endodontic practice us - november/december 2013 - vol6.6

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Top ten tips

#10When thingsgo wrongDr. Tony Druttman

Practice profileDr. Brian Trava

PAYING SUBSCRIBERS EARN 24 CONTINUING EDUCATION CREDITS PER YEAR!

Fiber posts and tooth reinforcementDrs. Leendert Boksman, Gary Glassman, Gildo Santos, and Manfred Friedman

clinical articles • management advice • practice profiles • technology reviews

November/December 2013 – Vol 6 No 6

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

Corporate profilePlanmeca

Pride Institute“Best of Class”special awards tribute

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Volume 6 Number 6 Endodontic practice 1

November/December 2013 - Volume 6 Number 6

ASSOCIATE EDITORSJulian Webber BDS, MS, DGDP, FICD Pierre Machtou DDS, FICDRichard Mounce DDSClifford J Ruddle DDSJohn West DDS, MSD

EDITORIAL ADVISORSPaul Abbott BDSc, MDS, FRACDS, FPFA, FADI, FIVCDProfessor Michael A Baumann Dennis G Brave DDSDavid C Brown BDS, MDS, MSDL Stephen Buchanan DDS, FICD, FACDGary B Carr DDSArnaldo Castellucci MD, DDSGordon J Christensen DDS, MSD, PhDB David Cohen PhD, MSc, BDS, DGDP, LDS RCSStephen Cohen MS, DDS, FACD, FICDSimon Cunnington BDS, LDS RCS, MSSamuel O Dorn DDSJosef Dovgan DDS, MSTony Druttman MSc, BSc, BChDChris Emery BDS, MSc. MRD, MDGDSLuiz R Fava DDSRobert Fleisher DMDStephen Frais BDS, MScMarcela Fridland DDSGerald N Glickman DDS, MSKishor Gulabivala BDS, MSc, FDS, PhDAnthony E Hoskinson BDS, MScJeffrey W Hutter DMD, MEdSyngcuk Kim DDS, PhDKenneth A Koch DMDPeter F Kurer LDS, MGDS, RCSGregori M. Kurtzman DDS, MAGD, FPFA, FACD, DICOIHoward Lloyd BDS, MSc, FDS RCS, MRD RCSStephen Manning BDS, MDSc, FRACDSJoshua Moshonov DMDCarlos Murgel CDYosef Nahmias DDS, MSGarry Nervo BDSc, LDS, MDSc, FRACDS, FICD, FPFAWilhelm Pertot DCSD, DEA, PhDDavid L Pitts DDS, MDSDAlison Qualtrough BChD, MSc, PhD, FDS, MRD RCSJohn Regan BDentSc, MSC, DGDPJeremy Rees BDS, MScD, FDS RCS, PhDLouis E. Rossman DMDStephen F Schwartz DDS, MSKen Serota DDS, MMScE Steve Senia DDS, MS, BSMichael Tagger DMD, MSMartin Trope, BDS, DMDPeter Velvart DMDRick Walton DMD, MSJohn Whitworth BchD, PhD, FDS RCS

CE QUALITY ASSURANCE ADVISORY BOARDDr. Alexandra Day BDS, VTJulian English BA (Hons), editorial director FMCDr. Paul Langmaid CBE, BDS, ex chief dental officer to the Government for

WalesDr. Ellis Paul BDS, LDS, FFGDP (UK), FICD, editor-in-chief Private DentistryDr. Chris Potts BDS, DGDP (UK), business advisor and ex-head of Boots

Dental, BUPA Dentalcover, VirginDr. Harry Shiers BDS, MSc (implant surgery), MGDS, MFDS, Harley St referral

implant surgeon

PUBLISHER | Lisa MolerEmail: [email protected] Tel: (480) 403-1505

MANAGING EDITOR | Mali Schantz-Feld Email: [email protected] Tel: (727) 515-5118

ASSISTANT EDITOR | Kay Harwell FernándezEmail: [email protected] Tel: (386) 212-0413 EDITORIAL ASSISTANT | Mandi GrossEmail: [email protected] Tel: (727) 393-3394 DIRECTOR OF SALES | Michelle Manning Email: [email protected] Tel: (480) 621-8955

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PRODUCTION MANAGER/CLIENT RELATIONS Adrienne Good Email: [email protected] Tel: (623) 340-4373 PRODUCTION ASST./SUBSCRIPTION COORD. Lauren Peyton Email: [email protected] Tel: (480) 621-8955 MedMark, LLC15720 N. Greenway-Hayden Loop #9Scottsdale, AZ 85260Tel: (480) 621-8955 Fax: (480) 629-4002Toll-free: (866) 579-9496 Web: www.endopracticeus.com

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© FMC, Ltd 2013. All rights reserved. FMC is part of the specialist publishing group Springer Science+Business Media. The publisher’s written consent must be

obtained before any part of this publication may be reproduced in any form whatsoever, including photocopies and information retrieval systems. While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any consequence arising from it. The views expressed herein are those of the author(s) and not necessarily the opinion of either Endodontic Practice or the publisher.

This quote from the book of John is inscribed on the lobby wall of the Central Intelligence Agency headquarters in Langley, Virginia, and I think of it often while treating patients. In clinical endodontics, as with all science, few things are as important as truth. Our essential sworn duty is to “do no harm.” We risk no greater harm to our patients than when we proceed on the basis of assumption, presumption, or habit, without first doing everything we can to ascertain the truth of our patient’s condition. Fortunately, we have tools today that allow us to see more, appreciate more, and evaluate more of a patient’s condition than ever before. My first epiphany in this realm was while still practicing general dentistry. My insatiable quest for continuing education took me to Santa Barbara, California, under the guidance of Dr. Cliff Ruddle. It was there that I first looked through a dental operating microscope. I was literally AMAZED! French author Marcel Proust once observed, “The true voyage of discovery consists not in seeking new landscapes, but in having new eyes.” As soon as I integrated a dental microscope into my general practice and peered through the lenses, I understood the truth of Proust’s wisdom. Thanks to the lighting and magnification of the scope, I was seeing the closest thing possible to the truth of my patient’s condition. Now I could see, with vivid clarity, every tooth margin. I looked, in intimate detail, at things that I saw clinically…but had not really seen. Shortly, I came to realize another truth: we cannot treat what we cannot see. And the better we can see it, the better we can treat it. Proper use of the microscope impacts everyone involved in patient care: the clinician who immediately gains confidence, the assistant (hopefully utilizing the assistant’s binoculars) who can better anticipate and understand the clinical conditions and needs, the office staff who know that their clinicians are providing the most well-informed care possible, and of course, the patients themselves who benefit from potentially reduced chair time, reduced pain and discomfort, decreased recovery times, and less risk of the need for future treatment. While attending graduate school at Boston University, my mentor, Dr. Herb Schilder, sometimes referred to me as “The Virus,” because I was so excited about new dental technologies — and I was all too eager to share that enthusiasm with my classmates, my teachers, and anyone else who would listen. But the truth is that my love affair is not really with technology itself, but with what I can do with it. And that still holds true today. The things that we are able to do today with technology in dentistry are truly amazing. Without question, I consider the dental operating microscope the single most important piece of technology that I have incorporated into my practice. Like the microscope, which I discovered purely by accident, more recently, Cone Beam Computed Tomography (CBCT) has proven to be a practice game changer for me. And like the microscope, it has transformed both the way that I practice and the way that I think about truth. I never anticipated the impact that visualizing dental anatomy in 3D would have on my staff, my patients, my practice, and me. CBCT has literally changed the way that I approach clinical endodontics. This technology is the epitome of John’s verse: it represents three-dimensional truth, and the freedom to treat patients confidently, creatively, and effectively because of the truth it provides. CBCT allows me to visually strategize the clinical execution of a procedure before I actually do it, whether it’s endodontic therapy, a careful manipulation of the Schniderian membrane for a sinus lift, or the placement of a dental implant — either done “free hand” or utilizing CBCT’s DICOM data to create a computer-generated surgical guide. Beyond visualizing the anatomy prior to the procedure, having the 3D scan on a large high-resolution monitor chairside provides a true representation of the operating space, and an incredible level of pretreatment confidence along with it. Procedures that once were difficult and created significant pretreatment anxiety for doctor, staff, and patient are now commonplace and are executed with ease. To the benefit of all, with CBCT we can digitally document the entire scope of a procedure, from initial evaluation, through treatment planning, and eventually, years of follow-up. This gives us the great luxury of going back to review past cases and learn from our own experiences, as well as to provide extensive treatment feedback to our referring doctors and the colleagues with whom we consult. With today’s technologies, endodontic professionals are closer than ever to attaining that ultimate scientific pursuit of truth. New tools and ever-evolving technologies add limitless stimulation to the practice careers of those who embrace them, and ultimately set us free in the greatest way imaginable: by giving us the freedom to continue to grow at what we do best, for our patients, our colleagues, and ourselves.

Thomas V. McClammy, DMD, MS aka: Clamdawg North Scottsdale Endodontics & Implantology (Arizona)Foundational Dental Seminars

Few things are as important as truth “And ye shall know the truth and the truth shall make you free…” ~ JOHN VIII-XXXII

TABLE OF CONTENTS

Corporate profilePlanmeca®

Innovative, upgradeable imaging

technology ..................................10

Endodontics in focusTop ten tips: Tip number 10 -

When things go wrong

In the last article in this series, Dr.

Tony Druttman focuses what to do

when things do not go according to

plan ...........................................18

2 Endodontic practice Volume 6 Number 6

Practice profile 6Dr. Brian TravaContinually learning and training, Dr. Trava discusses the joys of being a “tooth

saver.”

Case study 12Endodontics in 3DDrs. Derek Chu, David Jaramillo, Chad Gustafson, and Dwight Rice study the

benefits of CBCT, and its role in helping to diagnose and treat endodontic

problems

simple, adaptable endodontic solutions

A decade of success

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EndoREZ®

TABLE OF CONTENTS

Continuing educationFiber posts and tooth

reinforcement: evidence in the

literature

Drs. Leendert Boksman, Gary

Glassman, Gildo Santos, and Manfred

Friedman look at the literature for fiber

posts and the best techniques for

placement ...................................22

Management of an upper first

molar with three mesiobuccal root

canals

Dr. Peet van der Vyver presents a

case report to illustrate the clinical

management of an upper first

maxillary molar tooth with three

mesiobuccal root canals, using the

ProTaper Next system .................28

Special sectionTribute to Pride Institute’s “Best of

Class” Technology Awards ......34

Legal mattersUpholding the Endodontist’s

Standard of Care

Drs. Stephen Cohen and Edwin

Zinman discuss how to avoid patient

distrust .........................................44

TechnologyEndodontics made more efficient

with the ScanX Swift™

Dr. Howard Golan discusses a

different type of imaging technology

.....................................................46

AbstractsThe latest in endodontic research

Dr. Kishor Gulabivala presents the

latest literature, keeping you up-to-

date with the most relevant research

.....................................................48

Product insightThe rationale and use of electronic

apex locators

Dr. L. Stephen Buchanan offers

advice on getting to the root of the

matter ..........................................50

EndospectiveThe martensitic transformation:

still transforming endodontics

Dr. Rich Mounce discusses the

second generation of heat-treated

nickel-titanium alloys ....................53

Practice managementTechnology leads the charge for

improved patient experience,

increased cash flow

Jena McCoy-Lovern tackles some

challenges to establishing and

maintaining a positive relationship with

patients .......................................54

Industry news ............56

Materials & equipment .....................56


Fiber posts and tooth reinforcement 22

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The advantages of 2D & 3D in one comprehensive unitORTHOPHOS XG 3D is a hybrid system that provides clinical workflow advantages, along with the lowest possible effective dose for the patient. Its 3D function provides diagnostic accuracy when you need it most: for implants, surgical procedures and volumetric imaging of the jaws, sinuses and other dental anatomy.

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What can you tell us about your background?I grew up in Northern New Jersey, and would like to say I spent endless summers hanging at the shore, but I actually spent summers working with my father doing construction since the fourth grade. I benefited from a liberal arts education and graduated from Lycoming College with honors. I attended the University of Medicine and Dentistry, receiving both graduate and postgraduate degrees. I also enjoyed being an Associate Clinical Professor for 10 years. I started my first practice right out of school and have opened five offices in New Jersey since then.

Is your practice limited to endodontics?I am often asked if our practice is just limited to endodontics. My answer is we are limited to comprehensive endodontics. We limit ourselves to root canals, surgical endodontics, facial pain diagnosis, occlusion, TMD, and patients with special needs. A complete postgraduate program touches upon many areas of endodontics, and it is up to individuals what they limit themselves to.

What training have you undertaken?You are never done training and learning. Take continuing education courses that are not endodontic in nature. Anatomy, microbiology, restorative, and pathology helps you communicate with your peers on a more thorough comprehensive basis.

Why did you decide to focus on endodontics?So, why endodontics? At first, I thought it was fun, I had an aptitude for it, and loved doing it. I had a deep respect for the instructors in my department. To this day, I still love going to work.

How long have you been practicing, and what systems do you use?I have been fortunate to be practicing for close to 25 years. There was once a time when I use to say: “We have to be able to

do this on computers!” Careful for what you wish for. Plumber, move over on my speed dial, computer technician, step right in. We review radiographs from many different software systems. We have been exceptionally pleased with companies such as Adec, Schick, and Planmeca. The detail and support we feel has been consistent and dependable.

Who has inspired you?I was first and still inspired by my family dentist, Dr. Anthony Cipriano. I could tell as a teenager he really enjoyed what he did. Patients can sense that, young to old. That may be the tip of the day.

What is the most satisfying aspect of your practice?We are tooth savers! When told the tooth can’t be saved, nothing is more satisfying then keeping that tooth right where it erupted. Origin of facial pain, yes, we have it figured out; let’s put you in the right direction. The practice’s scope of treatment expands as well as the opportunity to collaborate with many of our colleagues from medicine to dentistry.

Professionally, what are you most proud of?On a professional level, I am most proud of my fellow colleagues in the office, both doctors and staff. “I’d rather be having a root canal.” Guess what? — you are! We work hard to make our patients want to come back.

What has been your biggest challenge?The biggest challenge we face is to have others understand that many teeth indicated for extraction can be saved. Quality CBCT imaging makes diagnosing and treatment more predictable.

What would you have become if you had not become a dentist?I was fortunate to choose my profession. As a child growing up, I wanted to be an astronaut. My career would have ended early; I have to take Dramamine before I go on carnival rides with my daughter.

What is the future of endodontics and dentistry?The future of endodontics is found in

Dr. Brian Trava


PRACTICE PROFILE

Multidimensional endodontics

“The ASI Endodontic carts are a great convenience. This space saving design allows me to be organized and efficient with only one foot control and without all of the cords draped over my counters.”

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The Cart, With Only One Foot ControlThe versatility of ASI’s custom integrated cart system allows for infinite positioning of the cart to easily maneuver within close reach during procedures and then out of patient view after procedures. Adding a monitor mount creates an intimate environment for both patient education and clinical use.

Side DeliveryAn ASI cart positioned at the doctor’s dominant side requires the least amount of tasking movements during a procedure and works efficiently with microscope dentistry.

Foot Control PlacementThe foot control tubing of an ASI system can be run underneath the floor through a conduit from the junction box to the patient dental chair. The end result creates easy access to the foot control without tubing running across the floor.

The Junction BoxIn addition to attractively concealing the standard connections of compressed air, suction and electricity, ASI’s unique in-wall junction box allows computer connections such as video, USB, network and other IT connections throughout the office to be easily organized and safely hidden from view.

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PRACTICE PROFILE

research and technology. Endodontic research has given us a much more comprehensive understanding of microbial infections, biofilm, and anatomy. Our practice has been the first to incorporate both CBCT and lasers in many ways to treat our patients. Patients are more educated, they want to save their natural teeth, and we have the tools available to us.

What are your top tips for main-taining a successful practice? 1. Listen to the patient2. Be fair to the patient3. Make sure the patient understands

what you’re doing and why you’re doing it

4. Communicate with the patient and the dentists

What advice would you give to budding endodontists?The best advice that I can give to a budding

endodontist is twofold. Look beyond the tooth. Take what you learned in school, and use it to treat the whole patient. To make it easier, invest in quality equipment backed by quality companies. Do your research. Look for a quality CBCT machine, a machine that allows you to study and diagnose the oral maxillary complex, TMJ, and sinus with great detail.

What are your hobbies, and what do you do in your spare time?Endodontics can be demanding. It is best to have distractions to take your mind away from the office. So, I became a soccer mom with my wife. There is nothing like kids to help you forget about the office for a weekend. Typically, when I am asked to lecture across the country, the first place I look for is a National Park to incorporate into our trip. It’s a great way to really appreciate what we work for.

TOP 10 FAVORITES LIST

1. My number one most indispensible piece of equipment in my office, our Promax 3D.

2. Explaining to patients how their CBCT image has given me the detail I need to help them.

3. Being the first to use the Waterlase MD to treat lesions without making a surgical flap.

4. Working with the NBA in Africa to help children.

5. Treating kids and special needs individuals when they were turned away from other practices.

6. Telling patients at 3 a.m. that it is normal; everybody calls me at this time to tell me they had a toothache for 2 weeks.

7. Having the opportunity to learn from other colleagues while lecturing in different areas of the country.

8. Enjoying problem solving and interacting with my colleagues.

9. Watching my daughter’s athletic ability and realizing it does skip a generation.

10. Finally, being able to hang at the shore.EP

This EHR Module is 2011 compliant and has been certified by an ONCDATCB in accordance with the applicable certification criteria adopted by the Secretary of Health and Human Services. This certification does not represent an endorsement by the U.S. Department of Health and Human Services or guarantee the receipt of incentive payments.

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TDO_GSR_062113_endo_practice_mag.indd 1 6/22/13 12:11 AM

Company historyPlanmeca is the world’s largest privately held dental imaging company and one of the industry’s leading manufacturers of panoramic and cephalometric X-rays. Over the past four decades, it has expanded its sales network in more than 100 countries worldwide. Planmeca’s imaging units offer superior image quality, reduced radiation during routine procedures, easy upgradeabililty, and advanced, user-friendly imaging software. Planmeca has been a leader in digital imaging and advanced computer-integrated dental care concepts for years and remains in the forefront of technology as the field of dentistry evolves. Since the company’s establishment, Planmeca’s developers have worked closely with dentists and leading universities to anticipate future trends, using this data to design an advanced line of high-tech products. From the introduction of the first microprocessor-controlled chair, to the development of the ProMax™ line of imaging units with SCARA (Selectively Compliant Articulated Robotic Arm) technology, Planmeca has always led the way with new technology. The company’s goal is to supply dental professionals with the highest quality dental equipment that is uniquely designed for today’s modern, technologically advanced practice.

