issn 2193-4673 • Vol. 17 • Issue 2/2021 roots international magazine of endodontics 2/21 technique Lane keeping assistance systems in endodontics trends & applications Principle-driven endodontics: Proven case results case report Er:YAG laser for superior endodontic treatment
editorial | Magda Wojtkiewicz Managing Editor While taking care of others, you should remember to take care of yourself Self-care is one of those things that is essential, but we often do not take enough time for it, or feel that we do not have enough time or knowledge. However, taking care of yourself—your body, health and mental well- being—is most important not only in order to feel better but also in order to perform better in the long run and to be able to help others better. Back pain is one of the most common problems among dental professionals. The results of a study conducted in 2015 showed a 70.0% incidence of back pain among dentists, lower back pain predominating in 47.6% of cases.1 Such ﬁndings demonstrate a high prevalence of lower back pain among dental professionals. Unfortunately, the importance of ergonomic working posture is usually not the focus of dental students and young practitioners. Dr Ali Nankali in his article “Back pain—a clinician’s nightmare” (page 42) empha- sises that many young clinicians are aware of their incorrect posture and positioning, yet they do not know how to correct it: “The lack of conﬁdence does not allow them to challenge their habits on their own, and so they often seek help” and “Many dentists who do not know how to manage back pain try to work in a stand- ing or a different sitting position, which, unfortunately, is reported to lead to more intense pain, especially in the upper and lower back areas”. Another study, conducted by Swedish researchers between 2012 and 2014, concluded that “understand- ing the relationship between working conditions and well-being is crucial to being able to design speciﬁc interventions for oral healthcare providers which will improve their working conditions and health”.2 The lead author of the study, Dr Charlotte Wåhlin from Linköping University, recommends that dental professionals use ergonomic exercises in the daily practice to prevent work-related disorders. Undeniably, offering high-quality treatment to patients should be the focus of every dental professional, but it should never come at the expense of their health or well-being. Therefore, striking a balance between self- care, including correct working posture, atmosphere at work, and physical and mental health, and professional performance is crucial for obtaining the best results in the long term. Magda Wojtkiewicz Managing Editor References 1. Gaowgzeh RA, Chevidikunnan MF, Al Saif A, El-Gendy S, Karrouf G, Al Senany S. Prevalence of and risk factors for low back pain among dentists. J Phys Ther Sci. 2015 Sep;27(9):2803–6. doi: 10.1589/jpts.27.2803. 2. Wåhlin C, Lindmark U, Wagman P, Johnston V, Rolander B. Work and health characteristics of oral health providers who stay healthy at work— a prospective study in public dentistry. Eur J Physiother. 2021 Apr 6. doi: 10.1080/21679169.2021.1905876. roots 2 2021 03
| content editorial While taking care of others, you should remember to take care of yourself 03 Magda Wojtkiewicz practice management Slow down everyone—dentistry does not need to be done at speed Part 2: The cornerstones of Slow Dentistry are beneﬁ cial for every dentist 06 An interview with Prof. Katalin Nagy page 20 study Comparative evaluation of the accuracy of the AirPex and DentaPort ZX apex locators in detecting working length: An ex vivo study 08 Dr Rosalba Diana, Dr Raffaella Castagnola, Dr Mauro Colangeli, Claudia Panzetta, Dr Luca Marigo, Dr Nicola Maria Grande, Dr Filippo Cardinali & Dr Gianluca Plotino technique Lane keeping assistance systems in endodontics Dr Barbara Müller trends & applications page 32 Principle-driven endodontics: Proven case results Drs Brett E. Gilbert & Richard Mounce case report Er:YAG laser for superior endodontic treatment Dr Igor Križnar The use of a new bioceramic material in endodontic microsurgery Dr Leandro Pereira Aesthetics in endodontic microsurgery Dr Philippe Sleiman 12 14 20 24 28 page 42 Restoration of an endodontically treated tooth using a composite bilayer approach 32 Dr Katja Winner-Sowa news A new era of advanced dental restorative materials has begun Monique Mehler 34 Moving away from amalgam: New online tool helps dentists chose suitable restorative materials 38 Jeremy Booth Study determines work-related factors that keep oral health providers well 40 Franziska Beier opinion Back pain—a clinician’s nightmare Dr Ali Nankali manufacturer news meetings International events about the publisher submission guidelines international imprint 42 46 48 49 50 Cover image courtesy of edwardolive/Shutterstock.com. issn 2193-4673 • Vol. 17 • Issue 2/2021 roots international magazine of endodontics 2/21 technique Lane keeping assistance systems in endodontics trends & applications Principle-driven endodontics: Proven case results case report Er:YAG laser for superior endodontic treatment 04 roots 2 2021
CanalProTM Jeni Digital assistance system for canal preparation Jeni – ready – go! NEW The revolutionary CanalPro Jeni in a nutshell! Watch now! https://youtu.be/Qw3uc3hSTkg Autonomous «navigation» in the endo canal owing to revolutionary software › Digital assistance system for canal preparation controls the file movement at millisecond intervals › Movement profile of the file continuously adapts to the individual root canal anatomy › Irrigation recommendation is indicated by an acoustic signal › Due to the integrated apex locator and fully insulated angled handpiece, continuous measurement of the working length is possible in real time email@example.com | jeni.coltene.com . 1 2 4 0 6 9 6 6 0 0
| practice management Slow down everyone—dentistry does not need to be done at speed Part 2: The cornerstones of Slow Dentistry are beneﬁ cial for every dentist An interview with Prof. Katalin Nagy, honorary global Ambassador for Slow Dentistry, Hungary By Monique Mehler, Dental Tribune International queueing up in the waiting room. Then again, if a den- tist could treat them in a very short time, he or she was considered a very good dentist. I know that it was al- most half a century ago, but I still remember that, and it was obvious that we had a very long way to go. You can imagine the changes that have happened in my country since then, changes that were even more evident when SARS-CoV-2 began spreading everywhere in the world, but the changes started before that. Is Slow Dentistry only important when it comes to specialties like endodontics or oral surgery, for ex- ample, or would any general dental practitioner beneﬁt from this approach? I would emphasise that the cornerstones of Slow Dentistry are beneﬁcial for every single dentist, as well as dental hygienists and dental assistants. These cornerstones not only describe the rights of patients, but also help dental professionals to be able to maintain long-lasting quality work in a safe environment, which will elevate the stan- dard of their private practice and boost their businesses probably more than advertising—what they have been paying for over the years. The necessary time for patient appointments is vital for successful treatment, well-being, understanding and safety. Do you think patients realise that they have this power? I think that, most of the time, patients in my country are still not completely aware of their rights. Sometimes, they choose a dentist according to the interior design of their dental ofﬁces (which I also ﬁnd important) as an inaccu- rate measure of the quality of treatment. These days, there is a growing emphasis on qual- ity over quantity, that is, preferring an object or ser- vice that is worthwhile rather than a quick and easy ﬁx. As Dr Miguel Stanley explained in Part 1 of this series (roots magazine 1/21) this is what Slow Dentistry—a more patient-oriented and wholesome approach to den- tistry—is built on. It also seeks to bring the focus in dental care back to clinical excellence rather than single-minded emphasis on proﬁt. In this interview, Slow Dentistry Honorary Global Ambassador for Hungary Prof. Katalin Nagy speaks about why dental practice makes different demands in the twenty-ﬁrst century. Prof. Nagy, Slow Dentistry has come a long way. How did you observe the process? Besides my academic career, I have been practising as a dentist for more than 40 years. I clearly remember that, at the very beginning when I opened my private ofﬁce in Hungary, people used to measure the success of a dentist according to the number of patients who were Ten years ago, after spending a long time in dental schools, also overseas, I introduced a subject into the dental undergraduate curriculum called communica- tion in dentistry. Communication needs not only skills but also time for patients and professionals. The idea of Slow Dentistry has helped me to reinforce this initiative of teaching communication in dental schools, which allows 06 roots 2 2021
