issn 2193-4673 • Vol. 16 • Issue 2/2020 roots international magazine of endodontics 2/20 including special ROOTS SUMMIT special Lecture programme, abstracts and speaker information study Impact of reciprocal and OTR motion on mechanical NiTi files’ resistance case report Management of intracanal separated instruments

editorial | Steve Jones Co-chairman ROOTS SUMMIT Dear readers, Welcome to this year’s second issue of the roots magazine. There are many ways that the world has changed during this period as we wage a global battle against SARS-CoV-2. Our hope is that all of you are well and that you are staying safe during this difficult time. We also wish you a safe return to your practices. The current situation has forced us to reschedule ROOTS SUMMIT to one year later than planned. The location remains the same, Prague in the Czech Republic, and the dates will be 20–23 May 2021. As so many people registered for our terrific programme, we will be hosting an online event for registered participants this Friday, 22 May, and Saturday, 23 May. Please take a look at the programme pages and join us for this valuable programme. There will also be an offer to register for the live event in 2021, and early registration for 2021 will include this exclusive online content. It gives us great pleasure to be able to showcase the work of the members of our Facebook group, ROOTS (www.facebook.com/groups/rootsendo). This month, Dr Sourav Banerjee’s case report, “Manage- ment of iatrogenic pulpal floor perforation in a mandi bular molar with MTA and PRF”, provides a terrific example and comprehensive summary of the practical and use- ful information that is shared multiple times per day on ROOTS. If you have not already joined, please visit www.rootsendoforum.com and do so. Thank you for picking up this issue, and we wish you continued good health and a safe return to normalcy. Steve Jones Co-chairman ROOTS SUMMIT roots 2 2020 03

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ROOTS SUMMIT special: roots-summit.com | Dr Daniel Černý (Czech Republic) Dr Daniel Černý received his dental degree from the Charles University’s Faculty of Medicine in Hradec Králové, Czech Republic, in 1998. Between 1998 and 2007, he worked as an assis- tant professor at the same faculty. He is currently completing his doctoral degree with a focus on adhesive post-endodontic treatment at Palacký University Olomouc in the Czech Republic. Since 2001, he has maintained a private practice limited to adhesive dentistry and endodontics in Hradec Králové. Černý has been the President of the Czech Endodontic Society since 2015. He was the co-founder and first Pres- ident of the Česká akademie dentální estetiky [Czech academy of dental aesthetics] from 2007 to 2009. From 2009 to 2013, he served on the editorial board of LKS—Časopis České stomatologické komory [journal of the Czech Dental Chamber]. He is also the co-founder of the Dental Summit congress in Prague, Czech Republic. He has been the co-owner and director of the HDVI continuing education institute since 2010. Černý has contributed four chapters to dental books and lectures both nationally and internationally. Dr Hugo Sousa Dias (Portugal) Dr Hugo Sousa Dias grad- uated with a DDS from University Fernando Pessoa, Porto, Portugal, and com- pleted the postgraduate pro- gramme in endodontics at the University of Lisbon, Portugal. Besides running a practice limited to endodontics in Porto, he is Director of the Master in Endodontics clinical residency programme at Foramen Dental Education, Porto. Dias is the founder of the Portuguese Group for Endodontic Study (study club), and a member of the European Society of Endodontology and the Sociedade Portuguesa de Endodontologia [Portuguese endodontic society]. He has given more than 40 lectures around the world and is co-author of a chapter in the book The Root Canal Anatomy in Permanent Dentition (Springer, 2018). Dr Marian Fanica (Romania) Dr Marian Fanica gradu- ated from the University of Medicine and Pharmacy Carol Davila in Bucharest, Romania. He received a bachelor’s degree in den- tistry in 2005 and a master’s degree in endodontics in 2015. His practice has been limited to endodontics since 2015 with a field of interest also in dental adhesives. Dr Fanica is an international lecturer and hands-on dental trainer in Europe and Asia. His professional memberships include the European Association of Osseointegration, the Society of Esthetic Dentistry in Romania and the Dentistry National Organi- zation in Romania. Prof. Gianluca Gambarini (Italy) Prof. Gianluca Gambarini is head of endodontics and restorative dentistry at the Sapienza Univer- sity of Rome, Italy, and di- rector of the dental school’s master of endodontics programme. He maintains a private practice limited to endodontics in Rome, where his focus is on endodontic materials and clinical endodontics. As an international lecturer and researcher, Gambarini has held more than 500 presentations at world’s most renowned international congresses and universities. He has also received several awards and led research projects funded by national and international grants. In addition to that, Gambarini is an active consultant in the development of new technologies, surgical proce- dures and materials for root canal therapy. Furthermore, he holds patents concerning endodontic technologies he has developed. Currently, Gambarini serves as Chair- man of the Clinical Practice Committee of the European Society of Endodontology. Dr Bogdan Moldoveanu (Romania) Dr Bogdan Moldoveanu graduated from the Fac- ulty of Dental Medicine at the Iuliu Hațieganu University of Medicine and Pharmacy in Cluj-Napoca, Romania, and then pursued postgraduate studies in endodontics at the dental school of the University of Turin, Italy. There, he grad- uated with a master’s degree in clinical and surgical micro- endodontics. He also holds a certificate in dental implantology from the Carol Davila University of Med- icine and Pharmacy in Bucharest, Romania. He is an assistant professor at the University of Turin, where he teaches in the master’s programme in clinical and sur- gical micro-endodontics, and he is an assistant profes- sor at the Iuliu Hațieganu University of Medicine and Pharmacy in the discipline of dentistry, endodontics, m o c . k c o t s r e t t u h S / u L a D © e u g a r P i Please visit www.roots-summit.com for the ROOTS SUMMIT 2020 online programme. roots 2 2020 09

