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| content page 08 editorial ROOTS SUMMIT 2020 2021 2022! Steve Jones ROOTS SUMMIT special ROOTS SUMMIT “is not to be missed” An interview with Dr Gianluca Plotino ROOTS SUMMIT 2022— “I can’t wait to experience the best endo meeting again” An interview with Dr Jenner Argueta ROOTS SUMMIT means “practical lectures, enough time for the topics, no need to skip anything” An interview with Dr Daniel Černý Lecture programme, abstracts and speaker information case report Automatic assistance: Freedom to navigate root canals Prof. Eugenio Pedullà page 24 Digital technology in endodontics Dr Bartlomiej Karaś Root canal therapy of necrotic primary molars— using a single-file reciprocating system Drs Benjamín Rodríguez & Jenner Argueta technique High-end technology for simplicity Adj Prof. Philippe Sleiman page 30 The golden era of root canal shaping Dr Ahmed Shawky interview Laser protocol for peri-implantitis treatment An interview with Dr Michał Nawrocki “The correct choice of an animal model is vital” An interview with Dr Alexis Gaudin research The key role of vitamin D in immune health and regeneration Prof. Shahram Ghanaati, Dr Karl Ulrich Volz & Dr Sarah Al-Maawi manufacturer news meetings International events about the publisher submission guidelines international imprint Cover image courtesy of FKG (www.fkg.ch). issn 2193-4673 • Vol. 18 • Issue 1/2022 roots international magazine of endodontics 1/22 including special interview ROOTS SUMMIT “is not to be missed” case report Automatic assistance: Freedom to navigate root canals technique High-end technology for simplicity 04 roots 1 2022 03 06 07 08 10 20 24 30 36 38 42 46 48 54 56 57 58

| ROOTS SUMMIT special ROOTS SUMMIT “is not to be missed” An interview with Dr Gianluca Plotino By Franziska Beier, Dental Tribune International For your hands-on course, which will focus on how to use different fi les for root canal anatomy, you encourage participants to bring well-preserved ex- tracted teeth to practise on. What instruments and clinical techniques will participants get to know during your workshop? During my workshop, the clinical procedures for treating root canals having various diffi culties will be explained and demonstrated on resin teeth in order to show the standard clinical techniques and the use of various instruments. I encourage all participants to bring natural teeth because trying the instruments on extracted teeth that have open access cavities will give them a better overview of the performance of the tools. I will show them how to integrate the reciprocat- ing instruments R-PILOT (VDW) and RECIPROC blue (VDW) and the VDW.ROTATE rotary fi les into their practices. 4 DAYS OF ENDODONTICS 12 LECTURES Dr Gianluca Plotino register at www.roots-summit.com 14 HANDS-ON-COURSES Could you briefl y summarise your lecture on mini- mally invasive approaches in endodontic procedures and tell us what the take-home message for attend- ees will be? Following the trend of minimally invasive dentistry, the concept of minimally invasive endodontics emerged. However, I prefer to call it anatomically invasive endodontics as all endodontic procedures must be guided by the original root canal anatomy. In my lecture, I will describe how to fi nd a good balance between maximising the preservation of the tooth structure and keeping endodontic procedures safe and effi cient. What are you personally looking forward to at the upcoming ROOTS SUMMIT? All lectures given by my colleagues and friends deserve to be followed with the utmost attention, and I will be there to learn. In addition, I will be happy to see so many friends in person after such a long time! Can you name three reasons why everyone inter- ested and involved in endodontics should come to the event? It’s one of the most important endodontic events of the year, one of the fi rst to take place as an in-person event after a long time, and it has a great scientifi c, cultural and social offering. It is not to be missed! ROOTS SUMMIT, one of the most exciting endodontic events of this year, will kick off in May in Prague in the Czech Republic. One of the speakers will be Dr Gianluca Plotino, who will contribute to the rich programme with a hands-on course and a lecture. In this interview, Dr Plotino, who maintains a private practice specialising in endodontics and restorative dentistry in Rome in Italy, gives a preview of his congress topics and explains why endodontists should attend the event. Dr Plotino, you will be very busy at this year’s ROOTS SUMMIT, as you will present two different topics. What do you fi nd most rewarding about teaching? I love it when people thank me and tell me that my sug- gestions, tips and tricks have changed their professional lives! That is a priceless experience! 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. 06 roots 1 2022

| ROOTS SUMMIT special ROOTS SUMMIT means “ practical lectures, enough time for the topics, no need to skip anything” An interview with Dr Daniel Černý By Franziska Beier, Dental Tribune International 4 12 14 DAYS OF ENDODONTICS LECTURES HANDS-ON-COURSES Dr Daniel Černý register at www.roots-summit.com Dr Daniel Černý, who has been the president of the Czech Endodontic Society since 2015, is one of many renowned and enthusiastic speakers at this year’s ROOTS SUMMIT. Ahead of the event, Dental Tribune International spoke with Dr Černý about what visitors can expect from the city of Prague and from his lecture topic and asked him how he applies the things he has learned at ROOTS SUMMIT in his daily practice. But if you want to delve a little deeper, I recommend visiting Prague Botanical Gardens on an early morning in May. From there, you can climb up to the historic Vyšehrad Fortress to sense a bit of early Prague history and enjoy the great views. Afterwards you can casually stroll through the winding streets of the Praha 1 district with its small shops, restau- rants and cultural institutions. Dr Černý, this year’s ROOTS SUMMIT will take place in your home country. Can you tell us a bit about the event venue and also about Prague itself? What are three city highlights which international participants should not miss? I am excited about ROOTS SUMMIT coming to Prague. There are those highlights you can fi nd in every guide, such as Charles Bridge, the astronomical clock in Old Town Square or Prague Castle, and they are certainly worth a visit. The congress venue is quite new and technologically ad- vanced, and I believe the ROOTS community will enjoy it as much as I did last year when the annual meeting of the Czech Endodontic Society was held there. Together with Dr Radek Mounajjed, you will hold a lecture on the advanced adhesive endodontic/restorative concept. What can attendees expect to take away from it? 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. 08 roots 1 2022

