the biologic aim of root canal treatmentis achieved WITHOUT compromising efficiency.SELECTED CASESDr. Gilberto Debelian (Norway)Pre-op Post-op 1 y. follow-upTooth 46Dx: Chr. apical periodontitisTx: PulpectomyTreatment Details:MB & ML: BR4 35/.04DB & DL: BR6 50/.04Dr. Martin Trope (USA)NEW HANDLE AND NEW RUBBER STOPPre-opTeeth 36 and 37Dx: Symptomatic pulpitisTx: PulpectomyPost-opTreatment Details:MB & ML: BR5 40/.04DB & DL: BR6 50/.04More details and information onwww.biorace.ch

I case report _ cavernous sinus infectionA cavernous sinus infection:A root-canal caseAuthor_ Dr Philippe Sleiman, LebanonFig. 1 Fig. 2Fig. 1_Palatal and mesial rootspierced the sinus membrane.Fig. 2_The opening in the middle ofthe sinus could lead to misdiagnosis.Fig. 3_The infection occupied thegreater part of the maxillary sinusand perforated the sinus.Fig. 4_The infection invaded the orbit.Fig. 5_Thickening of the cavernoussinus._Once upon a time, a patient walked into my officewithout an appointment. She introduced herselfand said that her otorhinolaryngologist had referredher to my office. I asked my assistant to take the X-rays,conduct computed tomography (CT) scanning andschedule the patient as soon as possible. During coffeebreak, I was going through the scans and decided tolook at not only the printouts but all of the slides burnton the CD. As I was browsing through the slides, I realisedthat the palatal and mesial roots were piercingthe sinus membrane and there was infection aroundthem (Fig. 1). I went a few millimetres up and saw anopening in the middle of the sinus (Fig. 2). Today I knowthat it would have been a fatal error on my part hadI stopped at this level. I do not know what made mecontinue my observation, but fortunately I did.A few millimetres higher, the infection was occupyingthe greater part of the maxillary sinus andperforating the sinus (Fig. 3). Even further up, theinfection was invading the orbit (Fig. 4). The really unpleasantsurprise was a thickening of the cavernoussinus observed in two slides (Fig. 5), and cold sweatcovered my face. At this point, any flare-up, inflammationor infection could lead to such severe consequencesas thrombosis in the cavernous sinus, bringingabout a true life-or-death drama for the patient.Before presenting the rest of the clinical case, hereis a brief summary of the sinuses._Sinus definition—physiologySinuses are air-filled cavities with classical, pseudo -stratified, ciliated columnar epithelium interspersedwith goblet cells. The cilia sweep mucus towards theostial opening. Obstruction of sinus ostia might leadto mucous impaction and decreased oxygenation inthe sinus cavities. During obstruction of the ostia, thepressure in the sinus cavity may decrease, which inturn causes the symptom of pain, particularly in thefrontal region.Fig. 3 Fig. 4 Fig. 514 Iroots4_2010

case report _ cavernous sinus infection ISphenoidal sinusesThe sphenoidal sinuses are located in the body ofthe sphenoid bone and may extend into its wings.They are unevenly divided and separated by a bonyseptum. Because of this extensive pneumatisation(formation of air cells or sinuses), the body of thesphenoid is fragile. Only thin plates of bone separatethe sinuses from several important structures: theoptic nerves and optic chiasm, pituitary gland, internalcarotid arteries and cavernous sinuses. The sphenoidalsinuses are derived from a posterior ethmoidalcell that begins to invade the sphenoid, giving riseto multiple sphenoidal sinuses that open separatelyinto the sphenoidal recess. The posterior ethmoidalarteries and posterior ethmoidal nerve supply thesphenoidal sinuses.Complications of sphenoidal sinusitis (diplopia inchildhood)The most common complication of sphenoidalsinusitis is meningitis. Any surrounding tissue adjacentto sphenoid sinus may be infected. As a result ofthe close anatomical relationship with the sphenoidalsinuses, cranial nerves II to IV, the dura mater, pituitarygland, cavernous sinus, internal carotid artery,spheno-palatine artery and pterygopalatine nervehave been reported to be infected by dissemination.Complications such as orbital cellulitis, orbitalabscess, orbital apex syndrome, blindness, meningitis,epidural and subdural abscesses, cerebral infarcts,pituitary abscess, cavernous sinus thrombosis andinternal carotid artery thrombosis have been describedin literature.Clinical suspicion is very important for determiningthe diagnosis because the symptoms, history andphysical examination do not specifically indicatesphenoidal sinusitis. High-resolution axial and coronalCT is recommended for the diagnosis of sphenoidalsinusitis and potential intracranial complications.However, cranial magnetic resonance imagingis superior to CT in terms of detecting the involvementof cranial nerves, cavernous sinus, surrounding neurovasculartissue and the presence of a tumour.The most common pathogens in the aetiologyof sphenoidal sinusitis are Staphylococcus aureus,Streptococcus pneumonia and some aerobic andanaerobic Streptococcus spp. fungi, particularly Aspergillusspp., should be kept in mind in immunosuppressedpatients. Uren and Berkowitz reported eightchildren with Idiopathic subglottic stenosis, five outof which had been treated successfully with medicaltherapy. The remaining three children, either unresponsiveto medical therapy or complicated cases, hadundergone endoscopic sphenoidotomy. At the beginning,parenteral antibiotic therapy should be administered,since this infection may cause serious, evenfatal, complications. A three- to four-week antibiotictherapy should be completed. Topical decongestantsand irrigation with saline solution are recommendedas adjunctive therapy.Since the sphenoid sinus has anatomical relationshipswith several vital structures, any delay in correctdiagnosis and, therefore, in prompt and adequatetreatment, can result in severe and life-threateningcomplications 1 , such as meningitis, pituitary abscess,peri-orbital cellulitis, orbital cellulitis, optic neuritis,carotid artery thrombosis and cavernous sinus thrombosis.Sphenoiditis is generally associated with inflammationof the maxillary and ethmoidal sinuses.When complications occur, patients also complainof facial pain, paraesthesia at the level of the V1, V2, V3areas, sixth nerve palsy, ocular signs and symptoms(blurred vision, diplopia, eye tearing, proptosis, visualloss, ptosis) and mental status changes. These complicationsare due to the anatomical relationship of thesphenoid sinuses with nearby vital structures such asthe middle cranial fossa, hypophysis, superior orbitalfissure, optical canal and cavernous sinus, which containthe internal carotid artery and cranial nerves III toVI. Thus, when a sinus infection spreads to these structures,it may mimic other neurological disorders, thusdelaying correct diagnosis and appropriate treatment.Maxillary sinusesEmbryologically, the maxillary sinus is first to appear,initially, as a depression of the nasal wall belowthe middle turbinate. The growth of the sinus is relatedto the development and eruption of the maxillary molarteeth, and does not reach full size until the eruptionFig. 6Fig. 6_Immediate post-op X-ray.roots4_2010I15

I case report _ cavernous sinus infectionFig. 7 Fig. 8Figs. 7 & 8_i-CAT scan showinghealing of the sinuses.of the permanent dentition. The maxillary sinus, alsoknown as the antrum of Highmore, is the largest of theparanasal sinuses. The roof of the maxillary sinus isformed by the alveolar part of the maxilla. The rootsof the maxillary teeth, particularly the first two molars,often produce conical elevations in the floor of thesinus.Infection of the maxillary sinusesMaxillary sinusitis (inflammation of maxillarysinus) may be of dental origin. The dental causes ofmaxillary sinusitis include peri-apical infection, perio -dontal disease or perforation of the antral floor andantral mucosa at the time of dental extraction. Rootsand foreign objects forced into the maxillary sinus atthe time of operation may also be the causative factorsof sinusitis. The non-dental source of maxillary sinusitisincludes allergic conditions, chemical irritation orfacial trauma (fracture involving a wall or walls of themaxillary sinus).The patient may complain of a sense of fullnessover the cheek, especially on bending forward. Othercomplaints with regard to maxillary sinusitis mayinclude headache, facial pain and tenderness to pressure.The pain may also be referred to the premolarand molar teeth, which may be sensitive or painful topercussion.Relationship of the teeth to the maxillary sinusThe close proximity of the three maxillary molarteeth to the floor of the maxillary sinus poses po -tentially serious problems. During removal of a molartooth or root-canal treatment, root fracture may occur.If proper retrieval methods are not used, a pieceof the root may be driven superiorly into the maxillarysinus, while in the case of endodontic treatmentoverextension or over-obturation of the material maydrive material into the sinus. A communication maybe created between the oral cavity and the maxillarysinus as a result and an infection may occur. Becausethe superior alveolar nerves (branches of the maxillarynerve) supply both the maxillary teeth and the mucousmembrane of the maxillary sinuses, inflammation ofthe mucosa of the sinus is frequently accompanied bya sensation of toothache in the molar teeth._Cavernous sinusThe cavernous sinus is located on each side ofthe sella turcica on the upper surface of the body ofthe sphenoid, which contains the sphenoid (air) sinus.The cavernous sinus consists of a venous plexus ofextremely thin-walled veins that extends from thesuperior orbital fissure anteriorly to the apex of thepetrous part of the temporal bone posteriorly. Thevenous channels in these sinuses communicate witheach other through venous channels anterior andposterior to the stalk of the pituitary glands, the intercavernoussinuses and sometimes through the superiorand inferior petrosal sinuses and emissary veinsto the pterygoid plexuses.Inside each cavernous sinus is the internal carotidartery with its small branches, surrounded by thecarotid plexus of sympathetic nerve(s), and the abducentnerve (cranial nerve VI). The oculomotor (cranialnerve III) and trochlear (cranial nerve IV) nerves, plustwo of the three divisions of the trigeminal nerve(cranial nerve V) are embedded in the lateral wall ofthe sinus. The artery, carrying warm blood from thebody’s core, traverses the sinus filled with cooler bloodreturning from the capillaries of the body’s periphery,allowing for heat exchange to conserve energy orcool the arterial blood. Pulsations of the artery withinthe cavernous sinus are said to promote propulsion ofvenous blood from the sinus, as does gravity. 216 ICavernous sinus thrombosis usually results frominfections in the orbit, nasal sinuses and superior partof the face (the danger triangle). In persons withthrombophlebitis of the facial vein, pieces of an inroots4_2010

case report _ cavernous sinus infection IFig. 9 Fig. 10fected thrombus may extend into the cavernous sinusproducing thrombophlebitis of the cavernous sinus.The infection usually involves only one sinus initiallybut may spread to the opposite side through the intercavernoussinuses.Thrombophlebitis of the cavernous sinus mayaffect the abducent nerve as it traverses the sinusand may also affect the nerves embedded within thelateral wall of the sinus. Septic thrombosis of thecavernous sinus often results in the development ofacute meningitis and sometimes the life of the patientmay be endangered._Case reportAfter examining the patient, I called her otorhinolaryngologistand a neurologist to meet in the eveningto discuss the case and we decided to put the patienton antibiotic therapy for three days prior to the beginningof the treatment. In the meantime, a conservativetreatment was outlined, including root-canaltreatment and tooth restoration.Three days later, the patient returned to my officewhere I opened the tooth under strictest infectioncontrolconditions. The canals were enlarged usingTwisted Files (SybronEndo) to the size of 40, taper0.04 in the apical part. No swelling was observed andobturation was done in the same session using Real -Seal (SybronEndo), followed by composite coronalrestoration placed immediately in order to stop anypossible coronal leakage (Fig. 6).The patient was checked regularly and an i-CATwas performed. I was very pleased to see the positiveresults and the healing of the greater part of theinfection (Figs. 7 & 8). Most importantly, a completehealing of the cavernous sinus was observed (Fig. 9).At the 18-month check-up, we saw the healing ofthe sinus above the molar._ConclusionA fatal error may have been made had I decidedto extract the tooth. Under these circumstances, wewould have potentially caused a flare-up, which couldhave resulted in severe consequences. It is importantto underline that we should trust our root-canal treatmentand use strict measures in bacteria and microorganismcontrol, starting from access cavity openingto the root-canal shaping, especially in the last 3mm,where a size 40.04 Twisted File was used for apicalenlargement. Obturation was done with RealSeal. Thishighly bio-compatible material is zinc and eugenolfree, making aspergillosis and sinus inflammation dueto paste extrusion beyond apex highly unlikely. The finalresults demonstrate a complete healing of the sinuses,of which the patient was very relieved to learn (Fig. 10).The main message of this article is that we needto take our time in determining the correct diagnosisfor each case that is presented to our office. We haveto go beyond the oral sphere. The proper approachcan ensure excellent results in a simple and straightforwardtreatment.I would like to thank Phd Yulia Vorobyeva, interpreterand translator, for her help with this article._Editorial note: A list of references is available from thepublisher._contactDr Philippe SleimanDubai Sky ClinicBurjuman Business Tower, Level 21Trade Center Street, Bur DubaiDubai, UAEphil2sleiman@hotmail.comrootsFigs. 9 & 10_Healing of the sinuses.roots4_2010I17