ROOTS SUMMIT special: roots-summit.com | inside the root canal, choosing the correct type of post for core-buildups, what are the best materials for core-buildups and why. Other issues discussed will include conserving the maximum amount of dentine possible through the use of car- ies detectors, the use of silane primers with glass fiber posts, minimising shrinkage through the use of delayed light activa- tion, removal of old posts predictably, and crown lengthening with minimal ferrule effect. Participants will learn multiple tips and tricks which will greatly improve patient outcomes. 10:00–11:00 Digital planning in intentional replantation and autotransplantation Dr Francesc Abella In recent years, primary endodontic treatment, nonsurgical retreatment and microscopical surgery have achieved suc- cess rates of around 90 per cent. However, there are situations in which the tooth cannot be saved using these techniques. The first part of this lecture will discuss intentional replanta- tion. This is an accepted endodontic treatment procedure in which a tooth is extracted and treated outside the oral cavity and then reinserted into its socket to correct an obvious radiographic or clinical endodontic failure. It should not be considered a last-resort treatment prescribed only for un- salvageable teeth as proposed by Grossman. Although inten- tional replantation is not a frequently performed procedure, it yields a tooth survival rate of 88 per cent, according to a recent meta-analysis. In addition, the new advances in com- puter-aided rapid prototyping (CARP) models (tooth replicas) and 3D-printed guiding templates allow us to apply this tech- nique in a much more predictable way. In situations where the tooth cannot be saved, there is the option of performing an autotransplant (both open and closed apex). The com- plications observed in the past can be overcome thanks to advances in diagnostic and surgical techniques, particularly CARP models and 3D-printed guiding templates. The digital planning not only allows for the selection of the most suitable donor tooth according to tooth morphology, but also shows the ideal 3D position and the required dimensions of the alveolus during surgery. Moreover, the use of tooth replicas can reduce the additional socket time and possible donor tooth injury during the procedure. Through the results of two in vivo investigations, as well as clinical cases and videos, we will teach the digital step-by-step to plan all types of cases. 11:00–12:00 Prognostic factors in endodontic retreatment Dr Gianluca Plotino The long-term prognosis of the endodontically treated tooth is closely related both to the quality of the endodon- tic therapy itself and to the quality of the coronal restoration. The evolution of materials, techniques and technologies in endodontics has undoubtedly helped clinicians to improve the prognosis of endodontic therapies, especially in teeth previously considered unrestorable, contributing to a con- sequent increase in the confidence of patients and dental colleagues in the endodontist. After the lecture, participants should know what the endodontic prognosis in the re- treatment of a compromised tooth is; understand what the endodontic prognosis in already treated compromised teeth destined for endodontic surgery is; describe what the endodontic treatment options in the severely compromised teeth are and select the correct materials, devices and thera- peutic approaches for each different clinical situation. 12:00–13:00 Separated instruments—my approach Dr Hugo Sousa Dias The endodontic management of a fractured instrument within the root canal is a difficult process that requires training, ex- perience and knowledge of the methods/techniques that can be used. It is a time-consuming and challenging procedure often associated with anxiety for both clinician and patient and has a variable success rate. In this webinar, I will demonstrate my clinical approach to these challenging situations. 13:00–14:00 The new CanalPro Jeni motor: The instantaneous control for fully automated shaping and disassembling retreatment procedures Dr Eugenio Pedullà Endodontic treatment has proven to be one of the most suc- cessful procedures in dentistry. Several instruments and some kinematics were proposed for safe and efficient endodontic preparation. However, each kinematic (like continuous rotation or reciprocation) has some advantages and disadvantages as well as sometimes after the first root canal treatment, endodontic retreatment with the removal of the old filling material (usually gutta-percha and sealer) by different manual or rotary instruments could be required to achieve the final success of the treatment. During this webinar, we will go through the pros and cons of the different kinematics related to endodontic procedures as well as the strength and weakness of different rotary files used to remove the filling material in the different anatomical conditions. Moreover, we will introduce the new fully automated, electric controlled, CanalPro Jeni motor and its “self-driving mode” and “shaping guided by irrigation” algorithm for shaping instruments and the new file Remover to accomplish gutta-percha removal. 14:00–15:00 Endodontic access: What size best contributes to long-term endodontic success Dr Stephen Buchanan The best access cavities are cut in a precise balance be- tween conservation and convenience form. Cut huge access cavities and expect to see relatively huge numbers of root-fractured teeth within five years of treatment. I will show you why I cut as little tooth structure as possible while ensur- ing ideal pathways into each canal. Experience has shown that the quality of the access preparation more than any other single factor is critical to the remainder of the case. The discussion will explain the techniques and tools neces- sary to create perfect entry paths. This webinar will include a live demonstration of dynamic CT guidance for creating minimally invasive access cavities in calcified teeth. m o c . k c o t s r e t t u h S / u L a D © e u g a r P i Please visit www.roots-summit.com for the ROOTS SUMMIT 2020 online programme. roots 2 2020 13

education | The channel will be as interactive as possible. People will be able to ask questions about issues that they are not able to solve themselves or need advice on. As you know, I am not only a specialist in endodontics but a specialist in all that is related to restorative dentistry. I work on restoration of endodontically treated teeth, con- servative dentistry, prosthetic dentistry and interdisciplinary treatments. So, in the future, my goal for “endo channel” is to share my 360° experience in dentistry, to convey the relationship of endodontics to the other disciplines of den- tistry. “endo channel” will not be focused on endodontics only but all the components of restoration of endodontically treated teeth and the strategies for restoring teeth in general, with an interdisciplinary focus for treatment, such as periodontics and orthodontics related to endodontics. This is my new, long-term project and I hope to be able to reach and help as many people as possible around the world and communicate my message about endodontics. You offer courses at your center and are often invited to teach all over the world. Why did you feel the need to create such a channel? I felt the need to communicate with people all around the world, people that follow me, in a different manner from the live courses I teach and so the idea of “endo channel” came to life. I want people who are interested to be able to follow my ideas and work in order to learn how to perform endodontic treatments in the best possible way and with the most updated techniques and technologies. Will “endo channel” be available at a cost or free? The platform was launched at the beginning of March 2020. I plan to publish monthly courses. The first course, con- sisting of four episodes, is already ready to be launched and will be available for all on the platform. I will update my endodontic social media pages, Facebook and Instagram, when something new is published on “endo channel”. People will be able to subscribe yearly to have access to the entire content of the channel and be able to follow everything that I publish, including articles and webinars. There is also the possibility of choosing to subscribe only to one specific event or course of interest during the year. A subscription for access to the entire content is not required if one is only interested in a specific course. Those who do not wish to pay any subscription fee will have free access to some basic endodontic information and free content. How do you foresee the importance of social media in teaching? I am increasingly focusing on web platforms and online education because with this type of education you can reach more people around the world. A lot of people have called me or written to me about their interest in my course, but they often cannot afford to take the time or pay the costs to come to Rome or other locations where I teach. “The importance of the practical sessions and the interaction between the teacher and the participants is still of utmost importance and should be maintained.” Therefore, the technology that we have today has really made it easy to help and reach more people. Among the advantages of a live course is the impor- tance of learning by doing, performing in the practical part of a course immediately what one has been taught in the theoretical session, with the teacher available to address problems or questions one might have in put- ting the theory into practice. Do you see in the future education being offered only via the web or do you feel that live courses will still have to be available? The importance of the personal, direct contact with people in a set location is still very important for persons who want to go even deeper into something that they are interested in learning. The theoretical aspect is important, and my theoret- ical courses offer a lot of practice possibilities, as I have made sure to include clinical videos that clearly show the clinical techniques. The practical sessions and the interaction be- tween the teacher and the participants are still of utmost im- portance and should be maintained, even more so for people who feel they need practical training, and so I think that both online courses and live ones will still be needed. Editorial note: This interview was first published in the Clinical Masters magazine, volume 6, issue 2020. about Dr Gianluca Plotino received his degree in dentistry in 2002 from the Università Cattolica del Sacro Cuore in Rome, Italy, and completed his PhD there in 2009. He maintains a private practice specialising in endodontics and restorative dentistry in Rome. Dr Plotino has been awarded several international prizes, published more than 100 articles in scientific, peer-reviewed journals, 2 textbooks and has contributed to numerous chapters in reputable textbooks. He gives lectures and presents courses across the world. He is a certified member of the European Society of Endodontology, an international member of the American Association of Endodontists, and an active member of the Italian Academy of Endodontics, the Italian Society of Endodontics and the Italian Society of Conservative Dentistry. roots 2 2020 15