| ROOTS SUMMIT special Lecture programme ROOTS SUMMIT 2022 Day 1: Thursday, 26 May 2022 Day 3: Saturday, 28 May 2022 8:30–16:30 The fi rst day is designated for hands-on coursework Day 2: Friday, 27 May 2022 8:30–10:00 Digital planning in intentional replantation and auto-transplantation Dr Francesc Abella 10:45–12:30 Large lesions: Endodontic or surgical treatment Dr Catherine Ricci 13:30–15:00 Bioceramics in endodontics Dr Meetu Ralli Kohli 15:45–17:15 Endodontic microsurgery: Management of complex cases Dr Jaime Silberman 8:30–10:00 Root to crown: Advanced adhesive endodontic/restorative concept Drs Daniel Černý & Radek Mounajjed 13:30–15:00 Evidence-based treatment choices in modern endodontic treatment Dr Igor Tsesis 15:30–17:00 Endodontic algorithms in decision-making and clinical workfl ow Dr Roberto Cristian Cristescu 17:15–18:45 Two-dimensional vs 3D endodontics Prof. Gianluca Gambarini Day 4: Sunday, 29 May 2022 8:30–10:00 Minimally invasive approaches in endodontic procedures Dr Gianluca Plotino 10:45–12:30 Irrigation and disinfection of the root canal Prof. Matthias Zehnder 13:30–15:30 The art of endodontics in the age of MIE Dr Stephen Buchanan Please visit www.roots-summit.com for the ROOTS SUMMIT 2022 programme. 10 roots 1 2022 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

| ROOTS SUMMIT special Speakers ROOTS SUMMIT 2022 Dr Francesc Abella (Spain) Dr Francesc Abella graduated in 2005 in dentistry from the Universitat Interna- cional de Catalunya, Barcelona, Spain. From 2005 to 2014, he com- pleted his master’s degree and PhD in endodontics at the same university. He works in a private practice limited to endodontics and restorative dentistry in Barcelona, and in clinical endodontics, his areas of special interest include CBCT in endodontics, microcomputed tomogra- phy, dental anatomy, dental traumatology, periapical pathology, adhesive restoration and restoration of endodontically treated teeth. Besides his work in private practice, he is involved in endodontic re- search projects in the postgraduate endodontic programme of the Universitat Internacional de Catalunya. Over the years, Dr Abella has given several lectures and hands-on courses worldwide. He is the author of several papers in peer-reviewed journals and part of the expert committee convened by the European Society of Endodontology on the use of CBCT. Dr Abella is also an active member of the Asocia- cion Española de Endodoncia [Spanish association of endodontics] and the secretary of the Sociedad Española de Odontología Conservadora y Estética [Spanish society of conservative and aesthetic dentistry]. Dr Stephen Buchanan (US) Dr Buchanan re- ceived his dental degree in 1978 from the University of the Pacifi c Arthur A. Dugoni School of Dentistry in San Francisco, US. In 1980, he completed the endodontic graduate programme at Temple University in Philadelphia, US. He began pursuing 3D anatomy research early in his career. In 1989, he established Dental Education Labora- tories, a state-of-the-art training facility devoted to hands-on instruction where he still teaches end- odontic treatment, retreatment and segmented fi le retrieval. Early in his career, Dr Buchanan identifi ed the power of video and fi lm media in training and produced the award-winning video series, The art of endodontics. Dr Buchanan also holds a number of patents for dental instruments and techniques. Most notably, he was the fi rst dentist to introduce 12 roots 1 2022 Please visit www.roots-summit.com for the ROOTS SUMMIT 2022 programme.

| ROOTS SUMMIT special Dr Meetu Ralli Kohli (India/US) Dr Meetu Ralli Kohli earned her BDS from the Government Dental College and Research Institute, Bangalore, India, and pursued her DMD and specialty train- ing in endodontics at the University of Pennsylvania, Philadelphia, US. During the course of her training, she received the esteemed Louis I. Grossman Award, Samuel R. Rossman Scholarship and Sherrill Ann Siegel award and scholarship for demonstrating excellence in patient care, clinical skills and research. She is Clinical Associate Professor of Endodontics and the Director of the Continuing Education and International Programme at the Department of Endodontics of the University of Pennsylvania School of Dental Medicine. She also maintains a part-time private practice limited to endodontics in Pennsylvania. Dr Kohli has published in national and international peer-reviewed journals and has contributed to books on microsurgical retreatment. Her publications have been recognised as best clinical research papers by the Journal of Endodontics. She is on the scientifi c advisory board as a reviewer for the Journal of Endodontics, International Endodontic Journal and Quintessence International, and is the associate editor of the Color Atlas of Microsurgery in Endodontics. Dr Kohli has served on the American Association of Endodontists Constitution and Bylaws Committee and currently serves on its Research and Scientifi c Affairs Committee. She is a diplomate of the American Board of Endodontics and an examiner for the Indian Board of Endodontics. Dr Radek Mounajjed (Czech Republic) Dr Radek Mounajjed graduated from the Damascus University Faculty of Dentistry, Syria, in 1994. He then completed his residency in general dentistry in 1997 and in prosthodontics in 2000, respectively. He com- pleted his PhD in 2004 at the Charles University Faculty of Medicine, Hradec Králové, Czech Republic. Dr Mounajjed has been working at the multidisci- plinary D.C.M clinic in Hradec Králové as a full-time prosthodontist since 2001, and at Palacký University Olomouc, Czech Republic, as an external teacher since 2012. Dr Mounajjed is the author of many publications and book chapters. He has presented more than 150 talks, both nationally and internationally, and has been invited to speak at Harvard University and Mayo Clinic, both US. On top of that, Dr Mounajjed is the co-founder of HDVI, an accredited dental continuing education centre in the Czech Republic. He is also a fellow of the Academy of Prosthodontics in the US and International College of Prosthodontists. Outside of dentistry, he enjoys building and fl ying radio- controlled model airplanes. Dr Gianluca Plotino (Italy) Dr Gianluca Plotino graduated in dentistry from the Università Cattolica del Sacro Cuore, Rome, Italy, in 2002. He obtained his PhD there in 2009 and received certifi cation as fi rst and second level professor in 2018. Dr Plotino works in his own private practice limited to endodontics and restorative dentistry in Rome. He has received several international prizes, published more than 90 articles in scientifi c peer-reviewed jour- nals on various endodontic and restorative topics, and contributed numerous chapters to textbooks. Plotino is an associate editor of the European Endodontic Journal and the Giornale Italiano di Endodonzia and serves on the editorial board of several other journals. He is a certifi ed 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 and the Italian Society of Conservative Dentistry. Dr Catherine Ricci (France) Dr Catherine Ricci grad- uated from the Univer- sité Paris Diderot (Paris 7) in France in 1983. In the same year, she be- came a certifi ed member of the Société Française 14 roots 1 2022 Please visit www.roots-summit.com for the ROOTS SUMMIT 2022 programme.

