november 2017 vol. 31 - sie · restorative dentistry and endodontics universitat internacional de...

EDITORIAL

◆ EDITORIAL

FOCUS

◆ REGENERATIVE ENDODONTIC PROCEDURES: A REVIEW OF THE LITERATURE AND A CASE REPORT OF AN IMMATURE CENTRAL INCISOR

ORIGINAL ARTICLES

◆ BULK VS WEDGE SHAPE LAYERING TECHNIQUES IN V CLASS CAVITIES: MARGINAL INFILTRATION EVALUATION

◆ EVALUATION OF CYCLIC FATIGUE RESISTANCE OF MODERN NICKEL—TITANIUM ROTARY INSTRUMENTS WITH CONTINUOUS ROTATION

◆ COMPARATIVE ANALYSIS OF ROOT CANAL CHANGES AFTER PREPARATION WITH THREE SYSTEMS USING CONE-BEAM COMPUTED TOMOGRAPHY

◆ IN-VITRO EVALUATION OF APICAL MICROLEAKAGE OF TWO OBTURATION METHODS OF IMMATURE PERMANENT TEETH: ORTHOGRADE APICAL PLUG OF MINERAL TRIOXIDE AGGREGATE AND ROOT CANAL FILLING COMBINING CUSTOM GUTTA-PERCHA CONE WITH CALCIUM SILICATE-BASED SEALER

CLINICAL ARTICLE

◆ RECIPROC BLUE:THE NEW GENERATION OF RECIPROCATION

CASE REPORTS

◆ CLINICAL MANAGEMENT OF HORIZONTAL ROOT FRACTURES AIDED BY THE USE OF CONE-BEAM COMPUTED TOMOGRAPHY

ISSN 1121 – 4171

2 | November 2017 | Vol. 31 |

Available online at www.sciencedirect.com

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35° Congresso Nazionale SIE - Bologna, 9-11 Novembre 2017

Vieni a scoprire le novità presso lo stand SIMIT DENTAL

Organo Uffi ciale della SIE – Società Italiana di Endodonzia

EDITOR IN CHIEF

Prof. SANDRO RENGOProfessor and Chair of Endodontics, Federico II University of NaplesItaly, Former President of SIE

ASSOCIATE EDITORS

DOTT. GIANLUCA PLOTINOPrivate Practice, Grande Plotino Torsello - Studio di Odontoiatria, Rome - Italy

Prof. CARLO PRATIFull Professor of Endodontics and Ope-rative Dentistry, Dean Master in Clinical EndodontologyHead Endodontic Clinical Section Dental School - University of Bologna, Bologna, Italy

ASSISTANT EDITORS

Prof. BERUTTI ELIOProfessor and Chair of EndodonticsUniversity of TurinDental SchoolFormer President of SIE

Prof. CERUTTI ANTONIOProfessor and Chair of RestorativeDentistryUniversity of BresciaDental SchoolActive member of SIE

Prof. COTTI ELISABETTAProfessor and Chair of EndodonticsUniversity of CagliariDental SchoolActive member of SIE

Prof. DI LENARDA ROBERTOProfessor and Chair of EndodonticsDean of Dental SchoolUniversity of TriesteDental School

Prof. GAGLIANI MASSIMOProfessor and Chair of EndodonticsUniversity of MilanDental School

Prof. PIATTELLI ADRIANOProfessor and Chair of Oral PathologyUniversity of ChietiDental School

EDITORIAL COMMITTEE

Prof. AMATO MASSIMOAssociate ProfessorUniversity of SalernoDepartment of Medicine and SurgeryActive member of SIE

Dr. BADINO MARIOPrivate practice in Milan SIE Offi cer

Dr. CARDINALI FILIPPOPrivate practice in AnconaActive member of SIE

Dr. CASTRO DAVIDE FABIOPrivate practice in Varese SIE Offi cer

Dr. CORAINI CRISTIANPrivate practice in Milan Active member of SIE

Prof. FORTUNATO LEONZIOAssociate Professor of Odontostomatological Illnesses, University of Magna Graecia, CZ ItalyActive Member of SIE

Dr. FABIANI CRISTIANOPrivate practice in Rome Active member of SIEDr. FORNARA ROBERTOPrivate practice in MagentaCertifi ed Member of ESESIE Offi cer Prof. MANGANI FRANCESCOProfessor and Chair of Restorative DentistryUniversity of Rome Tor Vergata Dental SchoolActive member of SIEDr. PISACANE CLAUDIOPrivate practice in Rome Active member of SIEProf. RE DINOProfessor and Chair of Prosthodontics University of Milan Dental SchoolActive member of SIEDr. TASCHIERI SILVIOPrivate practice in MilanActive member of SIEDr. TOSCO EUGENIOPrivate practice in FermoActive member of SIE

EDITORIAL BOARD

Dr. BARBONI MARIA GIOVANNAPrivate practice in Bologna Active member of SIEDr. BATE ANNA LOUISEPrivate practice in Cuneo Active member of SIEDr. BERTANI PIOPrivate practice in Parma Elected President of SIEProf. CANTATORE GIUSEPPEProfessor of Endodontics University of Verona Dental School Former President of SIEDr. CASTELLUCCI ARNALDOPrivate practice in FlorenceFormer President of SIE Former President of ESE Prof. CAVALLERI GIACOMOProfessor and Chair of Endodontics University of Verona Dental School Former President of SIEDr. COLLA MARCOPrivate practice in Bolzano Active member of SIEProf. GALLOTTINI LIVIOProfessor and Chair of Endodontics II University of Rome La Sapienza Dental SchoolActive member of SIEProf. GEROSA ROBERTOProfessor and Chair of Endodontics University of Verona Dental School Active member of SIEDr. GIARDINO LUCIANOPrivate practice in Crotone Member of SIEDr. GORNI FABIOPrivate practice in MilanFormer President of SIE Dr. GRECO KATIA Lecturer in Endodontology University of Catanzaro Scientifi c Board Coordinator SIEProf. KAITSAS VASSILIOSProfessor of Endodontics University of Thesalonikki (Greece) Active member of SIEDr. LENDINI MARIOPrivate practice in Turin Scientifi c Secretary of SIE

Prof. MALAGNINO VITO ANTONIOProfessor and Chair of Endodontics University of Chieti Dental School Former President of SIEDr. MALENTACCA AUGUSTOPrivate practice in RomeFormer President of SIE

Dr. MANFRINI FRANCESCAPrivate practice in RivaActive member of SIE

Dr. MARCOLI PIERO ALESSANDROPrivate pratice in Brescia

Dr. MARTIGNONI MARCOPrivate practice in Rome President of SIE

Dr. PECORA GABRIELEFormer Professor of Microscopic Endodontics Post-graduate courses University of Pennsylvania (USA)Active member of SIE

Dr. PONGIONE GIANCARLOPrivate practice in Naples Active member of SIE

Prof. RENGO SANDROProfessor and Chair of Endodontics University of Naples Dental School Former President of SIE

Prof. RICCITIELLO FRANCESCOProfessor of Restorative Dentistry University of Naples Dental SchoolVice-President of SIE

Dr. SBERNA MARIA TERESAPrivate practice in Milan SIE Offi cer

Dr. SCAGNOLI LUIGIPrivate practice in Rome Active member of SIE

Dr. TESTORI TIZIANOPrivate practice in Como Former Editor of Giornale Italiano di Endodonzia

INTERNATIONAL EDITORIAL BOARD

LESLIE ANGClinical assistant professor of Endodontics Division of Graduate Dental Studies National University of Singapore

CARLOS BOVEDAProfessor Post-graduate Courses University of Caracas (Venezuela)

PETER CANCELLIERClinical instructor at the University of Southern California (USA) School of Dentistry GraduateEndodontic Program President of the California State Association of Endodontists

YONGBUM CHOInternational lecturer and researcher Private practice in Seoul (Korea)

GILBERTO DEBELIANAdjunct associate professor Department of EndodonticsUniversity of North Carolina, Chapel HillUniversity of Pennsylvania, Philadelphia (USA)

JOSE ANTONIO FIGUEIREDOClinical lecturer in Endodontology Eastman Dental Institute, London (UK)

GARY GLASSMANInternational lecturer and researcher Private Practice in Ontario (Canada) Editor in Chief of Dental Health

GERARD N. GLICKMANProfessor and Chairman of Endodontics School of Dentistry University of Washington (USA)

VAN T. HIMELProfessor of Endodontics School of Dentistry University of Tennessee (USA)

JEFFREY W. HUTTERProfessor and Chairman of Endodontics Goldman School of Dental Medicine Boston University (USA)

JANTARAT JEERAPHATProfessor of Endodontics Mehidol University of Bangkok (Thai-land) Dental School

NEVIN KARTALProfessor of Endodontics Marmara University Istanbul (Turkey) School of Dentistry

BERTRAND KHAYATInternational lecturer and researcher Private practice in Paris (France)

RICHARD MOUNCEInternational lecturer and researcher Private practice in Portland (Oregon)

GARY NERVOInternational lecturer and researcher Private practice in Melbourne (Australia)

CARLOS GARCIA PUENTEProfessor of Endodontics University of Buenos Aires (Argentina) School of Dentistry

MIGUEL ROIGProfessor and Head Department of Restorative Dentistry and Endodontics Universitat Internacional de Catalunya, Barcelona, (Spain)

CLIFFORD J. RUDDLEAssistant Professor Dept. of Graduate Endodontics Loma Linda University (USA)

MARTIN TROPEProfessor and Chairman of Endodontics School of DentistryUniversity of North Carolina (USA)

JORGE VERAProfessor of Endodontics University of Tlaxcala (Mexico)

EDITORIAL BOARD

Stessa semplicità di utilizzo

Maggiore flessibilità e sicurezza

Stessa efficienza

di taglio

Nuovo trattamento termico

Un grande strumento che continua a migliorare

MASTER IN ENDODONZIA CLINICA

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Meet the expert

Unica data: 9 novembre 2017

Il Master di Endodonzia Clinica

incontra il Dott. Ghassan Yared -

ideatore del sistema endodontico

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Il Prof. Carlo Prati introduce la serata.

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Giovedì 9 novembre 2017 · ore 20.00

Evento gratuito riservato ai primi 100 iscritti

Per informazioni ed iscrizioni:

[email protected]

045 82.81.888

Si ringrazia la SIE - Società Italiana

di Endodonzia e la FAM - Fondazione Alma Mater per

l’organizzazione della serata.

©2017 Dentsply Sirona. All rights reserved.

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PART OF THE novità

novitànovità

Organo Uffi ciale della SIE – Società Italiana di Endodonzia

Editorial/Editoriale

63 EditorialEditorialeS. Rengo

Focus

65 Regenerative endodontic procedures: a review of the literature and a case report of an immature central incisorProcedura di rigenerazione endodontica: revisione della letteratura e caso clinico di un incisivo centrale immaturoM. Llaquet, M. Mercadé, G. Plotino

Original articles/Articoli originali

73 Bulk vs wedge shape layering techniques in V class cavities: marginal in ltration evaluationStrati cazione a massa unica vs strati cazione obliqua in cavita’ di V classe: valutazione dell’in ltrazione marginaleL.G. Roberto, P. Francesco, V. Carmine, M. Marco, A. Angela, L. Angelo

78 Evaluation of cyclic fatigue resistance of modern Nickel—Titanium rotary instruments with continuous rotationValutazione della resistenza alla fatica ciclica di strumenti rotanti a rotazione continua prodotti con moderne leghe Nickel-TitanioM. Amato, G. Pantaleo, D. Abdellatif, A. Blasi, R.L. Giudice, A. Iandolo

83 Comparative analysis of root canal changes after preparation with three systems using Cone-Beam Computed TomographyAnalisi comparativa alla CBCT delle modi cazioni canalari dopo la preparazione con tre diversi sistemiD. Oget, J. Braux, C. Compas, M. Guigand

TABLE OF CONTENTSSIE BOARD 2017

Editor in ChiefSandro Rengo

Associate EditorsGianluca PlotinoCarlo Prati

Assistant EditorsElio BeruttiAntonio CeruttiElisabetta CottiRoberto Di LenardaMassimo GaglianiAdriano PiattelliGianluca PlotinoCarlo PratiEditorial CommitteeMassimo AmatoMario BadinoFilippo CardinaliDavide Fabio CastroCristian CorainiCristiano FabianiRoberto FornaraLeonzio FortunatoFrancesco ManganiClaudio PisacaneDino ReSilvio TaschieriEugenio Tosco

SIE - BOARD OF DIRECTORS

Past PresidentPio BertaniPresidentFrancesco RiccitielloPresident ElectVittorio FrancoVice PresidentMaria Teresa SbernaSecretaryRoberto FornaraTreasurerFilippo CardinaliCultural CoordinatorMauro RigoloneComunication’s CoordinatorItalo Di GiuseppeAdvisersKatia GrecoAlberto RieppiSIE - Società Italiana di EndodonziaLegal Head Offi ce:Via San Pietro snc 98050 Lipari - Isola di Panarea (ME)Headquarters: Via Pietro Custodi, 3 20136 MilanoContacts:Tel. 02.8376799 Fax. 02.89424876Email: [email protected]@endodonzia.itPEC: [email protected]: www.endodonzia.itwww.journals.elsevier.com/giornale-italiano-di-endodonzia/

2 | November 2017 | Vol. 31 |

>

89 In-vitro evaluation of apical microleakage of two obturation methods of immature permanent teeth: orthograde apical plug of Mineral Trioxide Aggregate and root canal filling combining custom gutta-percha cone with Calcium Silicate-based sealer Valutazione in vitro della in ltrazione apicale di due metodi di trattamento degli apici immaturi: chiusura ortograda con apical plug e MTA e chiusura con coni customizzati di guttaperca e sealer calciuo-silicatico BiorootR. Hamdan, J. Michetti, C. Dionnet, F. Diemer, M. Georgelin-Gurgel

Clinical Article/Articolo Clinico

96 Reciproc blue: the new generation of reciprocationReciproc blue: la nuova generazione della reciprocazioneG. Yared

Case reports/Casi clinici

102 Clinical management of horizontal root fractures aided by the use of cone-beam computed tomography Trattamento clinico-chirurgico di fratture radicolari orizzontali con l’ausilio di tomogra a computerizzata a fascio conicoJ. Martos, L.P. Amaral, L.F.M. Silveira, M.F. Damian, C.B. Xavier, A. Lorenzi

TABLE OF CONTENTSEDITORIAL OFFICE

Gaia GarlaschèE-mail: [email protected]: www.journals.elsevier.com/ giornale-italiano-di-endodonzia/

Managing DirectorPio Bertani

Editorial DirectorRoberto Fornara

PUBLISHING

Publishing Support ManagerPonni Brinda [email protected]

Giornale Italiano di Endo-donzia was founded in 1987 and is the offi cial journal of the Italian Society of Endodontics (SIE). It is a peer-reviewed journal publishing original articles on clinical research and/or clinical methodology, case reports related to Endodontics. The Journal evaluates also contributes in restorative dentistr y, dental t r auma to logy, expe r imen ta l pathophysiology, pharmacology and microbiology dealing with Endodontics. Giornale Italiano di Endodonzia is indexed in Scopus and Embase and pub l i shed online only on ScienceDirect. SIE members can access the journal through the website: www.journals.elsevier.com/giornale-italiano-di-endodonzia/

Copyright © 2017 Società Italiana di Endodonzia. Production and hosting by Elsevier B.V. All rights reserved.

REGISTRATION Court of Milan n ° 89, 3 March 2009

Giornale Italiano di Endodonzia - full text available on ScienceDirect©

Volume 31 | n. 2 | November 2017

Amsterdam • Boston • Jena • London • New York • Oxford • Paris • Philadelphia • San Diego • St. Louis

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Thinking ahead. Focused on life.

Programma preliminare

GIOVEDÌ 9 NOVEMBRE ORE 14.30 - 18.00

CORSO PRE-CONGRESSO “L’ENDODONZIA CHIRURGICA” Elio Berutti, Damiano Pasqualini, Mauro Rigolone

VENERDÌ 10 NOVEMBRE ORE 8.45 - 19.00

8.45 > Cerimonia di Apertura dei Lavori e Saluto delle Autorità

Sessione I - INTERAZIONE TRA ORGANO PULPARE E MATERIALIPRESIDENTI DI SESSIONE: Sandro Rengo, Maria Teresa Sberna

9.30 > Interazioni epitelio-mesenchima nell’o-dontogenesi > Francesco Riccitiello10.00 > Interazione tra organo pulpare e bio-materiali > Domenico Ricucci10.30 > Interazioni tra materiali, organo pul-pare e tessuti paradontali: aspetti innovativi e tecniche cliniche > Carlo Prati

Sessione II - L’OUTCOME IN ENDODONZIAPRESIDENTI DI SESSIONE: Massimo Amato, Andrea Polesel

11.30 > Incappucciamento diretto della polpa: risultati clinici a lungo termine nel manteni-mento della vitalità pulpare > Lucio Daniele12.10 > Il trattamento endodontico ortogrado:

quali i fattori che più influenzano il suo outco-me? > Denise Pontoriero12.50 > Il contributo dell’energia Laser usata nel trattamento endodontico: tipi e modi d’uso per migliorare i risultati clinici > Vasilios Kaitsas, Mario Mancini

14.30-16.30 > Sessione III - MASTER CLINICIAN SESSION SPONSORIZZATE DENTSPLY SIRONA E DENTALICA MICROMEGA PRESIDENTE DI SESSIONE: Roberto Fornara

11.30-13.30 > Sessione Finale PREMIO RICCARDO GARBEROGLIO

14.30-16.30 > Sessione Finale PREMIO GIORGIO LAVAGNOLI

17.00-19.00 > Sessione IV - TAVOLE CLINICHE ISTITUZIONALI SIESABATO 11 NOVEMBRE ORE 9.00 - 14.00

Sessione V - LA GESTIONE DEI CASI COMPLESSIPRESIDENTI DI SESSIONE: Filippo Cardinali, Daniele Angerame

9.00 > Strategie operative per la gestione del-le anatomie alterate nei ritrattamenti > Alberto Rieppi

9.40 > La CBCT nella pianificazione e il tratta-mento di casi complessi > Roberto Fornara10.20 > Il rationale in Endodonzia Chirurgica: possibilità e limiti > Fabio Gorni, Luigi Scagnoli

Sessione VI - IL RESTAURO POST-ENDODONTICOPRESIDENTI DI SESSIONE: Pio Bertani, Giuseppe Cantatore

11.30 > Prevenire l’Endodonzia mediante una corretta Conservativa Adesiva > Francesco Mangani12.10 > L’utilizzo di materiali di nuova genera-zione nelle riabilitazioni protesiche post-en-dodontiche > Enrico Gherlone12.50 > Il Restauro Post-Endodontico: evo-luzione, indicazioni ed eventuali alternative ai mezzi di ancoraggio intracanalari > Marco Ferrari

9.00-11.00 > Sessione Finale PREMIO FRANCESCO RIITANO

11.30-13.30 > Sessione di RICERCA LIBERA

13.30 > Premiazioni Vincitori Sessioni Finali Premi SIE14.00 > Chiusura Lavori e Saluto del Presidente

35° CONGRESSO NAZIONALE SIE | BOLOGNA 9-11 NOVEMBRE 2017

PALAZZO DELLA CULTURA E DEI CONGRESSI | PIAZZA DELLA COSTITUZIONE, 4A | 40128 BOLOGNA

www.endodontics.it

EDITORIAL/EDITORIALE

Regenerative medicine is an area of research which is grow-ing more and more and whose aim is to heal damaged tissuesand organs. Regenerative medicine itself is not new at all.According to Greek mythology, the Titan Prometheus hasbeen punished by Zeus because he had stolen the fire forthe humankind. Because of that, he was chained to a rock,where an eagle ate his liver during the day but the liver, for itspart, regenerated it during the night. Nowadays we knowthat, fortunately for Prometheus, the liver has a remarkablecapacity to regenerate after being injured and to adjust itssize to match its host. What determines the healing potentialof an injured tissue is the presence of self-renewing progeni-tor cells that contribute to the regeneration of the organ inwhich they resided.

Like the liver of Prometheus, that contained intra-hepaticand extra-hepatic progenitor cell populations, the dentalpulp is a tissue that contains post-natal mesenchymal stemcells called dental pulp stem cells (DPSCs). Furthermore, thestem cells from the apical papilla of immature teeth (SCAP)are capable to differentiating into odontoblast-like cellsforming a dentin-like tissue.

The ultimate goal of endodontic treatment is to retain thenatural dentition. In this context, regenerative endodonticsprovides the hope of converting the non-vital tooth into avital one, once again. It uses the concept of tissue engineer-ing on substituting traumatized and pathological pulp withfunctional pulp tissue.

In this issue of GIE, a Focus article reviews regenerativeendodontic procedures, which can be considered one of themost exciting developments in dentistry today.

Nowadays ‘‘regenerative dentistry’’ is not only the repair-ing and regenerating dental tissues, but it is increasinglyrelated to concepts such as ‘‘waste medicine’’, which repre-sent the translational medicine in a smart version, re-usingwaste biological tissues, just like the newly discovered

‘‘Human periapical cyst-MSCs’’, stem cells recently isolatedfrom dental cysts.

In the next future, advances in developmental, cell andmolecular biology, immunobiology, and biomaterials, willunlock new opportunities to refine existing regenerativetherapies and develop novel ones.

La medicina rigenerativa e un’area della ricerca in rapidacrescita ed ha come obiettivo la guarigione di tessuti e organidanneggiati. Di per se, la medicina rigenerativa non e nuova.Infatti, secondo la mitologia greca, il Titano Prometeo fupunito da Zeus perche rubo il fuoco per l’umanita. Perquesto, fu incatenato giorno e notte ad una roccia, doveun’aquila gli mangiava il fegato che, perennemente, gliricresceva. Oggi sappiamo che, fortunatamente per Prome-teo, il fegato ha una straordinaria capacita di rigenerarsidopo un danno e di regolare la sua dimensione adattandosi alsuo ospite. Quello che determina il potenziale di guarigionedi un tessuto ferito e la presenza di cellule progenitrici auto-rinnovabili che contribuiscono alla rigenerazione dell’organoin cui risiedono.

Come il fegato di Prometeo, che conteneva le popolazionidi cellule progenitrici intraepatiche ed extraepatiche, lapolpa dentale e un tessuto che contiene cellule staminalipost-natali chiamate cellule staminali della polpa dentale(DPSC). Inoltre, le cellule staminali della papilla apicaledei denti immaturi (SCAP) sono in grado di differenziarsi incellule odontoblastiche, che sono in grado di formare unatipologia di dentina.

L’obiettivo finale di un trattamento endodontico equello di mantenere la dentizione naturale. In questocontesto, l’endodonzia rigenerativa fornisce la speranzadi convertire nuovamente un elemento dentario non vitalein uno vitale, sostituendo la polpa danneggiata con nuovotessuto pulpare sano e funzionale. In questo numero diGIE, una review esamina le procedure rigenerative endo-dontiche: attualmente, tali procedure possono essereconsiderate uno dei progressi piu emozionanti in odon-toiatria.

Tuttavia, ‘‘l’odontoiatria rigenerativa’’ non e solo ripar-azione e rigenerazione di tessuti dentali, bensı e sempre piuaffine a concetti come ‘‘waste medicine’’, che rappresenta la

Giornale Italiano di Endodonzia (2017) 31, 63—64

Peer review under responsibility of Societa Italiana di Endodonzia.


ScienceDirect

j our na l h omepa ge : w ww.e l se v ier. com/ loc ate /g i e

http://dx.doi.org/10.1016/j.gien.2017.10.0011121-4171/� 2017 Societa Italiana di Endodonzia. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-NDlicense (http://creativecommons.org/licenses/by-nc-nd/4.0/).

medicina traslazionale nella versione piu smart riutilizzandodei tessuti biologici di scarto, come nel caso delle ‘‘humanperiapicalcyst-MSCs’’, cellule staminali recentemente iso-late da cisti dentali.

Nel prossimo futuro, le innovazioni nello sviluppotecnologico, nella biologia cellulare e molecolare,nell’immunobiologia e negli biomateriali apriranno nuove

possibilita, al fine di perfezionare le terapie rigenerativegia esistenti e di svilupparne nuove.

Sandro RengoEditor-in-Chief

Giornale Italiano Di EndodonziaE-mail address: [email protected]

64 S. Rengo

CASE REPORT/CASO CLINICO

Regenerative endodontic procedures: areview of the literature and a case report ofan immature central incisor

Procedura di rigenerazione endodontica: revisione della letteratura e casoclinico di un incisivo centrale immaturo

Marc Llaquet a,*, Montse Mercade b, Gianluca Plotino c

aDepartment of Endodontics, Universitat Internacional de Catalunya, Barcelona, SpainbDepartment of Dentistry, Universitat de Barcelona, Barcelona, SpaincGrande, Plotino & Torsello — Studio di Odontoiatria, Rome, Italy

Received 12 January 2017; accepted 30 March 2017Available online 26 May 2017


KEYWORDSBiodentine;Necrotic immaturepermanent teeth;Regenerative endodontictreatment.

Abstract

Background: Trauma of developing teeth may lead to pulpal necrosis with subsequent arrest-ment of root development, making them more susceptible to fracture. Regenerative endodonticprocedures induce maturogenesis in necrotic immature permanent teeth in order to promotecontinuation of root growth. Mineral trioxide aggregate (MTA) is widely used as a blood clotprotecting material, although it presents a potential drawback of discoloration. Biodentine is atricalcium silicate cement with adequate bioactive properties that solve the problem ofdiscoloration.Case report: The current case report demonstrates a maturogenesis of an upper central incisorwith chronic apical abscess. Calcium hydroxide was used as intracanal medicament for a week.After a blood clot was formed, Biodentine was placed over it. Periapical healing and root growthwere evident at 6 months follow-up. Cone Beam Computed Tomography (CBCT) confirmed apicalclosure and complete healing at 1 year.Key-learning points: Apical closure of necrotic immature permanent teeth is possible by meansof regenerative endodontic procedure.Regenerative endodontic procedure with Biodentine has


* Corresponding author at: Universitat Internacional de Catalunya, C/Josep Trueta, s/n, 08197 Sant Cugat del Valles, Barcelona, Spain.E-mail: [email protected] (M. Llaquet).


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Introduction

The majority of traumatic injuries to young permanent teethoccur before root formation is complete.1 The most fre-quently affected teeth are the central and lateral maxillaryincisors, located in a highly aesthetic zone, with a 20—30%prevalence in young patients.2 Up to half of these trauma-tized teeth may result in pulpal necrosis, but only 8.5% willexhibit signs and symptoms of disease.3 If total destruction ofHertwig’s epithelial root sheath occurs, arrestment of normalroot development leads to divergent dentinal walls andabsence of the apical stop, which poses clinical challengesfor conventional root canal treatment.

The apexification technique with calcium hydroxide, andmore recently with MTA-like materials, has traditionally beenthe clinician’s first choice. Although this technique has a highsuccess rate regarding periapical healing, it does not allowthe root to growth nor in both length and or width orthickness, leaving the tooth with short roots, and with thinwalls that are prone to fracture.4

Regenerative endodontic procedures (REP) were proposedto overcome the drawbacks related to the clinical manage-ment of necrotic immature permanent teeth (NIPT)5 and aregaining prominence over traditional apexification amongresearchers and clinicians.

REP are described as ‘biologically based proceduresdesigned to replace damaged structures, including dentineand root structures, as well as cells of the pulp—dentinecomplex’.6

Different terminologies have been used for REP. At pre-sent, the term revascularization is broadly widely used in thecurrent literature, but many authors challenge its use. Initi-ally, Trope choose this term because the nature of the tissuethat formed after the treatment within into the root canalswas unpredictable, and the only certainty was the presenceof a blood supply.7

Wigler et al., in contrast, claimed that ‘proceduresdesigned to promote continued root development in NIPTshould be described as maturogenesis, rather than revascu-larization’, because it describes clinically and radiographi-cally the apical maturation in NIPT.8 In a letter to the editorof the Journal of Endodontics, Huang and Lin agreed thatrevascularization was more applicable to events followingdental trauma than to endodontic procedures. Moreover, theterm revascularization is imprecise because it only considersone aspect of the newly formed tissues.9

Iwaya et al. (2001)5 and Banks and Trope (2004)10 were thefirst to publish a REP case report (called revascularization) ona necrotic mandibular central incisor and on a necroticimmature permanent mandibular second premolar respec-tively. According to their reports, after provoking intracanalbleeding, the blood clots were covered with calcium hydro-xide and MTA respectively. The findings of both studiesshowed a thickening of the root canal walls and continuedroot development.5,10

All regenerative endodontic procedures are based on theresearch published by Nygaard Ostby (1961), which demon-strated that vasculature could be established to support new

PAROLE CHIAVEBiodentine;Denti permanentiimmaturi necrotici;Trattamento dirigenerazioneendodontica.

some advantages over that performed with MTA: No tooth discoloration, hort setting time, asymanipulation. CBCT is the best technique to evaluate root canal growth (length and wide).� 2017 Societa Italiana di Endodonzia. Production and hosting by Elsevier B.V. This is an openaccess article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Riassunto

Background: Il trauma di elementi dentari in via di sviluppo puo in alcuni casi esitare in necrosipulpare con successivo arresto della crescita radicolare e maggiore suscettibilita alle fratture.Tale procedura di rigenerazione endodontica induce la maturazione degli elementi al fine dipromuovere il proseguimento della crescita radicolare (maturogenesis). Nonostante la presenzadi potenziali svantaggi in termini di discolorazione, il mineral trioxide aggregate (MTA) vienecomunemente utilizzato come materiale a protezione del coagulo ematico. Biodentine e uncemento a base di tricalcio silicato con adeguate proprieta bio-attive capace di ovviare leproblematiche di discolorazione.Caso clinico: Il seguente caso studio dimostra lo sviluppo radicolare (maturogenesis) di unincisivo centrale superiore affetto da ascesso apicale cronico. Come medicazione intracanalaree stato usato l’idrossido di calcio per una settimana. A seguito della formazione del coaguloematico, e stato successivamente posizionato al di sopra Biodentine. Si e riscontrata evidenteguarigione e crescita radicolare a 6 mesi di osservazione. La tomografia computerizzata conebeam (CBCT) ha confermato la chiusura apicale e completa guarigione ad 1 anno.Punti chiave: La chiusura apicale di elementi dentari permanenti immaturi e necrotici e possibiletramite la procedura di rigenerazione endodontica. La procedura di rigenerazione endodonticaattraverso l’utilizzo di Biodentine ha mostrato alcuni vantaggi quando confrontata con l’MTA:assenza di discolorazione dentale, tempo di indurimento ridotto, facilita di utilizzo. La CBCTrappresenta la miglior tecnica per valutare la crescita del canale radicolare (in lunghezza elarghezza).� 2017 Societa Italiana di Endodonzia. Production and hosting by Elsevier B.V. This is an openaccess article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

66 M. Llaquet et al.

tissue growth in the empty root canal through the formationof a blood clot in the pulp space.11 According to this principle,the periapical area is intentionally damaged to promotebleeding and a fibrin clot, which begins healing after tissueinjury. Fibrin, a biopolymer secreted to promote haemostasisand wound healing, is responsible for blood clot formationand stabilization, which serves as a scaffold for stem cellsderiving from apical papilla (SCAP).12,13

SCAP provides a source of primary odontoblasts thatpromotes the continuation of root development and, as aresult of proximity to the periodontal blood supply, cansurvives pulp necrosis even in the presence of periradicularinfection.13

Research into the nature of the tissues developed insideempty root canals after REP has become the order of the day.Numerous histological and immunohistochemical studies arebroadly in agreement that tissues formed inside empty rootcanals after REP are mainly cement-like, bone-like and con-nective tissue.14

Recent studies have confirmed that these tissues becomereparative instead of regenerative after the death of theprimary odontoblasts.15 In fact, a fibrous non-mineralizedconnective tissue with varying degrees of inflammation anddystrophic calcifications has been observed inside rootcanals.16

These tissues have been observed to stain positively forbone sialoprotein (BSP) but negatively for dentine sialopro-tein (DSP), the latter being proteins that have a role indentinogenesis.16,17 Other investigations report the absenceof both polarized cells resembling odontoblasts or pulp-liketissue inside the canals after REP.18,19 Furthermore, collagenfibrils secreted by undifferentiated dental pulp stem cellsafter treatment did not resemble the dentine extracellularcollagen matrix.20 Some authors have concluded that con-tinued root development is mostly provided by cementumand poorly mineralized bone.16,17

On the other hand, studies in animals have identified theimmunohistological expression of vascular endothelialgrowth factors (VEGF) and factor VIII, the two main factorsimplicated in angiogenesis. These studies found newlyformed connective tissues, vessels and hard-mineralizedtissues.21 Research in this area continues.