study | 2 Fig. 2: An artificial canal used in this study: 16 mm in length, 90° angle of curvature and 2.5 mm radius of curvature. There are plenty of factors influencing file fracture: the operator’s experience, instrumentation technique (access, sequence used, glide path), instrument design and heat treatment of its alloy, degree and radius of the canal’s curvature, parameters set on the endodontic motor (speed, torque) and the type of file motion (continuous rotation, reciprocation, Optimum Torque Reverse).12 The aim of the present study was to investigate the im- pact of reciprocal motion and Optimum Torque Reverse motion on file fracture in cyclic fatigue testing and during the preparation of artificial canals in resin blocks, where a file apart from working in a curved canal has to widen this canal. The files used in the test were RECIPROC blue R25 (VDW) and Endostar E3 Azure 25/.06 (Poldent). RECIPROC blue R25 files are thermally treated NiTi in- struments and have a nominal size of 0.25 mm at the tip and a taper of 0.08 mm/mm in the last 3 mm from the tip. The instruments have an S-shaped cross section. These are left-cutting files designed to operate in reciprocal motion. Endostar E3 Azure 25/.06 files are thermally treated NiTi instruments and have a nominal size of 0.25 mm at the tip and a constant taper of 0.06 mm/mm. They also have an S-shaped cross section. These are right-cutting files de- signed to operate in rotary, reciprocal and Optimum Torque Reverse motion.13 Both instruments (RECIPROC blue and Endostar E3 Azure) undergo post-manufacture complex heating–cooling proprietary treatments that result in a visible titanium oxide layer on the surface of the instrument which gives the characteristic blue colour. This treatment changes the transition temperatures between martensitic phase and austenitic phase, which is claimed by the manufacturers to result in superior mechanical properties of the NiTi instruments. Reciprocal motion for canal preparation was proposed by Yared in 2008.14 In such motion, the file performs alternately partial clockwise (CW) rotation and partial counterclock- wise (CCW) rotation. This partial rotation is referred to in degrees, for example 180° CW and 90° CCW, which means that a file alternately moves half of the rotation CW and then a quarter of the rotation CCW. So, for the file to make a full rotation (360°), it needs four cycles CW and CCW. The use of reciprocating motion was shown to extend the lifespan of a NiTi instrument.15 The recommended reciprocal mo- tion for the RECIPROC blue R25 file is 150° CCW and then 30° CW rotation at a speed of 300 rpm.16 Optimum Torque Reverse (OTR) motion was patented by J. Morita in 2015. This new motion was introduced to exploit reciprocation’s benefits and minimise its dis- advantages, such as increased transportation of the debris towards the apex.17 OTR motion combines rotary motion with reciprocation. When a file is inserted into the canal, it rotates 360° CW, and when the force acting on the file is too large, the file reverses its rotation in a CCW direction by 90° and then continues rotation in the CW (cutting) direction for 180°. During this half rotation in the cutting direction, sensors of the handpiece calculate the force acting on the file. If the force is too large, the file will auto- matically reverse rotation again (90° in the CCW direction) and then it will rotate in the CW direction for 180° and the motor will calculate the acting force again. So, if the force acting on the file is constantly too large, the file performs a reciprocal motion (180° CW and 90° CCW). If the force acting on the file is small, the file constantly rotates in the CW direction.18 One can set five levels of torque to acti- vate reciprocal motion in OTR motion: 0.2 Ncm, 0.4 Ncm, 0.6 Ncm, 0.8 Ncm and 1.0 Ncm. The smaller the torque that is set, the more often the file works in reciprocation (90° CCW and 180° CW). All right-cutting files, like Endostar E3 Azure, can operate in OTR motion. Materials and methods For the test, the following files were used: 40 new RECIPROC blue R25 files with a 0.25 mm tip size and a variable taper (.08 at the tip to 0.04 at the shaft) and 40 new Endostar E3 Azure 25/.06 files with a 0.25 mm tip size and a constant taper of .06. All instruments used were 25 mm long. The files were examined under a stereomicroscope (Leica M50, Leica Microsystems) at roots 2 2020 17