I feature _ interview“We are constantlytrying to maintain ourtechnological lead”An interview with Audrey Stefani, Dr Stephan Gruner & Dr Khaled A. BaltoAudrey Stefani Dr Stephan Gruner Dr Khaled A. Balto_It all started with a nerve broach in 1907.MICRO-MEGA, whose headquarters are located inBesançon (France), has been manufacturing endo -dontic tools for over a hundred years and played adecisive role in endodontics through new developments.Internationally, the innovative company hasa recognised reputation of being a specialist in dentalinstruments. At this year’s Adviser Group for Endo -dontics (AGE) meeting, roots met with Audrey Stefani,MICRO-MEGA Marketing Manager; Dr StephanGruner, Country Manager MICRO-MEGA Germany;and Dr Khaled A. Balto (Saudi Arabia), Associate Professorand moderator of the AGE meeting._roots: Mrs Stefani, for over a century MICRO-MEGA has been operating successfully in the dentalmarket. Could you tell us anything in particular thatstands out for you in the company’s history?Audrey Stefani: MICRO-MEGA is proud of havingset international milestones with handpieces andcontra-angle handpieces, micro-motors, endodonticfiles and NiTi files.A fact that perhaps only a few people know is thatMICRO-MEGA used to be the sole manufacturer ofhandpieces and contra-angle handpieces for thelarge brands in Germany and other countries.The Citoject, for example, was a MICRO-MEGAproduct, manufactured under Heraeus’ own brandfor Heraeus. Today, it is still available as LigaJect fromMICRO-MEGA, even after it was phased out of production.To a considerable degree, the company wascharacterised by being able to launch world-firstinnovations on the market regularly, and we are ableto build on this expertise today.18 Iroots4_2010

feature _ interview I_Which MICRO-MEGA products have set standardson the international dental markets?MICRO-MEGA inventions have set world standards;for example, in 1957 with the first dismountablehandpieces with tungsten-carbide bearings; in1963, Giromatic, the first contra-angle handpieceable to produce an alternating 90° rotation and speciallymade root-canal tools; in 1964, micro-motorswith 40,000 rotations per minute, on the basis ofwhich micro-motors are built today by all manufacturers;in 1974, the Masserann Kit for the removal offractured endodontic tools from root canals; in 1996,HERO 642, a clear and simple system of rotary NiTifiles; in 2002, HERO Shaper, a rotary NiTi file system.I could go on with this list indefinitely.“MICRO-MEGAis proudof having setinternationalmilestones.”Audrey StefaniAll these experiences led to the development ofthe Revo-S file system, which was launched in 2009.This system enables a root-canal preparation withonly three files. Revo-S is currently state-of-the-arttechnology; however, development is ongoing, whichis why we hold the AGE symposium every year._In autumn 2009, MICRO-MEGA joined a groupof companies under the management of SycoTec. InMarch of this year, the Canadian SciCan joined theEuropean duo. The group is now amongst the topten manufacturers of dental equipment worldwide.What opportunities does such a strong group offer?One great asset is that we are able to join forcesand learn from one another. Our focus here in Europenaturally lies in Germany and France, but we are alsogoing to enter new markets. If possible, we will usejoint marketing, and joint research and developmentin order to consolidate our position on the market.An important part of the strategy is to maintain andfurther the SciCan and MICRO-MEGA brands._Is the name of the group still under debate?Indeed, we have debated this for a while but havefinally agreed on a name. I am proud to announce thatMICRO-MEGA, SciCan and SycoTec are members ofthe Sanavis Group._MICRO-MEGA sells its products worldwide.Which countries are the most important in terms ofturnover? And which regions hold the most potentialin your opinion?Europe has always played an important role in ourcorporate development. The most important importingcountries are Germany and, in our domesticmarket, France. North and South America are in theprocess of development, particularly with the introductionof our rotary NiTi systems. We have alsorecorded good growth figures in the Asia-Pacificregion. Moreover, we are keenly observing the MiddleEastern region. As you can see, MICRO-MEGA asan internationally known brand is in the process ofexploiting current potential markets.There is every chance of success, particularly sinceresearch and development in the group have nowreached global player magnitude and we know howto take advantage of this._Dr Gruner, are you currently working on thedevelopment of new products?Dr Stephan Gruner: Thanks to the abovementionedsynergies, our newly created group isgoing to get things moving in the dental world. Weare constantly trying to maintain our technologicallead and thus work hard and intensively. An event likethe AGE helps keep MICRO-MEGA’s finger on thepulse of world trends._Have your expectations of this year’s AGE meetingbeen met?The AGE meeting has once again helped usprogress scientifically thanks to top-notch researchresults presented by the speakers. During our internalMICRO-MEGA sessions, we were able to discussinternational market demands further, which werethen tested for feasibility and formed into projects.“The AGE meetinghas once againhelped us progressscientifically.”Dr Stephan Gruner_Prof Shimon Friedman lectured on The endo -dontic treatment outcome: The impact of the newtechnologies. Would you please summarise the mostimportant points for us?Prof Friedman is world-renowned in the field ofendodontics. Together with co-authors Dr Thuan Daoroots4_2010I19

I feature _ interviewet al., he authored the world famous Toronto Study,a series of articles in the Journal of Endodontics. Thisis an extensive piece of work that illustrates andanalyses the status of endodontics, starting with thepublication of the first results in the year 2000 up toand including 2010.In his excellent lecture, Prof Friedman made clearthat differences in the evaluation and success or failureof an endodontic treatment greatly depend on themethods and structure of the evaluating studiesthemselves. If the correct evaluation criteria areapplied, the success rate of endodontic treatmentsover the last ten years is around 88 to 95%. Amongstthe various authors, a high consistency of results isnoticeable. These studies are encouraging._The new product Revo-S was a part of furtherpresentations. Dr Balto, in connection with the innovativeRevo-S concept you also spoke about the ‘thirddimension’ of endodontic treatment. Would youplease illustrate the main points of the system?“Revo-S is theresult of 17 years ofcritical performanceanalysis.”Dr Khaled A. BaltoDr Khaled A. Balto: In general, endodontic rotarysystems are evaluated with regard to the parametersof geometric features, taper, tip size, etc. Therefore,the equation for efficiency of a given file has longbeen considered to be inner core size and symmetricdesign (which means perfect geometry), which resultsin stronger files. After 17 years of using RotaryNiTi files, we have learned that the equation for efficiencyis rather the asymmetric design and efficientclearing of dentinal debris. This understanding wasapplied in the conception of the Revo-S system.Revo-S is the result of 17 years of critical performanceanalysis, which for the first time addressed theconcept of dynamic asymmetry. As a result, we nowhave files with better penetration and a better clearingeffect. Moreover, it is efficient, with only threefiles for initial treatment and much less likelihood ofseparation. To perceive the bio-mechanics of the filein the ‘third dimension’, the canal depth, the kineticsof Revo-S—the way it rotates inside the root canal—are analysed._What is your view of endodontics in the Arabicregion compared to the Western world?Endodontics is a rapidly growing speciality in theArab world in general, particularly in Saudi Arabia.Rotary endodontics, micro-training, warm obturationtechniques as well as modern retreto-dontics areall an integral part of teaching curricula at many universities.However, as in many other countries in theworld, there is a wide range of performance resultsdepending on the experience of the dentists and thedifficulty of the cases. Individual variation plays a significantrole in the treatment standards. For example,being an associate in a practice limited to microendodonticsin Jeddah, I treat patients from all overthe world as well as locals. I have managed failuresfor treatments rendered domestically and from othercountries. All in all, I do not see substantial differencesbetween the different countries in regards to thestandard of treatment however, there might be a differencein the number of well qualified individuals._Your comprehensive publications illustrate thewide range of your work. What are you working on atthe moment?Being an academic, clinician and researcher atthe same time is rather difficult but not impossible.As Deputy Director of the Center of Excellence forOsteoporosis Research in Jeddah, my current researchfocuses on osteoporosis as it relates to oral health.Since I returned from Harvard Dental School, where Ireceived my D.M.Sc., the essence of my research interesthas remained the same, which is in brief: cellularand molecular mediators of infection-induced bonedestruction, evidence-based dentistry and other clinicalendodontic research._Apart from publishing, how do you exchangeinformation with international colleagues?The world has become a small village thanks tothe recent developments in information and communicationtechnology. The Internet is the driving forcefor today’s information exchange. Online publishing,discussion forums, YouTube, etc. make it easy to stayin touch and remain updated on new developments.In my opinion, postgraduate training programmes inendodontics constitute the most important cornerstone.As Director of the Saudi Board of Endodontics,I have the privilege of reviewing articles and thusam constantly kept up to date on what’s new. Addi -tionally, I value the international interaction that ispossible through conferences and meetings like theAGE meeting.We would like to thank you for this interview andwish you continuing success._Editorial note: The interview was led by Jeannette Endersand Steffi Goldmann.20 Iroots4_2010

Everything Endo.Every step of the way.DIAGNOSTICSSHAPEOBTURATIONCLEANDiagnostics > Shape > Clean > Obturation.Everything endo from SybronEndo.SybronEndo Europe, Basicweg 20, 3821 BRAmersfoort, The NetherlandsTel: +31 33 4536 159 fax: +31 33 4536 153email: endo@sybrondental.com

I special _ advancements in endodonticsEndodontic success:The pursuit of ourpotentialAuthor_ Dr Wyatt D. Simons, USAFig. 1a_A mid-root, cystic-appearingradio-lucency was noted withoutperi-apical involvement.Fig. 1b_Upon CBCT evaluation, alateral portal of exit can be visualisedin the centre of this mid-root radio -lucency. This aided in the diagnosisof disease of endodontic origin andfurthered the success of treatment.Fig. 1c_Lateral system instrumentedwith a sharp J-curve of a stiff#15 hand file.Fig. 1a Fig. 1b Fig. 1cFig. 2a_When the cyst was surgicallyremoved, the mid-root lateral wasnoted to be sealed with gutta-percha.Fig. 2b_The sealed upward-facinglateral can be seen on the post-opdigital image._Endodontics is currently experiencing an excitingperiod in its evolution: a period when progressiveclinicians have become empowered to increasetheir rates of success owing to new technologies thatenhance vision, disinfection and the protective seal ofthe entire root-canal system. Early in my endodonticjourney, Dr Herbert Schilder, a pioneering clinician,encouraged me to reach my full potential. We allaspire to reach our individual potential, and it is thiscollective pursuit of excellence that guides the futuresuccess of our specialty.Our pursuit of higher success rates comes at a timeof unique opportunity, a time when the comparativesuccess rates between implants and endodonticallytreated teeth are being scrutinised 1–2 —and a timewhen some patients have been known to be advisedto make decisions based mainly on a comparison ofresearch-quoted technical success rates.Fig. 2aFig. 2bDedicated clinicians are able to strive for improvedsuccess rates owing to many recent advances in ourfield. This article focuses on three areas of endo -dontics that have undergone profound advancementrecently. The efficacy of our treatment has improvedowing to our increased ability to visualise, disinfectand seal the entire root-canal system in three dimensions.22 Iroots4_2010