us to have the necessary and appropriate discussion before and throughout the treatment procedure. Currently, you are the Slow Dentistry honorary global ambassador for Hungary. How did that come about, and what do you aim to accomplish through this role? If you consider where Hungary started half a century ago, you would understand the great importance of this role. Also, dental tourism is very popular in our country. Patients arrive from another country for full-mouth dental treatment and typically remain for seven to ten days. I am very sceptical about the quality of the long-term success of those treatments. I would like to introduce a collaboration between Slow Dentistry and the Hungarian Dental Association through which we could grant the Slow Dentistry badge to those dental ofﬁces which are working strictly according to Slow Dentistry’s principles. It could be a great help for both Hungarian and foreign patients in choosing their dentist in order to receive quality treatment in the safest environment. Dr Miguel Stanley, who founded Slow Dentistry and wrote in Part 1 of this series that “The general pub- lic currently has no idea of their rights at a dental appointment.” What is your take on this? Throughout my career, I have been able to work in differ- ent countries. Dental education has always been famed in our country, and there is a high percentage of practi- cal learning opportunities for our students. After gradua- tion, practitioners tend to forget what they learned about quality and safety and how to apply this. Slow Dentistry summarises and structures those most important rules “Communication needs not only skills but also time for patients and professionals.” that we have learned over the years and which every single dental professional can follow. I am also hoping that, after easing of COVID-19 lockdown restrictions, we as Hungarian dental professionals can invite Dr Stanley to a meeting to convey these extremely important messages of Slow Dentistry to our audi- ence, because I believe that a personal discussion with Dr Stanley, who has amazing communication talents, always gives a unique and irreplaceable boost. Editorial note: Visit www.slowdentistry.com for more details. about Prof. Katalin Nagy has received university training and specialty qual- iﬁcations in oral surgery, prosthodon- tics and implantology. Her main ﬁeld of research is oral cancer. Prof. Nagy is currently adviser to the Hungarian health minister on dental issues, being president of the Hungarian Dental Association, and she is head of the Department of Oral Surgery at the University of Szeged, as well as the owner of two private dental ofﬁces in Szeged and Budapest in Hungary. roots 2 2021 07
study | the limitation of providing a 2D image of a 3D com- plex structure. The use of radiographs alone in work- ing length determination led to over-instrumentation in 33% of molars and 56% of premolars.10 The intro- duction of electronic apex locators (EALs) into clini- cal practice allowed, when used with appropriate radiographs, the determination of a more predictable and accurate working length,11, 12 and a substantially lower number of radiographs are necessary when us- ing EALs, consequently reducing patient exposure to X-ray radiation.13 Vieyra et al. showed that Root ZX lo- cated minor foramina 68% of the time in premolar and anterior teeth compared with radiographs, which did so 20% and 11% of the time in anterior and premolar teeth, respectively.14 In the last decades, different generations of EALs have been developed. Several studies have been conducted on different EALs to evaluate their accuracy under different conditions.15–18 The DentaPort ZX (J. Morita) is a third-generation EAL based on dual frequencies (8 and 0.4 kHz), and it is considered the gold standard EAL to which any new device should be compared. Several ex vivo19 and in vivo20 studies have clearly demonstrated its precision. Among these studies, as an example, Connert et al. showed that, in a com- parison of nine apex locators using micro-CT, the DentaPort ZX was the most accurate at detecting api- cal constrictions and major foramina, having an accu- racy of 99% and 100%, within a tolerance of ± 0.5 mm or ± 1.0 mm, respectively.15 AirPex (Eighteeth, Changzhou Sifary Medical Technol- ogy) is a new wireless apex locator that is charged on a charging base. It weighs 15 g, and its dimensions are 4.8 × 2.8 × 1.6 cm. In the literature, no data is yet avail- able on this EAL. Thus, the aim of the present ex vivo study was to compare the accuracy of the AirPex and the DentaPort ZX EALs in determining working length in extracted teeth. Material and methods In this study, 15 single-rooted teeth, extracted for peri- odontal or orthodontic reasons, were selected. The teeth were placed in a 5.25% sodium hypochlorite (NaOCl) solution for 2 hours in order to remove organic residue. The remaining tissue was removed from the external root surfaces using a periodontal scaling instrument. Finally, the teeth were stored in normal saline (0.9% sodium chloride) before testing. To rule out previously treated root canals, open apices, resorbed roots, teeth with two canals or teeth ﬁlled with amalgam or composite, two digital radiographs in both buccolingual and mesiodistal projections were obtained. After standard access cavity preparation, the 1 Fig. 1: Determination of the actual working length under a stereomicroscope at 20× magniﬁcation. As a particular detail, a grey spot shows the ﬁle on top of the major apical foramen. patency of the apical foramen was assessed with size 10 and 15 K-ﬁles (Dentsply Maillefer). Samples in which a size 20 K-ﬁle reached the apex were ruled out and substituted. The actual working length (AWL) was determined by introducing a size 10 K-ﬁle into the canal until its tip emerged in the apical foramen under 20× magniﬁca- tion using a stereomicroscope (Zeiss Axiophot, Carl Zeiss) linked to a digital camera (Moticam Pro SMP, Motic; Fig. 1). With the aim of reducing the risk of stop- per movement, two silicone stoppers were positioned on the ﬁle. After the removal of the ﬁle, the distance between the stoppers and the ﬁle tip was measured to establish the AWL. The roots of each tooth were immersed in a plastic box ﬁlled with alginate, leaving the most coronal 5 mm uncov- ered. Alginate was useful for obtaining an environment as analogous as possible to the oral one. The wire of the EAL was connected to the ﬁle inserted into the root canal, while the lip clip was immersed in the alginate. AirPex (Fig. 2) and the DentaPort ZX (Fig. 3) were used according to the manufacturer’s instructions. When the AirPex was used, a size 10 K-ﬁle was inserted gently until 2 3 Fig. 2: The AirPex apex locator. Fig. 3: The DentaPort ZX apex locator. roots 2 2021 09
| study the red bar appeared on the device and then retracted until the apical position was reached (last green bar at the 0.0 mark). When the operator used the DentaPort ZX, a size 10 K-ﬁle was introduced through the root canal until the device showed a red line on the display, in- dicating that the apex had been reached. It was then removed to the last green line on the display. Measurements were considered valid if the reading re- mained stable for at least 5 seconds. Each measure- ment was repeated three times for each tooth and each EAL, and in order to reduce bias, all measurements were taken by the same operator and repeated three times. All working lengths were measured on the ﬁle using a digital caliper, and the mean value was consid- ered the result. All measurements recorded were expressed as means and standard deviations. Positive values indicated mea- surements that extruded beyond the apical foramen, and negative values indicated measurements that were short of the apical foramen. The measurements were grouped according to the device used to obtain them. Differences between the electronic working length (EWL) and the AWL were paired, and statistical analysis was performed using one-way ANOVA and Tukey tests, a signiﬁcant difference set at P < 0.05. Results When considering a margin of accuracy of ± 0.5 mm, AirPex showed an accuracy of 84.5% and the DentaPort ZX showed an accuracy of 86.6%. Considering a margin of accuracy of ± 1 mm, the two EALs showed an accu- racy of 100%. The main difference between EWL and AWL was 0.09 ± 0.33 mm for AirPex and 0.08 ± 0.35 mm for the DentaPort ZX (Fig. 4). No statistically signiﬁcant differences were found between AirPex and the Denta- Port ZX (P > 0.05). Discussion The aim of this study was to compare ex vivo the ac- curacy of two EALs, AirPex and the DentaPort ZX. The accuracy of the two EALs was evaluated considering the major foramen more reproducible than the apical constriction.21 Moreover, in the present study, as elec- tronically measured canal length was inﬂuenced by the root canal diameter, single-rooted teeth with narrow root canals were selected, and a size 10 K-ﬁle was used to obtain AWL and EWL. In fact, Ebrahim et al. reported that, when the diameter of a root canal increased, elec- tronic measurement with a small K-ﬁle become shorter22 and that, in wide apical foramina, the EALs become more reliable at determining the working length of teeth if a tight-ﬁt ﬁle was used.23 Alginate was used in the present study to simulate peri- odontal ligament and to ensure the best medium possi- ble for testing the EALs ex vivo. Alginate as a substitute for periodontal ligament was investigated by Lipski et al., who showed a 100% rate of correct measurement.24 On the contrary, gelatine, agar-agar, saline and ﬂower sponge soaked in saline showed a rate of correct measurement of 96.7%, 76.7%, 73.4% and 63.4%, respectively.25 4 Fig. 4: Main difference and standard deviations between electronic working length and actual working length of AirPex and the DentaPort ZX and actual working length. AWL = actual working length. 10 roots 2 2021
