ORTHOPHOS®
XG3D
•Visualizecanalanatomypriortotreatment
•MARSforbetterdiagnosisaroundmetal
•Easypatientpositioning
Learnmor...
simply better dentistry™
1145 Towbin Avenue Lakewood, New Jersey 08701
Visit us on the web at www.sswhiteburs.com
Simply B...
INTRODUCTION
Volume 7 Number 2	 Endodontic practice 1
March/April 2014 - Volume 7 Number 2
ASSOCIATE EDITORS
Julian Webber...
TABLE OF CONTENTS
Clinical
Clinical guidelines for the use
of ProTaper Next™
instruments:
part 2
Drs. Peet J. van der Vyve...
simple, adaptable endodontic solutions
Perfect delivery.
Optimal performance.
Easy removal.
UltraCal®
XS
800.552.5512
ultr...
TABLE OF CONTENTS
Technology
3D Apical Cork — part 3
In the third article of this series,
Dr. Wyatt Simons reviews the
tec...
ORTHOPHOS XG 3D
ORTHOPHOS XG 3D
The right solution for
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Implantologists
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seamless...
What can you tell us about your
background?
I have a bachelor’s degree in chemistry
with a minor in business. I was accept...
PRACTICEPROFILE
Volume 7 Number 2	 Endodontic practice 7
at your life and say, ‘I wish I would have
…’” I have lived his “...
8 Endodontic practice	 Volume 7 Number 2
PRACTICE PROFILE
Top Favorites
There are two main aspects to my life: my
home and...
OPERATORY COMPUTER
MICROSCOPE
ONLINE PORTAL
IMAGING EQUIPMENT
We’re that something you’ve been searching for. Ask yourself...
History of Ultradent
Ultradent Products, Inc., began when one
forward-thinking dentist, Dr. Dan Fischer,
set out to create...
CORPORATEPROFILE
Volume 7 Number 2	 Endodontic practice 11
and files proved able to better follow the
natural canal anatom...
In part 1 of this series, published in the
January/February issue of Endodontic
Practice US, the authors outlined the clin...
CLINICAL
Volume 7 Number 2	 Endodontic practice 13
points make contact with the canal wall at
any time. This will contribu...
Case report 1
The patient, a 41-year-old female,
presented with irreversible pulpitis on her
maxillary right second premol...
CLINICAL
Volume 7 Number 2	 Endodontic practice 15
management and treatment will be (Pruett,
Clement, Carnes, 1997).
	 Aga...
16 Endodontic practice	 Volume 7 Number 2
CLINICAL
Figure 3E demonstrates the final result
after obturation, and Figure 3F...
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18 Endodontic practice	 Volume 7 Number 2
CLINICAL
References
Castellucci A, ed. Endodontics Volume II.
Florence, Italy: I...
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The use of MTA (Angelus, Londrina,
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ucts, New Milford, Connecticut) (Figure 1)
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CLINICAL
Volume 7 Number 2	 Endodontic practice 21
Figure 8: Preoperative radiograph of clinical case Figure 9: Clinical p...
Figure 17: Bleeding of the pulp exposure controlled
22 Endodontic practice	 Volume 7 Number 2
CLINICAL
the commercially av...
simple, adaptable endodontic solutions
Irrigation amplification
All grown up
Ultradent now offers Consepsis (2% chlorhexid...
24 Endodontic practice	 Volume 7 Number 2
CLINICAL
Figure 23: Valo LED curing light used to set the glass ionomer
Figure 2...
coat of the fifth-generation bonding agent
MPa (Clinician’s Choice Dental Products,
New Milford, Connecticut) was applied
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Abstract
Aim: The purpose of this study was to
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microhardness properties.
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28 Endodontic practice	 Volume 7 Number 2
CLINICAL
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  1. 1. ORTHOPHOS® XG3D •Visualizecanalanatomypriortotreatment •MARSforbetterdiagnosisaroundmetal •Easypatientpositioning Learnmoreat Sirona3D.com A new concept in canal preparation Dr. Ghassan Yared PAYING SUBSCRIBERS EARN 24 CONTINUING EDUCATION CREDITS PER YEAR! TF™ Adaptive: a novel approach to nickel-titanium instrumentation Drs. Gianluca Gambarini and Gary Glassman clinical articles • management advice • practice profiles • technology reviews March/April 2014 – Vol 7 No 2 P R O M O T I N G E X C E L L E N C E I N E N D O D O N T I C S Corporate profile Ultradent Clinical guidelines for the use of ProTaper Next™ instruments: part 2 Drs. Peet J. van der Vyver and Michael J. Scianamblo Practice profile Dr. Ernest Reeh Product profile Coltene Surgitip-Endo
  2. 2. simply better dentistry™ 1145 Towbin Avenue Lakewood, New Jersey 08701 Visit us on the web at www.sswhiteburs.com Simply Better Endodontics™ The V-Taper™ 2H System is the most efficient and effective endodontic file system in the world. Endodontist Recommended The V-Taper™2H NITI rotary endodontic file system utilizes only 3 files to allow you to complete most root canal cases. The V-Taper™2H performance enhanced system is the only system that offers you these industry leading advantages, all in one file: Conservation • Efficiency • Flexibility • Strength 20 ( V06 )V06 )( Conservative V-Taper™2H files with their patented taper, are the most minimally invasive file on the market today. Efficient Complete most root canals using only 2-3 V-Taper™2H files, fewer files means lower cost per root canal treatment Flexible V-Taper™2H files are heat treated to increase flexibility to insure navigation of even the most curved canals without ledging, transportation or zipping. Strong V-Taper™2H files are designed with a Parabolic Core, which was the strongest core design in a recent test conducted at the University of Michigan. The V-Taper™2H Rotary System advances the science of file design, manufacturing, and materials. “All dentin is not created equally, EndoGuide® Burs and V-Taper™2H Files foster conservation at the heart of the tooth, peri-cervical dentin. The preservation of healthy dentin leads to longer lasting restorations.” – Dr. Eric Herbranson, Endodontist 25 ( V06 ) 17 Call for an in-office demo today. 800-535-2877
  3. 3. INTRODUCTION Volume 7 Number 2 Endodontic practice 1 March/April 2014 - Volume 7 Number 2 ASSOCIATE EDITORS Julian Webber BDS, MS, DGDP, FICD Pierre Machtou DDS, FICD Richard Mounce DDS Clifford J Ruddle DDS John West DDS, MSD EDITORIAL ADVISORS Paul Abbott BDSc, MDS, FRACDS, FPFA, FADI, FIVCD Professor Michael A Baumann Dennis G Brave DDS David C Brown BDS, MDS, MSD L Stephen Buchanan DDS, FICD, FACD Gary B Carr DDS Arnaldo Castellucci MD, DDS Gordon J Christensen DDS, MSD, PhD B David Cohen PhD, MSc, BDS, DGDP, LDS RCS Stephen Cohen MS, DDS, FACD, FICD Simon Cunnington BDS, LDS RCS, MS Samuel O Dorn DDS Josef Dovgan DDS, MS Tony Druttman MSc, BSc, BChD Chris Emery BDS, MSc. MRD, MDGDS Luiz R Fava DDS Robert Fleisher DMD Stephen Frais BDS, MSc Marcela Fridland DDS Gerald N Glickman DDS, MS Kishor Gulabivala BDS, MSc, FDS, PhD Anthony E Hoskinson BDS, MSc Jeffrey W Hutter DMD, MEd Syngcuk Kim DDS, PhD Kenneth A Koch DMD Peter F Kurer LDS, MGDS, RCS Gregori M. Kurtzman DDS, MAGD, FPFA, FACD, DICOI Howard Lloyd BDS, MSc, FDS RCS, MRD RCS Stephen Manning BDS, MDSc, FRACDS Joshua Moshonov DMD Carlos Murgel CD Yosef Nahmias DDS, MS Garry Nervo BDSc, LDS, MDSc, FRACDS, FICD, FPFA Wilhelm Pertot DCSD, DEA, PhD David L Pitts DDS, MDSD Alison Qualtrough BChD, MSc, PhD, FDS, MRD RCS John Regan BDentSc, MSC, DGDP Jeremy Rees BDS, MScD, FDS RCS, PhD Louis E. Rossman DMD Stephen F Schwartz DDS, MS Ken Serota DDS, MMSc E Steve Senia DDS, MS, BS Michael Tagger DMD, MS Martin Trope, BDS, DMD Peter Velvart DMD Rick Walton DMD, MS John Whitworth BchD, PhD, FDS RCS CE QUALITY ASSURANCE ADVISORY BOARD Dr. Alexandra Day BDS, VT Julian English BA (Hons), editorial director FMC Dr. Paul Langmaid CBE, BDS, ex chief dental officer to the Government for Wales Dr. Ellis Paul BDS, LDS, FFGDP (UK), FICD, editor-in-chief Private Dentistry Dr. Chris Potts BDS, DGDP (UK), business advisor and ex-head of Boots Dental, BUPA Dentalcover, Virgin Dr. Harry Shiers BDS, MSc (implant surgery), MGDS, MFDS, Harley St referral implant surgeon PUBLISHER | Lisa Moler Email: lmoler@medmarkaz.com MANAGING EDITOR | Mali Schantz-Feld Email: mali@medmarkaz.com Tel: (727) 515-5118 ASSISTANT EDITOR | Elizabeth Romanek Email: betty@medmarkaz.com EDITORIAL ASSISTANT | Mandi Gross Email: mandi@medmarkaz.com DIRECTOR OF SALES | Michelle Manning Email: michelle@medmarkaz.com NATIONAL SALES/MARKETING MANAGER | Drew Thornley Email: drew@medmarkaz.com PRODUCTION MANAGER/CLIENT RELATIONS | Adrienne Good Email: agood@medmarkaz.com PRODUCTION ASST./SUBSCRIPTION COORD. | Jacqueline Baker Email: JBaker@medmarkaz.com MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 Fax: (480) 629-4002 Toll-free: (866) 579-9496 Web: www.endopracticeus.com www.medmarkaz.com SUBSCRIPTION RATES 1 year (6 issues) $99 3 years (18 issues) $239 © FMC, Ltd 2014. All rights reserved. FMC is part of the specialist publishing group Springer Science+Business Media. The publisher’s written consent must be obtained before any part of this publication may be reproduced in any form whatsoever, including photocopies and information retrieval systems. While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any consequence arising from it. The views expressed herein are those of the author(s) and not necessarily the opinion of either Endodontic Practice or the publisher. The theme of the upcoming AAE meeting in Washington, DC, is “Striving for Perfection.” What a great title for an annual meeting and life philosophy. One of the aspects we enjoy the most about having six partners at Commonwealth Endodontics is the impromptu discussions on treatment planning and patient management that have helped us as we strive for perfection. Just over a year ago, we added cone beam computed tomography (CBCT) to our office. Although we knew that it would be an important tool to have at our disposal, we were not sure of the benefits it would offer. After all, we have been providing top level care for over 15 years without a CBCT. “How would a CBCT really improve our patient care?” was the lingering question. Like other important advances that have specifically benefited the specialty of endodontics, the CBCT is considered an indispensable tool for treatment. Although the CBCT has value in general practice and other dental specialties, its impact will likely be the greatest on endodontics. Having the ability to appreciate the tooth in three dimensions revolutionizes patient care. No longer are we wholly dependent on a static two-dimensional image that provides an incomplete picture. Finally, we can see the tooth in its true form. One immeasurable advantage of the CBCT is how it provides a platform for patient discussions. Unlike two-dimensional static radiography, we are able to move throughout a tooth and surrounding tissues to help tell a story. The story can be about a cracked tooth where the patient can now see the resulting bone loss at the level that the crack propagates. The story can be about a periapical radiolucency that was obscured by the maxillary sinus. The story can be about how extensive the resorptive defect really is. Ultimately, the CBCT empowers the patient to make better informed treatment decisions. The conversation changes from “We can access your tooth and see if we can locate another canal” to “The canal right there needs to be located.” The CBCT has made treatment, retreatment, and apicoectomies more predictable. It has also made the choice of extraction and replacement more clear. We have been able to save our patients money, time, and have spared them postoperative discomfort by being able to make more accurate and appropriate diagnoses with CBCT imaging. The AAE recommends the use of CBCT imaging for a variety of purposes. These uses include evaluating canal and root morphology, diagnosis of periapical and non-endodontic pathology, intraoperative and postoperative assessment, root resorption, trauma, pre-surgical treatment planning, and dental implant treatment planning. We ultimately chose the Orthophos® XG 3D by Sirona. This unit provides options for both small view and mid-size views. The small view provides 100-micron slices of a sextant for endodontic evaluation. The voxel size for both the mid and small views are well below the AAE-recommended maximum limit for endodontic evaluation. Our mid-size views have been requested by general dentists and specialists alike who do not have CBCT imaging capabilities in their offices. They typically prefer the mid-size view because they would prefer to see the entire maxillary and mandibular arch. Referral for CBCT has been requested for TMJ evaluations, implant placements, and hard structure pathology evaluations. The Orthophos XG 3D unit integrates nicely with the Cerec system, allowing complete restoration and placement of implants and other teeth that includes everything from the surgical stents to the crown milling. Being able to provide CBCT imaging for our referring dentists has augmented how we have become of further assistance to our community. While you are at the annual meeting this year, I encourage you to take time out to visit the vendors and ask questions of them. Then ask your colleagues how it has changed their practice. You will be pleasantly surprised at how well CBCT imaging benefits your practice. In the words of many of our patients, “That’s amazing!” One note of caution; if you try CBCT imaging, you will not want to practice without it. Dr. Tim Finkler Dr. Tim Finkler received his DDS and Certificate in Endodontics from the Virginia Commonwealth University. Prior to entering his endodontic program, he completed a 2-year General Practice Residency at McGuire Veterans Affairs Medical Center in Richmond, Virginia. He received a BS in Electrical Engineering from The Virginia Military Institute and practiced as a Registered Professional Engineer before his dental career. He retired from over 20 years of service in the Virginia Air National Guard. His military service included time with the 203rd REDHORSE and the 192nd Fighter Wing. He is now a partner in Commonwealth Endodontics and practices in Richmond and Newport News, Virginia. Striving for perfection
