When technology meets biology

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90 MAY 2015 // dentaltown.com
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691
WHEN
TECHNOLOGY
MEETS
BIOLOGY
By Dr. Mile Churlinov
Abstract
Today, successful dentistry can mean multidisciplinary treatment of care, or at least a multidisci-
plinary approach, with the help of current technology. We have all witnessed how an outstanding
endodontic therapy can mean nothing if the restorative plan has not been done properly, or has
been delayed. After endodontic therapy, tooth temporization has proven to be one of the weakest
links in the longevity of the treated tooth. With CBCT, ultrasound, CAD/CAM and the operat-
ing microscope (OM) as weapons of choice, today’s dentists have the ability to turn an endo visit
into a single-visit, endo-restorative treatment.
Objectives
At the end of this program, participants will:
1. Understand how microscopes help in endodontics,
2. Understand what advantages CBCT brings to endodontics,
3. Understand the factors involved in determining the best restoration for endodontically
treated teeth,
4. Learn how ceramic restorations can be fabricated at the same appointment as the endontic
appointment.
TECHNOLOGY
CE_Churlinov.indd 90 4/21/15 1:53 PM

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dentaltown.com MAY 2015 91
Introduction
What’s biology without technology? We want to achieve more,
to understand more, to comprehend more, and we ask technology
to live up to our expectations regarding these goals. I ask, “Why
do today’s children not wear watches?” It’s not because they don’t
like wearing watches. The reason they don’t wear them is because
a watch is a single-function device, unlike the phone you use, or
perhaps the car you drive. We are in a multitasking era, where
only time matters.
Let’s discuss how we currently use technology in saving a
tooth that needs a root canal and subsequent restoration from
start to finish. We want to see what we are doing, so we’ll start
with the dental operating microscope.
Imagine life without magnification. Imagine looking at the
earth from space without the ability to see what’s happening
beyond the surface. Details are important. We have to observe
them before we can understand them. The science of investigating
small objects using such an instrument is called microscopy. Any
device that enhances or improves a clinician’s resolving power is
extremely beneficial in producing precision dentistry.1
Dr. Harvey
Apotheker introduced the dental OM in 1981. The first OM was
poorly configured and ergonomically difficult to use and only
capable of one magnification of 8x.
In 1999, Dr. Gary Carr1-3
introduced an OM that had Galilean
optics and was ergonomically configured for dentistry. It also had
several advantages that allowed for easy use of the scope in nearly
all endodontic and restorative procedures. Today, many dentists
practicing endodontics rely on an OM to achieve top results.
Figs. 1-4 show what a dentist can see using an OM during endodontics.
Despite the use of an OM, there are times when a clinician still
will not find a certain canal. In the case below, the DB and the
MB2 are obliterated. Despite magnification from the microscope
and despite ample effort from the clinician, they are not visible.
Does the dentist keep digging until the floor is perforated and
he or she ruins the prognosis? Or should the dentist act wisely
and send the patient for a CBCT? Obviously, a dentist would use
this technology to compensate for limits. The case below gives an
example of what a dentist who uses CBCT during endodontics
can see. It’s highly doubtful that these canals would be found
without the use of a CBCT.
Fig. 5 DB canal searching. The canal was totally calcified.
Fig. 6 The lesion of endodontic origin is obvious around the mesials
and distal of the canals.
CBCT
What exactly is CBCT? It is a diagnostic imaging modality
that provides high-quality, 3D representations of the osseous
elements of the maxillofacial skeleton. CBCT systems are available
that provide small field-of-view images at low dose with sufficient
spatial resolution for applications in endodontic diagnosis,
treatment guidance and post-treatment evaluation.4
The pioneering efforts of those using conventional computed
tomography (CT) and micro-CT, and the introduction of
maxillofacial CBCT in 1996 allowed for the first clinically
practical technology which demonstrated the application of
3D imaging for endodontic treatment.5
CBCTs are useful both
preoperatively and postoperatively in enododontics.
Preoperative assessment
Imaging achieves visualization of dental and alveolar hard-
tissue morphology and pathologic alterations, aiding in correct
diagnosis. Imaging provides information on the morphology
of the tooth, including location and number of canals, pulp-
chamber size and degree of calcification, root structure, direction
and curvature, fractures, iatrogenic defects, and the extent of
dental caries.
The effects of periradicular and periapical disease can
be determined, including the degree of root resorption and
characteristics of periapical osteolysis. Larger lesions, only
Fig. 1 Fig. 2
Fig. 3 Fig. 4
Fig. 5
Fig. 6