| technique Lane keeping assistance systems in endodontics Dr Barbara Müller, Germany A fully automatic navigation assistant for root canal therapy? What may initially sound like robo - doc treatment or treatment by remote control will take end- odontics a signiﬁcant step for- ward on the way to sustainable, reliable preparation. Cases pre- sented in this article illustrate how digital endodontic assis- tance systems will revolutionise everyday treatment in the future. Fig. 1: Fully automated CanalPro Jeni endodontic motor. ages that could lead to ﬁle breakage. With the innovative CanalPro Jeni endodontic motor, the user works continuously forwards, applying only slight pressure, while the digital co-pilot decides inde- pendently on the progress of motion. Complex algorithms control the variable ﬁling mo- tions. The computer’s reaction time is in the millisecond range and thus signiﬁcantly faster than that of humans. Rotary motion, speed and torque have already been adjusted before the user even notices that he or she may have been applying too much pressure. The experienced endodontic expert, in particular, may wonder whether the assistance of the endodontic motor can be trusted when used in the dental practice. However, a fully automatic endodontic motor is more precise than the conventional contra-angle handpiece alone. In the begin- ning, it takes a bit of courage to constantly push forwards and rely on the co-pilot to reduce the rotation speed or to let the ﬁle rotate backwards if the system detects resis- tance before noticing anything oneself. Furthermore, the new types of endodontic motors, such as CanalPro Jeni, also fully respect the classic rinsing protocol: an acoustic signal indicates when and how often rinsing should be performed between ﬁle changes. This consistent forward motion can ultimately save considerable time during prepa- ration, especially in the case of complex anatomies. In such complicated root canal proﬁles, endodontic specialists can save between 10 and 30 minutes with Jeni, time that is important for extensive rinsing and disinfection. Shaping according to the original anatomy The beneﬁts of modern endodontic assistance systems quickly become apparent, especially with regard to highly curved root canals, as illustrated by the following two patient cases. In Case 1, periapical periodontitis was diagnosed in tooth #37 after CBCT imaging in a patient aged approx- imately 50 years (Fig. 2). The mesial root canal entrances were difﬁcult to identify because they contained well- adapted, tooth-coloured composite. The treating endodontic specialist, Dr Thomas Rieger from Memmingen in Germany, selected the appropriate sequence of ﬂexible NiTi ﬁles Strictly speaking, an intelligent lane assistant of the type we are familiar with from road safety was a long overdue, logical progression in technical advancement of apex lo- cators and so on. Whereas clinicians nowadays often as- sist machines in high-tech surgery, it is only logical that the digital co-pilot should be able to support the endodontic expert on his or her route to the apex, when the ﬁeld of vision is limited and the anatomy is unclear. While treating a strongly curved S-shaped root canal some time ago, Italian endodontic specialist Prof. Eugenio Pedullà came up with an idea that was as simple as it was capti- vating: the vision of autonomous driving could also make root canal preparation far safer and more efﬁcient in dental practice as well. Lane departure warning, trafﬁc jam alerts or cruise control, all useful features of modern mobility de- velopment, could just as easily be put to use for endodontic treatment. In collaboration with international dental special- ist COLTENE, he then developed the appropriate proto- type. Prof. Pedullà was so proud of the device, which has been available since 2020, that he even bestowed his nick- name on the new endodontic motor, the “enchanting Jeni”, which ﬁnds its way independently through the root canal and adapts ﬁling motion to the conditions prevailing in the respective root section within milliseconds (Fig. 1). Moving steadily from the coronal to apical aspect Using this innovative work aid for the ﬁrst time requires a little bit of getting used to in the beginning. Traditionally, ﬂexible nickel–titanium (NiTi) ﬁles are inserted gradually into the root canal in dabbing up and down motions. Up to now, tactile feedback has enabled the dentist to sense the course of the curvature and thus avoid misalignments or block- 12 roots 2 2021
| case report Er:YAG laser for superior endodontic treatment Dr Igor Križnar, Slovenia 1 2 Figs. 1 & 2: Initial situation: tooth #36 with broken lingual wall. In the ﬁeld of endodontics, practitioners routinely face the challenge of removing bioﬁlm and debris from dif- ﬁcult-to-reach areas in the root canals. Anatomically complex root canal systems with lateral canals, canal branches, isthmuses and tubules represent a signiﬁcant challenge for successful endodontic treatment. Irrigation is a general method for cleaning areas that are inacces- sible to mechanical instruments.1 The Er:YAG photoacoustic technique has been a suc- cessful method of removing bioﬁlm and debris from the dental root system for many years. The mechanism of cleaning and disinfection by photoacoustic irrigation is based on the mechanical removal of bioﬁlm and debris via the turbulent movement of liquid (the irrigant) and simultaneously by the chemical reaction of the irrigant itself. Turbulent ﬂuid motion results from the formation of cavitation vapour bubbles and their implosion, which releases a large amount of energy and consequently triggers ﬂuid motion.2–4 There are several methods of Er:YAG photoacoustic irri- gation.5, 6 The pioneering single-super-short pulse (SSP) method is very successful in generating photoacous- tic and shock waves in an inﬁnite irrigation space, but in tight spaces such as a root canal, the cavitation dynamic is signiﬁcantly slowed down owing to friction on the dentinal walls and the limited space available 3 4 Fig. 3: Radiograph of tooth #36 before crown lengthening and endodontic treatment. Fig. 4: Tooth #36 immediately after crown lengthening. 20 roots 2 2021
case report | for rapid ﬂuid movement during expansion and con- traction of the bubbles. A modiﬁed method, known as SWEEPS (shock wave enhanced emission photo- acoustic streaming),5, 6 has been developed as an up- grade of the SSP technique and is particularly suitable for very conﬁned spaces. Unlike the SSP technique, the SWEEPS technique delivers pulses in pairs. The second pulse exerts pressure on the ini- tial bubble, which is generated by the ﬁrst pulse, and accel- erates its collapse and the emergence of a new generation of bubbles. In this way, even in very narrow geometries, shock waves are formed that travel faster than sound (acoustic waves). The optimal time difference between pulses in a pair depends on the volume and anatomy of the conﬁned space. When the correlation between tooth anatomy and the time between pulses in a pair cannot be deﬁned ex- actly, a special modality of the method, known as AutoSWEEPS, is used, whereby the time separation between laser pulses in a pair varies continuously be- tween 250 and 650 microseconds, in increments of 10 microseconds. This ensures that during each cleaning cycle there is always an optimal time distance between the pulses, which is necessary for the emission of shock waves and thus for the maximum possible ﬂow efﬁciency according to the dimensions of the irrigation system.5, 6 The efﬁciency of either SSP or SWEEPS in removing bio- ﬁlm and debris can be enhanced with chemical irrigants. In endodontics, the two most commonly used irrigants are sodium hypochlorite and EDTA. Endodontically treated teeth are often more prone to crown or root fracture compared with vital teeth. Several factors contribute to this, the most