  4. 4. TABLE OF CONTENTS Clinical Clinical guidelines for the use of ProTaper Next™ instruments: part 2 Drs. Peet J. van der Vyver and Michael J. Scianamblo illustrate the use of ProTaper Next instruments in difficult and challenging endodontic cases........................12 MTA: the new material of choice for pulp capping Drs. Leendert (Len) Boksman and Manfred (Manny) Friedman delve into the benefits of MTA ....................20 The influence of mineral trioxide aggregate (MTA) thickness on its microhardness properties — an in vitro study Drs. Iris Slutzky-Goldberg, Lea Sabag, and David Keinan test the effect of the MTA thickness on its microhardness properties............26 2 Endodontic practice Volume 7 Number 2 Corporate profile 10 Ultradent Ultradent continues to keep a finger on the pulse of the endodontic specialty ON THE COVER 0.2 mm tooth slice polarized photo Maxillary central incisor Transversal slice. Photo courtesy of Dr. Stanislav Heranin Practice profile 6 Dr. Ernest Reeh Focus on patients, family, academics, and endodontics
  5. 5. simple, adaptable endodontic solutions Perfect delivery. Optimal performance. Easy removal. UltraCal® XS 800.552.5512 ultradent.com Scan to watch a short video of UltraCal XS. Don’t change your technique. Make it easier with UltraCal® XS and Citric Acid 20%. NaviTip tip delivers UltraCal XS where it is needed in the canal. ©2014 Ultradent Products, Inc. All Rights Reserved. UltraCal® XS and Citric Acid 20% UltraCal XS, a uniquely formulated calcium hydroxide paste (pH 12.5), can be easily delivered with the NaviTip® tip exactly where it is needed in the canal. Calcium hydroxide offers strong antimicrobial effects and potentially stimulates the healing of bone to promote healing in infected canals.1 For two-appointment RCTs, no other medicament works better than UltraCal XS. When it comes time to remove UltraCal XS from the canal, look no further than Ultradent’s Citric Acid 20%, delivered with the NaviTip FX tip. Citric Acid 20% easily dissolves calcium hydroxide, and the small fibers attached to the NaviTip FX tip easily scrub the walls of the canal, which also helps remove the smear layer. So you know the canal is ready for obturation. 1. Gomes BP, Ferraz CC, Vianna ME, Rosalen PL, Zaia AA, Teixeira FB, et al. In vitro antimicrobial activity of calcium hydroxide pastes and their vehicles against selected microorganisms. Braz Dent J. 2002;13(3):155-61. Use NaviTip® tip to place UltraCal® XS in the canal, and use Citric Acid with the NaviTip® FX® tip to easily remove it. NaviTip tip NaviTip FX tip with brush fibers
  6. 6. TABLE OF CONTENTS Technology 3D Apical Cork — part 3 In the third article of this series, Dr. Wyatt Simons reviews the technological breakthroughs of the Cork technique and system of obturation with emphasis given to the revolutionary 3D plugger ...............32 Continuing education A new concept in canal preparation Dr. Ghassan Yared discusses canal preparation with only one reciprocating instrument without prior hand filing......................................36 TF™ Adaptive: a novel approach to nickel-titanium instrumentation Drs. Gianluca Gambarini and Gary Glassman examine how to achieve rotary motion when you want it — and reciprocation when you need it......42 Product profile Sonendo® aims to transform the future of endodontics ................50 Surgitip-endo aspirator tip for root canals .........................................54 Endospective Transcendent endodontics: the seven key attributes Dr. Rich Mounce reflects on the qualities and equipment that can improve future results....................52 Step-by-step The Laschal FXP set incorporates transferred oscillation technology .....................................................56 Legal matters Ethics, morals, and law in the professional office Dr. Bruce H. Seidberg discusses how ethical and moral behavior are governed by law ...........................57 Industry news ............60 Materials & equipment ......................60 Anatomy matters Influence on Fees, Reputation, Longevity, and Because: part 10 Dr. John West discusses four more reasons why anatomy should matter. .....................................................61 4 Endodontic practice Volume 7 Number 2 3D Apical Cork 32
  7. 7. ORTHOPHOS XG 3D ORTHOPHOS XG 3D The right solution for your diagnostic needs. Implantologists will appreciate the seamless clinical workflow from initial diagnostics, to treatment planning, to ordering surgical guides and final implant placement. Endodontists will enjoy instantly viewable 3D volumetric images for revealing and measuring canal shapes, depths and anatomies. Orthodontists will benefit from high- quality pan and ceph images for optimized therapy planning. General Practitioners will achieve greater diagnostic accuracy for routine cases. “With my Sirona 3D unit, I can see the anatomy of canals, calcification, extent of resorption, frac- tures, and sizes of periapical radiolucencies, all of which influence treatment plans for my patients. Combine that with the metal artifact reduction software that reduces distortions from metal objects, my treatment process is a lot less stressful. My patients benefit from the technology and my referrals appreciate the value.” ~ Dr. Kathryn Stuart, Endodontist - Fishers, Indiana For more information, visit www.Sirona3D.com or call Sirona at: 800.659.5977 The advantages of 2D & 3D in one comprehensive unit ORTHOPHOS XG 3D is a hybrid system that provides clinical workflow advantages, along with the lowest possible effective dose for the patient. Its 3D function provides diagnostic accuracy when you need it most: for implants, surgical procedures and volumetric imaging of the jaws, sinuses and other dental anatomy. www.facebook.com/Sirona3D
  8. 8. What can you tell us about your background? I have a bachelor’s degree in chemistry with a minor in business. I was accepted off of the alternate list for dental school and then attained my DDS degree, graduating third in my class and awarded the James McCutcheon Gold Medal. (This award is presented to the student who, over the 4 years of the DDS program, had shown to possess, to an outstanding degree, those qualities of scholarship, leadership, and character, which may be expected to lead to a distinguished position in the dental profession.) I have taken specialty training in endodontics and have a master’s degree in Material Science, a PhD in Biophysics with a related-field minor in engineering. I am a Diplomate of the American Board of Endodontics (Board Certified) and a former faculty member at the University of Minnesota Endodontics Department. I have consulted for 3M and Carestream Dental (formerly Kodak Imaging), and have lectured both nationally and internationally on a variety of science and dental topics, as well as written peer-reviewed scientific articles and abstracts. Is your practice limited to endodontics? Yes. Why did you decide to focus on endodontics? By my second year in dental school, I developed a keen interest in endodontics. I especially enjoyed the particular attention to the fine detail and the high level of fine motor control needed. I had done research in chemistry and wanted to do research in endodontics. As a result of frequent discussions with the director of the endodontics department, arrangements were made for me to be able to conduct research as a graduating second-year dental student. I was able to present my work at an International Association of Dental Researchers (IADR) conference, as well as have my name associated with three other projects with which I was involved. I continued my research interests, and the following year also presented at the IADR conference and had my name associated with seven other projects that I had also been involved in during the year and summer break. After dental school, I had wanted to go into endodontics as a specialty, but felt I should appreciate general dentistry before going to graduate school. I worked in a private general dental practice for 2 years and then attended endodontic graduate school. I did research during my endodontic residency and published two papers as a result of my graduate program research, as well as winning a national research award for my student research presentation award at the American Association of Endodontists (AAE) meeting. I have always had a passion for endodontics and enjoy the challenges my many colleagues send me. How long have you been practicing? I graduated from dental school in 1984 and practiced as a general dentist for 2 years. I then spent 2 years in an endodontic residency, graduating in 1988, and have been practicing as an endodontist since graduation. I went on to do a PhD after my endodontic specialty training but made it a requirement of my PhD program that I was able to do private practice 1 day a week. I worked for 7 years (during and after my PhD program) for Boynton Health Services as their endodontist. I then worked in several group practices before setting up our own endodontic practice with my wife, who is also an endodontist. Currently, I practice 2 to 3 days per week, and my wife practices 2 days per week, so we both can have some time to enjoy our four children ages 11, 9, 9 (yes, twins), and 5 year olds. They grow up so fast, and we both wanted to have time with them. Who has inspired you? I have had several people who inspired me. Initially, my dad, who told me when I was deciding to either follow chemistry (when I had standing job offers after graduation in chemistry) or go into dentistry (which would have been an unknown). My dad, who was a man of few words, told me, “You have always wanted to be a dentist,” (which I had since I was about 8 years old), and he said to me, “You never want to look back Dr. Ernest Reeh 6 Endodontic practice Volume 7 Number 2 PRACTICE PROFILE Focus on patients, family, academics, and endodontics
  9. 9. PRACTICEPROFILE Volume 7 Number 2 Endodontic practice 7 at your life and say, ‘I wish I would have …’” I have lived his “no regrets” philosophy ever since. My other mentors include the head of the endodontics department in dental school, who made doing research possible; Dr. Don Collins, the Dean who created a program when none existed to make it possible for me to do research; Dr. Gordon Thompson and my mentor doing dental research, who was just joining the endodontic faculty at the time; and the abundantly enthusiastic Dr. Ken Zakariasen. In endodontic graduate school, I had two people who had a major influence in my life and career — Dr. Harold Messer, a brilliant scientist and the head of the endodontics division; and Dr. William “Bill” Douglas, a renowned biomaterials expert who opened his lab and mentored me during my masters and PhD programs. I learned many things, not only about dentistry and research, but also about teaching and mentoring. What is the most satisfying aspect of your practice? I feel most satisfied when my doctors have the confidence in me to refer tough cases that challenge my skills and abilities. As I like to say, “I enjoy challenges; I just hope that not every case during the day will be a tough one!” I feel satisfied when I can treat cases that were thought to be untreatable endodontically. I appreciate when I can be a part of their team and be a part of the treatment planning for cases. Professionally, what are you most proud of? My master’s thesis work. I am sometimes at an endodontic meeting, and a resident will see my name tag and ask if I am the guy who published the work on stiffness of endodontically treated teeth. I reply that I am. Then they tell me that I am “classic literature in endo,” and I reply that I like to think of myself as contemporary literature in endo! I have been told that my work is one of the 10 most referenced papers in dentistry. That makes me very proud of the work I did. What do you think is unique about your practice? We offer a very personalized experience. We work on one patient at a time, and each gets our undivided attention for his or her appointed time. We have created an environment that is very calming from the appearance of the office, to the music, to the aromas, to the friendly interaction from each staff member. Patients are exquisitely numb, so care is done comfortably. Many patients who tell us they are difficult to get numb are surprised how easy care is for them. What has been your biggest challenge? Insurance. Need I say more? What would you have become if you had not become a dentist? Probably a neurovascular surgeon. I enjoy surgery, and I am very fine motor skill- oriented, so it would be another good fit for me. What is the future of endodontics and dentistry? There is so much information that it is not possible for one person to do everything well. General dentists who take a lot of programs in endodontics certainly advance their skills and can do more and more complex cases but at the expense of other areas of dentistry. Most dentists want some balance in their profession, so they do not want to do more advanced cases. Even those who have trained further still need the help of their endodontist as there is a lot to learn in a 2- to 3-year advanced specialty degree. There continues to be improvements, and it is part of the endodontist’s job to explain the pros and cons to our general dental colleagues. Clearly, as knowledge continues to Dr. Reeh’s team