special _ advancements in endodontics I_Precise 3-D visualisationThe ability to visualise the complexities of pulpalanatomy has had a tremendous impact on our abilityto diagnose and treat complex endodontic disease. 3–6For decades, the microscope has enhanced the qualityof our endodontic treatment. The knowledge thatgreater expertise and quality outcomes can resultfrom increased visualisation is self-evident. Currently,cone beam computed tomography (CBCT)allows us to visualise the intricacies of individualpulpal anatomy more clearly in 3-D. 7 CBCT uncoversdetails of anatomy in the pulpal system and bone priorto initiating treatment, which in turn guides diagnosisand contributes significantly to more predictabletreatment. 8–9 The following cases illustrate examplesof how CBCT can aid the clinician in endodontic diagnosisand treatment.When a patient presents with swelling of thelower right vestibule, a comprehensive examinationis performed, including a 2-D digital peri-apicalradiograph. In this case, a mid-root, cystic-appearing,radiolucent lesion was noted without peri-apicalinvolvement (Fig. 1a). Upon CBCT evaluation, a lateralportal of exit was visualised in the centre of thisosseous defect, which aided in the diagnosis of a lesionof endodontic origin (Fig. 1b). 10–11 Once comprehensivepulpal testing had been completed, tooth#28 was confirmed to be non-vital.After analysing the information provided by theCBCT image, the infected lateral system was moreeasily located and instrumented with the sharpJ-curve of a stiff #15 hand file (Fig. 1c). Treatmentwas enhanced by directly instrumenting this aspectof the pulpal system, as we know that this increasesdisinfection. 12 After non-surgical treatment hadbeen completed, surgical intervention was perfor -med owing to the appearance and size of the lesion.When the radicular cyst (confirmed histologically)had been removed, the surgical microscope displayedthe lateral portal of exit to be sealed with guttapercha(Fig. 2a). In addition, the sealed upwardfacinglateral system can be seen on the post-operativedigital image (Fig. 2b).Fig. 3aComprehensive treatment of the entire pulpalsystem dictates endodontic success. 13 Figures 3aand b illustrate the common challenge that arisesas the result of a second mesio-buccal system (MB2)in upper molars. Once clinicians visualise whethercomplex pulpal anatomy is present with CBCT, theycan confidently and conservatively locate it under themicroscope. With utilisation of this new technology,incomplete endodontic therapy should be a thing ofthe past.CBCT has a profound impact on our ability tolocate and treat calcified pulpal systems. 14 Figure 4aillustrates a calcified molar in need of endodontictherapy. Upon initial microscopic treatment, difficultyin locating the mesio-lingual (ML) system wasencountered. Calcium hydroxide was placed and aCBCT image was taken. The location of the elusivecanal was visualised as being patent and at the levelof the current conservative exploration, but 0.25mmto the lingual (Fig. 4b). Upon microscopic re-entry intothe case, the ML canal was conservatively located andcomprehensive treatment was completed (Fig. 4c)._Relentless pursuit of complete disinfectionRevolutionary advancements in endodontic disinfectionhave intensified our desire to reach higher levelsof disinfection. One such device that facilitates thisgoal is the EndoVac (Discus Dental; Figs. 5a & b). 15–17The EndoVac provides thorough irrigation of thecomplete root-canal system, including the criticallyFig. 3bFigs. 3a & b_CBCT technology iscommonly used for confirmation ofthe presence and location of an MB2.This allows for confident, conservativeand comprehensive treatment.Fig. 4a_A calcified molar in need ofendodontic therapy.Fig. 4b_After initial explorationfor the calcified ML system, calciumhydroxide was placed and a CBCTimage was taken. The location of theelusive canal was visualised to bepatent and at the level of the currentconservative exploration, but0.25mm to the lingual.Fig. 4c_CBCT information allowedfor the conservative location of thecalcified ML system and completionof comprehensive treatment of theentire root-canal system.Fig. 4a Fig. 4b Fig. 4croots4_2010I23

I special _ advancements in endodonticsFig. 5a_MacroCannula aids in theremoval of gross debris duringtreatment, especially in the midrootto coronal areas.Fig. 5b_MicroCannula facilitates theremoval of microscopic debris at theapical 1mm of the root-canal system.Fig. 6_SAF file offers us the ability toshape the morphology of individualpulpal systems in 3-D.Fig. 6Fig. 5aimportant apical region. 18–22 The device delivers thedisinfecting solution to the coronal aspect of the pulpalsystem and draws the solution to the apical regionof the pulpal system by way of evacuation. This techniqueallows for a safe, comprehensive irrigation ofthe entire root-canal system. 23–25 This technologyovercomes the limitations of solution surface tensionsand apical vapour locks that occur in deep, difficult-to-reachareas of pulpal systems. 26 In addition,the continuous movement of the solution increasesmicrobial hydrolysis. 27In the pursuit to increase successful outcomes, theprogressive clinician must stay at the forefront of newtreatment modalities that may increase our efficacyin attaining higher levels of disinfection. Traditionalendodontic techniques are basedon the theory that files shapeand irrigation solutions clean. 28We know the limitations of currentrotary files in shaping themorphology of complex rootcanalsystems. On average, mostfile systems reach less than 50%of canal walls. 29 Therefore, ourinability to reach many surfacesof the root-canal system physicallyhas dictated that disinfection relymainly on the many techniques ofirrigation. However, a new treatmentmodality challenges this method. TheSelf Adjusting File Endodontic Systemdistributed by Henry Schein, Inc.,spearheads this new direction into3-D shaping. The SAF instrument (Fig.6) was designed to reach the majorityof pulpal walls in a 3-D fashion.30–31 This potential quantum leapin our ability to reach all pulpal wallsphysically, significantly increasesour efficacy in disinfection. 32 Thismay set forth a paradigm shift inthe way we approach our shapingand disinfecting techniques.Fig. 5b_Higher success rates with the 3-Dseal of the entire root-canal system—advances in the coronal sealOnce the 3-D intricacies of a root-canal systemhave been evaluated, shaped and disinfected, thensuccess ultimately lies in our ability to seal this complexand vulnerable system from the pathogenicsource of endodontic disease, the oral cavity. 33–34Overall endodontic success rates would be higher ifall clinicians placed the coronal seal immediatelyafter the canals are sealed. This is the time when theisolated pulpal system is at its highest level of disinfection.We know that endodontic disease emanatesfrom the oral cavity and we strive to disinfect andseal the smallest of crevices within canal systems,but what about the main portal of entry for thesepathogens? Figure 7 illustrates a lack of respect forthis well-understood requirement for success. Arelatively similar case treated in Figure 8 has a significantlyincreased overall prognosis.In addition to common sense, the amount ofquality research that supports this imperative finalobjective of successful endodontic treatment is staggering.35–43 A recent, impressive study was performedby one of the largest insurance companies in the USin an effort to evaluate the success of endodonticoutcomes. In assessing over 1.4 million endodonticcases over an eight-year period, they found a successrate of 97%. Pretty impressive! However, it was alsofound that in the 3% of cases that failed, 85% didnot have coronal coverage. 44 Imagine the achievablesuccess rate of modern endodontic therapy shouldan immediate seal of the entire root-canal systembecome the standard of practice.Endodontists should diligently educate those intheir local dental community of the overwhelmingimportance of this immediate final phase of successfulroot-canal therapy. A universal practice of placingthe coronal seal as a final phase of treatment willgreatly enhance the success of our profession. Theprudent endodontic practitioner should exclude any24 Iroots4_2010

special _ advancements in endodontics IFig. 7_This case illustrates a lackin respect for the need to place aproper coronal seal immediatelyafter obturation.Fig. 8_This relatively similar caseillustrates a significantly increasedprognosis owing to the fulfilment ofthis final requirement for success.knowledgeable clinician contributing to the patient’sdental health, who does not respect this imperativeobjective for a successful outcome. Reasons for havinga separate clinician complete the coronal seal ata later time are usually business related. These typeof rationalisations do not adhere to our HippocraticOath to promote the best interests of the patient.Figures 9a and b illustrate the reproducible healingpotential of lesions of endodontic origin when thisfinal objective of successful endodontic therapy isaccomplished.Fig. 7 Fig. 8Currently, many are in favour of alternatives to theretention of natural teeth through successful endo -dontic therapy. Not since the focal infection era havewe seen such ill-advised loss of viable teeth. Theseopponents of endodontic therapy feel that the field isa dying profession. They speak of root-canal therapyas a holding pattern for an implant. Indeed, this statementmay be true when the requirements for successfultreatment are not strictly adhered to. Fortunately,dedicated clinicians have never been equippedwith so many tools to diagnose correctly and treatcomplex endodontic disease. The ability to provideendodontic excellence is more attainable today becauseof our ability to see, disinfect and seal the entireroot-canal system in 3-D.Figs. 9a & b_Deep dentinal bondingwas accomplished with a dualcuredresin to complete the finalrequirement of successful endodontictherapy.Fig. 10_Most dual-cured applicationtips can be augmented with asecurely fastened etchant tip toallow for deep placement intoconfined spaces.The cornerstone of a successful coronal seal is theability to obtain deep dentinal bonding. For accurateplacement into deep, confined spaces, most-dualcured application tips can be augmented with a securelyfastened etchant tip (Fig. 10). The etchant tipby Pulpdent (ref #22D100) works quite well in thisregard. In order to maximise deep dentinal bonding,a dual-cured bonding agent should be used in conjunctionwith a dual-cured resin. 45 The typical sequenceto attain maximum deep dentinal bondingafter obturation is solvent, etchant, pre-bond, followedby the mixing of A and B. Owing to the compatibilityof the materials, this older generation ofbonding agents has been shown to have increasedbond strength when used in conjunction with a dualcuredresin. 45In addition to providing the coronal seal of theroot-canal system, deep dentinal bonding must alsoensure the retention of the core. Each case should beindividually assessed in this regard._The future of endodonticsFig. 9aFig. 9bFig. 10roots4_2010I25

I special _ advancements in endodonticsFig. 11a_Annotated 3-D model of alower molar that illustrates complexpulpal anatomy.Fig. 11b_Endodontic therapy thatillustrates the respect for the naturalpulpal anatomy present.Fig. 12a_Post-op image of the abilityto seal complicated pulpal anatomy.Fig. 12b_Healing observed whenobjectives for successful endodontictherapy are accomplished.Fig. 11aFig. 11bFig. 12aFig. 12bFig. 13_Illustration of the objectiveto have continual seal of the entireroot-canal system from the apex tothe cavo-surface.Further advancement in our ability to visualiseroot-canal systems and the surrounding structuresin 3-D will continue to revolutionise our capacity todiagnose and treat endodontic disease. The quality ofendodontic therapy provided will increase as thescience of CBCT develops. Future advancement in thisscience will focus on our ability to more clearly renderand manipulate these images. Figure 11a is an annotated3-D model of a lower molar that illustrates pulpalanatomy that is encountered in clinical practice. 46Figure 11b displays the endodontic outcomes possiblewhen such natural complexities are respected.There are many exciting advancements on thehorizon to aid in our pursuit of higher levels of disinfection.Further exploration into the potential toshape individual pulpal anatomy on a 3-D basis willcontinue. The science of irrigation may one day takeus from disinfection to sterilisation. Figures 12a and billustrate the successful outcome that can be accomplishedwhen intricate areas of an infected root-canalsystem can be disinfected and sealed.Future advancement in the pursuit of a precisecoronal seal will be in the form of products and devicesthat aid in the technique-sensitive procedure of placingdeep dentinal bonding. Figure 13 illustrates thisobjective of a continuous seal of the entire root-canalsystem from the apex to the cavo-surface.Fig. 13These advances in endodontic treatment modalitieswill undoubtedly have a significant impact on ourability to attain greater success rates. However, the futureof our profession is in the hands of skilled andcommitted clinicians who strive to move our professionforward. Progressive exploration into the areasdiscussed in this article will keep endodontic therapyat the forefront of treatment options available forpatients._26 Iroots4_2010