Although there are no evidence-based guidelines to sup-port a standard protocol to achieve the most favourableoutcome in REP, a number of regenerative endodontic treat-ment protocols have been proposed depending on the type ofthe irrigant10; the irrigation method22; the intracanal dres-sing23; the type of scaffold24; and the blood clot-protectingmaterial.20

Mechanical instrumentation of the root canal is contra-indicated in REP due to the thin walls of teeth, which couldfurther increase the risk of root fracture.4 Therefore,disinfection of the root canal system depends solely onthe irrigant’s effectiveness. The most widely used disin-fection irrigant is sodium hypochlorite (NaOCl), in differentconcentrations, including 6%, 5.25%, 2.5%, 1.25% and0.5%.25

Furthermore, ethylenediaminetetraacetic acid (EDTA) hasbeen shown to promote the release of growth factorsembedded in dentine that participate in both the regenera-tive processes as well as stem cell proliferation, migration,and differentiation.26

Due to its extended residual antimicrobial properties,chlorhexidine has been successfully associated with NaOClas a disinfecting agent.27 Some authors have combined NaOClwith 3% hydrogen peroxide as a disinfection solution that hasprovided successful results.28

Periapical extrusion of NaOCl has cytotoxic effects andprovokes pain, localized, or widespread swelling and ecchy-mosis.29 In cases of an immature apex, special care should betaken to avoid irrigant extrusion. The negative-pressureirrigation technique may deliver the irrigants up to theworking length, avoiding extrusion to the periapical space.30

Regarding the intra-canal dressing, triple antibiotic paste(TAP) and calcium hydroxide are the most widely used med-icaments. According to the latest published review, TAP andits modifications were applied in 86% of studies, while cal-cium hydroxide was used in 13.5%.31 Some authors have usedformocresol as inter-appointment medicament, but it hasbeen demonstrated that formocresol causes minimumimprovement in root length and thickness.32

Although TAP has been shown to be more effective ineradicating bacteria,33 it has the potential for tooth disco-loration, which results from contact between minocyclineand the root canal walls during the REP.34 Exclusion ofminocycline (known as double antibiotic paste)5 or substitu-tion of minocycline by amoxicillin, doxycycline, clindamycin,tetracycline or cefaclor has been reported to solve thisproblem.31

Platelet-rich plasma (PRP), the most widely used bloodvenous derivatives, is a mass of autologous plasma with a highplatelet concentration, which is recommended as a scaffoldfor its abundance of growth factors (GFs).21

Some authors have used platelet-rich fibrin (PRF) as ascaffold with embedded growth factors. However, the resultshave shown only minor improvements in periapical healing,dentinal wall thickening, root lengthening and apical closure.35

A study in animals showed increased the success rate ofREP in cases in which modified TAP (Ciprofloxacin, Metroni-dazole and Cefixime) was used as an intracanal dressing andPRP as a scaffold instead of a blood clot.36

The main drawbacks to PRP and PRF are related to theneed for centrifugation, mainly to obtain PRP, and the needto collect venous blood from young patients.

During REP, a protective material is placed coronal to theblood clot to prevent recontamination and to induce differ-entiation of mesenchymal stem cells to produce new dentaltissues. There is one clinical study that reports successfulresults with the use of glass ionomer as a protective mate-rial.37 Different silicate calcium cements are more often usedto this end, such as Calcium-enriched mixture (CEM)cement38 and TheraCal LC.20

To date, MTA has been the material of choice for vital pulpcapping and REP procedures due to the survivability ofundifferentiated dental pulp stem cells (DPSC) after theirexposure to MTA, which has the capacity to form new hardtissues.39

However, in addition to its ease of displacement within theclot during condensation, this material has other drawbacks,among them, long setting time, difficult handling20 andpotential tooth discoloration.40 Because anterior teeth aremore susceptible to trauma, it is important for aestheticreasons to use calcium silicate materials that do not causetooth discoloration after REP.

Regenerative endodontic procedures 67

To avoid these shortcomings, a number of different materi-als have been developed, such as Biodentine (Septodont, SaintMaurdes-Fosses, France),20 which is a calcium-silicate mate-rial that sets in approximately 12 min, does not wash out easily,is simple to handle41 and does not cause discoloration.40

Accordingly, in the present case report, the authorsdescribed a regenerative endodontic procedure (REP) totreat an upper central incisor with a chronic apical abscess.

Report

An 8-year-old boy suffered a trauma to the upper left centralincisor tooth, but he did not receive any treatment for it untilone year later, when he came to the Department of Endo-dontics (Universitat Internacional de Catalunya) complainingof a sinus tract. On clinical examination, the tooth was nottender to percussion or palpation. Diagnosis was completedwith radiographic examination, which showed a large peri-apical lesion in both the periapical radiograph and the conebeam computed tomography (CBCT) scan (Fig. 1).

After obtaining written informed consent from thepatient’s parents, we began the treatment. Following rubberdam isolation, the pulp cavity was accessed and the workinglength was determined using a K-type file (Dentsply Maillefer,Baillagues, Switzerland) 1 mm shorter than the root apex.Without instrumentation, the tooth was irrigated with 30 mlof 5.25% NaOCl with the aid of the Endovac system (Sybro-nEndo, Orange, CA). The canal then was irrigated with 10 mLof sterile saline and dried with sterile paper points. Subse-quently, creamy calcium hydroxide was delivered into the

canal with a lentulo spiral instrument and the tooth wastemporized with Cavit G (3M ESPE, St Paul, USA) for 1 week(Fig. 2).

By the following appointment after 1 week the sinus tracthad healed. The patient was administered a local infiltrationof Mepivacaine 3% without epinephrine. The pulp space wasflushed with 10 ml sterile saline to eliminate calcium hydro-xide and finally irrigated with 1 mL 17% EDTA for 60 s. Theroot canal was dried with paper points and a sterile #30 K-filewas used to stimulate blood clot formation. Bleeding wasstopped at the level of the cementoenamel junction (CEJ)and a blood clot formed after 10 min. Subsequently, a 3 mm-Biodentine barrier was placed over the clot to seal the rootcanal at the CEJ level and was verified radiographically. Afterwaiting 12 min for the Biodentine to set, the definitiverestoration was performed (Fig. 2).

The patient returned for follow-ups at 4 weeks, 3 months,6 months and 1 year; examination included evaluation ofclinical signs and symptoms, root development, periapicalhealth and pulp vitality. At 2 years (Fig. 3), a CBCT scanrevealed increased root length and dentine wall thickness aswell as apical closure. Moreover, periapical radiolucency hadalmost completely disappeared. Sensibility test showed noresponse to either cold or electric pulp test. Finally, no signsof discoloration were observed.

Discussion

As discussed in the introduction to this article, the termrevascularization is debatable. Many authors claim that it

Figure 1 Initial radiographic and clinical examination. Periapical X-ray and CBCT showed open apex and large radiolucency.


should be used only for events related to dental trauma,considering the nature of tissues inside the root canal aftertreatment; therefore the current literature is replacing thisterm with maturogenesis.8

The basic principle of maturogenesis is found in continuedroot development and hard tissue deposition of immatureteeth reimplanted after traumatic or intentional avul-sion.42,43 Root canal maturogenesis is based on inducing ablood clot in the canal space by mechanically irritating theperiapical tissues, which promotes mesenchymal stem cellswithin the root canal, which differentiate in order to stimu-late root development.12 Regardless of the type of tissuegrowth, REP promotes greater root development than con-ventional apexification methods do.44

Due to potential detrimental effects on stem cell survival,there is no consensus whether maximum NaOCl concentra-tion should be used.45 On the one hand, it has been reportedthat dentine conditioning with high concentrations of NaOClresulted in lower survival rates of stem cells from apicalpapilla (SCAP). On the other hand, this effect can be reversedwith the application of 17% EDTA after the use of NaOCl.25 Forthis reason, 5.25% NaOCl was used, in accordance with

Trevino, who observed a 74% survival rate of human stemcells exposed to 6% NaOCl, followed by 17% EDTA.46 Con-sidering the immature apex of the tooth, irrigants wereflushed using the Endovac system to avoid irrigant extrusionthrough the apex.

There is no agreement about the use of inter-appointmentmedicaments. In one study, 90% of the cases that wereadministered TAP showed complete radiographic healing at12 months follow-up,47 although a more recent REP outcomestudy, in which calcium hydroxide was used, revealed theresolution of periapical disease in all cases except one(94.2%).48 On the basis of these results, and in order to avoidtooth discoloration, we used calcium hydroxide as an inter-appointment medicament, as supported by the literature.8

The sealing properties and excellent biocompatibility ofMTA makes it the material of choice for clot protection.39

However, because anterior teeth are more susceptible totrauma, MTA, which may causes tooth discoloration,49 is notthe most indicated material for this type of tooth. Other MTA-like materials (or calcium silicate based materials) could beused for that purpose. Biodentine is a relatively new calciumsilicate cement commercialized as a dentine substitute that

Figure 2 Clinical images of the first appointment: access cavity and work length establishment, and of the second appointment: rootcanal irrigation with EDTA 17% using Endovac system, blood clot formation and Biodentine placement.


could be used for all MTA indications. Its advantages include:no tooth discoloration, easy handling,40 fast setting time(12 min) and promotion of bone regeneration, as confirmedby recent cell culture studies.50,51

Predictors of a clinically successful REP include lack ofsigns and symptoms of disease, such as pain, swelling, sinustract, radiographic evidence of periapical healing, as well asincreased root length and canal wall thickness, indicatingcontinued root development,47,48,52 and many authorsinclude positive response to sensitivity testing.44,47 The sur-vival of a permanent tooth is particularly important in youngpatients undergoing continued cranioskeletal developmentbecause implants are contraindicated at this stage.

Unhealed periapical lesions (sinus tract or swelling recur-rence, root resorption and larger or unchanged periapicallesion), fractures, and failure to induce periapical bleedingare the main causes associated with failures after RET.53

There is a discrepancy between the view of the patientand the clinician as to what a successful outcome is: for thepatient it is one that prolongs the functional life of anasymptomatic tooth without discoloration. However, noprognostic study considers tooth discoloration as a clinicalfailure after REP.

In two retrospective analyses, REPs showed a highertendency than apexification in eliminating apical lesionsmore rapidly. Nevertheless, in terms of radiographic healing,no statistical differences were identified between the twotechniques.47,48 Alobaid et al. observed a complete resolu-tion of the radiographic lesions in 90% of the cases at one yearREP. The remaining cases still showed radiographic evidenceof disease but were clinical symptom-free.47 According to

these results, Nagy et al. found that both MTA apexificationand REP promoted healing in 100% and 90% of the casesrespectively.54 Kahler et al. obtained similar results with90.3% complete healing of periapical radiolucencies.55

Teeth with preoperative apical diameters wider than1 mm have been reported to show a greater increase in rootthickness, length, and apical narrowing. Moreover, patientsyounger than 13 years old show a notable decrease in rootapical diameter.52

From all the treatment modalities described for the man-agement of NIPT, including conventional root canal treat-ment, MTA or calcium hydroxide apexification and REP,Jeeruphan et al.44 found that the percentage changes in rootthickness and length were significantly greater in teethtreated with REP (28.2% and 14.9%) than with those treatedwith MTA apexification (0% and 6.1%) and calcium hydroxideapexification (1.5% and 0.4%). The survival rate was signifi-cantly higher in both the REP group and the MTA apexificationgroup (100% and 95.5%) when compared to the calciumhydroxide apexification group (77.2%).44

Chen et al. reported that 96% of the cases treated bymeans of REP presented some degree of apexogenesis. Inaddition, 76.2% and 79.2% of the cases, showed increasedroot length and thickness, respectively, and 55.4% of thesample exhibited complete apical closure.56 Similarly, Saoudet al. found complete apical closure in 55% of REP treatedteeth, with all cases confirming at least a 20% decrease inapical diameter.57 Kahler et al. concluded that apical closureafter treatment in 47.2% of the cases was incomplete, com-pared to 19.4% cases of complete. In addition, increasein root length varied from 2.7% to 25.3% and root dentin

Figure 3 Two-years clinical and radiographic (CBCT) follow-up: an increase of root length and root canal thickness can be observed,as well as almost complete resolution of the periapical lesion.


thickness, from 1.9% to 72.6%.55 Accordingly, Nagy et al.observed an increase in root length and thickness of 11.8%and 12.7%, respectively, whereas no changes were detectedin the MTA apexification group.54 In the present case, a CBCTscan taken of the patient for orthodontic reasons showedincreased root length and thickness and complete apicalclosure at 2-year follow-up.

Regarding pulp vitality, Chen et al. established that half ofthe sample responded to sensitivity tests (cold, heat, andelectrical).48 In contrast, Saoud et al. found that none of theteeth regained responsiveness to pulpal sensitivity testsduring the follow up period.57 Similarly, in the present case,the patient responded to neither cold nor electric pulp test,and no signs of discoloration were observed.

In spite of these findings, there is a need for long-termprognostic studies with larger samples in order to evaluatethe prognosis of REP versus apexification.

Conclusion

The 2-year follow-up showed apical closure of an immaturecentral incisor after REP with Biodentine.

Conflict of interest

The authors have no conflict of interest to declare.

Acknowledgment

The authors wish to thank Mark Lodge for his linguisticassistance.

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42. Cvek M, Cleaton-Jones P, Austin J, Lownie J, Kling M, Fatti P. Pulprevascularization in reimplanted immature monkey incisors-pre-dictability and the effect of antibiotic systemic prophylaxis.Endod Dent Traumatol 1990;6(4):157—69.

43. Kling M, Cvek M, Mejare I. Rate and predictability of pulprevascularization in therapeutically reimplanted permanentincisors. Endod Dent Traumatol 1986;2(3):83—9.

44. Jeeruphan T, Jantarat J, Yanpiset K, Suwannapan L, KhewsawaiP, Hargreaves KM. Clinical research: Mahidol study 1: comparisonof radiographic and survival outcomes of immature teeth treatedwith either regenerative endodontic or apexification methods: aretrospective study. J Endod 2012;38:1330—6.

45. Essner MD, Javed A, Eleazer PD. Effect of sodium hypochlorite onhuman pulp cells: an in vitro study. Oral Surg Oral Med OralPathol Oral Radiol Endod 2011;112(5):662—6.

46. Trevino EG, Patwardhan AN, Henry MA, Perry G, Dybdal-Har-greaves N, Hargreaves KM, et al. Basic research: effect ofirrigants on the survival of human stem cells of the apical papillain a platelet-rich plasma scaffold in human root tips. J Endod2011;37:1109—15.

47. Alobaid AS, Cortes LM, Lo J, Nguyen TT, Albert J, Abu-Melha AS,et al. Radiographic and clinical outcomes of the treatment ofimmature permanent teeth by revascularization or apexifica-tion: a pilot retrospective cohort study. J Endod 2014;40(8):1063—70.

48. Chen SJ, Chen LP. Radiographic outcome of necrotic immatureteeth treated with two endodontic techniques: a retrospectiveanalysis. Biomed J 2016;39(5):366—71.

49. Belobrov I, Parashos P. Treatment of tooth discoloration after theuse of white mineral trioxide aggregate. J Endod 2011;37(7):1017—20.

50. Zanini M, Sautier JM, Berdal A, Simon S. Basic research: bioden-tine induces immortalized murine pulp cell differentiation intoodontoblast-like cells and stimulates biomineralization. J Endod2012;38:1220—6.

51. Laurent P, Camps J, About I. Biodentine TM induces TGF-b1release from human pulp cells and early dental pulp mineraliza-tion. Int Endod J 2012;45(5):439—48.

52. Estefan BS, El Batouty KM, Nagy MM, Diogenes A. Influence of ageand apical diameter on the success of endodontic regenerationprocedures. J Endod 2016;42(11):1620—5.

53. Nagata JY, Soares AJ, Souza-Filho FJ, Zaia AA, Ferraz CC,Almeida JF, et al. Microbial evaluation of traumatized teethtreated with triple antibiotic paste or calcium hydroxide with 2%chlorhexidine gel in pulp revascularization. J Endod 2014;40(6):778—83.

54. Nagy MM, Tawfik HE, Hashem AA, Abu-Seida AM. Regenerativepotential of immature permanent teeth with necrotic pulpsafter different regenerative protocols. J Endod 2014;40(2):192—8.

55. Kahler B, Mistry S, Moule A, Ringsmuth AK, Case P, Thomson A,et al. Revascularization outcomes: a prospective analysis of 16consecutive cases. J Endod 2014;40(3):333—8.

56. Yu-Po C, del Mar Jovani-Sancho M, Sheth CC, Chen Y-P, Jovani-Sancho MDM. Is revascularization of immature permanent teethan effective and reproducible technique? Dental Traumatol2015;31(6):429—36. 8pp..

57. Saoud TM, Zaazou A, Nabil A, Moussa S, Lin LM, Gibbs JL. Clinicaland radiographic outcomes of traumatized immature permanentnecrotic teeth after revascularization/revitalization therapy. JEndod 2014;40(12):1946—52.


ORIGINAL ARTICLE/ARTICOLO ORIGINALE

Bulk vs wedge shape layering techniques in Vclass cavities: marginal infiltrationevaluation

Stratificazione a massa unica vs stratificazione obliqua in cavita’ di V classe:valutazione dell’infiltrazione marginale

Lo Giudice Roberto a,*, Puleio Francesco b, Verrusio Carmine c,Matarese Marco b, Alibrandi Angela d, Lizio Angelo a,b,c,d

aDepartment of Clinical and Experimental Medicine, Messina University, ItalybDepartment of Biomedical and Dental Sciences and Morphofunctional Imaging, Messina University, ItalycDepartment of Neurosciences, Reproductive and Odontostomatological Sciences, Naples ‘‘Federico II’’University, ItalydDepartment of Economics, Statistics, Mathematics and Sociology, Messina University, Italy

Received 28 February 2017; accepted 16 July 2017Available online 18 August 2017


KEYWORDSV class cavities;Microleakage;Stratification technique;Bulk filling;Wedge-shape layering.

Abstract

Objective: The aim of this in vitro research was to assess if the different stratification techniquescould influence the marginal gap in V class restoration.Material and methods: Standard 6 � 4 � 4 mm class V cavities were prepared on the buccal sideof 24 extracted sound human premolars. Specimens were randomly divided in two groups: (A)Bulk filling technique; (B) Wedge-shape layering technique. The interfacial sealing ability of thestratification techniques was evaluated by scoring the 7% methylene blue penetration depththrough optical microscope observations. The infiltration assessment was performed with aprogressive score. Differences in infiltration scores recorded for the tested techniques wereevaluated for statistical significance (Mann—Whitney U test, p < 0.05).


* Corresponding author at: Department of Clinical and Experimental Medicine, Messina University, AOU Policlinico ‘‘G. Martino’’ Via C. Valeria,98100 Messina, Italy. Tel.: +39 3934399197.

E-mail: [email protected] (L.G. Roberto).


ScienceDirect



Introduction

An optimal conservative restoration requires a pre-operativechoice, regarding techniques and materials to be adoptedand considering the interaction between materials and theirown limits.1 The ‘‘ideal’’ material, that should have all thebiomechanical characteristics necessary to replace compro-mised dental tissues, does not exist.

Many aspects should be considered: chemical-physicalproperties of the material, necessity of anatomical andfunctional interconnection between restorative materialand biological dental structures, aesthetic integration andnatural appearance. Especially in cases of difficult adhesionachievement, the choice of a correct treatment plan hasparticular importance, directly involving the long-termresults of the restoration.2

The composites polymerization reaction involves a mono-mer molecules conversion into a polymer network and theformation of shorter covalent bindings. This reaction, influ-enced by the internal flowability of the material and thepolymerization speed, can be considered the main resinslimit because of the stress at the interface due to thepolymerization shrinkage.3

The most important challenge in adhesive dentistry islowering the polymerization shrinkage. The research, duringthe last 15 years, has been focused on creating high perfor-mance adhesive systems and low-shrinking material. How-ever most of the composites on the market show a volume

shrinkage values in the range of 2—3% and this determinesstress at the interface tooth/restoration that could inducegap and marginal micro-leakage formation.2—4

The penetration of acids, enzymes, ions, bacteria andtheir products within the margins of the restoration could beresponsible of marginal discoloration, post-operative sensi-tivity, secondary caries and pulp damage and are all linked tothe micro-leakage.5—7 The micro-gap dimension is observedbetween 5 and 20 mm and, being one of the most importantfactors in the long-term evaluation of the restoration, is themost predictive parameter for its survival.3

The inter-relation between resinous materials, adhesivesystems and cavity walls have to be considered when planningthe therapeutic strategy in order to reach the best perfor-mance.8,9 To choose the proper type of resin, an evaluationregarding its composition should be done considering theratio between the organic and the inorganic fraction.10 Anincreased filler percentage should determine a lower shrink-age, but reduces the sliding ability of the composite, causinga plastic deformation reduction at the free surface levelduring the reaction of polymerization.11—13 Composite resinshigh in inorganic volume could not achieve a proper dissipa-tion of the shrinkage stress while wear resistance isincreased.14—16

The nano-filled resins are characterized by low shrinkagedue to the presence of pre-polymerized particles of micro-filled composite (nano-cluster), reinserted within thematrix.16 To lower the polymerization shrinkage stress, many

PAROLE CHIAVECavita di V classe;Micro-infiltrazionemarginale;Tecniche distratificazione;Massa unica;Stratificazione obliqua.

Results: The A group showed a mean score of 1.166 � 1.114, registering the higher score of 3; theB group the mean score was 0.666 � 0.778, and a higher score of 2. The two tails Mann—Whitneyanalysis showed a 0.270 non-significant result.Conclusion: Considering the limitation related to the technique used for the infiltration analysisin small V class cavities, the infiltration score is not influenced by the different stratificationtechniques.� 2017 Societa Italiana di Endodonzia. Production and hosting by Elsevier B.V. This is an openaccess article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Riassunto

Obiettivi: lo scopo di questa ricerca in vitro e quello di valutare se differenti tecniche distratificazione possano influenzare il gap marginale in cavita di V classeMateriali e metodi: cavita standard di V classe di 6x4x4 mm sono state preparate sul versantevestibolare di 24 premolari umani integri. I campioni sono stati casualmente divisi in due gruppi:A) tecnica di stratificazione a massa unica; B) tecnica di stratificazione obliqua. La capacita disigillo, nella zona di interfaccia, delle differenti tecniche di stratificazione e stata valutata,tramite osservazione al microscopio ottico, assegnando un punteggio all’infiltrazione di unasoluzione di blu di metilene al 7%. La valutazione dell’infiltrazione e stata effettuata mediante unpunteggio progressivo (Osorio et al.) Le differenze nei punteggi di infiltrazione riferiti alle diversetecniche, sono stati valutati per la significativita statistica (test di Mann-Whitney U, p < 0.05)Risultati: il gruppo A ha mostrato un punteggio medio di 1.166 � 1.114, registrando un punteggiomassimo di 3; il gruppo B ha mostrato un punteggio medio di 0.666 � 0.778, ed un punteggiomassimo di 2. L’analisi a due code di Mann-Whitney ha mostrato un risultato non significativo di0.270.Conclusioni: considerando le limitazioni correlate alla tecnica di valutazione della microinfil-trazione usata, in piccole cavita di V classe il punteggio di infiltrazione non e influenzato dalledifferenti tecniche di stratificazione.� 2017 Societa Italiana di Endodonzia. Production and hosting by Elsevier B.V. Cet article estpublie en Open Access sous licence CC BY-NC-ND (http://creativecommons.org/licenses/by-nc-nd/4.0/)

74 L.G. Roberto et al.

techniques could be performed such as layering and incre-mental curing, even if these techniques cannot eliminate thestress completely.17 Scientific evidences have underlinedthat the composite stratification techniques lower the con-traction stress during the composite polimerization.17—19

Different stratification techniques are used, such as:� Bulk filling technique� Gingival-occlusal layering, used for small cavities� Wedge-shape layering, used to prevent the cavities walldeformation.

The aim of this in vitro study was to determine if differentstratification techniques could affect the marginal gap insmall V class restorations.

Materials and methods

Sample preparation

In the present study 24 caries-free premolar teeth, extractedfor periodontal reasons were used. After the extraction,samples were cleaned and stored for a period that was lessthan 3 months in physiologic solution at room temperature.On the buccal surface of the samples class V cavities withdimensions of 6 � 4 � 4 mm were performed. Variations of�1 mm were considered acceptable. The 4 mm depth waschosen to assure that the cavities could be filled and cured intoto. Cavities gingival margins are placed about 1.5 mmocclusally from the cement-enamel junction (Fig. 1).

The cavity preparation was carried out by a single opera-tor by using a disposable pear shape diamond bur (012

Summit Dentsply ADD manufacturer’s details) with a high-speed hand-piece under water cooling. Cavity margins wererefined with an Arkansas bur using low-speed hand-pieceunder water cooling (Shofu Dura — White-Stone Fg 025,ADD manufacturer’s details).

Restorative protocol

All the samples were subjected to the same restorativeprotocol as follows:

35% phosphoric acid was applied to the enamel margins for1500, and then rinsed with air/water spray for 1500, then,Scotch Bond XT (3M-ESPE, St. Paul, MN, USA) was appliedon enamel and dentin following manufacturer’s instructions.

The composite used in this study to restore the class Vcavities, (Filtek Supreme 3M-ESPE St. Paul, MN, USA) is basedon aromatic and aliphatic traditional dimethacrylates.

The 24 teeth were randomly divided into two groups inrelation to the different stratification technique used:- Group A: 12 samples restored using bulk filling technique.- Group B: 12 samples wedge-shape layering technique.

The polymerization of the adhesives and composites wascarried on with LED lamp (LED Anthos T, ADD manufacturer’sdeteails).

Experimental procedure

After 1 week of water storage at 37 8C, the teeth weresubmitted to a thermo-cycling (500 cycles of 2000, 5—55 8C). Subsequently the root apexes of the samples weresealed with epoxy resin and the outer surface was isolatedwith varnish. The restoration had a margin of about 1 mmaround not isolated area.

After being stored in a dry environment for 24 h, teethwere immersed in the methylene blue 7% solution at roomtemperature for 3 days. Then the samples were rinsed andsectioned longitudinally at the middle of the restoration(Fig. 2).

For the evaluation of infiltration depth, an optical micro-scope (OPMI PRO ERGO S7B ZEISS) with 12.5� magnificationwas used.20,21

Sample analysis

The marginal infiltration score was assessed using the systemproposed by Osorio et al.,22 that, evaluating, under magni-fication the dye penetration in the cavity walls, assign toeach sample a score as follows:0: No infiltration1: Infiltration does not cross the centre of the interested wall

cavity2: Infiltration crosses the centre of the interested wall cavity3: Axial infiltration4: Axial infiltration reaches surrounding dentinal tubules.

This evaluation was carried out separately by two differ-ent operators. In case of disagreement, the highest score wasassigned for statistical analysis.22,23

The numerical data are expressed as mean and standarddeviations (SD) and median. Statistical analyses were per-formed using SPSS 17.0 for Window package. The non-para-metric Mann Whitney test was used in order to compare

Figure 1 Cavity scheme (Width � Height � Dept).V class, 6 � 4 � 4 buccal cavity.

Bulk vs wedge shape layering techniques in V class cavities 75

groups A and B and p < 0.05 was considered to be statisticallysignificant.

Results

The statistical analysis shows for the 12 samples of the V classrestored using the bulk filling technique a mean score of1.166 with a SD of �1.114, a median value of 1 and an higherscore of 3.

For the 12 samples of V class cavities restored using thewedge-shape layering technique, the mean score is 0.666with a SD of �0.778, a median value of 0.5 and the higherscore of 2.

The Mann—Whitney test showed a non-significant differ-ence between the groups ( p = 0.270).