study | Table 1 Group Group 1 Group 2 Group 3 Group 4 Table 2 TtF Mean (SD) FL Mean (SD) Group NPB Median (SD) 31.2 (2.90) 4.01 (0.34) Group 1 40.1 (3.35) 3.95 (0.32) Group 2 89.6 (6.33) 3.78 (0.29) Group 3 217.3 (23.25) 3.79 (0.41) Group 4 7 (1.20) 9 (1.10) 10 (1.10) 14 (1.29) Table 1: Means and standard deviations of the time to fracture (TtF) in seconds and the fractured fragment length (FL) in millimetres. Table 2: Medians and standard deviations of the number of prepared blocks (NPB) until file fracture occurred. – Group 1: RECIPROC blue R25 in continuous rotation CCW at 300 rpm and a torque of 2 Ncm – Group 2: RECIPROC blue R25 in reciprocation (“ RECIPROC with the same file was continued in the next blocks until fracture occurred. ALL” programme) Statistical analysis – Group 3: Endostar E3 Azure 25/.06 in continuous rotation CW at 300 rpm and a torque of 2 Ncm – Group 4: Endostar E3 Azure 25/.06 in reciprocation of OTR motion with the activation torque set at the lowest level (0.2 Ncm) so that a file in the artificial canal constantly worked in reciprocal motion 180° CW to 90° CCW and at a speed of 300 rpm. The tests were run on resin endodontic training blocks (VDW) containing an artificial canal 18.5 mm long with a 55° curvature in the apical area (Fig. 5). Each file was used to prepare canals in consecutive resin blocks until the file fractured. The number of blocks prepared until fracture occurred for each file was noted down, including the block in which fracture occurred. All the canals were instrumented by just one operator (the author of the article). The blocks were installed in a bench vice to secure their stability during the canal preparation. The patency of the canal was first determined with a size 10 K-type file (Poldent). The file was inserted into the canal until the tip could be seen in the foramen. Next, the canal was widened to size 20/.02 with a size 20/.02 Endostar NT2 file (Poldent) to the working length (18 mm). The aim was to standardise the canals in the blocks so that the files worked in the canals with the same initial size. Thereafter, the proper canal preparation started. With the RECIPROC blue file or Endostar E3 Azure file, four cycles were made including three pecking movements in the apical direc- tion. In the fourth cycle, the working length of 18 mm was reached. Between every cycle, the canal was irrigated with distilled water from a syringe with a side-vented needle. Next, the size 10 K-type file was inserted until the tip of the file was visible in the apex (patency), and again the canal was irrigated with distilled water. Between cycles, file edges were cleaned on a sponge. After achieving working length, the canal was considered prepared and the work Statistical analysis was performed with the IBM SPSS programme (Version 25.0, IBM Corp.). To check significant statistical differences among groups, the Kruskal–Wallis test was performed. When significant statistical differences occurred, the Games–Howell post-hoc test was used. It helped to identify among which groups exactly signifi- cant statistical differences occurred. The choice was made based on homogeneity variances in compared groups. The level of p < 0.05 was considered statistically significant. Results Cyclic fatigue resistance test The means and standard deviations of the time-to-fracture values (in seconds) of the tested groups are shown in Table 1. The analysis showed statistically significant differences among all four tested groups (p < 0.001). Group 4 gained the highest results in comparison with the remaining three groups. Group 1 gained the lowest results. Comparing the influence of the type of motion (continuous rotation vs reciprocation) on time to fracture for the same type of files (Group 1 vs Group 2; Group 3 vs Group 4), statistically significant prolongation of time to fracture occurred in reciprocal motion dedicated to RECIPROC files and in OTR reciprocal motion (p < 0.001; Fig. 6). The means and standard deviations of the length of the fractured fragments (mm) are also shown in Table 1. The analysis did not show statistically significant differences in the length of the fractured fragments (p > 0.05). Preparation of canals in resin blocks The medians and standard deviations of the number of prepared blocks until fracture for all tested groups are shown in Table 2. Statistically significant differences con- cern all groups compared with one another (p < 0.001), roots 2 2020 19

study | 8 Fig. 8: First line (RECIPROC blue R25, continuous rotation): six blocks prepared without fracture, and the file fractured inside the seventh block. Second line (RECIPROC blue R25, reciprocation): eight blocks prepared without fracture, and the file fractured inside the ninth block. Third line (Endostar E3 Azure 25/.06, continuous rotation): nine blocks prepared without fracture, and the file fractured inside the tenth block. Fourth line (Endostar E3 Azure 25/.06, OTR recipro cation): thirteen blocks prepared without fracture, and the file fractured inside the fourteenth block. The research for this article consisted of two parts: cyclic fatigue resistance testing and resin block prepa- ration. The aim was to check the influence of reciprocal motion on the lifespan of files both in the fatigue test and in the conditions in which the file works in curved canals and undergoes torsional strain resulting from canal widening (resin block test), which simulated the conditions in which a file works during an endodontic treatment. In a systematic review of in vitro studies by Ahn et al.,15 it was found that, in most studies, reciprocal motion increases a file’s resistance to fatigue in comparison with continuous rotation. There are very few studies which have investigated the influence of reciprocal motion on the lifespan of files which, at the same time, are affected by a fatigue mechanism and torsional stress. The results of this research show that using reciprocal motion during preparation of the canals decreases the risk of a file fracturing in a canal (Fig. 8). In the present study, OTR motion was investigated because it is a new motion in endodontics and there is very little research on the influence of this motion on cyclic fatigue.29, 30 There has been no research on the influence of OTR motion on file fracture during canal preparation until now. Based on the present study, re- ciprocation of OTR motion prolongs the time to fracture and enables preparation of a larger number of canals before fracture. Conclusion Within the limitations of this study, both reciprocal motions (the one dedicated to RECIPROC files and OTR motion) significantly increased resistance to cyclic fatigue of the tested files compared with continuous rotation. Also, the number of canals in resin blocks prepared until file fracture significantly increased with the use of the two reciprocal motions. Editorial note: A list of references is available from the publisher. about Dr Sławomir Gabry ´s graduated with a DDS from the Jagiellonian University School of Medicine in Cracow in Poland. He is a member of the Polskie Towarzystwo Endodontyczne (Polish association of endodontics) and the European Society of Endodontology and a core member of the Dental Masters Group. Since 2011, he has cooperated with the research department of Polskie Towarzystwo Endodontyczne. For eight years, with Poldent, he has conducted the postgraduate endodontic programme Endo Akademia. roots 2 2020 21