feature
determined by imaging, may necessitate adjunctive surgical
procedures in addition to conventional intracanal therapy.
Diagnostic radiographs help predict the potential for complications,
permit root-fracture detection, and demonstrate periapical lesions.4
Postoperative
A postoperative radiograph immediately after root-canal
obturation is made to assess the sealing condensation and
containment of the root-canal filling material within the root-
canal system. In cases where periradicular healing is incomplete,
it acts as a baseline for the assessment of healing in the medium
to long term. Imaging is important in evaluating the results of
previous therapy, delayed healing, evaluating potential obstacles
to retreatment, as well as surgical considerations.6
Success in endodontics is assessed in the healing of the
periapical bone adjacent to obturated canals. Research has
shown that in evaluating the healing of periapical lesions using
2D periapical radiographs, there was only 47 percent agreement
between six examiners. Goldman et al. also reported that when
those same examiners evaluated the same films two different
times, they had only 19 percent to 80 percent agreement between
the two evaluations.7-8
The most common pathologic conditions that involve teeth are
the inflammatory lesions of the pulp and periapical areas. Dr. Sara
Lofthag-Hansen compared the accuracy of three observers using
high-resolution, limited-FOV CBCT to intraoral radiographic
paralleling technique using two images, one with a horizontal
tube-shift difference of about 10 degrees for the diagnosis of
periapical pathology on 46 teeth.9
While CBCT and intraoral radiographs identified 53 roots
with lesions, CBCT identified an additional 33 roots with lesions.
Observers agreed that additional clinically relevant material
was provided by CBCT imaging in 32 of the 46 (69.5 percent)
of teeth imaged. Drs. Andreas Stavropoulos and Ann Wenzel
compared CBCT to digital- and film-based intraoral periapical
radiography for the detection of periapical bone defects on 10
frozen pig mandibles by four calibrated examiners. They reported
that CBCT provides greater diagnostic accuracy (61 percent)
compared with digital (39 percent) and conventional radiographs
(44 percent).10
The CBCT is an important piece of technology in
successful endodontics.
So now we have reached the point where the endo is great, the
patient feels great, and everybody’s happy. Now, it’s time for the
restoration.
Coronal restorations must be considered carefully even before
endodontic therapy begins. Very often, what seems to be successful
endodontic treatment turns into an extraction because of
preexisting unsatisfactory periodontal and restorability situations.
All caries and existing dubious restorations must be removed
before endodontic treatment, to allow inspection for tooth cracks
and the location of sound cavity margins. Something we should
keep in mind is that restorative materials, cusp coverage and
artificial crowns with ferrules are factors that might significantly
influence the subsequent fracture resistance of endodontically
treated teeth.
Do we have to cover all the cusps in endodontically treated
teeth? What are the limits of the direct technique? All those
questions are hard to answer, as there are not enough long-
term studies that cover all factors. Many details relevant to the
restoration of endodontically treated teeth have been discussed
elsewhere.17-18
Increasing the width of the occlusal isthmus, the
depth of the preparation, as well as the presence—or lack of—
sound enamel, have significant influence on tooth fracture.
Furthermore, the choice of materials selected for the restoration
of endodontically treated teeth plays an important role in tooth
longevity. Post-endodontic tooth fractures might occur due to loss
of tooth structure and induced stresses caused by access cavity
preparation, instrumentation, unnecessary cervical dentin removal,
irrigation of the root canal, obturation of the instrumented root
canal, post-space preparation, and post selection.
Coronal restorations, as well as inappropriate selection of
tooth abutments for a prostheses, are also factors.12
Although
the long-term functional survival of endodontically treated
permanent teeth was reported as 97 percent after eight years
in a very large epidemiologic survey, coronal and/or radicular
tooth fractures continue to remain important reasons for post-
endodontic tooth repairs and extractions.13-15
The prevalence of
With CBCT, ultrasound,
CAD/CAM, and the operating
microscope as weapons of
choice, today’s dentists have
the ability to turn an endo
visit into a single-visit,
endo-restorative treatment.