Discussion

A consequence of polymerization reaction of compositematerials is a volumetric shrinkage of 2—3%.2,4,24 This con-traction is transferred to the dental tissues manifesting as astress that could cause deformation, gap between resin andcavity walls, micro-crack formation, infiltration of intraoralfluids and a consequent post-operative sensitivity.25

The layering technique in direct restorations is widelyrecognized as an important factor to determine a bettermarginal adaptation and to reduce the stresses generatedby the polymerization shrinkage.17 Different layering tech-niques have been proposed for direct restoration of class Vcavities,26—28 however the most effective restorative tech-nique to reduce stress is still unknown.

The bulk stratification let operator realize a one-timerestoration, useful when treating complex clinical case orwhen a shortening of the operating time is needed, especiallyconsidering that the adhesion characteristics could minimizeits disadvantages.29—31

Several authors suggest the use of an incremental layeringtechnique rather than a bulk filling technique, in order toreduce polymerization stress. This procedure should ensureminimal infiltration, especially when the restoration marginlies near or beyond CEJ.24,32,33

From the statistical analysis of the infiltration scoresobtained in the present study, it is evident how the valuesof the bulk technique are double in score compared to thelayering technique’s one, but showing a lack of statisticalsignificance. This aspect could be linked to the high standarddeviation registered that could be related to limitation of theinvestigation protocol used to assess the leakage.

However, this data could be related to the V class cavitiesdimension. In such a small cavity the polymerization stressesand the composite contraction are greatly thwarted by a24.2 � 3.4 MPa bonding strength on dentine and 26.5 � 4.9on enamel that overcome this mechanical issue (shear bondstrength and physicochemical).34

These results agree with other studies that have shownthat in small class V cavities a direct restoration with bulktechnique does not cause a significant increase in the amountof microleakage.35 Sensi et al.36 did not observed significantdifferences in the treatment of V classes using occlusallayering or bulk technique.

Moreover, the results have shown that, regardless of thetechniques used, the bond between the dentine and the resinwas able to withstand the stress generated by the polymer-ization shrinkage leading to low level of micro-leakage evenin difficult cases.4,23,37

The self-etch adhesive approach, was chosen, thanks toless operative steps resulting in a lower incidence of possibletechnical mistakes.22,23,38 However, the literature under-lined how an enamel insufficient adhesion potential maylead to an insufficient quality of the marginal restorationcausing marginal infiltration and inflammatory reac-tion.23,27,32,39 To overcome this minus, a selective enamelpre-etching should be performed and, as evident in an invitro study, the bonding force became greatly increased.23

Figure 2 Specimen sample: The arrows indicate the bluecolorant solution infiltrationCe.W. = cervical wall, A.W. = axial wall, Co.W. = coronal wall.

76 L.G. Roberto et al.

Conclusion

In small V class cavities, the marginal infiltration scoreanalysis, carried out by the system proposed by Osorio, usedto evaluate the restorative techniques, bulk or wedge-shape,shows that these two did not statistically influence themarginal infiltration score and the presence of detectablemarginal gap. This results may be linked to the infiltrationanalysis technique used that obtain a high standard deviationvalues and so a lack of statistical significance.


The authors deny any conflict of interest.

References

1. Ferracane JL. Status of research on new fillers and new resins fordental composites. In: Dent 3th Int Symp Kurary; Adv Adhes.1999. p. 3—29.

2. Baratieri LN, Camabarro S, Lopes GC. Effect of resin viscosity andexamination beveling on the clinical performance of Class V Com-posite Restorations: three-year results. Oper Dent 2003;28:482—7.

3. Van Ende A, De Munck J, Mine A, Lambrechts P, Van Meerbeek B.Does a low-shrinking composite induce less stress at the adhesiveinterface? Dent Mater 2010;26(3):215—22.

4. Lo Giudice G, Cicciu M, Cervino G, Lizio A, Visco A. Flowable resinand marginal gap on tooth third medial cavity involving enameland radicular cementum: a SEM evaluation of two restorationtechniques. Indian J Dent Res 2012;23(6):763—9.

5. Davidson CL, de Gee AJ. Relaxation of polymerization contractionstresses by flow in dental composites. J Dent Res 1984;63(2):146—8.

6. Brannstrom M. Dentin and pulp in restorative dentistry. MedicalLondon Wolfe Publishing Ltd.; 1982.

7. Marco S, Rullo R, Albino A, Masullo M, De Vendittis E, Amato M.The thioredoxin system in the dental caries pathogen Strepto-coccus mutans and the food-industry bacterium Streptococcusthermophilus. Biochimie 2013;95(11):2145—56.

8. Mohammadi Z, Giardino L, Palazzi F, Shalavi S, Alikhani MY, LoGiudice G, et al. Effect of sodium hypochlorite on the substan-tivity of chlorhexidine. Int J Clin Dent 2013;6(2):173—8.

9. Lo Giudice G, Cutroneo G, Centofanti A, Artemisia A, Bramanti E,Militi A, et al. Dentin morphology of root canal surface: aquantitative evaluation based on a scanning electronic micro-scopy study. BioMed Res Int 2015;2015.

10. Guggenberger R, Weinmann W. Exploring beyond methacrylates.Am J Dent 2000;13(5 SPEC. ISS.):82D—4D.

11. Kidd EAM. Microleakage: a review. J Dent 1976;4(5):199—206.12. Giachetti L, Bertini F. A review of current techniques placation

for posterior direct resin. Restor G It Cons 2006;IV(October/December (4)):241—8.

13. Feilzer AJ, De Gee AJ, Davidson CL. Quantitative determinationof stress reduction by flow in composite restorations. Dent Mater1990;6(3):167—71.

14. Feilzer AJ, de Gee AJ, Davidson CL. Setting stress in compositeresin in relation to configuration of the restoration. J Dent Res1987;66(11):1636—9.

15. Gladys S, Van Meerbeek B, Braem M, Lambrechts P, Vanherle G.Comparative physic-mechanical characterization of new hybridrestorative materials with conventional glass-ionomer and resincomposite restorative materials. J Dent Res 1997;76:883—94.

16. Miyazaki M, Hinoura K, Onose H, Moore BK. Effect of fillercontent of light-cured composites on bond strength to bovinedentine. J Dent 1991;19(5):301—3.

17. Relhan N, Ponnappa KC, Relhan A, Jain A, Gupta P. An in-vitrocomparison of micro leakage between two posterior composites

restored with different layering techniques using two differentLED modes. J Clin Diagn Res 2015;9(5):ZC78—81.

18. Lo Giudice G, Lipari F, Lizio A, Cervino G, Cicciu M. Toothfragment reattachment technique on a pluri traumatized tooth.J Conserv Dent 2012;15(1):80—3.

19. Hickel R, Manhart J. Longevity of restorations in posterior teethand reasons for failure. J Adhes Dent 2001;3(1):45—64.

20. Lo Giudice G, Lo Giudice R, Matarese G, Isola G, Cicciu M,Terranova A, et al. Evaluation of magnification systems inrestorative dentistry. An in-vitro study. Dent Cadmos2015;83(5):296—305.

21. Riccitiello F, Maddaloni G, D’Ambrosio C, Amato M, Rengo S,Simeone M. Operating microscope: diffusion and limits. G ItalEndod 2012;26(2):67—72.

22. Osorio R, Toledano M, de Leonardi G, Tay F. Microleakage andinterfacial morphology of self-etching adhesives in class V resincomposite restorations. J Biomed Mater Res Part B Appl Bioma-ter 2003;66:399—409.

23. Lo Giudice G, Lo Giudice R, Lizio AS, Pantaleo G, Lipari F,Simeone M, et al. Effects of pre-etching in class V cavitiesrestored with silorane and methacrylate-based composites. DentMed Probl 2016;53(3):365—72.

24. Lutz E, Krejci I, Oldenburg TR. Elimination of polymerization stres-ses at the margins of posterior composite resin restorations: a newrestorative technique. Quintessence Int 1986;17(12):777—84.

25. Ricciardi CA, Lacquaniti A, Cernaro V, Bruzzese A, Visconti L,Loddo S, et al. Salt-water imbalance and fluid overload inhemodialysis patients: a pivotal role of corin. Clin Exp Med2016;16(3):443—9.

26. Krejci I, Lutz F. Marginal adaptation of class V restorations usingdifferent restorative techniques. J Dent 1991;19(1):24—32.

27. Zidan O, Tsuchiya T. A comparative study of the effects ofdentinal bonding agents and application techniques on marginalgaps in class V cavities. J Dent Res 1987;66(3):716—21.

28. Blunck U, Roulet JF. In vitro marginal quality of dentin-bondedcomposite resins in Class V cavities. Quintessence Int1989;20(6):407—12.

29. Cicciu M, Risitano G, Lo Giudice G, Bramanti E. Periodontalhealth and caries prevalence evaluation in patients affectedby Parkinson’s disease. Parkinson’s Dis 2012;2012:541908.

30. Lo Giudice G, Lo Giudice A, Isola G, Fabiano F, Artemisia A,Fabiano V, et al. Evaluation of bond strength and detachmentinterface distribution of different bracket base designs. ActaMed Mediterr 2015;31(3):585—90.

31. Lo Giudice G, Nigrone V, Longo A, Cicciu M. Supernumerary andsupplemental teeth: case report. Eur J Paediatr Dent2008;9(2):97—101.

32. Lo Giudice G, Matarese G, Lizio A, Lo Giudice R, Tumedei M,Zizzari VL, et al. Invasive cervical resorption: a case series with 3-year follow-up. Int J Periodontics Restor Dent 2016;36(1):102—9.

33. Mullejans R, Lang H, Schuler N, Badawi MOF, Raab WHM. Incre-ment technique for extended Class V restorations: an experi-mental study. Oper Dent 2003;28(4):352—6.

34. Latta MA. Shear bond strength and physicochemical interactionsof XP bond. J Adhes Dent 2007;9:245—8.

35. Albers HF. Tooth colored restoratives — principles andtechniques, 9th Ed. Hamilton: BC Decker Inc.; 2002: 183—202.

36. Sensi LG, Marson FC, Baratieri LN, Junior SM. Effect of placementtechniques on the marginal adaptation of class V compositerestorations. J Contemp Dent Pract 2005;6(4):17—25.

37. Paduano S, Uomo R, Amato M, Riccitiello F, Simeone M, Valletta R.Cyst-like periapical lesion healing in an orthodontic patient: a casereport with five-year follow-up. G Ital Endod 2013;27:95—104.

38. Di Lorenzo P, Niola M, Buccelli C, Re D, Cortese A, Pantaleo G,et al. Professional responsibility in dentistry: analysis of aninterdepartmental case study. Dent Cadmos 2015;83:324—40.

39. Iandolo A, Iandolo G, Malvano M, Pantaleo G, Simeone M. Moderntechnologies in endodontics. G Ital Endod 2016;30:2—9.

Bulk vs wedge shape layering techniques in V class cavities 77


Evaluation of cyclic fatigue resistance ofmodern Nickel—Titanium rotary instrumentswith continuous rotation

Valutazione della resistenza alla fatica ciclica di strumenti rotanti a rotazionecontinua prodotti con moderne leghe Nickel-Titanio

Massimo Amato a,d, Giuseppe Pantaleo b,d, Dina Abdellatif c,d,Andrea Blasi b,d, Roberto Lo Giudice c,d, Alfredo Iandolo b,d,*

aDepartment of Medicine and Surgery, University of Salerno, Salerno, ItalybDepartment of Neurosciences, Reproductive and Odontostomatological Sciences, University of NaplesFederico II, Naples, ItalycUniversity of Alexandria, EgyptdMedical Sciences and Stomatology Department, School of Dentistry, University of Messina, Messina, Italy

Received 4 February 2017; accepted 6 September 2017Available online 28 September 2017


KEYWORDSCyclic fatigue;Nickel-Titanium;Continuous rotation;Rotary instruments.

Abstract

Aim: The aim of present study was to compare cyclic fatigue resistance of three modern Ni—Tiinstruments used with continuous rotation.Materials and methods: For this study 3 groups of rotating instruments with continuous rotation(HyFlex EDM, Twisted File Adaptive, Revo S SU) have been used, each group consisted of 20 files.The various groups were subjected to cyclic fatigue testing through an artificial metal device. Astatistical analysis with Kruskal—Wallis test and Mann—Whitney test was performed.Results: There were statistically significant differences between the three groups. The HyFlexEDM instruments have a fracture resistance slightly higher than the Twisted file and far higherthan Revo S SU.


* Corresponding author at: University of Naples Federico II, via S.Pansini 5, 80131 Naples, Italy.E-mail: [email protected] (A. Iandolo).


ScienceDirect

j ou rn al home pag e: www. el sev ie r. com/l oca te/ g i e


Introduction

The use of Ni-Ti represented a turning point in the history ofEndodontics, in fact it allowed the production of new endo-dontic instruments both manual and rotating with higherfeatures than stainless steel one, achieving more effectiveand reproducible results.1—3

Ni—Ti alloys used in dentistry have a fair atomic composi-tion of Ni and Ti, corresponding to 55% of Ni and 45% of Ti.4,5

In the past the only way to improve performance of Ni—Tiinstruments was to change their dimensions, tip, cross-sec-tional and flutes design.6,7 With the development of M-wireand Twisted File technology the instruments have beencommercialized aiming at improving safety.8 The movementkinematics is another important factor.9 Ni—Ti instrumentshave been traditionally used with a continuous motion,but in the last years a reciprocating movement has beenintroduced.10,11

Some authors demonstrated that the reciprocating motioncan extend cyclic fatigue resistance of Ni—Ti instrumentswhen compared to continuous rotation, but these are onlypreliminary results.12,13

Although the use of Ni—Ti alloy involves a series of advan-tages, the use of these rotating instruments in Endodonticsinvolves a possible and increased risk of fracture compared tosteel files use.14—16

Cyclic fatigue occurs when a metal is subjected torepeated cycles of tension and compression that causes itsstructure to break down, ultimately leading to fracture.17

Torsional fatigue is the twisting of a metal about its long-itudinal axis at one end, while the other end is in a fixedposition.18,19

The resistance to cyclic fatigue of Ni—Ti rotary instru-ments can be increased via improvements in the manufac-turing process or by the use of new alloys with superiormechanical properties.20,21 There have been many studies

on the cyclic resistance of different Ni—Ti rotary instrumentswith different designs or compositions.22—24

Therefore, the aim of this study was to compare cyclicfatigue resistance of new rotating files produced with mod-ified Ni—Ti alloys with rotating files produced with commonNi—Ti alloy.


Three Ni—Ti rotary instruments — HyFlex EDM (Coltene/Whaledent, Langenau, Germany), Twisted file Adaptive(Kerr, Orange, CA, USA), Revo S SU(Micro-Mega, BesanconCedex, France) — were selected for the cyclic resistancetest. Each group included 20 unused instruments, the sizeof instruments in Group 1 and 2 was 25/08 and 25/06 forGroup 3.

Group 1 was composed by HyFlex EDM Ni—Ti, instrumentswith complete new properties due to their innovative man-ufacturing process using electric discharge machining thatcreate unique surface of the new Ni—Ti files and makes theHyFlex EDM files stronger and more fracture resistant.25

Group 2 was composed by Twisted Files Adaptive, theseare formed by twisting a triangular blank in combinationwith heat treatment and special surface conditioning, whichconserves the natural grain structure.26 Group 3 was com-posed by Revo S SU, Ni—Ti instruments with asymmetricalcross-section that provides less stress on the instrument andmore flexibility.27

To evaluate the resistance to cyclic fatigue testing of allinstruments, a metal device has been created. The devicewas composed by a support base to which a rigid lockingsystem for the handpiece was connected. At the head of thehandpiece cubes with artificial canals have been set. Theentrance of the cubes artificial canal was set in axis with thetools inserted in the handpiece head (Fig. 1).

PAROLE CHIAVEFatica ciclica;Nickel-Titanio;Rotazione continua;Strumenti rotanti.

Conclusions: Modern Ni—Ti alloys increase resistance of the rotating instruments to cyclicfatigue.� 2017 Societa Italiana di Endodonzia. Production and hosting by Elsevier B.V. This is an openaccess article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Riassunto

Obiettivo: Lo scopo di questa ricerca e stato valutare la resistenza alla fatica ciclica di tredifferenti Files rotanti prodotti con nuove leghe Ni-Ti con movimento di rotazione continua.Materiali e Metodi: Per la verifica di questo studio sono stati utilizzati 3 gruppi di strumentirotanti a rotazione continua (HyFlex EDM, Twisted File Adaptive, Revo S SU), ogni gruppocomprendeva 20 files. I vari gruppi sono stati sottoposti a test di fatica ciclica attraverso undispositivo metallico artificiale. E’ stata effettuata una analisi statistica con test di Kruskal-Wallise test di Mann-Whitney.Risultati: Sono state rilevate differenze statisticamente significative tra i vari gruppi. Glistrumenti HyFlex EDM hanno mostrato una resistenza alla frattura leggermente superiore aiTwisted file e nettamente superiore ai Revo S Su.Conclusioni: Le moderne leghe Ni-Ti determinano una maggiore resistenza dello strumentorotante alla fatica ciclica.� 2017 Societa Italiana di Endodonzia. Production and hosting by Elsevier B.V. Cet article estpublie en Open Access sous licence CC BY-NC-ND (http://creativecommons.org/licenses/by-nc-nd/4.0/)

Cyclic fatigue resistance of modern nickel—titanium rotary instruments 79

The cubes were created through 3D printing (precision0.1 mm) with a material similar to dentin, to simulate con-ditions similar to a true root canal during the test. Theartificial canal had an angle of 908 and an arch of 5 mm(Fig. 2).

To avoid variables, for each instrument a new artificialcanal has been used. Each instrument was rotated within theartificial canal for a length of 13 mm.

The endodontic motor used was the Elements Motor(Sybron Endo) with Sybron Endo 8:1 contra-angle. Continuousrotation at 300 rpm has been used and the maximum torquedelivered by the device.

Each instrument was rotated until fracture occurrence,easily detectable because the device allowed the completevisibility of the working part of the instrument during thetest. The times from start of the rotation to the point offracture, were recorded using a digital stopwatch 1/1000 s.

Mean and standard deviation were calculated (Table 1).All data were recorded and subjected to statistical evalua-

tion with Kruskal—Wallis and Mann—Whitney tests. Statisticalsignificance was set at p < 0.05.

Results

Kruskall—Wallis test indicated significant differences amongthe tested instruments with p = <0.001. Mann—Whitney sig-nificance test was set at p < 0.05, it showed that HyFlex EDMhad a very similar fracture resistance but slightly above tothe Twisted File and higher than Revo S Su.

Discussion

In the literature, there is still a debate regarding the impactof torsional stress and metal fatigue on the fracturing of Ni—Ti rotary instruments.28 A number of studies have stated thatfatigue is the predominant mechanism in material fail-ure.29,30 Different types of rotary files exhibit differencesin resistance to fatigue failure due to differences in variousdeterminants such as their manufacturing process, structuralcharacteristics and geometric designs, surface texture.31—33

It has been clearly shown that multiple factors contributeto file separation, and cyclic fatigue is one of the leadingcauses. Fatigue failure usually occurs by the formation ofmicro crack at the surface of the file that starts from surfaceirregularities.34,35 During each loading cycle micro cracksdevelop, getting deeper in material, until complete separa-tion of the file.36

Gambarini et al.37 also concluded that instruments madeof M-wire alloy did not show higher resistance to fatigue whencompared to instruments produced by the traditional Ni—Ti.Further research is required regarding the different factorsinvolved in this matter.

All tested instruments fractured at the point of the max-imum flexure within the curved part of the artificial canalwhere the stress concentrates.

Recent literature show that reciprocating motion canextend cyclic fatigue life when compared to continuousrotation.12,13,38 However, the term reciprocating motionincludes several possible movements and angles, each ofwhich may influence performance and strength of the nickeltitanium instruments. All the reciprocating instruments havebeen commercialized with motors allowing a rotating reci-procation, but angles are not clearly disclosed by manufac-turers; however, all studies showed increased lifespan of theinstruments, mainly related to the reduction of instrumenta-tion stress by using a reciprocating motion.39,40 This reduc-tion of instrumentation stress is the main advantage ofreciprocating movements, even if it has been shown thata lot of different reciprocating movements can be used,each one affecting performance and safety of the Ni—Tiinstruments.41,42

Figure 1 Device created for the cyclic fatigue resistance testsof the rotary instruments.

Figure 2 The artificial canal had an angle of 908 and an arch of5 mm.

Table 1 Mean and standard deviation of tested Ni—Ti instru-ments expressed in milliseconds.

Mean � standard deviation

HyFlex EDM 93385,00 � 2088,635Twisted file 80020,00 � 3095,770Revo S Su 31935,00 � 2077,011

80 M. Amato et al.

In this study HyFlex EDM showed the best characteristics interms of cyclic fatigue resistance than Twisted Files and RevoS Su.

Finally it should be noted that in clinical conditions, rotaryfiles are used in a dynamic mode, endure torsional stressesand cyclic fatigue at the same time and are bind to the rootcanal walls; therefore, their fatigue resistance may be dif-ferent from the results of this study. Further research isrequired.

Conclusions

This study showed how modern Ni—Ti alloys increase resis-tance of the rotating instruments to cyclic fatigue. HyFlexEDM and Twisted Files showed the best characteristics. How-ever, further studies investigating the different factors whichcan affect the instruments cyclic fatigue resistance arenecessary.


The authors have no conflict of interest to declare.

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20. Riccitiello F, Stabile P, Amato M, Rengo S, D’Ambrosio C. Thetreatment of the large periradicular endodontic injury. MinervaStomatol 2011;60:417—26.

21. Iandolo A, Pantaleo G, Malvano M, Simeone M, Amato M. Non-surgical management of complex endodontic cases with severalperiapical lesions: a case series. G Ital Endod 2016;30:101—10.

22. Kaval ME, Capar ID, Ertas H. Evaluation of the cyclic fatigue andtorsional resistance of novel nickel—titanium rotary files withvarious alloy properties. J Endod 2016;42:1840—3.

23. Simeone M, Valletta A, Giudice A, Di Lorenzo P, Iandolo A. Theactivation of irrigation solutions in endodontics: a perfectedtechnique. G Ital Endod 2015;29:65—9.

24. Spagnuolo G, Desiderio C, Rivieccio V, Amato M, Rossetti DV,D’Anto V, et al. In vitro cellular detoxification of triethyleneglycol dimethacrylate by adduct formation with N-acetylcys-teine. G Dent Mater 2013;29:e153—60.

25. Pirani C, Iacono F, Generali L, Sassatelli P, Nucci C, Lusvarghi L,et al. HyFlex EDM: superficial features, metallurgical analysisand fatigue resistance of innovative electro discharge machinedNiTi rotary instruments. Int Endod J 2016;49:483—93.

26. Gambarini G, Grande NM, Plotino G, Somma F, Garala M, De LucaM, et al. Fatigue resistance of engine-driven rotary nickel—titanium instruments produced by new manufacturing methods.J Endod 2008;34:1003—5.

27. Basrani B, Roth K, Geoffrey S, Kishen A, Peters OA. Torsionalprofiles of new and used Revo-STM rotary instruments: an in vitrostudy. J Endod 2001;37:989—92.

28. Kiefner P, Ban M, De-Deus G. Is the reciprocating movement perse able to improve the cyclic fatigue resistance of instruments?Int Endod J 2014;47:430—6.

29. Di Lorenzo P, Niola M, Buccelli C, Re D, Cortese A, Pantaleo G,et al. Professional responsibility in dentistry: analysis of aninterdepartmental case study. Dent Cadm 2015;83:324—40.

30. Riccitiello F, Maddaloni G, D’Ambrosio C, Amato M, Rengo S,Simeone M. Operating microscope: diffusion and limits. G ItalEndod 2012;26:67—72.

31. Arslan H, Karatas E, Capar ID, Ozsu D, Doganay E. Effect ofProTaper Universal, Endoflare, Revo-S, HyFlex coronal flaringinstruments, and Gates Glidden drills on crack formation. JEndod 2014;40:1681—3.

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32. Amato M, Scaravilli MS, Farella M, Riccitiello F. Bleaching teethtreated endodontically: long-term evaluation of a case series. JEndod 2006;32:376—8.

33. Iacono F, Pirani C, Generali L, Bolelli G, Sassatelli P, Lusvarghi L,et al. Structural analysis of HyFlex EDM instruments. Int Endod J2017;50:303—13.

34. D’Anto V, Valletta R, Amato M, Schweikl H, Simeone M, PaduanoS, et al. Effect of nickel chloride on cell proliferation. Open DentJ 2012;6:177—81.

35. Peng C, Hui WU, Wang L, Xin HU, Deng S, Li C, et al. Cyclic fatigueresistance of two nickel—titanium instruments in different cur-ving angles: a comparative study. Braz Oral Res 2015;29:1—7.

36. Iandolo A, Ametrano G, Amato M, Rengo S, Simeone M. IG-File:un nuovo strumento per l’ottimizzazione della detersione cana-lare e per la misurazione del diametro apicale. G Ital Endod2011;25:72—81.

37. Gambarini G, Grande NM, Plotino G, Somma F, Garala M, DeLuca M, et al. Fatigue resistance of engine-driven rotary

nickel-titanium instruments produced by new manufacturingmethods. J Endod 2008;34:1003—5.

38. Sekar V, Kumar R, Nandini S, Ballal S, Velmurugan N. Assessmentof the role of cross section on fatigue resistance of rotary fileswhen used in reciprocation. Eur J Dent 2016;10:541—5.

39. Spagnuolo G, Ametrano G, D’Anto V, Rengo C, Simeone M,Riccitiello F, et al. Effect of autoclaving on the surfaces of TiN-coated and conventional nickel—titanium rotary instruments.Int Endod J 2012;45:1148—55.

40. Scolari G, Lazzarin F, Fornaseri C, Rengo S, Amato M, Cicciu D,et al. A comparison of nimesulide beta cyclodextrin and nimesu-lide in postoperative dental pain. Int J Clin Pract 1999;53:345—8.

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82 M. Amato et al.


Comparative analysis of root canal changesafter preparation with three systems usingCone-Beam Computed Tomography

Analisi comparativa alla CBCT delle modificazioni canalari dopo la preparazionecon tre diversi sistemi

Diane Oget a,c,d,1, Julien Braux b,c,d,1, Celine Compas a,c,d,Martine Guigand b,c,d,*

a Laboratoire d’analyse des contraintes mecaniques-dynamique et transfert aux interfaces, LACM-DTI EA4302LRC-CEA0534, Franceb EA 4691 Biomateriaux et inflammation en site osseux (BIOS), SFR CAP-Sante (FED 4231), Universite de Reims-Champagne-Ardenne, 1 avenue du Marechal Juin, 51095 Reims Cedex, FrancecUFR Odontologie, 2 rue du General Koenig, 51100 Reims, FrancedCHU de Reims, 47 rue Cognacq Jay, 51100 Reims, France

Received 20 March 2017; accepted 4 April 2017Available online 13 July 2017


KEYWORDSCone-Beam ComputedTomography;Canal curvature;Canal transportation;Revo-S1;HEROShaper1 andProTaper1.

Abstract

Introduction: The aim of this study was to investigate the morphological changes in the rootcanal trajectory on extracted teeth after preparation with Endoflare/Revo-S1, Endoflare/HeroShaper1 and ProTaper1 using Cone-Beam Computed Tomography (CBCT).Methods: 39 root canals with similar curvatures were divided into three homogeneous groups(n = 13). Root canals in Group 1 were shaped with Endoflare/Revo-S1; Group 2 with Endoflare/Hero Shaper1, and Group 3 with ProTaper1. All specimens were scanned pre- and postoperativelyusing the Kodak1 9000C 3D imaging system. Changes in both degree and position of the root canal


* Corresponding author at: EA 4691 Biomateriaux et inflammation en site osseux (BIOS), 1 avenue du Marechal Juin, 51095 Reims Cedex,France.

E-mail: [email protected] (M. Guigand).1 Those authors have contributed equally to this manuscript.


ScienceDirect



Introduction

Canal shaping is a critical aspect of endodontic treatment. Itinfluences the outcome of the subsequent phases of irriga-tion, root canal filling and therefore, the success of theendodontic treatment. Once the canal is shaped, it shouldhave a uniformly tapered funnel shape, increasing in dia-meter from the apical foramen to the coronal orifice. Thisshape enhances the efficiency of the irrigation and allows theplacement of an effective tooth filling.1

The development of Nickel—Titanium (Ni—Ti) rotaryinstrumentation has been a great technological advance.These instruments enable root canals to be shaped withfewer procedural errors.2,3 Procedural errors such as trans-portation and loss of working length were mainly associated

with the use of stainless-steel files, which had insufficientflexibility.4,5 Ni—Ti rotary instruments also work faster thusreducing operating time.2

A number of techniques are currently available to eval-uate canal transportation and centring ability of instrumentsduring root canal preparation. Micro-Computed Tomographyseems to be a promising tool for root canal anatomy studiesbut this technique is time-consuming and not indicated forchairside use. Recently, Cone-Beam Computed Tomography(CBCT) has become available for clinicians and many endo-dontic applications have been identified.6,7 The aim of thisstudy was to investigate the morphological changes in theroot canal trajectory after preparation with Endoflare/Revo-S1, Endoflare/HeroShaper1 and ProTaper1 usingCBCT.