Patented SCARA technologyWhat truly sets Planmeca apart from the competition is the company’s patented, exclusive SCARA technology. This robotic arm, which comes standard on all ProMax units, enables free geometry based on image formation and can produce any movement pattern required. The precise, free-flowing arm movements allow for a wide variety of imaging programs not possible with any other X-ray unit on the market; this allows the dental professional to take images based on diagnostic needs, not machine limitations.

Anatomically accurate extraoral bitewing programPlanmeca’s ProMax S3, 3D, and 3D Mid imaging units offer an exclusive extraoral bitewing program, possible only with SCARA technology. This innovative program consistently opens

interproximal contacts, eliminates patient positioning errors, and is more diagnostic than other intraoral modalities. ProMax extraoral bitewings are ideal for a number of patients, from the elderly and those requiring periodontal work to those with claustrophobia, sensitive gag reflexes, or those in pain. All of this comes in a true bitewing program that enhances clinical efficiency and takes less time and effort than a conventional intraoral bitewing.

Upgradeable innovationOne of Planmeca’s greatest contributions to dental imaging is its innovative, upgradeable product platform — all based on exclusive, patented SCARA technology. Since it’s software-driven, SCARA technology enables limitless possibilities to upgrade existing equipment, allowing the new dentist on a smaller budget to grow while making only appropriate and necessary equipment investments. For example, Planmeca products can be upgraded from a 2D panoramic X-ray to a combination of pan/ceph capabilities, which can be further upgraded to accommodate 3D imaging needs. Whether it is the transformation of a film to a 3D unit, or the addition of a cephalometric arm, Planmeca offers solutions for every upgrade need. This single piece of technology makes the ProMax the most versatile all-in-one X-ray unit available on the market.

Reduced radiation for safer proceduresAll Planmeca products are designed around the ALARA radiation principle (As Low As Reasonably Achievable). Through specially designed programs, such as horizontal and vertical segmenting, autofocus, and pediatric pans, dental professionals are able to provide their patients with excellent care without compromising their safety. Horizontal and vertical segmenting options limit the exposure to diagnostic areas of interest. By selecting these options, patient dosage can be reduced by up to 93%, which is highly advantageous when follow-up images are needed. Autofocus automatically positions the focal layer using a low-dose scout image of the patient’s central incisors, and uses landmarks within the patient’s anatomy to calculate placement. The result is a

fast, diagnostic pan every time, which drastically reduces retakes caused by false positioning. Pediatric programs further lower the dose by automatically selecting the narrow focal layer of young patients, adjusting the collimator, and reducing the area of exposure from the top and the sides. This reduces the dosage area while still providing full diagnostic information.

Digital Perfection™: the new standardBuilding on the well-established all-in-one idea of integration, Planmeca introduced the Digital Perfection concept in 2011. Seamless integration of dental equipment and software creates efficient diagnostic tools, optimized workflow, and advanced infection control methods that result in a treatment environment where all equipment shares an open interface. The company works worldwide with all aspects of the dental industry, including dental schools, dentists, and dental team members, as well as dealers, and uses the latest technologies to create the best products for dental offices and patients alike. As a forerunner in digital imaging technology, Planmeca delivers complete dental solutions based on integrated high-tech device and software options with exquisite design.

For more information, visit www.planmecausa.com

This information was provided by Planmeca.

Planmeca®: innovative, upgradeable imaging technology


CORPORATE PROFILE

“The company’s goal is to supply dental professionals

with the highest quality dental equipment that is

uniquely designed for today’s modern, technologically

advanced practice.”

EP

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Endodontic therapy is performed millions of times a year with relatively high

success rates. Success is based on an accurate diagnosis and execution of the indicated treatment plan. Advancements in the treatment and diagnosis of root canal therapy (apex locators, development of NiTi instruments, rotary instrumentation, new irrigating solutions, evolving technique, and cone beam computed tomography (CBCT) all play important roles in treatment success. The application of new technology has made major advances in diagnosis and treatment, particularly in the area of radiography. Radiographic assessment and clinical tests are essential in making an accurate diagnosis. Radiographic interpretation allows evaluation for the presence of periapical pathosis, hard and soft tissue configurations, and other contributing factors in patient care. High quality radiographic evaluation is an essential component in objectively diagnosing teeth with suspected endodontic problems (Patel, et al., Ozen, 2009, and Yoshioka, 2011). It is well established that conventional periapical radiographs have limitations such as anatomical noise, two-dimensional and geometric distortions (Humonen & Orstavik, 2002, Patel, 2009). Conventional intraoral radiographs image a three-dimensional structure and display it onto a two-dimensional surface, causing the image to have overlaps, distortion, and blockage of key anatomical structures. This results

Endodontics in 3D


CASE STUDY

Drs. Derek Chu, David Jaramillo, Chad Gustafson, and Dwight Rice study the benefits of CBCT, and its role in helping to diagnose and treat endodontic problems

in more radiopaque structures masking or blocking more radiolucent structures. With the development of CBCT, it is now possible to overcome some of these limitations. CBCT technology is significantly more sensitive than conventional radiography in detection of apical periodontitis (Estrela, 2008). CBCT scans are now able to aid in difficult endodontic diagnostic cases where clinical tests and conventional radiology are

inconclusive. Detection of apical periodontitis can be accomplished earlier with CBCT than with conventional radiography because CBCT detects bone loss prior to the involvement of cortical bone. Earlier detection and diagnosis of bony involvement associated with apical periodontitis may allow earlier intervention, if appropriate, which can result in superior treatment outcomes.

Referral PA

Derek Chu, DDS, is Assistant Professor, Department of Endodontics, Loma Linda University School of Dentistry, California.

David E. Jaramillo, DDS, is Associate Professor, Department of Endodontics, Loma Linda University School of Dentistry.

Chad Gustafson, DDS, is in Private practice in Endodontics in Central California.

Dwight Rice, DDS, is Associate Professor, Department of Oral Diagnosis Radiology and Pathology, Loma Linda University School of Dentistry.

Endodontist’s PAs

Postoperative radiographsPossible involvement of tooth No. 12 but could also be thin buccal plate

CA

SE

ST

UD

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CBCT technology has been shown to detect 28% more periapical pathosis versus conventional radiography (Patel, et al.). The following three case reports will demonstrate the benefits of CBCT, and its role in helping to diagnose and treat endodontic problems.

Case report No. 1The patient presented to the Loma Linda University School of Dentistry graduate endodontic clinic for endodontic evaluation of tooth Nos. 11 and 12. The patient had mild tenderness when pressing below his eye on the left side for several months. He had no pain on chewing, and it had never awakened him. The oral exam revealed

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CASE STUDY

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extensive crown and bridge reconstructive dentistry. Tooth Nos. 11-13 were restored with porcelain-fused-to-metal crowns with tooth No. 11 serving as an abutment for a multiunit bridge. There was no sinus tract, and probing depths were 2-3 mm around tooth Nos. 11-13. There was no tenderness to percussion.

Preoperative radiographsPalpation over the buccal apical area of tooth Nos. 11 and 12 was consistent with the patient’s chief complaint and a hard, bony-like swelling was noted in the vestibule, which was not present on the contralateral area of tooth Nos. 5 and 6. Tooth Nos. 11-13 responded to cold, but the response was delayed. Two PA

radiographs were taken, but no definitive periapical pathosis was noted, and the PDL appeared normal around all apices. No endodontic cause could be found. A small field of view CBCT scan was recommended to identify location and size of expansive lesion. The CBCT indicated a periapical radiolucency surrounding the apex of

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tooth No. 11. The apical bone surrounding tooth No. 12 appears to be normal. The radiolucency is consistent with a periapical granuloma or cyst related to a necrotic pulp tooth No. 11. A tentative diagnosis No. 11 necrotic pulp/symptomatic apical periodontitis was determined. Root canal treatment was recommended for tooth No. 11. The canal was cleaned and shaped to length. The canal was obturated with warm vertical compaction and GP. The access was sealed with a bonded composite restoration. A 6-month follow-up visit was recommended to evaluate apical healing.

Case significanceClinical signs and symptoms did not provide enough information for a conclusive endodontic diagnosis for tooth No. 11, and no definitive lesion could be detected with two-dimensional radiographs. CBCT allowed for the detection of apical pathosis and aided in the diagnosis.

Case report No. 2A male patient presented in the Loma Linda School of Dentistry graduate endodontic clinic referred for endodontic evaluation of tooth No. 3. He reported having pain on the upper right side of his mouth. He had mild tenderness when palpating around the buccal mucosa of tooth No. 3. Clinical evaluation showed a sinus tract

present along with purulent discharged after palpating the swelling. The clinical exam revealed mobility, the periodontal probings were within normal limits, and there was no pain to percussion. The radiographs revealed that tooth No. 3 had been previously treated, and the sinus tract was traced with GP leading to tooth No. 3. He recalled that the tooth was previously

treated 2 to 3 years prior. Tooth No. 3 was diagnosed having a recurring/persistent infection and treatment planned for non-surgical retreatment. During retreatment, a missed MB2 canal was located, cleaned, and shaped to length. Calcium hydroxide was placed in the canals, and the patient was scheduled to return in 1 week to complete treatment.

Final obturation was performed using warm vertical compaction of GP. At a 5-month follow-up, patient reports having tenderness recur when palpating over the area where the previous swelling was. Clinical exam reveals slight tenderness to palpation on buccal mucosa of tooth No. 3 again. Tooth mobility, percussion, and periodontal probing were

REfEREncEs

Patel S. New dimensions in endodontic imaging: Part 2. Cone beam computed tomography. Int Endod J. 2009;42(6):463–475.

Patel S, Horner K. The use of cone beam computed tomography in endodontics. Int Endod J. 2009;42(9):755–756.

Patel S, Dawood A, Whaites E, Pitt Ford T. New dimensions in endodontic imaging: part 1. Conventional and alternative radiographic systems. Int Endod J. 2009;42(6):447–462.

Patel S, Dawood A, Mannocci F, Wilson R, Pitt Ford T. Detection of periapical bone defects in human jaws using cone beam computed tomography and intraoral radiography. Int Endod J. 2009;42(6):507-515.

Yoshioka T, Kikuchi I, Adorno CG, Suda H. Periapical bone defects of root filled teeth with persistent lesions evaluated by cone-beam computed tomography. Int Endod J. 2011;44(3):245–252.

Ozen T, Kamburoğlu K, Cebeci AR, Yüksel SP, Paksoy CS. Interpretation of chemically created periapical lesions using 2 different dental cone-beam computerized tomography units, an intraoral digital sensor, and conventional film. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009;107(3):426–432.

Huumonen S, Ørstavik D. Radiological aspects of apical periodontitis. Endod Topics. 2002;1(1):3–25.


CASE STUDY

within normal limits. Patient was referred for CBCT scan for further evaluation. Evaluation of CBCT scan confirmed the presence of an apical lesion of endodontic origin, and the patient was scheduled for endodontic surgery. CBCT provided the opportunity to determine the size of the lesion and establish the location of the sinus in preparation for the osteotomy to be performed. The surgery was completed, and a biopsy sample taken. Biopsy report: periapical granuloma. At 2-month recall, the patient reported that the pain had subsided. The clinical exam revealed no signs of swelling or sinus tract. All the tests were within normal limits.

Case report No. 3A male patient presented in the Loma Linda School of Dentistry dental hygiene clinic for routine dental maintenance. A firm, localized, solitary 5 mm swelling on the inside of the left upper lip (buccal to tooth No. 9) was noted. There was also a sinus tract present associated with the swelling. He reported no pain, and was not aware of

the findings. The PA radiographs revealed an impacted canine superimposed over the apex of tooth No. 9. The buccal mucosa above tooth No. 9 was red with a slight swelling where the apex of tooth No. 9 would be. The patient had a CBCT scan to establish the orientation and proximity of tooth No. 11 in regards to the apex of tooth No. 9. The CBCT scan also showed the presence of apical periodontitis on tooth No. 9, establishing tooth No. 9 as the source of infection. Endodontic evaluation and treatment was done prior to evaluation for surgical removal of tooth No. 11. CBCT technology demonstrated its important value in these presented cases. CBCT scans provide additional information for visualizing the anatomic features present and for overcoming the limitations of conventional dental radiography. EP

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The causes of endodontic failure are predominantly of bacterial origin

resulting either from retained microbes or from those reintroduced into the root canal space:1. Untreated and or contaminated canal

space. This will include inadequately cleaned, missed, or ledged canals.

2. Instrument separation preventing proper shaping, cleaning, and obturation of canal space.

3. Perforation.4. Leakage resulting from an inadequate

coronal seal. The successful management of an endodontic failure depends on many different factors. The correct diagnosis is of major importance and reference to the earlier article in this series may be helpful. As CBCT technology becomes more established, we come to depend more heavily on it to help diagnose endodontic failure. Even the best quality digital periapical images will sometimes hide the truth (Figures 1A and 1B). When things do not go according to plan, the best thing to do is to stop and re-evaluate before making things worse. With experience, correct case assessment can often prevent pitfalls during treatment.

Failure of endodontic treatmentNo treatment can be guaranteed to be 100% successful, and endodontics is no exception, even though success rates of over 90% can be achieved. If an endodontic failure is diagnosed, it is important to know why it has failed. A very good knowledge of root canal anatomy is important as well as an understanding of the techniques used in endodontic procedures. This is why very often endodontic retreatments are carried out by specialists and form a significant proportion of their work.

Tip number 10 — When things go wrong


ENDODONTICS IN FOCUS

In the last article in this series, Dr. Tony Druttman focuses what to do when things do not go according to plan.

Figure 1A: Tooth No. 15 appears on a periapical to be well root treated

Tony Druttman, MSc, BChD, BSc, is an endodontist working in central London. He is also a part-time teacher at the Eastman Dental Institute, University of London, and lectures in the UK and abroad.

Figure 1B: The equivalent CBCT image shows an endodontic lesion associated with the MB root

Figure 2A: Endodontic lesion of the mesiobuccal root of tooth No. 14

Figure 2B: Retreatment of tooth No. 14 including the MB2 canal

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Case assessment should include the following:Degree of treatment complexityRestorability of the toothPeriodontal statusMedical statusCostSkill of the practitionerPatient’s wishes

Missed canalsMost endodontic failures are due to the presence of residual infection. This is caused by canals that have been missed or canals that have been inadequately cleaned. The most common cause of failure of upper molars is due to untreated MB2 canals (Figures 2A and 2B). These are often missed because they are very

small and difficult to identify without magnification. Canal anatomy can be diverse, and it is important to identify all the canals that are present, rather than just the ones that one expects to find. It is also important to appreciate that canals sclerose from coronal to apical, and that the entrance to a canal can be some way apical to the pulp chamber. The operating microscope is invaluable in this respect.

Inadequately cleaned canalsConventional understanding is that files shape, and irrigants clean. If a canal is oval in cross section, then very often canal debris is packed into the lateral extensions of the canal, and it is difficult for the irrigants to remove the debris. This is particularly the case in the isthmus region of molar teeth.

Often a symptomatic root-filled tooth will look fine on a radiograph, and a diagnosis may be difficult to establish. It is important to remember that a radiograph is only a two-dimensional image of a three-dimensional object. Tissue remnants may be left in the root canal after obturation (Figures 3A and 3B). An oval cross section and a circular cross section can look exactly the same on a radiograph.

Fractured instrumentsInstrument fracture occurs either through torsional stress or flexural failure. Fracture due to torsion occurs when the tip or any other part of the instrument binds in the canal while the handpiece keeps turning. When the elastic limit of the metal is exceeded, fracture of the instrument

Figure 3A: Tooth No. 30 appears to be well root treated, and yet has symptoms Figure 3B: Tooth No. 30 has been retreated. A second distal canal has been identified

Figure 4: Sectioned root tip of root filled showing a round preparation in an oval canal Figure 5: Rotary nickel-titanium instrument fracture due to coronal binding


ENDODONTICS IN FOCUS

becomes inevitable (Figure 5). This is often due to the application of excessive apical force on the handpiece and can occur coronally as well as apically. Flexural failure occurs because of metal fatigue. The instrument does not bind in the canal, but rotates freely until the fracture occurs at the point of maximum flexure. This type of failure is due to their use in curved canals (Figure 6). Incorrect rotational speeds and torque settings may also contribute to this type of failure. The presence of a fractured instrument does not necessarily cause a failure. The question has to be asked, “At what point in the procedure did the instrument

separate?” If the mishap has occurred early in the cleaning and shaping process, and the instrument has blocked the access to the more apical part of the canal, then failure is likely to occur. This is because bacteria left behind are inaccessible to disinfection procedures (Figures 7A and 7B). On the other hand, if the last instrument in the sequence has separated at the working length, then the likelihood is that the canal has already been debrided adequately, and the presence of the fragment may not affect the prognosis of the tooth (Figure 8). Either way, it is important that the patient is informed. Fracturing an instrument in a canal is not negligent, but failing to inform

the patient is. Removal of the instrument is often possible with the aid of the operating microscope and ultrasonics; however, a great deal of care has to be taken not to remove excessive amounts of the tooth structure (Figure 7B).

PerforationsPerforations (Figure 9) can occur when looking for sclerosed canals, and sometimes it is hard to know if the true canal has been located, or if a perforation has been created, even when using magnification. Apex locators are very useful in helping to distinguish between the two, and this is recommended as soon as

Figure 8: Fractured instrument in the mesial root 8 years after treatment

Figure 9: Perforation of the mesiobuccal root during root canal preparation

Figure 10A: Failed endodontic treatment of tooth No.19 Figure 10B: Endodontic retreatment. Note the sealer in the mesial root beyond the blockage

Figure 10C: Six-month review of tooth 19 shows healing of the endodontic lesion associated with the blocked canals

Figure 6: Instrument fracture due to flexural fatigue in the mesiobuccal canal of tooth No. 15

Figure 7A: Fractured instrument in the distal root of a symptomatic tooth 30

Figure 7B: Tooth 30 fractured instrument removed and the tooth retreated

Perforation

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the canal wall has been breached. Strip perforations occur when canals have been over enlarged, often by using Gates Glidden drills too far apically or when the access cavity has not been shaped correctly. Perforations should be repaired as soon as possible, preferably at the same appointment. If they are left, bone loss around the perforation can occur, and it may not heal if left too long. MTA has proved to be an excellent repair material, although because it is a material based on Portland cement, it can be difficult to control. The new bioceramic materials that are coming onto the market show promise as MTA substitutes.