AD_References1. Doyle SL, Hodges JS, Pesun IJ, Baisden MK, Bowles WR.Factors affecting outcomes for single-tooth implants andendodontic restorations. J Endod. 2007 Apr;33(4):399–402.2.Iqbal MK, Kim S. For teeth requiring endodontic treatment, whatare the differences in outcomes of restored endo donticallytreated teeth compared to implant-supported restorations? IntJ Oral Maxillofac Implants. 2007;22 Suppl: 96–116.3. Estrela C, Bueno MR, Leles CR, Azevedo B, Azevedo JR.Accuracy of cone beam computed tomography and panoramicand periapical radiography for detection of apical periodontitis.J Endod. 2008 Mar;34(3):273–9.4. Patel S, Dawood A, Mannocci F, Wilson R, Pitt Ford T. Detectionof periapical bone defects in human jaws using cone beamcomputed tomography and intraoral radiography. Int Endod J2009 Jun;42(6):507–15.5. Tyndall DA, Rathore S. Cone-beam CT diagnostic applications:caries, periodontal bone assessment, and endodontic applications.Dent Clin North Am. 2008 Oct;52(4):825–41, vii.6. Stavropoulos A, Wenzel A. Accuracy of cone beam dentalCT, intraoral digital and conventional film radiography for thedetection of periapical lesions. An ex vivo study in pig jaws. ClinOral Investig. 2007 Mar;11(1):101–6.7. Patel S. New dimensions in endodontic imaging: Part 2. Cone beamcomputed tomography. Int Endod J. 2009 Jun; 42(6): 463–75.8. Low KM, Dula K, Bürgin W, von Arx T. Comparison of PeriapicalRadiography and Limited Cone-Beam Tomography in PosteriorMaxillary Teeth Referred for Apical Surgery. J Endod.2008;34(5):557–62.9. Cotton TP, Geisler TM, Holden DT, Schwartz SA, Schindler WG.Endodontic applications of cone-beam volumetric tomography.J Endod. 2007 Sep;33(9):1121–32.10. Schilder H. Filling root canals in three dimensions. Dent ClinNorth Am. 1967 Nov:723–44.11. Schilder H. Canal debridement and disinfection. In Pathwaysof the Pulp. 1 st Ed., St. Louis: Mosby Co., 1976:111–33.12. Byström A, Sundqvist G. Bacteriologic evaluation of the efficacyof mechanical root canal instrumentation in endodontictherapy. Scand J Dent Res. 1981 Aug;89(4):321–8.13. West JD. The relationship between three-dimensional endo -dontic seal and endodontic failure. Master Thesis. Boston:Boston University, 1975.14. Matherne RP, Angelopoulos C, Kulild JC, Tira D. Use of conebeamcomputed tomography to identify root canal systemsin vitro. J Endod. 2008 Jan;34(1):87–9.15. Hockett JL, Dommisch JK, Johnson JD, Cohenca N. Antimicrobialefficacy of two irrigation techniques in tapered andnontapered canal preparations: an in vitro study. J Endod.2008 Nov;34(11):1374–7.16. Brito PR, Souza LC, Machado de Oliveira JC, Alves FR, De-DeusG, Lopes HP, Siqueira JF Jr. Comparison of the effectivenessof three irrigation techniques in reducing intracanal Enterococcusfaecalis populations: an in vitro study. J Endod. 2009Oct;35(10):1422–7.17. Miller TA, Baumgartner JC. Comparison of the antimicrobialefficacy of irrigation using the EndoVac to endodontic needledelivery. J Endod. 2010 Mar;36(3):509–11. You can also subscribe viawww.oemus.com/abo✂I hereby agree to receive a free trial subscription of (4 issues per year). I would like to subscribe to for € 44 includingshipping and VAT for German customers, € 46 including shipping and VAT for customers outsideof Germany, unless a written cancellation is sent within 14 days of the receipt of the trial subscription.The subscription will be renewed automatically every year until a written cancellationis sent to OEMUS MEDIA AG, Holbeinstr. 29, 04229 Leipzig, Germany, six weeks prior to therenewal date.Reply via Fax +49 341 48474-290 to OEMUS MEDIA AG or per E-mail to:grasse@oemus-media.deLast NameFirst NameCompanyStreetZIP/City/CountyE-MailSignatureNotice of revocation: I am able to revoke the subscription within 14 days after my order by sendinga written cancellation to OEMUS MEDIA AG, Holbeinstr. 29, 04229 Leipzig, Germany.UnterschriftOEMUS MEDIA AGHolbeinstraße 29, 04229 LeipzigTel.: +49 341 48474-0Fax: +49 341 48474-290E-Mail: grasse@oemus-media.de

I special _ advancements in endodonticsEditorial note: Dr Simons perfor -med all treatments pre sentedin this article. He does not currentlyhave an interest in anyproducts discussed in this article.All CBCT images were taken withthe Kodak 9000 3D CBCT and all2-D images were taken with theKodak 6100._about the author18. Baumgartner JC, Falkler WA Jr. Bacteria in the apical 5 mmof infected root canals. J Endod. 1991 Aug;17(8):380–3.19. Susin L, Parente JM, Loushine RJ, Ricucci D, Bryan T, WellerRN, Pashley DH, Tay FR. Canal and isthmus debridementefficacies of two irrigant agitation techniques in a closedsystem. IEJ (In Press).20. Parente JM, Loushine RJ, Susin L, Gu L, LooneySW, WellerRN, Pashley DH, Tay FR. Root canal debridement usingmanual dynamic agitation or the EndoVac for final irrigationin a closed system and an open system. IEJ (In Press).21. Nielsen BA, Baumgartner CJ. Comparison of the EndoVacSystem to Needle Irrigation of Root Canals. J Endod 2007;33(5):611–5.22. Shin SJ, Kim HK, Jung IY, Lee CY, Lee SJ, Kim E. Comparisonof the cleaning efficacy of a new apical negative pressure irrigatingsystem with conventional irrigation needles in the rootcanals. Oral Surg Oral Med Oral Pathol Oral Radiol Endod.2010 Mar;109(3):479–84.23. Desai P, Himel V. Comparative Safety of Various IntracanalIrrigation Systems. J Endod 2009;35:545–9.24. Mitchell RP, Yang SE, Baumgartner JC. Comparison of apicalextrusion of NaOCl using the EndoVac or needle irrigation ofroot canals. J Endod. 2010 Feb;36(2):338–41.25. Gondim E Jr, Setzer FC, Dos Carmo CB, Kim S. Postoperativepain after the application of two different irrigation devices ina prospective randomized clinical trial. J Endod. 2010 Aug;36(8):1295–301.26. Tay FR, Gu LS, Schoeffel GJ, Wimmer C, Susin L, Zhang K, ArunSN, Kim J, Looney SW, Pashley DH. Effect of vapor lock on rootcanal debridement by using a side-vented needle for positivepressureirrigant delivery. J Endod. 2010 Apr;36(4):745–50.27. Clegg MS, Vertucci FJ, Walker C, Belanger M, Britto LR. Theeffect of exposure to irrigant solutions on apical dentinbiofilms in vitro. J Endod. 2006 May;32(5):434–7.28. Baker NA, Eleazer PD, Averbach RE, Seltzer S. Scanningelectron microscopic study of the efficacy of various irrigatingsolutions, J Endod. 1975 Apr;1(4): 127–35.29. Peters OA, Schönenberger K, Laib A. Effects of four Ni-Tipreparation techniques on root canal geometry assessedrootsDr Wyatt D. Simons is a diplomate of the American Board ofEndodontists. After graduating from the University of the Pacific,Arthur A. Dugoni School of Dentistry, in 1999, he completed hisspecialty training in endodontics at Boston University in 2001.Dr Simons is an Adjunct Assistant Professor of Endodontics atthe University of the Pacific and lectures nationally.In 2004, he founded Signature Specialistsin San Clemente, California,where he practises and presents livetraining seminars. Dr Simons is passionately committed tothe advancement of the profession of endodontics. Most recently,he presented live treatment to the American Associationof Endodontists (AAE) as part of the Master Clinician Series at the2010 AAE conference. To learn more about Dr Simons, go to www.signaturendo.com.by micro computed tomography. Int Endod J. 2001 Apr;34(3):221–30.30. Metzger Z, Zary R, Cohen R, Teperovich E, Paqué F. The Qualityof Root Canal Preparation and Root Canal Obturation inCanals Treated with Rotary versus Self-adjusting Files:A three-dimensional micro-computed Tomographic Study.J Endod. 2010 Sep;36(9):1569–73.31. Peters OA, Boessler C, Paqué F. Root canal preparation witha novel nickel-titanium instrument evaluated with microcomputedtomography: canal surface preparation over time.J Endod. 2010 Jun;36(6):1068–72.32. Metzger Z, Teperovich E, Cohen R, Zary R, Paqué F, HülsmannM. The self-adjusting file (SAF). Part 3: removal of debris andsmear layer-A scanning electron microscope study. J Endod.2010 Apr;36(4):697–702.33. Kakehashi S, Stanley HR, Fitzgerald RJ. The effects of surgicalexposures of dental pulps in germfree and conventional laboratoryrats. J South Calif Dent Assoc. 1966 Sep;34(9):449–51.34. Möller AJ, Fabricius L, Dahlén G, Ohman AE, Heyden G. Influenceon periapical tissues of indigenous oral bacteria and necrotic pulptissue in monkeys. Scand J Dent Res. 1981 Dec; 89(6):475–84.35. Southard DW. Immediate core build-up of endodonticallytreated teeth: the rest of the seal. Pract Periodontics AesthetDent. 1999 May;11(4):519–26; quiz 528.36. Tronstad L, Asbjørnsen K, Døving L, Pedersen I, Eriksen HM.Influence of coronal restorations on the periapical health ofendodontically treated teeth. Endod Dent Traumatol. 2000Oct;16(5):218–21.37. Heling I, Gorfil C, Slutzky H, Kopolovic K, Zalkind M, Slutzky-Goldberg I. Endodontic failure caused by inadequate restorativeprocedures: review and treatment recommendations.J Prosthet Dent. 2002 Jun;87(6):674–8.38. Weine FS. In Endodontic Therapy. 5 th Ed., St. Louis: Mosby Co.,1996:4.39. Ray HA, Trope M. Periapical status of endodontically treatedteeth in relation to the technical quality of the root filling andthe coronal restoration. Int Endod J. 1995 Jan;28(1):12–8.40. Torabinejad M, Ung B, Kettering JD. In vitro bacterial pene -tration of coronally unsealed endodontically treated teeth.J Endod. 1990 Dec;16(12):566–9.41. Alves J, Walton R, Drake D. Coronal leakage: endotoxin penetrationfrom mixed bacterial communities through obturated,post-prepared root canals. J Endod. 1998 Sep;24(9):587–91.42. Ricucci D, Gröndahl K, Bergenholtz G. Periapical status ofroot-filled teeth exposed to the oral environment by loss ofrestoration or caries. Oral Surg Oral Med Oral Pathol OralRadiol Endod. 2000 Sep;90(3):354–9.43. Swanson K, Madison S. An evaluation of coronal microleakagein endodontically treated teeth. Part I. Time periods. J Endod.1987 Feb;13(2):56–9.44. Salehrabi R, Rotstein I. Endodontic treatment outcomes in alarge patient population in the USA: an epidemiological study.J Endod. 2004 Dec;30(12):846–50.45. Schwartz RS, Fransman R. Adhesive dentistry and endodontics:materials, clinical strategies and procedures for restoration ofaccess cavities: a review. J Endod. 2005 Mar;31(3):151–65.46. Brown WP, Herbranson EJ. Brown and Herbranson Imaging:www.brownherbransson.com/tutorial_atlas.shtml.28 Iroots4_2010

DOWNPACK & BACKFILLFAST AND TIGHTLY SEALED ROOT CANAL FILLINGSTIME-SAVING AND LONG-LASTING 3D OBTURATION OF ROOT CANALSFilling was never so easy!• Obturation device for downpack and backfillDevice designed for your comfort• Ergonomically designed handpieces with large operation angleand feather-touch activation by flexible silicone ringLateral or vertical obturation? Better results with Calamus ®• Vertical condensation is a faster method to achieve a long-lasting,tightly sealed, three dimensional root canal filling• Reliable obturation of lateral canals as well as minimal risk of root fractureswww.dentsplymaillefer.com