case report | between mineralised and non-mineralised parts of the tooth and can cause a sharp lateral bend in the canal. As the malformation commonly dates back to childhood, dilacer- ated roots are mostly detected on the radiograph (Fig. 1). After clinical and radiographic examination, acute pulpitis and symptomatic apical periodontitis were diagnosed. We advised the patient on a non-surgical root canal therapy. At the beginning of the endodontic treatment, tooth #14 was isolated with a dental dam. The canals were then scouted using small hand files (ISO 06, 08 and 10). In order to regain patency, EDTA gel was dispensed into the pulp chamber before we used a combination of a watch-winding and envelope motion to work our way through the canal with the files. Actual preparation of the canal was performed using the latest generation of NiTi files by COLTENE. In close cooperation with leading universities and global endo- dontic specialists, the renowned research department of the company developed an extremely versatile concept which meets various demands encountered in practice. The modular HyFlex system facilitates root canal pre- paration with rotary instruments for both experts and beginners. As the name already indicates, the HyFlex is a highly flexible NiTi file which proves to be incredibly fracture- resistant. There are two types of sets: the classic CM model and the EDM version. 3a–c Figs. 3a–c: CM-treated NiTi file: new (a); save for reuse (b); and unwound (c). Modular NiTi file system for more flexibility The abbreviation “CM” stands for “controlled memory” effect, which improves certain physical qualities of the alloy, mainly the flexibility, resistance to cyclic fatigue and lack of restoring forces in curved canals. 4a–c Figs. 4a–c: HyFlex CM file sequence: 15/.04 (a); 20/.04 (b); and 25/.04 (c). roots 2 2020 23

case report | 7 8 Fig. 7: Cone fit (Case 2). Fig. 8: Postoperative radiograph (Case 2). paction technique. At the follow-up, the postoperative radiograph showed the beautifully twisted locations of the three reliably obturated canals (Fig. 8). The pa- tient was very relieved and left the clinic with a positive prognosis. Growing awareness of dental health Discussing case reports with my international col- leagues, I often find that the challenges of endodontics are very much the same around the globe. Treatment options do not differ much thanks to the worldwide standards that have risen substantially over the last 20 years. One part of this development is definitely the high-quality imaging techniques that provide the basis for a thorough analysis even before the actual operation takes place. Another shaping factor is the precision of modern NiTi instruments. Virtually un- breakable, the files allow endodontic experts to “walk like an Egyptian” elegantly around every curve and help them to follow the natural design of the 3D root canal system. One trend I have witnessed in our dental clinic is the growing number of younger patients in need of endo- dontic treatment. In this group, long-lasting solutions are particularly important. This can easily be achieved by taking enough time for the mechanical and chemical preparation while choosing a durable obturation ma- terial like gutta-percha that will stay in the canal for a substantial amount of time. These new patients are well informed and have a clear idea of what they are willing to invest. It is crucial to walk them through the process and explain about the advantages of modern endo dontic equipment. If the patient understands the oppor tunities a solid root canal therapy offers and knows about the alternatives, he or she will quickly agree to the clinical procedure. Conclusion A detailed radiographic examination usually allows endodontists to come up with the right treatment plan. The corresponding sequence of prebendable NiTi files like the HyFlex system helps the dentist to navigate severely curved and shaped root canals according to their natural design. Even in comparatively young patients, the long-term prognosis after endodontic treatment is good if modern technical auxiliaries are combined with the right manual skills. This article is part of a three-part series that is titled So Many Roots to Travel and was developed by COLTENE. In the series, endodontic specialists around the world discuss their most spectacular cases and show how they met the treatment challenge using modern NiTi instruments. about Dr Ahmed Shawky, BDs, MSc, PhD, is a lecturer of endodontics and holds special workshops at Cairo University in Egypt. Dr Shawky is a silver member of Style Italiano. He works in a private clinic in Cairo. roots 2 2020 25

case report | 4 5 Fig. 4: Modified size 3 Gates–Glidden bur creating a staging platform. Fig. 5: Radiograph after removal of the coronal part of gutta-percha and creation of a staging platform. At present, there is no standardised procedure for safe and consistently successful instrument fragment removal. In each case, the chances of success should be bal- anced against potential complications. There are four treatment options for managing fractured instruments: to be followed prior to any decision and, particularly, ini- tiation of efforts to retrieve the fragment. It is necessary to inform the patient about the incident, the procedures necessary to correct it, the alternative management mo- dalities, and the impact of this iatrogenic error, as well as all alternative treatment options on prognosis.1 – no intervention; – non-surgical management; – surgical management; and – tooth extraction.1 When the clinician decides to manage a clinical case of a separated instrument, it is important to take into con- sideration that all procedures include the risk of additional errors that may eventually jeopardise the prognosis of the tooth, and the clinician should continuously re-evaluate the progress of management procedures, and consider alternative options when needed. There are certain steps The clinician should take into consideration the fragment location, as it provides fundamental information for de- cision-making regarding the potential management and risks associated with the process. Another factor to evaluate is the type of instrument fractured and its size. These factors can dictate which technique or approach the clinician needs to adopt in order to deal with this challenging clinical situation. Various techniques and instruments, which quite often have to be combined, have been advocated for fragment Fig. 6: Schematic representation of a staging platform. roots 2 2020 27

case report | 11 13 a size 25 Endo clean tip, space was created around the fragment (exposure of the coronal 2 mm). During this stage, using the same tip, the active part (blades) of the separated instrument was smoothed in order to avoid damaging the loop wire (Figs. 7a & b). 10 Taking into consideration the wire characteristics and resistance, the Endo- Cowboy device (which has a 0.1 mm lasso made of specially drawn stain- less steel wire with higher tear resistance and a 0.4 mm cannula; Köhrer Medical Engineering) was used as a loop device, fol- lowing the manufacturer’s instructions (Figs. 8 & 9). Using two operators—one taking care of the loop de- vice, controlling under the microscope the attachment of the loop around the separated fragment, and the second operator acti- vating the device (tightening the lasso around the frag- ment)—the fragments were removed with up and down movements with the loop device attached to the frag- ment (Figs. 10–13). All canals were instrumented with a size 8, 10, 12 and 15 D Finder (MANI) to obtain a manual glide path. Cleaning and shaping were performed up to size 25/0.06 with Silk files (MANI) in all root canals and a Tri Auto ZX2 motor (Morita). Irrigation was performed throughout the treatment with 5.25 % sodium hypo- chlorite. A final irrigation protocol was done with 17 % EDTA and 5.25 % sodium hypochlorite, and the irrigant was activated with a manual dynamic activation tech- nique. Obturation was performed using 4 % gutta- percha cones and BioRoot RCS (Septodont), employing the hydraulic condensation technique (Figs. 14–16). The pulp chamber was sealed with Ionoseal (VOCO), and a temporary restoration was made. The patient was referred to her dentist for the permanent coronal res- toration. At a follow-up visit after six months, the tooth was asymptomatic (Fig. 17). Discussion 12 Figs. 10–12: Removed fragment. Fig. 13: Radiograph after removal of the fragment. Fragment removal is time-consuming and technically dif- ficult to perform and might jeopardise the outcome of the endodontic treatment. To improve the success of the file retrieval technique, most of the time, a combination of techniques is needed, and there are certain common steps to follow: – conducting a radiographic examination with more than one angulation or with a cone beam computed tomography scan, to confirm the presence of the frag- ment, to reveal its location in relation to the root canal curvature, and to estimate its size and length; – redefining the access cavity to allow better visualisation and unobstructed manipulation; – keeping the staging platform, created with a modified Gates–Glidden bur, centered in order to allow better visualisation of the fragment and the surrounding dentinal root canal walls; – placing PTFE tape over other exposed orifices in multicanal teeth in order to prevent dislodgement of the fragment into another root canal; – maintaining constant visualisation using magnification during management efforts; The intracanal fracture of endodontic files with the possible retention of fragments in the root canal is an unwanted complication in everyday clinical practice. – taking frequent working radiographs during the re- trieval procedure in order to check the level of retrieval and amount of dentine loss; roots 2 2020 29