Blocked canalsThere are situations where teeth with endodontic lesions have canals that remain

blocked in spite of our best efforts. These teeth should not be condemned, as very often the lesions will heal. This may be due to the lesion being associated with other canals in the tooth or because the majority of the bacteria have been removed, and any remaining are entombed and denied access to nutrients (Figure 8). Canals that are apparently blocked to even the smallest of endodontic instruments are often patent, and this is only determined on the postoperative radiograph, when cement is forced into the uninstrumented part of the canal during obturation (Figures 9A and 9B).

ConclusionsWith technologies, such as the operating microscope, ultrasonics, CBCT, high quality digital radiography, and materials

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such as MTA, and more recent substitutes available to us in endodontics nowadays, many teeth can be salvaged, which would previously have been condemned to extraction. These include the teeth where previous endodontic treatment has failed, and where there have been procedural errors during treatment. There is an increasing preoccupation within the profession with dental implants driven by the efforts of the industry. When a tooth has to be extracted or has been lost, there is no better substitute than an implant; however, there is nothing better than the natural dentition. Endodontics plays a vital role in maintaining the natural tooth, keeping or restoring it to health and function. It is important that the skills and knowledge required to do so are not lost.

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Traditional thinking that a post is only placed to retain a core and serves

no other purpose may no longer be valid (Hajizadeh, et al., 2009). The preservation of dentin during access opening, shaping the canal, preparing the root for placement of a post, and during restoration with an onlay, or full coverage preparation is critical to the clinical longevity and success of the final restoration (Pilo, Shapenco, Lewinstein, 2008). It is now well recognized that excess removal of dentinal support, not only in the root but also coronally, changes the flexural behavior and resistance to failure, and that overflaring the canal for straightline access to the canals weakens the dentinal complex (Trope, Ray, 1992; Reeh, Messer, 1989; Linn, Messer, 1994; Panitvisai, Messer, 1995). Dentin coronally must be maintained, not only to give support to the core build-up (Fokkinga, et al., 2005; Creugers, et al., 2005), but as well, because clinical and in

vitro studies support the fact that survival of endodontically treated teeth restored with posts is directly proportional to the residual coronal dentin that remains (Ferrari, et al., 2007; Oliveira, Denehy, Boyer, 1987). Post preparation of the root canal space must not remove additional dentin, as this contributes to a reduced fracture toughness (Figure 1). Ree, et al., (2010) state that, “No additional dentin should be removed beyond what is necessary to complete the endodontic treatment.” If this concept is to be adhered to clinically, then, of course, the use of parallel-sided posts must be eliminated from our clinical protocol, as these posts usually require removal of sound apical radicular dentin, creating sharper internal line angles, resulting in a weakened root and a higher root fracture risk (Figure 2) [Sorensen, Mito, 1998]. As well, the parallel post does not complement the tapered shape of the prepared canal, resulting in excess luting composite in the coronal aspect of the canal, which can decrease bonding efficacy and decrease dislocation resistance (Figure 3) [Boksman, 2011]. If we adhere to the concept of minimal dentin removal in the root, and if we recognize that most root canals are ovoid in shape, then a wholly different treatment approach than what we have been taught in the past is indicated. Boksman, et al., (2013) have recommended utilizing a tapered master quartz fiber post (Macro-Lock Post™ X-RO™ Illusion™, Clinician’s Choice Dental Products) with additional FiberCones™ placed into the irregularity (lateral spaces) of the canal (Figures 4 and 5). This technique is similar to using a master

Fiber posts and tooth reinforcement: evidence in the literature


CONTINUING EDUCATION

Drs. Leendert Boksman, Gary Glassman, Gildo Santos, and Manfred Friedman look at the literature for fiber posts and the best techniques for placement

Figure 1: Especially in ovoid canals (which are the norm), post preparation can needlessly remove dentin and result in weakening the remaining tooth structure, while leaving lateral gutta percha that compromises bonding/cementation

Leendert (Len) Boksman, DDS, BSc, FADI, FICD, graduated from the Faculty of Dentistry, University of Western Ontario, Canada, with a DDS in 1972. After 7 years in private practice, he joined the Faculty of Dentistry at Western as an assistant professor of operative dentistry, shortly thereafter attaining the tenured position of associate professor. He has authored more than 100 articles and several chapters in textbooks and was awarded the Ontario Dental Association Award of Merit in 2005. He has recently been appointed as adjunct professor in the University of Technology Dental School, Jamaica, where he donates his time. Dr. Boksman is a paid part-time consultant to Clinical Research Dental and Clinician’s Choice.

Gary Glassman, DDS, FRCD(C), graduated from the University of Toronto, Faculty of Dentistry in 1984. The author of numerous publications, Dr. Glassman lectures globally on endodontics, is on staff at the University of Toronto, Faculty of Dentistry in the graduate department of endodontics, and is adjunct professor of dentistry and director of endodontic programming for the University of Technology, Jamaica. Dr. Glassman is a fellow of the Royal College of Dentists of Canada, and the endodontic editor for Oral Health dental journal. He maintains a private practice, Endodontic Specialists, in Toronto, Canada.

Gildo Coelho Santos Jr., DDS, MSc, PhD, received his DDS (1986) and MSc in dental clinics (1999) from Federal University of Bahia, and PhD in prosthodontics (2003) from University of São Paulo (Brazil). Dr. Santos was appointed as assistant professor, division of restorative dentistry at the University of Western Ontario Schulich School of Medicine and Dentistry in 2006, and in 2011 was appointed chair of the division of restorative dentistry. Dr. Santos is a part-time consultant (research and development) for Clinical Research Dental and Clinician’s Choice.

Manfred Friedman, BDS, BChD, graduated from the University of Witwatersrand and Johannesburg (South Africa) in 1971 and then obtained his BChD Honours at the University of Pretoria in 1980. He immigrated to Canada in 1987 where he took up a full-time position at the University of Western Ontario (UWO) and was appointed as director of dentistry at the Southwestern Regional Center for developmentally challenged adults from 1987 to 1994. He currently has a full-time practice in London, Ontario, restricting his practice to endodontics, and is a major part-time adjunct professor at Schulich School of Medicine and Dentistry at UWO. Dr. Friedman has given numerous courses on endodontics, with particular interests in rotary instrumentation, endodontic materials, apex locators, and restoring the endodontically treated tooth.

Educational aims and objectivesThis clinical article aims to explain why the literature should be scoured to find the best fiber post available and the best techniques for placement.

Expected outcomesCorrectly answering the questions on page 32, worth 2 hours of CE, will demonstrate the reader can realize that materials and techniques for fiber post restoration of endodontically treated teeth are continuously evolving with the inevitable outcome of better clinical results for patients.

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gutta-percha point with accessory gutta-percha points, which is well understood. Utilizing this approach provides several clinical advantages (Akkayan, et al., 2010; Maceri, Martignoni, Vairo, 2008; Li et al., 2011; Mossavi, Maleknejad, Kimyai, 2008; Porciani, et al., 2008) including:•Moreanti-rotationalresistance•Decreased volume of composite or

cement lateral to the post to decrease the “C” and “S” factor constraints (volumetric shrinkage)

•Betteradhesion to the rootcanalwalls,resulting in decreased microleakage and increasing resistance to dislodgement, as well as decreased likelihood for lateral perforation.

Choosing the right fiber postThe combination of a post (or multiple posts)

that transmits light efficiently, with sufficient extended light-curing time/output, results in better composite polymerization. The indirect cast gold/metal/zirconia post and core has been largely replaced with a single appointment restoration of a direct post and core. Fiber posts such as the UniCore® Post (Ultradent), the quartz fiber posts manufactured by RTD (St Egreve, France), the Macro-Lock X-RO, and the DT Light-Post® (Bisco Canada, BC) have many physical characteristics that make them more desirable clinically, rather than metal and zirconia posts:1. The elastic modulus (or a material’s stiffness) of fiber posts more closely approximates that of dentin (18.6GPa), allowing some slight flex in function, dissipating stress, and reducing the likelihood of damage to the root (Ferrari,

Scotti, 2002; Duret, Duret, Reynaud, 1996). Stainless steel has an elastic modulus of about 200GPa, titanium alloy 110GPa and zirconia 300GPa (Goracci, Ferrari, 2011). The stiffness of metal and zirconia posts creates more internal stress, zones of tension and shear during function and parafunction (Rodrigues-Cervantes, et al., 2007), which can result in unrestorable catastrophic root fractures.2. Fiber posts have a high flexural strength, and according to a study by Stewardson, et al., (2004): “The flexural strength of fiber-reinforced composite endodontic post materials exceeds the yield strength of gold and stainless steel, and two of the FRC (fiber reinforced composite) posts were comparable to the yield strength of titanium.” It must be noted here that not all fiber posts are created equal. There are differences in fracture load, flexural strength, fiber diameter, fiber/matrix ratio, type of fiber (with quartz fiber posts having higher failure resistance), light transmission, shape, post surface adhesion, quality of fiber, structural defects/voids, and manufacturing quality, which all affect the clinical outcome and longevity (Seefeld, et al., 2007; Freedman, Jain, 2008; Bassi, 2001; Boudrias, Sakkal, Petrova, 2001; Maceri, Martignoni, Vairo, 2008). The clinician must make an informed choice for choosing a fiber post – looking for the best attributes – in order to select the post with superior properties based on independent research. The dental practitioner must also be aware of the best adhesive combinations and techniques, as there are some incompatibilities between dual-cure core materials and simplified acidic adhesives due to residual acidity. There is a variation in the results of the scientific literature when evaluating fiber posts, not only because of the differences in the posts themselves, but also because of the cementing/

Figure 2: To seat the inserted parallel-sided post into the tapered canal would require more apical removal of vital dentinal structure needlessly weakening the root and creating an apical stress point

Figure 3: The taper of the Macro-Lock post allows respect for the dentin, and ensures a more even and minimal amount of surrounding composite resin, thereby reducing polymerization contraction forces

Figure 4: In irregular or ovoid canals, the use of FiberCones lateral to the Macro-Lock X-RO has many clinical advantages, increasing longevity

Figure 5: A clinical photograph showing the placement of FiberCones laterally to the main Macro-Lock Post, which decreases composite volume, adds anti-rotational elements, and decreases microleakage



bonding/adhesive systems used. To date, multiple articles in the scientific literature support the statement that, “Only specific combinations of dentin adhesives and luting cements prove efficient, with total etch adhesives combined with dual-cure cement (composite) appearing to be the best choice” (Dietschi, et al., 2008; Radovic, et al., 2008).3. Fiber posts are not subject to galvanic or corrosion activity. The corrosion of base metals predisposes to a high percentage of failures with cast posts, which can also create a negative esthetic outcome of a dark root and darkening of the gingival collar (Figure 6A) [Rosenstiel, Land, Fujimoto, 2000; Torbjorner, Karlsson, Odman, 1995]. Milnar (2010) and others have published excellent papers showing that the use of a light-transmitting post can eliminate this common esthetic challenge, allowing not only light transmission down the canal, eliminating the dark gingival color, but also the creation of superb clinical esthetics with translucent ceramics over a composite core (Figure 6B) [Martelli, 2000; Strassler, 1999].4. Clinically, heavily restored teeth may hold up to normal occlusal function but many fail in cyclic fatigue-repeated functional, stress and torque (Duret, Duret, Reynaud, 1996). Fiber posts are more fatigue resistant than metal posts, and the quartz fiber post is found to be more than twice as fatigue resistant as the stainless and titanium alloy posts (Wiskott, et al., 2007). During repeated fatigue loading, the flexural strength of metal posts can decrease by 40%, while there is only a 14% decrease in a fiber composite post (Duret, Duret, Reynaud, 1996). 5. Endodontic procedures fail due to faulty technique, the inability to access or completely debride a canal, microleakage/bacterial contamination/exposure to endotoxins after endodontic therapy is performed, but before a final restoration is placed (all endodontic procedures should be followed by immediate restoration) [Magura, et al., 1991; Alves, Walton, Drake, 1998], or due to failure and microleakage of the coronal restoration. It has been estimated that 25% of retreatments involve the presence of a post. Fiber posts are atraumatically removed in a matter of a few minutes with available proprietary removal drill systems (Anderson, et al., 2007; Frazer, et al., 2008; Gesi, et al., 2003). No discussion of the restoration of a badly broken-down endodontically treated

tooth would be complete without discussing the concept of the circumferential ferrule, which is defined as “a metal band or ring that encircles the tooth in order to provide retention and resistance form, as well as protect the tooth from fracture” (Yonker, Rubinstein, Nidetz, 2011). Most of the published articles, based on in vivo and in vitro data, suggest that a 2 mm ferrule is best for improving resistance to fracture with significant decreases when the ferrule is 1 mm or nonexistent (daSilva, et al., 2010; deLima, et al., 2009; Hu, et al., 2005). However, it is not only the height of the remaining dentin that is critical for creating the ferrule, but just as important is the width of the remaining dentin and the number of

walls. As shown in Figures 7 and 8, there is a drastic difference in outcomes when preparing a ferrule in a modestly flared canal versus a wide flare. As can be seen, when a wide flare exists, the preparation of a ferrule actually removes the dentinal lateral walls, creating a standalone core that essentially has no ferrule at all. It is important to note here that glass ionomer cements and resin modified glass ionomers lack the physical properties to function as a core material (Gateau, Sabek, Dailey, 2001; Mollersten, Lockowandt, Linden, 2002).

Clinical guidelinesIn their article on “Rethinking the ferrule”,

Figure 6A: The common esthetic failure when using metallic posts with discoloration of the tooth structure as well as the gingival collar

Figure 6B: The result of placing a light transmitting fiber post with a translucent ceramic

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Jotkowitz, et al., (2010) provide one of the best regression analyses and clinical guidelines in the literature, evaluating the effects of the height, number of walls remaining, thickness of the walls, and whether a mesial-distal or buccal-lingual wall is remaining in relationship to the functional stresses involved. A simple example would be the difference of losing a lingual wall on an upper central, – even if three walls remain – which can be catastrophic due to the torque placed on the lingual in function, as opposed to losing an interproximal wall that has little weakening effect when lingual stress is applied. Their conclusion is that no ferrule equals unrestorable. “Clinical protocols should feature well-defined inclusion criteria, including delineation of the number of residual coronal walls, for a clearer assessment of the influence of the remaining tooth structure on treatment outcomes” (Ferrari, et al., 2012). As the number of remaining walls decrease, the fracture resistance decreases when no post is used, but the fracture resistance is increased significantly when fiber posts are placed – except when there is no wall left (Nam, et al., 2010).

“The success rate for all posts decreases drastically in the absence a residual coronal wall” (Ferrari, et al., 2012). The literal definitions of reinforcement from various sources include:• Adevicedesignedtoprovideadditional

strength• Tostrengthenbyaddingextrasupport• Tomakestronger• To strengthenwith some addedpiece,

support or material• Tomakeastructurestronger. Much of the dental literature and texts from the 1970s to the early 1990s indicate that a post is placed when there is insufficient structure left to retain a core/crown, and that metal posts do not reinforce the root (Sorensen, Engleman, 1990; Caputo, Standlee, 1976; Sorensen, Martinoff, 1984; Assif, Gorfil, 1994). Retrospectively, looking at research on endodontically treated teeth utilizing metal posts certainly supports this finding (Trope, Maltz, Tronstad, 1985; Guzy, Nichols, 1979). However, more recent research articles and publications are creating a body of work that fiber posts do indeed make the root more resistant to fracture and may

strengthen the root. What follows is only a partial list with short summaries of some of the more recent relevant studies supporting the notion of reinforcement by using fiber posts.

Reinforcement D’Arcangelo, et al., (2008) studied the fracture resistance and deflection of teeth restored with a fiber post, and prepared for veneers. Seventy-five human maxillary central incisors with similar anatomic crowns were included: no preparation, veneer preparation, endodontic access filled with composite, endodontic access with composite and veneer preparation, and fiber post placement (RTD Endo Light-Post) followed by veneer preparation. All specimens were thermo-cycled and submitted to fracture strength tests by using a displacement measurement system. Preparation for veneers increased the deflection values of the specimens, but the fiber-reinforced post restoration with veneer preparations did not show statistically significant differences from the intact unprepared incisor. When investigating the fracture resistance and failure mode of premolars restored with composite resin and various prefabricated posts, Hajizadeh, et al., (2009) utilized 60 extracted teeth with four subgroups: no cavity preparation, endodontics with an MOD and no post, endodontics with a DT Light-Post (RTD) and MOD, and the last group with endodontics, Filpost (Filhol Dental, UK) and an MOD composite restoration. The teeth restored with the DT Light-Post and composite were as strong as the control (the unprepared tooth) and stronger than those teeth restored with composite alone without a post, and those restored with a titanium post and composite. In the DT Light-Post group, 86% of the fractures were “restorable,” which was much higher than any of the other three groups. According to the authors: “There is growing evidence that fiber posts provide the additional benefit of increased fracture resistance.” The effect of placing fiber posts under zirconia-ceramic crowns was studied by Salameh, et al., (2008). Ninety mandibular second molars were divided into three test groups representing various extents of coronal damage, endodontically accessed and obturated with warm vertical condensation. Half of the specimens were

Figure 7: The typical result of creating a full crown with a ferrule in a moderately tapered endodontic access opening

Figure 8: When preparing a ferrule on a tooth with a wide flare, the preparation removes all lateral dentin, creating a standalone core that drastically decreases the clinical success rate



restored with composite, the other half with a translucent FRC post (Rely-X™ Fiber Post, 3M™ ESPE™) with a composite core. The insertion of the fiber post improved the support under the zirconia crowns, which resulted in higher fracture loads and favorable failure type compared to a composite core build-up. Maccari, et al., (2003) utilized 30 single-rooted endodontically treated teeth to evaluate the fracture resistance of different prefabricated esthetic posts. Included in the study were Aestheti-Post (RTD), FibreKor™ Post (Pentron), and Cosmopost (a ceramic post system, Ivoclar Vivadent). They summarized that the mean fracture resistance of the glass fiber prefabricated esthetic posts proved a higher fracture resistance than the ceramic post, which was less than one-half of the fiber posts. The fracture resistance and failure pattern of endodontically treated maxillary incisors restored with composite resin, with and without fiber-reinforced composite posts under different types of full coverage crowns, was studied by Salameh, et al., (2008). One hundred and twenty maxillary incisors were endodontically treated and divided into four groups of 30 each and further divided into two subgroups of restoration with or without a fiber post (Postec® Plus, Ivoclar Vivadent). Restorations placed were PFM, Empress® II, SR Adoro® crowns and Cercon® crowns with all preparations including a 2 mm ferrule. Fracture tests showed that the type of crown was not a significant factor affecting the fracture resistance, but the presence of a post was. The authors state that: “Although prosthodontic textbooks do not generally advocate the placement of fiber posts in endodontically treated incisors, the results of this study indicate that the use of fiber posts in such teeth increases their resistance to fracture and improves the prognosis in case of fracture.” In a study of 80 endodontically treated maxillary premolars treated with or without fiber posts, and MOD cavity preparations restored with different types of crowns including porcelain fused to metal, lithium disilicate, fiber-reinforced composite or zirconia crowns, Salemeh, et al., (2007) loaded the restorations until failure, recording the maximum breaking loads. Under vertical loading conditions, the fracture loads of teeth restored with fiber posts were significantly greater than those without posts, and the fiber

posts significantly contributed to the reinforcement and strengthening of pulpless teeth by supporting the remaining tooth structure against vertical compressive stresses. There are many more studies showing the reinforcement of tooth structure with fiber posts (Schmitter, et al., 2006; Carvalho, et al., 2005; Rosentritt, et al., 2004; Goncalves, et al., 2006; Naumann, Preuss, Frankenberger, 2007; Hayashi, et al., 2006; Hayashi, et al., 2008; Salameh, et al., 2010; Ferrari, et al., 2007; Nothdurft, et al., 2008).