| ROOTS SUMMIT special Lecture abstracts ROOTS SUMMIT 2022 Day 1: Friday, 27 May 2022 8:30–10:00 Digital planning in intentional replantation and auto-transplantation Dr Francesc Abella In recent years, primary endodontic treatment, nonsurgical retreatment and microscopical surgery have achieved success rates of around 90%. How- ever, there are situations in which the tooth cannot be saved using these techniques. The fi rst part of this lecture will discuss intentional replantation. 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 cor- rect an obvious radiographic or clinical endodontic failure. It should not be considered a last-resort treatment prescribed only for “hopeless” teeth as proposed by Grossman. Although intentional re- plantation is not a frequently performed procedure, it yields a tooth survival rate of 88% according to a recent meta-analysis. In addition, the new advances in computer-aided rapid prototyping (CARP) models (tooth replicas) and 3D-printed guiding templates allow us to apply this technique in a much more predictable way. In situations where the tooth cannot be saved, there is the option of performing an auto-transplant (both open and closed apex). The complications 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 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. After this lecture, participants should: 1) know the main indications for intentional replan- tation, as well as how to digitally plan the whole process; 2) know the advantages and possible complications of tooth auto-transplantation; and 3) know the indications for the different types of auto-transplantation: fresh extraction sockets, early extraction sockets with soft-tissue healing, early extraction sockets with partial bone healing, and surgically created sockets. 10:45–12:30 Large lesions: Endodontic or surgical treatment Dr Catherine Ricci Lesions are the result of the evolution of apical periodontitis and are due to bacterial proliferation. Sometimes, root canal disinfection allows, with 16 roots 1 2022 Please visit www.roots-summit.com for the ROOTS SUMMIT 2022 programme.

| Xxxxxx | ROOTS SUMMIT special Day 2: Saturday, 28 May 2022 8:30–10:00 Root to crown: Advanced adhesive endodontic/restorative concept Drs Daniel Černý & Radek Mounajjed Long-term data show that survival of nonvital teeth has always been a challenge. Both endodontic and restorative dentistry contribute critically to the treat- ment outcome. The presented concept of care has been developed by both endodontists and prostho- dontists over 18 years of cooperation. It is based on four main ideas common to both fi elds: tissue pres- ervation (unnecessary hard dental tissue loss should be prevented); replacement with similar materials (lost tissue should be replaced with material of sim- ilar physical properties); adhesion (all components of reconstruction should adhere to each other) and safety (when failure occurs, it should not be catastrophic). Over the years, the protocol has been extended from nonvital teeth only to teeth with compromised integrity and challenged vitality. The endodontist delivers a ready-to-use abutment tooth free of pathology for the fi nal reconstruction regardless of the tooth vitality. In this lecture, the decision-making process, material selection, complete workfl ow and long-term outcomes will be presented. After this lecture, participants should be able to: 1) identify clinically relevant factors for reconstruc- tion of nonvital teeth and teeth with challenged vitality; 2) indicate the need for different adhesive tools to construct the build-up of the abutment tooth with fi bre posts and various resin composites; and 3) describe critical details of ideal fi nal restoration considerations. A decision on intervention for an endodontically treated tooth with a periapical radio- lucency should be based on the technical feasi- bility of the treatment, systemic factors and patient values. This presentation will discuss a patient-focused clin- ical decision-making process regarding the manage- ment and preservation of natural teeth based on the principles of evidence-based medicine. After this lecture, participants should be able to: 1) identify the main reasons for the persistence of endodontic disease and possible treatment alter- natives; 2) recognise the possibilities and limitations of modern endodontic treatment; and 3) incorporate an evidence-based approach in the decision-making process on treatment choice. 15:30–17:00 Endodontic algorithms in decision-making and clinical workfl ow Dr Roberto Cristian Cristescu This lecture will focus on some decision-making steps during endodontic clinical procedures in the dental offi ce. The current standard of care requires dentists to base their actions on scientifi c evidence and to be able to put that evidence into clinical practice while keeping in focus the patient’s quality of life during the treatment. We will follow some important guidelines for clinical endodontics and will exemplify them with clinical cases that refl ect the diagnosis and treatment spectrum of a general dental offi ce. After this lecture, participants should: of nonvital teeth. 1) have a clearer decision-making algorithm for their 13:30–15:00 Evidence-based treatment choices in modern endodontic treatment Dr Igor Tsesis The treatment alternatives for apical periodontitis include nonsurgical endodontic retreatment, surgi- cal endodontic treatment, or tooth extraction, and in certain cases, a follow-up protocol may be con- sidered. The long-term prognosis, the alternatives in case of treatment failure, post-treatment quality of life, and patient’s preferences should all be rec- ognised and incorporated in the treatment choice clinical work; 2) be able to understand how to start making their own clinical decision fl owcharts for different endodontic procedures; and 3) have a better understanding of the possible outcomes of different treatment paths. 17:15–18:45 Two-dimensional vs 3D endodontics Prof. Gianluca Gambarini This lecture will address the use of CBCT in end- odontics for diagnosis, the treatment plan, access cavity design, working length determination, man- 18 18 roots roots 1 2022 1 2022 Please visit www.roots-summit.com for the ROOTS SUMMIT 2022 programme.