  10. 10. 8 Endodontic practice Volume 7 Number 2 PRACTICE PROFILE Top Favorites There are two main aspects to my life: my home and family, and my office and staff. Hence, the list goes in two directions: Family favorites 1. Date night with my lovely wife 2. Kid activities 3. Family game night (Something we do one night per week usually on the weekend.) 4. Our home (I like to just be home and enjoy what we have done.) 5. Enjoying my hobbies Office favorites 6./5. Quiet time (because it is so rare) 4. P5 Newtron® (Satelec Acteon) ultrasonics 3. Schick Elite Digital radiography 2. Carestream 9000D cone beam computed tomography (three- dimensional imaging) 1. Our staff (They are all great in their own ways and are an integral part of my life.) expand, the need for specialists becomes increasingly important. Endodontics is not about to be replaced by implants, and we are now seeing that retaining natural teeth is still first best compared to a good second best of an implant as the pendulum starts to swing away from replacing many teeth to preserving natural teeth. What are your top tips for main- taining a successful practice? There is no easy answer. First and foremost is providing a high level of care, but that is not enough. One has to create an experience for the patient that proves the value in the services provided. On top of it all is maintaining a highly motivated, well- trained staff that enjoy what they do. We create an environment in which the staff enjoys coming to work. Our staff currently averages over 10 years with our office. What advice would you give to budding endodontists? It is to not about all the devices. Cone beam, torque-sensing motors, and so on are all good, but it is about the patient. One person once told me, “Patients don’t care how much you know until they know how much you care.” Keep the patient experience in the forefront, doing what is right, and the rest will follow naturally. What are your hobbies, and what do you do in your spare time? My biggest hobby is my family. I love to spend time with my wife and kids, from little stuff like building a snowman to going to bigger things like going skiing. Four kids always take a lot of effort, but it’s worth it. I hope to share in my kids’ hobbies to the extent they want to include me. My kids enjoy chess, and I am the chess master for the chess club at their school. They wanted to try downhill skiing, so we took up skiing this year. I like cross-country skiing also, but none of them shows much interest, so I haven’t done any for a while. I have a few hobbies of my own that I enjoy. I enjoy automotives through reading car magazines (I subscribe to three), going to the auto show (usually with a friend as the kids typically don’t want to go), going to advanced driving skills courses; and I have an old car that I tinker with. I enjoy camping. I made a campsite down a path in our backyard. The kids and I go camping a couple of times each summer, as well as Cub Scout camps. (Mom typically doesn’t like to camp but, on occasion, is a good sport and joins us.) I have a wood shop in my basement and have a number of projects that I like to do. I am currently working on a chessboard and chess pieces with my boys. I also enjoy cooking. I do not like being a short-order cook preparing multiple different meals for the kids and grown-ups, but unfortunately, that is most of what I do presently. It is just where we are at in our lives. When I get a chance, I like to cook and bake and am known for the cheesecakes that I make and for presentation of dishes. Dr. Reeh’s family EP
  11. 11. OPERATORY COMPUTER MICROSCOPE ONLINE PORTAL IMAGING EQUIPMENT We’re that something you’ve been searching for. Ask yourself: WHAT IF I could surround myself with employees committed to clinical and practice excellence? WHAT IF my support team was exceptional because of complete commitment to my vision? WHAT IF I had immediate, meaningful, and quality contact with my referrals every minute of every day? WHAT IF I had hundreds of world-class endodontists mentoring me daily, helping me to become more successful? WHAT IF my patients recognized immediately that my practice was centered around quality? C a l l 1 - 8 7 7 - 4 3 5 - 7 8 3 6 o r e m a i l u s a t s a l e s @ t d o 4 e n d o . c o m f o r a f r e e d e m o o f t h i s t i m e - s a v i n g p r o g r a m . MAKE IT POSSIBLE WITH TDO SOFTWARE
  12. 12. History of Ultradent Ultradent Products, Inc., began when one forward-thinking dentist, Dr. Dan Fischer, set out to create dental products more effective than those that were currently available. Dissatisfied with many dental options, Dr. Fischer hoped to develop better products that were not only advanced for their time but would also set future industry standards. It all began in 1974, when, upon graduating from Loma Linda University and starting his own dental practice in the Salt Lake Valley, Dr. Fischer noticed a dire need for more rapid, profound hemostasis. At the time, no products existed on the market that predictably controlled bleeding and sulcular fluid, which made getting accurate impressions and the overall practice of high-quality operative dentistry a challenge. Experimenting with various chemistries after-hours and often drawing his own blood to test their hemostatic effects, Dr. Fischer discovered a solution that, when combined with his innovative scrubbing technique, achieved rapid, profound hemostasis every time. This product, known as Astringedent® , is now considered Ultradent’s flagship product. In order to share it with the industry, Dr. Fischer founded Ultradent in 1978. What began as a family-only business quickly grew as word of Ultradent’s groundbreaking, high-quality products spread. In 35 short years, the company expanded from a small home operation to the 220,000-square-foot facility in South Jordan, Utah, that Ultradent calls home today. Ultradent’s headquarters houses 1,100 employees and continues to expand, breaking ground last fall Ultradent 10 Endodontic practice Volume 7 Number 2 CORPORATE PROFILE By maintaining close relationships with top endodontic researchers at several domestic and international universities, as well as by keeping several highly skilled dentists on staff, Ultradent continues to keep a finger on the pulse of this important and rapidly growing area of dentistry. products, application device materials, and techniques. Ultradent’s product family now includes world-class adhesives, composites, tooth whitening systems, and endodontic products that are used by clinicians around the world, including dental professionals in large group practices, dental and veterinary labs, private practices, government agencies, and universities. Over the last decade, Ultradent expanded its reach to orthodontics, serving as the parent company for Opal Orthodontics. Also headquartered in South Jordan, Utah, Opal Orthodontics houses its own on-site orthodontic clinic. A minimally invasive philosophy Dr. Fischer has said, “Respecting and preserving our patients’ dentate throughout their life: this should be among our principal responsibilities. I believe to my bootstraps in respecting human tissues to the ultimate degree, in preserving mineral mother dentin, and in respecting supporting tissues as well. It comes down to first and foremost, remembering the fabulous human behind that oral cavity.” He goes on, “The more I cut the tooth, the more I weaken the tooth, and the more of the tooth I cut, and the more times I cut, the sooner I will kill the tooth. Trauma to the tooth is additive, even over decades!” Ultradent strives to offer the latest and greatest in technology, and Dr. Fischer’s passion for a minimally invasive approach to dentistry has and will continue to guide the development of every new product created in the future. It was this very approach that led to the creation of Ultradent’s extensive line of endodontic products available to clinicians today. Ultradent endodontics Endo-Eze® AET classic stainless steel files, Ultradent’s extensive line of endodontic products and solutions, were born out the necessity for a successful endodontic protocol that met the minimally invasive philosophy that Dr. Fischer so passion- ately advocates. The result: the Endo- Eze Anatomic Endodontic Technology (AET) technique. Because of the 30° reciprocating motion of the handpiece, the system produces less-invasive root canal therapies, as the combination of motion Dr. Dan Fischer on a 10,000-square-foot building to create space for increased molding and manufacturing. One of the most vertically integrated dental companies in the world, Ultradent manufactures over 90% of its products (which includes over 500 materials, devices, and instruments) at its Utah campus. Instead of saving on production costs through outsourcing, which many U.S. manufacturers do, Dr. Fischer firmly believes in the opposite. He says, “The more one outsources, the more one ships production, or R&D, or other aspects to other parts of the world, the more one loses touch with what has made them who they are.” Ultradent exports approximately 70% of its products internationally to countries in nearly every continent in the world. Ultradent currently holds dozens of patents and trademarks on unique
  13. 13. CORPORATEPROFILE Volume 7 Number 2 Endodontic practice 11 and files proved able to better follow the natural canal anatomy. This stands in contrast to the popular rotary NiTi systems, which are not designed to replicate the naturally formed canal, but to prepare the canal in a round, conical shape. By following the natural canal shape, the files minimize excess removal of healthy tooth structure. Ultradent offered a number of endodontic products before introducing AET and has created a number of market- leading devices and chemistries since its introduction. A few of these are outlined here: NaviTip® In the year 2000, Ultradent introduced NaviTip — the very first endodontic tip capable of delivering irrigants to just about any part of the root canal system. Today, with the world’s smallest and most technologically sophisticated cannula for irrigation and delivery, NaviTip remains unsurpassed in its performance. NaviTip features a unique rigidity at the handle of the tip, making it strong enough to be introduced as deep as needed in the canal. And the annealed and rounded tip end gives it the ability to navigate down the tiny intricate curvatures of any canal of any tooth. Available in four lengths (17 mm, 21 mm, 25 mm, and 27 mm), three gauges (29 ga, 30 ga, and 31 ga), and even with a flocked end to help clean debris or product out of a canal, NaviTip is available in an option to suit any need a clinician may have. The NaviTip even has a version with sideport openings that deliver irrigants toward the canal walls rather than toward the apex, which minimizes the risk of expressing strong chemistries past the apex. Endo-Eze® Arios™ and Endo-Eze AET TiLOS™ Building on the success of the AET files, Ultradent developed the Endo-Eze TiLOS system with several well-respected American and international specialists. This very simple technique uses both stainless steel and NiTi files in combination with traditional hand files. If the clinician prefers, the TiLOS system can be used without traditional hand files as well. The award-winning TiLOS system is available in convenient, autoclavable, preconfigured patient kits as well as refills. The simplest is the RediPack, which contains the files needed to treat about 90% of endodontic cases. The TiLOS technique still uses a reciprocating handpiece, which provides a “milling” rather than “drilling” motion. Experience has shown that a milling motion reduces the amount of file separation that occurs. And of course, the TiLOS instruments and technique follow the minimally invasive Ultradent philosophy that the company has been built on. More and more clinicians are discovering Ultradent’s Engine Pack, which contains three engine-driven files. This preconfigured kit is perfect for the preflaring of canals — something every clinician does, but often requires gathering the necessary files from different kits to do so. The Engine Pack contains all the files needed for this preflaring procedure, it’s autoclavable, very economical, and it can be integrated into any technique currently being taught today. The pulse of the endodontists For many years, Ultradent has developed and provided endodontic equipment such as files, delivery tips, irrigants, handpieces, sealer, and gutta percha with the goal of simplifying and elevating the quality of endodontic outcomes. By maintaining close relationships with top endodontic researchers at several domestic and international universities, as well as by keeping several highly skilled dentists on staff, Ultradent continues to keep a finger on the pulse of this important and rapidly growing area of dentistry. Ultradent proudly offers the latest and most cutting- edge metals, file types, and technologies, while continually working to refine and work toward less-invasive endodontic solutions and protocol. To learn more about the endodontic products mentioned or the wide array of additional endodontic solutions provided by Ultradent, please visit ultradent.com, or call 800-552-5512. This information was provided by Ultradent. EP