I special _ transparent teethTransparent teeth:A powerfuleducational toolAuthor_ Dr Sergio Rosler, Argentinathorough examination of the pulp chambers and rootcanals. 7–9 It was also utilised in the study of apicalleakage. 10 Today, the clearing technique remainsuseful only as a teaching and research tool, with littleor no clinical applicability. 11Fig. 1 Fig. 2_Since the early days of dentistry, dentists haveexplored the morphology of the internal root anatomy.From the pre-X-ray period to the techno logy-drivenpresent, the study and exami nation of the root-canalsystem has become an obsession for endo dontists.Several methods such as radiographic 1 and histolo -gical examinations, 2–3 cross-and longitudinal sectioning,4 and root-clearing techniques, to name a few,were widely used in the past. Today, different computerisedtomography studies 5 and observations underdental operating microscopes 6 are performed to lightup the dark confines of the dental pulp.In 1913, Hermann Prinz successfully cleared teethusing the protocol proposed by Spaltholz in 1906. 12Okumura performed in-depth studies of the pulpanatomy and classified the canals according to theirdistribution and prevalence. 13 In order to simplify thecanal system visually, he injected ink into the pulpcavity. 13 Samples can also be stained with Haematoxylinand Eosin, which are largely used to colourhistological preparations. Compared with otherprocedures such as radiographic and histologicalexaminations, the tooth-clearing technique has thefollowing advantages:_retains the original form of the root;_enables the observation of minute details of theroot-canal morphology;_is inexpensive;_samples can be conserved for a long time; and_is easy to perform._The tooth-clearing techniqueOver the last 100 years, the tooth-clearing techniquewas utilised in human dental pulp morphologystudies, as it provides a 3-D view of the pulp cavityin relation to the exterior of the teeth and allows aFig. 330 Iroots4_2010

special _ transparent teeth IThe clearing process consists of three basic steps:demineralisation, dehydration and clearing of theroot structure. 14–15Sample preparation_Store extracted teeth in 10% formal saline untiluse. 11_Scale calculus and any remains of periodontal tissue._Decoronate samples and negotiate canals with a#10 file (this will enhance acid penetration)._Store samples in 4.2% NaOCl solution (the organictissue removal can be enhanced by placing thesolution with the samples in the Ultrasonic Cleanerfor 20 minutes)._Wash under running water and dry._Indian ink can be drawn through the root-canal systemby applying negative pressure to the apical end.Demineralisation_Store samples in 5% nitric acid (HNO 3 ) for threedays._Change solution every eight hours._Manual or mechanical agitation promotes evendemineralisation of the root._Wash samples under running water for four hours 16to clean.Dehydration_Dehydrate samples by using ascending grades ofalcohol: 60% ethanol for eight hours, 80% ethanolfor four hours, and 96.6% ethanol for two hours._Dry samples with paper towels.Clearing_The sample should be placed in xylene for two hoursto harden prior to placing the samples in methylsalicylate to render them transparent. 16 (This step isessential if samples are going to be used for practisinginstrumentation or obturation techniques.)_Store samples in methyl salicylate in order to preservetheir transparency.Please note: Always use proper protection whenhandling these dangerous solutions. Disposal of theused solutions should be done according to countryregulations._Educational toolSuccessful root-canal treatment depends on adequatecleaning, shaping and filling of the root-canalsystem. However, in order to achieve this goal, it isimperative that the operator has a detailed know -ledge of the root-canal morphology of each individualFig. 4 Fig. 5tooth that is treated. Demineralised and clearedteeth may become a very valuable aid in the teachingof endodontic techniques. Hasselgren and Tronstad 17used cleared teeth to teach and practise instrumentationand obturation procedures in a preclinicalcourse at Lund University, Sweden. At the end of thecourse, the students were asked to give their opinionsregarding the use of the transparent teeth in thelearning process. The reaction was very favourableand encouraged the head of the department to extendthe use of cleared teeth in following courses. 17Dipping the samples in xylene for two hours, assuggested by Robertson in 1980, prior to placingthem in methyl salicylate will return dentine hardnessto values slightly lower than those found in normaldentine. 16 This yields new possibilities for dentistseager to learn, who wish to practise new techniques,procedures and protocols, from rotary instrumen -tation with NiTi files to thermoplastic obturationwith warm gutta-percha. Dentists are able to seewhat is actually happening with much greater detail,which is a significant improvement to working with asimulated canal in plastic blocks. Additionally, thetactile feeling experienced is very similar to the realclinical situation.In summary, this simple and inexpensive techniquewill enable dentists to visualise the root-canalmorphology in detail while allowing them to practisealmost every endodontic procedure desired._Editorial note: A list of references is available from thepublisher._contactrootsDr Sergio Rosler graduatedfrom the University ofBuenos Aires, Argentina, in1996, and had become aspecialist in Endodontics by2005. He has been a specialistin Oral Implantologysince 2009 and works inprivate practice in BuenosAires. He can be contactedat sarosler@hotmail.com.ar.roots4_2010I31

I research _ CBCTCBCT applications in dentalpractice:A literature reviewAuthors_ Dr Mohammed A. Alshehri, Dr Hadi M. Alamri & Dr Mazen A. Alshalhoob, Saudi ArabiaFig. 1Fig. 1_Impacted teeth in closeproximity to vital structures shouldbe evaluated with CBCT.Figs. 2a & b_Peri-apical lesionshown as peri-apicalradiograph (a) and CBCT (b; imagescourtesy of Dr Fred Barnett).Fig. 2a_Two-dimensional imaging modalities havebeen used in dentistry since the first intra-oralradiograph was taken in 1896.Significant progress in dental imagingtechniques has since beenmade, including panoramic imagingand tomography, which enablereduced radiation and faster processingtimes. However, the imaginggeometry has not changedwith these commonly used intraoraland panoramic technologies.Cone-beam computed tomography(CBCT) is a new medicalimaging technique that generates3-D images at a lower cost and absorbed dosecompared with conventional computed tomography(CT). This imaging technique is based ona cone-shaped X-ray beam centred on a 2-Ddetector that performs one rotation around theobject, producing a series of 2-D images. Theseimages are re-constructed in 3-D using a mo -dification of the original cone-beam algorithmdeveloped by Feldkamp et al. in 1984. 1 Imagesof the craniofacial region are often collected witha higher resolution than those collected with aconventional CT. In addition, the new systems aremore practical, as they come in smaller sizes. 2Today, much attention is focused on theclinical applications—diagnosis, treatment andFig. 2bfollow-up—of CBCT in the various dental disciplines.The goal of the following systemic reviewis to review the available clinical and scientificliterature pertaining to different clinical appli -cation of CBCT in the dental practice._Materials and methodsClinical and scientific literature discussingCBCT imaging in dental clinical applications wasreviewed. A MEDLINE (PubMed) search from1 January 1998 to 15 July 2010 was conducted.Cone-beam computed tomography in dentistrywas used as key phrase to extend the search to allthe various dental disciplines. The search revealed540 papers that were screened in detail.Owing to a lack of relevance to the subject, 406papers were excluded. Thus, the systemic reviewconsisted of 134 clinically relevant papers, whichwere analysed and categorised (Table I)._AnalysisOral and maxillofacial surgeryCBCT enables the analysis of jaw pathology, 3–11the assessment of impacted teeth (Fig. 1), supernumeraryteeth and their relation to vital structures,6,12–21 changes in the cortical and trabecularbone related to bisphosphonate-associated osteonecrosisof the jaw 5,22–23 and the assessmentof bone grafts. 24 It is also helpful in analysing andassessing paranasal sinuses 6,25 and obstructivesleep apnea. 27–28As the images are collected from many dif -ferent 2-D slices, the system has proven itssuperiority in overcoming superimpositions andcalculating surface distances. 28–29 This advantagemade it the technique of choice in mid-face fracturecases, 30–31 orbital fracture assessment andmanagement 32 and for inter-operative visualisationof the facial bones after fracture. 33–34 Since itis not a magnetic resonance technique, it is thebest option for intra-operative navigation duringprocedures, including gun-shot wounds. 35–3632 Iroots4_2010

esearch _ CBCT ICBCT is largely used in orthognathic surgeryplanning when facial orthomorphic surgery isindicated that requires detailed visualisation ofthe inter-occlusal relationship in order to augmentthe 3-D virtual skull model with a detaileddental surface. With the aid of advanced software,CBCT facilitates the visualisation of softtissue to allow for control of post-treatmentaesthetics, for example in cleft palate cases toevaluate lip and palate bony depressions. 37–42Research is underway to assess its ability todetect salivary gland defects. 43 Honda et al. 44describe a clinical case in which the time neededto complete a tooth auto-transplant case wassignificantly shortened owing to the applicationof CBCT.EndodonticsCBCT is a very useful tool in diagnosing apicallesions (Figs. 2a & b). 21,45–56 A number of studieshave demonstrated its ability to enable a dif fe -rential diagnosis of apical lesions by measuring thedensity from the contrasted images of these lesions,in whether the lesion is an apical granulomaor an apical cyst (Figs. 3a & b). 49,55–57 Cotton et al. 46used CBCT as a tool to assess whether the lesionwas of endodontic or non-endodontic origin.CBCT also demonstrated superiority to 2-Dradiographs in detecting fractured roots. Verticaland horizontal root fracture detection is describedin several clinical cases. 21,46,55–59 It is alsoagreed that CBCT is superior to peri-apical radiographsin detecting these fractures, whetherthey are bucco-lingual or mesiodistal. 60–61In cases with inflammatory root resorption,lesions are detected much easier in early stageswith CBCT compared to conventional 2-D X-ray. 21,62In other cases, such as external root resorption,external cervical and internal resorption, not onlythe presence of resorption was detected, but alsothe extent of it. 21,46,54,56,63–64Fig. 3aCBCT can also be used to determine rootmorphology, the number of roots, canals andaccessory canals, as well as to establishing theworking length and angulations of roots andcanals. 21,25,46,55–56,58,65–67 It also is accurate in assessingroot-canal fillings. 47,51,56,58 Owing to itsaccuracy, it is very helpful in detecting the pulpalextensions in talon cusps 68 and the position offractured instruments. 69It is also a reliable tool for pre-surgical as -sessment of the proximity of the tooth to ad jacentvital structures, size and extent of lesions,as well as the anatomy and morphology of rootswith very accurate measurements. 21,46,48,50,54–58,69–72Fig. 3bFigs. 3a & b_Apical cyst shown asorthopantomogram (a) and CBCT (b).Specialty Number of articles in %Oral and maxillofacial surgery 36 26.86Endodontics 32 23.88Implantology 22 16.42Orthodontics 16 11.94General dentistry 14 10.45Temporomandibular joint disorder 8 5.97Periodontics 5 3.73Forensic dentistry 1 0.75Table IFig. 4a_Orthopantomogram fora full-mouth rehabilitation case.Only limited data can be obtainedfrom this image.Fig. 4b_CBCT images for the samepatient. Data obtained from theseimages regarding bone quality,implant length and diameter,implant location and proximityto vital structures is magnificent.Fig. 4aFig. 4broots4_2010I33

I research _ CBCTAdditionally, in cases in which teeth are assessedafter trauma and in emergency cases, its appli -cation can be a useful aid in reaching a properdiagnosis and treatment approach. 46,55,73–74Recently, owing to its reliability and accuracy,CBCT has also been used to evaluate theCBCT is a reliable tool in the assessment of theproximity to vital structures that may interferewith orthodontic treatment. 104–105 In cases in whichmini-screw implants are placed to serve as atemporary anchorage, CBCT is useful for ensuringa safe insertion 106–108 and to assess the bone densitybefore, during and after treatment (Fig. 6). 109–110Fig. 5a Fig. 5b Fig. 5cFig. 5a_Clinical picture of multipleimplants placed in 2005.Fig. 5b_Peri-apical radiographfor the implants replacing teeth #8and #9. Little data can becollected from such an image.Fig. 5c_The CBCT image clearlydemonstrates the amountof bone loss.canal preparation in different instrumentationtechniques. 75–76ImplantologyWith increased demand for replacing missingteeth with dental implants, accurate measurementsare needed to avoid damage to vitalstructures. This was achievable with conventionalCT. However, with CBCT giving moreac curate measurements at lower dosages, it isthe preferred option in implant dentistry today(Figs. 4a & b). 2,6,11,18,70,77–89With new software that constructs surgicalguides, damage is also reduced further. 77,84,90–93Heiland et al. 94 describe a technique in whichCBCT was used inter-operatively in two casesto navigate the implant insertion following microsurgicalbone transfer.CBCT enables the assessment of bone qualityand bone quantity. 18,26,70,80–81,85,88,95–97 This leadsto reduced implant failure, as case selection canbe based on much more reliable information.This advantage is also used for post-treatmentevaluation and to assess the success of bonegrafts (Figs. 5a–d). 18,88OrthodonticsOrthodontists can use CBCT images in orthodonticassessment and cephalometric analysis.6,70,84,98–99 Today, CBCT is already the tool ofchoice in the assessment of facial growth, age,airway function and disturbances in tooth eruption.100–103Having different views in one scan, such asfrontal, right and left lateral, 45-degree viewsand sub-mental, also adds to the advantagesof CBCT. 111,124 As the images are self-correctedfrom the magnification to produce orthogonalimages with 1:1 ratio, higher accuracy is ensured.CBCT is thus considered a better option for theclinician. 113Temporomandibular joint disorderOne of the major advantages of CBCT is itsability to define the true position of the condylein the fossa, which often reveals possible dis -location of the disk in the joint, and the extentof translation of the condyle in the fossa. 18,56,114With its accuracy, measurements of the roof ofthe glenoid fossa can be done easily. 115–116 Anotheradvantage of some of the available devicesis their ability to visualise soft tissue around theTMJ, which may reduce the need for magneticresonance imaging in these cases. 117Owing to these advantages, CBCT is the imagingdevice of choice in cases of trauma, pain, dysfunction,fibro-osseous ankylosis and in detectingcondylar cortical erosion and cysts. 70,87,118–120With the use of the 3-D features, the imageguidedpuncture technique, which is a treatmentmodality for TMJ disk adhesion, can safely beperformed. 121PeriodonticsCBCT can be used in assessing a detailed morphologicdescription of the bone because it hasproved to be accurate with only minimal error34 Iroots4_2010