important being that non-vital teeth often have less sound tooth structure owing to progressive carious lesions, trauma or previous restorations. Certain clinical procedures may also lead to a higher incidence of tooth fracture in endodontically treated teeth, such as creation of large access cavities, excessive mechanical shaping of the roots, prolonged use of different irrigating solutions (sodium hypochlorite, EDTA) and medications (calcium hydroxide) during endodontic treatment, improper restorative treatment without cuspal coverage in the posterior region, and high masticatory forces in cer- tain individuals. Once the tooth has broken off below the gingival margin, it is often very difﬁcult to restore it properly, and additional clinical procedures such sur- gical lengthening of the clinical crown or orthodontic extrusion are needed. When placing a new restoration, the biologic width of the tooth has to be respected and the margin of the restoration should be at least 2.15–2.30 mm (preferably around 3.0 mm) from the crestal bone, to allow for a normal epithelial junction and connective tissue attachment to avoid chronic inﬂammation and periodontal tissue loss. 5 7 6 8 Figs. 5 & 6: Tooth #36 with broken lingual wall 14 days after crown lengthening. Figs. 7 & 8: Tooth #36 with composite build-up before endodontic treatment. Case presentation A 28-year-old male patient was referred to our clinic for endodontic treatment of a mandibular molar owing to chronic periapical periodontitis. He stated that a few weeks before the appointment, a large part of the tooth had broken off. The patient was healthy, took no medi- cation and reported no allergies. There was no trauma to the dentition in the patient’s dental history. Intra-oral examination revealed moderate plaque control and oral hygiene. All third molars had been removed in the past, and teeth #16, 24, 26 and 36 had already been endodonti- cally treated. The gingiva was quite healthy, pink in colour, and did not bleed on probing. Probing depth was normal around all teeth. There were no pathological conditions on the tongue, mucosa, or hard or soft palate, or in the oropharynx. The occlusion was Angle Class I. The intra-oral clinical ex- amination showed that tooth #36 had a large mesioocclu- sal-distal (MOD) composite ﬁlling and that the buccal wall was intact, whereas the lingual wall of the tooth crown had broken off about 2 mm below the gingival margin. The tooth was slightly tender to percussion and sensitive to palpation adjacent to the apex of the tooth. The mobility of the tooth had not increased. Probing depth was normal, but there was slight bleeding on probing on the lingual side (Figs. 1 & 2). Analysis of a radiograph showed the large MOD ﬁlling and the broken lingual wall of the tooth (Fig. 3). The tooth had been endodontically treated in the past; the root ﬁllings were porous and short in the mesial root. There were bone lesions (chronic periapical periodontitis) under both the mesial and distal roots. Diagnosis The diagnosis was chronic periapical periodontitis and a broken lingual wall of the tooth crown. roots 2 2021 21
| case report Table 1 Application Source Mode Energy Frequency Handpiece Table 3 Application Source Mode Energy Frequency Handpiece Table 5 Application Source Mode Energy Frequency Handpiece Gingivectomy Step 1 Er:YAG SP 150 mJ 15 Hz HCN 14 Gingivectomy Step 2 Er:YAG LP 100 mJ 15 Hz HCN 14 Endodontic cleaning Er:YAG AutoSWEEPS 20 mJ 15 Hz HCN 14 Treatment plan Healing after surgical crown lengthening may be painful, and the sutures may interfere with good oral hygiene, in addition to being unpleasant for the patient. An alternative approach is the use of Er:YAG laser irradiation, which is readily absorbed in the water component of the collagen of the gingiva and bone, causing instantaneous vaporisation and enabling a precise and superﬁcial cutting action with- out the risk of damage to the surrounding bone. Therefore the clinical crown lengthening procedure of gingivectomy and osteoplasty should be performed with an Er:YAG laser using shorter pulse modes (short pulse and micro-short modes, respectively), since there are almost no unwanted thermal effects on the surrounding tissue. The procedure can be ﬁnished with longer pulses (long pulse [LP] and very long pulse [VLP]) for coagulation of the blood vessels, thus reducing bleeding and enabling smoothing of the gingiva. In this way, the crown length of the tooth can be increased and a temporary ﬁlling can be performed, which enables further endodontic treatment of the tooth. 22 roots 2 2021 Table 2 Application Source Mode Energy Frequency Handpiece Table 4 Application Source Mode Energy Frequency Handpiece Osteoplasty Step 1 Er:YAG MSP 165 mJ 15 Hz HCN 14 Gingivectomy Step 3 Er:YAG VLP 80 mJ 15 Hz HCN 14 Treatment procedures Before the clinical crown lengthening procedure, the peri- odontal tissue around tooth #36 was analysed. The gingiva was inspected to conﬁrm that the height of the keratinised gingiva was sufﬁcient and that there would be at least 3 mm of keratinised gingiva left after the repositioning of the gingival margin. The gingiva surrounding tooth #36 was lo- cally anaesthetised using Ubistesin (1:100,000 adrenaline; 3M ESPE). The level to which the lingual wall had broken off was marked on the gingiva covering it, and 3 mm was subtracted from this level to mark where the new margin of the crestal bone should be. For the gingivectomy, an Er:YAG laser was used with the Varian tip positioned perpendicularly in non-contact mode 0.5 mm from the gingiva. Air and water spray were set to 3 and 2, respectively (Table 1). For the osteoplasty, slightly different parameters were used. The Varian tip was in- serted parallel to the tooth surface in non-contact mode, and water and air levels were set to 3 and 2, respectively (Table 2). During the treatment, a periodontal probe was used to check the exact level to which the crestal bone had to be osteomised. The procedure was ﬁnished with longer pulses (LP and VLP) for coagulation of the blood vessels in the gingiva, thus decreasing the bleeding, and for smooth- ing of the gingiva (Tables 3 & 4). After the procedures, there was minimal bleeding, and the wound was left to heal for 14 days (Fig. 4). At the second appointment after 14 days, a temporary composite ﬁlling was used to recreate the lingual wall, thus preparing the tooth for endodontic treatment (Figs. 5–8).
case report | 9 10 Fig. 9: Radiograph of tooth #36 three months after the clinical crown lengthening and endodontic treatment. Fig. 10: Panoramic radiograph three months after the treatment. A dental dam was placed on the tooth and the working ﬁeld isolated. An endodontic access cavity was prepared and the root canals were negotiated to the apex with a size 8 hand C-ﬁle. Sequentially larger rotary ﬁles (HyFlex CM and EDM, COLTENE) were used to working length up to size 30 for the mesial canals and size 40 for the distal canal. Between each ﬁling, the AutoSWEEPS irrigation protocol was used with 2.5% sodium hypochlorite for 30 seconds, followed by a 30-second rest phase, and no water or air. The access cavity was ﬁlled with irrigant constantly during the procedure. After the ﬁnal shaping of the canals, the ﬁnal irrigation protocol was performed. This consisted of a single 30-second irrigation cycle with EDTA, followed by a single cycle with distilled water and three 30-second cycles with 2.5% sodium hypochlorite, using the laser parameters stated in Table 5. After drying, a calcium hydroxide dress- ing was placed in the canals and the endodontic access cavity was temporarily sealed. At the third clinical appointment, the calcium hydroxide was rinsed out of the canals. For the irrigation, a single 30-second EDTA cycle, followed by a single 30-second distilled water cycle and three cycles of 30-second AutoSWEEPS irrigation with 2.5% sodium hypochlorite were repeated, using the same energy setting as at the ﬁrst clinical appointment. The canals were dried and ﬁlled with gutta-percha cones and a bioceramic sealer (Biodentine, Septodont) using the cold lateral compaction technique. A stronger temporary ﬁlling made of composite material was placed at the end of the procedure. The patient was referred back to his general practitioner with instructions for a ﬁnal restoration of the tooth with an endocrown after six months, once the periodontal tissue and the periapical lesions had healed completely. In the ﬁrst week of healing, the patient rated his pain one on a scale of one to ten. Fourteen days after the crown lengthening procedure, the gingival margin looked healthy and had reattached at the new level with no observable bleeding on slight probing. It was possible to perform the composite build-up as an endodontic pretreatment with minimal effort. The endodontic treatment was ﬁnished without any complications, and the three-month radio- graphic follow-up showed excellent healing of the periapi- cal lesions (Figs. 