  14. 14. In part 1 of this series, published in the January/February issue of Endodontic Practice US, the authors outlined the clinical guidelines for the use of the ProTaper Next™ (Dentsply/Maileffer) instruments. (ProTaper Next is only available in North America through DENTSPLY Tulsa Dental Specialties.) There are five instruments in the system, but most canals can be prepared by using only the first two instruments. The first instrument in the system is the ProTaper Next X1, with a tip size of 0.17 mm and a 4% taper. This instrument is used after creation of a reproducible glide path by means of hand instruments or PathFile™ rotary files (DENTSPLY Tulsa Dental Specialties). The ProTaper Next X1 is always followed by the second instrument: the ProTaper Next X2 (0.25 mm tip and 6% taper). The ProTaper Next X2 can be regarded as the first finishing file in the system, as it leaves the prepared root canal with adequate shape and taper for optimal irrigation and root canal obturation. The ProTaper Next X1 and X2 have an increasing and decreasing percentage tapered design over the active portion of the instruments. The last three finishing instruments are the ProTaper Next X3 (0.30 mm tip with 7% taper), ProTaper Next X4 (0.40 mm tip with 6% taper), and the ProTaper Next X5 (0.50 mm tip with 6% taper). These instruments have a decreasing percentage taper from the tip to the shank. The ProTaper Next X3, X4, and X5 can be used to either create more taper in a root canal or to prepare larger root canal systems. The advantages of the ProTaper Next system include the following: • The instruments are manufactured from M-Wire that contributes toward more flexible instruments, increased safety, and protection against instrument fracture (Gutmann and Gao, 2012), allowing the clinician to treat more complex root canal systems with a high level of success. • The instruments have a bilateral symmetrical rectangular cross section with an offset from the central axis of rotation (except in the last 3 mm of the instrument, D0-D3), creating an asymmetric rotary motion. The exception is the ProTaper X1, which has a square cross section in the last 3 mm to give the instruments a bit more core strength in the narrow apical part. The asymmetric rotary motion allows the instrument to experience a rotational phenomenon known as precession or swagger (Scianamblo, 2011). According to Van der Vyver and Scianamblo (2013), this design characteristic includes six benefits: 1. It further reduces (in addition to the progressive tapered design) the engagement between the instrument and the dentin walls because only two cutting Clinical guidelines for the use of ProTaper Next™ instruments: part 2 12 Endodontic practice Volume 7 Number 2 CLINICAL Drs. Peet J. van der Vyver and Michael J. Scianamblo illustrate the use of ProTaper Next instruments in difficult and challenging endodontic cases Figure 1A: Preoperative radiograph of a maxillary right second premolar Dr. Peet J. van der Vyver is extraordinary professor at the Department of Odontology, School of Dentistry, University of Pretoria and Private Practice, Sandton, South Africa (see www.studio4endo.com for more). Michael J Scianamblo, DDS, is an endodontist and the developer of Critical Path Technology. He is a postgraduate and fellow of the Harvard School of Dental Medicine and has served as a faculty member of the University of the Pacific and the University of California, Schools of Dentistry in San Francisco. Figure 1B: Length determination radiograph. Note the “S”-shaped canal configuration Figure 1C: Postoperative radiograph after canal obturation with GuttaCore obturators
  15. 15. CLINICAL Volume 7 Number 2 Endodontic practice 13 points make contact with the canal wall at any time. This will contribute to a reduction in taper lock, screw-in effect, and stress on the file. 2. It ensures debris removal in a coronal direction because the off-center cross section allows for more space around the flutes of the instrument. This will lead to improved cutting efficiency, as the blades will stay in contact with the surrounding dentin walls. Root canal preparation is done in a very fast and effortless manner. 3. The swaggering (asymmetric) rotary motion of the instrument initiates activation of the irrigation solution during canal preparation, improving debris removal. 4. It reduces the risk of instrument fracture because there is less stress on the file and more efficient debris removal. 5. Every instrument is capable of cutting a larger envelope of motion (larger canal preparation size) compared to a similarly sized instrument with a symmetrical mass and axis of rotation. This allows the clinician to use fewer instruments to prepare a root canal to the adequate shape and taper to allow for optimal irrigation and obturation. 6. There is a smooth transition between the different sizes of instruments because the design ensures that the instrument sequence itself expands exponentially. The aim of this article is to illustrate the use of ProTaper Next instruments in complex and challenging endodontic cases. The preparation technique for minimally invasive root canal preparation with ProTaper Next instruments will also be discussed. “S”-shaped root canals A major challenge in endodontics is the treatment of “S”-shaped or bayonet- shaped root canals. This type of root canal configuration can be present in root canal systems of maxillary laterals, canines, and premolars, as well as mandibular molars (Rueben, et al., 2008). The authors would recommend using PathFile No. 3 (ISO tip 0.19 mm) (after PathFile Nos. 1 and 2) in these challenging root canal systems as the final glide path preparation file. This will increase the glide path size before introducing the ProTaper Next X1, resulting in less engagement as the file travels down the canal curvatures. Figure 2A: Preoperative radiograph of a maxillary right first molar Figure 2B: Length determination radiograph. Note the “S”-shaped canal configuration in the distobuccal root canal Figure 2C: Postoperative radiograph after glide path preparation with PathFiles and canal preparation with ProTaper Next X1 and X2. Obturation was done with GuttaCore obturators. Note maintenance of “S”-shaped curvature in the obturated distobuccal root canal system
  16. 16. Case report 1 The patient, a 41-year-old female, presented with irreversible pulpitis on her maxillary right second premolar (Figure 1A). The length determination radiograph revealed an “S”-shaped canal configuration (Figure 1B). The canal was negotiated and glide path enlarged using PathFile Nos. 1, 2, and 3. Canal preparation was done with ProTaper Next X1 and X2. In this case, emphasis was placed on using a backstroke, outward brushing motion with the ProTaper Next instruments to remove restrictive dentin in the canal, allowing the instruments to progress apically. The canal was obturated (Figure 1C) with a size 20 GuttaCore™ obturator to working length followed by another X2 GuttaCore obturator (DENTSPLY Tulsa Dental Specialties) to ensure adequate obturation of the oval coronal part of the root canal system. 14 Endodontic practice Volume 7 Number 2 CLINICAL Case report 2 A 45-year-old male patient presented with severe pain on his maxillary right first molar. A preoperative periapical radiograph revealed placement of a deep amalgam restoration (Figure 2A). The length determination radiograph revealed an “S”-shaped canal configuration in the distobuccal root canal (Figure 2B). The root canals were negotiated to working length, and the glide paths enlarged using PathFile Nos. 1 and 2. PathFile No. 3 was used in the distobuccal root canal. Canal preparation was done with ProTaper Next X1 and X2 in all three root canals. After gauging with a size 25 nickel- titanium hand instrument, it was decided to enlarge the palatal root canal to a ProTaper Next X3. All three root canals were obturated with matching ProTaper Next gutta-percha cones using the Calamus® Dual Obturation Unit (DENTSPLY Tulsa Dental Specialties) (Figure 2C). Note the maintenance of the “S”-shaped curvature in obturated distobuccal root canal system. Challenging curvatures in the apical third of root canals Apical root canal curvatures must always be respected and never straightened. Ac- cording to Catellucci (2005), straightening these curves would mean displacing the apical foramen from its original position, which can lead to treatment failure. Other problems that can be encountered when treating curved canals include ledge formation, perforation, zip formation, and file separation (Ingle, 2005). It is very important to identify canal curvatures during initial canal negotiation in order to avoid the above-mentioned preparation errors. The greater the angle of curvature and the smaller the radius of curvature, the more complex the Figure 3A: Non-vital mandibular left first molar and inadequately root canal treated mandibular right second molar Figure 3B: Initial length determination radiograph. Note that the files were short in all the root canals in the mandibular second molar Figure 3C: Periapical radiograph demonstrating the fit of the plastic inserts of ProTaper obturators to the corrected working length (mandibular second molar) after canal negotiation with C+ and K-files and preparation with ProTaper Next Figure 3D: Final result after the canals were obturated with ProTaper obturators Figure 3E: Periapical radiograph (30° mesial angulated) demonstrating respect of the original canal anatomy after canal preparation with ProTaper Next instruments Figure 3F: Six-month follow-up periapical radiograph illustrating periapical healing
  17. 17. CLINICAL Volume 7 Number 2 Endodontic practice 15 management and treatment will be (Pruett, Clement, Carnes, 1997). Again, the authors would recommend using all three PathFiles in these challenging root canal systems to enlarge the glide path prior to canal preparation. It is also important to note that the reduced apical tapers of the ProTaper Next instruments (compared to ProTaper Universal) are ideal for maintaining apical curvatures or “S”- shaped root canals. Case report 3 The patient, a 27-year-old male, presented with a non-vital mandibular left first molar and an inadequately root canal treated mandibular right second molar (Figure 3A). Access cavities were prepared, and the previous gutta percha was removed from the canals of the second molar. A length determination radiograph revealed sharp apical curvatures in the last few millimeters of the mesial and distal roots of the mandibular first molar. It was also noted that the working length was short in the canals of the second molar (Figure 3B). A combination of C+ and K-files were used to negotiate the canals in the mandibular second molar to full working length. A reproducible glide path was established in all the root canals, and the glide paths enlarged to ISO 0.19 mm using PathFiles. The coronal two-thirds of the canals were prepared with ProTaper Next X1 and X2 using a backstroke, outward brushing motion to remove restrictive dentin in the canals, allowing the instruments to progress towards the apical third. The apical third of the root canals were prepared with a controlled push-pull motion, allowing the instruments to progress up to working length. The prepared root canals were gauged with a size 25 nickel-titanium hand file. The file was snug at working length except in the distal canal of the lower first molar. This canal was enlarged with a ProTaper Next X3 instrument. Figure 3C shows radiographic confirmation of the working length and the fit of the plastic carriers of size 25 ProTaper obturators (without gutta percha). All the canals were obturated (Figure 3D) with size 25 ProTaper obturators, except the distal root canal in the lower first molar that received a size 30 ProTaper obturator. Figure 4A: Preoperative radiograph of non-vital maxillary left first and second molars Figure 4B: Length determination radiograph for the maxillary first molar orders@engineeredendo.com www.engineeredendo.com The Finishing File is the most cost effective and simplest way to clean a canal! THE FUTURE HAS RETURNED. THE ORIGINAL PLASTIC ENDODONTIC ROTARY FINISHING FILE IS BACK. MANUFACTURER DIRECT. MADE IN THE U.S.A.