esearch _ CBCT Imargins. 56,122 The measurements proved to be asaccurate as direct measurements with a periodontalprobe. 56,123 Furthermore, it also aids inassessing furcation involvements. 20,56,116CBCT can be used to detect buccal and lingualdefects, which was previously not possible withconventional 2-D radiographs. 56,124 Additionally,owing to the high accuracy of CBCT measurements,intra-bony defects can accurately bemeasured and dehiscence, fenestration defectsand periodontal cysts assessed. 56,125–127 CBCT hasalso proved its superiority in evaluating theoutcome of regenerative periodontal therapy. 124demonstrate that 134 papers were clinically relevantand that the most common clinical applicationsare in the field of oral and maxillofacialsurgery, implant dentistry, and endodontics.CBCT has limited use in operative dentistry owingto the high radiation dose required in relationto its diagnostic value.General dentistryBased on the available literature, CBCT is notjustified for use in detecting occlusal caries, sincethe dose is much higher than conventional radiographswith no additional information gained.However, it proved to be useful in assessing proximalcaries and its depth. 20 Table II shows examplesof typical doses of various dental radiologicalprocedures in dental practice.Forensic dentistryMany dental age estimation methods, whichare a key element in forensic science, are describedin the literature. CBCT was establishedas a non-invasive method to estimate the age ofa person based on the pulp–tooth ratio. 128_DiscussionCBCT scanners represent a great advance indento-maxillofacial (DMF) imaging. This technology,introduced into dental use in the late1990s, 129 has advanced dentistry significantly.The number of CBCT-related papers publishedeach year has increased tremendously in the lastyears. The above systematic review of the lite -rature related to CBCT-imaging applicationsin dental practice was undertaken in order tosummarise concisely the indications of this newimage technique in different dental specialties.Fig. 5dThe literature on CBCT is promising and needsfurther research, especially with regard to its usein forensic dentistry, in order to explore morepotentially beneficial indications in that area.No literature concerning direct CBCT indicationsin prosthodontics was found. However, severaloverlapping indications were found in other dentalspecialties attributing to the final standard ofcare in prosthodontic treatment. These indicationsinclude but are not limited to bone grafting,soft-tissue grafting, prosthetically driven implantplacement, maxillofacial prosthodonticsand temporomandibular joint disorder. CBCT imagescan also be of great value in special casesin which multiple teeth have to be assessed forrestorability (Figs. 7a–e).The latest CBCT units have a higher resolution,lower exposure, are less expensive and designed foruse in dentistry. Additionally, the flat-panel detectorsappear to be less prone to beam-hardeningartefacts. There are, however, several importantdisadvantages as well, such as susceptibility toIntra-oral (F speed, rectangular collimator)Fig. 6Fig. 5d_Total buccal plate destructionis evident in this CBCT image.Fig. 6_CBCT image to assess thebone density during treatment.Table II_Typical doses of variousdental radiological procedures.0.001 mSvCone-beam computed tomography in dentis -try was used as key phrase in this systemic review.Other terminology encountered in the literature,such as cone-beam volumetric scanning, volumetriccomputed tomography, dental CT, dental3-D CT and cone-beam volumetric imaging, didnot result in additional relevant papers. 130The clinical applications for CBCT imaging indentistry are increasing. The results of this reviewIntra-oral (E speed, round collimator)Full-mouth set (E speed, round collimator)Lateral cephalogram (F speed, rare-earth screen)Dental panoramic technique (F speed, rare-earth screen)CBCT (both jaws)Hospital CT scan (both jaws)0.004 mSv0.080 mSv0.002 mSv0.015 mSv0.068 mSv0.6 mSvTable IIroots4_2010I35

I research _ CBCTmovement artefacts, low contrast resolution,limited capability to visualise internal soft tissuesand, owing to distortion of Hounsfield Units,CBCT cannot be used for the estimation of bonedensity.It is crucial that the ALARA principle (As LowAs Reasonably Achievable) is respected during3. CBCT examinations should potentially add newinformation to aid the patient’s management.4. CBCT should not be repeated on a patient‘routinely’ without a new risk/benefit assessmenthaving been performed.5. When accepting referrals from other dentistsfor CBCT examinations, the referring dentistmust supply sufficient clinical informationFig. 7a Fig. 7b Fig. 7cFig. 7a_Multiple endodonticallytreated teeth with a historyof peri-apical surgery.Fig. 7b_Peri-apical image showinga compromised crown-to-root ratio.Fig. 7c_CBCT image showing theabsence of the buccal plate anda compromised palatal plate,indicating that the teeth need to beextracted and site grafting performedbefore implant placement.treatment, as far as the radiation dose of CBCTimaging is concerned. CBCT imaging will improvepatient care, but users have to be trained to beable to interpret the scanned data thoroughly.Dentists should ask themselves whether theseimaging modalities actually add to their diagnosticknowledge and raise the standard of dentalcare or whether they only place the patient ata higher risk. Continuous training, education andthorough research are thus absolutely essential.One of the most clinically useful aspects ofCBCT imaging is the highly sophisticated softwarethat allows the huge volume of datacollected to be broken down, processed or reconstructed.131 This makes data interpretation muchmore user friendly, if the appropriate technicaland educational knowledge is available.The increasing popularity of CBCT resulted innumerous CBCT-unit manufacturers, frequentpresentations at conferences and an increasein published papers. This resulted in an uncontrolledand non-evidence based exchange of radiationdose values and attributed to the limitedtechnical knowledge about medical imaging devicesfor new-user groups. As a result, the EuropeanAcademy of DentoMaxilloFacial Radiologyhas developed the following basic principles onthe use of CBCT in dentistry: 1321. CBCT examinations must not be carried outunless a history and clinical examination havebeen performed.2. CBCT examinations must be justified for eachpatient to demonstrate that the benefitsoutweigh the risks.(results of a history and examination) to allowthe CBCT practitioner to perform the justificationprocess.6. CBCT should only be used when the questionfor which imaging is required cannot beanswered adequately by lower dose conventional(traditional) radiography.7. CBCT images must undergo a thorough clin -ical evaluation (radiological report) of theentire image dataset.8. Where it is likely that evaluation of soft tissueswill be required as part of the patient’sradiological assessment, the appropriate imagingshould be conventional medical CT orMR, rather than CBCT.9. CBCT equipment should offer a choice of volumesizes, and examinations must use thesmallest that is compatible with the clinicalsituation, if this provides a lower radiationdose to the patient.10. Where CBCT equipment offers a choice ofresolution, the resolution compatible with anadequate diagnosis and the lowest achievabledose should be used.11. A quality assurance programme must beestablished and implemented for each CBCTfacility, including equipment, techniques andquality-control procedures.12. Aids to accurate positioning (light-beammarkers) must always be used.13. All new installations of CBCT equipmentshould undergo a critical examination and detailedacceptance tests before use to ensurethat radiation protection for staff, membersof the public and patient are optimal.14. CBCT equipment should undergo regular routinetests to ensure that radiation protection,36 Iroots4_2010

I research _ CBCTfor both practice/facility users and patients,has not significantly deteriorated.15. For staff protection from CBCT equipment,the guidelines detailed in Section 6 of theEuropean Commission document Radiationprotection 136: European guidelines on ra -diation protection in dental radiology shouldbe followed.16. All those involved with CBCT must have receivedadequate theoretical and practicaltraining for the purpose of radiological practicesand relevant competence in radiationprotection.17. Continuing education and training afterqualification are required, particularly whennew CBCT equipment or techniques areadopted.18. Dentists responsible for CBCT facilities, whohave not previously received ‘adequate theoreticaland practical training’, should undergoa period of additional theoretical andpractical training that has been validated byan academic institution (university or equivalent).Where national specialist qualificationsin dento-maxillofacial radiology exist,the design and delivery of CBCT trainingprogrammes should involve a DMF radiologist.19. For dento-alveolar CBCT images of the teeth,their supporting structures, the mandibleand the maxilla up to the floor of the nose(for example, 8 cm x 8 cm or smaller fields ofview), clinical evaluation (radiological report)should be done by a specially trained DMFradiologist or, where this is impracticable,an adequately trained general dental practitioner.20. For non-dento-alveolar small fields of view(for example, temporal bone) and all craniofacialCBCT images (fields of view extendingbeyond the teeth, their supporting structures,the mandible, including the TMJ, andthe maxilla up to the floor of the nose), clinicalevaluation (radiological report) shouldbe done by a specially trained DMF radiologistor by a clinical radiologist (medicalradiologist)._ConclusionCBCT is most frequently applied in oral andmaxillofacial surgery, endodontics, implant dentistryand orthodontics. CBCT examination mustFig. 7d_Extractions done for teeth#7, 8, 9 and 10 were atraumaticand bone grafting was performed.Fig. 7e_Temporisation done andhealing of the grafted sites for futureimplant placement is awaited.Fig. 7dFig. 7enot be carried out unless its medical necessityis proven and the benefits outweigh the risks.Furthermore, CBCT images must undergo a thoroughclinical evaluation (radiological report) ofthe entire image dataset in order to maximise thebenefits.Future research should focus on accurate datawith regard to the radiation dose of these units.CBCT units have small detector sizes and thefield of view and scanned volumes are limited,which is the reason that CBCT units specific toorthodontic and orthognathic surgery are notyet available. Additional publications on CBCTindications in forensic dentistry and prosthodonticsare also desirable._Editorial note: A complete list of references is availablefrom the publisher._about the authorsCAD/CAMDr Mohammed A. Alshehri is a Consultantfor Restorative and Implant Dentistry at theRiyadh Military Hospital, Department ofDentistry and Assistant Clinical Professorat the King Saud University, College of Dentistry,Department of Restorative Dental Sciences.He can be contacted at dr_mzs@hotmail.com.Dr Hadi M. Alamri and Dr Mazen A. Alshalhoobare interns at Riyadh Colleges of Dentistryand Pharmacy.38 Iroots4_2010

I industry news _ VDWThe RECIPROC systemDr Ghassan Yared_Canal curvature has always introduced complexityinto canal preparation. Dr James B. Roane’sbalanced force technique (1985) was a promisingconcept using stainless-steel hand instruments insmall clockwise and counter-clockwise movements.Based on Dr Roane’s idea but using rotary NiTi instrumentsand a reciprocating motor, Dr Ghassan Yared(Canada) developed the method to ingenious perfection.After an experimentation phase of more thanseven years, he sent his first description of the canalpreparation technique with only one rotary instrumentto roots in March 2007. In the hands of theexperienced endodontist, it worked. However, morethan three years and a team of engineers, metallurgistsand electronic technicians were necessary toturn a great idea into a professional product, consistingof Reciproc instruments, motor, paper points andgutta-percha points. Dr Yared and VDW Germanynow introduced the system for the first time at the 8 thWorld Endodontic Congress in Athens.The majority of all canal anatomies can be preparedwith the new technique using only one reciprocatingfile and without glide path or initial instrumentation.In reciprocation, the Reciproc file is initially driven ina cutting direction and then reverses to release theinstrument. One rotation of 360° is completed in severalreciprocating movements.Root-canal preparation without creating a glidepath goes against the current teaching standard forrotary instrumentation, which requires an initial glidepath in order to minimise the risk of fracture due to aninstrument binding in the canal. However, in reciprocation,the angles of alternating right and left rotationsare significantly lower than the angles at whicha Reciproc instrument would fracture. These anglesare stored in the Reciproc endodontic motor, preventingthe instrument from rotating past its specificangle of fracture. The centring ability of the reciprocationtechnique allows the instrument to follow thenatural path of least resistance, which is the rootcanal. Reciproc instruments have been specificallydesigned for use in reciprocation and are producedwith M-wire NiTi in an innovative thermal-treatmentprocess. This alloy has both increased resistance tocyclic fatigue and greater flexibility than commonNiTi material. Another advantage of the specificdesign is an enormous capacity to remove debris fromthe canal thanks to deep flutes. Additionally, the flexibleS-shaped cross-section with two cutting edgesprovides high cutting ability at reduced friction.From three file sizes—R25, R40 or R50—the onematching the canal size best needs to be selected. Theinitial taper of each file is larger over the first 3mmfrom the tip, enabling a #30 irrigation syringe to beplaced close to the apex. The canal shape obtainedwith each of the three instruments is optimal for allmodern obturation techniques.The Reciproc system is designed for convenienceand safety. The instruments are specified forsingle use, making the work flow more efficientand reducing the risk of contamination. One Reciprocinstrument does the job of several hand and rotaryinstruments. Single use also protects from the risk ofmaterial fatigue caused by over-use. The Reciprocsystem is manufactured by VDW Germany and willbe available from January 2011 onwards. Please visitwww.endodonticcourses.com/literature and checkout a number of videos on single file reciprocationwith the RECIPROC system and give it a try!__contactVDW GmbHBayerwaldstr. 1581737 MunichGermanyinfo@vdw-dental.comwww.vdw-dental.com // www.reciproc.comroots40 Iroots4_2010