case report | 6 9 7 10 8 11 diminished and the pulp chamber had been filled with flowable composite (Fig. 1), while the clinical examination showed a large and abraded composite restoration. A dental dam was placed on the tooth in order to isolate the operating field (Fig. 2),3 and the root canal therapy be- gan. The first step in the correct shaping of the root canal system is the access cavity.4 It ideally must be the coronal projection of the root canals, and it is meant to be as small as practical. The coronal composite was carefully removed with a diamond-coated bur as soon as the pulp cham- ber floor was reached (Fig. 3). After creation of the access cavity, the carboxylate cement that had been placed in the root canals in the primary treatment was removed, and the root canal openings were sought and found with the help of the operating microscope (Fig. 4). Subsequently, it was managed to remove the cement from the root canals. Since the primary treatment had not respected the basic principles of 3D cleaning, shaping and filling of the root ca- nal system, it was necessary to consider these, as the pulp was still present in the root canals. The scouting phase was executed, first with thin stainless-steel manual instruments and NiTi rotary files (Fig. 5), and then NiTi reciprocating files were used to shape the root canal system (Fig. 6).5 After root canal enlargement, irrigation was performed by means of 5 % sodium hypochlorite carried by a 0.3 mm stainless-steel side-vented needle (Fig. 7), endeavouring to bring the needle tip as close as possible to the working length.6 The fluid was then activated with sonic inserts7 according to Tonini and Cerutti (Fig. 8).8 The root canals were then dried with aspiration (Figs. 9 & 10) and paper cones (Fig. 11). The obturation phase was carried out with warm gutta- percha according to the continuous wave compaction technique (Figs. 12 & 13). A provisional restoration was then placed, and the patient was sent back to the refer- ring dentist for the final indirect restoration (Fig. 14). 12 13 14 roots 2 2020 33

case report | 24 26 27 The choice relative to the clinical protocol was guided by the clinical scenario. While there were no differences in the shaping system selected (since the combination of manual scouting and reciprocating NiTi files permitted shaping of the root canals, decreasing the risk of instrument fracture, even in presence of strong curvatures), the irrigation tip and the obturation method selected were different. The different choice of irrigation tips was due to the availability of the products and to the anatomy of the root canals. Since it was rational to suppose that mechanical shaping alone was not able to remove in toto pulp rem- nants, the smear layer and bacteria, irrigation played an important role in both cases. In the first case, a thin metal side-vented tip was used. The root canals were quite straight, so this kind of tip 29 31 32 roots 2 2020 35 23 25 28 30

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case report | 5 6 7 8 (Fig. 2), under the operating microscope, I noticed bleeding from the mesiopalatal angle. Extending the access cavity to that side led to the discovery of a separate canal, which may have been a second palatal or an independent mesial canal. For shaping, you need to start, after establishing a glide path, with 21 mm stainless-steel hand files. I use a 17 mm orifice opener because it allows me to work way in the back with indirect vision, and this step will shape the first part of the canal, making it easy for the remain- ing rotary files to follow the path that has been created. The final radiographs revealed four separate root canals (Fig. 3). Figure 4, a micro-CT scan done by Dr Volokitin, shows almost the same anatomy. Case 2 The patient was referred for a root canal therapy of his maxillary molar. Upon creating the access cavity un- der a clinical microscope, we could see that the entry to the second mesial canal was at a distance from the entrance to the first (Fig. 5). Figure 6 shows the proximity of the second mesiobuccal canal to the palatal canal. Increasingly, second mesial canals are being treated in the maxillary second molar owing to the use of the microscope, ultrasonic instruments and irrigation and of course owing to the clinical knowledge regarding the use of these and owing to the use of CBCT imag- ing sometimes. Figure 7 shows an immediate postoperative radiograph of the treatment. A micro-CT scan of a similar root canal system is shown in Figure 8. Case 3 Irreversible pulpitis was causing this patient a great deal of pain. When examining the preoperative radiograph (Fig. 9), I saw doubled periodontal ligament on the mesial root, which clearly indicated a second canal in this root. The opening of the second mesiobuccal canal was very tight and very small; nevertheless, it had a separate exit. The immediate postoperative radiograph in Figure 10 does not show it, but an image at a further 15° angle would clearly show the independent exit of the second mesiobuccal canal. A micro-CT scan of a similar anat- omy—as we can never find two identical anatomies— is illustrated in Figure 11. Case 4 This type of anatomy is the most challenging, as it requires all your skills and high-tech equipment. The patient was referred for irreversible pulpitis of a maxillary 9 10 11 roots 2 2020 39