  18. 18. 16 Endodontic practice Volume 7 Number 2 CLINICAL Figure 3E demonstrates the final result after obturation, and Figure 3F illustrates healing of the periapical pathology around the roots on a 6-month postoperative radiograph. Minimally invasive canal preparation According to Gutmann (2013), minimally invasive endodontic (MIE) procedures can range from diagnosis to making a decision to treat (or not to treat) the case. They also include the following: 1. Minimal removal of dentin during access cavity preparation (Clark, Khademi, 2010), enlarging and shaping of the root canal system to retain as much as sound dentin as possible 2. Retention of tooth structure during disassembly and retreatment procedures We have to accept that if access openings are too restricted, it can impact on the final result of treatment. Gutmann (2013) further suggests that efforts should be made to minimize the excess removal of cervical tooth structure in the canal orifice through the use of Peeso reamers, Figure 5A: ProTaper Next X1 is introduced into the canal and used in a push- pull motion. Restrictive dentin is removed on the outstroke, pulling motion. The push-pull motion was repeated a few times until the instrument progressed approximately 4 mm (arrow). The instrument was removed from the root canal; the flutes cleaned; and the canal irrigated, recapitulated, and re- irrigated Figure 5B: The file was reintroduced into the root canal, and the same protocol repeated. The instrument now progressed up to the apical third of the root canal (arrow) Figure 5C: The last cutting cycle carried the file up to working length (arrow) Gates Glidden burs, and orifice-opening instruments. These instruments tend to straighten the canal and weaken the root canal walls, predisposing them to cracks and, in some cases, can even lead to root canal wall- stripping defects. For some clinicians, it might be an option not to brush excessively with ProTaper Next instruments but rather to use the “push-pull” preparation technique. Case report 4 The patient, a 39-year-old male, presented with non-vital maxillary first and second molars (Figure 4A). He also reported that his previous dentist, for pain relief, did emergency root canal treatments on both teeth. The temporary filling on the upper first molar was removed, and four root canal orifices located and explored (mesiobuccal, mesiobuccal 2, distobuccal, and palatal). Figure 4B shows a periapical radiograph confirming the working lengths that were electronically measured with the Propex Pixi™ apex locator (Dentsply/Maillefer). Reproducible glide paths were established by using a size 10 K-file by hand, followed by mechanically enlarging the glide paths in all four root canals using PathFile Nos. 1, 2, and 3. All four root canals were prepared with ProTaper Next using the following technique, resulting in minimally invasive canal preparations. In order to explain the technique, we will outline the preparation steps for one of the mesiobuccal root canals. ProTaper Next X1 was introduced into the canal and used in a push-pull motion. Restrictive dentin was removed on the out- stroke, pulling motion. The push-pull mo- tion was repeated a few times until the in- strument progressed approximately 4 mm (Figure 5A). The instrument was removed from the root canal; the flutes cleaned; and the canal irrigated, recapitulated, and re-ir- rigated. The file was re-introduced into the root canal, and the same protocol repeat- ed (Figure 5B). After three cutting cycles of 4 mm each, the full working length was reached (Figure 5C). ProTaper Next X2 was introduced and used following the same protocol.
  19. 19. Now in single-use pouches to use only what you need. For predictable results, think ProRoot® MTA. Trusted in over 4 million cases, it’s proven to provide a strong seal that sets in moisture and biocompatibility for a normal healing response. Call 1-800-662-1202 to order or learn more. ProRoot MTA. The first name in root repair. © 2014 DENTSPLY International, Inc. ADPRMTA Rev. 0 2/14 1-800-662-1202 For the latest information consult www.TulsaDentalSpecialties.com Pulp capping Furcal repair Root resorption Repair of root perforation Apexification Root-end filling Clinical Applications
  20. 20. 18 Endodontic practice Volume 7 Number 2 CLINICAL References Castellucci A, ed. Endodontics Volume II. Florence, Italy: IL Tridente; 2005. Clark D, Khademi J. Modern molar endodontic access and directed dentin conservation. Dent Clin North Am. 2010;54(2):249-273. Gutmann JL. Minimally invasive dentistry (Endodontics). J Conserv Dent. 2013;16(4):282- 283. Gutmann JL, Gao Y. Alteration in the inherent metallic and surface properties of nickel-titanium root canal instruments to enhance performance, durability and safety: a focused review. Int Endod J. 2012;45(2):113-128. Ingle JI. Root canal preparation. In: PDQ Endodontics. BC Decker, ed. Hamilton, Ontario: PMPH-USA; 2005: 129. Pruett JP, Clement DJ, Carnes DL Jr. Cyclic fatigue testing of nickel-titanium endodontic instruments. J Endod. 1997;23(2):77-85. Reuben J, Velmurugan N, Vasanthi S, Vijayalakshm P. Endodontic management of a maxillary second premolar with an S-shaped root canal. J Conserv Dent. 2008;11(4):168-170. Scianamblo MJ, inventor. US patents 6942484, 7094056,7955078, 20060228669. 2011. Van der Vyver PJ, Scianamblo. Clinical guidelines for the use of ProTaper Next instruments: part one. Endod Practice. 2013;16(4):33-40. Figure 6A: ProTaper Next X3 gutta-percha cone and three size 20 GuttaCore verifiers fitted to working lengths prior to obturation Figure 6B: Postoperative result after obturation After two cutting cycles of 4 mm each, full working length was reached. A size 25/02 nickel-titanium hand file was used to gauge the apical foramen. The file fitted snug at working length, and shaping was complete. The mesiobuccal, mesiobuccal 2, and distobuccal canals were prepared up to ProTaper Next X2, and the palatal canal was prepared up to ProTaper Next X3. Because the instruments were used in a push-pull motion instead of a deliberate brushing motion, the canal shapes were generally smaller in size and more conservative. The concept of larger apical sizes has been advocated to improve bacterial reduction. However, maintaining smaller sizes (> 20 < 40) would seem desirable for the preservation of radicular dentin in the majority of cases and to rather focus on improved methods for cleaning and disinfecting root canal systems (Gutmann, 2013). The palatal canal was obturated with a ProTaper Next X3 gutta-percha cone using the Calamus Dual Obturation Unit (Dentsply/Maillefer). It was decided to obturate the two mesiobuccal and distobuccal canals with GuttaCore cross- linked gutta-percha carriers. It must be noted that because of the more conservative canal preparations obtained with the push-pull preparation protocol, it was not possible to passively fit a size X2 GuttaCore verifier (size 025) up to working length in the prepared root canals. Only size 20 GuttaCore verifiers fitted passively, without resistance to working length (Figure 6A). The selected root canals were then obturated using three size 20 GuttaCore obturators. Figure 6B shows the final result after obturation. Carrier- based obturation also forms part of the MIE concept due to the minimal amount of application forces involved during the obturation process onto the remaining root structure. EP
  21. 21. DENTSPLY MAILLEFER / T: 1-800-924-7393 / F: 1-800-924-7389 / MAILLEFER.DENTSPLY.COM ©DENTSPLY International, Inc., DENTSPLY Maillefer Sharpen Your Clinician’s Root Canal Visibility Introducing the new Detect™ Apex Locator from Maillefer. Detect™ Apex Locator is innovative, aesthetically pleasing, and delivers successful root canal therapy. Other features include: • Large color display to facilitate file tracking • Progressive sound control for dual control • Fully automatic device • Powered by rechargeable battery • Latest multi-frequency technology enables location of the apex in most types of canal conditions Check out our website for a short technique and product educational video perfect for customer demonstrations: maillefer.com Extended apical zone from 0.9 to 0.0 The cursor on the tooth icon indicates the progression of the file in the canal A solid tone will emit when the apex is reached The OVER icon indicates when the file passes the apex ADDAL3 Rev.0 11/13
  22. 22. The use of MTA (Angelus, Londrina, Brazil/Clinician’s Choice Dental Prod- ucts, New Milford, Connecticut) (Figure 1) has revolutionized endodontics, since its introduction to dentistry in 1993.1 (It has been on the dental market since about 1998.) In the years since, it has proven to be an exceptional material with a wide range of clinical uses, all scientifically and clinically proven.2-4 Initially recommended as a material for filling root end surgical preparations and for perforation repair, this material is also advocated for immediate apical sealing in teeth with open apices,5 pulpotomies, apexification, or apexogenesis in vital teeth with open apices,6-9 and other endodontic and reparative procedures. The extraordinary success in perforation repair since its introduction has motivated its use in these many other areas. This article will look at the success, practicality, and scientific basis for use in pulp capping procedures, particularly in permanent teeth, as MTA has been described very recently as “the material of choice”10 for this treatment. Properties of MTA MTA stands for mineral trioxide aggregate, denoting the three dominant oxides in the material’s composition — namely, calcium, aluminum, and selenium. Its particle sizes are strictly controlled during manufacturing, as they all need to be less than 10 microns, so that the material may be completely hydrated. MTA has a similar mechanism of action to calcium hydroxide11 in that the main component of the material, calcium oxide, when in contact with a humid environment, is converted into calcium hydroxide.12 This results in a high pH of 12.5, making its surroundings inhospitable for bacterial growth, and producing an antibacterial effect for a long period of time. But unlike calcium hydroxide products, such as DYCAL® (Dentsply, York, Pennsylvania), MTA Angelus (Angelus Dental Solution, Londrina, Brazil/Clinician’s Choice Dental Products, New Milford, Connecticut) has very low solubility, so it maintains a hard, excellent marginal seal. Finally, unlike most dental materials, MTA actually needs moisture to set, so it thrives in a moist environment. Of MTA: the new material of choice for pulp capping 20 Endodontic practice Volume 7 Number 2 CLINICAL Drs. Leendert (Len) Boksman and Manfred (Manny) Friedman delve into the benefits of MTA Figure 1: MTA Angelus (Clinician’s Choice Dental Products) Dr. Leendert (Len) Boksman, DDS, BSc, FADI, FICD, is a paid part-time consultant to Clinician’s Choice and is a former Associate Professor with tenure in the Department of Operative Dentistry, Faculty of Dentistry University of Western Ontario. He has recently retired from private practice, but consults on a part-time basis, lectures nationally and internationally, and publishes extensively in the field of Restorative Dentistry. He volunteers as an Adjunct Clinical Professor at UTech School of Oral Health Sciences Dental Faculty Kingston, Jamaica. He can be reached at lenpat28@gmail.com. Manfred (Manny) Friedman, BDS, BChD, maintains a private practice limited to endodontics in London, Ontario, and is an adjunct clinical professor in the Division of Restorative Dentistry at the Schulich School of Medicine and Dentistry at the University of Western Ontario. He can be reached at ndofriedman@rogers. com Figure 2: Preoperative radiograph of carious pulp exposure on tooth No. 30 Figure 3: Radiograph of periapical radiolucency Figure 4: One year follow-up with healthy pulp and resolution of the periapical lesion Figure 5: Preoperative radiograph of pulp exposure Figure 6: MTA placed after caries removal and pulp exposure Figure 7: Dentin bridge formation after 40 days