Bella CenterCopenhagenWelcome to the44th Scandinavian Dental FairTheleading annual dental fair in Scandinavia2011The 44th SCANDEFAA invites you to exquisitely meet the Scandinavian dental market andsales partners from all over the world in springtime in wonderful CopenhagenSCANDEFA, A, organized byReservation of a boothBella Center, is being held inBook online atwww.scandefa.dka.dkconjunction with the AnnualSales and Project Manager, Jo Jaqueline OgilvieScientific Meeting, organizedjjo@bellacenter.dk, T +45 32 47 21 25by the Danish DentalAssociationTravel information(www.tandlaegeforeningen.dk).Bella Centeris located just a 10 minute taxi drive from CopenhagenAirport. A regional train runs from the airportto Orestad Station,tion,More than 200 exhibitors andonly 15 minutes drive.11.349 visitors participated atSCANDEFAA 2010 on 14,220 m 2Book a hotel in Copenhagenof exhibition space.www.visitcopenhagen.com/tourist/plan_and_bookFotos from Bella Center, Wonderful Copenhagenwww.scandefa.dk

I meetings _ 8 th World Endodontic CongressGreece inspiredus once againAuthor_ Dr Antonis Chaniotis, Greece_Athens, the home ofdemocracy, philosophy andculture, welcomed evidence-based endodontics from6 to 9 October for the 8 th World Endodontic Congress.What an interesting combination for those luckyenough to have attended the meeting! The organisingcommittee and the Greek team tried their utmostto satisfy the expectations of the demanding audience.Honestly, with the impressive list of internationalkeynote speakers the organisers were able toattract—Profs Syngcuk Kim (USA), Paul Abbott(Australia), Craig Baumgartner (USA), Edgar Schäfer(Germany), Ken Hargreaves (USA) and Shimon Friedman(Canada)—this was relatively easy. To me, it feltas if chapters of classic endodontic textbooks poppedup right in front of me.The congress was sponsored by major dentalindustry players. DENTSPLY Maillefer played a key roleas gold sponsor of the event. In a pre-congress coursewith Prof Sergio Kuttler, DENTSPLY launched the newWaveOne reciprocating file. DENTSPLY also organisedhands-on courses at their booth and a wonderfulcocktail party, which was held on the top floor of theAthens Hilton Hotel. The view of Athens from up therewas absolutely breathtaking!There was a tangible feeling of competition in theentire exhibition hall. The Self Adjusting File team dida great job promoting their new irrigation file structureand VDW and MICRO-MEGA also launched newproducts. Frankly speaking, promoting anything atthis meeting was a difficult task because of the verydemanding audience. Each participant sought documentationfor just about everything being presented.When appropriate evidence was not yet available,the audience acted with reserve and caution.The scientific programme was opened with a bit ofdental history by Prof John Ingle (USA). Did you knowthat the first short Walt Disney ever made was on dentistry?In 1922, Walt Disney created Tommy Tucker’sTooth, a silent film about children’s oral health, while42 Iroots4_2010

meetings _ 8 th World Endodontic Congress Ihe was still a struggling cartoonist in Kansas City.Payment for the film allowed Disney to settle debtsand head for Los Angeles, where he launched his historiccareer in animation and moviemaking. I, as wellas many others in the audience, enjoyed watching thefilm for the very first time. Prof Ingle, we are gratefulfor your contribution to the congress!Lectures of the highest quality marked the congressin Athens. Prof Hargreaves, Dr Gabriela Martin(Argentina) and many others presented evidence forrevascularisation and regeneration efforts. Antibioticpastes, scaffolds, cells and growth factors performedon the stage under the guidance of the speakers.Researchers and industry leaders are working onthese issues and some major advances in this fieldmay be very near.Dr Enrique Merino (Spain) explored the endo–implant controversy and Dr Giuseppe Cantatore(Italy) lectured on A critical approach to new NiTiinstruments for mechanical glide path. It was impossibleto attend every session, as there were simultaneouslectures in different halls, as well as high-qualityposter sessions. One presentation that impressedme in particular was Three-dimensional photographyin endodontics by Dr Moscoso and colleagues fromthe University of Catalonia in Barcelona, Spain.Imagine your PowerPoint presentations and yourmicroscope videos being transformed into a 3-Dvisual experience!Dr Luc van der Sluis (The Netherlands) and thefluid dynamics team were also present and gave anoverview of their interesting research on irrigationdynamics and delivery techniques. “Maybe in thefuture we will produce some kind of bioactive yogurtto fill the canals effectively,” commented Dr van derSluis in a private conversation. In my opinion, until wedo, we will have to present and seek evidence foreverything we do.Effective root-canal debridement and disinfectiontechniques were reconsidered by Prof Baumgartnerin his inspiring lecture. Are we close to sterilisation ofthe infected root-canal system? According to ProfBaumgartner we are “pretty close”.On the last day of the congress, Prof Kim held apassionate lecture on evidence-based endodonticmicrosurgery and Prof Friedman’s closing lectureoffered the best of current evidence for treatmentoutcomes, supporting what we do and that aboutwhich are passionate—Evidence-based Endodontics,which was the theme of the congress.A lucky few had the privilege of watching Prof Kimperform live surgery on a mandibular molar underthe microscope. The event was sponsored by Satelecand Carl Zeiss and took place at the facilities of theUniversity of Athens Dental School.In closing, I would also like to say a few wordsabout the social programme. The welcome receptiontook place on a cruise boat, at which the Ouzo andGreek wine served offered attendees the opportunityto relax after the high level but exhausting sessions.The Gala Dinner, which was held at the well-knownAegli Zappiou Restaurant, was so entertaining thatmany of the participants found it difficult to wake upin time for the morning sessions. Prof Baumgartner,we thank you for waking all of us up in the first tenminutes of your inspiring lecture.I could write many more pages about what happenedin Athens during the 8 th World EndodonticCongress, but I think I have made my point. Thank youAthens! We will remember you as a wonderful host!_roots4_2010I43

I meetings _ ESMD 2010A meeting of minds—Seeing is believingAuthor_ Dr David English, UK_From 16 to 18 September 2010, over 300de legates from 30 different countries assembled inVilnius, Lithuania, for the second congress of the EuropeanSociety of Microscope Dentistry (ESMD). I haveattended several meetings dedicated to microscopedentistry during my career and have to admit that thisone was as good as they get.Simply put, the better you can see something, thebetter you can understand and treat it, and, thanks tothe great imaging ability of microscopes, the better youcan document and share the information with your patientsand colleagues. For those of us who have alreadyadopted this technology in our daily work, there is nogoing back. Today, the operating microscope (OM) is nolonger only used by endodontists. Prosthodontists andperiodontists equally are enhancing their treatmentswith magnification, illumination and documentation.On the first day of the programme, delegateswere able to select from a variety of hands-on workshops,including microsurgery suturing, non-surgicalendo dontics, precision preparation techniques forcrowns and veneers, 3-D obturation techniques, softtissuemanagement around implants and microsur -gical reconstructive procedures. Alternatively, masterclasses in practice management, digital imaging,matrix-free composite build-ups, laser use, toothdiscolouration treatment and 3-D diagnosis wereoffered. The main programme, which offered introductoryworkshops on microscope use, allowed internationalspeakers to demonstrate their expertise andthe accuracy of their periodontal, prosthodontic andendodontic skills. The wonderful aspect of presentationsat today’s meetings is the tangible manner inwhich information can be presented through videoand still photography taken through the OM—and notonly one or two images but a whole stream of picturesthat really convey the techniques, benefits and outcomesof the treatment. This is a level of discussion,education and knowledge transfer that was previouslynot possible.An innovative and successful live demonstration ofa periodontal surgery, performed by Dr Jan Behring,and a molar preparation, performed by Dr Horst44 Iroots4_2010

meetings _ ESMD 2010 IBehring, was offered via satellite link from a dentalclinic in Hamburg, Germany. The presentations, whichwere moderated by Prof Stefan Ioan Stratul (Romania),alternated between the two treatment rooms in theclinic as the procedures progressed. Most of the imagesshown in the main lecture hall came from full-HD videocameras mounted on the clinicians’ OMs. I have tocongratulate my colleagues on presenting theseprocedures in real time (!) to over 200 eager attendees,who were also able to ask questions throughout thetreatment process. In fact, the entire session was alogistical, educational and treatment triumph!A selection of workshops and lectures on staff andpractice management interspersed the programmeand was received with much interest. Dentists who useOMs are very focused on their clinical skills. However,microscope use requires a good support team anda securely based business. Additionally, it is true thatpatients do not judge us based on our clinical skills only,but also on the image of our practice. We need to beaware of the image our practice conveys and not onlyfocus on what we see though our microscopes!Another real strength of this congress was theopportunity to meet the suppliers and manufacturersin the exhibition hall. Attendees were able to check outthe latest in microscope technology, as well as instrumentationand imaging. The industry sponsors, such asSigma Dental Systems, Global Surgical, DENTSPLYMaillefer, EMS and Nobel Biocare, who help make thesemeetings possible, must also be recognised.The social programme was very well organised, witha welcome reception at the National Gallery of Art anda gala dinner at the Vilnius Town Hall the followingevening. Vilnius is a most interesting place to visit—a mix of the very old and the very new and an awarenessof the really quite recent changes in Lithuania’spolitical climate.The venue, the Radisson Blu Hotel Lietuva overlookingthe Neris river, was just a short walk from the ancienttown centre of Vilnius, making it well located andattractive at the same time, with great views over Vilniusand good ambience and customer service overall.Microscope-using dentists might be seen as aspecial ‘breed’, a rather elitist self-selecting group. Inmy opinion, microscope-using dentists are concerneddental clinicians, following a logical progression ofendeavour that modern technology allows. Additionally,they are knowledgeable, open to sharing theirexperiences and a wonderful group of people to bearound. This congress was a great opportunity to gainexposure in this regard and my heart-felt congratulationsgo to the organisers. I look forward to the 2012Berlin meeting._roots4_2010I45