PAROLE CHIAVETomografiacomputerizzata a fascioconico;Curvature canalare;Trasporto canalare;Revo-S1;HEROShaper1 andProTaper1.

curvature were assessed. Canal transportation was calculated for each slice by comparing theposition of the root canal centroid before and after instrumentation. Statistical analysis wascarried out by the non-parametric Kruskal—Wallis test ( p < 0.05), and Mann—Whitney testapplying the Bonferroni correction (p < 0.05).Results: The mean of curvature degree decreases significantly (p < 0.003) for each group, withno statistical differences between the three groups. Mean canal transportation scores rangedfrom 52 mm (Revo-S1) to 85 mm (ProTaper1) in the apical third; 51 mm (Revo-S1) to 87 mm(ProTaper1) in the middle third, and 77 mm (HEROShaper1) to 119 mm (ProTaper1) in thecervical third. In the apical and the middle parts, Revo-S1 produced statistically less transpor-tation than HEROShaper1 (respectively p = 0.01708, p = 0.01328) and ProTaper1 (respectivelyp = 0.02402, p = 0.0202).Conclusion: All instruments produced a small curvature deviation and mild canal transportation.Revo-S1 resulted in less transportation in the apical and middle thirds.� 2017 Societa Italiana di Endodonzia. Production and hosting by Elsevier B.V. This is an openaccess article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Riassunto

Obiettivi: Lo scopo di questo studio e stato quello di studiare le alterazioni morfologiche dellatraiettoria canalare su denti estratti dopo la preparazione con Endoflare/Revo-S1, Endoflare/HeroShaper1 e ProTaper1 utilizzando tomografia computerizzata a fascio conico (CBCT).Materiali e metodi: Metodi: 39 canali radicolari con curvature simili sono stati suddivisi in tregruppi omogenei (n = 13). I canali radicolari del gruppo 1 sono state sagomati con Endoflare/Revo-S1, quelli del gruppo 2 con Endoflare/Eroe Shaper1 e quelli del Gruppo 3 con ProTaper1.Tutti i campioni sono stati sottoposti a scansione CBCT prima e dopo la preparazione canalareutilizzando il sistema di imaging 3D Kodak1 9000C. Sono stati valutati sia i cambiamenti del gradoe della posizione della curvatura canalare che il trasporto del canale, confrontando la posizionedel canale radicolare centroide prima e dopo strumentazione. L’analisi statistica e stataeffettuata utilizzando il test non parametrico di Kruskal-Wallis (p < 0,05) e il test di Mann-Whitney applicando la correzione di Bonferroni (p < 0,05).Risultati: Il grado di curvatura e risultato diminuito significativamente in tutti i gruppi(p < 0,003), senza evidenziare pero differenze statisticamente significative tra i tre gruppi. Ivalori di trasporto canalare medio variavano da 52 mm (Revo-S1) a 85 mm (ProTaper1) nel terzoapicale, da 51 mm (Revo-S1) a 87 mm (ProTaper1) nel terzo medio e da 77 mm (HEROShaper1) a119 mm (ProTaper1) nel terzo cervicale. Nel terzo apicale e medio i Revo-S1 hanno determinatostatisticamente meno trasporto degli HEROShaper1 (rispettivamente p = 0,01708, P = 0,01328) edei ProTaper1 (rispettivamente p = 0,02402, P = 0,0202).Conclusioni: Tutti gli strumenti hanno prodotto una piccola modificazione della curvatura e unleggero trasporto canalare. Gli strumenti Revo S1 ha dimostrato un minor trasporto nei terziapicale e medio.� 2017 Societa Italiana di Endodonzia. Production and hosting by Elsevier B.V. Cet article estpublie en Open Access sous licence CC BY-NC-ND (http://creativecommons.org/licenses/by-nc-nd/4.0/)

84 D. Oget et al.


Thirty nine root canals with completely formed apices wereselected from a pool of teeth that have been extracted forperiodontal or orthodontic purposes (agreement DC-2014-2262). Teeth were stored in a 0.5% chloramines solution andaccess cavities were prepared by using round burs and Endo-Zburs (Maillefer Dentsply). Canal length and patency weredetermined with size 10 MMC files (Micro-Mega). Then, dis-tribution of samples was performed after the first imagingprior to instrumentation.

A cut from the 3D reconstruction in the main axis of thecurvature of the selected canal was identified. The degree ofcurvature was determined by a modified version of theBerbert and Nishiyama method (Fig. 1), initially describedfor a 2D image.8,9 The teeth were randomised into threehomogeneous groups. Each group was shaped with a Ni—Tirotary system: Revo-S1, HEROShaper1 and ProTaper1

according to the manufacturers’ guidelines.Group 1 was prepared using Endoflare1 for coronal flaring

and Revo-S1 up to SU (size 25, taper 6%).Group 2 was shaped using Endoflare1 for coronal flaring

and HeroShaper1 up to size 30 (taper 4%).Group 3 was prepared using SX1 for coronal flaring and

Protaper1 up to F2 (size 25, taper 8%).

For all groups irrigation with a 3% NaOCL solution wasperformed after each files passage (at least 32 ml). Then, a14% EDTA flush flow (2 ml for 1 min) was performed to removethe smear layer and was followed by a 3% NaOCL irrigationand a distilled water final rinse.

The 3D acquisitions were performed using Cone-BeamComputed Tomography in small fields, 3D 9000C (Kodak1,University Hospital of Rennes-France). For analysis, the teethwere subjected to two acquisitions: the first one was per-formed after the opening of the pulp chamber and the secondonce the procedure was completed. Precise repositioning ofpre- and post-preparation images was ensured by a custom-made mounting device. Acquisition parameters were, forcutting: 76 mm, 70 kV, 3.2 mA, 10.77, and, for exposure:69 mGy/cm2. The spatial resolution is 76 mm. During acquisi-tion, the CBCT imaging system data plate stores 4—5 teethsamples. The file was then divided into several files contain-ing a stack of slices corresponding to only one sample. Thisfile, in the TIFF format, can be opened and analysed withImageJ1 software (http://imagej.nih.gov/ij/). This pro-gram provides opportunities for analysis and many importantfunctions.

Trajectory analysis: degree and position ofcurvature

On a cut provided from the data obtained using a 3D recon-struction, the degree and position of curvature were calcu-lated using the modified Berbert and Nishiyama technique.8

From the tangent to the pulp floor, point A is placed at thecentre of the canal entrance and point A’ is placed about1 mm from A on the path of the canal. These two points forma straight line. Then point B is placed at the apical foramenand point B’ about 1 mm from B on the path of the canal.These last two points form a second straight line. These twolines intersect at point C, and a ratio of the distances AC/CBrepresent the coefficient of the position of the curvature.Angle e represents the degree of curvature (Fig. 1).

Trajectory analysis: root canal transportation

To investigate the canal trajectory along the entire rootlength, the Image J software was used. Stacks of images inthe grey scale were processed in order to determine the rootcanal transportation. This transportation is determined bycomparing the coordinates of the geometric centre,‘‘centroid’’ of the canal before and after instrumentation.The displacement of the canal centre is then established(Fig. 2) by calculating the difference between the relativeposition of the centroids before and after treatment aftersetting the centroid of the root itself as reference.

For a given sample, a thresholding of the root was firstperformed in order to determine the geometric centre of theroot (x and y coordinates of the piecewise zone for each cut),which remains identical before and after instrumentation.This step was necessary in order to eliminate the bias of apossible skewing while repositioning the teeth according to afixed landmark. Therefore, the coordinates of the root cen-troid were used as the reference point.

Then, a second thresholding was performed to determinethe coordinates of the canal’s geometric centre before and

Figure 1 Modified version of the Berbert and Nishiyamamethod. From the tangent to the pulp floor, point A is placedat the centre of the canal entrance and point A’ is placed about1 mm from A on the path of the canal. These two points form astraight line. Then point B is placed at the apical foramen andpoint B’ about 1 mm from B on the path of the canal. These lasttwo points form a second straight line. These two lines intersectat point C, and a ratio of the distances AC/CB represent thecoefficient of the position of the curvature. Angle e representsthe degree of curvature.

Comparative analysis of root canal changes after preparation with three systems 85

after instrumentation. For each canal, the values were auto-matically calculated for the whole stack according to thepiecewise zone: first for the root contour, then for the canal.For each cut, the processed values represent the coordinatesof the geometric centre of the root contour and the canalbefore and after instrumentation. All these series of valuesrelated to the geometric centres are then listed in Exceltables. In order to eliminate the bias related to the reposi-tioning of the root within the landmarks, the measurementbased on the contours of the root, before and after instru-mentation, remains unchanged, and is used as a reference.The measurement consists in subtracting the coordinates ofthe canal centroid from this reference. These new values,calculated according to the root contours: coordinates of thecanal centroid before (‘‘xPRE’’ and ‘‘yPRE’’) and after(‘‘xPOST’’ and ‘‘yPOST’’) instrumentation are used to assessroot canal transportation.

Statistical analysis

Statistical analysis was performed with the software StatXact7.0-Cytel-USA using the Wilcoxon and Kruskal—Wallis testwith a threshold value of p = 0.05. The Kruskal—Wallis testis then completed by Mann—Whitney tests using the Bonfer-roni correction to assess differences between groups.

Results

Degree and position of curvature

The mean degree of curvature respectively decreases of7.078 for the Revo-S, 6.928 for the HeroShaper and 98 forthe Protaper (Table 1). The difference between before and

after instrumentation shows a statistically significant devia-tion of curvature for all groups (p < 0.003). In addition, thereis no statistically significant difference among the threesystems (p > 0.6).

In contrast, the mean coefficient of curvature positionbefore and after instrumentation shows no statistically sig-nificant difference (p > 0.5) for all systems (Table 1).

The position variation of the curvature among the threesystems did not differ significantly (p > 0.7), with similaraverages of low values.

Canal transportation

In the apical third, the mean transportation was about 53 mmfor the Revo-S1 group, 77 mm for the HERO Shaper1 and85 mm for the ProTaper1 with statistically significant differ-ences between Revo-S1 and HERO Shaper1 ( p = 0.01708)and ProTaper1 ( p = 0.02402) (Fig. 3).

In the middle third, statistically significant differenceswere found between Revo-S1 and HeroShaper1 system( p = 0.01328) as well as between Revo-S1 and ProTaper1

( p = 0.0202). The mean transportation values are about51 mm for the Revo-S1 group, 69 mm for HeroShaper1 and87 mm for ProTaper1 (Fig. 4).

In the coronal third, the mean transportation values wereabout 77 mm, 94 mm and 119 mm for HEROShaper1, Revo-S1

and ProTaper1 respectively with no statistically significantdifferences ( p > 0.05) (Fig. 5).

Discussion

The aim of this in vitro study was to assess and compare theshaping ability of three Ni—Ti rotary systems, Revo-S1,HeroShaper1 and ProTaper1 with a simple imaging systemwhich can be used in vivo.

In terms of degree of curvature, a statistically significant( p < 0.003) root canal straightening (6.92—98) after prepara-tion is shown for each group. Although no statistically sig-nificant difference is demonstrated between the threesystems, the ProTaper1 group records a mean straighteningwhich is higher than the other groups (98). These results arein agreement with the already published data of the litera-ture: in 2007, Yang et al.10 using a modified Bramantetechnique, compared root canal preparations with ProTa-per1 and HEROShaper1 and the results of this study showedmore straightening of the curvature for the ProTaper1 sys-tem for both the degree and the radius of curvature.

The compilation of all cross-sections performed every76 mm using CBCT enables the Image J software1 to renderan accurate analysis of the actual shape changes of the canal.

Figure 2 Transportation of the position of the centroid of thecanal before and after preparation.

Table 1 Variations of the curvature according to the modified version of the Berbert and Nishiyama method.

Variation of curvature in degrees(means � SD)

Variation of position of the curvature(AC/CB ratio) (means � SD)

HERO Shaper1 6.928 � 3.90 * �0.08 � 0.76Revo-S1 7.078 � 5.11 * 0.00 � 0.65Pro Taper1 9.008 � 6.19 * 0.04 � 1.1* Represents a statistically significant difference between the angle of curvature before and after treatment.

86 D. Oget et al.

All the studied techniques produce a shift in the centre of thecanal; this confirms the results of the study conducted byHartmann et al. in 2007.11 In the apical third, the Revo-S1

system better respected the original canal trajectory thanHeroShaper1 in a statistically significant way ( p = 0.01708).These data confirm the results of the study of Yang et al. in2007.10 Revo-S1 is also significantly more respectful of thecanal path than the ProTaper1 system ( p = 0.0242). Theseresults are in agreement with those recorded in the CBCTstudy conducted by Hashem et al. in 2012.12

In the middle third, the Revo-S1 system causes less canaltransportation, with a statistically significant differencecompared to the HEROShaper1 ( p = 0.01328) and ProTaper1

( p = 0.0202) systems. The highest root canal transportation islocated at the cervical third for all groups and ranges from76 mm to 119 mm. This can be explained by the high taper ofthe orifice openers that have been used.

The ProTaper1 group achieves the highest canal transpor-tation for each third. In a similar study conducted in 2013,Elsherief et al.13 did not find any statistically significantdifference between the amount of transportation inducedby Revo-S1, HEROShaper1 and ProTaper1. They alsorecorded lower transportation values than in the presentstudy. These contradictory results may be explained by thelower spatial resolution used in the above-mentioned study(125 mm vs. 76 mm). However, in 2011, Ozer using CBCTwith a125 mm spatial resolution recorded the similar values asthose reported in the present study for the apical root canaltransportation induced by the ProTaper1 system.14

The biological samples used in this study represent anadequate model despite the difficulty to obtain perfectlyidentical groups; however, regarding the degree of curva-ture, there was no statistically significant difference amongthese groups. The use of resin blocks would have led tostrictly identical conditions but these simulators offer some

Figure 3 Root canal transportation values in the apical third.Red bar represents median value. Black points represent max-imum and minimum values. Black bars represent first and ninthdecile and limits of white rectangle represents first and thirdquartile.* represents a statistically significant difference betweengroups.

Figure 4 Root canal transportation values in the middle third.Red bar represents median value. Black points represent max-imum and minimum values. Black bars represent first and ninthdecile and limits of white rectangle represents first and thirdquartile.* represents a statistically significant difference betweengroups.

Figure 5 Root canal transportation values in the cervical third.Red bar represents median value. Black points represent max-imum and minimum values. Black bars represent first and ninthdecile and limits of white rectangle represents first and thirdquartile.

Comparative analysis of root canal changes after preparation with three systems 87

drawbacks such as surface texture and hardness of thematerial, which are very different from that of the tooth.In addition, the circular or oval section of the artificial canaldiffers from that of a natural canal15 and this substitutionmethod does not offer any information about remainingdentin thickness after root canal instrumentation.16

CBCT is now easily available to clinicians and data fromthe literature have shown that measurements taken from theCBCT images are reliable. Indeed, studies comparing ‘‘virtual’’measurements to the same measurements following dissectionor histological sections show high correlation coefficients. Forexample, in 2010, Michetti et al.17 found 93% of correlationbetween the areas of the canal calculated on histological crosssections and CBCT images, and Kim et al.18 obtained 94% ofcorrelation in the distance between the apex of the mandib-ular molar and the mandibular canal measured on both CBCTreconstruction and dissection samples.

In addition, in this in vitro study, this non-invasive methodallows complementary investigations such as Scanning Elec-tron Microscopic observations of the root canal walls afterinstrumentation.

Calculation of the root canal transportation was per-formed on all the sections obtained from the CBCT recon-struction i.e. every 76 mm of the canal. This was achievedthrough an automated method of calculation using the ImageJ software1. In the literature, the root canal transportationis often studied on a few sections using a manual imageanalysis.11,19,20

In the present study, the analysis using an automaticthreshold technique is based on the greyscale differencesof the reconstructed image. The image resolution is aboutone pixel (76 mm). The threshold determines the shape of thecanal and is homothetic to determine the geometric centre.

In very thin root canals, the quality of CBCT images is notsufficient to precisely analyse the apical areas because itdoes not allow the detection of the canals using this auto-matic threshold method preoperatively.

Micro-computed tomography remains the gold standardtechnique for non-destructive in vitro studies of root canaltrajectory, but it cannot be used for in vivo studies. It alsorequires an extensive protocol for both acquisition and dataprocessing.15 Nevertheless, in this study, the transportationvalues recorded after using the Protaper1 system are reallyclosed to those found in high resolution micro-computedtomography studies.21,22

Conclusion

Under the conditions of this study, all systems tested producea small deviation of the curvature. Revo-S1 is significantlymore respectful of the canal shape than ProTaper1 andHEROShaper1.


The authors have no conflicts of interest to declare.

References

1. Schilder H. Cleaning and shaping the root canal. Dent Clin NorthAm 1974;18:269—96.

2. Gluskin AH, Brown DC, Buchanan LS. A reconstructed computer-ized tomographic comparison of Ni—Ti rotary GT files versustraditional instruments in canals shaped by novice operators.Int Endod J 2001;34:476—84.

3. Young GR, Parashos P, Messer HH. The principles of techniques forcleaning root canals. Aust Dent J 2007;52(1 Suppl.):S52—3.

4. Morgan LF, Montgomery S. An evaluation of the crown-downpressureless technique. J Endod 1984;10:491—8.

5. Glickman GN, Dumsha TC. Problems in canal cleaning andshaping. In: Gutmann JL, et al., editors. Problem solving inEndodontics. 3rd edn, St Louis: Mosby; 1997. p. 91—122.

6. Patel S. New dimensions in endodontic imaging: Part 2. Conebeam computed tomography. Int Endod J 2009;42:463—75.

7. Patel S, Dawood A, Whaites E, Pitt Ford T. New dimensions inendodontic imaging: Part 1. Conventional and alternative radio-graphic systems. Int Endod J 2009;42:447—62.

8. Berbert A, Nishiyama CK. Curvaturas radiculares. Uma novamethodologia para mensuracao e localizacao. Revista Gauchade Odontologia 1994;42:356—8.

9. Bramante CM, Betti LV. Comparative analysis of curved root canalpreparation using Nickel—Titanium instruments with or withoutEDTA. J Endod 2000;26:278—80.

10. Yang GB, Zhou XD, Zheng XL. Shaping ability of progressive versusconstant taper instruments in curved root canals of extractionteeth. Int Endod J 2007;40:707—14.

11. Hartmann M, Barletta F, Fontanella V, Vanni J. Canal transporta-tion after root canal instrumentation: a comparative study withcomputed tomography. J Endod 2007;33:962—5.

12. Hashem AAR, Ghoneim AG, Lufty RA, Foda MY, Omar GAF. Geo-metric analysis of root canals prepared by our rotary NiTi shapingsystems. J Endod 2012;38:996—1000.

13. Elsherief SM, Zayet MK, Hamouda IM. Cone-beam computedtomography analysis of curved root canals after mechanicalpreparation with three nickel-titanium rotary instruments. JBiomed Res 2013;27:326—35.

14. Ozer SY. Comparison of root canal transportation induced bythree rotary systems with noncutting tips using computed tomo-graphy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod2011;111:244—50.

15. Peters O. Current challenges and concepts in the preparation ofroot canal systems: a review. J Endod 2004;30:559—67.

16. Yun HH, Kim SK. A comparison of the shaping abilities of 4 nickel—titanium rotary instruments in simulated root canals. Oral SurgOral Med Oral Pathol Oral Radiol Endod 2003;95:228—33.

17. Michetti J, Maret D, Mallet JP, Diemer F. Validation of cone-beamcomputed tomography as a tool to explore root canal. J Endod2010;36:1187—90.

18. Kim TS, Caruso JM, Christensen H, Torabinejad M. A comparisonof cone-beam computed tomography and direct measurement inthe examination of the mandibular canal and adjacent struc-tures. J Endod 2010;36:1191—4.

19. Gergi R, Rjeily JA, Sader J, Naaman A. Comparison of canaltransportaton and centering ability of twisted files, Pathfile-ProTaper system, and stainless steel hand K-files by using com-puted tomography. J Endod 2010;36:904—7.

20. Sanfelice CM, Da Costa F, So M, Vier-Pelisser F, Bier C, Grecca F.Effects of four instruments on coronal pre-enlargement by usingcone beam computed tomography. J Endod 2010;36:858—61.

21. Loızides AL, Kakavetsos VD, Tzanetakis GN, Kontakiotis EG,Eliades G. A comparative study of the effects of two nickel-titanium preparation techniques on root canal geometryassessed by microcomputed tomography. J Endod2007;33:1455—9.

22. Stern S, Patel S, Foschi F, Sherriff M, Manocci F. Changes incentring and shaping ability using three nickel-titanium instru-mentation techniques analysed by micro-computed tomography(mCT). Int Endod J 2012;45:514—23.

88 D. Oget et al.


In-vitro evaluation of apical microleakage oftwo obturation methods of immaturepermanent teeth: orthograde apical plug ofMineral Trioxide Aggregate and root canalfilling combining custom gutta-percha conewith Calcium Silicate-based sealer

Valutazione in vitro della infiltrazione apicale di due metodi di trattamentodegli apici immaturi: chiusura ortograda con apical plug e MTA e chiusura conconi customizzati di guttaperca e sealer calciuo-silicatico Bioroot

Rami Hamdan a,*, Jerome Michetti a,b, Claire Dionnet a,Franck Diemer a,c, Marie Georgelin-Gurgel a

a Service d’Odontologie Conservatrice-Endodontie, Faculte de Chirurgie Dentaire, Toulouse and the CHU deToulouse, 3 Chemin des Maraıchers, 31400 Toulouse, Franceb IRIT — UMR CNRS 5505, Avenue de l’etudiant, 31400 Toulouse, Francec Institut Clement Ader (ICA, FRE CNRS 3687), 3 Rue Caroline Aigle, 31400 Toulouse, France

Received 14 May 2017; accepted 25 July 2017Available online 20 September 2017



* Corresponding author.E-mail: [email protected] (R. Hamdan), [email protected] (J. Michetti), [email protected] (C. Dionnet),

[email protected] (F. Diemer), [email protected] (M. Georgelin-Gurgel).


ScienceDirect



Introduction

Complete sealing of the root canal system with a biologicalinert material is essential1 to prevent the re-infection of theroot canal which is a major factor influencing the treatmentoutcome.2 Root canal filling of immature teeth with thindentinal walls and open apices needs a particular manage-ment; it is technically difficult to control the compaction ofthe root filling material.3 Conventional root canal filling of

the immature teeth with gutta-percha is not adequate as itdoes not reinforce the remaining root.4,5

In the literature, several therapeutic methods are pro-posed to solve this problem: partial pulpotomy, revascular-ization, apexogenesis and apexification.6 Apexification isa method to induce a calcified barrier in a root with an openapex or the continued apical development of an incompleteroot in teeth with necrotic pulp.7 After apexification,the tooth is usually sealed with a root canal sealer and

KEYWORDSApexification;Custom gutta-perchacone;Open apex;Tricalcium silicatecement.

PAROLE CHIAVEMTA. BIOROOT;Sigillo apicale;Tecnica ortograda;Apici immature;Tricalcio-silicati.

Abstract

Aim: The aim of this study was to assess whether an obturation, combining a custom gutta-percha cone with the BIOROOTTM-RCS sealer, displays similar sealing quality to the orthogradeapical plugs of MTA CAPS1 in immature teeth with irregular wide apices.Methodology: Thirty-four immature permanent premolars with apical diameter varying between(1—3 mm) were chosen for this study and were divided into two groups. They were imbedded in wetsponge, which simulated the periapex. In the first group; 5 mm orthograde plugs of MTAwere placedusing an appropriate plugger. In the second group; a custom gutta-percha cone was fabricated andused for root canal filling with the BIOROOTTM-RCS sealer. The specimens were stored at 37 8C and100% humidity during five weeks to allow the complete set of the filling materials. The apical leakagewas evaluated using a dye penetration test with 50%-weight silver-nitrate. The teeth were thenembedded in a transparent resin and sectioned transversally at 1 and 3 mm from the apex. The sliceswere examined under optical microscope and were given scores from (0) to (4). When scoring a slicewas difficult, spectroscopy for energy dispersion using a scanning electron-microscope was used toconfirm the score. The results were compared using the Fisher test with p < 0.05.Results: Silver-nitrate was found in both groups in all slices at 1 mm. At 3 mm, the difference ofmicro-leakage was not significant.Conclusions: The custom gutta-percha cone combined with BIOROOTtm-RCS sealer displays similarleakage resistance to the orthograde MTA plugs.� 2017 Societa Italiana di Endodonzia. Production and hosting by Elsevier B.V. This is an open accessarticle under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Riassunto

Obiettivi: Lo scopo del presente studio e stato valutare le capacita di sigillo marginale delBIOROOTTM-RCS sealer utilizzato in combinazione con un cono di guttaperca customizzato e diconfrontarlo con il sigillo ottenuto con la tecnica di chiusura ortograda con il sistem T CAPS1

utilizzando elementi con apice irregolare ed immaturo.Materiali e metodi: Trenta quattro premolari permanenti immaturi con diametro apicalevariabile da 1 a 3 mm sono stati selezionati a divisi in due gruppi. Entrambi sono stati immersiin una spugna bagnata che ha simulato la area apicale. Nel primo gruppo e stata eseguita unotturazione ortograda di 5 mm con MTA CAPS utilizzando un adeguato plugger. Nel secondo gruppoe stato fabbricato un cono custom di guttaperca e applicato nel canale con il sealer BIOROOT. Icampioni sono stati mantenuti a 378 in 100% di umidita per completare la reazione di indurimento.La penetrazione apicale del colorante e stata valutata con il nitrato di argento al 50%. I denti cosıtrattati c sono stati inglobati in una resina trasparente e sezionati trasversalmente a 1 e 3 mmdall’apice. Le sezioni erano poi valutate al microscopio ottico e ad ognuna attribuito uno score da 0a 4. Quando risultava difficile dare uno score, la sezione era valutata al microscopio elettronico ascansione collegato con un EDS (spettroscopio a dispersione di energia) per confermare il risultato.La valutazione statistica e stata effettuata con il Fisher test al valore p < 0.05.Risultati: Il nitrato di argento (ovvero il colorante) e stato rilevato in entrambi i gruppi nellesezioni a 1 mm. Nelle sezioni a 3 la differenza non era significativa.Conclusioni: La tecnica custom-made con guttaperca e BIOROOT sealer ha dimostrato valori dipenetrazione apicale del colorante al nitrato di argento simile alla tecnica ortograda tradizionalecon MTA:� 2017 Societa Italiana di Endodonzia. Production and hosting by Elsevier B.V. Cet article estpublie en Open Access sous licence CC BY-NC-ND (http://creativecommons.org/licenses/by-nc-nd/4.0/)

90 R. Hamdan et al.

gutta-percha. Many studies demonstrated the efficacy ofcalcium hydroxide pastes to form a hard apical barrier8 butthis method requires a long period of treatment (mean timeneeded 12.9 month).9 Such an extended time of treatmentincreases the tooth fracture risk.10 Apexification with mineraltrioxide aggregate MTA is a trustworthy technique to manageopen apices3,11,12 and is recommended by numerous studies toaccomplish the apical closing.3,13,14 The regenerative treat-ment of teeth with pulp necrosis and incomplete root forma-tion is becoming part of the therapeutic endodontic arsenal ofimmature teeth. Despite the promising results of many pub-lished case reports, the protocol of revitalization procedurehas not been established yet.15 The regenerative proceduresappear to develop an instructed endodontic rehabilitationinstead of physiological-like tissue regeneration.16

Numerous in vitro studies have tried to assess the ability ofdifferent methods and materials to manage the root canalfilling with immature teeth. However, most of these studieswere performed on simulated immature apices, i.e. the apexwas enlarged by using a Gates Glidden drill,17 diamond bur18

or Ni-Ti files.19 Thus, the resulting shape of the simulatedimmature apex remains regular. The shape irregularities ofthe open apex in in vivo situations increase the difficulty ofmanaging the root canal filling.

New sealing materials based on tricalcium silicate aregetting an increased interest in the endodontic research.It was shown that these cements are biocompatible,20,21

ensure a good root canal sealing22,23 and increase the rootfracture resistance.24 A major disadvantage is the retreat-ability, these cements become hard after the setting and it isnot possible to eliminate the cement completely by using theconventional retreatment methods.25,26 Using tricalcium sili-cate cement with immature tooth could be interesting con-sidering the reinforcement of the root structure, the goodquality of sealing and the low risk of extrusion in the periapexas manufacturers recommend the use of single cone or lateralcompaction techniques. When used for orthograde obtura-tion, the calcium silicate-based cements showed similarmarginal adaptation to the orthograde MTA plugs with simu-lated open apices.19

Recently, Septodont (Saint-Maur Des Fosses, France) hasintroduced a new tricalcium silicate sealer named (BIOR-OOTTM RCS). According to the manufacturer, this cement ismade from pure calcium silicate and is monomer-free ensur-ing zero shrinkage, contains pure mineral formulation thatwill not stain teeth. It offers an excellent adhesion to dentinand to gutta-percha points, a great ability to seal auxiliarycanals due to its high flowability and hydrophilic behaviorthat allows a continuous sealing in the presence of moisture.

The objective of this study was to assess whether a rootcanal filling, combining a fabricated custom gutta-perchacone with the BIOROOTTM RCS cement, displays comparablesealing quality to orthograde plugs of MTA CAPS1 (Acteon,Pierre Roland, Merignac-France) in immature teeth withirregular wide apices. The null hypothesis tested in this studyis that there is no difference in apical leakage between thesetwo methods using a dye penetration test with silver nitrate.


Thirty-four immature permanent maxillary and mandibularpremolars which where extracted for orthodontic reasons

were selected for this study. The criteria for tooth selectionwere: wide apex, no visible root caries and fractures. Theanatomical difficulty was evaluated by measuring the apicaldiameter by taking photos of the apices placed next to amillimeter paper with a camera Canon EOS 600D Digital SLRequipped with macro Tamron1 SP 90MM F/2.8 Di VC USD 1:1.The teeth were divided into two groups (MTA group and B.C.group) with respect to their measured apical diameters tocreate two balanced groups.27 All teeth were coated by twocoats of two different nails polish. The crowns of all teethwere then removed to obtain a standardized length of15 mm.

The working length (WL) is determined to be short 0.7 mmof the point where the K-file size 15 was first visible with abinocular at �16 magnifications. In all specimens, the rootcanal preparation was chemical shaping rather than mechan-ical shaping. The teeth were irrigated with at least 5 mL of2.5% sodium hypochlorite and 3 mL of 17% EDTA solution andwere dried with paper points.

The samples were imbedded in wet sponge which simu-lated the periapex and prevented the extrusion of fillingmaterial out of the apex.28

In group 1 (the MTA group): 5 mm orthograde MTA plugswere placed in all teeth using an appropriate plugger. Theteeth were then temporarily filled with a moist paper pointand Cavit (ESPE, Cergy Pontoise, France). Two days later, theCavit was removed and the remaining part of the canal wasfilled with GC-Fuji-IX GP Fast1 (GC Corporation, Japan).

Figure 1 (a) The fabricated master gutta-percha cone. (b) Thecustom cone is fitted to the working length (Control radiography).