  23. 23. CLINICAL Volume 7 Number 2 Endodontic practice 21 Figure 8: Preoperative radiograph of clinical case Figure 9: Clinical presentation of the lesion after rubber dam isolation Figure 10: Initial rough cavity outline Figure 11: Use of short shank bur interferes with vision Figure 12: Relative lengths of short vs. long burs Figure 13: Increased visibility of lesion with long shank bur TYPHOON ACCESSORY FILES CONTROLLED MEMORY NiTi™ TECHNOLOGY Navigate the canal and find working length quickly with X-PLORER Canal Navigation Files. Available in 15/.01, 20/.01, 20/.02, and 25/.02. The INSTIGATOR 25/.08 (21mm) Orifice Opener File beautifully and efficiently shapes and enlarges the coronal area of the root canal. Up to 600% more resistant to fatigue failure with 2-3 times the torsional strength of regular NiTi files.* Unlike traditional NiTi files that try to straighten within the canal, TYPHOON™ files adapt perfectly to the canal path. These balanced lateral cutting forces along the length of the canal dramatically reduce ledging and transportation – effortlessly navigating even the most tortuous of canals. * Shen Y, Qian W, Abtin H, Gao Y, Haapasalo M. Effect of Environment of Fatigue Failure of Controlled Memory Wire Nickel-Titanium Rotary Instruments. J Endod 2012;38:376-380 1-800-265-3444 • www.clinicianschoice.com AAE Booth #229
  24. 24. Figure 17: Bleeding of the pulp exposure controlled 22 Endodontic practice Volume 7 Number 2 CLINICAL the commercially available MTA products, MTA Angelus is well suited for pulp capping procedures due to its setting time of 10 minutes, compared with the 4-hour setting time of the other commercially available MTA. It is also packaged in airtight bottles, allowing the practitioner to use only what is exactly needed without introducing undue moisture into the remainder. Use of MTA for direct pulp capping This combination of desirable qualities makes MTA “the material of choice” for cases of pulp exposure in both primary teeth and permanent teeth13,14 (Figures 2-4). Pulpal exposure is inevitable when excavating many large carious lesions. While many dentists are hesitant to perform direct pulp capping procedures due to previously unpredictable results Figure 18: MTA is placed by ultrasonic vibration of plastic instrument Figure 19: First increment of MTA placed Figure 20: Second increment of MTA fully covers pulp exposure Figure 21: LC Glass Ionomer is placed with a Skini syringe Figure 22: Initial placement of the light cured glass ionomer with conventional materials, MTA is a more predictable and reliable material for direct pulp capping teeth, with reversible pulpitis, as borne out by numerous clinical and histological studies.15-19 Mente, et al., recently concluded, “MTA appears to be more effective than calcium hydroxide for maintaining long-term pulp vitality after direct pulp capping.”20 Numerous other studies show much promise in the long- term health of pulps that have been capped using MTA, and years of clinical use have demonstrated the superlative ability of this material in dentin bridge formation (Figures 5-7).21,22 MTA clinical case presentation A young female patient presented to the dental office with a large carious exposure on the distal of tooth No. 30, as evidenced by the radiograph in Figure 8. Since there was no evidence of periapical rarefaction and no spontaneous pain, it was decided to place a direct pulp cap, if after excavating the caries, the bleeding could be controlled without the use of hemostatic agents. After delivering a mandibular block, and isolation with the rubber dam (Paro Dam – Clinician’s Choice Dental Products, New Milford, Connecticut), the clinical photograph of the distal caries is shown in Figure 9. The initial outline form was created using a pear-shaped 332 carbide bur followed by removal of the soft caries with a round carbide bur (Figure 10). When excavating deep caries and using a regular length bur (Figure 11), the head of the handpiece interferes with adequate vision of the caries removal process. As evidenced by Figure 12, the use of a long shank bur (Figure 13) Figure 14: Photo of pulp exposure Figure 15: NaOCl placed over pulp exposure Figure 16: Cotton used to dry area
  25. 25. simple, adaptable endodontic solutions Irrigation amplification All grown up Ultradent now offers Consepsis (2% chlorhexidine), ChlorCid (3% sodium hypochlorite), and EDTA 18% in 480ml bottles* to give you the best value on the irrigants you use with every endodontic procedure. And with Ultradent’s economically priced irrigants, you do not have to sacrifice ease of use. Designed with a unique flip-top cap, Ultradent’s economy-size irrigants are easy to dispense into a container or even backfill a syringe—so easy, in fact, you can do it with one hand. Use NaviTip to easily deliver Ultradent irrigants just short of the apex. Available with regular and sideport delivery. Irrigants Don’t change your technique. Make it easier—and more economical—with Ultradent’s economy-size irrigants. © 2014 Ultradent Products, Inc. All Rights Reserved. 800.552.5512 ultradent.com Unique flip-top cap makes backfilling syringes easy. Scan to watch a short video about Ultradent irrigants. *Smaller-volume syringes still available.
  26. 26. 24 Endodontic practice Volume 7 Number 2 CLINICAL Figure 23: Valo LED curing light used to set the glass ionomer Figure 24: Triodent V3 ring used to create separation for tight contact Figure 25: UltraEtch is placed on enamel first may complicate access for distal molars, but the distancing of the head of the handpiece from the occlusal cavo-surface margins allows better visualization of the caries removal process. The final removal of the caries is accomplished with the use of a new sterile diamond round bur, which causes less tissue damage to the pulp than the round carbide bur (which also will be contaminated by the caries excavation). The initial carious pulp exposure is shown in Figure 14. A cotton pledget soaked in 5½% sodium hypochlorite (NaOCl) is placed over the pulp tissue and removed when the bleeding has stopped (Figure 15). The area is delicately dried with the use of tissue in cotton pliers (Figure 16). At this point in the procedure, the area is not washed, nor air dried. With the area decontaminated with the bleach and the bleeding stopped (Figure 17), the MTA (Angelus Dental Solution, Londrina, Brazil/ Clinician’s Choice Dental Products, New Milford, Connecticut) is prepared by mixing the powder and liquid according to the manufacturer’s instructions. The MTA is picked up by a plastic instrument, carried to the exposure site, and is deposited by vibrating the plastic instrument with an ultrasonic tip (Figure 18). Figure 19 shows the first increment placed. Similarly, a second increment is carried to the exposure site and is deposited by the vibration of the ultrasonic (Figure 20). The vibration simplifies the placement of the MTA with the material smoothly flowing from the plastic instrument and adapting well to the tooth structure facilitating a good seal. To protect the MTA during its setting, a light- cured glass ionomer (Fuji 2 LC GC America, Alsip, Illinois) is injected precisely over the MTA site with a Skini Syringe and Endo- Eze® canula (Ultradent Products, Salt Lake City, Utah) (Figures 21, 22) and fully light cured with a Valo® broad spectrum curing light (Figure 23). After careful cutback of the glass ionomer cement and a cleaning of all the margins, a Triodent contoured matrix band was placed, followed by the insertion of a Wave-Wedge. The Wave-Wedge does not cause separation but only serves to adapt the matrix gingivally. A Triodent V3 green molar ring (Triodent) was placed to create tooth separation, and the band was burnished with a ball burnisher to confirm contact with tooth No. 31 (Figure 24). Ultra-Etch® was placed for 15 seconds over the glass ionomer, remaining dentin, and enamel margins (Figures 25, 26), gently washed, and lightly dried. A single Figure 26: Then the entire cavity is flooded by phosphoric acid Figure 27: MPa bonding agent is placed as a single coat and light cured Figure 28: Initial fill with Cosmedent Nano
  27. 27. coat of the fifth-generation bonding agent MPa (Clinician’s Choice Dental Products, New Milford, Connecticut) was applied with a micro-brush (Figure 27), air thinned, and the ethanol solvent evaporated. After light curing with the Valo, the A2 Cosmedent Nano composite (Cosmedent) was incrementally placed, first laterally to decrease the C factor vectors, light cured, and then the center valley filled in, adapted, and light cured (Figure 28). After initial recapitulation of the occlusal anatomy with a 7802 bur (Figure 29), the rubber dam was removed, and a diamond impregnated Groovy Occlusal polishing point (Clinician’s Choice Dental Products, New Milford, Connecticut) (Figure 30) was used to create the final polish of the Nano-filled composite. The final restoration is shown in Figure 31 with the final postoperative radiograph (Figure 32) showing the close adaptation of the MTA, glass ionomer and the Cosmedent Nano. Summary statement The clinical and research evidence clearly support the use of MTA as the “new” pulp capping material of choice. References 1. Lee SJ, Monsef M, Torabinejad M. Sealing ability of a mineral trioxide aggregate for repair of lateral root perforations. J Endod. 1993;19(11):541-544. 2. Parirokh M, Torabinejad M. Mineral trioxide aggregate: a comprehensive literature review--Part I: chemical, physical, and antibacterial properties. J Endod. 2010;36(1):16-27. 3. Torabinejad M, Parirokh M. Mineral trioxide aggregate: a comprehensive literature review-part II: leak-age and biocompatibility investigations. J Endod. 2010;36(2):190-202. 4. Parirokh M, Torabinejad M. Mineral trioxide aggregate: a comprehensive literature review-Part III: Clinical applications, drawbacks, and mechanism of action. J Endod. 2010;36(3):400-413. 5. Kratchman SI. Perforation repair and one-step apexification procedures. Dent Clin North Am. 2004;48(1):291-307. 6. Shayegan A, Petein M, Abbeele AV. Beta-tricalcium phosphate, white mineral trioxide aggregate, white Portland cement, ferric sulfate, and formocresol used as pulpotomy agents in primary pig teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008;105(4):536-542. 7. Holland R, de Souza V, Murata SS, Nery MJ, Bernabé PF, Otoboni Filho JA, Dezan Júnior E. Healing process of dog dental pulp after pulpotomy and pulp covering with mineral trioxide aggregate or Portland cement. Braz Dent J. 2001;12(2):109-113. 8. Ng FK, Messer LB. Mineral trioxide aggregate as a pulpotomy medicament: an evidence-based assessment. Eur Arch Paediatr Dent. 2008;9(2):58-73. 9. Chacko V, Kurikose S. Human pulpal response to mineral trioxide aggregate (MTA): A histological study. J Clin Pediatr Dent. 2006;30(3):203-210. 10. Parirokh M, Torabinejad M. Mineral trioxide aggregate: a comprehensive literature review--Part III: Clinical applications, drawbacks, and mechanism of action. J Endod. 2010;36(3):400-413. 11. Castellucci A. The use of mineral trioxide aggregate in clinical and surgical endodontics. Dent Today. 2003;22(3)74-81. 12. Duarte MA, Demarchi AC, Yamashita JC, Kuga MC, Fraga Sde C. pH and calcium ion release of 2 root- end filling materials. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003;95(3):345-347. 13. Farsi N, Alamoudi N, Balto K, Al Mushayt A. Clinical assessment of mineral trioxide aggregate (MTA) as direct pulp capping in young permanent teeth. J Clin Pediatr Dent. 2006;31(2):72-76. 14. Tuna D, Olmez A. Clinical long-term evaluation of MTA as a direct pulp capping material in primary teeth. Int Endod J. 2008;41(4):273-278. 15. Pitt Ford TR, Torabinejad M, Abedi HR, Bakland LK, Kariyawasam SP. Using mineral trioxide aggregate as a pulp-capping material. J Am Dent Assoc. 1996;127:1491-1494. 16. Faraco IM Jr, Holland R. Response of pulp of dogs to capping with mineral trioxide aggregate or a calcium hydroxide cement. Dent Traumatol. 2001;17(4):163-166. 17. Bogen G, Kim JS, Bakland LK. Direct pulp capping with mineral trioxide aggregate. J Am Dent Assoc. 2008;139:305-315. 18. Bodem O, Blumenshine S, Zeh D, Koch MJ. Direct pulp capping with mineral trioxide aggregate in a primary molar: a case report. Int J Paediatr Dent. 2004;14(5):376-379. 19. Mussolino de Queiroz A, Assed S, LeonardoI MR, Nelson-Filho P, Bezerra da Silva LA. MTA and calcium hydroxide for pulp capping. J Appl Oral Sci. 2005;13(2). 20. Mente J1, Geletneky B, Ohle M, Koch MJ, Friedrich Ding PG, Wolff D, Dreyhaupt J, Martin N, Staehle HJ, Pfefferle T. Mineral trioxide aggregate or calcium hydroxide direct pulp capping: an analysis of the clinical treatment outcome. J Endod. 2010;36(5). 21. Min KS, Park HJ, Lee SK, Park SH, Hong CU, Kim HW, Lee HH, Kim EC. Effect of mineral trioxide aggregate on dentin bridge formation and expression of dentin sialoprotein and heme oxygenase-1 in human dental pulp. J Endod. 2008;34(6):666-670. 22. Asgary S, Parirokh M, Eghbal MJ, Ghoddusi J, Eskandarizadeh A. SEM evaluation of neodentinal bridging after direct pulp protection with mineral trioxide aggregate. Aust Endod J. 2006;32(1):26-30. EP Figure 29: Initial trimming with 7802 multi-fluted finishing bur Figure 30: After occlusal adjustment, a Groovy polishing point is used Figure 31: Final clinical result Figure 32: Postoperative radiograph of MTA pulp cap CLINICAL Volume 7 Number 2 Endodontic practice 25