| case report Automatic assistance: Freedom to navigate root canals Prof. Eugenio Pedullà, Italy Introduction Mechanical root canal preparation with nickel–titanium (NiTi) instruments activated by endodontic motors has made root canal preparation more predictable in the clinical setting, as well as significantly reduced working time and stress on the practitioner. Since the introduction in the late 1980s of cen- tric continuous rotary motion for NiTi files, new mechanised techniques have been proposed with the aim of minimising the risk of fracture of endodontic instruments by exploiting the benefits of different kinematics in endodontic therapy. Thus, trans-axial, eccentric and reciprocating motion were introduced for the activation of NiTi instruments to shape root canals. In particular, reciprocating motion (better classified as partial reciprocation with rotational effect) has asymmetrical angles of rotation in the anti- clockwise and clockwise directions. Continuous rotation and reciprocation have advantages but also disadvantages. Indeed, the former allows easy progres- sion in root canals, but it does not protect the NiTi files from the risk of torsional fracture. Reciprocation increases file fracture resistance, reducing the screw-in effect but increas- ing the possibility of apical debris accumulation or extrusion. Therefore, hybrid motions have been designed to com- bine rotary and reciprocating movements, taking advan- tage of each. Hybrid endodontic motors have just two movements, changing the angle during activation, pass- ing from a complete (360°) rotation to a single asymmet- rical reciprocation with fixed and asymmetrical angles (clockwise differing from anticlockwise) depending on the torsional stress applied to the NiTi file. However, digital technology can facilitate continuous control of the file movement. The CanalPro Jeni end- odontic motor (COLTENE; Fig. 1) allows fully automatic assistance in the shaping of root canals using different rotary motion, angle, speed and torque, automatically changed by the complex and patented algorithms of the motor. Rotary movement, speed and torque are 1 Fig. 1: The fully automatic CanalPro Jeni endodontic motor (COLTENE). 20 roots 1 2022

| case report 3 4 5 Fig. 3: Pre-op radiograph of tooth #35. Incomplete endodontic obturation and a metal post were visible. A radiolucent periradicular lesion was detectable laterally on the distal aspect of the root. Fig. 4: Final radiograph of the endodontic retreatment (with the dental dam still on the tooth) showing complete and compact filling of the endodontic space, including the filling of a lateral canal and a little extrusion of sealer though it in the site of the lateral radiolucent lesion. Fig. 5: Follow-up radiograph at one year of the endodontic retreatment of tooth #35. Healing of the lateral radiolucent lesion confirmed the success of the endodontic retreatment performed with HyFlex Remover and EDM files activated by CanalPro Jeni. Case 1 In this first case, periapical periodontitis of tooth #35 is pre- sented. The 44-year-old patient was first diagnosed with acute pulpitis of a mandibular premolar in 2017. Tooth #35 received root canal therapy and was then obturated with gutta-percha and sealer and restored with a metal post and composite materials. Unfortunately, the success of the treatment was not long-lasting. In 2020, the patient pre- sented at our practice with acute pain symptoms and pain on percussion or biting. The preoperative periapical radio- graph showed periapical periodontitis even laterally on the distal aspect of the root of tooth #35 (Fig. 3). The patient finally agreed to the necessary endodontic retreatment. The first step in retreatment is the complete removal of inadequate or aged gutta-percha filling. Therefore, after the removal of the composite and metal post with ultra- sonic tips, the 30/.07 HyFlex Remover file (COLTENE), activated by the automatic Jeni motion of CanalPro Jeni, was used for the gutta-percha disassembling procedure. The fast and continuous changes of the movement per- formed by the automatic Jeni motion, combined with the efficiency of the heat-treated HyFlex Remover file, al- lowed fast and safe removal of the previous obturation material. In a recent paper, it was reported that the use of the innovative CanalPro Jeni kinematics accelerates the time for removal of root filling materials.1 Indeed, within seconds, clean access to the apical third was achieved. 15 K-type file. After determination of the working length (WL), the HyFlex EDM file system, activated by the fully automatic Jeni motion of CanalPro Jeni, was used in the single-length technique. Thus, after the 20/.05 HyFlex EDM file reached the WL, the 25/~ HyFlex EDM OneFile and then the 40/.04 file were used to WL. Jeni motion al- lowed the files to reach the WL just by guiding the files in the apical direction and removing the files from the root canal and irrigating on the sounding of the long beep. After this, the reinsertion of the file into the root canal was deeper than the previous depth of insertion, and this procedure was repeated until the WL was reached. In this case, the 20/.05 file reached the WL in one pass, the OneFile in two passes and the 40/.04 file in one pass of the instrument. The 50/.03 HyFlex EDM finishing file was then used to 1 mm from the WL in order to create a stop for the 50/.02 master cone used for the micro-seal thermoplasticised obturation technique. The postoperative periapical radiograph showed perfect adaption of the obturation material used and filling of a large lateral distal canal that probably was the cause of the periapical lesion and symptoms of the tooth (Fig. 4). The one-year follow-up radiograph showed the healing of the periapical lesion, and the patient reported no symptoms during that time (Fig. 5). Case 2 Subsequently, when the untreated part of the root canal was reached, scouting was done with a #10 and A 32-year-old male patient presented at our practice, having been referred to us by his dentist for further endodontic evaluation of pain in the left side of his maxilla. During the 22 roots 1 2022