9 & 10). For the ﬁnal restoration, the level of the gingival margin might have had to have been slightly adjusted further using the same procedure. Conclusion Our clinical case shows that the Er:YAG laser can be used with great ease and predictability when crown lengthening is indicated. This procedure can be performed as a pre- treatment of the tooth for endodontic treatment or before placing the ﬁnal restoration. It is easy to perform, but just as important—or even more so—is that it causes minimal to no pain and discomfort for the patient and promotes excellent healing of the periodontal tissue. Moreover, this case demonstrates the successful use of the SWEEPS mode to increase the ﬂuid dynamics of the irrigant and thereby to improve the cleaning efﬁcacy of the root canals in the treatment of chronic periapical peri- odontitis. As the sodium hypochlorite reaches even the most apical parts of the root canal system and provides sufﬁcient disinfection, it is not necessary to prepare the canals to larger apical sizes or tapers, which is the case when only conventional irrigation methods are used. This technique truly represents a paradigm shift in the way that endodontic treatment is performed. about Dr Igor Križnar graduated with a DMD in 2006 from the University of Ljubljana in Slovenia and began working as an assistant in the department of endodontics and operative dentistry in the Faculty of Medicine. He acquired the professional title of dental specialist in endodontics in 2014. Until the end of 2015, he worked as an assistant at the faculty, where he was engaged in work with dental students in clinical and preclinical practice. At the same time, he worked as a dental specialist at the University Medical Centre in Ljubljana. He was also engaged in research work and earned his PhD in endodontics from the University of Ljubljana in 2016. In December 2015, he entered into full-time private clinical practice focusing mainly on endodontics. In 2019, he completed the Laser and Health Academy master in laser dentistry. Dr Križnar has published numerous scientiﬁc papers in various journals and has actively participated in many international and local conferences and symposia. roots 2 2021 23
| case report The use of a new bioceramic material in endodontic microsurgery Dr Leandro Pereira, Brazil titis and has an 83% success rate.2 However, with the growing use of microscopy associated with ultrasound and MTA (mineral trioxide aggregate), endodontic micro- surgery has evolved signiﬁcantly and became a viable alternative to conventional retreatment.3, 4 The evolution of technique has improved the success rate from less than 60%5–8 to 90%.6, 7, 9–12 A success rate of less than 60% for the macro-surgical technique (no microscope and no ultrasound) does not deﬁne it as a viable option for treating the complexity of periapical periodontitis. Case presentation A female patient, aged 64 and with an ASA I physical status (healthy), blood pressure of 125/85 mmHg, a heart rate of 61 bpm, oxygen saturation of 98%, a temperature of 36.5 °C and a weight of 69 kg, presented to the clinic on 28 November 2017 complaining about pain and swell- ing around teeth #26 and 27. During examination, a buccal acute abscess was ob- served between these teeth, in the apical region. The patient reacted with light pain to tests of apical palpation and vertical percussion. The response to horizontal per- cussion was negative. Thermal and electrical pulp test results were negative for both teeth. Radiographically, two porcelain-fused-to-gold crowns and two intra-radicular posts (probably glass ﬁbre) pre- sented with correct adaptation. Endodontic treatment of both teeth was deﬁcient, and periapical pathology could be observed (Fig. 1). Preoperative tomography revealed a buccal cortical bone rupture at the distobuccal root 1 Fig. 1: Radiographic view during ﬁrst emergency consultation. Summary Despite the high rate of success in the treatment of peri- apical disease with conventional endodontics, failures may occur. Such unfavourable results may be reversed by standard retreatment, tooth extraction or microsur- gery. With a rate of positive outcomes of above 90%, endodontic microsurgery is a therapeutic alternative to be considered for the functional and aesthetic preserva- tion of teeth with recurrent periapical disease. Introduction Endodontic treatment has a high success rate. However, failure occurs.1 Conventional retreatment is commonly selected to deal with persistent periapical periodon- 2 3 Fig. 2: Tomogram of the distobuccal root of tooth #26. Fig. 3: Tomogram of the periapical lesion of tooth #27. 24 roots 2 2021
case report | 4 5 6 Fig. 4: Pre-op radiograph. Fig. 5: Immediate post-op radiograph. Fig. 6: Four-month post-op radiograph. of tooth #26 and periapical disease in teeth #26 and 27 (Figs. 2 & 3). After careful analysis of all clinical and imaging data, the diagnosis was chronic periapical periodontitis of teeth #26 and 27 probably because of unsatisfactory root canal ther- apy. As an emergency procedure, the abscess was drained. Two alternatives were considered to solve the case. The ﬁrst would have involved removal of the crowns and posts with the purpose of providing access for standard re- treatment. Consequently, after root canal intervention, the posts and crowns would have had to have been re- built. The second was a microsurgical approach aimed at root canal retro-ﬁlling of both teeth. One major beneﬁt of the latter would have been that the posts and crowns would not have had to have been removed. After detailed explanation of all advantages and compromises of the two options, endodontic microsurgery was selected. For personal reasons, the patient did not return until 8 April 2018 (Fig. 4), and surgery was scheduled for 4 June 2018. Preoperative medication was 4 mg of oral dexamethasone for pre-emptive analgesics,13 1 hour before the procedure. Local anaesthesia was administered with 3.6 ml of 4% artic- aine and 1:100,000 adrenaline: palatal inﬁltration of 0.9 ml and 2.7 ml at the site between the attached gingiva and buccal oral mucosa. After anaesthesia, two intrasulcular incisions were followed by a vertical releasing incision. Piezo-syndes- motomy was performed with an ultrasonic tip (PR1, mectron). Because of the infection, the buccal cortical bone had already ruptured, which facilitated ﬁnding the apex of the distobuccal root of tooth #26. However, osteotomy was required to reach the apices of the buccal roots of tooth #27 and mesiobuccal root of tooth #26. Piezo-osteotomy was performed with the ultrasonic tips OT12 and OP7 (mectron) and exposed the entire lesion. For the api- cectomies, the ultrasonic piezoelectric system was also used (OT12 tip). All apices were cut perpendicular to the long axis of the roots to completely remove any possi- ble ramiﬁcations and branching of the root canal system. With ultrasonic tips P1 and P1T (Helse Ultrasonic), the retro- preparation was performed. The root canals were retro-ﬁlled with Bio-C Repair (Angelus). Material insertion at the retro- cavity was facilitated by product consistency and its ready- to-use, premixed presentation. There was no need for speciﬁc instruments or applicators to ﬁll the retro-cavity. With this step done, to avoid connective tissue growth into the osseous defect, the apical bone cavity was ﬁlled with surgical calcium sulphate (New Osteo, GMReis; Fig. 5). Postoperative images were obtained at baseline and at four months, when it was possible to observe complete bone repair (Figs. 6–12). Discussion The operating microscope, ultrasonic inserts and bio- active retro-ﬁlling materials, associated with technological and scientiﬁc advances, increased the positive outcomes of this type of treatment from 60% to over 90%. 7 8 Fig. 7: Four-month post-op tomogram of tooth #27. Fig. 8: Four-month post-op tomogram of the mesiobuccal root of tooth #27. roots 2 2021 25