feature
cusp fractures increased significantly with the number of restored
surfaces present, and the age of the patients, in particular those
over age 55. Failure to replace interim (temporary or provisional)
restorations with more-permanent restorations after endodontic
treatment resulted in very high tooth losses of 66 percent during a
mean follow-up time of three years.16
Now what about the question of direct restorations or crowns
on posterior endodontically treated teeth?
Fig. 7. A first molar restored with resin
Many excellent dentists are using direct restoration to restore
endodontically treated teeth. Fig. 7 shows a first molar that was
restored with resin in this manner.
There are many systematic reviews regarding this topic, but
nevertheless it’s shown that most of them are retrospective and, as
with all retrospective studies, there cannot be a standard clinical
study methodology or reporting methodology that will contribute
to effective analysis of results. According to the systematic review
by Dr. Petros Koidis and others, the results show that teeth that
have had root canals and are covered with crowns have a higher
long-term survival rate (89 percent).19
Now we are going to restore the tooth right after the root
canal. Single-visit dentistry is a great service to our patients. This
can be done directly with resin, or with the merger of technology
and biology—it can be with the use of CAD/CAM technology.
CAD/CAM dentistry was developed in 1980 for creating
dental restorations. This process allows dentists to construct,
produce and insert individual ceramic restorations directly at the
point of treatment in a single appointment, rather than multiple
appointments with additional lab work. The first applications
were successfully carried out on patients in 1985.
This technology makes it possible to produce and integrate
ceramic restorations in a single appointment. Unlike other
materials such as amalgam or gold, ceramic has better aesthetic
qualities. In addition, digital impressions can be more comfortable
for patients than traditional impressions.
Why is enhanced vision
necessary in dentistry?
Any device that enhances
or improves a clinician’s
resolving power is extremely
beneficial in producing
precision dentistry.
Fig. 7
Fig. 13
Fig. 9
Fig. 8
Fig. 10
Fig. 11 Fig. 12
Figs. 8-13A. A premolar that
was restored with the help
of CAD/CAM right after the
endodontic treatment
Fig. 13A

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Dr. Mile Churlinov was born in 1985 in Macedonia. He graduated as a dental technician from Medical Higher School, University St. Kliment
Ohridski, Bitola-Macedonia. He then graduated from dental school at Medical University of Plovdiv, in Bulgaria. Dr. Churlinov did his postgrad-
uate training in endodontics under the direction of Dr. Arnaldo Castellucci. Dr. Churlinov is the author of many articles on endo-restorative
topics. He lives in Sofia and practices at Medical Dent Consult.
Author Bio
Further clinical studies reveal that the success rate of CAD/
CAM restorations is 95.5 percent following a period of nine years,
and 84 percent after 18 years.22
The digital mapping technology
of CAD/CAM that charts the inside of the patient’s mouth
completely accurately and down to the last detail ensures that
there are no issues with inaccurate dental impressions, and also
cuts down on the negative patient experience of bulky impressions
and unnecessary debris in the mouth.
In conclusion, technology is playing a significant role in
how we treat teeth that need endodontics and their subsequent
restorations.
Below is a case from start to finish showing technology in
dentistry at its best. ■
Figs 14 & 15. The endodontic treatment is done incorporating the use of
microscopes and CBCT for the best results.
Fig. 16. Using CAD/CAM, the tooth is imaged for its final same-day restoration
(after bonding of the core).
Fig. 17. The restoration is milled and glazed or polished.
Fig. 18. Shows the tooth after the root canal, after placement of the core,
and the final restoration.
References
1. Gary B. Carrr, DDS; Carlos A.F. Murgel, DDS PHD- The use of the operating microscope in
Endodontics.
2. Carr GB, Magnification and illumination in endodontics. In: Hardinb FJ, editor. Clarks clinical
dentistry, vol.4. St. Louis, MO: Mosby; 1998. P. 1-14
3. Gary GB. Microscopes in endodontics. J Calif Dent Assoc 1992;20(11):55-61
4. William C. Scarfe,1,* Martin D. Levin,2 David Gane,3 and Allan G. Farman: Use of Cone Beam
Computed Tomography in Endodontics - Int J Dent. 2009; 2009: 634567.
5. Farman AG, Levato CM, Scarfe WC. 3D X-ray: an update. Inside Dentistry. 2007;3(6):70–74.
6. Rushton VE, Horner K, Worthington HV. Screening panoramic radiology of adults in general
dental practice: radiological findings. British Dental Journal. 2001;190(9):495–501.
7. Goldman M, Pearson AH, Darzenta N. Endodontic success—who’s reading the radiograph? Oral
Surgery, Oral Medicine, Oral Pathology. 1972;33(3):432–437.
8. Goldman M, Pearson AH, Darzenta N. Reliability of radiographic interpretations. Oral Surgery
Oral Medicine and Oral Pathology. 1974;38(2):287–293.
9. Lofthag-Hansen S, Huumonen S, Gröndahl K, Gröndahl H-G. Limited cone-beam CT and intra-
oral radiography for the diagnosis of periapical pathology. Oral Surgery, Oral Medicine, Oral Pathology,
Oral Radiology, and Endodontology. 2007;103(1):114–119.
10. Stavropoulos A, Wenzel A. Accuracy of cone beam dental CT, intraoral digital and conventional film
radiography for the detection of periapical lesions. An ex vivo study in pig jaws. Clinical Oral Investiga-
tions.2007;11(1):101–106.
11. Eakle WS, Maxwell EH, Braly BV. Fractures of posterior teeth in adults. J Am Dent Assoc
1986;112:215-8
12. Weirong Tang, DDS,* Younong Wu, DDS, MSc, PhD,*,† and Roger J. Smales, BDS, MDS(Hons),
DDSc‡. Identifying and Reducing Risks for Potential Fractures in Endodontically Treated Teeth
13. Salehrabi R, Rotstein I. Endodontic treatment outcomes in a large patient population in the USA: an
epidemiological study. J Endod 2004;30:846–50.
14. Hansen EK, Asmussen E, Christiansen NC. In vivo fractures of endodontically treated posterior
teeth restored with amalgam. Endod Dent Traumatol 1990;6:49–55.
15. Zadik Y, Sandler V, Bechor R, Salehrabi R. Analysis of factors related to extraction of endodontical-
ly treated teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;106:e31–5.
16. Lynch CD, Burke FM, Ni Riordaín R, Hannigan A. The influence of coronal restoration type on the
survival of endodontically treated teeth. Eur J Prosthodont Restor Dent 2004;12:171–6.
17. Morgano SM, Rodrigues AHC, Sabrosa CE. Restoration of endodontically treated teeth. Dent Clin
North Am 2004;48:397–416.
18. Cheung W. A review of the management of endodontically treated teeth: post, core and the final
restoration. J Am Dent Assoc 2005;136:611–9.
19. A.F. Stavropoulou, P.T. Koidis * A systematic review of single crowns on endodontically treated teeth:
Journal of Dentistry 35 (2007) 761–767
20. Manocci F, Bertelli E, Sherriff M, Watson TF, Ford TRP. Three-year clinical comparison of survival
of endodontically treated teeth restored with either full cast coverage or with direct composite restoration.
Journal of Prosthetic Dentistry 2002;88:297–301
21. G. V. Arnetzl, G. Arnetzl: Design of preparations for all-ceramic inlay materials. Int J Comput
Dent, 2006. 9(4):289-98
22. B. Reiss: Klinische Ergebnisse von Cerec Inlays aus der Praxis über einen Zeitraum von 18 Jahren.
Int J Comput Dent 2006, 1:11-22
Fig. 14 Fig. 15
Fig. 16 Fig. 17
Fig. 18

