A2 ◊Page A1 manufacturer’s predefined recom- mendations for each file type. The endodontic motor also provides ten user-programmable memories for all modes (EAL, CW, CCW, REC, or ATR), more than 60 speeds, and—of course—a high-precision built-in apex locator and a range of automat- ic apical functions. ENDO TRIBUNE Dental Tribune Middle East & Africa Edition | 5/2021 Agility as practical credo As with any device, practice validates innovation. With its ergonomic handpiece weighing only 157 g, perfect balance, and fully rotatable ultra-slim contra-angle head, the Rooter X3000 ensures a comfortable grip, agile handling, and excellent visibility of the operating field. FKG has designed and developed all de- tails to provide maximum freedom of use to the practitioner, optimizing both speed and efficiency. Features include complete adaptability of the device and its display for both left- and right-handed users, a broad range of user-controlled settings, extensive file brand compatibility, wireless charging stand, and volume control. For further information, contact the FKG Dentaire team: FKG Dentaire SA Crêt-du-Locle 4 CH-2304 La Chaux-de-Fonds Switzerland Tel. +41 32 924 22 44 Email: info@fkg.ch Web: www.fkg.ch FB: www.facebook.com/FKGDentaire Principle-driven endodontics: Proven case results By Drs Brett E. Gilbert & Richard Mounce, USA This article was written to demon- strate that the application of proven literature and/or evidence-based endodontic principles leads to excel- lent clinical results, irrespective of the materials used. We will describe the key points to achieving excellent results in initial non-surgical endo- dontic treatment in the key areas of diagnosis, shaping, irrigation, obtu- ration and restoration. Assessing “proven” and “literature-/ evidence-based” techniques and ma- terials is easier said than done. We cannot prove by high-level studies that warm obturation is better than cold lateral condensation, nor can we prove that activated irrigation is superior to passive cold irrigation, among a host of other such clinical questions. However, lower levels of evidence in studies certainly lead us to adopt new techniques but not with the confidence that the efficacy can be proved without doubt to be an improvement over older techniques. Fig.1: Sodium hypochlorite accident post-op, extra-oral. Fig.2: Sodium hypochlorite accident approximately five months post-op, intra-oral (dif- ferent case from that shown in Figure 1). Fig.3: Calcium hydroxide extruded into the mandibular canal through a perforation. An example is a study by Gutarts et al., which showed that 1 minute of ul- trasonic activation of irrigating solu- tion resulted in significantly cleaner canals histologically in the mesial root of mandibular molars.1 This is a low level of evidence (in vivo/ex vivo, low N), but certainly compelling and a valid justification to adopt the tech- nique.1 We will incorporate many of these references, but we want to em- phasise that Level 1 studies are not in place to validate these techniques to the highest possible evidence levels. The above notwithstanding, regard- less of philosophies and corporate relationships, it is the overwhelming preference of endodontists globally to use warm obturation techniques and activated irrigation (concepts discussed in greater detail later in this article). Specialist preferences also are hedged by the eyeball test, the visual evidence that is observed in treatment in comparison with pri- or techniques. Hence, this article will focus on key technique objectives that universally are agreed upon. As a starting place, before ever pick- ing up a syringe, the two single great- est prerequisites for creating excel- lent endodontic results are time and comprehensive treatment planning. It is essential that the clinician have enough time to carry out the treat- ment in a relaxed but productive environment, in essence, practising with high efficiency. It is axiomatic that the clinician only starts cases that he or she believes he or she can finish well and never treats a patient solely for money. All procedures must be carefully pre-planned. Such treatment plan- ning includes performing high-level imaging and a thorough clinical ex- amination to determine a definitive diagnosis. Preoperative treatment planning includes informed consent, assurance of restorability, profound pain control (local anaesthesia), visu- alisation and magnification (surgical microscope), instrumentation (stain- less-steel and nickel-titanium [NiTi]), irrigation and disinfection protocols, obturation and coronal seal strate- gies prior to endodontic access. A lack of treatment planning strategies is the harbinger of endodontic mis- adventure (Figs. 1–3). While a discussion of each principle- driven step required in a first-time endodontic procedure would fill a textbook, there are a number of key features of well-treated cases that are showcased in this article. Please see the caption that accompanies each case and describes its application of the principles discussed. As a starting place, assuming a thor- ough examination and indication i r e l s o R o g r e S r D © Fig.4: Cleared tooth showing the true complexity of the anatomy within this molar tooth. for treatment in addition to de- tailed informed consent, the most difficult gateway to comfortable patient treatment is anaesthesia for the “hot” mandibular molar. Flu- ency with the Gow-Gates injection as well as intraosseous anaesthesia (X-Tip, Dentsply Maillefer) will in large measure eliminate shortcom- ings in anaesthesia when standard block injections do not profoundly anaesthetise an anxious patient with a severely inflamed pulp. is Managing complex anatomy much simpler if the clinician has a preoperative road map. The CBCT scan provides the road map and the surgical microscope the lens (liter- ally) through which to visualise the result. Aside from a relaxed patient who is profoundly numb, being able to visualise anatomy by taking a pre- operative (and possibly intra-opera- tive) CBCT scan and using a surgical microscope during treatment has no substitute. These methods are the current gold standard in that 3D im- aging shows the clinician the true re- ality of a clinical situation as opposed to the suggestion gained from a 2D radiograph. Proper interpretation of imaging prior to and/or during en- dodontic treatment goes a long way towards taking the guesswork out of identifying canal location and other anatomical complexities as the pro- cedure unfolds. In a 2014 study by Ee et al., it was determined that, with a preoperative CBCT scan, compared with 2D radiographs alone, the treat- ment plan was modified 62% of the time.2 That the information gained from 3D imaging changed the plan of treatment more than six times out of ten is a significant game- changer (Fig. 4).2 While there are many preoperative clinical features to be considered prior to starting treatment, the key pre-operative decision points are the patient’s medical and dental history and anxiety level, the position of the tooth, space limitations to reaching the tooth and the canal anatomy. It is incumbent on the clinician to assess ÿPage A3