  28. 28. Abstract Aim: The purpose of this study was to test the effect of the MTA thickness on the microhardness properties. Materials and method: A total of 30 roots from extracted single canal human teeth were divided into 3 groups of 4-mm, 6-mm, and 10-mm long root sections. After canal preparation, white MTA (ProRoot® , DENTSPLY Tulsa Dental Specialties) was delivered into the root canal space using an MTA carrier. The microhardness was measured after 4 weeks using a Vickers Diamond Microhardness Test for each sample. Statistical analysis included one- way analysis of variance and the t-test at a 5% level of significance. Results: The 10-mm thick ProRoot MTA was significantly harder than the 6-mm or 4-mm material (p < 0.0001); there was no statistical difference in microhardness between the 4-mm thick and the 6-mm thick material (p > 0.05). Conclusions: MTA was found suitable for filling the entire root canal space in compromised cases on the basis of its microhardness. Introduction Mineral trioxide aggregate (MTA) was first described in the dental literature by Lee, et al.1 MTA is composed of three powdered ingredients, which are 75% Portland cement, 20% bismuth oxide, 5% gypsum, and trace amounts of SiO2 , CaO, MgO, K2 SO4 , and Na2 SO4 .1 There are four major components in Portland cement: tricalcium silicate, dicalcium silicate, tricalcium aluminate, and tetracalcium aluminoferrite. The self-setting properties of calcium silicate cements are attributed to the progressive hydration reaction of the orthosilicate ions.3 Calcium silicate hydrate gel polymerizes and hardens over time, forming a solid network, which is associated with an increased mechanical strength.4 MTA proved to be superior to materials, such as amalgam, IRM, and Super-EBA, in both biocompatibility and sealing ability.5-10 Many applications were suggested for the clinical use of this material, among them as a root end- filling material,11 root perforation repair,12,13 and a direct pulp capping following pulpotomy.14-15 MTA is also commonly used for one-step apexification.16 In an in vivo study, which compared MTA and calcium hydroxide ability to stimulate root-end closure in necrotic permanent teeth with immature apices, none of the MTA-treated teeth showed any clinical or radiographic pathosis.17 It was also shown that root canal-treated teeth obturated with MTA exhibit higher fracture resistance than untreated teeth.18 The compressive strength and surface microhardness of calcium silicate cements tend to increase with time.19 The effect of condensation pressure on the surface hardness of ProRoot demonstrate a negative correlation, in which higher condensation pressures produce lower surface hardness values.20 This may be related to forcing the liquid out of the mix prior to setting resulting in alteration to the powder liquid ratio. However, higher condensation pressures resulted in fewer voids and micro-channels when analyzed by SEM.20 The microhardness of MTA can be influenced by the pH values of the mixing medium, and even the mixing techniques used.21 More porosity and unhydrated structure were observed in White MTA (WMTA) exposed to low pH values.22,23 The placement of MTA is technique- sensitive, and according to several studies, the application of ultrasonic energy may improve its sealing properties.24,25 It was also demonstrated that acid etch applied 4 hours after mixing MTA with water significantly reduced its resultant compressive strength compared with the controls, but these differences were not significant after 24 and 96 hours.19 However, newer formulas of trioxide aggregate may set even after 15 minutes that may make it more resistant to acid etching. The manufacturer recommends to place 3- to 5-mm thick MTA. This is in accordance with the results of previous studies, which suggested a minimum thickness of 3-4 mm when the material was used as a root-end filling material26 to prevent apical leakage.27 In another in vitro study, which tested white and gray MTA for microhardness, a 5-mm thick barrier was significantly harder than a 2-mm barrier,28 regardless of the type of MTA used. This may be attributed to a sufficient bulk of material that can also get hydration through all its thickness. The purpose of this study was to measure the microhardness of MTA in vitro in relation to its thickness and to compare the microhardness when the material was used only as root-end filling (4- or 6-mm thick) or for obturation of the entire root canal (10 mm). Materials and methods An in vitro examination of MTA microhardness in extracted teeth was carried out using the technique previously described by Valois and Costa.27 The influence of mineral trioxide aggregate (MTA) thickness on its microhardness properties — an in vitro study 26 Endodontic practice Volume 7 Number 2 CLINICAL Drs. Iris Slutzky-Goldberg, Lea Sabag, and David Keinan test the effect of the MTA thickness on its microhardness properties Dr. Iris Slutzky-Goldberg is from the Department of Endodontics, The Hebrew University-Hadassah School of Dental Medicine, Jerusalem, Israel. Dr. Lea Sabag is a graduate student, The Hebrew University-Hadassah School of Dental Medicine, Jerusalem, Israel. When this study was carried out, Dr. David Keinan was a postgraduate student, Department of Endodontics, The Hebrew University-Hadassah School of Dental Medicine, Jerusalem, Israel. He now works in the Department of Endodontics, Medical Corps, Tel Hashomer Hospital, Ramat-Gan, Israel.
  29. 29. 28 Endodontic practice Volume 7 Number 2 CLINICAL Thirty extracted, single-canal human teeth, stored in tap water at 4° C, were used for this study. The crowns were separated from the roots at the cemento-enamel junction and were divided according to length into three groups of 10 teeth each: standardized to 10 mm, 6 mm, and 4 mm. The canals were instrumented with Gates Glidden burs No. 1-No. 4 (Dentsply Maillefer Switzerland) in a crown-down manner until the No. 1 size bur could pass through the apical foramen. The specimens were then prepared with K-files until an ISO size 90 file could be visualized 1 mm past the apex. Irrigation with 10 ml 3% sodium hypochlorite was used throughout the instrumentation, followed by a final flush of 5 ml. To provide a simulated periapical environment, the root segments were placed in saline, as previously described by Lee, et al.1 Following previously described procedures white MTA (Dentsply Maillefer Switzerland) was delivered into to the canal space by using ultrasonically vibrated pluggers,29 and the teeth were sealed with Coltosol® F (Coltène Whaledent), a premixed non-eugenol provisional filling material. The MTA was allowed to set at 37° C and 100% humidity for 24 hours. All samples were stored in tap water for 4 weeks at 37° C and 100% humidity. The samples were then removed, sectioned longitudinally with a diamond bur, and embedded in resin. The samples were then polished with a variable speed grinder polisher (IsoMet® -6 Buehler Düsseldorf, Germany). Microhardness measurements were carried out using a Vickers Diamond Microhardness Tester MHT-1 (Matsuzawa, Tokyo,Japan)oneachsample.Theindenter exerted 500g pressure for 15 seconds on the set material, producing one impression with two orthogonal diagonals. The samples were evaluated under an optical microscope (Olympus Optical Microscope, Hamburg, Germany) at 10X magnification; digital images were captured and imported into a Photo Shop Pro version 5.01 (Jasc Software, Inc., Minneapolis, Minnesota). Indentation size was measured in microns. Microhardness was calculated according to the following equation: F - Pressure in kg applied to the material d - average of the two diagonals in millimeters The results were statistically analyzed by one-way analysis of variance and the t-test. Significance was set at 5%. Results More measurements were carried out in the 10-mm samples (N = 37) than in the 4-mm (N = 15) or 6-mm (N = 15) samples, as the 10-mm length roots allowed more indentation sites (Table 1). As can be seen in the 10-mm thickness group (N = 37), the indentation size was between 76-146 microns (average, 92 ±16 microns). In the 6-mm thickness group (N = 15), indentation size was 90-123 microns (average 107 ±12 microns). In the 4-mm thickness group (N = 15), the indentation size was 96.5-133.5 microns (average 110 ±11 microns). The microhardness in the 10-mm group was an average 1131 ±254 MPa; for the 6-mm group,823 ± 182 MPa; and for the 4-mm group, 760 ± 146 MPa. Statistical analysis showed that the 10- mm thick MTA was significantly harder than the 6-mm or 4-mm thick MTA (p < 0.0001); no statistical difference in microhardness was found between the two other groups (p > 0.05). Discussion Initially, mineral trioxide aggregate was introduced for the repair of root perforations.1 As hard tissue induction is one of its exceptional properties, it has been recommended for use as an apical barrier in the treatment of immature teeth with necrotic pulps and open apices.30 The setting and hardening of calcium silicate cements are hydration reactions and require water.31 We used ProRoot white MTA, since gray MTA may cause discoloration when placed in the coronal area or near the CEJ in anterior teeth.32 There are several composition differences between gray MTA and white MTA. White MTA contents of Al2 O3 , MgO, and Fe2 O3 are much less than in gray MTA.33 The particle size distribution of white MTA is approximately 8 times smaller than that of gray MTA, and this could provide more surface area for hydration reactions and greater early strength.33 The minimal thickness recommended in the literature for ProRoot MTA when used as root-end filling material is 3 mm26 and; for apexification, 4 mm.34 Five-mm thick ProRoot MTA was recommended as an apical barrier, based on findings that showed that 5-mm MTA was significantly harder than 2-mm thick MTA.28 The results of our study did not show any statistical difference between the 6-mm and 4-mm thick samples, suggesting that with regard to microhardness, a minimum MTA thickness of 4 mm may be sufficient for apical closure. The higher microhardness demon- strated in the 10-mm group as compared with the 4-mm group or the 6-mm group was a surprising finding of the study. MTA requires moisture for setting.9 An in vitro study by Budig and Eleazer35 had shown that even dry MTA packed into the root canal space can set by outside moisture penetrating through the root when soaked in saline for 72 hours. Therefore, it should have been expected that there will not be any statistical difference in microhardness between the 4- and 6-mm long samples. One possible explanation for the better results of the 10-mm long samples can Group 1 10 mm Group 2 6 mm Group 3 4 mm Number of items 37 15 15 Mean value (MPa) 1131 823 760 Highest value (MPa) 1568.69 1099.46 975.55 Lowest value (MPa) 423.28 602.92 509.73 Standard deviation 254 182 146 Confidence interval 95% [1059-1203] [709,6-936,1] [646,3-872,8] Median 1177 795 756 Average absolute deviation from median 160 154 120 Table 1: Microhardness of MTA samples