| case report 9 11 10 12 Fig. 9: Four-month post-op tomogram of the distobuccal root of tooth #27. Fig. 10: Four-month post-op tomogram of tooth #26. Fig. 11: Four-month post-op tomogram of the mesiobuccal root of tooth #26. Fig. 12: Four-month post-op tomogram of the distobuccal root of tooth #26. Selection of the retro-ﬁlling material is essential for success.14 Besides ﬁlling the site, the substance must protect the surgical wound, be radiopaque, bioco m- patible, impermeable, antimicrobial and osteocon- ductive, and behave optimally in moist environments. Products such as Cavit (3M ESPE), zinc oxide eugenol, calcium hydroxide, amalgam, gutta-percha, tricalcium phosphate and hydroxyapatite have been used to seal retro-cavities.15 However, none of them was able to re-establish the original architecture of the affected sites.16 The introduction of bioactive sealers, such as MTA (the precursor of the bioceramic group), brought great prog- ress regarding sealing properties and biocompatibility. MTA presents the most desired features of a reparative substance: it is biocompatible with tissue and stimulates new formation of cementum, has outstanding behaviour in moist conditions, induces biomineralisation and pro- motes greater sealing than all other materials.15–17 However, MTA has two inconveniences: handling and tooth staining. Both are no longer any trouble with the launch of a new generation of bioceramic products. These offer all the biological characteristics of MTA, but improved consistency and presentation too. Bio-C Repair is an example of these new products that facilitate clinical handling. It is premixed and ready to use, and its consistency enables easy shaping with a spatula, facil- itating cavity insertion. The other relevant feature is that Bio-C Repair does not stain the tooth or the surround- ing tissue.18–25 Conclusion The synergy of clinical microscopy and ultrasonic devices enables the execution of extremely precise treatments. Endodontic microsurgery, when performed according to modern concepts, is a remarkable therapeutic alterna- tive, being predictable and viable for the conservation of teeth with secondary or persistent periapical periodon- titis. A new generation of premixed bioceramic products simpliﬁes retro-ﬁlling procedures and may elicit quicker and complete apical bone repair. Editorial note: A list of references is available from the pub- lisher. This article was ﬁrst published in the US in issue 1/19 of roots—the international CE magazine of endodontics. about Dr Leandro Pereira is a specialist in endodontics, operating microscopy and inhalation sedation and has a master’s degree and doctorate in pharmacology, anaesthesiology and drug therapy from the University of Campinas in Brazil. He is a lecturer in the department of endodontics at São Leopoldo Mandic university at its Campinas campus and coordinator of the photography in dentistry programme at the university’s Belo Horizonte campus and of the endodontic microsurgery programme at the Brånemark Osseointegration Center in São Paulo. He is a member of the American Association of Endodontists. 26 roots 2 2021
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| case report Aesthetics in endodontic microsurgery Dr Philippe Sleiman, UAE Endodontic microsurgery is the last resort in dealing with very speciﬁc pathology in endodontics in order to save the tooth. A major consideration is the ﬂap design and the aesthetics, especially in the anterior zone, and sometimes things can be more complicated with the presence of crowns and veneers. The initial status of the gingiva, whether healthy or inﬂamed, and whether there are pockets or not, can inﬂuence our ﬂap design, after a careful analysis of the bone situation. Usually, a hori- zontal incision on the gingiva leaves a scar, and a multi- ple ﬂap design has a horizontal cut design, a technique that I seek to avoid. The absolute concern is the papilla and the cervical area around the teeth, and this one of the major keys of success in aesthetic consideration in microsurgery. The incision should be clean and parallel to the axis of the tooth and as close as possible to the tooth. This area should be elevated with the same motion as cutting, using a small, ﬂat microblade (Fig. 1), and this area should not be touched again or scraped when elevating the ﬂap. All the ﬁbres and microﬁbres must be preserved in order to have a fast recovery later and reattachment of those ﬁbres that will lead to almost immediate stabilisation and prevent a drop of the gingiva in this area. The second and equally important step is management of the papilla. Using the same blade, one needs to enter 1a 2a 2c 1b 2b 2d 3a 3b 3c 3d Figs. 2a–3d: Case 1. Fig. 2a: Pre-op. Fig. 2b: 3-month follow-up. Fig. 2c: 4-year follow-up. Fig. 2d: 6-year-follow-up. Fig. 3a: Pre-op. Fig. 3b: 2 years. Fig. 3c: 4 years. Fig. 3d: 6 years. 28 roots 2 2021
case report | into the interproximal area to go as deep as possible to the palatal area, if working in the maxilla, from both sides and to elevate the papilla with the tip of the triangle intact (Figs. 1a & b), and it must remain intact. The area in which the ﬂap has been elevated, especially around the tooth, should be kept hydrated so that the ﬁbres can remain in a good condition. Replacing the ﬂap in its original place is crucial. Using a modiﬁed technique will allow replacement of the ﬂap and the papilla with slight force, directed coronally that will keep the papilla and the ﬂap in their original places and prevent them from dropping, for the best aesthetic results. Case 1 The patient presented to the ofﬁce with a swelling in the maxillary anterior (Figs. 2a–d). According to the patient, she had undergone a previous surgery in the area to treat a cyst, and she was told that bone grafting was performed. We placed a gutta-percha cone that led us to the infected area. The radiographs (Figs. 3a–d) and the i-CAT scan (KaVo Kerr) showed us that the pathology was around the apical part of the teeth, one amalgam retro- grade ﬁlling had been placed and the area of the bone grafting did not seem right. The patient was very con- cerned about the aesthetics, as she had veneers and did not plan to have them replaced. This added to the challenge of treatment with such inﬂamed gingiva. The surgery was redone, and the three-month follow-up radiograph and photograph (Figs. 2a–3d) showed great results: the gingiva seemed to be healthy and in place. The six-year follow-up photograph showed the stability of the results and the radiograph the bone healing. Case 2 The patient was referred to our ofﬁce suffering from swell- ing and pain in the anterior area. According to the pa- 4b 4d 4c 4e 4a Figs. 4a–e: Case 2. tient, she had had the same episode six months before and root canal therapy was done on the lateral incisor. The clinical examination revealed a swelling on top of both the central and the lateral incisor and that a crown had been placed on the central incisor. The radiographs revealed the presence of a large radiolucency in proximity to the nerves and little residual bone (Figs. 4a–e), around 3 mm on the buccal plate between the lateral incisor and the canine. The central incisor had previously undergone apicectomy and had a very large post that would have made retreatment very tricky. A zero apicectomy for the lateral incisor and a normal apicectomy redo for the central apicectomy were per- formed. The postoperative follow-up showed a great result for the papilla, beautiful conservation of the aes- thetics and complete bone healing (Figs. 5a–c). Case 3 The patient was referred owing to failed root canal ther- apy, but this was a misdiagnosed case (Fig. 6), as she was suffering from lateral root resorption alongside a cyst in the apical area above the lateral and the central inci- sor. This infection developed, causing swelling inside her 5a 5b Figs. 5a–c: Case 2. Fig. 5c: 18 months post-op. 5c roots 2 2021 29
| case report 6 7 8a 8b 9a 9b 9c Figs. 6–9c: Case 3. Fig. 8b: 18-month follow-up radiograph. Fig. 9a: 1-month follow-up. Fig. 9b: 3-month follow-up. Fig. 9c: 18-month follow-up. upper nostril (Fig. 7), and after consulting with an oto- rhinolaryngologist, she was referred. A zero apicectomy and root canal retreatment were performed, and the lateral resorption was addressed, continually bearing the aes- thetics in mind. The one-, three- and 18-month follow-up showed complete bone healing and stable resorption with periodontal ligament formation (Figs. 8a & b) and a beautiful smile (Figs. 9a–c). 10a 10b Case 4 This case was one of the most challenging regarding the aesthetic concerns, as the patient had previously under- gone two endodontic surgeries that had failed, and re- treatment involving a complete redo of her crowns and smile was required. The status of the gingiva was not en- couraging for any intervention, as the consequences can be unpredictable. The patient was put on mild antibiotics for one week in order to lower the inﬂammation or infec- tion, followed by gentle cleaning and change of crowns to temporary crowns. This was followed after 48 hours by a long treatment involving redo of the microsurgeries and zero apicectomies combined with root canal retreatment. The major challenge was to manage the gingiva and the non-existent papillae. The eight-month follow-up showed superb bone healing and a new smile (Figs. 10a–d). Conclusion Microsurgery in endodontics is both challenging and satisfying. Following protocols can assure successful treatment outcomes. about Dr Philippe Sleiman is an assistant professor at the Faculty of Dental Medicine of the Lebanese University in Beirut in Lebanon and an Adj. Prof. at UNC University of North Carolina. 10c 10d Figs. 10a–d: Case 4. Fig. 10c: Immediate post-op. Fig. 10d: 8-month follow-up. 30 roots 2 2021
is coming to PRAGUE 26–29 May 2022 Prague, Czech Republic www.ROOTS-SUMMIT.com 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 18.5 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 International GmbH.