Continual advancement It is impossible to summarize them all, but it seems obvious that our concept of restoring endodontically treated teeth is continually advancing as new products and bonding techniques evolve. Even when there are variations in the types of fiber posts used in the studies, and different cementation and adhesive protocols, there is compelling evidence that fiber posts can reinforce tooth structure. To create balance in this overview of the literature, it must be said that there are, of course, some published scientific articles that do not show a reinforcing effect of fiber posts (Fokkinga, et al., 2005; Kreijci, et al., 2003; Abdul, et al., 2006). In addition to the traditional definition of mechanical reinforcement – restoring a compromised tooth to a fracture strength equal to or greater than its original “untreated” fracture resistance – we clinicians perhaps should be more focused on the predictability of outcomes, particularly in worst-case scenarios. That is the contribution of the post versus no post, or composite only, to the remaining structures. The most predominant conclusion emerging from the growing body of in vitro (and clinical) data is that failures of fiber posts in situ are more likely to be described as “non-catastrophic” or “repairable,” which is usually not the case with high modulus posts (Cormier, Burns, Moon, 2001; Fokkinga, Creugers, Kreulen, 2003; Le Bell-Ronnlof, et al., 2001; Cagadiaco, et al., 2008). Furthermore, recently published clinical trials correlate the success rate to the number of remaining dentin walls (Ferrari, et al., 2012; Bitter, et al., 2009; Naumann, et al., 2012). Variations in the literature on fiber posts are the results of: use of natural teeth or bovine teeth, in vivo versus in vitro results, the effect of the

periodontal ligament in distributing some of the stresses, loading technique (vertical, horizontal, or at an angle), the type and quality of the post, the recognition of the “secondary smear layer” and how it affects adhesion, the type of radicular dentin that is to be bonded, the adhesive used, the light carrying or transmission capability of the post, the type of composite used to cement the post, the amount of composite lateral to the post, the filler loading of the composite, and the amount of critical dentin that is removed to place the post.

Unique challengesAdhesive bonding in the root canal has its unique challenges due to dentinal structure in the canal (coronal dentin bonds better than apical dentin), the “secondary smear layer” of debris from gutta percha and sealer that compromises the ability of simplified systems to actually bond to the root surface (results in mainly frictional resistance), “C” and “S” factor polymerization effects, curing to depth when using dual-cured composite (all dual-cured composites have a higher polymerization percentage when exposed to sufficient light), resulting in better overall physical properties, and material incompatibilities. Fiber post restoration techniques require a meticulous protocol, and the clinician is urged to scour the literature, not only for the best fiber post available, but also the best techniques for placement. Materials and techniques for fiber post restoration of endodontically treated teeth are continuously evolving with the inevitable outcome of better clinical results for our patients.

AcknowledgementThe authors would like to thank Mrs. Laura Delellis for her work creating the figures used in this article. This article has been reprinted with kind permission from Oral Health (May 2013) pp. 32-46.

REfEREncEs

The full list of references is available upon request.

EP

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IntroductionSuccessful endodontic therapy requires thorough knowledge of the root and the root canal morphology (Sert, Bayirili, 1997). According to Vertucci (2005), a major cause of post-treatment disease is the inability to locate, debride, and obturate all the canals in a root canal system. In general, there is an increased prevalence of missed roots and root canals that results in failure of endodontic treatment (Cantatore, et al., 2006). According to Cleghorn, et al., (2006), the mesiobuccal root of the maxillary first molar has generated more research and clinical investigation than any other root in the oral cavity. Frequent failure of endodontic treatment in maxillary first permanent molars is likely due to the failure to locate and obturate the second mesiobuccal canal (Weine, 2004). With the advent of new instruments, equipment, and techniques (such as operating microscopes and ultrasonic instruments), an increase in the number of second mesiobuccal canals was demonstrated in clinical investigations (Vertucci, 2005). Cleghorn, et al., (2006), demonstrated that two or more canals can be present in the mesiobuccal root (with 57% of 8,339 teeth of the 34 laboratory and clinical studies analyzed). They also reported that a single canal at the apex of the mesiobuccal root was found 62% of the time, while two separate canals at the apex were present 39% of the time. In a recent micro-CT study, it was demonstrated that the second mesiobuccal canal was present in 80% of the cases (24 teeth). In 42% of the specimens, it was a completely independent root canal. In vitro and in vivo studies have also reported the incidence of a third canal in

the mesiobuccal root of upper maxillary first molars to be between 0.5 and 9% (Table 1). Complete deroofing of the pulp chamber, straightline access, removal of pulp calcification and dentin ledges can help with the identification of supplemental root canal systems in the mesiobuccal root (Ahmed, Saini, 2012). The purpose of this article is to present a case report to illustrate the clinical management of an upper first maxillary molar tooth with three mesiobuccal root canals, using the ProTaper Next system.

Case report The patient, a 38-year-old male, presented with the main complaint of bite sensitivity on his upper right first molar. A clinical examination revealed that the tooth was previously restored with a large composite restoration. The tooth tested nonvital. Radiographic examination revealed that the composite restoration was placed very

close to the pulp (Figure 1). After informed consent, it was decided to do a root canal treatment. The tooth was anesthetized and isolated with a rubber dam. An initial access cavity was prepared using a diamond bur until the roof of the pulp floor was removed. The access cavity was extended to ensure straightline access into the mesial and distal root canals. Mesiobuccal, second mesiobuccal, distobuccal, and palatal root canal orifices were visible under magnification (Figure 2). Size 14 and 12 long shank stainless steel burs (Dentsply/Maillefer) [Figure 3],

Management of an upper first molar with three mesiobuccal root canals



Dr. Peet van der Vyver presents a case report to illustrate the clinical management of an upper first maxillary molar tooth with three mesiobuccal root canals, using the ProTaper Next system

Figure 1: Preoperative radiograph showing a deep composite restoration on the upper right first maxillary molar

Dr. Peet van der Vyver is a part-time lecturer at the University of Pretoria’s School of Dentistry and is in private practice in Sandton, South Africa.

Educational aims and objectivesThis clinical article aims to illustrate the clinical management of an upper first maxillary molar tooth with three mesiobuccal root canals.

Expected outcomesCorrectly answering the questions on page 32, worth 2 hours of CE, will demonstrate the reader recognizes how to manage an upper first maxillary molar tooth with three mesiobuccal root canals using the ProTaper Next system.

Figure 2: Occlusal view of the initial access cavity preparation. Note the presence of a second mesiobuccal root canal

Figure 3: Size 14 and 12 long shank stainless steel burs (Dentsply/Maillefer)

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operating at a speed of 800rpm, were used to remove a dentin protuberance (arrow) between the mesiobuccal and second mesiobuccal canal orifices. This was done under 12x magnification using a six-step dental operating microscope (Global) [Figure 4]. Note there was still evidence of an overlying dentin ledge covering the mesial aspect of the pulp floor (arrow) [Figure 5]. Start-X™ tip No. 2 (Dentsply/Maillefer) [Figure 6] was used to remove the remaining dentin ledge, exposing the orifice

of a third mesiobuccal root canal (Figure 7). An X-Gates instrument (Dentsply/Maillefer) [Figure 8] was used at a speed of 800rpm to enlarge all the located canal orifices as well as to remove the restricted dentin on the mesial aspects of the three mesiobuccal root canals. Figure 9 shows the final access cavity preparation after the walls were smoothed with a Start-X No. 1 ultrasonic tip (Figure 10). The five located root canals were negotiated to working length using size 08 K- and C+ files (Dentsply/Maillefer) [Figure

11]. Figure 12 shows a radiographic view of the length determination. Note that the first and second mesiobuccal canals join, ending in one apical foramen. Initial glide paths were established by using a size 10 K-file (Dentsply/Maillefer) until the file was loose in each canal. The initial reproducible glide paths were enlarged by taking PathFiles® No. 1 (0.13 mm) and 2 (0.16 mm) (Dentsply/Maillefer) [Figure 13] to full working length. Irrigation with 3.5% sodium hypochlorite and recapitulation to working length with a size

Author Year Type of Study Percentage

Acosta Vigouroux and Trugeda Bosaans

1978In vitro study(Visual examination)(n=134)

3/134 (2.25%)

Martínez-Berná and Ruiz-Badanelli

1983In vivo study(Clinical investigation)(n=338)

3/338 (0.88%)

Neaverth et al. 1987In vivo study(Clinical investigation)(n=228)

7/228 (3.1%)

Kulid and Peters 1990In vitro study(Horizontal cross sections)(n=51)

1/51 (1.96%)

Sert and Bayirli 2004In vitro study(Clearing method)(n=200)

1/200 (0.5%)

Rwenyonyi et al. 2007In vitro study(Clearing method)(n=221)

1/221 (0.5%)

Baratto Filho et al. 2009

Ex vivo study(Operating microscope and radiographic examination)(n=140)

1/140 (0.72%)

Park et al. 2009In vitro study(micro-CT)(n=46)

3/46 (6.5%)

Beljic-Ivanovic and Teodorovic

2010In vitro study(Radiographic)(n=200)

18/200(9%)

Degerness and Bowles 2010In vitro study(Stereomicroscope)(n=90)

1/90 (1.1%)

Neelakantan et al. 2010In vitro study(CBCT)(n=220)

2/220 (1%)

Micro CT: micro-computed tomography; CBCT: Cone-beam computed tomography

Figure 4: Global six-step dental operating microscope fitted with LED illumination

Figure 5: Occlusal view of the access cavity preparation after a No. 12 round bur was used to remove some of the dentin protuberance between the mesiobuccal and second mesiobuccal canal orifices. Note there was still evidence of an overlying dentin ledge covering the mesial aspect of the pulp floor (arrow)

Figure 6: Start-X ultrasonic tip No. 2 (Dentsply/Maillefer)

Table 1: Review of the percentage of third mesiobuccal canals in the mesiobuccal roots of maxillary first molar teeth (adapted from Ahmed and Sani, 2012)



08 K-file was done after each instrument. Reproducible glide paths were confirmed when a size 15 K-file could travel 4-5 mm in each root canal without any difficulty or resistance to negotiation. Root canal preparation was done with the ProTaper Next® system (Dentsply/Maillefer) [Figures 14A-14C]. ProTaper Next X1 (17/04) was introduced and slided down the glide path in a rotary motion (speed of 300rpm and torque of 3N/cm). A deliberate brushing motion was incorporated, especially when resistance to progress down a root canal was observed. The last 2 mm of each root canal was prepared by taking the file in controlled motion (without brushing) towards the full working length. The X1 file was taken three times up to working length and immediately withdrawn from each canal. Canals were irrigated with 3.5% sodium hypochlorite and recapitulated to working length with the size 08 K-file. ProTaper Next X2 (25/06) was then used, using the same protocol as described above. Apical foramen gauging was done by trimming a non-standardized fine gutta-percha cone in an Endo Gutta Percha Gauge (Dentsply/Maillefer) to ISO size 025 (Figure 15). This trimmed gutta-percha cone was fitted to working length in each prepared root canal. The trimmed gutta-percha cone fitted snug at working length in the first, second,

and third mesiobuccal and distobuccal root canals. However, when this cone was fitted into the palatal root canal, it was observed that the cone could move 1.5 mm past the determined working length. This indicated that the apical foramen size was larger than a size 025. ProTaper Next X3 (30/07) was then used to enlarge the preparation in the palatal root canal, using the same brushing protocol as described above for the use of X1 and X2. The last 2 mm of the root canal was prepared by taking the X3 file in controlled motion (without brushing) towards the full working length. The X3 file was taken twice up to working length and immediately withdrawn from the canal. Again, the apical foramen was gauged by trimming a non-standardized fine gutta-percha point to an ISO size 030, using the same gauge. This trimmed gutta-percha cone fitted snugly at working length. After canal preparation, the canals were copiously irrigated by activating 3.5% sodium hypochlorite with the EndoActivator® (Dentsply/Maillefer) for 1 minute in each canal followed by activating 17% EDTA for 30 seconds in each root canal. A final rinse of sodium hypochlorite for 1 minute was done before the canals were dried with paper points. Matching ProTaper Next gutta-percha points were fitted into the prepared canals, and cone fit was confirmed with

a radiograph. The gutta-percha cones were buttered with AH Plus Jet™ Root Canal Cement (Dentsply/Maillefer) before all five root canals were obturated with the continuous wave of condensation technique using Calamus® Dual (Dentsply/Maillefer) downpack and backfill technology. Figure 16 demonstrates the immediate postoperative result after obturation.

DiscussionThe upper first maxillary molar can present to the clinician as an endodontic challenge (Ahmed, Saini, 2012). It can have a wide range of internal and external radicular morphological variations that can complicate treatment. In addition, their close relationship to the floor of the maxillary sinus and superimposition of the zygomatic arch can often obscure their accurate interpretation (Cantatore, et al., 2006; Cleghorn, et al., 2006). One of the main challenges of treating maxillary upper molars with multiple root canals is to locate all the canal orifices. Examination of the pulp chamber and pulp chamber floor under high magnification and bright illumination can provide the clinician with valuable information. The dentin protuberances or ledges generally obscure the access to additional canals in the mesiobuccal root canal system. It can be removed with a combination of

Figure 7: Three mesiobuccal root canals were visible after removal of the overlying dentin ledge

Figure 8: X-Gates bur (Dentsply/Maillefer)

Figure 9: Final access cavity preparation after the walls were smoothed with a Start-X No. 1 ultrasonic tip and the mesial canal orifices were enlarged with an X-Gates bur

Figure 10: Start-X ultrasonic tip No. 1

Figure 11: Size 08 C+ and 08 K-file (Dentsply/Maillefer)

Figure 12: Radiograph illustrating the length determination. Note that the first and second mesiobuccal canals join

Figure 13: PathFiles No. 1 and 2 (Dentsply/Maillefer)

Figure 14A: ProTaper Next X1 (yellow ring) Figure 14B: ProTaper Next X2 (red ring)

Figure 14C: ProTaper Next X3 (blue ring)

Figure 15: Non-standardized fine gutta-percha cone trimmed to size 025 in Endo Gutta Percha Gauge

Figure 16: Immediate postoperative result after obturation

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different sizes of long shank round burs and ultrasonic instruments, using the developmental grooves as guidelines. It is important to note that the nickel-titanium PathFiles were only used for glide path enlargement. After the initial canal negotiation with the size 08 C+ and K-files, a size 10 K-file was used to create an initial reproducible glide path in all the root canals, before the size 13 and 16 PathFiles were used to enlarge the glide path. ProTaper Next was used for root canal preparation in this case report. The key benefits of ProTaper Next include simplicity, excellent cutting efficiency, and predictable final canal shape to allow for cone fit with tug-back. The system also ensures a 6% taper in the apical third of a canal after preparation with only two instruments, the X1 and X2. The ProTaper Next instruments make use of the progressively tapered design. Each file presents with an increasing and decreasing percentage tapered design on a single file concept. The design ensures that there is reduced contact between the cutting flutes of the instrument and dentin wall, and reduced chance for taper lock (screw effect). At the same time, it also increases flexibility and cutting efficiency (Ruddle, 2001). Another benefit of the system is the fact that the instrument is manufactured from M-wire and not traditional nickel-titanium alloy. Research by Johnson, et al., (2008), demonstrated that the M-wire alloy could reduce cyclic fatigue by 400% compared to similar instruments manufactured from conventional nickel-titanium alloys. The added metallurgical benefit contributes towards more flexible instruments, increased safety, and protection against

instrument fracture (Gutmann, 2012). All of these benefits allow the clinician with more confidence to attempt average, as well as more challenging, endodontic cases. The last major advantage towards root canal preparation with the ProTaper Next system is the fact that the instruments present with an asymmetrical, rectangular cross section (except in the last 3 mm of the instrument, D0-D3). Rotation of the instrument produces a snake-like (swaggering) wave of movement. The benefits of this design characteristic include: • It further reduces (in addition tothe progressive tapered design) the

engagement between the instrument and the dentin walls. This will contribute to a reduction in taper lock, screw-in effect, and stress on the file• Removalofdebrisinacoronaldirectionbecause of the off-center cross section that allows for more space around the flutes of the instrument. This will lead to improved cutting efficiency, as the blades will stay in contact with the surrounding dentin walls. Root canal preparation is done in a very fast and effortless manner• Reducestheriskofinstrumentfracturebecause there is less stress on the file and more efficient debris removal.

REfEREncEs

Acosta Vigouroux SA, Trugeda Bosaans SA. Anatomy of the pulp chamber floor of the permanent maxillary first molar. J Endod. 1978;4(7):214-219.

Ahmed HMA, Saini D. Management of a maxillary first molar tooth with unusual mesiobuccal root anatomy. Arch Orofac Sci. 2012;7(2):101-106.