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unable to locate. Subsequently, after several appointments to locate the mesiolingual canal, the second general den- tist had perforated the floor of the pulp chamber. He did not inform the patient of this, but placed a temporary res- toration and kept him on oral antibiotics and analgesics. After several days, the patient reported to the dentist with pain and was advised to have the tooth extracted and replaced with an implant, as it could not be saved. Since the patient was unwilling to do so, however, the dentist referred him to our practice. When I had a close look at the preoperative radiograph from the referring dentist (Fig. 1a), I observed that there was insufficient obturation of the mesial canals and almost no obturation of the distal canal. Both roots dis- played periapical radiolucency. The clinical examination revealed a Grade I mobility, and the tooth was tender to percussion. The periodontal examination ruled out any pockets and loss of attachment. We took an intra-oral periapical radiograph (Fig. 1b), from which we observed the loss of coronal structure and a large radiolucent area over the furcation area and the periapical area of both the mesial and the distal roots. A CBCT scan of tooth #46 was advised to check for any details that may have been missed in the intra-oral periapical radiograph (Figs. 2a–g). From the CBCT scan, it could be observed that there was inadequate obturation of the distal canal on the horizontal plane, no obturation beyond the middle third in the mesial canals and a breach of the floor of the pulp cham- ber. The questionable prognosis was explained to the patient, and written consent was obtained. An inferior alveolar nerve block was administered, and a dental dam was placed. When the tempo- rary restoration was removed, blood began oozing out from the pulp chamber. After initial haemo - stasis, a large blood clot could be observed on the floor of the pulp chamber (Fig. 3). The clot and the underlying granulation tissue were removed with a sharp spoon excavator, and the pulp chamber was irrigated with saline. Then a sterile cotton pel- let soaked in 1 % sodium hypochlorite was placed in the chamber for two to three minutes until the oozing of the blood stopped. The mesiolingual canal was located under the dental operating microscope (Sanma Medineers) using an RS-1 ultrasonic tip (KaVo Kerr) at the #5 power setting without water, attached to a P5 NEWTRON scaler (ACTEON). The orifice was enlarged using micro-openers (DENTSPLY Maillefer). The previous obturation was removed using retreatment rotary files (Endostar, Poldent). Coronal pre-flaring was done using 25/.08 TF files (KaVo Kerr). A glide path and patency were established in all the canals with a 10/.02 2b 2c case report | 2a Figs. 2a–g: Pre-op CBCT images of tooth #46: No obturation material in the distal and mesiobuccal canal (a); scanty obturation of the canals and breach of the floor of the pulp chamber, no obturation beyond a few millimetres down the orifice (b & c); radiolucency in the furcation area and periapical region of both roots (d–g). roots 2 2020 43

case report | Table I: Canal dimensions Canal Mesiobuccal Mesiolingual Distal Length (mm) Initial master Final master apical file apical file 21.0 21.0 21.5 30/.02 35/.02 40/.02 30/.04 35/.04 40/.04 Table II: Irrigation protocol followed First appointment Throughout shaping with 6 % sodium hypochlorite and 18 % HEBP via double-side-vented needle delivery in positive pressure irrigation at 1 ml/15 s, with exchange between every file and ultrasonic activation Post-shaping continuous negative pressure irrigation and evacuation with EndoVac in two phases: – Phase I (macro-debridement): with same irrigation solution used during shaping, 5 ml per canal, with 0.55 mm MacroCannula until middle third of canal at 1 ml/10 s – Phase II (micro-debridement): with another 5 ml per canal of same irrigation solution with 0.32 mm MicroCannula until electronic working length at 0.5 ml/10 s Second appointment Irrigation with 17 % EDTA for 1 min and ultrasonic activation for 30 s Negative pressure irrigation (same protocol as for first appointment) 2g AH Plus sealer (Dentsply Sirona) was applied to the canal walls using the respective gutta-percha master cones. The gutta-percha cones were pre-sterilised by placing them in 2 % chlorhexidine for ten minutes. The canals were then obturated by Schilder’s warm vertical com- paction using Touch ’n Heat (SybronEndo), heat carri- ers and Buchanan hand pluggers (SybronEndo). After the corono-apical downpacking, the rest of the canal was back-filled with thermoplastised gutta-percha using a System B gun (SybronEndo). The backfilling was done keeping it 3 mm short of the orifice to allow the core to form orifice plugs that would increase the retention and coronal seal by increasing the surface area for bond- ing (Fig. 5). Then the pulp chamber was cleaned with 70 % isopropyl alcohol and treated with 17 % EDTA for one minute. Since the defect was large, it was decided to place a PRF membrane beneath the MTA. Blood (10 ml) was drawn from the cubital region and collected in two Vacutainer tubes without anti-coagulant. The tubes were then immediately placed in a portable centrifuge. The centrifuge was set at 3,000 rpm for ten minutes. The canal orifices were protected from accidental blocking with MTA by packing sterile PTFE in them. The middle layer of PRF (the bottom layer contains red blood cells and the top layer contains platelet-poor plasma) was iso- lated with a pair of sterile tweezers and placed in a sterile membrane- forming box then carried to the perforation site and adapted lightly. Then MTA Plus (Prevest Denpro) was mixed and placed in increments and adapted all along the margins and into the defect. Finally, a moist sterile gauze was placed over the MTA, and the access 3 4 5 Fig. 3: Intra-op image of tooth #46 captured under the dental operating microscope at 16× magnification. Fig. 4: Intra-op image of tooth #46 captured under the dental operating microscope at 16× magnification showing the clean perforation defect prior to its sealing with MTA and PRF. Fig. 5: Intra-op image of tooth #46 under the dental operating microscope at 16× magnification showing the sealed pulpal floor perforation with MTA and the obturated mesial canals with room for orifice plugs for the core material. roots 2 2020 45

Discussion The success of an endodontic treatment is esti- mated to be high, over 98 per cent for initial treat- ment and over 95 per cent in retreatment cases, according to peer-reviewed literature and evi- dence-based studies, but failures do happen for a spectrum of reasons, which include biological and technical aspects that ultimately lead to an increased bacterial load within the canal space. An endodontic treatment may be deemed to have failed if the treated tooth presents with symp- toms or periapical radiolucency or both. The var- ious reasons for failure could be coronal leakage from a poor or inadequate post-endodontic res- toration, a missed canal or anatomy, incomplete instrumentation of the canals and spaces, insuffi- cient irrigation and disinfection of the canals. To achieve adequate cleaning in the apical re- gion, adequate apical sizes should be created without sacrificing the precious radicular den- tine. In this regard, the sequential flaring and enlargement of the canal (hybrid flaring tech- nique) at different levels has a substantial advantage in having the benefits of all the techniques and combining them to enhance the outcome of the case. The stages of the instrumentation protocol are as follows: 1. The canals are located using 8/.02 and 10/.02 K-type files in a watch-winding motion. The files are not advanced any further than the beginning of the first curvature. 2. Coronal pre-flaring is performed with 6–8 % taper orifice shapers in rotary motion until the beginning of the curvature of the canal. The canals are flooded with irrigation solu- tion (sodium hypochlorite and HEBP). 3. The glide path and patency are established with 8 and 10 K-type files in a watch-winding motion with an electronic apex locator at- tached to record the EWL. 4. Widening of the glide path is done using 12/.02 and 15/.02 K-type files in manual bal- anced force motion, and a 10/.02 K-type file is used in between to confirm patency and irrigation solution is exchanged between files. 5. The initial master apical file is selected from any 2 % taper K-type file larger than 15 that binds 3–4 mm short of the EWL. 6. Apical enlargement is done using sequential 2 % taper K-type file larger than 15 to shape the canal either manually using the balanced force technique or attached to an engine- driven handpiece that uses alternating clock- wise and anticlockwise motion until the 6d 6e 6f case report | roots 2 2020 47