  30. 30. Available in: Economical 15 Pack Operatory 5 Pack A BIOACTIVE AND BIOCOMPATIBLE DENTIN SUBSTITUTE a restorative dentin substitute • Root perforations • Resorption • Direct & indirect pulp caps • Pulpotomies • Deep Caries • Apexification Incomplete prior endodontic therapy, periapical demineralization and an iatrogenic furcal perforation View of the furcal perforation Biodentine is passively placed over furcal perforation and smoothed 3 mos. later the tooth is asymptomatic, functional and firm. Photos courtesy of Dr. Francois Bronnec, DDS, MSc FREE CE CREDIT on Biodentine, visit SeptodontLearning.com Contact your dealer for a SPECIAL OFFER on Biodentine For more clinical cases and other information, visit septodontusa.com/products/biodentine
  31. 31. 30 Endodontic practice Volume 7 Number 2 CLINICAL be related to a higher pH remaining in the longer sample following irrigation with the basic sodium hypochlorite. Nekoofar, et al.,21 had already demonstrated the effect of the pH on the physical properties of MTA. The results of this study imply that MTA can be used for obturation of the entire root canal, as previously suggested by Whiterspoon, et al.29 This holds true for the coronal fragment of a horizontally fractured tooth,36 for short-length canals as well as in compromised cases, such as treatment of a necrotic immature tooth37 or young permanent teeth after traumatic injury.38 The superior healing properties of MTA, which are attributed to its osteoconductive and cementogenic properties, appear to render the use of MTA for filling of the entire root canal system with improved healing rate,39 and in compromised cases, such as internal root resorption.40 Furthermore, it was also found that MTA resisted bacterial leakage to a higher degree than did gutta percha and sealer when used as an obturation material.38 The use of MTA for filling the entire root canal system may also serve to reinforce the root.41 Furthermore, sealing the entire root canal with MTA will enable completion of the root filling in one visit, a reduction in treatment time, thereby facilitating the timely restoration of the tooth.29 The microhardness test is non- destructive, and any further consequences of any changes of strength in the superficial layers will affect the possibility of the material to fail over time.42 One should also bear in mind that microhardness is only one of the physical properties that should be examined when considering the ability of MTA to serve as a total root filling material in compromised cases. The prudent clinician has also to recognize the fact that removal of the set material, especially in curved canals may be impossible.43 Further study, including long-term success, is required to determine the suitability of MTA as a root canal obturation material. Conclusions Based on the results obtained from this in vitro study, the 10-mm thick ProRoot MTA exhibits greater microhardness than the 4-mm thick or 6-mm thick material. No statistical difference in microhardness was observed between the 4-mm and the 6-mm thick groups. On the basis of its microhardness, it appears that ProRoot MTA is suitable for root canal obturation in selected compromised cases. References 1. Lee SJ, Monsef M, Torabinejad M. Sealing ability of a mineral trioxide aggregate for repair of lateral root perforations. J Endod. 1993;19(11):541–544. 2. Sarkar NK, Caicedo R, Ritwik P, Moiseyeva R, Kawashima I. Physicochemical basis of the biologic properties of mineral trioxide aggregate. J Endod. 2005;31(2):97−100. 3. Gandolfi MG, Van Landuyt K, Taddei P, Modena E, Van Meerbeek B, Prati C. Environmental scanning electron microscopy connected with energy dispersive x-ray analysis and Raman techniques to study ProRoot mineral trioxide aggregate and calcium silicate cements in wet conditions and in real time. J Endod. 2010;36(5):851–857. 4. Zhao W, Wang J, Zhai W, Wang Z, Chang J. The self- setting properties and in vitro bioactivity of tricalcium silicate. Biomaterials. 2005;26(31):6113–6121. 5. Torabinejad M, Watson TF, Pitt Ford TR. Sealing ability of a mineral trioxide aggregate when used as a root end filling material. J Endod. 1993;19(12):591–595. 6. Torabinejad M, Hong CU, McDonald F, Pitt Ford TR. Physical and chemical properties of a new root-end filling material. J Endod. 1995;21(7):349-353. 7. Fischer EJ, Arens DE, Miller CH. Bacterial leakage of mineral trioxide aggregate as compared with zinc-free amalgam, intermediate restorative material, and Super-EBA as a root-end filling material. J Endod. 1998;24:176–179. 8. Adamo HL, Buruiana R, Schertzer L, Boylan RJ. A comparison of MTA, Super-EBA, composite and amalgam as root-end filling materials using a bacterial microleakage model. Int Endod J. 1999;32(3):197–203. 9. Torabinejad M, Hong CU, Pitt Ford TR, Kettering JD. Cytotoxicity of four root end filling materials. J Endod. 1995;21(10):489–92. 10. Camargo SE, Camargo CH, Hiller KA, Rode SM, Schweikl H, Schmalz G. Cytotoxicity and genotoxicity of pulp capping materials in two cell lines. Int Endod J. 2009;42(3):227–237. 11. Torabinejad M, Smith PW, Kettering JD, Pitt Ford TR. Comparative investigation of marginal adaptation of mineral trioxide aggregate and other commonly used root-end filling materials. J Endod. 1995;21(6):295–299. 12. Ford TR, Torabinejad M, Abedi HR, Bakland LK, Kariyawasam SP. Using mineral trioxide aggregate as a pulp capping material. J Am Dent Assoc. 1996;127(10):1491–1494. 13. Main C, Mirzayan N, Shabahang S, Torabinejad M. Repair of root perforations using mineral trioxide aggregate: a long-term study. J Endod. 2004;30(2):80–83. 14. Pitt Ford TR, Torabinejad M, McKendry DJ, Hong CU, Kariyawasam SP. Use of mineral trioxide aggregate for repair of furcal perforations. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1995;79:756–763. 15. Holland R, de Souza V, Murata SS, Nery MJ, Bernabé PF, Otoboni Filho JA, Dezan Júnior E. Healing process of dog dental pulp after pulpotomy and pulp covering with mineral trioxide aggregate or Portland cement. Braz Dent J. 2001;12(2):109–113. 16 . Kratchman SI. Perforation repair and one-step apexification procedures. Dent Clin North Am. 2004;48(1):291-307. 17. El-Meligy OA, Avery DR. Comparison of apexification with mineral trioxide aggregate and calcium hydroxide. Pediatr Dent. 2006;28(3):248-253. 18. Bortoluzzi EA, Souza EM, Reis JM, Esberard RM, Tanomaru- Filho M. Fracture strength of bovine incisors after intra-radicular treatment with MTA in an experimental immature tooth model. Int Endod J. 2007;40(9):684–691. 19. Kayahan MB, Nekoofar MH, Kazandağ M, Canpolat C, Malkondu O, Kaptan F, Dummer PM. Effect of acid-etching procedure on selected physical properties of mineral trioxide aggregate. Int Endod J. 2009;42(11):1004–1014. 20. Nekoofar MH, Adusei G, Sheykhrezae MS, Hayes SJ, Bryant ST, Dummer PM. The effect of condensation pressure on selected physical properties of mineral trioxide aggregate. Int Endod J. 2007;40(6):453-461. 21. Nekoofar MH, Aseeley Z, Dummer PM. The effect of various mixing techniques on the surface microhardness of mineral trioxide aggregate. Int Endod J. 2010;43(4):312–320. 22. Saghiri MA, Lotfi M, Saghiri AM, Vosoughhosseini S, Aeinehchi M, Ranjkesh B. Scanning electron micrograph and surface hardness of mineral trioxide aggregate in the presence of alkaline pH. J Endod. 2009;35(5):706-710. 23. Shie MY, Huang TH, Kao CT, Huang CH, Ding SJ. The effect of a physiologic solution pH on properties of white mineral trioxide aggregate. J Endod. 2009;35(1):98-101. 24. Hachmeister DR, Schindler WG, Walker WA 3rd, Thomas DD. The sealing ability and retention characteristics of mineral trioxide aggregate in a model of apexification. J Endod. 2002;28(5):386– 390. 25. Lawley GR, Schindler WG, Walker WA III, Kolodrubetz D. Evaluation of ultrasonically placed MTA and fracture resistance with intracanal composite resin in a model of apexification. J Endod. 2004;30(3):167-172. 26. Lamb EL, Loushine RJ, Weller RN, Kimbrough WF, Pashley DH. Effect of root resection on the apical sealing ability of mineral trioxide aggregate. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003; 95(6):732-735. 27. Valois C, Costa ED Jr. Influence of the thickness of mineral trioxide aggregate on sealing ability of root-end fillings in vitro. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2004;97(1):108-111. 28. Matt GD, Thorpe JR, Strother JM, McClanahan SB. Comparative study of white and gray mineral trioxide aggregate (MTA) simulating a one- or two-step apical barrier technique. J Endod. 2004;30(12):876-879. 29. Witherspoon DE, Small JC, Regan JD, Nunn M. Retrospective analysis of open apex teeth obturated with mineral trioxide aggregate. J Endod. 2008;34(10):1171–1176. 30. Bakland LK. Management of traumatically injured pulps in immature teeth using MTA. J Calif Dent Assoc. 2000;28(11):855– 858. 31. Maltese C, Pistolesi C, Bravo A, Cella F, Cerulli T, Salvioni D. Effects of setting regulators on the efficiency of an inorganic acid based alkali-free accelerator reacting with a Portland cement. Cements and Concrete Research. 2007;37:528–3536. 32. Asgary S, Parirokh M, Eghbal MJ, Brink F. Chemical differences between white and gray mineral trioxide aggregate. J Endod. 2005;31(2):101–103. 33. Asgary S, Parirokh M, Eghbal M, Stowe S, Brink F. A qualitative X-ray analysis of white and grey mineral trioxide aggregate using compositional imaging. J Mater Sci Mater Med. 2006;17(2):187−191. 34. Giuliani V, Baccetti T, Pace R, Pagavino G. The use of MTA in teeth with necrotic pulps and open apices. Dent Traumatol. 2002;18(4):217-221. 35. Budig CG, Eleazer PD. In Vitro Comparison of the Setting of dry ProRoot MTA by moisture absorbed through the Root. J Endod. 2008;34(6):712-714. 36. Erdem AP, Ozdas DO, Dincol E, Sepet E, Aren G. Case Series: root healing with MTA after horizontal fracture. Eur Arch Paediatr Dent. 2009;10(2):110–113. 37. Mohammadi Z, Yazdizadeh M. Obturation of immature non-vital tooth using MTA. Case report. N Y State Dent J. 2011;77(1):33-35. 38. Al-Kahtani A, Shostad S, Schifferle R, Bhambhani S. In-vitro evaluation of microleakage of an orthograde apical plug of mineral trioxide aggregate in permanent teeth with simulated immature apices. J Endod. 2005;31(2):117–119. 39. Bogen G, Kuttler S. Mineral trioxide aggregate obturation: a review and case series. J Endod. 2009;35(6):777–790. 40. Jacobovitz M, de Lima RK. Treatment of inflammatory internal root resorption with mineral trioxide aggregate: a case report. Int Endod J. 2008;41(10):905-912. 41. Cauwels RG, Pieters IY, Martens LC, Verbeeck RM. Fracture resistance and reinforcement of immature roots with gutta percha, mineral trioxide aggregate and calcium phosphate bone cement: a standardized in vitro model. Dent Traumatol. 2010;26(2):137-142. 42. Kang JS, Rhim EM, Huh SY, Ahn SJ, Kim DS, Kim SY, Park SH. The effects of humidity and serum on the surface microhardness and morphology of five retrograde filling materials. Scanning. 2012;34(4):207-214. 43. Boutsioukis C, Noula G, Lambrianidis T. Ex vivo study of the efficiency of two techniques for the removal of mineral trioxide aggregate used as a root canal filling material. J Endod. 2008,34(10):1239-1242. EP
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