Baratto Filho F, Zaitter S, Haragushiku GA, de Campos EA, Abuabara A, Correr GM. Analysis of the internal anatomy of maxillary first molars by using different methods. J Endod. 2009;35(3):337-342.

Beljic-Ivanovic K, Teodorovic N. Morphological characteristics of mesiobuccal root canals of first maxillary molars [from Serbian]. Srp Arh Celok Lek. 2010;138(7-8):414-419.

Cantatore G, Berutti E, Catellucci A. Missed anatomy: frequency and clinical impact. Endod Topics. 2006;15(1):3-31.

Cleghorn BM, Christie WH, Dong CC. Root and root canal morphology of the human permanent maxillary first molar: a literature review. J Endod. 2006;32(9):813-821.

Degerness RA, Bowles WR. Dimension, anatomy and morphology of the mesiobuccal root canal system in maxillary molars. J Endod. 2010;36(6):985-989.

Gutmann GL, Gao Y. Alteration in the inherent metallic and surface properties of nickel-titanium root canal instruments to enhance performance, durability and safety: a focused review. Int Endod J. 2012;45(2):113-128.

Johnson E, Lloyd A, Kuttler S, Namerow K. Comparison between novel nickel-titanium alloy and 508 nitinol on the cyclic fatigue life of ProFile 25/.04 rotary instruments. J Endod. 2008;34(11):1406-1409.

Kulid JC, Peters DD. Incidence and configuration of canal systems in the mesiobuccal root of maxillary first and second molars. J Endod. 1990;16(7):311-317.

Martínez-Berná A, Ruiz-Badanelli P. Maxillary first molars with six canals. J Endod. 1983;9(9):375-381.

Neaverth EJ, Kotler LM, Kaltenbach RF. Clinical investigation (in vivo) of endodontically treated maxillary first molars. J Endod. 1987;13(10):506-512.

Neelakantan P, Subbarao C, Ahuja R, Subbarao CV, Gutmann JL. Cone-beam computed tomography study of root and canal morphology of maxillary first and second molars in an Indian population. J Endod. 2010;36(10):1622-1627.

Park JW, Lee JK, Ha BH, Choi JH, Perinpanayagam H. Three-dimensional analysis of maxillary first molar mesiobuccal root canal configuration and curvature using micro-computed tomography. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009;108(3):437-442.

Ruddle CJ. The ProTaper endodontic system: geometries, features, and guidelines for use. Dent Today. 2001;20(10):60-67.

Rwenyonyi CM, Kutesa AM, Muwazi LM, Buwembo W. Root and canal morphology of maxillary first and second permanent molar teeth in a Ugandan population. Int Endod J. 2007;40(9):679-683.

Sert S, Bayirli GS. Evaluation of the root canal configurations of the mandibular and maxillary permanent teeth by gender in the Turkish population. J Endod. 2004;30(6):391-398.

Vertucci FJ. Root canal morphology and its relationship to endodontic procedures. Endod Topics. 2005;10(1):3-29.

Weine FS. Initiating endodontic treatment. In: Weine FS, ed. Endodontic Therapy. 6th ed. St Louis, MO: Mosby; 2004:106-110.

EP

1. The preservation of dentin during access opening, shaping the canal, preparing the root for placement of a post, and during restoration with an onlay, or full coverage preparation is critical to the ________ of the final restoration. a. clinical longevityb. successc. removald. both a and b

2. It is now well recognized that excess removal of dentinal support, not only in the root but also coronally, changes the flexural behavior and resistance to failure, and that overflaring the canal for straightline access to the canals _____the dentinal complex. a. fortifiesb. weakens c. sharpensd. maintains

3. Post preparation of the root canal space ______additional dentin, as this contributes to a reduced fracture toughness.a. must remove b. must not bond withc. must not remove d. can fracture

4. If we adhere to the concept of minimal dentin removal in the root, and if we recognize that most root canals are _________, then a wholly different treatment approach than what we have been taught in the past is indicated.a. perfectly round in shapeb. not flexuralc. overflaredd. ovoid in shape

5. The combination of a post (or multiple posts) that transmits light efficiently, with sufficient extended light-curing time/output, results in better _____.a. composite polymerization b. fracture loadc. fiber diameterd. dual core acidity

6. The elastic modulus (or a material’s stiffness) of fiber posts more closely approximates that of dentin (18.6GPa), allowing _____.a. some slight flex in functionb. dissipating stressc. reducing the likelihood of damage to the rootd. all of the above

7. _____ are not subject to galvanic or corrosion activity.a. Dentin adhesivesb. Fiber posts c. Coronal dentind. Crowns

8. Clinically, ______ may hold up to normal occlusal function, but many fail in cyclic fatigue-repeated functional stress and torque. a. a natural non-treated toothb. dentinc. heavily restored teeth d. any ovoid canal

9. No discussion of the restoration of a badly broken-down endodontically treated tooth would be complete without discussing the concept of the ________, which is defined as “a metal band or ring that encircles the tooth in order to provide retention and resistance form, as well as protect the tooth from fracture.”a. circumferential ferruleb. thermo-cycled bandc. residual coronal ringd. metallic post retention band

10. The most predominant conclusion emerging from the growing body of in vitro (and clinical) data is that failures of fiber posts in situ are more likely to be described as _______, which is usually not the case with high modulus posts.a. “non-catastrophic” b. “repairable”c. “catastrophic”d. either a or b

Fiber posts and tooth reinforcement: evidence in the literature

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ENDODONTIC PRACTICE CEC

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EP V6.6 VAN DER VYVER

1. According to Vertucci, a major cause of post-treatment disease is the inability to _______all the canals in a root canal system.a. locateb. debridec. obturated. all of the above

2. According to Cleghorn, et al.,________has generated more research and clinical investigation than any other root in the oral cavity.a. the mesiobuccal root of the maxillary first molar b. the distobuccal root of the maxillary first molarc. the palatal root of the maxillary first molard. the mesiobuccal root of the mandibular first molar

3. In a recent micro-CT study, it was demonstrated that the second mesiobuccal canal was present in _____ of the cases (24 teeth).a. 25%b. 50%c. 64%d. 80%

4. ______ can help with the identification of supplemental root canal systems in the mesiobuccal root.a. Complete deroofing of the pulp chamberb. Straightline accessc. Removal of pulp calcification and dentin ledgesd. All of the above

5. Irrigation with ____sodium hypochlorite and recapitulation to working length with a size 08 K-file was done after each instrument.a. .35%b. 1%c. 3.5% d. 35%

6. One of the main challenges of treating maxillary upper molars with multiple root canals is to _____.a. avoid obturationb. locate all the canal orifices c. control the glide pathd. achieve taper lock

7. Examination of the pulp chamber and pulp chamber floor ____can provide the clinician with valuable information.a. under high magnificationb. with bright illuminationc. before debris removald. both a and b

8. The _____ generally obscure the access to additional canals in the mesiobuccal root canal system.a. maxillary sinusesb. dentin protuberancesc. ledgesd. both b and c

9. Research by Johnson, et al., demonstrated that the M-wire alloy could reduce cyclic fatigue by ____ compared to similar instruments manufactured from conventional nickel-titanium alloys.a. 50%b. 100%c. 200%d. 400%

10. The added metallurgical benefit contributes towards more _____.a. flexible instrumentsb. increased safetyc. protection against instrument fractured. all of the above

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Special Awards tribute from MedMark, llc

and Pride Institute

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Dear Readers:

As publisher of three dental specialty magazines, I have spoken with many dentists and seen many dental products over the years. That is why I am thrilled to have the opportunity to spotlight Pride Institute’s ”Best of Class” Technology Award winners on behalf of Orthodontic Practice US, Implant Practice US, and Endodontic Practice US. The evolution of products with a meaningful impact on dentistry is vital to patient care and practice progress. These products and services have undergone scrutiny by Pride Institute’s knowledgeable panel of judges who invested a year of their time and effort to explore the attributes that

made them stand out from the competition.

From fledgling products to those that have already achieved name recognition, the winners represent an amazing array of categories from clinical to business applications. Since panelists who receive compensation from dental companies are prevented from voting in that company’s category, the result is an unbiased look at the products and their practical applications to dentistry, providing the dental professional with a product perspective untainted by manufacturer intervention.

Pride Institute’s ”Best of Class” Technology awards debuted in 2009, and through print and digital media coverage have grown to impact approximately 150,000 dentists. At the ”Tech Expo” at the American Dental Association’s Annual Awards Session, held October 31 – November 3 in New Orleans, attendees will be able to interact face-to-face with the companies and participate in technology-centered education provided by members of the panel and esteemed consultants of Pride Institute.

The Pride ”Best of Class” Awards were created and are organized by Dr. Lou Shuman, President of Pride Institute, who works tirelessly to maintain the rigorous standards of the selection process and its communication process through all its multimedia partners. The panel’s unrelenting pursuit to select technologies that provide continuous improvement for the dental community has resulted in a huge following, which continues to grow each year, culminating in the ADA Pride Tech Expo at the ADA Annual Session. Attendees have the opportunity to experience all the winners in one location for a hands-on experience, as well as are provided CERP presentations by all the expert panel members themselves.

This year’s winners are:3Shape TRIOS®

ActionRun® Clinical Reactivation®

Align Technology SmartTrack™

DEXIS® Imaging Suite and DEXIS go®

Doxa Ceramir® Crown and Bridge

Gendex GXDP-700™ SRT™ Technology

Glidewell Laboratories BruxZir® Shaded

Interactive Diagnostic Imaging Tru-Align®

Henry Schein Dental Viive™

i-CAT® FLX Cone Beam 3D

Isolite Systems Isodry®

Kerr SonicFill™

Lexicomp® Online™ for Dentistry featuring: VisualDX® Oral

Liptak Dental DDS Rescue™

Orascoptic XV1

SciCan STATIM G4

Sesame Communications Sesame 24-7

Ultradent VALO®

LED Dental VELscope® Vx

Enjoy this tribute to some very special products and services. We at MedMark hope that the insights you gain from reading these pages and the benefits that you reap from implementing the products will raise your practices to new levels of clinical excellence and business success.

Thank you, and again, congratulations to the ”Best of Class” Technology Award winners for 2013!

Best regards,

Lisa MolerPublisher MedMark, llc

Letter from the Publisher

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Dear Readers:

The excitement and enthusiasm surrounding Pride Institute’s 2013 ”Best of Class” Technology Awards continue to invigorate the winning companies long after they are announced. This initiative culminates in the honorees’ participation in the ”Tech Expo” at the American Dental Association’s Annual Session —where attendees have a chance to interact and gain insight into

the dynamic and technology-centric products and services that are impacting the contemporary dental practice.

The ”Best of Class” Awards have attained a reputation of the highest integrity due to its rigorous and unbiased selection process and its distinguished panel of technology experts. The panel searches for companies that show initiative, and commit time, resources, and expertise in developing new technologies or improving existing ones. Their characteristics differentiate them in a compelling way, thus creating significant value for the clinician.

I am very proud of the integrity of our unbiased and not-for-profit process. The thoughtful and many times heated debate, which is the hallmark of the panel’s decision-making process, takes place with absolute honesty and openness. Panel members must divulge all paid relationships with manufacturers, and as a result, are not allowed to vote in that specific category. Also, we are not tied down to have to choose a winner for every technology category in dentistry. If there is no clear differentiator in a category, there is no winner.

The mission is to provide the dental community the benefit of having the opportunity to discover what our dental technology experts would choose to have in their own practices. As you read about these companies, know that they can provide a significant benefit in achieving the ultimate goal of the ”Best of Class” award process —selecting the technologies that allow us to provide the best possible care to our patients.

Sincerely,

Dr. Lou ShumanPresident of Pride Institute

Lou Shuman, DMD, CAGS President of Pride Institute, Best of Class founder John Flucke, DDS Writer, speaker, and Technology Editor for Dental Products Report Marty Jablow, DMD Writer, speaker, technology consultant, and columnist for Dr. Bicuspid

Paul Feuerstein, DMD Writer, speaker, and Technology Editor for Dental Economics Parag Kachalia, DDS Vice-Chair of Preclinical Education, Research and Technology, University of Pacific School of Dentistry Larry Emmott, DDS Writer, speaker, and Technology Editor for dentalcompare.com Titus Schleyer, DMD, PhD Associate Professor and Director, Center for Dental Informatics at the University of Pittsburgh, School of Dental Medicine

THE DISTINGUISHED PANEL

Letter from the founder of Pride “Best of Class” Technology Awards

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DEXIS® IMAGING SUITE AND DEXIS GO®

DEXIS® Imaging Suite is the latest software program in a long, dynamic history of bringing the best possible imaging solutions to general dentists and specialists alike. This innovative program has been rewritten on a next-generation code platform combining the image management capabilities of the award-winning DEXIS® 9

with a solid base for growth and exciting tools and applications. One such application is the new companion iPad app, DEXIS go® that provides a sleek, engaging new way for dental professionals to

communicate with patients using an iPad®. It is designed to provide a great visual patient experience around image presentation in support of clinical findings and treatment recommendations. Like DEXIS Imaging Suite, DEXIS go functions as an imaging hub, displaying all radiographic and photographic images within a patient’s record. DEXIS users will find a comfortable familiarity with its simplicity and quad environment now infused with a modern iPad-style flair and elegance.

BRUXZIR® SHADED RESTORATIONS

BruxZir® Shaded restorations are made of monolithic zirconia with no porcelain overlay. Exhibiting class-leading durability with up to 1465 MPa of flexural strength and high fracture toughness, they can be used in almost any clinical situation, but are ideal for demanding situations like bruxers, implant restorations, and areas with limited occlusal space. Because BruxZir zirconia is a monolithic material, it can be milled to a feather edge, for a more natural and hygienic emergence profile. BruxZir

Shaded restorations display translucency and color similar to natural dentition, making them a more esthetic alternative

to PFMs with metal occlusals/linguals or full-cast gold restorations. The BruxZir Shaded formulation offers complete color penetration all the way through the restorations, ensuring greater shade consistency and preventing any shade change after occlusal adjustment. For the second consecutive year, The Pride Institute recognizes BruxZir restorations as ”Best of Class.”

BruxZir Shaded restorations are available nationwide at an Authorized™ BruxZir Laboratory near you.

For more information: www.bruxzir.com

i-CAT® FLX COMPLETE 3D TREATMENT SOLUTION

i-CAT® FLX is the complete 3D Treatment Solution. It optimizes clinical control over scan size, resolution, modality, and dose to help deliver optimum patient care, assist clinicians to quickly diagnose complex problems with less radiation, and aid in developing treatment plans more easily and accurately. Features include QuickScan+ for a full-dentition 3D scan at a lower dose than a 2D panoramic*; Visual iQuity™ technology for i-CAT’s clearest images*; SmartScan STUDIO’s touchscreen for easy selection of the appropriate scan size and resolution for each patient’s need; Tx STUDIO™ planning software with integrated tools for implant, surgical, and orthodontic applications; and i-PAN 2D panoramics.

*Data on file

ISODRY® DENTAL ISOLATION SYSTEM

The Isodry® dental isolation system is a proven, easy-to-use alternative to traditional forms of dental isolation, such as the rubber dam or manual suction and retraction. The system aids in dental procedures by improving patient management and giving dental professionals unprecedented control of the oral environment: keeping the patient’s mouth open, improving visibility, controlling suction and oral humidity, and minimizing sources of contamination.

The key to Isodry’s effectiveness are the Isolite Mouthpieces that work with the system. Morphologically correct Isolite Mouthpieces are available in five sizes and are designed to fit patients from pediatric to large adult.

The wide range of mouthpieces means that it is now much easier to have effective isolation for every patient of every size. Isolite Mouthpieces also provide an added measure of safety during the dental procedure — protecting the patient from foreign body aspiration and shielding the tongue and cheek from injury by the handpiece or other dental instruments.

For more information:www.isolitesystems.com

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VALO® AND VALO CORDLESS

Ultradent created VALO in 2009 to address the many problems left unsolved by other curing lights on the market. Since its introduction, VALO has proven to be the most powerful light on the market, thanks to its multiwavelength light-emitting diode (LED) and optimally collimated beam capable of polymerizing any dental material, including porcelain and underlying resins. The ergonomic design of VALO’s wand-style body and large footprint of the curing head provides unprecedented access to the oral cavity where other curing lights simply cannot reach.

Precision milled from a solid bar of high-grade, aircraft aluminum, VALO’s unique unibody construction ensures unsurpassed durability. The award-winning line of VALO curing lights now includes the original VALO,

VALO Cordless, VALO Ortho, and VALO Ortho Cordless. Each one offers a unique combination of features that allows dental professionals to consistently deliver the right power in the right place.

For more information:www.ultradent.comCall 1-800-552-5512

VELSCOPE® VX SYSTEM

Distributed by DenMat, Velscope® Vx is the industry’s leading adjunctive screening device used to discover

oral mucosal abnormalities. When used in combination with standard examination procedures, Velscope Vx facilitates the early discovery and visualization of abnormal tissue, including oral cancer. A Velscope Vx examination is easy, painless to the patient, takes just one or two minutes to administer, and does not require additional rinses or stains. The portable Velscope Vx handpiece emits a safe blue light, which excites fluorophores from the surface tissue to the membrane where premalignant changes typically begin. The Velscope’s proprietary filter makes fluorescence visualization possible by blocking reflected blue light, and by enhancing

the contrast between normal and abnormal tissue. The Velscope Vx system includes the handpiece, a charging station, and sanitary covers for the handpiece and lens. A digital camera accessory is also available to capture images of abnormal tissue.

SESAME 24-7 CLOUD-BASED ONLINE PATIENT ENGAGEMENT MANAGEMENT SYSTEM

Sesame 24-7 is a cloud-based online patient engagement management system that helps dental and orthodontic practices accelerate new patient acquisition, build patient loyalty, and transform the patient experience. Sesame 24-7 is an end-to-end system, which provides state-of-the-art web design that optimizes viewing across any device, Search Engine Optimization (SEO), social network management, online sweepstakes and contests, and Search Engine Marketing (SEM) services. It also includes Dental Sesame, a robust patient engagement portal that helps practices maintain a loyal patient community that shows up for appointments, pays their bills on time, and refers friends to the practice. Sesame 24-7 delivers everything a dental practice needs to leverage the Internet to expand growth and profitability.