case report | and inductive nature of MTA and the autologous nature of PRF, their combination seems promising. Follow-up Though the prognosis of the case initially appeared to be poor, the six- and 14-month follow-ups showed a favour- able outcome. The periapical healing was considerable and the furcation defect too had responded well. It ap- pears that adequate cleaning and shaping of the canals and the use of a detailed irrigation and disinfection protocol and a biocompatible, autologous and tissue-conductive material to seal the perforation acted in synergy to ad- dress the biological aspect of the treatment. The aspect that remained to be evaluated was the functional one, for which there was need for more extensive follow-up. Conclusion From the case described, it may be concluded that, since it is in evidence that the initial endodontic treatment has a higher percentage of success compared with retreat- ment, all efforts should be made to deliver the best care on the first go. It was also learnt that whenever possible a decision should be taken to refer the case to a specialist rather than attempt treatment with a limited knowledge and armamentarium, as the Hippocratic oath says, “at least to do no harm”. Lastly, sometimes the worst appearing case may be salvageable, and adequate cleaning, shaping, irrigation and disinfection, the use of biocompatible regenerative materials and above all the host response play a vital role. Editorial note: A list of references is available from the publisher. contact Dr Sourav Banerjee obtained a BDS from Rajiv Gandhi University of Health Sciences in Bengaluru in India and thereafter a Postgraduate Certificate in Education (PGCE) in micro- endodontics from the University at Buffalo in the US. He studied MSc in medical microbiology form Manipal and dental implantology through Nobel Biocare and later obtained a postgraduate certificate in education and a postgraduate diploma in hospital management. He is a consultant micro-endodontist and restorative dentist at Omkarananda Dental Care & Research in Jamshedpur in India. He is a fellow of the Academy of Fixed Ortho - dontics and director at Dr Sourav Banerjee’s Micro Endodontic Training Academy. Dr Banerjee can be contacted at fde.academy@gmail.com. AD IrriFlex® ROOT CANAL IRRIGATION NEEDLE Scan to learn more about IrriFlex. Visit pd-dental.com to join MyPD platform and get access to unique materials, case studies, clinical articles and webinars. Produits D entaires SA . Vevey . S witzerlan d

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practice management | I am sure that you are looking forward to the next issue of roots magazine, in which I will present the 12th part of this unique series on communication protocols and consider further interesting and useful topics. Are you curious about what’s next? We will talk about how to retain your newly won patients from abroad and turn them into loyal advocates, who will promote your prac- tice in their respective home countries. As you can see— we are still not done with the topic of medical tourism, as there are many more interesting aspects to explore that you, as your clinic’s leader, can capitalise on. I will con- tinue the discussion of the topic and provide five crucial points necessary to meet your goals. Until then, remember that you are not only the dentist at your clinic but also its manager and leader. For questions and further information and guidance, don’t hesitate to reach out by e-mailing me at dba@yiannikosdental.com or see our website, www.dbamastership.com. I look for- ward to our next step towards business growth and ed- ucational development. Let’s keep in touch! their needs but also satisfies their desires. If you are the expert, show them. You could, for instance, inform them on the benefits to themselves of your unique dental equipment, or demonstrate your difference through the processes that you and your team employ. Show them that you offer not only a treatment but also a great ex- perience. 3. Use before and after photographs in your promotional online channels People are usually rather cautious about spending a great deal of money travelling abroad for treatment that they do not know the outcome of beforehand. Distribut- ing contrastive before and after photographs and mak- ing them publicly available via online promotional tools, such as Google Ads, social media, blogs or your home- page, can be a great way to assure prospective patients that you deliver on your promises with regard to treat- ment outcomes. 4. Highlight your credentials Highlighting your credentials encourages patients from abroad to visit you. When they come to you, they must feel that they already know you and that you are well educated—you need to accomplish that via your online presence. 5. Make use of your media resources Use all your promotional media resources wisely to make your clinic visible and known. Draw up a promotional plan for every month and keep to it. 6. Ask loyal patients to submit testimonials Video testimonials or testimonials in written form from patients who have visited you before can be a vital pro- motional tool for you and can greatly influence prospec- tive patients’ decisions. about 7. Be prompt in your response Do not delay in answering prospective patients’ e-mails. You could have set templates for different treatments that they may ask about. Consider setting up preprogrammed e-mail responses on veneers or implants in which you ex- plain the materials that you use, the associated price and the benefits for them. This will certainly save you time. Isn’t that easy? Dr Anna Maria Yiannikos (DDS, LSO, M.Sc., MBA) is one of the first two women worldwide to have obtained a master’s degree in laser dentistry. She has owned a dental clinic for 23 years now and leads the innovative Dental Business Administration Mastership Course at RWTH Aachen University in Germany. She is an adjunct faculty member of the Aachen Center for Laser Dentistry. Use the above-mentioned steps as a protocol in your daily practice and you will soon notice an influx of new patients from abroad and—most importantly—feel in control of this new situation. You now know the ex- act steps required to attract and engage with patients from other countries. Moreover, I am confident that you will most likely experience an increase in income as a consequence too. Just try it and let me know what you think! contact Dr Anna Maria Yiannikos Adjunct Faculty Member of AALZ at RWTH Aachen University Campus, Germany DDS, LSO, M.Sc., MBA dba@yiannikosdental.com www.dbamastership.com roots 2 2020 55

Online class taught by Dr. Arnaldo Castellucci: A MODERN APPROACH TO MICROSURGICAL ENDODONTICS duration: 1 hour | language: english/russian | Q&A | 99 € OBSERVE DISCUSS YOUR CASE ON DEMAND ALL DEVICES GUARANTEED Online classes taught by the world’s best doctors directly from their practice: www.MasterClass.Dental Tribune Group GmbH is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Tribune Group GmbH designates this activity for 1 continuing education credits. This continuing education activity has been planned and implemented in accordance with the standards of the ADA Continuing Education Recognition Program (ADA CERP) through joint efforts between Tribune Group GmbH and Dental Tribune Int. GmbH.

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