| case report Digital technology in endodontics Use of dynamic navigation to access and shape canals in teeth with pulp canal obliteration after trauma Dr Bartlomiej Kara ´s, Poland 1 2a 2b Fig. 1: Intra-oral view of the initial situation. Visible discoloration of the right central incisor. Figs. 2a & b: CBCT scan, sagittal (a) and coronal planes (b). Visible pulp canal obliteration and periapical lesion. Introduction Pulp canal obliteration (PCO) is one of the complications which may occur in dental pulp after tooth trauma. It is also one of the mechanisms of pulp healing after trauma; how- ever, pulp necrosis too may occur as a result of trauma. PCO can be recognised clinically as early as three to 12 months after trauma. PCO is an effect of the deposition of hard tis- sue, such as sclerotic or reparative dentine; however, the underlying mechanisms of PCO are still unclear. Oginni et al. report that partial obliteration was present in 56.9% and total obliteration in 43.1% of 276 cases of teeth after trauma, and they suspect that the mechanism of formation of oblit- eration is related to damage to the neurovascular supply.1 The types of injuries mostly responsible for PCO have also been investigated. It was revealed that luxation, subluxation, intru- sion and concussion are the most frequent causes of trauma. In the case of concussion, teeth with developing apices have a better prognosis and a lower likelihood of developing PCO. 3a 3b 3c Figs. 3a–c: Planning of the virtual guide in Navident software (ClaroNav). The axis and depth of the preparation are shown. 24 roots 1 2022 Jacobsen and Kerekes report that, although PCO necrosis and periapical disease are rare, they can occur after many years after the trauma. Bastos and Cortes emphasise that crown discoloration can be present in many cases and can be a first visible factor of PCO. Usually, the colour changes to dark yellow or even grey. Management of PCO owing to a lack of patency can be very challenging for clinicians. Creating a proper access cavity (one that will not sacrifice too much tooth structure) and lo- cating the root canal orifice in the calcified tooth requires experience and additional equipment, like a dental oper- ating microscope. According to Carvalho and Zuolo, using the dental operating microscope increases the probability of finding all the orifices located in the pulp chamber floor. Boveda and Kishen state that creating a constricted access cavity should be very valuable in terms of a long-term prog- nosis, but can require an additional diagnostic protocol, for example capturing a CBCT scan before the treatment. Dynamic navigation Nowadays, thanks to the development of modern technol- ogies, it has become possible to perform treatment more conservatively and more predictably. The Navident dynamic navigation system (ClaroNav) is to a clinician what a GPS is to a driver. Navident uses a stereoscopic camera and marker (or reference) spheres so that the camera can track the movement of the operator. Also the system requires a CBCT scan of the patient and a digital guide, which is de- signed in the Navident software. After designing the guide, the clinician needs to register the patient’s teeth to calibrate the CBCT scan with a special tool (the wand). After regis- tration of the patient’s teeth, the clinician needs to calibrate the drill and the handpiece with dedicated markers. With

| case report 4 5 Fig. 4: Calibration of the Navident device. The tracers and camera are shown. Fig. 5: Intra-op view of the software. the combination of the prepared guide, tracking markers and dynamic tracking of the camera, the dentist can see the actual position of the drill and its angulation with a lag of 0.3–0.5 seconds on the computer screen. According to avail- able data, the accuracy of the equipment is 0.1 mm and 1°, which is significantly better than CAD/CAM-fabricated guides for endodontic treatment. It must be considered that the ac- curacy of the procedure may differ depending on the clinician. Case 1 A 36-year-old female patient came to the dental office with discoloration and pain of the maxillary right first incisor (Fig. 1). In the medical history taking, she reported a trauma approx- imately 15 years earlier. During the radiographic examination in the office of her general dentist, PCO was revealed. She was referred for a CBCT scan and endodontic treatment. During the consultation, the CBCT scan was performed with the 9000 C 3D with a voxel size of 0.1 mm (Carestream). The CBCT scan revealed a highly calcified pulp chamber and an almost invisible trace of the root canal (Fig. 2). The patient was informed about the new, beneficial technol- ogy which can help to preserve additional tooth structure during treatment. Before the treatment, the CBCT scan was uploaded to the software and the virtual guide was planned (Fig. 3). This is one of the most important parts of the protocol because during the treatment the Navident software tracks the handpiece and shows the correlation between the clinician’s work and the already planned guide. If the depth or direction is missed on the guide, there is a very high risk of root perforation. During the clinical procedure, the jaw tracker was placed on the patient’s teeth and fixed with impression material. Registration of the patient’s tooth position and calibration of the CBCT scan was performed with the help of the wand tool. The drill tag was attached to the handpiece, and the calibration of the handpiece and drill was performed with the calibration tool (Fig. 4). After all the registration and 6a 8a 6b 8b 7a 9a 7b 9b Figs. 6a & b: First stage of the access cavity creation (a). CBCT check, sagittal plane (b). The axis of the access cavity was visible. Figs. 7a & b: Hand fi le scouting of the canal orifi ce. Figs. 8a & b: Final preparation (a). The size of the access cavity and of the root canal orifi ce was checked with the #80 hand plugger (b). Figs. 9a & b: Drying the canal before obturation. 26 roots 1 2022

| case report 10a 12 10b 11a 11b Figs. 10a & b: Obturation with gutta-percha (a) and the control radiograph (b). Figs. 11a & b: Occlusal check (a) and the control radiograph of the com- posite seal (b). Fig. 12: CBCT check, sagittal plane. Measurement of the root thickness confirmed the size of the preparation. Healing of the periapical tissue was observed. Fig. 13: CBCT check, sagittal plane. The long axis of the root and the axis of the access cavity and root canal preparation 13 were visible. calibration procedures, the patient, tooth and guide were pre- pared for the access cavity creation. The access cavity was created with the EndoGuide bur (SS White Dental) with the aid of the Navident software. The greatest challenge of the procedure for the clinician is to work simultaneously with the fast-speed handpiece in the tooth and trace the position and angulation of the drill on the computer screen, potentially lead- ing to trouble with coordination in the first procedures (Fig. 5). After reaching the depth of drilling on the prepared guide, another CBCT scan was performed to check the accu- racy of the access cavity (Fig. 6). According to the image, the angulation of the access cavity had changed slightly to the palatal side and the root canal was reached with the #10 K-file (Kendo, VDW; Fig. 7). Shaping of the root ca- nal was performed with Endostar E3 Azure (Poldent) up to size 30/.04. After the shaping protocol, the size of the root canal orifice was checked with the #80 hand plugger, and it was indicated that the size was larger than #80 but smaller than #100 (Fig. 8). The irrigation protocol was per- formed with 5.25% sodium hypochlorite and 40.0% citric acid. Both solutions were activated with EDDY sonic tips (VDW), and sodium hypochlorite was additionally activated with elements free (Kerr) for intra-canal heating. The ca- nal was dried with paper points (Fig. 9) and obturated with warm gutta-percha using the continuous wave technique, and a control radiograph was performed (Fig. 10). The access cavity was sealed with a composite material, and another radiograph was performed (Fig. 11). The recall appointment took place four months after treat- ment. Healing of the periapical tissue was observed. Despite the limitations of the CBCT imaging related to the voxel size (0.1 mm), the size of the access cavity was found to be 1.1 mm ± 0.2 mm, confirming the measurement per- formed during treatment (Fig. 12). Moreover, we could also 14 15a 15b 15c 16a 16b 16c 17a 17b 17c Fig. 14: Intra-oral view of the initial situation. Visible discoloration of the right central incisor. Figs. 15a–c: CBCT scan, sagittal (a & b) and coronal planes (c). Pulp canal obliteration was visible in both teeth, and a periapical lesion was present around the left incisor. Internal resorption in the right incisor was suspected. Figs. 16a–c: Planning of the virtual guide for the right incisor. The axis and depth of the preparation are shown. Figs. 17a–c: Planning of the virtual guide for the left incisor. The axis and depth of the preparation are shown. 28 roots 1 2022