GENDEX GXDP-700™ SRT™ TECHNOLOGY

SRT image optimization technology delivers 3D scans with higher clarity and detail around scatter-generating material. By using SRT Technology, clinicians are able to reduce artifacts caused by metal or radiopaque objects such as restorations, endodontic filling materials, and implant posts. When a scan is prescribed near a known area of scatter generating material, the user only needs to select the SRT button from the GXDP-700 touchscreen interface to utilize this new optimization technology. From endodontic to restorative and the post-surgical

assessment of implant sites, SRT offers a significant improvement to image quality.

Gendex’s design philosophy focuses on delivering award-winning innovations with clinicians and patients in mind, and the addition of the SRT to the GXDP-700 platform aligns with that goal. The company’s strong history in continuing innovation, along with a deep dedication to deliver products that exceed the needs of dental professionals, have earned Gendex recognition as a global leader.

For more information: www.gendex.com

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DOXA CERAMIR® TECHNOLOGY

Ceramir is a revolutionary technology used to create a new class of unique materials called Nanostructurally Integrating Bioceramics (NIB). This Ceramir technology, which holds more than 100 patents, is the result of more than 25 years of extensive bioceramic research by Doxa. Ceramir Crown & Bridge permanent cement is the first

product utilizing NIB technology, creating a resilient, more natural, biocompatible dental luting cement that integrates with natural tooth

structure, is stable in the mouth, and exhibits tooth-like physical and mechanical properties. It is a self-sealing material that results in an alkaline seal for permanent acid resistance. Ceramir Crown & Bridge is indicated for PFM, zirconia, gold, metal and lithium disilicate full-coverage crowns and bridges, as well as gold inlays and onlays, and metal pre-fab or cast metal posts. Ceramir is incredibly easy to use because it eliminates the need for bonding agents, conditioners, special cleaners, and primers. It also cleans up extremely easily, and the patients are thrilled because of no pain during placement, or post-op sensitivity. It’s a new way to think about cementation!

STATIM G4

SciCan is proud to unveil the newest STATIM family member, the G4 series. The STATIM G4 is the same renowned and trusted autoclave it has been for over 20 years, but now boasts a new contemporary look and connectivity that is the first of its kind. The G4 technology will change the way you interact by providing a direct channel of communication through the Internet to you, or anyone you desire. Still powered by SciCan’s signature steam technology to provide sterilization and dryness at speeds faster than conventional chambered autoclaves, the STATIM has been drastically upgraded with a level of interactivity never seen before.

• Statim 2000 G4 cycles times: 6 minutes unwrapped – 14 minutes wrapped • Statim 5000 G4 cycle times: 9 minutes unwrapped – 17.5 minutes wrapped • A large 3.5” high-resolution touchscreen offers a vivid display of messages and current cycle information all with extraordinary clarity • SciCan’s STATIM G4 Technology offers a platform with endless possibilities. The product expansion and modes of communication will provide visibility from every facet, from usability to troubleshooting • Uses fresh steam distilled water with every cycle • Dri-Tec drying system for fast dry loads

For more information:www.scicanusa.comCall 1-800-572-1211

HENRY SCHEIN’S VIIVE™

Henry Schein’s Viive (pronounced ”Vive”) is a clean and elegant new practice management system designed for the Apple Mac®. The system takes full advantage of the Mac’s simplicity and esthetics, allowing dentists to use the same robust features and tools they have come to love in the Mac . Because a group of dentists who are also Mac enthusiasts actually designed Viive, the system has a unique patient-centric workflow that helps dentists work the way they want to work using the tools they’re most comfortable using.

Right from startup, Viive focuses on the patient with a patient screen that gives team members fast and easy access to nearly every feature, function, and task associated with that patient. It boasts a design that makes most of these accessible with just a single click. Viive also includes integration with a variety of advanced services from trusted partners — including leading digital imaging solutions—to expand the capabilities of your modern digital practice.

For more information:www.viive.com

Call 855-Mac-Viive for a personal demo of Viive.

3SHAPE TRIOS® COLOR NEXT-GENERATION INTRAORAL IMPRESSION SOLUTION

3Shape TRIOS® Color is a next-generation intraoral impression solution that is fast, accurate, and easy to use. TRIOS® Color is built on 3Shape’s Ultrafast Optical Sectioning™ technology, and its features include high accuracy capture in color, spray-and-powder-free scanning, clinical scan validation, intuitive Smart-Touch

user interface and more. TRIOS® is optimized for a wide range of indications.

Scanning is easy with 3Shape TRIOS® Color.

There is no need to hold the scanner at a specific angle or distance, and dentists or assistants can even rest the scanner on the teeth for support as they scan. The system contains a broad array of smart tools that lets dentists edit their scans and easily rescan specific areas. The built-in Communicate™ software lets dentists and labs interact and exchange case information, 3D designs, 2D treatment previews, and comments. As an integral part of every TRIOS® system, 3Shape offers yearly software upgrades to keep the system ever-strong with new features and enhanced performance.

For more information: www.3shapedental.com/trios

Call 1-908-867-0144

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SONICFILL™

SonicFill is the only easy to use, sonic-activated, Single-Fill™ dental posterior composite system for restorations that require no liner or additional capping layer. Proprietary sonic activation liquefies a highly-filled posterior composite, allowing it to flow into the cavity for effortless placement and superior adaptation. Along with low shrinkage stress and a high depth of cure, SonicFill lets you reliably place posterior cavities up to 5 mm in a single increment. It’s that fast, easy, and effective — greatly reducing procedure time. And with outstanding strength and Kerr’s patented 0.4 micron filler technology, restorations will last and look great.

XV1 FROM ORASCOPTIC

The new XV1 from Orascoptic is the first and only loupe with a built-in headlight. Traditional light systems employ an electrical cable that connects the headlight to a battery pack that is typically worn on a belt or in a pocket. These cables are notorious for breaking after getting caught on chairs, drawers, and doorknobs. By powering the headlight through circuitry embedded in the loupe frame itself, the XV1 eliminates the need for a separate battery pack, and consequently also eliminates the problematic cable.

The XV1 delivers a powerful, shadow-less illumination in a compact, comfortable design. Innovative capacitive touch controls make it easy to operate, even with instruments in hand. Choose from five stylish colors, and magnification powers between 2.5x and 4.8x.

For more information: www.orascoptic.com/xv1 for more product details.

Call 1-800-369-3698 to schedule a product demonstration.

SMARTTRACK™ ALIGNER MATERIAL

Align Technology recently introduced SmartTrack – a new highly elastic aligner material that has been shown to improve control of tooth movements with Invisalign®.

A study of 1,015 patients shows statistically significant improvement in the control of tooth movements such as rotation and extrusion (p<0.001). Percent of patients on track with treatment is also significantly higher at 5 months follow-up (p<0.001)*

SmartTrack features:

• More constant force over the two wear aligner wear to improve tracking

• Higher elasticity to improve tracking

• More precise aligner fit to improve control of tooth movement and finishing

”The clinical results with SmartTrack have been excellent so far,” said Dr. Clark Colville, an orthodontist in Seguin, Texas and a participant in the SmartTrack study. ”The fit around the teeth from aligner to aligner is better than with any group of patients I have treated with Invisalign in my practice. Without a doubt, SmartTrack is the most exciting change in Invisalign technology among the many that have been introduced in recent years.” Due to advantages in performance, SmartTrack material is now the new standard Invisalign material for all Invisalign aligner products in North America and Europe, as well as other International markets.

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Congratulations to all of the

2013 Winners

ACTIONRUN’S CLINICAL REACTIVATOR®

Dormant patients need more than a generic reason to return. ActionRun’s Clinical Reactivator® service gives each GP’s patients clinically personalized reasons to come back. Many of these clinical reasons are tailored for specialties’ referrals including orthodontics, endodontics,

and implants. Instead of simple, generic automated email or text solutions commonly offered by others, ActionRun is uniquely able to analyze each patient’s clinical record and compel dormant patients to return with

clinical reasons specific to each patient - even without a treatment plan. Clinical Reactivator® is completely autonomous and requires no involvement from staff. Because it is cloud-based, there is no hardware or software to buy or maintain. By effectively reactivating GP’s dormant patients, ActionRun increases referrals to specialists and improves those patients’ health while boosting production for both GPs and specialists. Because it works so consistently well, ActionRun uniquely offers a performance guarantee based on production from reactivated patients. Clinical Reactivator® is part of a complete line of HIPPA-compliant patient communication solutions offered by ActionRun.

LEXICOMP® ONLINE FOR DENTISTRY: COMPUTER ASSISTED DECISION SUPPORT FOR DRUG INTERACTIONS AND LESION DIAGNOSIS

Lexicomp Online for Dentistry provides industry-leading reference information and screening tools to help answer prescribing, diagnosis, and treatment questions. Dental professionals can help enhance patient safety by accessing dental-specific pharmacology information on over 8,000 prescription drugs, OTCs, and natural products,

plus decision support tools like VisualDx® Oral lesion diagnosis and an unsurpassed drug interactions screener.

VisualDx® Oral is the new lesion identification tool designed to help dentists quickly develop a differential diagnosis and reduce diagnostic error.

Available only through Lexicomp Online for Dentistry, dental professionals can have access to both VisualDx Oral’s specialist-level information and the top-rated dental-specific pharmacology information provided by Lexicomp – saving time in research and helping to enhance treatment safety. In addition to lesion diagnosis, Lexicomp Online for Dentistry is the only product that provides instant access to up-to-date, dental-specific pharmacology information and important clinical tools, such as drug interaction analysis and dental medication alerts. Lexicomp Online for Dentistry, enhanced with the revolutionary lesion diagnosis tool VisualDx Oral, will truly change how you practice dentistry, help save time in your office and help enhance treatment safety.

TRU-ALIGN®, THE LASER-ALIGNING RECTANGULAR COLLIMATION SYSTEM FROM IDI

Tru-Align®, the laser-aligning rectangular collimation system from IDI, lowers dental X-ray scatter radiation by as much as 60-70%, allaying patient fears and ensuring the safest and most beneficial dental office visit. Tru-Align® technology, while reducing radiation exposure, also significantly reduces the need for X-ray retakes from

the patented laser alignment system. Tru-Align® can be used with film, digital sensors, or phosphor plate (PSP) systems.

Oral health professionals are ”bound” by the ALARA principle when it comes to taking X-rays. ALARA stands for ”As Low

As Reasonably Achievable.” In other words, dentists are committed to minimizing radiation exposure. Tru-Align®provides dentistry with a solution for complying with the ALARA principle and protecting their patients and staff from unnecessary dental radiation, in compliance with the most current FDA, ADA, and NCRP guidelines.

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Contact Us

15720 North Greenway Hayden-Loop, Suite #9 Scottsdale, AZ 85260

Phone: 866-579-9496 Fax: 480-629-4002 Visit online: www.medmarkaz.com

Leading the industry in targeting the niche specialties of dentistry

boc2013.indd 10 10/22/2013 6:02:03 PM

We endodontists were initially trained as restorative (general) dentists. Then

we extended our studies by completing additional years of post-graduate training to enable us to list ourselves as specialists. We are licensed by the state, and recognized by our national and state dental organizations to employ our additional skills to render the highest level of endodontic therapy. But from what I have seen in over 40 years of practice, and serving as an expert witness for defense counsel (and yes, plaintiff’s counsel too), is that some of our endodontic colleagues get caught up in legal entanglements — even when they meet the Standard of Endodontic treatment care. How does this happen? And how can we avoid it? This can occur if the endodontists fail in their communication skills, also known as informed consent, or postoperatively, which can be akin to abandonment. My colleague, Dr. Ed

Zinman and I would submit that we need to consider a new non-legal term for judging ourselves — The Standard of Endodontic Excellence. Let’s first remember some of the traditional axioms, e.g., “Patients don’t care how much you know until they know how much you care.” Another axiom: “If you take good care of your patients, they’ll take good care of you.” So how do these axioms apply to our endodontists’ practices? We have seen a number of legal complaints filed against some of our well-intentioned colleagues, not always because they provided negligent therapy, but rather patients feel the endodontist betrayed their trust. How? Below are just a few examples of what engenders distrust of some patients causing them to write negative reviews on Yelp, sometimes filing complaints with the Department of Consumer Affairs, or even engaging a lawyer to file a malpractice complaint. We are all trained to perform microsurgery. Our specialty training includes knowledge of the anatomical variations of the inferior alveolar neurovascular bundle. So we are surprised and disappointed when there is a legal complaint filed against an endodontist from a patient suffering from permanent dysthesia, anesthesia, or persistent paresthesia. With the newer techniques and technologies available today, we wonder why an endodontist would perform periapical surgery on a mandibular posterior tooth without the benefit of a CBCT for treatment planning. Sure, years ago we could only count on a panoramic X-ray and periapical films to help us guide patients through the risks, benefits, and alternatives (implant, bridge, maybe just extraction) to periapical surgery on a mandibular posterior tooth — that was then w-a-y back in the 20th Century. But for years now, we’ve been able to refine our treatment planning with the benefit of CBCT. An endodontist is potentially placing the otherwise trusting patient in harm’s way if he/she recommends and/or performs lower premolar or molar surgery without first reviewing CBCT images. Of course, even without CBCT, most surgeries will

turn out well — except when they don’t! As today’s health care is undergoing a transformation, providing endodontic therapy is undergoing a transformation as well; this is best illustrated by more specialists functioning in the capacity of independent contractors, providing specialty care in the office of a general dentist. When an endodontist provides endodontic therapy in the office of a general dentist, does the endodontist have a microscope readily available? And what about the complete armamentarium of instruments and materials; are they also readily available in the general dentist’s office? Certainly this is possible, but improbable. Thus, two levels of specialty care are emerging in endodontics: the higher level in the endodontist’s office and a lower level in the clinical setting of the general dentist. There may be a short-term gain of more profit for the endodontist in exchange for compromising the quality of endodontic care that generations of endodontic professors, researchers, and

Upholding the Endodontist’s Standard of Care


LEGAL MATTERS

Drs. Stephen Cohen and Edwin Zinman discuss how to avoid patient distrust

Stephen Cohen, MA, DDS, FACD, FICD, is a Diplomate of the American Board of Endodontics and is in Private Endodontic Practice in San Francisco, California. He lectures worldwide on endodontics and is

the senior editor for all nine editions of the definitive endodontics textbook, Pathways of the Pulp, and a co-editor of the renamed 10th edition Cohen’s Pathways of the Pulp. Dr. Cohen served as the Chairman of the Endodontic Department, University of the Pacific Arthur A. Dugoni School of Dentistry and has continued as an Adjunct Clinical Professor of Endodontics. In addition to his academic appointments, Dr. Cohen has held leadership positions in many of the major professional and academic organizations in endodontics and dentistry, including as a Director of the American Association of Endodontists and as a fellow of both the American College of Dentists and the International College of Dentists.

Edwin J. Zinman, DDS, JD, graduated from the University of Pittsburgh School of Dentistry and received a Certificate in Periodontics and Oral Medicine from New York University College of Dentistry. He also received a JD

from University of California, Hastings College of Law. He has served on the Journal of Periodontology Editorial Board from 2000 to the present. He is a member of the American Academy of Periodontology, American Dental Association, California Dental Association, San Francisco Dental Society, Consumer Attorneys of California, and the American Association for Justice. He is currently practicing law in San Francisco, California. He has authored many articles and also has served as a teacher and consultant.

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clinicians worked so hard to establish. But our endodontic patients will pay the long-term price of increased retreatment of cases failing. If this trend continues, we are undermining the necessity for endodontics to be regarded as a specialty, and we will have sold our souls and ethics by potentially sliding down this slippery slope descending from excellence to mediocrity. Just as there is no double standard for endodontics in an HMO setting, there should not be a different standard depending upon the office location where endodontics is provided. Endodontists set and uphold the endodontic standard of care, and it should never be compromised for profit.1

After apical surgery, patients receive instructions regarding post-surgical care. Some endodontists do not reinforce the verbal instructions with written instructions. Some endodontists neglect to call surgical patients in the evening to follow-up on how the patients are faring after the local anesthesia has dissipated. Patients are

grateful (and pleasantly surprised) when the doctor calls them at home following surgery. In case patients have a worry (bleeding, pain, sutures irritating the lip or cheek, paresthesia, etc.) and cannot reach the endodontist by phone, they may become so agitated that they call their general dentist or go to the ER for help. Consequently, this now becomes a double loss for the endodontist insofar as being unreachable by the patient (patients feel very put off) and also sowing seeds of doubt in the mind of the referring dentist about the endodontist’s conscientious care for his/her referred patient. A worst case scenario is a patient with postoperative paresthesia and/or dysesthesia from an overfill into the inferior alveolar nerve canal (IAN). This otherwise avoidable injury can be reversed with microsurgery in the first 48 hours.2 If the endodontist did not prevent this adverse event with careful CBCT planning, the endodontist misses a second chance by not phoning the patient postoperatively to

be alerted, if not alarmed, that an immediate referral to a microsurgeon is mandated. Serving our patients to the best of our ability is the most satisfying reward. Any extra treatment time in the pursuit of excellence in the long run will more than compensate for the additional time we spend doing our best. We will gain the personal and professional satisfaction from our increasingly successful treatment results, fewer retreatments, and less time treating avoidable complications. The Standard of Excellent Endodontic Care for our patients will likely be manifested in a greater number of referrals as we distinguish ourselves by always striving to do our best and the professional satisfaction of achieving our goal.

REfEREncEs

1. Edelman v Zeigler, 233 Cal App. 2d 871(1965).

2. Pogrel MA. Damage to the inferior alveolar nerve as the result of root canal therapy. J Am Dent Assoc. 2007;138(1):65-69.

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Technology has made endodontic treatment faster and more efficient.