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1) The first operating microscope was introduced to dentistry
in what year?
A) 1797
B) 1954
C) 1981
D) 2002
2) The modern dental operating microscope that is functional for both
endodontics and restorative was introduced in what year?
A) 1999
B) 2014
C) 1797
D) 1954
3) What does CBCT stand for?
A) Coronal Buccal Centered Technology
B) Cone Beam Computed Tomography
C) Constant Broadening Controlled Technique
D) All of the above
4) Maxillofacial CBCT use began in what year?
A) 1954
B) 1972
C) 1990
D) 1996
5) Before endodontic treatment begins, the following should be done:
A) All caries removed
B) “Dubious” restorations removed
C) Determine that the tooth is restorable
D) All of the above
6) Preoperatively, CBCTs help …
A) To ahieve visualization of dental and alveolar hard tissue mor-
phology and pathologic alterations.
B) To assist correct diagnosis.
C) To provides information on the morphology of the tooth including
location and number of canals, pulp-chamber size and degree of
calcification, root structure, direction and curvature, fractures,
iatrogenic defects, and the extent of dental caries.
D) All of the above.
7) The most common pathologic conditions that involve teeth are the
inflammatory lesions of the pulp and periapical areas.
A) True
B) False
8) Which of the following are factors that might significantly influence
the subsequent fracture resistance of endodontically treated teeth?
A) Type of restorative material
B) Whether cuspal coverage is done
C) Extent of ferrule
D) All of the above
9) CAD/CAM dentistry was developed in what year?
A) 1797
B) 1954
C) 1980
D) 1990
10) CAD/CAM technology makes one-visit ceramic restorations possible.
A) True
B) False

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When Technology Meets Biology
By Dr. Mile Churlinov
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