Immature teeth obturation 91

In group 2 (the B.C. group): A non-standardized gutta-percha cone was fitted to within 3—4 mm of the workinglength. In very wide canals, two non-standardized gutta-percha cones were placed on a cold glass slap and were thenrolled and merged by another heated glass slap to formone gutta-percha cone. The new cone was fitted to within3—4 mm of the working length. The apical 3—4 mm of thefabricated cone were immersed in the Eucalypti-Aethero-leum1 solution (Fagron, Rotterdam, Netherlands) for 15 sand the cone was then inserted, with light pressure, intothe root canal which was filled with sodium hypochlorite2.5%. The maneuver was repeated until the fabricated conewas fitted to the working length. The gutta-percha cone wasrinsed and left in sodium hypochlorite 2.5% for few minutes toremove any Eucalypti residuals and to harden its surface. Thecanal was flushed with at least 5 mL of sodium hypochlorite2.5% for and dried with paper points. The BIOROOTTM RCScement was prepared in accordance with the manufacturersrecommendations and placed in the root canal using the fittedgutta-percha cone (Fig. 1). The coronal part of canal was sealedwithGC-Fuji-IX GPFast1 (GC Corporation, Japan).Radiographswere taken for all teeth after the root canal filling. The sampleswere then stored at 37 8C and 100% humidity for five weeks toallow the complete set of the sealer and the MTA.

Apical micro-leakage: A dye penetration test using 50%weight silver nitrate solution during one hour29 and in absenceof light was executed to all samples except for two teeth ineach group which were randomly chosen to serve as a control

groups. The teeth were then rinsed with distilled water for5 min to remove any traces of sliver nitrate. All samples werethen immersed in a photo-developing solution (Kodak Profes-sional D-76, Germany) for 24 h in presence of light. The teethwere then washed in distilled water and scaled with ultrasonichand piece to eliminate any residuals of silver nitrate. Allspecimens were embedded in a transparent polyester resin(Neovents, Sainte-Gemme, France) and were then transver-sally sectioned at 1 and 3 mm from the apex using a slow-speedsaw with water cooling. The photographs of all slices weretaken using a microscope (Leica—WILD M3B) at �16 magnifi-cation and a digital camera Canon EOS 600D Digital SLRequipped with macro Tamron1 SP 90MM F/2.8 Di VC USD1:1. The photographs were evaluated by two experimentedexaminers; the dye penetration test was scored (0, 1, 2, 3, 4)when (0%, <25%, 25—50%, 50—75%, 75—100%) respectively ofthe canal circumference were concerned by the leakageof silver-nitrate; score 0 means absence of leakage, score4 means complete infiltration (Fig. 2).

Scanning electron microscope analyses: Scanning ElectronMicroscopy (JEOL JSM-5310LV) was chosen to confirm thepresence/absence of silver-nitrate in the interface mate-rial/dentin or in dental tubules using spectroscopy for energydispersion EDS (Figs. 3 and 4).

Statistical analysis: Scores at 1 and 3 mm were analyzedusing the Fisher test with ( p < 0.05). Kappa values werecalculated to assess the inter-examiners agreement regard-ing slices scores.

Figure 2 Scores of the dye test. (a) Score 0: Absence of leakage. (b) score 1: <25% of canal circumference were concerned by theleakage of silver nitrate. (c) Score 2: 25—50% were concerned. (d): Score 3: 50—75% were concerned. (e) Score 4: complete infiltration.

92 R. Hamdan et al.

Results

The minimum and the maximum apical diameters were nearly1 mm and nearly 3 mm respectively. In the MTA group, theKappa values were 1 at 1 mm and 0.73 at 3 mm. In the B.C.group, the Kappa values were not calculable at 1 mm and 0.59at 3 mm; a strong agreement was found between examiners.

For the first examiner, the p-values between two groupswere 1 at 1 mm and 0.05 at 3 mm.

For the second examiner, the p-values between twogroups were 1 at 1 mm and 0.26 at 3 mm.

No significant difference in leakage was proved betweenthe two methods.

For both examiners at 1 mm, none of the slices of the B.C.group obtained a score of 0 whereas only one slice of the MTAgroup obtained a score of 0.

Discussion

When the root filling material can prevent the leakage ofsmall molecules, it would probably prevent the passage ofmicroorganisms.30 A dye penetration test using sliver-nitratewas used in this study to evaluate the apical leakage since itoffers clear results and the possibility of the SEM analysis.31

The fluid transport method is a sensitive technique, and if notstandardized, the precision of the results is operator depen-dent.32 The bacterial leakage model was criticized sincepossible microbial leakage pathways can exist and thusresults are incorrect.33 Analyzing marginal adaptation usingSEM is also used to evaluate the resistance to leakage.19,29

However, samples sectioning can possibly shift the fillingmaterial and can create hiatus.

The apical sealing of both methods was assessed in morephysiologically accurate conditions and not in enlargedapices where the shape remains relatively regular. The inter-ruption of radicular edification results in a large variety ofapical shapes.3 The results of the current study highlight aconsiderable difficulty to manage successfully the ortho-grade root canal filling of immature teeth with irregular wideapices. Both methods showed unsatisfying apical sealing andthe null hypothesis was accepted. When the apical diameterexceeds 1 mm, conventional orthograde obturation methodsseem to be unable to prevent the apical leakage.

In the current study, silver-nitrate was found nearly in allslices at 1 mm whereas at 3 mm, a slight superiority wasfound in the MTA group over the B.C. group. That can beexplained by the compaction of MTA with a suitable plugger,whereas in the B.C. group, no compaction was executed.The fabricated custom gutta-percha cone combined with a

Figure 3 Scanning Electron Microscope analysis of this slice. (a) Choosing multiple points of interest. (b) Choosing the same points onthe SEM image. (c) Energy Dispersion Spectroscopy EDS of the point n87 indicates the absence of the dye in this point. The sameprocedure was repeated for all points of interest and the final score given to this slice was 0 due to the absence.


tricalcium silicate sealer (BIOROOTTM RCS) displays similarleakage results to the trustworthy method of the MTA plugs,and can be considered for the everyday practice due to itseasiness where no specific materials are needed.

Only regenerative procedures allow the radicular edifica-tion to be resumed. Future investigations of regenerativedentistry would possibly establish an authentic treatment ofimmature teeth with wide irregular apices.

Conclusion

Within the limits of this study, it can be concluded that afabricated custom gutta-percha cone combined with trical-cium silicate sealer BIOROOTTM RCS displays similar leakageresistance to the orthograde MTA plugs and, due to its

easiness, can be taken into consideration to manage imma-ture teeth with wide irregular apices.

Declaration

All authors have contributed significantly and agree with thecontent of the manuscript.

This research did not receive any specific grant fromfunding agencies in the public, commercial, or not-for-profitsectors.


The authors deny any conflict of interest.

Figure 4 Scanning Electron Microscope analysis of this slice. (a) Choosing a zone of interest 1 and multiple points 2, 3, 4. (b) Choosingthe same points on the SEM image. (c) Energy Dispersion Spectroscopy EDS of these points indicates the presence of Silver at least withpoint 2.

94 R. Hamdan et al.

References

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2. Sundqvist G, Figdor D, Persson S, Sjogren U. Microbiologic ana-lysis of teeth with failed endodontic treatment and the outcomeconservative treatment. Oral Surg Oral Med Oral Pathol OralRadiol Endod 1998;85:86—93.

3. Simon S, Rilliard F, Berdal A, Machtou P. The use of mineraltrioxide aggregate in one-visit apexification treatment: a pro-spective study. Int Endod J 2007;40:186—97.

4. Bortoluzzi EA, Souza EM, Reis JM, Esberard RM, Tanomaru-FilhoM. Fracture strength of bovine incisors after intra-radiculartreatment with MTA in an experimental immature tooth model.Int Endod J 2007;40:684—91.

5. Hemalatha H, Sandeep M, Kulkarni S, Yakub S. Evaluation offracture resistance in simulated immature teeth using Resilonand Ribbond as root reinforcements-an in vitro study. DentTraumatol 2009;25:433—8.

6. Garcia-Godoy F, Murray P. Recommendations for using regenera-tive endodontic procedures in permanent immature traumatizedteeth. Dent Traumatol 2012;28:33—41.

7. AAE. Glossary of endodontic terms. Chicago: American Associa-tion of Endodontists; 2003.

8. Felippe W, Felippe M, Rocha M. The effect of mineral trioxideaggregate on the apexification and periapical healing of teethwith incomplete root formation. Int Endod J 2006;39:2—9.

9. Dominguez Reyes A, Munoz Munoz L, Aznar Martin T. Study ofcalcium hydroxide apexification in 26 young permanent incisors.Dent Traumatol 2005;21:141—5.

10. Andreasen J, Munksgaard E, Bakland L. Comparison offracture resistance in root canals of immature sheep teeth afterfilling with calcium hydroxide or MTA. Dent Traumatol2006;22:154—6.

11. Pace R, Giuliani V, Nieri M, Di Nasso L, Pagavino G. Mineral trioxideaggregate as apical plug in teeth with necrotic pulp and immatureapices: a 10-year case series. J Endod 2014;40:1250—4.

12. Sarris S, Tahmassebi J, Duggal M, Cross I. A clinical evaluation ofmineral trioxide aggregate for root-end closure of non-vitalimmature permanent incisors in children — a pilot study. DentTraumatol 2008;24:79—85.

13. Mente J, Hage N, Pfefferle T. Mineral trioxide aggregate apicalplugs in teeth with open apical foramina: a retrospective analysisof treatment outcome. J Endod 2009;35:1354—8.

14. Holden D, Schwartz S, Kirkpatrick T, Schindler W. Clinical out-comes of artificial root-end barriers with mineral trioxide aggre-gate in teeth with immature apices. J Endod 2008;34:812—7.

15. Galler K. Review: clinical procedures for revitalization: currentknowledge and considerations. Int Endod J 2015;49:926—36.

16. Diogenes A, Ruparel N, Shiloah Y, Hargreaves K. Regenerativeendodontics: a way forward. J Am Dent Assoc 2016;147:372—80.

17. Ahmed A-K, Sandra S, Robert S, Satish B. In-vitro evaluation ofmicroleakage of an orthograde apical plug of mineral trioxide

aggregate in permanent teeth with simulated immature apices.J Endod 2005;31:117—9.

18. Seong-Tae H, Kwang-Shik B, Seung-Ho B, Kee-Yeon K, WooCheolL. Microleakage of accelerated mineral trioxide aggregate andportland cement in an in vitro apexification model. J Endod2008;34:56—8.

19. Dennis T, Jianing H, Gerald NG, Karl FW. Comparative analysis ofcalcium silicate-based root filling materials using an open apexmodel. J Endod 2016;42:654—8.

20. Chen I, Salhab I, Setzer F, Kim S, Duck Nah H. A new calciumsilicate-based bioceramic material promotes human osteo- andodontogenic stem cell proliferation and survival via the extra-cellular signal-regulated kinase signaling pathway. J Endod2016;42:480—6.

21. Tay K, Loushine B, Oxford C, Kapur R, Primus C, Gutmann J, et al.In vitro evaluation of a Ceramicrete-based root-end filling mate-rial. J Endod 2007;33:1438—43.

22. Zhang W, Li Z, Peng B. Assessment of a new root canal sealer’sapical sealing ability. Oral Surg Oral Med Oral Pathol Oral RadiolEndod 2009;107:79—82.

23. Leal F, De-Deus G, Brandao C, Luna A, Fidel S, Souza E. Compar-ison of the root-end seal provided by bioceramic repair cementsand White MTA. Int Endod J 2011;44:662—8.

24. Topcuoglu H, Tuncay O, Karatas E, Arslan H, Yeter K. In vitrofracture resistance of roots obturated with epoxy resin—based,mineral trioxide aggregate-based, and bioceramic root canalsealers. J Endod 2013;39:1630—3.

25. de Siqueira Zuolo A, Zuolo M, da Silveira Bueno C, Chu R, CunhaR. Evaluation of the efficacy of TRUShape and reciproc filesystems in the removal of root filling material: an ex vivomicro-computed tomographic study. J Endod 2016;42:315—9.

26. Hess D, Solomon E, Spears R, He J. Retreatability of a bioceramicroot canal sealing material. J Endod 2011;37:1547—9.

27. De-Deus G. Research that matters — root canal filling andleakage studies. Int Endod J 2012;45:1063—4.

28. Matt G, Thorpe J, Strother J, McClanahan S. Comparative study ofwhite and gray mineral trioxide aggregate (MTA) simulating a one-or two-step apical barrier technique. J Endod 2004;30:876—9.

29. Xavier CB, Weismann R, de Oliveira MG, Demarco FF, Pozza DH.Root-end filling materials: apical microleakage and marginaladaptation. J Endod 2005;31:539—42.

30. Aqrawabi J. Sealing ability of amalgam, super EBA cement, andMTA when used as retrograde filling materials. Br Dent J 2000;188:266—8.

31. Wu W, Cobb E, Dermann K. Detecting margin leakage of dentalcomposite restorations. J Biomed Mater Res 1983;17:37—43.

32. De Bruyne M, De Bruyne R, Rosiers L, De Moor R. Longitudinalstudy on microleakage of three rootend filling materials by thefluid transport method and by capillary flow porometry. IntEndod J 2005;38:129—36.

33. Rechenberg D-K, De-Deus G, Zehnder M. Potential systematic errorin laboratory experiments on microbial leakage through filled rootcanals: review of published articles. Int Endod J 2011;44:183—94.


CLINICAL ARTICLE/ARTICOLO CLINICO

Reciproc blue: the new generation ofreciprocation

Reciproc blue: la nuova generazione della reciprocazione

Ghassan Yared *

Private Practice

Received 6 August 2017; accepted 18 September 2017Available online 10 October 2017


KEYWORDSReciprocation;NiTi instruments;Thermal treatments;Reciproc blue.

Abstract

Aim: This article introduces the Reciproc1 blue system and describes the clinical technique withand without creating a glide path.Methodology: The concept of canal preparation with only one mechanical instrument used inreciprocation was introduced several years ago. Studies and clinical research have shown theefficiency and the safety of the Reciproc1 instrument in the preparation of the majority of canalswithout creating a glide path, and in the retreatment procedure.Results: Reciproc1 blue, a thermally treated instrument is an improved version of the originalReciproc1 instrument; it has an increased resistance to cyclic fatigue and a greater flexibilityenabling a safer and smoother canal preparation procedure, and a wider range of clinicalapplications.Conclusions: This article introduces and describes the clinical technique with which the Reci-proc1 blue instrument is used, even without the need to create a glide path with manual filesbefore using the mechanical instrument.� 2017 Societa Italiana di Endodonzia. Production and hosting by Elsevier B.V. This is an openaccess article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).


* Correspondence at: Ghassan Yared, 101 Westmount Road, Guelph, ON, N1H 5J2, Canada.E-mail: [email protected].


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Introduction

The use of mechanical instruments in reciprocation withunequal forward and reverse rotation was introduced in2008.1 Reciproc1 series of instruments (VDW GmbH, Munich,Germany) were designed specifically for this type of motion.2

Reciproc1 blue (VDW GmbH, Munich, Germany), a ther-mally treated nickel—titanium instrument, is an improvedversion of the original Reciproc1.3 It has an increased resis-tance to cyclic fatigue and a greater flexibility.4

The present article describes the use of Reciproc1 blueseries of instruments for the canal preparation without anyprior instrumentation and without a glide path. Only oneinstrument is needed to enlarge the majority of the canals toan adequate size and taper regardless of the size of the canal,the degree of canal curvature or canal calcification.

Report

Clinical applications

The Reciproc1 blue system includes 3 instruments, similar tothe original Reciproc1 series, the Reciproc1 blue 25, Reci-proc1 blue 40 and Reciproc1 blue 50, matching paper points,matching gutta-percha cones, and matching gutta-perchaobturators (GuttaFusion1) (Fig. 1).

The Reciproc1 blue instruments have an S-shaped cross-section (Fig. 2). The three instruments have a regressivetaper starting at 3 mm from the tip. The Reciproc1 blue 25has a diameter of 0.25 mm at the tip and an 8% (0.08 mm/mm) taper over the first 3 mm from the tip. The Reciproc1

blue 40 has a diameter of 0.40 mm at the tip and a 6%(0.06 mm/mm) taper over the first 3 mm from the tip. TheReciproc1 blue 50 has a diameter of 0.50 mm at the tip and a5% (0.05 mm/mm) taper over the first 3 mm from the tip.

The instruments are used in conjunction with a motor(Fig. 3) at 10 cycles of reciprocation per second. The motor isprogrammed with the angles of reciprocation and speed forthe three instruments. The values of the forward and reverserotations are different. When the instrument rotates inthe cutting direction (forward rotation) it will advance in

the canal and engage dentine to cut it. When it rotates in theopposite direction, the reverse rotation (smaller than theforward rotation) the instrument will be immediately disen-gaged. The end result, related to the forward and reverse

PAROLE CHIAVEReciprocazione;Strumenti in nichel-titanio;Trattamenti termici;Reciproc blue.

Riassunto

Obiettivi: Questo articolo introduce il sistema Reciproc1 blue e descrive la tecnica clinica diutilizzo con e senza glide path.Materiali e metodi: Il concetto di preparazione del canale con un solo strumento meccanicousato in reciprocazione e stato introdotto diversi anni fa. Studi e ricerche cliniche hannodimostrato l’efficienza e la sicurezza dello strumento Reciproc1 nella preparazione dellamaggior parte dei canali senza dover creare un percorso di scivolamento (glide path) e nelleprocedure di ritrattamento.Risultati: Il Reciproc1 blue, uno strumento trattato termicamente, e una versione miglioratadello strumento originale Reciproc1; ha una maggiore resistenza alla fatica ciclica e unamaggiore flessibilita che consente una procedura di preparazione del canale piu sicura e piuscorrevole e una gamma piu ampia di applicazioni cliniche.Conclusioni: Questo articolo introduce e descrive la tecnica clinica con cui il sistema Reciproc1

blue viene utilizzato, anche senza la necessita di dover creare un sentiero di scorrimento construmenti manuali prima dell’utilizzo dello strumento meccanico.� 2017 Societa Italiana di Endodonzia. Production and hosting by Elsevier B.V. Cet article estpublie en Open Access sous licence CC BY-NC-ND (http://creativecommons.org/licenses/by-nc-nd/4.0/)

Figure 1 Reciproc blue instruments, and matching paperpoints, gutta-percha points and GuttaFusion obturators (fromtop to bottom).

Reciproc blue: the new generation of reciprocation 97

rotations, is an advancement of the instrument in the canal.The angles set on the reciprocating motor are specific to theReciproc blue instruments. They were determined using thetorsional properties of the instruments.

Technique

The technique is simple. In the majority of the canals, onlyone Reciproc1 blue instrument is used in reciprocation tocomplete the canal preparation without the need for handfiling or creating a glide path. The requirements for theaccess cavity and the straight-line access to the canals,and the irrigation protocols remain unchanged. The use ofdrills or orifice openers is not required prior to starting thecanal preparation with the Reciproc1 blue instrument.

The selection of the appropriate Reciproc1 blue instru-ment is based on an adequate radiograph (Fig. 4). If the canalis partially or completely invisible on the radiograph, thecanal is considered narrow and the Reciproc1 blue 25 is

Figure 2 S-shape cross section of the Reciproc blue instrument.

Figure 3 Reciprocating motors.

98 G. Yared

selected (Fig. 5). In the other cases, where the radiographshows the canal clearly from the access cavity to the apex,the canal is considered as relatively large (Fig. 6). A size 30hand instrument is inserted passively to the working length(verified with an apex locator) with a gentle watch windingmovement but without a filing action. If the file reaches theworking length, the canal is considered large; the Reciproc1

blue 50 is selected for the canal preparation. If the size 30hand file does not reach the working length passively, a size20 hand file is inserted passively in the canal. If it reaches theworking length, then the canal is considered medium in sizeand an Reciproc1 blue 40 instrument s used for the canalpreparation. If the hand file 20 does not reach the workinglength passively, the Reciproc1 blue 25 is selected.

Before commencing preparation, the length of the rootcanal is estimated with the help of an adequately exposed andangulated pre-operative radiograph. The silicone stopper isset on the Reciproc1 blue instrument at two thirds of that

length. The Reciproc1 blue instrument is introduced in thecanal with a slow in-and-out pecking motion without pullingthe instrument completely out of the canal. The amplitude ofthe in- and out- movements (pecks) should not exceed 3—4 mm. Only very light pressure should be applied. The instru-ment will advance easily in the canal in an apical direction.After 3 pecks, or if resistance is encountered before the 3 pecksare completed, the instrument is pulled out of the canal toclean the flutes. A #10 hand file is used to check patency to twothirds of the estimated length. The canal is copiously irrigated.The Reciproc1 blue instrument is then re-used in the samemanner until it reaches the two thirds of the estimated length.The canal is irrigated and a #10 file is used to determine theworking length with the aid of an apex locator and a radio-graph. The Reciproc1 blue instrument is re-used as describeduntil it reaches the working length. As soon as the workinglength is reached, the Reciproc1 blue instrument is withdrawnfrom the canal to avoid an unnecessary over-enlargement. The

Figure 5 (a) Canals not completely visible on pre-operative radiograph. A Reciproc blue size 25 was used to shape the canals. (b)Fitted gutta-percha cones. (c) Obturated root canals.

Figure 4 Selection of Reciproc blue instrument.

Figure 6 (a) Canal completely visible on pre-operative radiograph. A Reciproc blue larger than size 25 was used to shape the canal.(b) Fitted gutta-percha cone. (c) Obturated root canal.


Reciproc1 blue instrument can also be used with a brushingmotion against the walls of wide canals.

Discussion

With continuous rotation it is necessary to create a glide pathin order to minimize instrument binding and the risk offracture.5,6 Binding is less likely to occur when an instrumentis used in reciprocation with unequal forward and reverseangles and with the limited in- and out- movements asdescribed earlier.9 Therefore, a glide path is not requiredin the majority of the canals when instruments are used inthis manner. It has been shown the incidence of fracture ofinstruments used in reciprocation with unequal forward andreverse angles and with a pecking motion is very low7,8 incomparison to rotary instruments. However, just as with anycontinuous rotary system, it is possible to use the Reciproc1

blue instruments after creating a glide path with reciprocat-ing instrument, the R-Pilot1 (VDW GmbH, Munich, Germany)(Fig. 7) specifically designed for this purpose.

A glide path should be created with the R-Pilot1 prior tousing the Reciproc1 blue in some canals for example whenthe Reciproc1 blue instrument stops advancing in the canalor if advancement becomes difficult. In these canals, apicalpressure should not be exerted on the Reciproc1 blue instru-ment. The instrument should be removed from the canal andthe canal should be irrigated. Patency is established to theworking length with a #8 file and the R-Pilot1 instrument is

used to create a glide path to the working length. TheReciproc1 blue instrument can then be used safely to theworking length. The R-Pilot1 instrument is used with thesame reciprocating motor and settings, with a peckingmotion similar to the use of the Reciproc1 blue instrument.A glide path can also be created with the R-Pilot to reduce thestresses on the Reciproc1 blue instruments for example incanals with difficult access or canals presenting with acurvature in their coronal third (Fig. 8).

The access to the orifices of some canals such as themesio-buccal orifice of a mandibular second molar may bedifficult. Due to the thermal treatment of the Reciproc1 blueinstruments, it is safe to gently pre-curve their tip in order tomake the access to these orifices easier.

If an increased apical enlargement is required, a largerReciproc1 blue instrument, or a nickel—titanium hand orrotary instrument can be used.

Conclusion

In conclusion, the use of instruments in reciprocation withunequal forward and reverse rotations and with a limitedpecking motion has been shown to be very safe.7,8 Theintroduction of the Reciproc1 blue instruments withenhanced physical properties4 makes the procedure evensafer with respect to instrument fracture and maintenanceof canal curvature (internal evaluation) (Fig. 9).

Figure 9 Severely curved canal shaped with Reciproc blue size 25, without any prior instrumentation and without a glide path. Thecanal curvature was maintained.

Figure 8 Mesio-buccal canal in tooth #17 with a coronal curvature, an indication to create a glide path with the reciprocating R-Pilotprior to using the Reciproc blue instrument.

Figure 7 R-Pilot glide path reciprocating instrument.

100 G. Yared


Dr. Ghassan Yared has financial interests in Reciproc1 blue.

References

1. Yared G. Canal preparation using only one Ni—Ti rotary instru-ment: preliminary observations. Int Endod J 2008;41(April (4)):339—44.

2. https://www.vdw-dental.com/fileadmin/Dokumente/Sortiment/Aufbereitung/Reziproke-Aufbereitung/RECIPROC/VDW-Dental-RECIPROC-product-brochure-EN.pdf.

3. https://www.vdw-dental.com/fileadmin/Dokumente/Sortiment/Aufbereitung/Reziproke-Aufbereitung/RECIPROC-blue/VDW-Dental-Reciprocblue-brochure-EN.pdf.

4. De-Deus G, Silva EJ, Vieira VT, Belladonna FG, Elias CN, Plotino G,et al. Blue thermomechanical treatment optimizes fatigue

resistance and flexibility of the reciproc files. J Endod2017;43(March (3)):462—6.

5. Yared G. In vitro study of the torsional properties of new and usedProFile nickel titanium rotary files. J Endod 2004;30(June(6)):410—2.

6. Pereira ES, Singh R, Arias A, Peters OA. In vitro assessment oftorque and force generated by novel ProTaper Next Instrumentsduring simulated canal preparation. J Endod 2013;39(December(12)):1615—9.

7. De-Deus G, Arruda TE, Souza EM, Neves A, Magalhaes K, ThuanneE, et al. The ability of the Reciproc R25 instrument to reach thefull root canal working length without a glide path. Int Endod J2013;46(October (10)):993—8.

8. Plotino G, Grande NM, Porciani PF. Deformation and fractureincidence of Reciproc instruments: a clinical evaluation. IntEndod J 2015;48(February (2)):199—205.

9. Ha J-H, Kwak SW, Sigurdsson A, Chang SW, Kim SK, Kim H-C. Stressgeneration during pecking motion of rotary nickel-titanium instru-ments with different pecking depth. J Endod 2017;43(October(10)):1688—91.


CASE REPORT/CASO CLINICO

Clinical management of horizontal rootfractures aided by the use of cone-beamcomputed tomography

Trattamento clinico-chirurgico di fratture radicolari orizzontali con l’ausilio ditomografia computerizzata a fascio conico

Josue Martos a,*, Luana P. Amaral a, Luiz Fernando M. Silveira a,Melissa F. Damian a, Cristina B. Xavier b, Alesandro Lorenzi c

aDepartment of Semiology and Clinics, Faculty of Dentistry, Federal University of Pelotas, BrazilbDepartment of Oral and Maxillofacial Surgery, Faculty of Dentistry, Federal University of Pelotas, BrazilcCenter of Maxillofacial Diagnosis — ClinDoc, Pelotas, Brazil

Received 22 January 2017; accepted 18 May 2017Available online 13 June 2017


KEYWORDSDental trauma;Root fracture;Cone-beam computedtomography;Diagnosis;Treatment.

Abstract

Aim: To present a a therapeutic approach in a case series of teeth that suffered some rootfracture at different thirds with a follow-up period of 24 months.Summary: Dental trauma occurs with great frequency to the maxillary incisors, and, sometimes,horizontal root fractures are caused. The classification and severity of horizontal root fracturesare based on the location of the fracture line and on the degree of dislocation of the coronalfragment. Diagnosis of horizontal root fractures is based on clinical findings, sensibility tests, andprincipally in radiographic and cone-beam computed tomography (CBCT) examination. Thefollowing cases report describes the diagnosis and treatment of four maxillary central incisorswith horizontal root fractures. In three of the cases described, the healing occurred through theinterposition of connective tissue where radiographically was possible to observe a radiolucent atthe level of the fracture line and the rounding of the fragment angles. In one case, the healingoccurred by calcified tissue, which can be seen radiographically in the fracture line, but the


* Corresponding author at: Federal University of Pelotas, Faculty of Dentistry, Goncalves Chaves St., 457, CEP 96015-560 Pelotas, RS, Brazil.E-mail: [email protected] (J. Martos).


ScienceDirect



Introduction

Dental root fractures occur mainly in the anterior area of themaxilla, frequently due to a frontal impact, predominantly asa result of automobile accidents, violence and sportingactivities.1 The incidence of fractures in permanent teethoccurs at a rate of 0.5—7% of all traumatic injuries of teeth.2

This traumatic event is most observable in the maxillarycentral and lateral teeth, and rarely in mandibular incisors.3

The classification and severity of horizontal root fractures arebased on the location of the fracture line, i.e., cervical,medium, or apical; and on the degree of dislocation of thecoronal fragment.2

The clinical management of a root fracture dependson its pulp vitality, dislocation of the fragments, and the

location/extent of the fracture line. Root fracture healingthat can occur through hard tissue deposition or by theinterposition of connective and hard tissue between thefragments is dependent on two conditions: pulp integrityand invasion or no bacteria in the fracture line.4,5

The degree of mobility is related to the level of thefracture, but the diagnosis depends on the radiographicexamination for differentiation trauma of dislocation. It isconvenient to hold two or multiple radiographs with varia-tion in the vertical angle of incidence of the beam6 orcomplementation with another dimensional view by usingcone-beam computed tomography (CBCT), especially theoro-facial dimension.7—10

A series of clinical reports have shown important informa-tion regarding long-term survival of teeth with horizontal

PAROLE CHIAVETrauma dentale;Frattura radicolare;Tomografiacomputerizzata a fascioConico;Diagnosi;Trattamento.

fragments are in close contact. In addition to a proper treatment plan, the InternationalAssociation of Dental Traumatology (IADT) stresses the importance of patient compliance withfollow-up, and daily care visits for better healing after dental trauma. Knowledge of existingprotocols for this type of injury and periodic monitoring of cases has shown the success of thetreatment so far.Key-learning points:

(1) The diagnosis of root fractures requires a detailed examination, both clinical and radio-graphic.(2) The IADT developed a guideline in order to propose an effective treatment plan.(3) The CBCT facilitates the visualization of lines fracture.(4) An immediate approach after horizontal root fractures comprises reduction, splints andocclusal adjustment.� 2017 Societa Italiana di Endodonzia. Production and hosting by Elsevier B.V. This is an openaccess article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Riassunto

Obiettivi: Presentare un approccio terapeutico con una serie di casi di denti che hanno subitouna frattura radicale a diversi livelli con un periodo di follow-up di 24 mesi.Riassunto: Il trauma dentale si presenta con una grande frequenza negli incisivi mascellari e, avolte, si possono verificano fratture di radice orizzontale. La classificazione e la gravita dellefratture di radice orizzontale si basano sulla posizione della linea di frattura e sul grado didislocazione del frammento coronale. La diagnosi delle fratture di radice orizzontale e basatasui riscontri clinici, test di sensibilita e principalmente un esame radiografico intraorale e CBCT.I casi affrontati descrivono la diagnosi e il trattamento di quattro incisivi centrali mascellari confratture di radice orizzontale. In tre dei casi descritti, la guarigione si e verificata attraversol’interposizione di tessuto connettivo in cui radiograficamente e stato possibile osservare unradiotrasparenza a livello della linea di frattura e l’arrotondamento degli angoli dei frammenti.In un caso, la guarigione e stata caratterizzata da tessuto calcificato, che puo essere vistoradiograficamente nella linea di frattura, ma i frammenti sono in stretto contatto. Oltre ad unadeguato piano di trattamento, l’Associazione Internazionale della Traumatologia Dentale(IADT) sottolinea l’importanza delle visite di follow-up e del mantenimento quotidiano per unamigliore guarigione dopo traumi dentali. La conoscenza dei protocolli esistenti per questo tipodi lesioni e il monitoraggio periodico dei casi ha mostrato finora un buon successo deltrattamento.