However, there are still parts of the endodontic protocol that cannot be avoided that add time to the procedure. Taking radiographs is a fundamental part of endodontics. When traditional film radiographs are exposed and processed, there is a unit of time that goes by that the practitioner has to get up from the chair, leave the room, and wait for the X-rays to be exposed and processed. Digital sensor technology has significantly decreased this unit of time. The instantaneous processing of the digital image allows the practitioner to step out of the room and within minutes return to the procedure. No longer does the auxiliary have to process the film in another room, sometimes at the other end of the office, wait for the processing time, either dip or automatic, then return to the practitioner for evaluation. However, digital sensor technology does have its negatives. First, the sensor girth makes it sometimes very difficult for placement in the patient’s mouth. Now compound that by trying to fit this sensor around a rubber dam and clamp. As a practitioner who has done his fair share of endodontics, placement of the film is of utmost importance in order to see the apex of the tooth being worked on. When

a rubber dam clamp is placed, a rigid sensor can be difficult to place in the right position. If it moves or the patient moves it because he/she is uncomfortable, then repeat exposures may be needed. A second disadvantage of sensor technology is cost. These sensors are expensive, and when they break down, which is inevitable, or they are out of warranty, their replacement cost is high. An endodontic clinician has another option that takes advantage of digital technology, reduces the cost in the future, and will not have any placement or exposure issues like one can have with sensors. Phosphor storage plates (PSPs) are thin, flexible digital sensors that are exposed similarly to traditional dental film. With similar dimensions to film, PSPs allow for ease of placement, due to comparative dimensions with traditional film, and can be used with rubber dams and ring systems. Like other digital radiological technology, the dosage required to expose PSPs is less than traditional film. Furthermore, the plates are disposable. The replacement cost of the plates per the number or exposures per plate end up being similar to traditional film costs. The processor for

these plates, although an initial investment similar to sensors, has no moving parts and has a lifespan years and years longer than sensors. As with sensors, PSP technology can have disadvantages. One is the separate processing and exposure mediums. Once a PSP is exposed in the patient’s mouth, the PSP is delivered to the processor that is usually in a non-treatment room or hallway with a computer attached. Thus, the auxiliary or clinician exposes the PSP, removes his/her gloves, and walks the plate to the digital processor. This prevents the instantaneous advantage that sensors have over PSPs. However, a new PSP processor has been developed to close the gap between the exposure and the processing. The ScanX Swift (Air Techniques) is a one-slot PSP processor that is small enough to fit on a countertop in a dental treatment room. Thus, the auxiliary does not need to leave the treatment room after exposing the film. Once the plate is exposed, the auxiliary places the plate into the ScanX Swift, and in seconds, the image is in front of the operator ready for evaluation. In addition, there is a protective barrier that is placed

Endodontics made more efficient with the ScanX Swift™


TECHNOLOGY

Dr. Howard Golan discusses a different type of imaging technology

Dr. Howard Golan is a graduate of the University of Michigan School of Dentistry. He completed a general practice residency at North Shore University Hospital on Long Island, New York. After his GPR, Dr. Golan completed a 2-year Implant Surgery and Advanced Prosthetic Fellowship at NSUH. He has maintained a busy private practice on Long Island that he shares with his father, Dr. Marshall Golan. Dr. Golan implemented lasers into his practice in 2004 and has attained his Mastership certification in the World Clinical Laser Institute. Dr. Golan has been fortunate to be asked to lecture and teach laser-assisted dentistry throughout the United States and internationally. He is the co-founder of the Center for Laser Education and is a faculty member with the World Clinical Laser Institute teaching Certification Training Courses for that organization. Dr. Golan has instituted CAD/CAM technology into his practice for 7 years and has lectured on the subject. He is a graduate of the Alleman Center for Biomimetic Dentistry. He graduated from Concord Law School and has passed the California Bar Examination, obtaining his license to practice law in that state. Dr. Golan’s excels in teaching quick and productive integration of laser-assisted dentistry, minimally invasive concepts, and CAD/CAM technology into dental practices. He practices and teaches a biomimetic philosophy and is passionate about conserving tooth, soft tissue, and bone.

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over the ScanX Swift’s slot so that the auxiliary exposing the film does not have to deglove in order to process the image. The ScanX Swift provides the endodontic practice with almost instantaneous digital X-ray processing by moving the digital processor into the treatment room. This saves time. The one-slot processor provides a more economical option for those practices like endodontics that do not take a large amount of X-ray series. The ScanX Swift enhances infection control and lowers the cost of gloves and disposables by allowing the exposer of the X-ray to remain in the treatment room and contain possible cross-contamination. Finally, the PSPs are disposable, reducing high replacement costs in the future. Endodontic practices should seriously consider incorporating the ScanX Swift into their X-ray protocols. They will enjoy its convenience, long-term cost savings, and quality of image processing.

EP

Incomplete caries removal: a systematic review and meta-analysis [review] Schwendicke F, Dorfer CE, Paris S Journal of Dental Research (2013) 92(4): 306-14

Abstract Aim: Increasing numbers of clinical trials have demonstrated the benefits of incomplete caries removal, in particular in the treatment of deep caries. The aim was to systematically review randomized controlled trials investigating one- or two-step incomplete compared with complete caries removal. Methodology: Studies treating primary and permanent teeth with primary caries lesions requiring a restoration were analyzed. The following primary and secondary outcomes were investigated: risk of pulpal exposure, postoperative pulpal symptoms, overall failure, and caries progression. Electronic databases were screened for studies from 1967 to 2012. Cross-referencing was used to identify further articles. Odds ratios (OR) as effect estimates were calculated in a random-effects model. Results: From 364 screened articles, 10 studies representing 1,257 patients were included. Meta-analysis showed risk reduction for both pulpal exposure (OR [95% CI] 0.31 [0.19-0.49]) and pulpal symptoms (OR 0.58 [0.31-1.10]) for teeth treated with one- or two-step incomplete excavation. Risk of failure seemed to be similar for both complete and incomplete excavation, but data for this outcome were of limited quality and inconclusive (OR 0.97 [0.64-1.46]). Conclusions: Based on reviewed studies, incomplete caries removal seems

advantageous compared with complete excavation, especially in proximity to the pulp. However, evidence levels are currently insufficient for definitive conclusions because of high risk of bias within studies.

Influence of endodontic treatment in the post-surgical healing of human Class II furcation defects de Miranda JL, Santana CM, Santana RB Journal of Periodontology (2013) 84(1): 51-7

Abstract Aim: Treatment of molar furcation defects remains a considerable challenge in clinical practice. The degree of success in the management of furcation involvement is highly variable and related to the baseline clinical status of these defects. The identification of clinical parameters influential to the treatment outcomes is critical to optimize the results of surgical periodontal therapy. The impact of the endodontic treatment (ET) of the tooth on the healing potential of the periodontium is controversial. Therefore, the aim of this study was to evaluate the clinical response of buccal Class II furcation defects to open-flap debridement (OFD) and to determine the influence of ET in the clinical outcomes of therapy. Methodology: Sixty patients were divided into two treatment groups (n = 30): OFD; OFD in endodontically treated teeth (OFD + ET). The clinical variables evaluated were plaque (full-mouth plaque score), bleeding on probing, gingival recession, probing depth (PD), and vertical (VAL), and horizontal (HAL) attachment levels. Re-evaluation was performed 12 months after the surgical procedures.Results: Both treatments resulted in improvements in all the clinical variables evaluated. Postoperative measurements from OFD-treated and OFD + ET-treated sites showed, respectively, 1.2 +/- 1.2 and 1.3 +/- 1.3mm reduction in PD, 0.6 +/- 0.8 and 0.7 +/- 0.6mm VAL gains, and 0.7 +/- 1.1 and 0.8 +/- 1.6mm HAL gains. No significant differences were found between the groups.Conclusions: The present findings

demonstrate that adequate endodontic therapy performed more than 6 months before surgical treatment does not significantly influence the clinical parameters of healing of human mandibular buccal Class II furcation defects.

Correlation between endodontic broken instrument and nickel level in urine Saghiri MA, Sheibani N, Garcia-Godoy F, Asatourian A, Mehriar P, Scarbecz M Biol Trace Elem Res (2013) [Epub ahead of print]

Abstract Aim: To evaluate the correlation between the presence of separated endodontic instrument inside the dental canal and the nickel (Ni) level in the urine samples of subjected patients.Methodology: Same-gendered and near-aged participants were selected and were instructed to collect their urine in sterile nickel-free plastic containers. The procedures were carried out in the office, and samples were stored in a low-temperature cooler for 1 day and then transferred to the laboratory for electrothermal atomic absorption spectrometry. The level of Ni was measured, and the correlation coefficient was calculated. Data were analyzed using t tests, Pearson’s correlation coefficients, and linear regression analysis at a level of significance P < 0.05.Results: The statistical analysis showed significant difference in Ni level between endodontic and control groups (P < 0.05). There was no correlation between Ni level in urine and the age or time period of broken instrument inside the canal. However, Ni level of urine and the age of participants in the experimental group demonstrated a positive correlation. The amount of Ni element can be increased in the urine of patients who have experienced broken endodontic instrument inside the dental canal. However, there is no positive correlation between the remaining pieces of instruments inside the canal and the elevation of nickel amount in urine during the tested time period.

The latest in endodontic research


ABSTRACTS

Dr. Kishor Gulabivala presents the latest literature, keeping you up-to-date with the most relevant research

Kishor Gulabivala, BDS, MSc, FDSRCS, PhD, FHEA, is professor and chairman of endodontology, and head of the department of restorative dentistry at Eastman Dental Institute, University College London. He

is also training program director for endodontics in London.

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Conclusions: The aging of remaining broken instrument inside the canal does not show any remarkable concern regarding the Ni elevation in the urine excreted by an individual.

The critical apical diameter to obtain regeneration of the pulp tissue after tooth transplantation, replantation, or regenerative en-dodontic treatment Laureys WG, Cuvelier CA, Dermaut LR, De Pauw GA J Endod (2013) 39(6): 759-63

Abstract Aim: Regeneration of pulp-like tissue in the pulp chamber after tooth transplantation, replantation, or in regenerative endodontic treatment is only possible if the apical foramen is open. According to the literature, the success of regeneration decreases considerably if the foramen is smaller than 1 mm when measured on radiographs. The aim of this paper was to study histologically the relation between the width of the apical foramen and regeneration of tissue in the pulp chamber after auto-transplantation.Methodology: Fifteen single-rooted mature teeth of three adult beagle dogs were used. All experimental teeth were extracted and underwent apicoectomy. The teeth were photographed from the apical side, and the width of the foramen was calculated. The foramen width ranged from 0.24 to 1.09 mm. All teeth were replanted in infraocclusion. The observation period was 90 days after transplantation.Results: The 10 teeth with the smallest apical diameter, ranging between 0.24 and 0.53 mm, showed vital tissue in at least one-third of the pulp chamber. The six most successful teeth showing vital tissue in the entire pulp chamber had an apical diameter between 0.32 and 0.65 mm, and 80% of the experimental teeth with a diameter varying between 1.09 and 0.31 mm showed vital tissue in at least one-third of the pulp chamber 90 days after transplantation. Conclusion: The size of the apical foramen seems not to be the all decisive factor for successful revascularization and ingrowth of new tissue after transplantation. The minimum width of the apical foramen has not been determined, but a size smaller than 1 mm does not prevent revascularization and ingrowth of vital tissue. In this animal study, an apical foramen of 0.32 mm did not prevent ingrowth of new tissue in two-

thirds of the pulp chamber 90 days after transplantation.

Association between chronic peri-odontal and apical inflammation and acute myocardial infarction Willershausen I, Weyer V, Peter M, Weichert C, Kasaj A, Münzel T, Willershausen BOdontology (2013) [Epub ahead of print]

Abstract Aim: Evidence from epidemiologic studies suggests that periodontal diseases may exert a weak to moderate influence on the severity and course of coronary heart disease. The aim of this study was to investigate whether an association between chronic oral infections and the presence of an acute myocardial infarction (AMI) exists.Methodology: A total of 248 patients after AMI and 249 healthy controls were recruited for this study. The oral assessment included caries frequency (DMFT indices), number of teeth, probing pocket depths, bleeding on probing, clinical attachment level, as well as radiographs to diagnose apical lesions. The medical examination included a blood analysis, e.g., the determination of the serum concentration of C-reactive protein (CRP). Results: The data analysis showed statistically significant differences between AMI patients and the controls with regard to number of missing teeth (p = 0.001), DMFT index (p = 0.001) and presence of apical lesions of endodontic origin (p = 0.001). Logistic regression showed that the probability of having lesions of endodontic origin was with an odds ratio of 1.54 (95% CI 1.10-2.16; p = 0.012) considerably higher in the AMI patient group. Likewise, the AMI patients had with an odds ratio of 1.21 (95% CI 1.14-1.28; p < 0.001) a higher number of missing teeth. The data from the blood analysis, in particular the CRP values, showed no significant correlation with the number of apical lesions. Conclusion: The results of this study underline that patients who have experienced a myocardial infarction had more missing teeth and a higher number of inflammatory processes, especially of endodontic origin than healthy patients.

Quality of life and satisfaction of patients after nonsurgical primary root canal treatment provided by undergraduate

students, graduate students, and endodontic specialists Hamasha AA, Hatiwsh AInt Endod J (2013) (doi: 10.1111/iej.12106) [Epub ahead of print]

Abstract Aim: To assess the impact of primary root canal treatment on the perceived quality of life among a cohort of Jordanian patients, to assess the cohort’s satisfaction with their primary root canal treatment, and to evaluate the association of the level of training and experience of clinicians with these two parameters.Methodology: A systematic random sample of 302 subjects was selected from patients who attended undergraduate, graduate, and specialty clinics of Jordan University of Science and Technology. Participants were interviewed before and 2 weeks after completion of root canal treatment. The study instrument included the Oral Health Impact Profile questionnaire (Dugas, et al., 2002) and seven semantic differential scales. Data analyses included descriptive statistics and nonparametric analyses.Results: More than 90% of subjects reported improvements in the sense of taste, pain, eating, altering food temperature, self-consciousness, waking during sleep, interruption of meals, difficulty to relax, and difficulty to sleep after root canal treatment. There was no significant difference in terms of improvement amongst patients treated by specialists, graduate, or undergraduate students. The overall semantic differential score of intraoperative pain, pleasantness, chewing ability, and general satisfaction was approximately eight. Satisfaction of root canal treatment by specialists was higher in terms of time involved, intraoperative pain, pleasantness, and general satisfaction than those treatments by undergraduate students. Patients treated by specialists were least satisfied with the treatment cost compared to those patients treated by graduate or undergraduate students.Conclusion: The impact of root canal treatment on the quality of life was apparent. Satisfaction with root canal treatment approximates to eight on the semantic differential scale with preference for specialists over dental students. EP

canal until you have horsed a No. 15 KF to estimated length and have taken an X-ray; in small curved molar canals, this can be disastrous. Working initial negotiating files short in error invites apical blockage and ledging, while working them erroneously long invites ripping apically-curved canals straight, outcomes that happen more often than most of us realize. Yet the majority of general dentists do not use EALs. Why? Many have been unsuccessful in first use — no surprise — EALs are technique sensitive to use. Here are the technique touchpoints I consider when using an EAL:

1. Confirm a good condition of the EAL, its batteries, its cords, and its file probes (Figure 2). These are sensitive electronic devices with boards inside that can break when drop-kicked in an operatory. Be gentle with them. When the battery signal shows halfway, replace them with fresh batteries. When EAL cords have been autoclaved repeatedly, they may develop tarnish that inhibits conduction at the cord connections and at the end of the file probe where it touches the shank of the file being used. Using a bur brush here will take care of the tarnish. Ideally, use a straight file probe that has been gold-plated (this prevents oxidation) at its business end. These work the best of all EAL probe designs I have used (Figure 3). My least favorite is the spring-loaded test file leads that most dentists attach to their files. They are too wide to fit them between the rubber stop and handle in canals longer than 22 mm. Test leads attached to files during negotiation dampen tactile feedback, increasing the risk of damaging tortuous apical anatomy. The straight probe can be temporarily set on an alcohol gauze, located on the patient’s bib, as the assistant places the lip clip under the rubber dam, on the opposite side of the tooth being treated, with the EAL display nearby. When estimated length is approached, it is then very convenient to simply retrieve the file probe from under the patient’s chin; touch its thin, V-cut end to the file shank, between the rubber stop

and the handle (Figure 4). The file in hand is then advanced into the canal until the display meter pegs to the farthest red “apex” indication, and the instrument is turned slowly in a counterclockwise direction until the meter is only lit up to the simulated “.5 mm” mark, and the green bar opposite that mark stops blinking and holds steady for a couple of seconds. Lead sets typically need replacing in my office every 6 to 12 months. Not autoclaving EAL cords and probes is “no bueno,” and the temperature and steam fatigues the insulation, so accept this and pop for a new cord set every now and then.

2. Cut a nice access cavity. I am often asked how I use EALs when working next to metallic restorations, as it can be difficult to avoid shorting the signal. My first consideration is to make sure the line

The rationale and use of electronic apex locators


PRODUCT INSIGHT

Dr. L. Stephen Buchanan offers advice on getting to the root of the matter

L. Stephen Buchanan, DDS, FICD, FACD, is a Diplomate of the American Board of Endodontics and an assistant clinical professor at the post-graduate endodontic programs at USC and UCLA. He maintains

a private practice limited to endodontics and implant surgery in Santa Barbara, California, and is the founder of Dental Education Laboratories, a hands-on training center serving general dentists and endodontists upgrading their skills in new endodontic and implant technology. Dr. Buchanan can be reached through his business, Dental Education Laboratories, www.DELendo.com, [email protected].

Electronic apex locators (EALs) are my best friend in a root canal. Of all the

devices I use in practice, my RootZX-mini (J. Morita Manufacturing Corp.) is the most indispensable (Figure 1). This is borne out by the fact that most endodontists use an EAL to determine length in every root canal they treat. The rationale for using an EAL in every single canal you treat? A short review of the anatomy literature reveals conventional radiography to be no greater than 80% accurate for length determination, versus 97% accuracy with EALs. One of the worst endo concepts — ever — has been the procedural recommendation that we treat root canals a certain distance from the root apex — a strategy based on the average position of root canal foramina. Unfortunately, none of our patients are average. Every single root canal you enter for the next 35 years of practice will be different than the one before, so how is it going to work when we arbitrarily assign apical preparation sizes based on averages? Not so good, actually. When we decide all small canals should be enlarged to a No. 35 file size at the end of the prep, we will often have one of two untoward outcomes: apical damage or incomplete preparation. So it is with length determination. With an EAL, you will know immediately when you reach the end of root canals with the smallest, first negotiating files — data that is so critical to controlling our use of these instruments and preventing apical damage. Without an apex locator, you will NEVER know where you are in a root

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angles of the access cavity have been cut so that files may drop smoothly, without hitch, into each canal without significant flexure of their shank ends. A well-cut access cavity will allow files to be easily held away from an adjacent metal crown or alloy restoration. To do so, get a finger rest, look carefully as you center the file in the access prep, then direct your attention to the EAL display as you turn the file back and forth until the meter arrives at a reproducible length measurement. If you still have trouble keeping files from shorting, cut heat-shrink tubing (RadioShack®) into 9 mm lengths and place them on your initial negotiating files, and the procedure can go on. A little practice, and this will no longer be necessary. Not to brag, but I don’t have any greater difficulty using EALs through metallic restorations or crowns and would rather do that than work on teeth devastated by caries.