| case report Root canal therapy of necrotic primary molars—using a single-fi le reciprocating system Drs Benjamín Rodríguez & Jenner Argueta, Guatemala Introduction Pulpectomy is a root canal procedure for pulp tissue that is irreversibly infected or necrotic owing to caries or trauma. The root canal pulp tissue is removed, and the canal is commonly shaped with hand or rotary fi les.1 This pro- cedure is the standard of care when normal shedding coupled with the eruption of the permanent successor or long-term tooth retention is the priority goal and evidences a good healing outcome.2 Like in permanent teeth, it is crucial to achieve adequate disinfection in the root canal system of primary teeth.3 Premature extraction of necrotic primary molars leads to space loss, an important oral health concern in children because of the consequent improper arch length and altered successor eruption.3 Therefore, pulpectomy of primary teeth with severe pulp involvement should be considered the treatment of choice when indicated.3, 4 However, it represents a challenge because of the mor- phological complexities of the root canal system, presenting multiple roots, uneven apical resorption, fused roots, two mesiobuccal canals and two distobuccal canals in maxillary molars, as well as fi ns and isthmuses, among others.2 The disinfection protocol involves biomechanical preparation with hand or rotary instruments and mainly employs 0.5–5.5% sodium hypochlorite (NaClO) and 17% EDTA.5 Additionally children are more prone to an- xiety and stress during dental treatment,4, 5 which may require, in addition to well-established paediatric behaviour management, techniques inherent to the endodontic fi eld that help to make the procedure simpler and less time-consuming.6, 7 Stainless-steel hand fi les have been traditionally and, to some degree, successfully used for pulpectomy proce- dures in primary molars.7 Despite this, when they are used exclusively, they have multiple drawbacks because of their rigidity, making it diffi cult to negotiate the canals properly and to avoid procedural errors like ledge formation and perforation.8 Rotary instrumentation was later introduced and has proved to be very benefi cial in the practice of paediatric endodontics.8, 9 It takes less time, is less skill dependent and reduces the probability of errors that arise with hand fi les. Consequently, rotary instrumentation facilitates the creation of better conical space for a superior obturation protocol.10 However, these systems almost al- ways require a long sequence, and may become fatigued, owing to the rotational movement, increasing the probability of fi le fracture or distortion.11, 12 Continuous advances in the fi eld of endodontics have resulted in reciprocating instruments that have been ap- plied in root canal therapy of permanent teeth. The clock- wise and anticlockwise movement produces less binding of the instrument to the dentine wall, resulting in a decrease in cyclic fatigue and instrument fracture.13 Reciprocating instruments advocate the use of a single fi le for the entire root canal preparation. Being less time-consuming, it allows for a longer irrigation protocol. The technique used involves a cycle of instrumentation of in and out pecking motions of 2–3 mm in amplitude with slight apical pres- sure. Each cycle requires irrigation of the root canal with the irrigating solution and cleaning the fi le fl utes of all dentine remnants, debris and pulp tissue between each cycle.12, 13 In the research on primary molar pulpectomies, the results of the use of reciprocating instruments have been encour- aging so far, demonstrating good cleaning and shaping properties and shortened instrumentation time, thus being benefi cial for the preparation of primary teeth.14–17 However, we found no in vivo studies or clinical reports on the use of the R25 fi le (RECIPROC, VDW) in primary molar pulpec- tomy. In this article, we present a case series of primary molar pulpectomy using R25 in RECIPROC ALL motion in fi ve primary molars with a diagnosis of pulp necrosis and periapical disease. Pulpectomy procedure All the patients’ parents (or legal guardians) were informed about the procedure protocol and prognosis and signed a written consent. The pulpectomy procedures were per- formed by the same operator, an endodontist with ten 30 roots 1 2022

| case report 5 6 7 8 9 Case 2—Fig. 5: Initial condition. Severe decay and buccal abscess. Fig. 6: Four long root canals were detected. Fig. 7: Obturation and temporary restoration. Fig. 8: Fourteen-month control showing the successor eruption process advancing normally. Fig. 9: Clinical aspect at final evaluation showing healthy gingival tissue. Case 2 (Figs. 5–9) This male patient was 6 years and 7 months old and presented with severe tooth decay on the mandibular left first primary molar without any symptoms of pain. He experienced slight discomfort to percussion and palpation of the buccal gingiva. A buccal abscess and no mobility were observed. The radio- graph showed a large area of interradicular bone loss. The tooth was diagnosed with pulp necrosis and asymptomatic apical abscess. Pulpectomy was performed, and at a second appointment, a stainless-steel crown was placed upon con- firming absence of signs or symptoms of disease. At the 14-month recall, no clinical pathology was detected and a nor- mal eruptive process of the permanent premolars was ob- served in spite of the extrusion of the obturation material. Case 3 (Figs. 10–13) This male patient was 7 years old and presented with mild pain that had lasted for several days. An extensive and deep cavity in the mandibular left first primary molar was observed. There was no swelling of the gingiva, but the tooth was painful on percussion. The radiograph showed the severity of the decay but no consistent changes to the surrounding bone. Pulpec- tomy was the treatment of choice. The diagnosis of pulp ne- crosis was confirmed once the access cavity had been per- formed, and three canals were located and fully negotiated. At a second appointment, 15 days later, the tooth was totally asymptomatic and the decision was made to restore with a stainless-steel crown. The 36-month control showed the tooth to be in normal function and completely healthy. Case 4 (Figs. 14–18) This male patient was 4 years and 6 months old and pre- sented with constant and spontaneous pain of the mandib- ular left first primary molar that had lasted for several days but no facial oedema or buccal gingival swelling. Deep de- cay was observed but no mobility or deep probing depths. On the radiograph, the carious lesion could be seen to be 11 12 13 10 Case 3—Fig. 10: Initial radiograph. Fig. 11: Obturation and final restoration. Fig. 12: Control at 36 months showing the normal eruption process despite the slow resorption of the zinc oxide eugenol. Fig. 13: Clinical aspect at final evaluation showing healthy gingival tissue. 32 roots 1 2022