| case report Restoration of an endodontically treated tooth using a composite bilayer approach Dr Katja Winner-Sowa, Germany Introduction Case presentation Endodontically treated teeth often suffer substantial tooth loss owing to extensive caries, previous restorative treat- ment and the endodontic access itself. Their outcome does not depend solely on the obturation of the root canals but also on the quality of the coronal restoration. The residual sound tooth structure is of utmost impor- tance here. Consequently, the maximum preservation and conservation of enamel, dentine and the cemento- dentinal junction, not only upon restoration but also in the long term, deserve maximal attention. In this case report, a composite bilayer approach with a short-ﬁbre- reinforced composite is described as a modern postless adhesive alternative. After tooth #26 had undergone root canal therapy be- cause of irreversible pulpitis, a large and deep mesio- occlusal cavity was left (Fig. 1). Even though there was considerable loss of tooth structure, the remaining walls were sufﬁciently thick to opt for a direct restoration. This was also the most minimally invasive approach, as no tooth substrate needed to be sacriﬁced to shape the cavity. To support the remaining tooth structure and improve the durability of this restoration, a composite bilayer approach was used. The core of the restoration was ﬁlled with a ﬂowable ﬁbre-reinforced composite (everX Flow, GC), while at the surface, a universal composite with high wear resistance (G-ænial A’CHORD, GC) was used (Figs. 2–14). 1 4 2 5 3 6 Fig. 1: After sandblasting with alumina, clean cavity surfaces were left, ready for adhesive treatment. Fig. 2: The enamel margins were etched for 30 seconds with phosphoric acid gel. Fig. 3: The dentine was etched for 15 seconds. Fig. 4: After application of G-Premio BOND (GC). This universal adhesive can be used in three etching modes (in this case: total etch). Fig. 5: To strengthen the remaining tooth structure, the deepest part of the cavity was restored with everX Flow (Bulk shade, GC). Figs. 6 & 7: With a composite instrument, the matrix band was held to the adjacent tooth during polymerisation to ensure a tight contact point. 32 roots 2 2021
case report | 7 10 8 11 9 12 Fig. 8: The mesial wall was built up with G-ænial A’CHORD (Shade A2, GC). This composite has a ﬁne, silky consistency and does not stick to the instrument, which makes it easy to apply. G-ænial Universal Injectable (Shade A2, GC) was used as a liner at bottom of the approximal box. Figs. 9–11: Undermining cavity areas were built up with everX Flow (Dentin shade) to increase the fracture toughness. The cusps were built up one by one with G-ænial A’CHORD. Fig. 12: Finalised restoration. Note that the enamel was still dehydrated. Conclusion about When restoring posterior cavities, it is important to assess the loss of tooth substance and to select the right materi- als to assure a long-lasting restoration. In large, deep pos- terior cavities, the load-bearing capacity can be increased by using a ﬁbre-reinforced composite (everX Flow) in a suf- ﬁciently thick layer, covered by a conventional composite. The function of the overlying conventional composite is to give a wear-resistant surface and to provide surface gloss and aesthetics. G-ænial A’CHORD with its simpliﬁed uni-shade system and good handling and mechanical properties is the perfect all-rounder for this purpose. Editorial note: A list of references is available from the publisher. Dr Katja Winner-Sowa ﬁrst graduated as a dental technician in 2001. Soon thereafter, she started her dental studies and graduated in 2007 as a dentist from Goethe University in Frankfurt am Main in Germany. In 2012, she ﬁnished her habilitation qualiﬁcation at the University of Westphalia in Germany. She works as a dentist in Münster, where she has had her own private practice since 2012. In 2013, she obtained a master’s degree in endodontics from the Düsseldorf Dental Academy in Germany. 13 14 Fig. 13: After the occlusion check. Deﬂective contacts were removed. Fig. 14: After polishing with EVE points (EVE Ernst Vetter). A remarkably high gloss could be obtained with minimal polishing, and the shade blended in very well after rehydration. roots 2 2021 33
news | 3 Fig. 3: The in situ denture models show the enamel and composite slabs which were used in the University of California, San Francisco clinical trial. a clinical trial that tested the antibacterial composite in 25 patients who wore mandibular partial dentures with acrylic ﬂanges on both sides of the mouth.7 The research- ers recessed a human enamel slab and a composite sep- arated by a tiny gap into the ﬂanges, employing Inﬁnix in one ﬂange and a standard composite as a control in the other. The participants were not aware of which side of the denture contained which composite. This gap model simulated a faulty tooth–restoration interface and then exposed it to cariogenic challenge. After a four-week wearing period, samples were as- sessed in the laboratory using cross-sectional micro- hardness testing of the enamel. The UCSF researchers found that the average mineral loss for the Nobio side was signiﬁcantly lower (nearly 70%) than for the control side in every patient. key opinion leaders around the world, and according to Prof. Weiss, the feedback has been very positive so far. Perhaps, it is rather paradoxical to ask Prof. Weiss where he thinks the future of dental materials is heading, since it seems that he and his team have just set a new gold stan- dard, but for him, the vision is very clear: “We want every possible material to be equipped with Nobio technology so that patients can beneﬁt from this new generation of mate- rials that can shift the balance towards remineralisation and health.” Indeed, Prof. Weiss conﬁrmed that the company is already working on core build-up materials used in root canal therapy. Orthodontic cements and PMMA-based resins for partial and complete dentures are next on the agenda. Editorial note: A list of references is available from the publisher. Welcome to the future about In late summer 2020, the start-up, which Prof. Weiss founded in 2015 with Dr Julia Rothman, received FDA clearance to commercially distribute Inﬁnix. Reporting on this achievement, local online newspaper the Times of Israel concluded that the clearance “gives Nobio access to the [US] $1.4 billion dental materials market”. In his interview with DTI, Prof. Weiss said that the COVID-19 pandemic had changed the original roll-out plans for the products. Inﬁnix was to have been made available at the end of 2020 in Israel and the US, but that was changed to spring 2021. In the meantime, free prod- uct samples have been distributed to many practising Besides his role at Nobio and many other positions during his career, Prof. Ervin Weiss has trained hundreds of students of dentistry and dental research, published over 150 research articles, and presented more than 200 lectures, abstracts and research studies at international conferences in Israel and abroad. He holds ﬁfteen patents in the ﬁelds of dentistry and microbiology. He lives and works in Tel Aviv in Israel, where he runs a dental ofﬁce specialised in oral rehabilitation together with Dr Michal Dekel-Steinkeller. roots 2 2021 37
opinion | Besides causing discomfort, back pain caused by incorrect posture and positioning may also undermine clinicians’ conﬁ dence and affect treatment outcomes. do not have enough conﬁdence to correct their posture and positioning, and therefore the incorrect posture and positioning will remain. For the last seven years, I have paid special attention to the topic and discovered some interesting facts. For ex- ample, I now know that the wearing of glasses is one of the main factors affecting posture. Regular reading glasses, provided by an ophthalmologist, have a 22−25 cm focus point. Therefore, the student or practitioner maintains the recommended distance in order to see clearly. Asking for new glasses with a focus point of about 40−45 cm is an easy solution that could help tremendously. Another interesting fact is that practitioners know better than anyone that they have incorrect posture and posi- tioning, yet they do not know how to correct it. The lack of conﬁdence does not allow them to challenge their habits on their own, and so they often seek help. Choosing the right dental care unit Being a member of the dental community, I realised that the ﬁrst step for many professionals who suffer from back pain is getting a new patient chair. I contacted Planmeca, a well-known dental unit manufacturer based in Helsinki in Finland, to explore its opinion on the topic. Planmeca offers a selection of dental care units with many different conﬁgurations. Discussing the issue, Planmeca Senior Vice President Jukka Kanerva explained that the com - pany’s product philosophy has always been that its equipment needs to adapt to the user’s ways of working, not the other way around. Planmeca is a global company, and its products are dis- tributed in over 120 countries. In order to successfully function in all these markets, the company’s dental units have to adapt to different market requirements. “For ex- ample, the preferences of Japanese dentists differ greatly from those of their French colleagues. People come in different shapes and sizes, and dentists like different types of instrument delivery systems,” Kanerva explained. “Also, some like to treat their patients while sitting down, some while standing. This means that the design of the dental unit needs to adapt to several different variables. For this reason alone, our Planmeca Compact i5 dental unit has an almost unlimited number of different cus- tomer conﬁgurations available. All our units can also be customised for left-handed users,” he continued. As we can see from Planmeca’s response, manufac- turers are happy to provide practitioners with what is needed. Kanerva assured me that Planmeca follows ergonomic guidelines and studies closely since these are the backbone of its product development process. He commented: “We (Planmeca) also gather feedback from our customers by using many different methods, such as clinic visits by our usability specialists and trade show visits by our sales staff.” “Of course, anyone can submit their ideas through our website, and these submissions are saved in our data- base and analysed. The most common requests are those pertaining to a particular way of working, and these vary from country to country. Ease of use and ergonomics are the key attributes that dentists around the world are roots 2 2021 43