I meetings _ IDS 2011Endodontics:A central themeof IDS 2011_Endodontics provides an important foundationfor long-term and lasting tooth preservation. Inlight of an ageing society, this dental discipline is increasinglygaining importance. With evidence-basedsuccess rates of up to 85 per cent for treatments performedlege artis, endodontics has long been establishedin the range of therapies offered by generaldentists, while at the same time offering a variety oftasks for specialists. According to Dr Martin Rickert,Chairperson of the Board of the Association of GermanDental Manufacturers (VDDI), “The impressivescientific and technological progress in the field ofendodontics has improved the odds of long-termtooth retention tremendously and puts this specialityat the centre of a prophylactic-conservationist approachto dentistry.” The latest methods employed inconservation therapy include manual and automaticroot-canal preparation, efficient rinsing methodsduring disinfection, and modern instruments andmaterials for obturation. Today, even the treatment ofanterior teeth with fractured crowns and roots is possiblethrough the use of advanced fiber post systems,amongst other techniques. Additionally, if root-canalrevision should become necessary, endodontic specialistshave a range of minimally invasive microsurgicaltreatment options available to them, includingthe treatment of complex endo-periodontal lesions.46 IThe many years of intense collaboration betweena large number of specialists and companies in thedental industry have resulted in the well-engineeredinstruments and material systems available todaythat increase accuracy of diagnosis and, above all,improve treatment of root-canal lesions. Modernimaging techniques, for example, allow the precisevisualisation of the root canal and thus enable bothendometry up to the apex and the exact determinationof the file position during preparation. DigitalX-rays and digital volumetric tomography are alsobecoming increasingly important. Moreover, highroots4_2010

meetings _ IDS 2011 Idetermined by means of either X-rays or modern electrometricmeasuring units that cause no additionalexposure to radiation. Effective chemicals that canbe enhanced via ultrasound-supported or hydrodynamicmethods are used to irrigate root canals, whichfrequently determines the failure or success of theprocedure. Modern sealer adhesives and cementsbased on composites are available for bacteria-tightobturation. Classic methods, primarily gutta-perchatechniques, can also be used. There has been significantprogress in this regard as well. For example, newequipment systems for warm vertical condensationensure better adaptation of the thermally plasticisedgutta-percha to the canal walls. The 34 th InternationalDental Show (IDS) will be a particularly valuablesource of comprehensive information for anyonewishing to learn about the entire spectrum of newdevelopments in endodontics.Aside from routine tasks that can be performedby general dentists, endodontics also offers a challengingfield of work for specialists, which includescomplex revisions, root-end resections, and therestoration of teeth with fractured crowns and roots.In order to complete these treatments successfully,experts have a wide variety of tools available to them,such as loupe systems or surgical microscopes thatpermit minimally invasive microsurgical endodonticsurgery.resolution intra-oral cameras are used for the timesavingonline documentation of the treatment, aswell as for diagnostic purposes.Another important trend is the increased use ofmechanised root-canal preparation. In particular,computer-designed file geometries with optimisedconicities and cutting edges result in greater safetyand efficiency. Modern materials, such as nickeltitaniumor titanium-niobium alloys, have vastlyimproved the durability of rotating preparation andrevision files, thus virtually revolutionising endodontictreatment options. A conical preparation is nowalso possible in severely curved root canals. Highperformance,electronically controlled drive unitswith torque control largely help to eliminate frac -turing when using the mechanised files.Technological progress has also been made inother areas of endodontics. The working length isAt the next IDS, which will be held from 22 to 26March 2011, the solutions offered by endodonticspecialists and renowned companies in the dental industrywill demonstrate the integration of standardendodontic services and specialisation opportunitiesinto the day-to-day routine of a dental surgery. Interestedtrade visitors can take advantage of this expertiseand experience during the fair. Visitors will alsohave the opportunity to ask questions and discussproblems with the experts at a unique internationalforum. IDS is the ideal opportunity for dentists anddental technicians to gain the latest information onendodontics, as well as learn to implement it in theirdental surgery and to integrate complex treatmentsystems at an expert level. Successful endodontictreatment increases the likelihood of tooth preser -vation, makes for satisfied patients and ultimatelyenhances the image of the dentist’s surgery.“From 22 to 26 March 2011, the InternationalDental Show in Cologne—the world’s largest trade fairfor dental medicine and dental technology—will bethe best place for dentists interested in endodonticsand their assistants to talk to specialists from theexhibiting companies and experienced users aboutthe whole spectrum of modern endodontic conceptsand current trends in treatments and diagnostics,”concludes Dr Markus Heibach, President of the VDDI.__contactKoelnmesse GmbHP.O. Box 21076050532 KölnGermanyTel.: +49 221 821 0Fax: +49 221 821 2574info@koelnmesse.dewww.koelnmesse.derootsroots4_2010I47

I meetings _ eventsInternational Events2010Pulp Fiction 122–5 December 2010Jachranka, Polandprofident@profident.plwww.profident.pl/pulpfiction12-e.html2011Penn Endo Global Symposium28 & 29 January 2011Nuremberg, Germanyevent@oemus-media.dewww.oemus.comChicago Dental Society Midwinter Meeting24–26 February 2011Chicago, IL, USAwww.cds.orgIADR General Session & Exhibition16–19 March 2011San Diego, CA, USAsherren@iadr.orgwww.iadr.orgInternational Dental Show22–26 March 2011Cologne, Germanyids@koelnmesse.dewww.ids-cologne.deAAE Annual Session13–16 April 2011San Antonio, TX, USAinfo@aae.orgwww.aae.orgESE Congress14–17 September 2011Rome, Italyinfo@eserome2011.comwww.eserome2011.comFDI Annual World Dental Congress14–17 September 2011Mexico City, Mexicocongress@fdiworldental.orgwww.fdiworldental.orgDGEndo Annual Meeting3–5 November 2011Bonn, Germanysekretariat@dgendo.dewww.dgendo.de2013IFEA World Endodontic Congress23–26 May 2013Tokyo, Japanifea2013@convention.co.jpwww2.convention.co.jp/ifea201348 Iroots4_2010

about the publisher _ submission guidelines Isubmission guidelines:Please note that all the textual components of your submissionmust be combined into one MS Word document. Please do notsubmit multiple files for each of these items:_the complete article;_all the image (tables, charts, photographs, etc.) captions;_the complete list of sources consulted; and_the author or contact information (biographical sketch, mailingaddress, e-mail address, etc.).In addition, images must not be embedded into the MS Worddocument. All images must be submitted separately, and detailsabout such submission follow below under image requirements.Text lengthArticle lengths can vary greatly—from 1,500 to 5,500 words—depending on the subject matter. Our approach is that if youneed more or less words to do the topic justice, then please makethe article as long or as short as necessary.We can run an unusually long article in multiple parts, but thisusually entails a topic for which each part can stand alone becauseit contains so much information.In short, we do not want to limit you in terms of article length,so please use the word count above as a general guideline and ifyou have specific questions, please do not hesitate to contact us.Text formattingWe also ask that you forego any special formatting beyond theuse of italics and boldface. If you would like to emphasise certainwords within the text, please only use italics (do not use underliningor a larger font size). Boldface is reserved for article headers.Please do not use underlining.Please use single spacing and make sure that the text is left jus -tified. Please do not centre text on the page. Do not indent paragraphs,rather place a blank line between paragraphs. Please donot add tab stops.Should you require a special layout, please let the word processingprogramme you are using help you do this formatting automatically.Similarly, should you need to make a list, or add footnotesor endnotes, please let the word processing programme do it foryou automatically. There are menus in every programme that willenable you to do so. The fact is that no matter how carefully done,errors can creep in when you try to number footnotes yourself.Any formatting contrary to stated above will require us to removesuch formatting before layout, which is very time-consuming.Please consider this when formatting your document.Image requirementsPlease number images consecutively throughout the articleby using a new number for each image. If it is imperative thatcertain images are grouped together, then use lowercase lettersto designate these in a group (for example, 2a, 2b, 2c).Please place image references in your article wherever theyare appropriate, whether in the middle or at the end of a sentence.If you do not directly refer to the image, place the referenceat the end of the sentence to which it relates enclosed withinbrackets and before the period.In addition, please note:_We require images in TIF or JPEG format._These images must be no smaller than 6 x 6 cm in size at 300 DPI._These image files must be no smaller than 80 KB in size (or theywill print the size of a postage stamp!).Larger image files are always better, and those approximatelythe size of 1 MB are best. Thus, do not size large image files downto meet our requirements but send us the largest files available.(The larger the starting image is in terms of bytes, the more leewaythe designer has for resizing the image in order to fill up morespace should there be room available.)Also, please remember that images must not be embedded intothe body of the article submitted. Images must be submittedseparately to the textual submission.You may submit images via e-mail, via our FTP server or posta CD containing your images directly to us (please contact usfor the mailing address, as this will depend upon the country fromwhich you will be mailing).Please also send us a head shot of yourself that is in accordancewith the requirements stated above so that it can be printed withyour article.AbstractsAn abstract of your article is not required.Author or contact informationThe author’s contact information and a head shot of the authorare included at the end of every article. Please note the exactinformation you would like to appear in this section and formatit according to the requirements stated above. A shortbiographical sketch may precede the contact informationif you provide us with the necessary information (60 wordsor less).Questions?Claudia Salwiczek (Managing Editor)c.salwiczek@oemus-media.deroots4_2010I49

I about the publisher _ imprintrootsinternational magazine of endodontologyPublisherTorsten R. Oemusoemus@oemus-media.deCEOIngolf Döbbeckedoebbecke@oemus-media.deMembers of the BoardJürgen Isbanerisbaner@oemus-media.deLutz V. Hillerhiller@oemus-media.deManaging EditorClaudia Salwiczekc.salwiczek@oemus-media.deExecutive ProducerGernot Meyermeyer@oemus-media.deDesignerJosephine Ritterj.ritter@oemus-media.deCopy EditorsSabrina RaaffHans MotschmannPublished byOemus Media AGHolbeinstraße 2904229 Leipzig, GermanyTel.: +49-341/4 84 74-0Fax: +49-341/4 84 74-2 90kontakt@oemus-media.dewww.oemus.comPrinted byMessedruck Leipzig GmbHAn der Hebemärchte 604316 Leipzig, GermanyEditorial BoardFernando Goldberg, ArgentinaMarkus Haapasalo, CanadaKen Serota, CanadaClemens Bargholz, GermanyMichael Baumann, GermanyBenjamin Briseno, GermanyAsgeir Sigurdsson, IcelandAdam Stabholz, IsraelHeike Steffen, GermanyGary Cheung, Hong KongUnni Endal, NorwayRoman Borczyk, PolandBartosz Cerkaski, PolandEsteban Brau, SpainJosé Pumarola, SpainKishor Gulabivala, United KingdomWilliam P. Saunders, United KingdomFred Barnett, USAL. Stephan Buchanan, USAJo Dovgan, USAVladimir Gorokhovsky, USAJames Gutmann, USABen Johnson, USAKenneth Koch, USASergio Kuttler, USAJohn Nusstein, USAOve Peters, USAJorge Vera, MexicoClaudia Salwiczek, Managing EditorCopyright Regulations_roots international magazine of endodontology is published by Oemus Media AG and will appear in 2010 with one issue every quarter. The magazineand all articles and illustrations therein are protected by copyright. Any utilisation without the prior consent of editor and publisher is inadmissible and liableto prosecution. This applies in particular to duplicate copies, translations, microfilms, and storage and processing in electronic systems.Reproductions, including extracts, may only be made with the permission of the publisher. Given no statement to the contrary, any submissions to theeditorial department are understood to be in agreement with a full or partial publishing of said submission. The editorial department reserves the right tocheck all submitted articles for formal errors and factual authority, and to make amendments if necessary. No responsibility shall be taken for unsolicitedbooks and manuscripts. Articles bearing symbols other than that of the editorial department, or which are distinguished by the name of the author, representthe opinion of the afore-mentioned, and do not have to comply with the views of Oemus Media AG.Responsibility for such articles shall be borne by the author.Responsibility for advertisements and other specially labeled items shall not be borne by the editorial department. Likewise, no responsibility shall be assumedfor information published about associations, companies and commercial markets. All cases of consequential liability arising from inaccurate or faultyrepresentation are excluded. General terms and conditions apply, legal venue is Leipzig, Germany.50 Iroots4_2010

You can also subscribe viawww.oemus.com/abo✂ I hereby agree to receive a free trail subscription of (4 issuesper year). I would like to subscribe to (€ 44 includingshipping and VAT for German customers; € 46including shipping and VAT for customers outside ofGermany) unless a written cancellation is sent within14 days of the receipt of the trial subscription. The subscriptionwill be renewed automatically every yearuntil a written cancellation is sent to OEMUS MEDIAAG, Holbeinstr. 29, 04229 Leipzig, Germany, six weeksprior to the renewal date.Last Name, First NameCompanyStreetZIP/City/CountryE-mailSignatureReply via Fax to +49 341 48474-290or via E-mail to grasse@oemus-media.deNotice of revocation: I am able to revoke the subscription within 14 days after my order by sendinga written cancellation to OEMUS MEDIA AG, Holbeinstr. 29, 04229 Leipzig, Germany.Signatureroots 4/10OEMUS MEDIA AGHolbeinstraße 29, 04229 Leipzig, Germany, Tel.: +49 341 48474-0, Fax: +49 341 48474-290, E-mail: grasse@oemus-media.de

ADHESIVE CORE BUILD-UP SYSTEMComplete set for 15 post-endodontic treatment 0) 0)