| case report tract had resolved, so the decision was made to restore the tooth with a stainless-steel crown. Follow-up after 30 months showed periapical healing of mesial apical area of previous radiolucency and no signs or symptoms of disease or pain. Ramazani et al. in their in vitro study compared two rotary systems and RECIPROC in mesiobuccal canals of primary molars.28 They confirmed the RECIPROC system’s fast and good clean- ing and shaping ability. These were the first studies to advocate the use of the RECIPROC system in the primary dentition. Discussion Dental caries is a pathology of wide prevalence in the world, and it affects the dentition in the early stages of life, being most common in susceptible populations because of a lack of dental education and limited access to quality healthcare services.18 It is well known that it is essential to avoid space loss during childhood in order to preserve the natural dentition. Loss of proper space can lead to mal- position of permanent teeth and compromises nutrition, speech ability and self-confidence, among others.19 Primary molar pulpectomy is the treatment of choice to preserve primary natural dentition in teeth affected at the pulp– dentine complex and periodontally diseased as a result of bacterial invasion of the root canal system.20 Anxiety and stress regarding dental treatment in general are common, but must especially be taken into consideration when it comes to performing paediatric endodontic treat- ment.21 The search for and implementation of efficient end- odontic techniques requires proper understanding of the root canal system anatomy, root canal instrumentation, dis- infection and obturation techniques, and the importance of coronal restoration.20, 22 When it comes to root canal instru- mentation, hand file techniques have been widely used in endodontics, but they are time-consuming, uncomfortable at some point and susceptible to procedural errors, especially if performed by clinicians with limited clinical experience.22, 23 Mechanically driven instrumentation came to change the way we shape canals, providing a faster way to enlarge the root canal system in a convenient geometry to allow the appropri- ate movement of the irrigating solutions inside the root canal system.23, 24 Instrument design, nickel–titanium alloys and the type of movement are factors to take into consideration, be- cause they will directly influence the instrument performance. In paediatric dentistry, chair time is a factor to consider: the shorter, the better for the patient to manage anxiety and feel comfortable. Single-file reciprocating instrument sys- tems can be beneficial for paediatric endodontic treatment because they properly enlarge the geometry of the root canals, facilitate good shaping to enable proper distribution of irrigating solutions all along the working length and are less time-consuming than rotary and manual instru- mentation sequences.23, 25, 26 However, to the best of our knowledge, there is a lack of in vivo research on the use of reciprocating instruments in primary molar pulpectomy. Moraes et al. conducted an in vitro study employing a 3D-printed prototype of a maxillary primary central incisor.14 They concluded that the R40 file of the RECIPROC system was effective for instrumenting their 3D-printed model. Tyagi et al. in their in vivo study compared the use of a rotary system and the RECIPROC system for primary molar pulpec- tomy and evaluated the possible influence of the file system on child behaviour, among other factors.29 Their results re- garding clinical performance were in accordance with those of previous research. Nonetheless, they stated that the choice of file system did not significantly alter child behaviour. Dalzell et al. conducted a micro-CT study in which they evaluated the instrumentation efficacy of manual, Mtwo and RECIPROC blue files (VDW) in non-fused and fused primary molar roots and found significant differences in cleaning and shaping effectiveness in both fused and non-fused teeth.30 Additionally, they found more proce- dural errors when the reciprocating instruments were used. This last finding is contrary to those of previous research and our clinical experience so far. Although we have not seen the clinical performance of the RECIPROC blue system, it shares the geometrical design and motion of RECIPROC. Barasuol et al. compared the shaping ability of hand, rotary and reciprocating files in primary teeth in a micro-CT in vitro study.25 Their results showed more canal transportation in the middle third of the root canal with the R25 file. They also found a shorter instrumentation time with the RECIPROC system compared with manual instrumentation. To the best of our knowledge, ours is the first clinical report of the use of the R25 file in an in vivo scenario for primary molar pulpectomy. The long period of follow-up showed good results overall. These five cases were restored with complete stainless-steel crowns, and the time of their cementation was appropriate, avoiding recontamination of the root canal system. Our clinical experience over the years exceeds the cases re- ported here; however, these cases were presented because of their longer follow-up and proper stainless-steel resto- ration. The therapeutic success of our unreported cases follows the trend shown in this case series. Stainless-steel crowns are the preferred restoration for children at high risk of caries and teeth that have undergone pulp therapy. This may have contributed to the long-term success of treatment. Moghaddam et al. in their experimental study compared the cleaning efficacy and instrumentation time of RECIPROC and Mtwo (VDW) in primary molars.27 They concluded that using systems such as RECIPROC for pulpectomy is beneficial. The use of the operating microscope, coupled with the experi- ence of the operator in microscopic endodontics, may also have contributed to these results. The dental microscope is under- estimated and under-used in paediatric dentistry; however, its 34 roots 1 2022