| opinion Planmeca dental chair production in Helsinki in Finland. looking for. We are constantly following trends and devel- opments in the industry.” He also added that Planmeca has several qualiﬁed in-house dental professionals who help improve the daily dental workﬂow from a clinician’s point of view. Additionally, the company says that it tests its products in cooperation with dental clinics. So what, then, are the main factors that a dental unit manufacturer has to consider? “There are several key requirements regarding the design and manufacturing of dental units. First of all, wide and smooth movements of instrument delivery are crucial be- cause the unit needs to adapt to different working posi- tions. Wide movement range of the patient chair as well as the shape of the chair’s backrest are also important since they help to ensure that the clinician can get as close to the patient as possible and ﬁnd and maintain the best working position,” Kanerva explained. “In order to maintain an ergonomic way of working while treating a patient, all necessary equipment and instru- ments need to be close by, with the instruments always in the peripheral vision of the practitioner. In this way, hand and arm movements can be limited to the ﬁngers, wrist and elbow, and larger shoulder and torso move- ments can be avoided. We have also designed special mid-bending instrument arms that further contribute to an ergonomic workﬂow since they make instruments especially light to use.” As we can see from the manufacturer’s explanations, it is in its interest to listen to practitioners’ requirements. How- ever, statistics demonstrate that many clinicians are still suffering from back pain. Many dentists who do not know how to manage back pain try to work in a standing or a different sitting position, which, unfortunately, is reported to lead to more intense pain, especially in the upper and lower back areas. Having said that, there are some sit- uations where practitioners should stand to perform the required tasks. These include when extracting a tooth and when taking impressions. Maintaining the correct posture Maintaining a good posture helps practitioners achieve superior outcomes and protects them from future prob- lems such as back pain. It allows the practitioner to see the working area properly, which optimises perfor- mance and minimises the risk of iatrogenic damage. Contrary to popular belief, keeping the eyes closer to the working area does not help the clinician to have better control of a handpiece. In fact, being too close to the target area, less than 25 cm away, will not only decrease the level of accuracy but will also create dis- comfort for the patient. When talking to practitioners, I realised that many of them are turning to self-help sources. I found out that these sources are relatively expensive and written in a very general manner. To help clinicians, I spent nearly three years with both right- and left-handed students and practitioners to create and publish a textbook named Pos- turedontics. This textbook aims to show the best position and posture for treating each tooth surface area. The book was published a few years ago and has received excellent feedback. Some practitioners mentioned that it is difﬁcult to use the book at ﬁrst, but as soon as you understand it, you beneﬁt from it. In most cases, if a practitioner needs to move his or her head or change posture, he or she has not been able to see the working surface area correctly during the proce- 44 roots 2 2021
| manufacturer news High-quality microscope solutions Heads-up dentistry now within reach of all clinicians high-deﬁnition recording system allows clinicians to document and share procedural information. Zumax’s microscopes also allow the clinician to bypass the oculars for heads-up viewing in either 4K or 3D, eliminating musculoskel- etal strain from poor ergonomics. Visualisation is easily extended to a smartphone device for real-time viewing and sharing of treat- ment details with patients and other clinicians. “We are excited to bring this microscope technology to physicians all over the world,” said Karl Wang, CEO of Zumax. “As a medical technology manufacturer working closely with clinicians around the world, we’ve engineered the latest high-tech features into a sleek, modern design.” At the beginning of 2021, Zumax launched three new models: the OMS2380 R2, the OMS3200 R2 and the OMS3200 PRO. For more information, please contact firstname.lastname@example.org. About Zumax Medical Founded in 2005, Zumax Medical is a professional manufacturer of medical optical instruments located in Suzhou in China. The company was awarded the Chinese National High-Tech Enterprise designation in 2013. Zumax provides products for various ﬁelds, including dentistry, ophthalmology, otorhinolaryngology, head and neck surgery, and community and general medical practice. In the dental arena, Zumax is a standing member of the professional board of dental equipment and technology branch of the China Association of Medical Equipment, a member of the academic committee of dental equipment branch of the Chinese Stomatology Association and a member of the China Association for Medical Devices Industry. www.zumaxmedical.com/dental-microscope Operating microscopes provide complete visualisation inside a patient’s tooth with up to 29× magniﬁcation and integrated LED illumination. According to the American Association of Endodon- tists, higher magniﬁcation, especially through the use of a micro- scope, improves treatment outcomes and should be the standard for all dentists performing endodontic procedures. The potential for microscopes to transform the dental industry is tremendous. All clinicians who want to provide the highest level of patient care, grow their practices through new and improved procedures, and extend their careers with heads-up viewing and better ergonomics will beneﬁt from higher magniﬁcation through a microscope. Now, the latest generation of this technology is within reach for all areas of dental care. Zumax Medical’s microscopes are known for their superior high- deﬁnition optics, smooth balancing arms and economical pricing. A six-point magnetic arm enables the microscope to move ﬂuidly at the push of a button and stabilise upon release. An integrated
manufacturer news | The Jeni endodontic motor goes on tour COLTENE travels through Germany with its new workshop programme If you are thinking about buying a new car, you usually try out the object of your desire ﬁrst, with a test drive. It is much the same when it comes to the fully automatic Jeni endodontic motor from COLTENE, the international dental specialist: dentists can conveniently test- drive the assistance system at a location near them—from a short trip around the block all the way to a day-long road test. Trip around the block or road test? The innovation leader in Germany is taking the new CanalPro Jeni endodontic motor on the road in spring for its major city tour. Because the coronavirus restrictions still pose major challenges for dental practices, COLTENE is offering a new format for further education and training: at a number of locations across the country, dentists will have the opportunity to test-drive the Jeni endodontic motor at a time and place that suits them. In addition to 15 original dates, the company has already announced others. After starting in Germany, the tour will be extended to Europe in the autumn. The choice is between a short test drive of the assistance system as part of a 2.5 hour introduction or an extended road test, that is, a full-day seminar. Both workshops will be led by renowned and expe- rienced endodontic specialists and the COLTENE team of experts and address the special features of the intelligent endodontic motor. While mechanical reprocessing is now an established standard in endodontic practices, CanalPro Jeni works differently to ﬁling motion options known to date and navigates independently through the treatment. Here there are a number of popular sequences to choose from for the ﬂexible nickel–titanium (NiTi) ﬁles. The user works forwards continuously from the coronal to apical aspect, applying only slight pressure, while the motor decides on the progress of motion. Based on complex algorithms, the software can control the variable ﬁling motions at millisecond intervals by constantly regulating rotational motion, speed, torque and ﬁle stress. This makes the treatment even safer and therefore more comfortable. Endodontic innovations live The course will start with an introduction to the new Jeni repro- cessing system with HyFlex CM and EDM NiTi ﬁles. This will be followed by some theory and then a practical session, including numerous hand-on exercises on a practice block and tooth. This way, even endodontic beginners will soon become competent and efﬁcient at reprocessing with the Jeni. Dentists will also receive all relevant information for billing endodontic treatments correctly, proﬁtably and in accordance with legal requirements. To see what dates are currently available please go online to: events.coltene.com. The previous webinars on CanalPro Jeni and the HyFlex and MicroMega ﬁle systems can be accessed at any time from the COLTENE webinar archive: COLTENE Mediathek | GoToStage.com. An informative explanatory video on the COLTENE YouTube channel provides an introductory insight into the endodontic motor function- ality: https://youtu.be/Qw3uc3hSTkg. In addition, the COLTENE team of experts is available at all times to advise and support dentists, dental technicians and practice staff. You can contact them via e-mail (email@example.com) or through one of the social media channels, where you will ﬁnd questions and answers about speciﬁc use or support for optimal application and combination of dental materials and tools. www.coltene.com roots 2 2021 47 Jeni educational videoColtene events
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