Punti chiave di apprendimento:

1.La diagnosi di fratture radice richiede un esame dettagliato, clinico e radiografico.2.L’Associazione Internazionale della Traumatologia Dentale (IADT) ha sviluppato una lineaguida per proporre un efficace piano di trattamento.3.La CBCT facilita la visualizzazione delle linee di frattura.4.Un approccio immediato dopo le fratture di radice orizzontale comprende riduzione,splintaggio e regolazione occlusale.� 2017 Societa Italiana di Endodonzia. Production and hosting by Elsevier B.V. Cet article estpublie en Open Access sous licence CC BY-NC-ND (http://creativecommons.org/licenses/by-nc-nd/4.0/)

Management of horizontal root fractures 103

root fractures.11—18 Within this context, the location of theroot fracture had a substantial and relevant effect on toothsurvival.19,20

The following cases report describes the diagnosis andtreatment of four maxillary central incisors with horizontalroot fractures.

Case reports

Case 1

A 9-year-old female patient was presented with reportingdento-alveolar trauma to the anterior teeth resulting from afall in which the patient’s mouth struck the floor. The patientsought emergency care 10 days after the accident.

Clinical examination revealed that the right maxillarycentral incisor presented remarkable mobility, no sensitivityto percussion, a positive sensitivity test, and a soft colordiscrepancy. A slight extrusion of the right maxillary centralincisor was noted (Fig. 1a). Radiographic examinationrevealed the periodontal ligament and lamina dura withnormal appearance; however, a horizontal root fracturewas evident (Fig. 1b). Further analysis by a CBCT revealeda horizontal root fracture of the middle third and apical atthe buccal portion progressing to the middle third in palataldirection. A displacement of the fragments became apparentthrough the parasagittal view (Fig. 1c—e).

The treatment involved the placement of the semi-rigidsplint performed with 0.03-mm stainless steel braided wire,fixed with light-cured composite resin from lateral to lateral,and kept for 4 months (Fig. 1f and g). Furthermore, a lightincisal wear of the right upper incisor was performed.

The clinical and radiographic follow-up was performedperiodically, and 2 years after the trauma, the right maxillarycentral incisor was asymptomatic and presented positivepulp sensitivity (Fig. 1h and i). Radiographic examination

showed no change in radiolucent line between fragments,but the outer edges of the fragments were rounded and donot show pathological changes in both the coronal and theapical segment.

Case 2

Because of a motorcycle accident, a 39-year-old femalepresented with facial trauma 10 days before. Clinicalexamination reveals mobility in the maxillary right centralincisor, and complicated crown fracture in the maxillary rightlateral incisor with pulp exposure and uncomplicated frac-ture in the maxillary left central incisor (Fig. 2a). The pulpsensitivity tests gave an exaggerated response in traumatizedteeth. The periodontal tissues had no change, yet the lipmucosa was lacerated due to the trauma. A periapical radio-graph showed horizontal root fracture in the middle third ofthe maxillary right central incisor (Fig. 2b).

A further analysis provided by CBCT revealed through thecoronal and axial section, an oblique fracture with a rootpath apical portion in their buccal aspect, progressing to thethird middle in palatal direction (Fig. 2c—e). A large displa-cement of the fragments became apparent through comple-mentary parasagittal cut.

The treatment involved endodontic therapy in the max-illary right lateral incisor, followed by stabilization with aflexible splint for 4 months.

Clinical and radiographic follow-up was performed everymonth. After 24 months, the maxillary right central incisorwas asymptomatic with negative response to pulp test(Fig. 2f and g). The periodontal tissues showed no sign ofinflammation or fistula. Radiographically, we observed thecalcification of the apical segment and the beginning of thatprocess in the coronal segment. Radiographic examinationshowed no change in radiolucent line between fragments,but the outer edges of the fragments were rounded.

Figure 1 (a) Initial intraoral view of the case 1. (b) A preoperative radiograph showing horizontal root fracture at the apical third ofthe left maxillary central incisor. (c) CBCT showing the sagittal (d) axial (e) and panoramic view. (f) Semi-rigid splint performed. (g)Periapical radiograph at 4-months. (h) Buccal clinical aspect at 2-year follow-up. (i) Radiographic examination at 24-months.

104 J. Martos et al.

Case 3

A 16-year-old male patient was referred to the Departmentof Clinics with pain in the region of the upper incisors. Thepatient reported a bicycle accident two days ago and an

accomplishment of flexible splint fixated with light-curedcomposite resin from canine to canine in the teeth (Fig. 3a).

Clinical examination revealed a crown fracture of themaxillary left lateral incisor, small mobility, and a smoothcolor alteration in maxillary left central incisor. The pulp

Figure 2 (a) Image obtained 10 days after the trauma. (b) Periapical radiograph suggesting root fracture at the apical third of theright maxillary central incisor. (c) CBCTshowing the sagittal. (d) axial (e) and panoramic view. (f) 2-year follow-up evidencing healthyclinical appearance. (g) Periapical radiograph at 2-year follow-up displays healing of the horizontal root fracture.

Figure 3 (a) Initial intraoral view of the case 3. (b) A preoperative radiograph showing horizontal root fracture at the apical third ofthe left maxillary central incisor. (c) CBCTshowing the sagittal (d) axial (e) and panoramic view. (f) Clinical follow-up after 2-years. (g)Periapical radiograph at 2-year follow-up showing the interposition of hard tissue between the fragments.


sensitivity test appeared vital to thermal stimulation. Radio-graphic examination revealed horizontal root fracture in theapical third of the left maxillary central incisor (Fig. 3b).

Cone-beam computed tomography revealed oblique rootfracture with an apical trajectory in its buccal portion,progressing to the third middle in palatal direction(Fig. 3c—e). A discrete displacement of the fragmentsbecame apparent through the parasagittal cut.

The patient was wearing the flexible splint for 4 months,and the maxillary left lateral incisor was submitted to endo-dontic treatment. After 24 months, the maxillary left centralincisor presented a positive response to pulp test and normalmobility. The radiographic follow-up showed no change inradiolucent line between fragments, suggesting healing ofthe apical root fracture with the interposition of hard tissuebetween the fragments (Fig. 3f and g).

Case 4

The maxillary left central incisor of a 24-year-old malesuffered an impact due to a physical attack 2 years ago.The clinical examination revealed the presence of a slightdiscoloration of the maxillary left central incisor (Fig. 4a).The patient reported a root fracture in the maxillary leftcentral incisor. He reported an attempt to find a dentist fivedays after such trauma, and emergency care had beenrepositioning a flexible splint with 0.7-mm orthodontic wirefor a period of 3 months.

The clinical examination evidenced a small mobility and apositive response to thermal stimulation in the maxillaryleft central incisor. The periodontal tissues adjacent to the

traumatized tooth area had no alteration. The periapicalradiographic showed oblique root fracture in the apical thirdof the tooth maxillary left central incisor (Fig. 4b).

Cone-beam computed tomography revealed an obliqueroot fracture evolving into the middle third in palatal direc-tion (Fig. 4c—e). A serious displacement of the fragments wasevident by cutting the parasagittal about 3 months after thedental trauma.

The treatment consisted of clinical and radiographic fol-low-up. Furthermore, an occlusal relief through slight wearon the palate of the maxillary left central incisor and buccalof the mandibular left central incisor was performed.

After 35 months, the maxillary left central incisor wasasymptomatic with no mobility or pain with longitudinalpercussion, and the patient did not report any clinical symp-toms (Fig. 4f and g). The soft tissues showed no sign ofinflammation or fistulae. Radiographic examination showedno change in the radiolucent line between fragments, but theouter edges of the fragments were rounded and had nopathological alteration in both the coronal and the apicalsegments. The fragments were separated by the interposi-tion of hard and soft tissue between the fragments on theperiapical radiographs.

Discussion

Root fractures are commonly identified after some dentaltrauma; however, they are often asymptomatic and discov-ered in routine tests. In clinical cases presented, patientssought care a few days or shortly after trauma, favoring thedevelopment of a treatment plan and a better prognosis.

Figure 4 (a) Slight discoloration of the maxillary left central incisor. (b) A preoperative radiograph showing horizontal root fractureat the apical third of the left maxillary central incisor. (c) CBCT showing the sagittal (d) axial (e) and panoramic view. (f) Periapicalradiograph at 2-year follow-up showing the interposition of soft tissue between the fragments. (g) Clinical aspect at 2-year follow-up.


Most root fractures occur in the middle-third of the root,followed by apical and coronal third.21 In addition, it occursmost often in permanent teeth with closed apices where thefully formed root is solidly supported by the periodontaltissues.18,22

In the occurrence of root fracture, the healing events areinitiated locally, through the periodontal ligament and pulptissue, and led in two possible ways. If the pulp is intact, aunion with calcified hard tissue is formed between the frag-ments2,18; however, when the pulp is cut or severely damaged,a revascularization procedure starts; and while revasculariza-tion is ongoing, cells derived from the periodontal ligamentjoin the two fragments through the interposition of connec-tive tissue.18,23 Didactically, the sequelae of root fracturesmay be divided into four categories: (i) healing with calcifiedtissue, (ii) healing with interproximal connective tissue, (iii)healing with interproximal bone and connective tissue, and(iv) interproximal inflammatory tissue without healing.22,24,25

In the reported cases, most of the patients were young,and the affected region was the upper incisor, confirmingwith the literature,2 as well as oblique root fracture with anapical trajectory in its buccal portion, progressing to thethird middle in palatal direction. The causes of injuryobserved in this report were varied; among them weremotorcycle accidents, falls, and alleged physical assault.In most cases, radicular fractures and an apical mediumrequire a conservative replacement treatment, such ascrown fragment reposition for a period of time and occlusalimmediate relief, together with a long-term preservation inwell-established guidelines for the dental management oftraumatic injuries.9 These clinical characteristics were allconducted in the case shown, yielding a positive response tothis treatment.

Across all four cases reported that there was no adversechange during the clinical and radiographic preservation, orany indication of a necrotic pulp. What we could see, insubsequent radiographs, was the reabsorption of the sharpangles of the fragments due to the consequence of remodel-ing, similar as reported in other report.24

In three of the cases described, the healing occurredthrough the interposition of connective tissue where radio-graphically was possible to observe a radiolucent at the levelof the fracture line and the rounding of the fragment angles.In clinical case 3, the healing occurred by calcified tissue,which can be seen radiographically in the fracture line, butthe fragments are in close contact. The International Asso-ciation of Dental Traumatology (IADT) developed a consensusin 2012,9 guiding the conduct that the dentist should takebefore dental trauma in order to propose an effective treat-ment plan. The guidelines represent the best current evi-dence, based on data from the literature and a largeexperience of professionals.9

In the cases of horizontal root fractures, the consensussuggests that the diagnosis is based on clinical and radio-graphic findings, such as mobility or crown displacement, andin response to percussion tests; the gingival sulcus bleeding;pulp sensitivity testing (which may have negative initially,due to permanent or temporary damage pulp); and evencolor change of dental crown. To detect fractures in theapical or middle third, through radiographs, necessities ofthe variation of the incidence of vertical angle was sug-gested.9,26

In addition to a proper treatment plan, IADT stresses theimportance of patient compliance with follow-up, and dailycare visits for better healing after dental trauma. The patientand the patient’s parents should be instructed on the care oftooth trauma in sports and maintaining a proper oral hygiene,ordered with optimal healing. It is suitable to use an anti-bacterial agent such as chlorhexidine gluconate-free alcohol0.1% at 1—2 weeks, as an adjuvant in the oral environmentsuitability.9

We can have a better understanding of the long-termsurvival of teeth with root fractures when we analyze theAndreasen et al. study,19 which considered the fracture lineposition as influential in healing modalities in 492 cases,followed for 10 years after the injury. With these results,we can observe that the apical fractures have the bestprognosis; while cervical, the worst. Thus, it is clear thatmore apical the trace of root fractures, the greater thechances for healing and repair.

The diagnosis of radicular fractures require a detailedexamination, both clinical and radiographic, in order toobtain accurate results. In this respect, the X-rays are veryimportant tests to demonstrate structures that are not pos-sible to be observed on clinical examination. However, theygenerate a two-dimensional image, especially in limitedrepresentation of three-dimensional structures, which mayhamper diagnosis.27—29

Faced with the need for a better diagnostic imaging, aCBCT has gained ground in dentistry, as allowing a clear viewwithout overlay images, which facilitates the visualization oflines fracture.10,27 Through CBCT, it is possible to observe thedegree of separation of the fragments, the direction of thefracture line, the presence of bone lesions, and also theoccurrence of engagement of the adjacent structures.10,27

Periodic monitoring of cases has shown the success of thetreatment so far. In all of them, there is an absence ofsymptoms, negative response to percussion tests, and noexcessive mobility or no mobility. Of the four cases, threerespond positively to pulp sensitivity testing, and one of themhas not; however, so far no bone or periodontal change wasobserved in all of them.

Conclusion

The root fractures in anterior teeth are present in theemergency dental clinic and, being an unexpected occur-rence, require staff professionalism and good technical pre-paration. Knowledge of existing protocols for this type ofinjury is the first step to successful treatment in the middlethird and apical.


The authors deny any conflicts of interest.The authors warrants that the article is totally original,

does not infringe upon any copyright or other proprietaryright of any third party, is not under consideration for pub-lication by any other journal, and has not been submitted orpublished previously. The authors confirm that they havereviewed and approved the final version of the manuscriptand the revised English language was certificate by PaperCh-eck Language ProofReading and Editing Services.


References

1. Glendor U, Marcenes W, Andreasen JO. Classification, etiologyand epidemiology of traumatic dental injuries. In: AndreasenJO, Andreasen FM, Andersson L, editors. Textbook and color atlasof traumatic injuries to the teeth. 4th ed. Oxford, UK: Black-well/Munksgaard; 2007. p. 217—54.

2. Andreasen FM, Andreasen JO, Cvek M. Root fractures. In:Andreasen JO, Andreasen FM, Andersson L, editors. Textbookand color atlas of traumatic injuries to the teeth. 4th ed.Oxford, UK: Blackwell/Munksgaard; 2007. p. 337—71.

3. Caliskan MK, Pehlivan Y. Prognosis of root-fractured permanentincisors. Endod Dent Traumatol 1996;12:129—36.

4. Andreasen JO, Hjorting-Hansen E. Intraalveolar root fractures:radiographic and histologic study of 50 cases. J Oral Surg1967;25:414—26.

5. Andreasen FM. Pulpal healing after luxation injuries and rootfracture in the permanent dentition. Endod Dent Traumatol1989;5(3):111—31.

6. Kullman L, Al Sane M. Guidelines for dental radiography imme-diately after a dento-alveolar trauma, a systematic literaturereview. Dent Traumatol 2012;28:193—9.

7. Bornstein MM, Wolner-Hanssen AB, Sendi P, von Arx T. Compar-ison of intraoral radiography and limited cone beam computedtomography for the assessment of root-fractured permanentteeth. Dent Traumatol 2009;25:571—7.

8. Bernardes RA, de Moraes IG, Duarte MA, Azevedo BC, de AzevedoJR, Bramante CM. Use of cone-beam volumetric tomography inthe diagnosis of root fractures. Oral Surg Oral Med Oral PatholOral Radiol Endod 2009;108:270—7.

9. Diangelis AJ, Andreasen JO, Ebeleseder KA, Kenny DJ, Trope M,Sigurdsson A, et al. International Association of Dental Trauma-tology guidelines for the management of traumatic dental inju-ries: 1. Fractures and luxations of permanent teeth. DentTraumatol 2012;28:2—12.

10. Abella F, Morales K, Garrido I, Pascual J, Duran-Sindreu F, Roig M.Endodontic applications of cone beam computed tomography:case series and literature review. G Ital Endod 2015;29:38—50.

11. Oztan MD, Sonat B. Repair of untreated horizontal root fractures:two case reports. Dent Traumatol 2001;17:240—3.

12. Westphalen VPD, Sousa MH, Neto XS, Fariniuk F, Carneiro E.Management of horizontal root-fractured teeth: report of treecases. Dent Traumatol 2008;24:e11—5.

13. Andrade ES, Sobrinho ALPC, Andrade MGS, Matos JLF. Roothealing after horizontal fracture: a case with a 13-year followup. Dent Traumatol 2008;24:e1—3.

14. Chala S, Sakout M, Abdallaoui F. Repair of untreated horizontalroot fractures: two case reports. Dent Traumatol 2009;25:457—9.

15. Aguiar CM, Mendes DA, Camara AC. Horizontal root fracture ina maxillary central incisor: a case report. Gen Dent2013;61:12—4.

16. Polat-Ozsoy O, Gulsahi K, Veziroglu F. Treatment of horizontalroot-fractured maxillary incisors — a case report. Dent Trauma-tol 2008;24:e91—5.

17. Fagundes DS, Mendonca IL, Albuquerque MT, Inojosa IF. Sponta-neous healing responses detected by cone-beam computedtomography of horizontal root fractures: a report of two cases.Dent Traumatol 2014;30:484—7.

18. Belobrov I, Weis MV, Parashos P. Conservative treatment of acervical horizontal root fracture and a complicated crown frac-ture: a case report. Aust Dent J 2008;53:260—4.

19. Cvek M, Tsilingaridis G, Andreasen JO. Survival of 534 incisorsafter intra-alveolar root fracture in patients aged 7—17 years.Dent Traumatol 2008;24:379—87.

20. Andreasen JO, Ahrensburg SS, Tsilingaridis G. Root fractures: theinfluence of type of healing and location of fracture on toothsurvival rates — an analysis of 492 cases. Dent Traumatol2012;28:404—9.

21. Poi WR, Manfrin TM, Holland R, Sonoda CK. Repair characteristicsof horizontal root fracture: a case report. Dent Traumatol2002;18:98—102.

22. Hovland EJ. Horizontal root fractures: treatment repair. DentClin N Am 1992;18:150—3.

23. Jin H, Thomas HF, Chen J. Wound healing and revascularization:a histologic observation of experimental tooth root fracture.Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;81:26—30.

24. Andreasen FM, Andreasen JO, Boyer T. Prognosis of root frac-tured permanent incisors: prediction of healing modalities.Endod Dent Traumatol 1989;5:11—22.

25. Silveira LFM, Martos J, Silveira CF, Gomes DJ. Resolucion endo-doncica de una fractura radicular cervical. Endodoncia2009;27:31—6.

26. Martos J, Silva FS, Poglia ID, Damian MF, Silveira LFM. Influence ofX-ray beam angulations on the detection of horizontal rootfractures. Saudi Endod J 2015;5:129—33.

27. Costa FF, Pinheiro LR, Umetsubo OS, Santos Jr O, Gaia BF,Cavalcanti MG. Influence of cone-beam computed tomographicscan mode for detection of horizontal root fracture. J Endod2014;40:1472—6.

28. Barrett JF, Keat N. Artifacts in CT: recognition and avoidance.Radiographics 2004;24:1679—91.

29. Junqueira RB, Verner FS, Campos CN, Devito KL, Carmo AM.Detection of vertical root fractures in the presence of intracanalmetallic post: a comparison between periapical radiography andcone-beam computed tomography. J Endod 2013;39:1620—4.


109

LETTERA DEL PRESIDENTE

Carissimi Soci,

la SIE - Società Italiana di Endodonzia, sceglie nuovamente dopo due anni, Bologna come sede del 35° Congresso Nazionale.

Sarà ancora il Palazzo della Cultura e dei Congressi ad ospitare, tra il 9 e l’11 Novembre p.v., una manifestazione che si preannuncia un sicuro successo, sull’onda lunga dello straordinario interesse registrato durante il Congresso Internazionale, tenutosi a Roma nello stesso periodo del 2016. Segno, questo, di un’Endodonzia italiana in grande salute, che riesce ad attirare sempre più appassionati, grazie anche all’eccezionale lavoro dei Soci Attivi della SIE, che, tutti insieme e guidati da un Direttivo illuminato, sono in grado di dare vita ad eventi sempre più interessanti, coinvolgenti ed iconograficamente affascinanti.

Il Congresso sarà preceduto, giovedì 9 Novembre, dall’ormai consueto Cor-so Pre-Congressuale dal titolo: “L’Endodonzia Chirurgica”, che sarà tenuto da eminenti esponenti della scuola di Torino: Professori Elio Berutti e Damiano Pasqualini e dal Dott. Mauro Rigolone.

Venerdì 10 e Sabato 11, nella splendida Sala Europa, capace di oltre mille posti a sedere, si alterneranno 14 relatori in quattro diverse sessioni:

- Prof. Francesco Riccitiello, Dott. Domenico Ricucci e Prof. Carlo Prati per la 1^, dal titolo “Interazione tra organo pulpare e materiali”;

- I Dott.ri Lucio Daniele, Denise Pontoriero e il duo Vasilios Kaitsas - Mario Mancini nella sessione dal titolo “L’outcome in Endodonzia”;

- I Dott.ri Alberto Rieppi, Roberto Fornara e il duo Fabio Gorni - Luigi Scagnoli, nella sessione dal titolo “La gestione dei casi complessi”;

- infine nella sessione conclusiva non poteva mancare il delicato tema del “Restauro Post-Endodontico”, sa-pientemente affrontato dai Prof.ri Francesco Mangani, Enrico Gherlone e Marco Ferrari.

Oltre alle relazioni della sala plenaria sono previste le interessanti esposizioni dei finalisti dei Premi SIE: il Premio Francesco Riitano, che andrà alla migliore relazione su temi che riguardano la strumentazione, l’in-novazione e il rispetto dell’anatomia; il Premio Garberoglio, al miglior lavoro di ricerca; ed infine, il Premio Lavagnoli, per il miglior case-report.

Nel programma anche la due Master Clinician a cura dei Main Sponsor SIE Dentalica e Dentsply Sirona.

Infine al venerdì pomeriggio non potevano mancare le Tavole Cliniche a marchio SIE alle quali si è voluto dare un taglio molto pratico: momenti formativi veri è propri per offrire ai partecipanti la possibilità di cogliere diverse nozioni da utilizzare nell’immediato della loro attività clinica.

In conclusione, un programma ricco, utile e di alto profilo scientifico per di più nella cornice della splendida Bologna “La Dotta”: tanti motivi per non perdere questo nuovo evento per stare sempre inSIEme.

Il Presidente SIE Francesco Riccitiello

110

COORDINATORE CULTURALE

Dott. Mauro RigoloneVia Giovine Italia,1813100 Vercelli (VC)Tel. 0161-503450Fax 0161-503450e-mail: [email protected]

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SEGRETARI REGIONALI 2017/2018

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111

SOCI ONORARI

Borsotti Prof. GianfrancoBresciano Dott. BartoloMantero Prof. FrancoPecora Prof. GabrielePerrini Dott. Nicola

SOCI ATTIVI

Agresti Dott. DanieleAltamura Dott. CarloAmato Prof. MassimoAmbu Dott. EmanueleAmoroso D’Aragona Dott.ssa EvaAscione Dott.ssa Maria RosariaAutieri Dott. GiorgioBadino Dott. MarioBarattolo Dott. RanieroBarboni Dott.ssa Maria GiovannaBecciani Dott. RiccardoBeccio Dott. RobertoBertani Dott. PioBerutti Prof. ElioBianco Dott. AlessandroBonaccorso Dott. AntoninoBonacossa Dott. LorenzoBonelli Bassano Dott. MarcoBorrelli Dott. MarinoBoschi Dott. MaurizioBottacchiari Dott. Renato StefanoBotticelli Dott. ClaudioBrenna Dott. FrancoBuda Dott. MassimoCabiddu Dott. MauroCalabrò Dott. AntonioCalapaj Dott. MassimoCalderoli Dott. StefanoCampo Dott.ssa SimonettaCanonica Dott. MassimoCantatore Prof. GiuseppeCapelli Dott. MatteoCardinali Dott. FilippoCardosi Carrara Dott. FabrizioCarmignani Dott. EnricoCarratù Dott.ssa PaolaCarrieri Dott. GiuseppeCascone Dott. AndreaCassai Dott. EnricoCastellucci Dott. ArnaldoCastro Dott. Davide FabioCavalleri Prof. GiacomoCavalli Dott. GiovanniCecchinato Dott. LuigiCerutti Prof. AntonioCiunci Dott. Renato PasqualeColla Dott. MarcoConconi Dott. MarcelloCoraini Dott. CristianCortellazzi Dott. GianlucaCotti Prof.ssa ElisabettaCozzani Dott.ssa MarinaD’Agostino Dott.ssa AlessandraDaniele Dott. LucioDel Mastro Dott. GiulioDettori Dott.ssa Claudia

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Pasqualini Dott. DamianoPiferi Dott. MarcoPilotti Dott. EmilioPisacane Dott. ClaudioPolesel Prof. AndreaPollastro Dott. GiuseppePongione Dott. GiancarloPontoriero Dott.ssa Denise Irene KarinPortulano Dott. FrancescoPracella Dott. PasqualePreti Dott. RiccardoPulella Dott. CarmeloPuttini Dott.ssa MonicaRaffaelli Dott. RenzoRaia Dott. RobertoRapisarda Prof. ErnestoRe Prof. DinoRengo Prof. SandroRiccitiello Prof. FrancescoRicucci Dott. DomenicoRieppi Dott. AlbertoRigolone Dott. MauroRizzoli Dott. SergioRoggero Dott. EmilioRusso Dott. ErnestoSantarcangelo Dott. Filippo SergioSbardella Dott.ssa Maria ElviraSberna Dott.ssa Maria TeresaScagnoli Dott. LuigiSchianchi Dott. GiovanniSchirosa Dott. Pier LuigiSerra Dott. StefanoSimeone Prof. MicheleSmorto Dott.ssa NataliaSonaglia Dott. AngeloSqueo Dott. GiuseppeStorti Dott.ssa PaolaStrafella Dott. RobertoStuffer Dott. FranzTaglioretti Dott. VitoTaschieri Dott. SilvioTavernise Dott. SalvatoreTiberi Dott. ClaudioTocchio Dott. CarloTonini Dott. RiccardoTosco Dott. EugenioTripi Dott.ssa Valeria RomanaUberti Dott.ssa ManuelaUccioli Dott. UmbertoVecchi Dott. StefanoVenturi Dott. GiuseppeVenturi Dott. MauroVenuti Dott. LucaVeralli Dott. EduardoVignoletti Dott. GianfrancoVittoria Dott. GiorgioVolpi Dott. Luca FedeleZaccheo Dott. FrancescoZerbinati Dott. MassimoZilocchi Dott. FrancoZuffetti Dott. PierFrancesco

SOCI AGGREGATI

Cuppini Dott.ssa ElisaD’Alessandro Dott. AlfonsoFranchi Dott.ssa IreneGiovinazzo Dott. LucaMessina Dott. GiovanniMilani Dott. StefanoPaone Dott. PasqualeZaccheo Dott. Fabrizio

SOCI SCOMPARSIRicordiamo con affetto e gratitudine i Soci scomparsi:

Attanasio Dott. SalvatoreSocio AttivoCastagnola Prof. LuigiSocio OnorarioDe Fazio Prof. PietroSocio AttivoDolci Prof. GiovanniSocio OnorarioDuillo Dott. SergioSocio OnorarioGarberoglio Dott. RiccardoSocio OnorarioLavagnoli Dott. GiorgioSocio OnorarioPecchioni Prof. AugustoSocio OnorarioRiitano Dott. FrancescoSocio OnorarioSpina Dott. VincenzoSocio OnorarioZerosi Prof. CarloSocio Onorario

CONSIGLIO DIRETTIVO SIE BIENNIO 2017-2018

Past PresidentPio Dott. Bertani

PresidenteFrancesco Prof. Riccitiello

Presidente ElettoVittorio Dott. Franco

Vice Presidente Maria Teresa Dott.ssa Sberna

SegretarioRoberto Dott. Fornara

TesoriereFilippo Dott. Cardinali

Coordinatore CulturaleMauro Dott. Rigolone

Coordinatore della Comunicazione Italo Dott. Di Giuseppe

Revisori dei ContiKatia Dott.ssa GrecoAlberto Dott. Rieppi

STRUTTURA SOCIETARIA

OmniOpticTM è il sistema ideale per gli utenti che desiderano aumen-tare il potere di ingrandimento nel corso della loro carriera grazie alla possibilità di scegliere tra le quat-tro potenze di ingrandimento di-sponibili che vanno da 2.5X a 5,5X.Il design unico presenta una mon-tatura con un sistema di anco-raggio magnetico integrato che permette ai medici di aggiornare la loro potenza di ingrandimento senza dover ordinare un nuovo oc-chiale. Si può iniziare con una po-tenza di ingrandimento di 2,5X per le procedure di routine e prosegui-re fino a 3,5X o un ingrandimento maggiore per procedure più preci-se. Una distanza di lavoro coeren-te ad ogni livello di ingrandimento consente anche all’utente di cam-biare potenze di ingrandimento senza comprometterne il posizio-namento. Gli oculari sono facili da sostituire grazie ad un sistema ad

incastro con magneti senza dovere quindi avere un occhiale apposito per ciascun ingrandimento.Il nuovo sistema OmniOpticTM, come tutti i sistemi di ingrandi-mento della linea Orascoptic, è personalizzato in base alla con-formazione del viso, distanza di la-voro ed esigenze visive del cliente, caratteristiche che lo rendono uni-co nel settore dei sistemi di ingran-dimento professionali, lenti antiri-flesso e antigraffio per un comfort ottimale ed un’esperienza di visio-ne senza eguali. L’occhiale è disponibile esclusiva-mente con configurazione Throu-gh the lens (TTL) e supporta tut-te le montature disponibili della linea, dalla più classica montatura Victory™ in Titanio, alle monta-ture sportive Rydon™ e Rave™ in policarbonato (progettate e pro-dotte dal celebre marchio Rudy Project®), alla montatura Legend™

in alluminio. Il peso può variare da 57gr fino a 82gr per il maggior po-tere ingrandente. OmniOpticTM gode di una garan-zia a vita limitata sugli oculari e tre anni sulla montatura e viene spe-dito unitamente al kit di accessori standard composto da protezioni laterali, laccetto elastico stringi-testa, custodia personalizzata ed accessori per la manutenzione dei sistemi ingrandenti.