3. Use a lubricant such as RC-Prep® or ProLube® (Dentsply Tulsa Dental Specialties) during electronic length determination instead of NaOCl. This is the second requirement for working successfully through access cavities with adjacent metal. In fact, doing all initial negotiation procedures through an access cavity filled with lubricant will smooth out all EAL use as it helps eliminate the apical blockage so common in vital cases. Not only has there been no evidence-based research proving NaOCl is helpful for negotiation procedures, all of our clinical experience shows lubricants to be the ideal solution to have in the pulp chamber as initial negotiating files are taken into small curved canals. When sufficiently small first files are used in a bath of lubricating solution, apical soft tissue blockage can be totally avoided. Plus, all EAL readings are more stable with lubes, and most erratic with bleach. Lose the bleach...until later in the procedure.

4. Increase file size when EAL readings are erratic. Simply using one or two larger sizes of negotiating file works virtually every time when first or second files taken to length return an erratic, jumpy signal. Going to a larger size file, with a lubricant during EAL use will solve erratic signals for most brands of apex locators. Of all the unnecessary obstacles to success with EALs, this one was my bête’ noir for years until Johan Masrelleiz twigged

me to the use of lubricants during EAL use.

5. Use an EAL in every canal you treat, and you will become proficient. Pulling the office EAL from the back of a dusty closet once every 2 months — when radiographic length determination isn’t working — and expecting immediate success requires a rich fantasy life. Conversely, when I have an apex locator, I can be on a dental mission in an underserved region and do a pretty nice RCT with no X-ray machine. Get one, if you don’t already have one, and use that sucker EVERY time, and you will have way more fun doing RCT. Take this recommendation to heart, and soon you will be ready for the EAL home run.

6. Stop taking length determination radiographs. If you are able to accept gifts from heaven and are looking for a way to be more efficient when delivering RCT, eschew length determination radiographs. Remember? 80% versus 97%? So what do we accomplish when we stop everything to capture a length determination X-ray? To see files as they exit molar root structure, multiple X-rays are usually required, so why are we doing this? Furthermore, curved canals change length as they are worked. When you

use an EAL for each negotiating file, it is common to observe the loss of 1/4 to ½ mm of canal length just going from the 08 KF to the 10KF, as the original irregular canal path is smoothed. So do we capture a second length determination X-ray, after negotiation, and a third after shaping? Rather than spend the time to capture a radiographic record of a length that will change almost immediately after, consider this: Using today’s’ rotary instrumentation, I can literally cut an initial shape, a final shape, gauge the terminus, and fit a gutta-percha cone in less time than it usually takes to capture a well-angulated X-ray image of a No. 15 KF at length. Then, when I take an X-ray image with the cones in place, I

can be certain that the length represented will be stable to the completion of the case. If you want to eliminate working films altogether, use a lubricant and an EAL during apical gauging procedures, and you will know exactly where to fit the cone. I know this works; I practiced for 3 years (including live demonstrations) without taking a working film after canal location, and my apical accuracy improved.

EP

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The properties of superelasticity, shape memory, and controlled memory (CM)

provided by nickel-titanium (NT) alloys have done much to revolutionize the specialty of endodontics over the pre-NT era of Gates Glidden drill and hand file canal preparation. Endodontic use of NT alloys is represented by two distinct generations, a first generation made primarily of ground NT instruments possessing superelasticity and shape memory — clinically present in the austenite crystalline phase configuration (CPC) — and a second generation characterized by heat-treated NT alloys present (to one degree or another) in some combination of the martensite, R-phase, and austenite CPC (one version of which possesses CM). The value to endodontics of NT alloys is the martensitic transformation (MT). NT alloys, when stressed and/or subjected to heat (depending on their transformation temperatures), can move interchangeably between their martensite and austenite CPC. In essence, undergo the MT. The first generation of superelastic NT instruments was present primarily in the austenite phase. Austenite has a more ordered crystal lattice structure and is stiffer than martensite. Martensite is less ordered and more flexible than austenite. Due to the MT, NT files of the first generation in the austenite CPC can be stressed during clinical use and absorb a significant strain (approximately 8%) without deformation as the NT alloys changes CPC into martensite. Once the stress is released, the file reverts to its initial CPC (hence superelasticity — the ability to withstand the strain without deformation — and return to its original shape — shape memory. This ability to withstand the aforementioned strain with the applied

stress is invaluable in shaping root canals. NT files, used appropriately, are strong enough to resist both torque stresses and cyclic fatigue (bending stresses of tension and compression applied to the file as it rotates around a curvature) up to some elastic limit, after which the material will permanently deform and ultimately break if the stress is not removed. As a result of their proprietary thermomechanical processing, second generation nickel-titanium alloys possess different physical characteristics than their first generation counterparts. Second generation heat-treated alloys are manufactured in several methods: from heat-treated metal (M-wire, Dentsply), ground, and then processed (MounceFiles—Controlled Memory) and with R phase technology (Twisted Files, Axis/Sybron) — the flutes of the files are manufactured by twisting while the nickel-titanium is in an intermediate crystalline phase between martensite and austenite (R phase). Reciprocated systems and rotary NT systems are both available using second-generation heat treatments. The clinical implications of these new heat-processing technologies are nothing short of mind-blowing. Based on the available literature, generation two NT alloys are significantly more flexible and

The martensitic transformation: still transforming endodontics

Dr. Rich Mounce discusses the second generation of heat-treated nickel-titanium alloys

Rich Mounce, DDS, is in full-time endodontic practice in Rapid City, South Dakota. He has lectured and written globally in the specialty. He owns MounceEndo, LLC, marketing the rotary nickel-titanium MounceFile in

Controlled Memory© and Standard NiTi. He can be reached at [email protected], MounceEndo.com. Twitter: @MounceEndo

fracture resistant than generation one — the current literature is very positive with regard to the physical attributes of second-generation heat-treated instruments relative to the first generation. In addition to the aforementioned flexibility and fracture resistance of the generation two alloys, CM technology provides exciting features uniquely present among the second generation of NT files. CM files are largely in the martensitic state (more flexible state) during clinical use. They do not undergo the martensitic transformation because their transformation temperatures are much higher than their superelastic first generation counterparts. In addition, CM files do not possess shape memory — they rotate around a curvature and will remain curved as they function, minimizing possibilities for canal transportation. A clinical case utilizing CM technology is pictured in Figure 1. The reader is urged to read and study more on the second generation of heat-treated NT and further explore the possibilities of safe and efficient canal shaping using these instruments. An excellent summary article to begin such study is Shen, et al., Journal of Endodontics, Volume 39, Issue 2, Pages 163-172, February 2013. I welcome your feedback. EP

Canals shaped with the MounceFile Controlled Memory Assorted pack

Patient satisfaction is a priority at the office of endodontist Matthew T.

Ankrum, DDS. However, a few months ago we began to realize that the trend toward higher patient financial responsibilities could present a challenge to establishing and maintaining the warm, personal relationship between patients and staff that has been a hallmark of the practice. Historically, a revenue strategy hasn’t been considered a priority for patient-provider relationships. Patient eligibility and benefits verification were handled by employees responsible for contacting insurance companies. These calls or emails were initiated as soon as the patient’s procedure was scheduled. Typically, a predetermination of benefits was not requested because the endodontist tries to schedule procedures as soon as possible to relieve any patient pain. Due to the short amount of time available to verify benefits and the difficulty reaching insurance companies, patients seldom were asked to pay their portion of the bill at the time of service. In addition to spending an average of 60% of the day on the telephone to verify benefits, we also tracked claim payments. The practice’s revenue system did have a feature that showed when the claim was received and when it was processed, but there were many times a check was received before the system listed it as a processed claim. Because the validity of the information was suspect, we often had to make telephone calls to follow up on claims. Payment timeframes varied from 2 to 3 weeks from the best payers to 4 to 5 weeks for others. The delay in receipt of insurance payments delayed generation of bills to patients, with some patients not receiving final bills until almost 2 months

after their procedures. To address the strain that increased financial responsibility places on the patient-provider relationship, the practice implemented an integrated patient experience and revenue strategy. The change in process not only improved the staff’s ability to engage the patient in financial conversations prior to a procedure, but also led to unexpected benefits in every aspect of the office’s operations – including more timely insurance payments, improved patient payment rates, and enhanced staff productivity.

Patient-centric service importantAs a small practice with one practitioner,

one office manager who has a clinical background, and two dental assistants, the idea of implementing a revenue management system might never have been an initiative if not for a conversation with a colleague in another practice. When the colleague described access to real-time information online and the ability to collect patient responsibility at the time of service, the benefits became apparent. Once the decision was made to develop a new revenue management strategy, several essential goals were established for the new approach:

• FocusonpatientexperienceBecause an endodontist often sees a

Technology leads the charge for improved patient experience, increased cash flow


PRACTICE MANAGEMENT

Jena McCoy-Lovern tackles some challenges to establishing and maintaining a positive relationship with patients

Jena McCoy-Lovern is office manager at the endodontic practice of Matthew T. Ankrum, DDS, in Blacksburg, Virginia.

...the trend towardhigher patient financial responsibilities

could present a challenge to establishingand maintaining the warm, personal

relationship between patients and staff thathas been a hallmark of the practice.

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patient only once, it is critical to make a good first impression and establish a positive relationship in a single encounter. Our practice’s reputation relies on word-of-mouth recommendations throughout the community and positive feedback to referring dental providers. The new revenue strategy had to improve the patient’s experience in addition to any financial benefits the practice realized.

• ImprovestaffefficiencyTechnology had to enhance staff efficiency, providing such attributes as reliable, real-time benefits, and eligibility verification, claims filing and tracking, and patient billing. The new system needed to minimize the amount of time one staff person spent on the telephone with insurance companies, which could be better used in interactions with patients and support of clinical staff members.

• Enhance payer and patientcollectionsWaiting up to 3 months or more to receive the final payment from patients not only negatively affected practice cash flow, but also required staff time for follow-up. The practice needed a system that outlined the patient’s financial responsibility before or at the time of service to enable meaningful conversations about payment.

New strategy enhances reim-bursementThe new process, implemented in March 2013, focuses first on the patient by initiating financial conversations when patients are scheduled for their procedures. Easy access to benefits information enables a discussion that clearly outlines the cost of a procedure and the amount of the bill that is the patient’s responsibility. The ability to share detailed information about how the patient’s portion of the bill is determined provides patients with an opportunity to ask questions so they understand the process. This improves the patient’s comfort with the accuracy of the estimate and gives the patient time to ask about payment plans or other approaches to payment that fit their financial situation. Success of the new strategy is attributed to:

• Real-timeinformationEstimates are more accurate because the information is real-time, so patients can see

exactly what is applied to the deductible and how the co-pay is determined. Even when all of the payment isn’t collected at the time of service, these conversations eliminate the shock of a large, unexpected bill, and patients have time to make payment arrangements.

• ReliableclaimstrackingChanging the technology used to file and track claims has also significantly increased speed of insurance payments. One claim’s payment was received in 5 days after the procedure. While 5 days is uncommon, all claims are now paid faster than before – with accounts receivable days decreasing from 2 to 3 weeks to 1 week – and we no longer need to constantly call to follow up on claims processing. Clear reports that show the status of claims provide a quick look at what requires follow-up action, so time is not spent reviewing individual claims’ status.

• Correction of claims beforesubmission Another key to quicker claims processing is our ability to automatically check claims for incorrect patient identification data or other anomalies that might result in a rejection

or delay in payment. The ability to verify information with the patient and correct inaccuracies before the claim is submitted has decreased denials significantly.

• ShortertimeframeforpatientbillingAn unexpected benefit of faster claim payments is quicker payment by patients. They know upfront that they are responsible for a portion of the bill, and because their final bills are generated days following their procedure rather than many weeks, they are paying more quickly. Most payments are received after the first statement, and 95% of accounts are paid after two statements.

Technology enhances patient-focused service Not only did the new process improve efficiency for the staff member handling insurance, but overall efficiency in the office has improved. Having that person available to interact with patients in the office enabled the addition of an extra patient to each day’s schedule – so seven patients are now seen each day. The additional slot means the practice can respond more quickly to a patient’s acute need for treatment. As patients become increasingly more responsible for dental bills, it’s even more important for endodontic practices to assure patients have a positive experience throughout their visit. Taking a close look beyond the clinical approach to front- and back-office revenue processes is integral to meeting this new patient-provider dynamic. The most important lesson learned through this process is that management of benefits verification and claims payment should not be hard. It was only after leveraging technology to support revenue management that we realized how much time and effort was spent on activities that can be automated. One of the most rewarding benefits of the new strategy, however, is improved patient service. Although the practice has always been known as one that recognizes a patient’s name, we are now able to spend more time educating patients about clinical and financial issues. Our ability to answer their financial questions has greatly improved due to greater access to reliable, real-time information.

It was only after leveraging technology to

support revenuemanagement that we

realized how much time and effort was spent on

activities thatcan be automated.

EP

Carestream Dental’s CS 8100 digital panoramic imaging system receives 2013 International Medical Design Excellence Award

Carestream Dental announced its CS 8100 digital panoramic imaging system has been selected as the Bronze Winner in the Dental Instruments, Equipment, and Supplies category of the 2013 Medical Design Excellence Awards (MDEA) competition. Presented by UBM Canon and Medical Device & Diagnostic Industry (MD+DI) magazine, the MDEA program is the MedTech Industry’s Premier Competition for medical device design and innovation. It recognizes the achievements of medical device manufacturers, their suppliers, and the many people behind the scenes. For more information, please call 800-944-6365 or visit www.carestreamdental.com/CS8100.

Air Techniques announces the integration of ScanX with Curve Dental’s Cloud Software

Air Techniques, Inc., manufacturer of dental equipment announces the successful integration of ScanX digital imaging system and Curve Dental’s Cloud management software. Now, ScanX system users are able to save their digital X-ray images to Curve Dental’s Cloud.

Curve Dental is a web-based management software company for the dental practice. Curve uses the latest technology to capture the images from your sensor directly to the Cloud. There is no installation required; just log in to get started. Curve Dental customers can use ScanX to capture digital X-ray images directly to the Cloud.

For more information on Air Techniques, please visit: www.airtechniques.com. Become a fan of Air Techniques on Facebook and follow the company on Twitter.

DENTSPLY Maillefer introduces innovative Detect™ Apex Locator

Technologically advanced device features compact design, full-color screen, and progressive sound control

DENTSPLY Maillefer announced Detect™, an innovative apex locator featuring a full-color screen, progressive sound control, and the latest multi-frequency technology for improved visualization of the file progression. Supported by extensive research and testing, Detect will allow practitioners to sharpen root canal visibility and accurately measure root canal length during endodontic therapy. Detect features an easy-to-read full-color screen that shows an image of the tooth as well as a numerical value to indicate the file progression in the tooth. In addition to the large visual display, Detect emits audible information using progressive sound control. The device beeps faster as it approaches the apex, and once the apex is reached, emits a solid tone. Detect is fully automated and requires no calibration before use. Powered by a rechargeable, low-volt nickel-metal hydride (NiMH) battery, the Detect Apex Locator eliminates the need for frequent battery replacement and provides a nonstop operating time of about 6.5 hours on a full charge. With a compact, smart design, Detect stores away easily and fits comfortably in the hand to provide a steady hold during root canal procedures. For more information about Detect, visit www.maillefer.com or call 800-924-7393.


M A T E R I A L S&

E Q U I P M E N Tlllllllllllll lllllllllllll

INDUSTRY NEWS

ACTEON North America expands its current facility

ACTEON® North America, dental, medical, and veterinary device manufacturer, has completed the expansion of its current facility. ACTEON® North America’s new facility increases its current space by 60%. The addition will provide much-needed office and storage space for service and shipping staff. Located in Mount Laurel, New Jersey (just outside Philadelphia), ACTEON® North America provides all sales, marketing, customer service, and technical support for ACTEON® products in the United States and Canada. ACTEON® partners with all of the major dental chair delivery system manufacturers and dental distributors. For more information, visit: www.acteonusa.com.

Komet USA’s new F360™ endodontic files reduce root-canal preparation time

Two-file system undeniably simple

The Komet® F360™ endodontic file system permits preparation of most root canals with a simplified, time-saving sequence requiring only two files. Highly flexible to minimize canal transportation, the files feature a unique S-curve design and a thin instrument core to deliver outstanding cutting efficiency while respecting natural root-canal morphology. Only two files in sizes 025 and 035 are required for most root-canal preparations. Their .04 taper promotes optimal debridement of the canal, maintains file flexibility and thus reduces preparation errors, and permits ideal shaping of the root canal for subsequent obturation with any method.

For more information about Komet USA or the F360™ endodontic file system, call 888-566-3887 or visit www.komet-usa.com.

The Ideal 3D Imaging Systems...• Ideal for canal assessment and canal anatomy review

• Versatile volume sizes (small ø4 x 5 cm, medium ø8 x 8 cm,large ø8 x 11 cm or ø8 x 14 cm with vertical blending) for asingle impaction to full dentition, and beyond

• Secondary canal, hairline fracture

and calcification detection

• Patented SCARA technology for unlimited viewing

positions of treatment site

• Sharp image acquisition integrates seamlessly into Romexis

open architecture software for easy image analysis

and treatment planning

• Space saving - small footprint and compact design

• Mac OS compatible and DICOM compliant

PLANMECA®For a free in-office

consultation, please call

1-855-245-2908or email

www.planmecausa.com

10413_ProMax 3D_endopract:Layout 1 10/3/13 9:30 AM Page 1

• Designed with the endodontist in mind.

• Do your best work when you capture scans with a focused field-of-view with a high resolution of 76 μm.

• Make accurate assessments and diagnoses with our full-featured CS 3D Imaging Software.

• Experience seamless integration with all Carestream Dental software, as well as top endodontic practice management software programs.

To learn more about what a great image can do for your endodontic practice, visit carestreamdental.com/EP3D or call 800.944.6365 today.

© Carestream Health, Inc. 2013 9757 EN 90 AD 1113

The CS 9000 3D is ready to work hard for your practice. This technologically-advanced system will give you high-resolution 3D images that can

assist you in making accurate endodontic assessments and diagnoses. It will also show

your patients how dedicated you are to their oral health.

It’s amazing what a great image can do for your practice.

8634_Endo_3D_Ad-9x11.7_Chosen.indd 1 10/3/13 4:04 PM

endodontic practice us - november/december 2013 - vol6.6

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