Dopo il lancio di EyezoomTM ed Eyezoom MiniTM negli anni scorsi, gli unici sistemi ad ingrandimen-to variabile al mondo, Orascoptic si riconferma leader nei sistemi di ingrandimento professionali per il settore dentale e partner di eccel-lenza di Simit Dental da più di 16 anni.

Perché sceglierne solo uno?!

Orascoptic lancia OmniOpticTM, il primo ed unico sistema ad ingrandimenti intercambiabili che permette ai professionisti di selezionare l’ingrandimento ottimale per ciascuna procedura.

Per ulteriori informazioni visita il sito www.simitdental.it

ORASCOPTIC PRESENTA

- La storia di successo continua

La nuova generazione di strumenti di successo RECIPROC® per la preparazione canalare reciprocante è finalmente arrivata.

VDW®, specialista in Endodonzia, è lieta di annunciare l’introduzione sul mercato italiano della nuova generazione di strumenti RECIPROC®. L’innovativo processo produttivo rende il file molto più flessibile e riduce ulteriormente il rischio di frattura, rendendo la preparazione del canale radicolare ancora più sicura e più facile da eseguire per il dentista. Inoltre, se necessario, è possibile precurvare gli strumenti per ottenere un accesso più facile ai canali complessi.

Gli strumenti RECIPROC® blue vengono prodotti con una lega Nichel-Titanio, sottoposta ad un innovativo trattamento termico, che, modificando la sua struttura molecolare, fornisce agli strumenti RECIPROC® le proprietà aggiuntive descritte. Il processo termico inoltre attribuisce al file il caratteristico colore blu, da cui prende nome il file.

Gli strumenti RECIPROC® blue sono adatti sia per gli utenti più esperti che per chi desidera iniziare ad utilizzare il sistema reciprocante. RECIPROC® blue garantisce tutti i benefici già presenti nel sistema RECIPROC®. Anche la procedura di utilizzo del sistema reciprocante da parte del dentista rimane invariata, pertanto gli strumenti RECIPROC® blue possono essere utilizzati con tutti i motori endodontici VDW®.

Per la preparazione dei canali radicolari il sistema RECIPROC® costituisce senza dubbio il traguardo più importante dallo sviluppo di sistemi rotanti in NiTi. Dalla sua introduzione nel 2011, il sistema si è affermato all’interno degli studi dentistici coinvolgendo un numero sempre maggiore di utilizzatori. Un’indagine di mercato condotta nel 2014 conferma un elevato livello di soddisfazione tra gli utenti, che attribuiscono al sistema RECIPROC® una preparazione sicura, un basso rischio di frattura dello strumento, un’ampia gamma di indicazioni d’uso, una eccellente sagomatura e una adeguata preparazione apicale.

L’utilizzo di un unico strumento monouso riduce il rischio di contaminazione crociata e i tempi di lavoro in studio, grazie all’eliminazione delle procedure di pulizia e sterilizzazione. In media, circa l’80% dei canali sono interamente preparati con un solo strumento. Il 73% degli utenti utilizza RECIPROC® anche per il ritrattamento.

Maggiore flessibilità* Maggiore resistenza alla fatica ciclica*

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Gli strumenti RECIPROC® blue sono il 40% più flessibili rispetto agli strumenti RECIPROC®.

La resistenza alla fatica ciclica degli strumenti RECIPROC® blue è 2,3 volte superiore rispetto agli strumenti RECIPROC®.

DENTSPLY Italia S.r.l.Piazza dell’Indipendenza, 11/B · 00185 Roma · Fax 06 72640394 [email protected] · www.dentsplysirona.com

Two fi les to shape

2Shape è un sistema NiTi innovativo e versatile in grado di trattare la maggior parte dei canali radicolari.

La sequenza clinica breve con soli due strumenti e l’elevata effi cienza di taglio riducono i tempi di sagomatura rispettando l’anatomia originale del canale.

La nuova sezione asimmetrica con due profi li di taglio principali e uno secondario, garantisce un’eccellente capacità di taglio e aumenta l’effi cacia dello spazzolamento in appoggio parietale per una pulizia selettiva ed effi cace.

Il rischio di rottura dello strumento è signifi cativamente ridotto grazie all’esclusivo trattamento termico T-Wire, brevetto Micro-Méga, che aumenta la resistenza dello strumento alla fatica ciclica (+40%) e permette una migliore negoziazione delle curve. I due strumenti ritornano alla loro forma originaria dopo ogni utilizzo.

Gli strumenti sono disponibili in blister presterilizzati da 5 fi le nelle lunghezze 21, 25 e 31 mm. Il sistema include anche due strumenti per la rifi nitura dell’apice, oltre a coni di carta e di guttaperca corrispondenti alle misure dell’ultimo fi le usato.

DISTRIBUTORE ESCLUSIVO PER L’ITALIA DENTALICA S.p.A. – Via Rimini, 22 – 20142 Milano T 02.895981 – F 02.89504249 – [email protected] – www.dentalica.com

I ritrattamenti endodontici rappresentano una percentuale molto alta nel la-

voro di un dentista e ancora di più in quella di uno specialista in endodonzia.

Ritrattare endodonticamente un elemento dentario significa come prima cosa

rimuovere tutto il vecchio materiale da otturazione canalare, quindi negoziare

il forame apicale, sagomare nuovamente tutto il canale radicolare, deterge-

re ed otturare in maniera tridimensionale il complesso sistema canalare. Gli

Endo Re-Start sono tre strumenti endodontici in Nichel-Titanio costruiti per

rendere semplice, rapida, sicura e soprattutto completa la fase della rimozio-

ne del materiale da otturazione presente nei canali radicolari. Spesso la fase

più complicata durante un ritrattamento endodontico è costituita dalla penetrazione di uno strumento attraverso il materiale

presente nel terzo coronale del canale.

L’Endo Re-Start Opener, grazie alla sua punta tagliente, ad una parte lavorante lunga solo 5 mm e ad una conicita 010 e lo

strumento che meglio riesce a realizzare questa prima fase. Ad una velocita di 300 rpm e con il torque impostato a 1,8 N/cm

l’Endo Re-Start Opener viene spinto delicatamente attraverso il materiale da otturazione presente nella prima porzione rettilinea

del canale.

Prima di passare alla vera e propria fase di rimozione del materiale dall’interno del canale radicolare è sempre meglio ottenerne

il completo sondaggio. Lo strumento che trovo particolarmente utile per questo scopo è il Patency File. Il Patency File è un

K-file realizzato con un acciaio particolarmente resistente in quanto subisce durante la sua fabbricazione un trattamento termi-

co che lo rende più stabile e performante durante la fase di sondaggio.

La seconda fase di un ritrattamento endodontico consiste nella rimozione completa del vecchio materiale da otturazione ca-

nalare. E’ qui che entra in gioco lo strumento Endo Re-Start (disponibile con lunghezza da 21 o 25 mm). La sua conicità di

05 associata ad una punta raschiante da 0,25 e ad un innovativo disegno delle spire (piu ravvicinate a livello della punta dello

strumento e più distanziate lungo il resto della parte lavorante) crea quello che viene definito “Dynamic Twist”. Il Dynamic Twist

è responsabile contemporaneamente di penetrazione dello strumento e rimozione del materiale anche da canali curvi, cosa

questa impensabile fino ad oggi con un unico strumento da ritrattamento endodontico in Nichel Titanio.

TriAuto ZX2Massima precisione e sicurezza per il canale radicolare.

Il nuovo sistema endodontico aumenta l’efficienza e la sicurezza.

In Endodonzia la necessità di lavorare su struttu-re minuscole, in spazi molto limitati ed anche le particolari situazioni Anatomiche coinvolte pon-gono richieste straordinarie alle competenze del dentista, richiedendo sforzi speciali per garan-tire la sicurezza dei pazienti. Pioniere nel cam-po della Endodonzias, Morita ha sempre offerto soluzioni di alta qualità per i dentisti per molti decenni, puntando all’efficienza, comfort e sicu-rezza. Un esempio di questo è il nuovo TriAuto ZX2, un motore endo cordless, con localizzatore apicale integrato che ora include una funzionalità innovativa per una maggiore sicurezza: la funzio-ne ottimale glide path (OGP) mira a procedure ancora più precise all’interno del canale radico-lare e guida i dentisti e i pazienti al successo del trattamento, “seguendo percorsi sicuri.L’Endodonzia ha svolto un ruolo fondamentale in più di 100 anni di storia di Morita. Già nel 1991, è stato introdotto il primo Apex Locator del mondo che ha utilizzato le misure di impedenza, il Root ZX. Il passo successivo in questo sviluppo è stato il sistema modulare DentaPort ZX che grazie alla possibilità di integrazione con il Motore Endo, ha

facilitato la preparazione del canale radicolare.Con il ZX2 TriAuto, Morita ora presenta un nuovo motore endo con localizzatore apicale integrato. Il successore del TriAuto ZX, è l’unico sistema en-dodontico sul mercato che combina entrambe le funzioni in un unico manipolo. Un display LCD Mostra misure precise e fornisce un feedback perfetto dall’interno del canale radi-colare. Oltre a questo), il ZX2 TriAuto presenta due caratteristiche di sicurezza innovative -quali l’Optimum Torque reverse (OTR) e l’Optimum Gli-de Path (OGP)La funzione OTR consente di cambiare la dire-zione di rotazione del file quando viene superato il livello massimo di coppia. Combinata con la pic-colissima rotazione angolare, il rischio di rotture di file e microfessure è minimizzato. Inoltre, il sistema conserva il canale radicolare originale e assicura la rimozione affidabile dei detriti.La nuova funzione OGP semplifica la creazione del percorso canalare, rendendolo veloce e sicu-ro, e automatico. In più, il motore può realizzare la pervietà apicale usando una lima # 20 o più piccola. Possono essere utilizzati Niti file di di-

mensioni # 20 o più piccoli e file in acciaio dalla dimensione # 15. La funzione OGP in combinazio-ne con quella OTR permette allo strumento endo-dontico di essere portato alla lunghezza di lavoro più velocemente di quanto precedentemente possibile, senza blocco o formazione di scalini. Inoltre, TriAuto ZX2 conserva la struttura del dente naturale e rende il trattamento ancora più economico a causa di un ridotto consumo di file.Il display LCD mostra tutti i parametri importanti a colpo d’occhio, fornendo il controllo completo durante il trattamento. Un’altra caratteristica chiave del sistema en-dodontico è la piccola testina ed il basso peso (140 g), che permettono una migliore vista del campo di trattamento. Il fatto di essere cord-less migliora significativamente la flessibilità di trattamento e ottimizza il flusso di lavoro. Il funzionamento semplice ed intuitivo e le funzio-ni automatizzate garantiscono risultati affidabili in ogni momento. La maggiore efficienza riduce anche la durata del trattamento, fornendo tempo supplementare per il risciacquo e la disinfezione del canale radicolare.

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Nella spettacolare, elegantissima e storica cornice del Grand Hotel di Rimini, ubicato all’interno del parco Federico Fellini, nelle gior-nate comprese fra il 16 e il 18 giugno scorse, si è svolto il tradi-zionale Closed Meeting della So-cietà Italiana di Endodonzia.

Aggiornamento, convivialità, co-noscenza inter-personale e spirito societario, hanno rappresentato come di consueto il filo conduttore dell’evento. Per i membri del Con-siglio Direttivo i lavori sono iniziati nella giornata di giovedì 15 Giu-gno pomeriggio con la consueta riunione.

I Soci Attivi invece, hanno iniziato ad arrivare la mattina del venerdì 16. Nel pomeriggio, presso l’at-tiguo centro congressi del Grand Hotel sono iniziati i lavori del pro-gramma culturale con la relazione del Dott. Edoardo Foce sul tema “L’allungamento di corona clinica

nel recupero endodontico-restaura-tivo dell’elemento dentale compro-messo”. È seguita poi l’esposizione da parte della vincitrice del “Miglior caso clinico under 32”, la Dott.ssa Chiara Fossati. La serata si è conclusa con la ricercata e squisi-ta cena presso il ristorante Terraz-za del Grand Hotel.

Il giorno successivo, sabato 17, è stato dedicato alle riunioni delle varie Commissioni Societarie cuo-re pulsante delle attività della SIE. Si sono infatti riunite la Commissio-ne Culturale, coordinata dal Dott. Massimo Giovarruscio, al termine dei lavori della quale ha relaziona-to il Dott. Silvio Taschieri sul tema “Come leggere ed interpretare un lavoro scientifico”; la Commis-sione per la Ricerca, coordinata dal Prof. Giuseppe Cantatore; la Commissione WEB, coordinatore della comunicazione Dott. Italo Di Giuseppe e Web-Master Dott. Augusto Malentacca; le sezioni regionali, coordinate dal Dott. Cristian Coraini e dal Coordina-tore Culturale SIE Dott. Mauro Ri-golone. E finalmente, dopo tanto “dovere”, lavoro, riunioni, un po’ di relax in piscina e al mare, dove i più “facinorosi” ed atletici (si fa per dire…), hanno animato un tor-neo di beach-volley.La serata invece ha previsto un transfer per la cena, svoltasi pres-so il suggestivo ristorante “Riviera Mare” sulla spiaggia di Misano Adriatico.

La domenica mattina per alcuni soci è stata dedicata all’escursio-ne al magnifico Castello medieva-le di Gradara mentre per i più ai preparativi per i rientri a casa. Il Closed Meeting si è dunque concluso con i saluti fra i soci par-tecipanti, intervenuti in numero di 101, che si sono congedati dan-dosi appuntamento alle prossime numerose ed imminenti iniziative della SIE, più importante fra le quali il tradizionale 35° Congres-

so Nazionale, dal titolo “Endo-donzia, tra fondamenti e innova-zioni”, che si svolgerà come di consueto nelle giornate del 9, 10 e 11 Novembre, presso il Palaz-zo della Cultura e dei Congressi di Bologna.

VITA SOCIETARIA

16-18 GIUGNO 2017, RIMINI

Closed Meeting 2017Grand Hotel Rimini *****L - Parco Federico Fellini 47921 Rimini (RN)

Resoconto a cura del Dott. Cristian Coraini e del Dott. Italo Di Giuseppe

IL DOTT. FORNARA CHE APRE I LAVORI SCIENTIFICI

BENVENUTO DELLA SIE AI SOCI

GRAND HOTEL DI RIMINI

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LA CENA PRESSO IL GRAND HOTEL DI RIMINI

ULTIMA SERA DEL CLOSED MEETING!

I MEMBRI DELLA CAS

IL PRESIDENTE PROF. RICCITIELLO E IL RELATORE DOTT. FOCE

LA VINCITRICE DEL MIGLIOR CASO CLINICO UNDER 32 LA DOTT.SSA MICHELA CASERTA

IL DOTT. SCHIROSA A SPASSO PER RIMINI

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Il 13 maggio si è svolta, nella sug-gestiva Aula Magna del Centro Congressi Federico II, la Giornata Endodontica Regionale SEC. Tito-lo della Giornata è stato: “Endo-donzia semplice e predicibile”. L’evento, che ha visto la partecipa-zione di oltre 120 persone, si è aperto con il saluto del Presidente SIE Prof. Francesco Riccitiello che ha poi introdotto il Prof. Sandro Rengo ed il Prof. Gregorio Laino per gli indirizzi di saluto da parte delle Università Napoletane. La parola è quindi andata al Prof. Massimo Amato che ha dato il via ai lavori congressuali presentando il primo relatore della giornata il Dott. Giorgio Vittoria che ha mo-strato i vantaggi dell’utilizzo della diagnostica in 3D in Endodonzia. Il secondo relatore il Dott. Alfredo Iandolo ha invece parlato di de-tersione partendo dalla ricerca per poi arrivare alla clinica. La prima sessione mattutina si è conclusa con la presentazione del Dott. Marino Borrelli, veterano della sezione, sull’otturazione tridimen-sionale dello spazio endodontico con MB System. Durante il coffe break, in un aula precedentemen-te allestita il Dott. Giorgio Vittoria ha tenuto una affollatissima tavola clinica. La seconda parte della mattinata ha poi avuto inizio con la conferenza del Dott. Mariano Malvano, presentato dalla Dott.

ssa Paola Carratù, sulla risoluzio-ne di casi endodontici complessi. Ultima relazione della mattinata è stata quella del Prof. Michele Si-meone sull’Endodonzia chirurgica. Concludo ringraziando tutti coloro che hanno contribuito al successo di questa giornata. Grazie di cuo-re al Presidente SIE Prof. Riccitiello, al Prof. Rengo, al Prof. Laino ed a tutta l’Università degli Studi di Napoli Federico II e Luigi Vanvitel-li. Grazie al Prof. Massimo Amato ed a tutta l’Università Degli Studi di Salerno. Grazie ad ANDI Na-poli nelle figure del Dott. Pasquale Di Maggio e Giuseppe Pollastro, all’Ordine dei Medici e degli Odontoiatri di Napoli e di Saler-no ed all’AIO. Grazie ai numerosi Sponsor. Grazie a tutti i Relatori. Un ringraziamento particolare a Gaia che mi ha supportato nelle fasi organizzative e si è occupata con grande maestria della segre-teria e grazie a tutti voi, senza il vostro aiuto sarebbe stato impossi-bile organizzare la giornata. Non mi resta che augurarmi di vedervi di nuovo in tanti al prossimo con-gresso SEC.

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SINTESI DELLA GIORNATA ENDODONTICA REGIONALE SEC

Endodonzia semplice e predicibileNAPOLI, 13 MAGGIO 2017 - Dott. Giancarlo Pongione

LA SALA CONFERENZE

LA SPLENDIDA LOCATION DELLA GIORNATA REGIONALE CAMPANA

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LA TORTA DELLA SEC

IL PRESIDENTE PROF. RICCITIELLO E IL SEGRETARIO REGIONALE DOTT. PONGIONE

TUTTI I SOCI ATTIVI REGIONALI E RELATORI DELLA GIORNATA

LA TAVOLA CLINICA DEL DOTT. VITTORIA

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Il 27 maggio 2017 si è svolta la giornata endodontica regionale SEP/SEB nella splendida corni-ce di Matera “Città dei Sassi”. Suscitando grande interesse, i nostri amici relatori, che hanno voluto condividere con noi questa esperienza dedicandoci il loro prezioso tempo e la loro grande professionalità, hanno calamitato l’attenzione dei numerosi parteci-panti con esposizioni interessanti ed attuali. Il titolo della giornata “Possibili soluzioni di casi com-plessi” ha riscontrato grande suc-cesso da parte dei colleghi che, nonostante la splendida giornata di sole hanno affollato la sala fino alle ultime relazioni gratificando sia i relatori che gli organizzato-ri. Aver voluto inserire argomenti di grande attualità, tipo l’impor-tanza della CBTC nella diagnosi endodontica sia ortograda che chirurgica, magistramente esposta dal Dr. Fornara (nostro nuovo Se-gretario SIE), dell’utilizzo del Laser nell’irrigazione canalare illustrata-ci dal Dr. Olivi, è stato premiato dall’entusiasmo della platea. Con una divertente esposizione il Dr. Carrieri ci ha rinfrescato le idee sul trattamento del dolore, attraverso una capillare revisione della let-teratura, dando delle indicazioni specifiche a seconda delle varie situazioni da gestire prima, duran-te e dopo il trattamento in caso di

necessità. Con puntuale chiarezza il Dr. Parente ci ha illustrato come dirimere il dubbio se insistere nel recupero dell’elemento dentario o pensare a sostituirlo con un im-pianto. Centrando perfettamente il significato della giornata il Dr. D’Alessandro ha dimostrato come risolvere casi complessi adottando protocolli semplici da mettere in pratica nella nostra quotidianità, al pari del Dr. Manfredonia che ci ha illustrato come utilizzare con rela-tiva semplicità un materiale come MTA. Il Dr. Squeo ci ha ricordato la grande importanza della stru-mentazione manuale nell’affronta-re il sistema canalare sia nei casi semplici che in quelli complessi. Il Dr. De Fulvio ha calamitato l’at-tenzione sul recupero di elementi dentari trattati endodonticamente si con metodiche di restauro diret-to che indiretto. Un ringraziamento particolare va comunque ai nostri sponsor sia nazionali che locali che ci permettono ogni volta di poter organizzare eventi culturali interessanti e alla nostra sempre efficiente segretaria Gaia, che è riuscita a sopravvivere alle nostre abitudini tipicamente meridionali. Vi aspettiamo alla prossima!

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SINTESI DELLA GIORNATA ENDODONTICA REGIONALE SEP/SEB

Possibili soluzioni di casi complessiMATERA, 27 MAGGIO 2017 - Dott.ssa Eva Amoroso d’Aragona, Dott. Pier Luigi Schirosa

I SEGRETARI REGIONALI DOTT. SCHIROSA E DOTT.SSA AMOROSO D’ARAGONA

LE GUSTOSISSIME FRAGOLE GENEROSAMENTE OFFERTE DAL DOTT. SCHIROSA

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I PRESIDENTI DI SESSIONE DOTT. SCAGNOLI E DOTT.SSA AMOROSO D’ARAGONA

I PRESIDENTI DI SESSIONE DOTT. SCAGNOLI E DOTT.SSA AMOROSO D’ARAGONA CON IL RELATORE DOTT. FORNARA

I SEGRETARI REGIONALI CON IL RELATORE DOTT. OLIVI

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Nella splendida cornice dell’Aula Magna di Medicina dell’Univer-sità degli Studi di Genova si è svolta, il 10 di Giugno 2017, la Settima Giornata Endodontica Re-gionale SEL.Il considerevole numero di parteci-panti, data la soleggiata giornata estiva, ha seguito con interesse le relazioni dei nostri Soci Attivi loca-li, tutti esperti relatori Nazionali ed Internazionali.La giornata è iniziata in perfetto orario, dopo una breve introduzio-ne da parte della sottoscritta ed il saluto delle Autorità, nella fattispe-cie il Vice Presidente Nazionale dell’ANDI dott. Massimo Gagge-

ro ed il prof. Stefano Benedicenti, al quale rivolgo un personale rin-graziamento per il costante aiuto e supporto in ogni attività SIE da me organizzata.I Protocolli Endodontici dell’Endo-donzia Ortograda e Retrograda sono stati illustrati e spiegati in maniera semplice ed accattivante, con casi ed immagini impeccabi-li, da parte dei bravissimi relatori: la dott.ssa Maria Teresa Sberna, il dott. Luca Ivaldi, il dott. Andrea Polesel, il dott. Vaid Hazini, il dott. Massimo Zerbinati ed il dott. Mar-co Bonelli.Durante il lunch hanno avuto luogo due tavole cliniche (Simit e Dentali-

ca), anch’esse molto affollate, con grande soddisfazione degli Spon-sors, dai quali ho ricevuto perso-nalmente feedbacks molto positivi.La giornata si è conclusa, come da programma, nel tardo pome-riggio, ma in tempo per festeggiar-ne il successo con un brindisi tutti insieme in riva al bellissimo mare genovese.Con l’organizzazione di questo evento è terminata la mia avventu-ra da Segretario Regionale Ligure.Sono stati quattro anni intensi, im-pegnativi, ma allo stesso tempo bellissimi e stimolanti, anche gra-zie al clima di grande collabora-zione ed amicizia che da sempre

contraddistingue la nostra sezione.Ringrazio tutti, ma in particolare il mio predecessore, il dott. Andrea Polesel, per il tempo e l’aiuto de-dicatomi, anteponendo sempre il bene della SEL in ogni occasione.Passo il testimone all’amico dott. Luca Ivaldi, a cui mi metto a dispo-sizione come Segretario uscente, sperando di essere per lui altrettan-to preziosa.

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SINTESI DELLA GIORNATA ENDODONTICA REGIONALE SEL

Protocolli Endodontici: dalla diagnosi alla finalizzazioneGENOVA, 10 GIUGNO 2017 - Dott.ssa Denise Irene Karin Pontoriero

TUTTI I PARTECIPANTI E I RELATORI DELLA GIORNATA REGIONALE LIGURE

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LA DOTT.SSA PONTORIERO, SEGRETARIO REGIONALE CON IL RELATORE DOTT.SSA SBERNA

LA DOTT.SSA PONTORIERO CON IL RELATORE DOTT. IVALDI SEGRETARIO ENTRANTE

LA DOTT.SSA PONTORIERO CON IL RELATORE DOTT. POLESEL

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Con il quinto incontro svoltosi il 12 settembre, si è conclusa a Brescia, presso Astidental SPA, che ha mes-so a disposizione la sala, la terza edizione dell’Endodontic Course a cura della Sezione Lombarda della SIE.Come nelle precedenti edizioni, anche quest’anno il successo del Corso è stato decretato, non solo dal folto numero di partecipanti ma anche dal loro grande interes-se dimostrato in ogni incontro.Numerosissimi i giovani, sia stu-denti che neo-laureati, ma anche professionisti affermati determinati

nell’apprendere i più moderni orientamenti in Endodonzia.Si sono succeduti come relatori, alcuni Soci Attivi della nostra so-cietà, sempre pronti a prodigarsi nel mettere a disposizione degli iscritti, la loro esperienza clinica.Il Dott. Giovanni Cavalli e il Dott. Roberto Fornara nel primo incon-tro, hanno affrontato rispettivamen-te la diagnosi, il piano di tratta-mento in endodonzia e la visione reale dell’anatomia endodontica tramite l’utilizzo della CBCT.Nel secondo incontro, il Dott. Stefano Gaffuri insieme al Dott.

Giuseppe Venturi hanno affrontato l’importanza di una corretta cavità di accesso e l’utilizzo della diga di gomma, con relativa esercitazione pratica, mentre il Dott. Riccardo To-nini si è occupato della detersione del sistema radicolare.Il Dott. Luigi Cecchinato nel succes-sivo terzo appuntamento, ha tratta-to la sagomatura dei canali men-tre l’otturazione è stata argomento della quarta giornata a cura del Dott. Stefano Gaffuri e del Dott. Giuseppe Venturi.Il quinto incontro ha visto come re-latori i Dott.ri Giuseppe Squeo (Se-

zione Pugliese) e Cristian Coraini, rispettivamente su come diventare Socio Attivo e come eseguire correttamente il sigillo coronale post-terapia endodontica.Vanno ringraziate per la loro ap-prezzata partecipazione, le ditte Simit Dental, Morita e Komet, che hanno tenuto i rispettivi work shop durante il terzo, quarto e quinto in-contro, offrendo ai partecipanti la possibilità di testare i loro strumenti e motori dedicati all’Endodonzia moderna.

VITA SOCIETARIA

SIE ENDODONTIC COURSES 2017 - SLE

Corsi di formazione teorico/pratici della SIEBRESCIA, 12 SETTEMBRE 2017

TUTTI I PARTECIPANTI DELL’ENDODONTIC COURSE DI BRESCIA, IL SEGRETARIO REGIONALE DOTT. GAFFURI E IL RELATORE DELLA GIORNATA DOTT. FORNARA

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VITA SOCIETARIA

IL SEGRETARIO REGIONALE DOTT. GAFFURI E IL RELATORE DELLA GIORNATA DOTT. CORAINI

I PARTECIPANTI, IL SEGRETARIO REGIONALE E IL RELATORE DELLA GIORNATA DOTT. TONINI

LA SALA DEL CORSO IL SEGRETARIO REGIONALE E IL RELATORE DELLA GIORNATA DOTT. CAVALLI

LA PARTE PRATICA TENUTA DAL DOTT. SQUEO E IL SEGRETARIO REGIONALE DOTT. GAFFURI

I PARTECIPANTI, IL SEGRETARIO REGIONALE E IL RELATORE DELLA GIORNATA DOTT. CECCHINATO

I PARTECIPANTI, IL SEGRETARIO REGIONALE E IL RELATORE DELLA GIORNATA DOTT. VENTURI

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INSTRUCTION AUTHOR

CONTENT OF AUTHOR GUIDELINES: 1. General 2. Ethical Guidelines3. Manuscript Submission Procedure4. Manuscript Types Accepted 5. Manuscript Format and Structure 6. After Acceptance7. Open Access8. Creative Commons Attribu-tion-NonCommercial-NoDerivs (CC BY-NC-ND)9. Author Rights

The journal to which you are sub-mitting your manuscript employs a plagiarism detection system. By sub-mitting your manuscript to this journal you accept that your manuscript may be screened for plagiarism against previously published works.

1. GENERAL

Giornale Italiano di Endodonzia publishes original scientific articles, reviews, clinical articles and case reports in the field of Endodontolo-gy. Scientific contributions dealing with health, injuries to and diseases of the pulp and periradicular region, and their relationship with systemic well-being and health. Original scientific articles are published in the areas of biomedical science, applied materials science, bioengineering, epidemiology and social science re-levant to endodontic disease and its management, and to the restoration of root-treated teeth. In addition, re-view articles, reports of clinical ca-ses, book reviews, summaries and abstracts of scientific meetings and news items are accepted.

Please read the instructions below carefully for details on the submis-sion of manuscripts, the journal’s re-quirements and standards as well as information concerning the procedure after a manuscript has been accepted for publication in Giornale Italiano di Endodonzia. Authors are encouraged to visit GIE web site gi-endodonzia.com for further information on the pre-paration and submission of articles and figures.

2. ETHICAL GUIDELINES

Giornale Italiano di Endodonzia adheres to the below ethical guideli-

nes for publication and research.

2.1. Authorship and Acknowledge-mentsAuthors submitting a paper do so on the understanding that the manuscript has been read and approved by all authors and that all authors agree to the submission of the manuscript to the Giornale Italiano di Endodonzia.

Giornale Italiano di Endodonzia adheres to the definition of authorship set up by The International Committee of Medical Journal Editors (ICMJE). According to the ICMJE, authorship criteria should be based on 1) sub-stantial contributions to conception and design of, or acquisiation of data or analysis and interpretation of data, 2) drafting the article or revising it critically for important intellectual con-tent and 3) final approval of the ver-sion to be published. Authors should meet conditions 1, 2 and 3.

It is a requirement that all authors have been accredited as appropriate upon submission of the manuscript. Contributors who do not qualify as authors should be mentioned under Acknowledgements.Acknowledgements: Under acknowledgements please specify contributors to the article other than the authors accredited. Please also include specifications of the sour-ce of funding for the study and any potential conflict of interests if appro-priate.

2.2. Ethical ApprovalsExperimentation involving human subjects will only be published if such research has been conducted in full accordance with ethical principles, including the World Medical Associa-tion Declaration of Helsinki (version 2008) and the additional require-ments, if any, of the country where the research has been carried out. Manuscripts must be accompanied by a statement that the experiments were undertaken with the understanding and written consent of each subject and according to the above mentio-ned principles. A statement regarding the fact that the study has been inde-pendently reviewed and approved by an ethical board should also be included. Editors reserve the right to reject papers if there are doubts as to whether appropriate procedures have been used.

When experimental animals are used the methods section must clearly indi-cate that adequate measures were taken to minimize pain or discomfort.

Experiments should be carried out in accordance with the Guidelines laid down by the National Institute of He-alth (NIH) in the USA regarding the care and use of animals for experi-mental procedures or with the Euro-pean Communities Council Directive of 24 November 1986 (86/609/EEC) and in accordance with local laws and regulations.

All studies using human or animal subjects should include an explicit sta-tement in the Material and Methods section identifying the review and ethics committee approval for each study, if applicable. Editors reserve the right to reject papers if there is doubt as to whether appropriate pro-cedures have been used.

2.3 Clinical TrialsClinical trials should be reported using the guidelines available at www.consort-statement.org. A CONSORT checklist and flow dia-gram (as a Figure) should also be included in the submission material.

The Giornale Italiano di Endodonzia encourages authors submitting manu-scripts reporting from a clinical trial to register the trials in any of the fol-lowing free, public clinical trials regi-stries: www.clinicaltrials.gov, http://clinicaltrials.ifpma.org/clinicaltrials/, http://isrctn.org/. The clinical trial registration number and name of the trial register will then be published with the paper.

2.4 Systematic ReviewsSystematic reviews should be re-ported using the PRISMA guidelines available at http://prisma-statement.org/. A PRISMA checklist and flow diagram (as a Figure) should also be included in the submission material.

2.5 Conflict of Interest and Source of FundingGiornale Italiano di Endodonzia re-quires that all sources of institutional, private and corporate financial sup-port for the work within the manuscript must be fully acknowledged, and any potential conflicts of interest noted. Grant or contribution numbers may be acknowledged, and principal grant holders should be listed. Please include the information under Ack-nowledgements.

2.6 Appeal of DecisionThe decision on a paper is final and cannot be appealed.

2.7 Permissions

If all or parts of previously published illustrations are used, permission must be obtained from the copyright holder concerned. It is the author’s responsi-bility to obtain these in writing and provide copies to the Publishers.

3. MANUSCRIPT SUBMISSION PROCEDURE

Manuscripts should be submitted electronically by e-mail: [email protected]

3.1. Manuscript Files AcceptedManuscripts should be uploaded as Word (.doc) or Rich Text Format (.rft) files (not write-protected) plus sepa-rate figure files. GIF, JPEG, PICT or Bitmap files are acceptable for sub-mission, but only high-resolution TIF or EPS files are suitable for printing.

The text file must contain the abstract, main text, references, tables, and figu-re legends, but no embedded figures or Title page. The Title page should be provided as a separate file.In the main text, please reference fi-gures as for instance ‘Figure 1’, ‘Figu-re 2’ etc to match the tag name you choose for the individual figure files uploaded. Manuscripts should be formatted as described in the Author Guidelines below.

3.2. Blinded ReviewManuscript that do not conform to the general aims and scope of the journal will be returned immediately without review. All other manuscripts will be reviewed by experts in the field (generally two referees).Giornale Italiano di Endodonzia aims to forward referees´ comments and to inform the corresponding author of the result of the review process.

Manuscripts will be considered for fast-track publication under special circumstances after consultation with the Editor.

Giornale Italiano di Endodonzia uses double blinded review. The names of the reviewers will thus not be disclo-sed to the author submitting a paper and the name(s) of the author(s) will not be disclosed to the reviewers.

To allow double blinded review, ple-ase submit your main manuscript and

INSTRUCTION AUTHOR

CONTENT OF AUTHOR GUIDELINES:

1. General 2. Ethical Guidelines3. Manuscript Submission

Procedure4. Manuscript Types Accepted 5. Manuscript Format and

Structure 6. After Acceptance7. Open Access8. Creative Commons

Attribution-NonCommercial-NoDerivs (CC BY-NC-ND)

9. Author Rights

The journal to which you are sub-mitting your manuscript employs a plagiarism detection system. By sub-mitting your manuscript to this journal you accept that your manuscript may be screened for plagiarism against previously published works.

1. GENERAL

Giornale Italiano di Endodonzia publishes original scientific articles, reviews, clinical articles and case reports in the field of Endodontolo-gy. Scientific contributions dealing with health, injuries to and diseases of the pulp and periradicular region, and their relationship with systemic well-being and health. Original sci-entific articles are published in the areas of biomedical science, applied materials science, bioengineering, epidemiology and social science rel-evant to endodontic disease and its management, and to the restoration of root-treated teeth. In addition, re-view articles, reports of clinical cas-es, book reviews, summaries and ab-stracts of scientific meetings and news items are accepted.

Please read the instructions below carefully for details on the submis-sion of manuscripts, the journal’s re-quirements and standards as well as information concerning the procedure after a manuscript has been accepted for publication in Giornale Italiano di Endodonzia. Authors are encouraged to visit GIE web site gi-endodonzia.com for further information on the preparation and submission of arti-cles and figures.

2. ETHICAL GUIDELINES

Giornale Italiano di Endodonzia ad-heres to the below ethical guidelines for publication and research.

2.1. Authorship and Acknowledge-mentsAuthors submitting a paper do so on the understanding that the manuscript has been read and approved by all authors and that all authors agree to the submission of the manuscript to the Giornale Italiano di Endodonzia.

Giornale Italiano di Endodonzia ad-heres to the definition of authorship set up by The International Committee of Medical Journal Editors (ICMJE). According to the ICMJE, authorship criteria should be based on 1) sub-stantial contributions to conception and design of, or acquisiation of data or analysis and interpretation of data, 2) drafting the article or revising it crit-ically for important intellectual content and 3) final approval of the version to be published. Authors should meet conditions 1, 2 and 3.

It is a requirement that all authors have been accredited as appropriate upon submission of the manuscript. Contributors who do not qualify as authors should be mentioned under Acknowledgements.

Acknowledgements: Under acknowledgements please specify contributors to the article other than the authors accredited. Please also include specifications of the source of funding for the study and any potential conflict of interests if ap-propriate.

2.2. Ethical ApprovalsExperimentation involving human sub-jects will only be published if such research has been conducted in full accordance with ethical principles, including the World Medical Associ-ation Declaration of Helsinki (version 2008) and the additional require-ments, if any, of the country where the research has been carried out.

Manuscripts must be accompanied by a statement that the experiments were undertaken with the under-standing and written consent of each subject and according to the above mentioned principles. A statement regarding the fact that the study has been independently reviewed and approved by an ethical board should also be included. Editors reserve the right to reject papers if there are doubts as to whether appropriate pro-cedures have been used.

When experimental animals are used the methods section must clearly indi-cate that adequate measures were taken to minimize pain or discomfort.

Experiments should be carried out in accordance with the Guidelines laid down by the National Institute of Health (NIH) in the USA regarding the care and use of animals for exper-imental procedures or with the Euro-pean Communities Council Directive of 24 November 1986 (86/609/EEC) and in accordance with local laws and regulations.

All studies using human or animal subjects should include an explicit statement in the Material and Meth-ods section identifying the review and ethics committee approval for each study, if applicable. Editors reserve the right to reject papers if there is doubt as to whether appropriate pro-cedures have been used.

2.3 Clinical TrialsClinical trials should be reported us-ing the guidelines available at www.consort-statement.org. A CONSORT checklist and flow di-agram (as a Figure) should also be included in the submission material.

The Giornale Italiano di Endodonzia encourages authors submitting manu-scripts reporting from a clinical trial to register the trials in any of the fol-lowing free, public clinical trials reg-istries: www.clinicaltrials.gov, http://clinicaltrials.ifpma.org/clinicaltrials/, http://isrctn.org/. The clinical trial registration number and name of the trial register will then be published with the paper.

2.4 Systematic ReviewsSystematic reviews should be re-ported using the PRISMA guidelines available at http://prisma-statement.org/. A PRISMA checklist and flow diagram (as a Figure) should also be included in the submission material.

2.5 Conflict of Interest and Source of FundingGiornale Italiano di Endodonzia requires that all sources of institution-al, private and corporate financial support for the work within the man-uscript must be fully acknowledged, and any potential conflicts of interest noted. Grant or contribution numbers may be acknowledged, and princi-pal grant holders should be listed. Please include the information under Acknowledgements.

2.6 Appeal of DecisionThe decision on a paper is final and cannot be appealed.2.7 PermissionsIf all or parts of previously published

illustrations are used, permission must be obtained from the copyright holder concerned. It is the author’s responsi-bility to obtain these in writing and provide copies to the Publishers.

3. MANUSCRIPT SUBMISSION PROCEDURE

Manuscripts should be submitted elec-tronically by e-mail: [email protected]

3.1. Manuscript Files AcceptedManuscripts should be uploaded as Word (.doc) or Rich Text Format (.rft) files (not write-protected) plus sepa-rate figure files. GIF, JPEG, PICT or Bitmap files are acceptable for sub-mission, but only high-resolution TIF or EPS files are suitable for printing.

The text file must contain the abstract, main text, references, tables, and fig-ure legends, but no embedded figures or Title page. The Title page should be provided as a separate file.In the main text, please reference fig-ures as for instance ‘Figure 1’, ‘Figure 2’ etc to match the tag name you choose for the individual figure files uploaded. Manuscripts should be formatted as described in the Author Guidelines below.

3.2. Blinded ReviewManuscript that do not conform to the general aims and scope of the journal will be returned immediately without review. All other manuscripts will be reviewed by experts in the field (generally two referees).Giornale Italiano di Endodonzia aims to forward referees´ comments and to inform the corresponding author of the result of the review process.

Manuscripts will be considered for fast-track publication under special circumstances after consultation with the Editor.

Giornale Italiano di Endodonzia uses double blinded review. The names of the reviewers will thus not be dis-closed to the author submitting a pa-per and the name(s) of the author(s) will not be disclosed to the reviewers.

To allow double blinded review, please submit your main manuscript and title page as separate files.3.3. E-mail Confirmation of Submis-sionAfter submission you will receive an e-mail to confirm receipt of your man-

uscript. If you do not receive the con-firmation e-mail after 24 hours, please send an e-mail once again to [email protected] or contact [email protected].

3.4. Submission of Revised ManuscriptsAll the revised manuscripts will be sent to the author; to submit a revised masucript please re-contact the e-mail address of the journal: [email protected].

4. MANUSCRIPT TYPES ACCEPTED

Original Scientific Articles: must de-scribe significant and original experi-mental observations and provide suf-ficient detail so that the observations can be critically evaluated and, if necessary, repeated. Original Scien-tific Articles must conform to the high-est international standards in the field.

Review Articles: are accepted for their broad general interest; all are refereed by experts in the field who are asked to comment on issues such as timeliness, general interest and balanced treatment of controversies, as well as on scientific accuracy. Reviews should generally include a clearly defined search strategy and take a broad view of the field rather than merely summarizing the authors´ own previous work. Extensive or un-balanced citation of the authors´ own publications is discouraged.

Mini Review Articles: are accept-ed to address current evidence on well-defined clinical, research or methodological topics. All are refer-eed by experts in the field who are asked to comment on timeliness, gen-eral interest, balanced treatment of controversies, and scientific rigor. A clear research question, search strat-egy and balanced synthesis of the ev-idence is expected. Manuscripts are limited in terms of word-length and number of figures.

Clinical Articles: are suited to de-scribe significant improvements in clinical practice such as the report of a novel technique, a breakthrough in technology or practical approaches to recognised clinical challenges. They should conform to the highest scientific and clinical practice stand-ards.

Case Reports: illustrating unusual and clinically relevant observations are acceptable but they must be of suffi-ciently high quality to be considered worthy of publication in the Journal. On rare occasions, completed cases displaying non-obvious solutions to significant clinical challenges will be considered. Illustrative material must be of the highest quality and healing outcomes, if appropriate, should be demonstrated.

5. MANUSCRIPT FORMATAND STRUCTURE

5.1. Format

Language: The language of publica-tion is English. It is preferred that man-uscript is professionally edited. All services are paid for and arranged by the author, and use of one of these services does not guarantee accept-ance or preference for publication

Presentation: Authors should pay special attention to the presentation of their research findings or clinical reports so that they may be communi-cated clearly. Technical jargon should be avoided as much as possible and clearly explained where its use is unavoidable. Abbreviations should also be kept to a minimum, particu-larly those that are not standard. The background and hypotheses underly-ing the study, as well as its main con-clusions, should be clearly explained. Titles and abstracts especially should be written in language that will be readily intelligible to any scientist.

Abbreviations: Giornale Italiano di Endodonzia adheres to the conven-tions outlined in Units, Symbols and Abbreviations: A Guide for Medical and Scientific Editors and Authors. When non-standard terms appearing 3 or more times in the manuscript are to be abbreviated, they should be written out completely in the text when first used with the abbreviation in parenthesis.

5.2. StructureAll manuscripts submitted to Giornale Italiano di Endodonzia should include Title Page, Abstract, Main Text, Ref-erences and Acknowledgements, Ta-bles, Figures and Figure Legends as appropriateTitle Page: The title page should bear: (i) Title, which should be con-cise as well as descriptive; (ii) Ini-tial(s) and last (family) name of each author; (iii) Name and address of department, hospital or institution to which work should be attributed; (iv) Running title (no more than 30 letters and spaces); (v) No more than six keywords (in alphabetical order); (vi) Name, full postal address, telephone, fax number and e-mail address of au-thor responsible for correspondence.

Abstract for Original Scientific Ar-ticles should be no more than 250 words giving details of what was done using the following structure:•Aim: Give a clear statement of the main aim of the study and the main hypothesis tested, if any.•Methodology: Describe the meth-ods adopted including, as appropri-ate, the design of the study, the set-ting, entry requirements for subjects, use of materials, outcome measures and statistical tests.•Results: Give the main results of the study, including the outcome of any

statistical analysis.•Conclusions: State the primary con-clusions of the study and their impli-cations. Suggest areas for further re-search, if appropriate.

Abstract for Review Articles should be non-structured of no more than 250 words giving details of what was done including the literature search strategy.

Abstract for Mini Review Articles should be non-structured of no more than 250 words, including a clear research question, details of the liter-ature search strategy and clear con-clusions.

Abstract for Case Reports should be no more than 250 words using the following structure:•Aim: Give a clear statement of the main aim of the report and the clinical problem which is addressed.•Summary: Describe the methods adopted including, as appropriate, the design of the study, the setting, entry requirements for subjects, use of materials, outcome measures and analysis if any.•Key learning points: Provide up to 5 short, bullet-pointed statements to highlight the key messages of the report. All points must be fully justified by material presented in the report.

Abstract for Clinical Articles should be no more than 250 words using the following structure:•Aim: Give a clear statement of the main aim of the report and the clinical problem which is addressed.•Methodology: Describe the methods adopted.•Results: Give the main results of the study.•Conclusions: State the primary con-clusions of the study.

Main Text of Original Scientific Article should include Introduction, Materials and Methods, Results, Discussion and Conclusion.

Introduction: should be focused, out-lining the historical or logical origins of the study and gaps in knowledge. Exhaustive literature reviews are not appropriate. It should close with the explicit statement of the specific aims of the investigation, or hypothesis to be tested.Material and Methods: must contain sufficient detail such that, in combina-tion with the references cited, all clin-ical trials and experiments reported can be fully reproduced.

(i) Clinical Trials should be report-ed using the CONSORT guidelines available at www.consort-statement.org. A CONSORT checklist and flow diagram (as a Figure) should also be included in the submission material.(ii) Experimental Subjects: experi-mentation involving human subjects will only be published if such research has been conducted in full accord-ance with ethical principles, including

the World Medical Association Decla-ration of Helsinki (version 2008) and the additional requirements, if any, of the country where the research has been carried out. Manuscripts must be accompanied by a statement that the experiments were undertaken with the understanding and written consent of each subject and according to the above mentioned principles. A state-ment regarding the fact that the study has been independently reviewed and approved by an ethical board should also be included. Editors re-serve the right to reject papers if there are doubts as to whether appropriate procedures have been used.

When experimental animals are used the methods section must clearly indi-cate that adequate measures were taken to minimize pain or discomfort. Experiments should be carried out in accordance with the Guidelines laid down by the National Institute of Health (NIH) in the USA regarding the care and use of animals for exper-imental procedures or with the Euro-pean Communities Council Directive of 24 November 1986 (86/609/EEC) and in accordance with local laws and regulations. All studies using human or animal subjects should include an explicit statement in the Material and Meth-ods section identifying the review and ethics committee approval for each study, if applicable.Editors reserve the right to reject pa-pers if there is doubt as to whether appropriate procedures have been used.

(iii) Suppliers: Suppliers of materials should be named and their location (Company, town/city, state, country) included.

Results: should present the observa-tions with minimal reference to earlier literature or to possible interpretations. Data should not be duplicated in Ta-bles and Figures.

Discussion: may usefully start with a brief summary of the major findings, but repetition of parts of the abstract or of the results section should be avoided. The Discussion section should progress with a review of the methodology before discussing the results in light of previous work in the field. The Discussion should end with a brief conclusion and a comment on the potential clinical relevance of the findings. Statements and in-terpretation of the data should be appropriately supported by original references.

Conclusion: should contain a summa-ry of the findings.

Main Text of Review Articles should be divided into Introduction, Review and Conclusions. The Introduction section should be focused to place the subject matter in context and to justify the need for the review. The Review section should be divided

into logical sub-sections in order to improve readability and enhance un-derstanding. Search strategies must be described and the use of state-of-the-art evidence-based systematic approaches is expected. The use of tabulated and illustrative material is encouraged. The Conclusion section should reach clear conclusions and/or recommendations on the basis of the evidence presented.

Main Text of Mini Review Articles should be divided into Introduction, Review and Conclusions. The Intro-duction section should briefly intro-duce the subject matter and justify the need and timeliness of the literature review. The Review section should be divided into logical sub-sections to en-hance readability and understanding and may be supported by up to 5 tables and figures. Search strategies must be described and the use of state-of-the-art evidence-based sys-tematic approaches is expected. The Conclusions section should present clear statements/recommendations and suggestions for further work. The manuscript, including references and figure legends should not normally ex-ceed 4000 words.

Main Text of Clinical Reports and Clinical Articles should be divided into Introduction, Report, Discussion and Conclusion,. They should be well illustrated with clinical images, radio-graphs, diagrams and, where appro-priate, supporting tables and graphs. However, all illustrations must be of the highest quality

Acknowledgements: Giornale Ital-iano di Endodonzia requires that all sources of institutional, private and corporate financial support for the work within the manuscript must be fully acknowledged, and any poten-tial conflicts of interest noted. Grant or contribution numbers may be ac-knowledged, and principal grant holders should be listed. Acknowl-edgments should be brief and should not include thanks to anonymous ref-erees and editors.

5.3. ReferencesIt is the policy of the Journal to encour-age reference to the original papers rather than to literature reviews. Au-thors should therefore keep citations of reviews to the absolute minimum.

We recommend the use of a tool such as EndNote or Reference Man-ager for reference management and formatting. EndNote reference styles can be searched for here: www.end-note.com/support/enstyles.asp. Ref-erence Manager reference styles can be searched for here: www.refman.com/support/rmstyles.asp

In the text: a number in order of cita-tion is the reference inside the manu-script; example (1)Reference list: All references should be brought together at the end of the paper in numerical order and should

be in the following form.- Names and initials of up to six au-thors. When there are seven or more, list the first three and add et al.- Full title of paper followed by a full stop (.)- Title of journal abbreviated (es. Jour-nal of Endodontics : J Endod)- Year of publication followed by ;- Volume number - Issue number in parenthesis (es.: (5)) followed by :- First and last pages

Examples of correct forms of refer-ence follow:

Standard journal article(1) Somma F, Cammarota G, Plotino G, Grande NM, Pameijer CH. The ef-fectiveness of manual and mechanical instrumentation for the retreatment of three different root canal filling mate-rials. J Endod 2008;34(4):466—9.

Corporate authorBritish Endodontic Society - Guide-lines for root canal treatment. Gior-nale Italiano di Endodonzia 1979 ; 16: 192-5.

Journal supplementFrumin AM, Nussbaum J, Esposito M () Functional asplenia: demonstration of splenic activity by bone marrow scan (Abstract). Blood 1979; 54 (Suppl. 1): 26a.

Books and other monographs

Personal author(s)Gutmann J, Harrison JW Surgical Endodontics, 1st edn Boston, MA, USA: Blackwell Scientific Publica-tions, 1991.

Chapter in a bookWesselink P Conventional root-canal therapy III: root filling. In: Harty FJ, ed. Endodontics in Clinical Practice, (1990) , 3rd edn; pp. 186-223. Lon-don, UK: Butterworth.

Published proceedings paperDuPont B Bone marrow transplan-tation in severe combined immuno-deficiency with an unrelated MLC compatible donor. In: White HJ, Smith R, eds. Proceedings of the Third Annual Meeting of the International Society for Experimental Rematology; (1974), pp. 44-46. Houston, TX, USA: International Society for Exper-imental Hematology.

Agency publicationRanofsky AL Surgical Operations in Short-Stay Hospitals: United States-1975 (1978). DHEW publi-cation no. (PHS) 78-1785 (Vital and Health Statistics; Series 13; no. 34.) Hyattsville, MD, USA: National Cen-tre for Health Statistics.8

Dissertation or thesisSaunders EM In vitro and in vivo in-vestigations into root-canal obturation using thermally softened gutta-percha techniques (PhD Thesis) (1988). Dun-

dee, UK: University of Dundee.

URLsFull reference details must be given along with the URL, i.e. authorship, year, title of document/report and URL. If this information is not availa-ble, the reference should be removed and only the web address cited in the text.Smith A Select committee report into social care in the community [WWW document]. (1999) URL http://www.dhss.gov.uk/reports/report015285.html[accessed on 7 November 2003]

5.4. Tables, Figures and Figure Leg-ends

Tables: Tables should be dou-ble-spaced with no vertical rulings, with a single bold ruling beneath the column titles. Units of measurements must be included in the column title.Figures: All figures should be planned to fit within either 1 column width (8.0 cm), 1.5 column widths (13.0 cm) or 2 column widths (17.0 cm), and must be suitable for photocopy reproduction from the printed version of the manuscript. Lettering on figures should be in a clear, sans serif type-face (e.g. Helvetica); if possible, the same typeface should be used for all figures in a paper. After reduction for publication, upper-case text and num-bers should be at least 1.5-2.0 mm high (10 point Helvetica). After reduc-tion, symbols should be at least 2.0-3.0 mm high (10 point). All half-tone photographs should be submitted at final reproduction size. In general, multi-part figures should be arranged as they would appear in the final ver-sion. Reduction to the scale that will be used on the page is not necessary, but any special requirements (such as the separation distance of stereo pairs) should be clearly specified.

Unnecessary figures and parts (pan-els) of figures should be avoided: data presented in small tables or his-tograms, for instance, can generally be stated briefly in the text instead. Figures should not contain more than one panel unless the parts are logical-ly connected; each panel of a mul-tipart figure should be sized so that the whole figure can be reduced by the same amount and reproduced on the printed page at the smallest size at which essential details are visible.

Figures should be on a white back-ground, and should avoid excessive boxing, unnecessary colour, shading and/or decorative effects (e.g. 3-di-mensional skyscraper histograms) and highly pixelated computer drawings. The vertical axis of histograms should not be truncated to exaggerate small differences. The line spacing should be wide enough to remain clear on reduction to the minimum acceptable printed size.

Figures divided into parts should be labelled with a lower-case, boldface,

roman letter, a, b, and so on, in the same typesize as used elsewhere in the figure. Lettering in figures should be in lower-case type, with the first letter capitalized. Units should have a single space be-tween the number and the unit, and follow SI nomenclature or the nomen-clature common to a particular field. Thousands should be separated by a thin space (1 000). Unusual units or abbreviations should be spelled out in full or defined in the legend. Scale bars should be used rather than magnification factors, with the length of the bar defined in the legend rath-er than on the bar itself. In general, visual cues (on the figures themselves) are preferred to verbal explanations in the legend (e.g. broken line, open red triangles etc.).

Figure legends: Figure legends should begin with a brief title for the whole figure and continue with a short description of each panel and the symbols used; they should not contain any details of methods.

Permissions: If all or part of previ-ously published illustrations are to be used, permission must be obtained from the copyright holder concerned. This is the responsibilty of the authors before submission.

Preparation of Electronic Figures for Publication: Although low quality images are adequate for review pur-poses, print publication requires high quality images to prevent the final product being blurred or fuzzy. Submit EPS (lineart) or TIFF (halftone/photographs) files only. MS Power-Point and Word Graphics are unsuit-able for printed pictures. Do not use pixel-oriented programmes. Scans (TIFF only) should have a resolution of 300 dpi (halftone) or 600 to 1200 dpi (line drawings) in relation to the reproduction size (see below). EPS files should be saved with fonts em-bedded (and with a TIFF preview if possible). For scanned images, the scanning resolution (at final image size) should be as follows to ensure good repro-duction: lineart: >600 dpi; half-tones (including gel photographs): >300 dpi; figures containing both halftone and line images: >600 dpi.

6. AFTER ACCEPTANCE

Upon acceptance of a paper for publication, the manuscript will be forwarded to the Production Editor who is responsible for the production of the journal.

6.1. FiguresHard copies of all figures and tables are required when the manuscript is ready for publication. These will be requested by the Editor when re-quired. Each Figure copy should be marked on the reverse with the figure number and the corresponding au-thor’s name.

6.2 Proof CorrectionsThe corresponding author will receive an email alert containing a link to a web site. A working email address must there-fore be provided for the correspond-ing author. The proof can be down-loaded as a PDF (portable document format) file from this site. Acrobat Reader will be required in order to read this file. This software can be downloaded (free of charge) from the following Web site: www.adobe.com/products/acrobat/readstep2.html. This will enable the file to be opened, read on screen, and printed out in or-der for any corrections to be added. Further instructions will be sent with the proof. Hard copy proofs will be posted if no e-mail address is availa-ble; in your absence, please arrange for a colleague to access your e-mail to retrieve the proofs. Proofs must be returned to the Pro-duction Editor within five days of receipt, even if there are no correc-tions. Elsevier may proceed with publica-tion of the article if no response is received. As changes to proofs are costly, we ask that you only correct typesetting errors. Excessive changes made by the author in the proofs, excluding type-setting errors, will be charged sepa-rately. Other than in exceptional circum-stances, all illustrations are retained by the publisher. Please note that the author is respon-sible for all statements made in his work, including changes made by the copy editor.

7. OPEN ACCESS

Every peer-reviewed research article appearing in this journal will be pub-lished open access. This means that the article is universally and freely accessible via the internet in perpe-tuity, in an easily readable format immediately after publication. The author does not have any publication charges for open access. The Società Italiana di Endodonzia will pay to make the article open access. A CC user license manages the reuse of the article (see http://www.elsevier.com/openaccesslicenses). All articles will be published under the following license:

8. Creative Commons Attribution-NonCommer-cial-NoDerivs(CC BY-NC-ND)

For non-commercial purposes, lets others distribute and copy the article, and to include in a collective work (such as an anthology), as long as they credit the author(s) and provided

they do not alter or modify the article

9. AUTHOR RIGHTS

As an author you (or your employer or institution) have certain rights to reuse your work. For more information on author rights please see http://www.elsevier.com/copyright.

ISTRUZIONI AGLI AUTORI

Il Giornale Italiano di Endodonzia è una pubblicazione esclusivamente disponibile in formato elettronico e rappresenta l’organo ufficiale della Società Italiana di Endodonzia.

Si appoggia, per la sua diffusione ad Elsevier e gli articoli in esso pubblicati sono reperibili su Scopus.

La cadenza di pubblicazione è semestrale: Giugno/Novembre.

Per quanto attiene le norme editoriali per la pubblicazione di articoli aven-ti come tema l’Endodonzia in senso lato si pregano gli autori di riferirsi al documento in inglese reperibile sul sito www.gi-endodonzia.com.

Articoli in lingua italiana saranno pubblicabili, ma si darà preferenza a contributi in lingua inglese che po-trebbero avere una risonanza interna-zionale ben più ampia.

La Società Italiana di Endodonzia si farà carico di rivedere la forma dei contributi in lingua inglese attraverso un sistema di controllo specifico.

november 2017 vol. 31 - sie · restorative dentistry and endodontics universitat internacional de...

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