| technique High-end technology for simplicity Adj Prof. Philippe Sleiman, Lebanon use a rather simplified approach for treating the complex root canal anatomy. In this article, I will demonstrate this approach with reference to several cases. The orifice opening is done with the 25/.08 Traverse file, which has a maximum flute diameter of 1 mm. This is a file that I use in almost all of my cases. In straight canals, it goes as deep as it can and, in curved canals, is limited to working above the curve. In straight canals, ZenFlex offers a wide range of sizes, from 20 to 55, in both .04 taper and .06 taper. After using the ZenFlex for some time, the dentist can evaluate the size that he or she likes to use according to his or her experience and preferences and can use one ZenFlex file to finish the shaping. In this first example, the patient was referred for treatment of a sinus tract of the anterior maxilla (Fig. 1). A gutta-percha cone was placed inside the fistula, showing the way to the infection site. This was a straightforward case, prepared using the 25/.08 Traverse file in the upper part of the root canal, followed by a 10 K-File (Kerr) to determine the work- ing length and then a 40/.06 Traverse file taken to working length. Naturally, treatment involved complete chemical preparation and 3D sealing of the root canal space (Fig. 2). The next example was also a straightforward case. This was a maxillary lateral incisor with a necrotic pulp and a slightly resorbed apex. A 55/.06 ZenFlex file was used in a single-file technique to treat this canal (Fig. 3). In molars and narrow canals, a simple sequence is required in order to perform shaping. It can start with the 25/.08 Traverse file, taken to just above the curve, especially in mesial canals. Using a K-File, the dentist can determine the working length using an apex locator and use this length for preparation with rotary files. The K-File is also used to achieve patency. The second rotary file is the 13/.06 Traverse file, taken to working length, followed by the 20/.06 and 25/.06 ZenFlex files, also taken to working length. If the dentist is following an apical enlargement regime, a 30/.04 ZenFlex file can be used for the apical area (Fig. 4). Maxillary second molars are in my opinion one of the most challenging teeth to treat because of their position and unpredictable anatomy. In this example case, the patient was referred for irreversible pulpitis (Fig. 5). Looking at the preoperative radiograph, we can see the curvature of espe- cially the mesial and palatal root canals. The sequence used was as described before, starting with the 25/.08 Traverse 1 2 3 Since nickel–titanium (NiTi) files were introduced into root canal therapy, engineers have been seeking the perfect design and combination for optimal root canal therapy. Heat treatment and twisting of NiTi was a major breakthrough in this field. It opened up the era of heat treatment for rotary files, and now almost all files in the market are heat-treated, creating great flexibility, but putting aside cutting efficiency, cutting being the major task for rotary files in shaping root canals. The Traverse and now ZenFlex file systems (both Kerr) are produced using a novel heat treatment that combines cut- ting efficiency and flexibility in one file and in the necessary places. This new technology in heat treatment adds value to our daily work, as ultimately what matters is the treat- ment that we offer to our patients. Safety and cutting effi- ciency are apparent when using these files, allowing me to 4 Fig. 4: Technical card for small to medium canals. 36 roots 1 2022

| technique The golden era of root canal shaping Dr Ahmed Shawky, Egypt After access preparation and location of anatomy, the next challenge facing the endodontic clinician is to select the proper file alloy and sequence for the shaping procedure in order to be able to shape the anatomy safely and predictably and with- out any procedural errors. This article will show the advan- tages of the MG3 instruments (Shenzhen Perfect Medical Instruments) and how we can customise the sequence of these files according the anatomy encountered and case difficulty for predictable root canal shaping with a high safety margin. Files First, I will go through the components of the basic assortment of the MG3 Gold file system (Fig. 1). The main advantage of this file system is the presence of different designs and cross sections in the same instrument kit, a smart thing for dealing with different anatomies. Starter file (orifice modifier, 20/.10) This file has a short working segment (9 mm) and 19 mm length. This improves accessibility in restricted areas (Fig. 3). It is used for mechanical pre-flaring or orifice modification for elimination of coronal dentine resistance. It has a convex triangular cross section, which increases the blade strength, giving the instrument a high cutting efficiency. With this cross section, the instrument is subjected to excessive tor- sional load; therefore, this instrument must be used in brushing motion towards the outer walls and not pecking motion. Gliders (16/.02 and 19/.02) Another advantage of this system is that it has two glide path files (Fig. 4). They can be used sequentially, depend- ing on case difficulty. Sometimes, only one is used. The rectangular cross section provides four blades for better centring ability, avoiding transportation, and for high cut- ting efficiency for reproducible glide path preparation. The MG3 Gold files are machined with a variable pitch and helix (Fig. 2), allowing efficient coronal evacuation of debris and preventing a screw-in tendency. This also reduces the torsional load on the instrument that would otherwise occur because of debris accumulation or excessive friction with the root canal walls. The small size and taper of these files make them extremely flexible for negotiating mechanically difficult curvatures. Owing to the small size of the gliders, it is recommended to use them with brushing motion ahead of pecking motion to avoid torsional failure. Pitch 1 2 38 roots 1 2022

7 ration, only one large mesial orifice was identified. Ultra- sonic modification revealed the presence of two mesial canals originating from a single mesial orifice (sub-pulpal bifurcation). Mechanical pre-flaring with the 25/.06 MG3 Gold file, followed by mechanical body shaping with the 25/.04 file, created a smooth glide path down the two separate mesial canals despite coronal restriction. Following the reproducible glide path, shaping with the 20/.04, 25/.04 and 25/.06 files was not a difficult task. How to use the MG3 Gold instruments Case 1 (Fig. 7) The patient presented to the clinic and was diagnosed with symptomatic irreversible pulpitis and apical peri- odontitis of a mandibular third molar. After access prepa- Case 2 (Figs. 8 & 9) A patient with a mandibular third molar diagnosed with irreversible pulpitis and symptomatic apical periodontitis was referred to my practice. Under high magnification, the canal entrances were negotiated using medium- 8 9 40

| interview Laser protocol for peri-implantitis treatment An interview with Dr Michał Nawrocki By Dental Tribune International insufficient for me, and to be honest my knowledge of lasers, physics, indications and procedures was incom- plete at the time. Then in January 2016, I invited Dr Ilay Maden to my clinic to conduct a course and teach my colleagues and me about various Er:YAG and Nd:YAG procedures with the LightWalker laser. A few months later, I decided to extend my knowledge about lasers by attending the Master of Science in Lasers in Dentistry presented by Prof. Norbert Gutknecht in Aachen. Now, I cannot imagine continuing my daily practice and treat- ments without having LightWalker. Sometimes, I use it as an additional tool during certain procedures, but very often it’s a crucial and necessary tool for me to use to conduct a particular procedure. What procedures do you perform with laser? Laser can be used in all fields of dentistry; however, I am mainly focused on implantology and surgery, as well as prosthodontics. In prosthodontics, it can be used for sulcus conditioning, preparation for veneers and removal of complete ceramic crowns, as well as during more chal- lenging procedures like crown lengthening before tooth preparation. We can use it in gingivectomy (Nd:YAG laser) and bone recontouring (Er:YAG laser). All my surgery cases are finished with photo-biomodulation using the Nd:YAG Genova handpiece. I have observed that wound healing is much faster and better in such cases owing to pain reduction, disinfection, reduction of oedema and the laser’s analgesic function. Sometimes, I have to conduct an endodontic treatment during the procedure (which is quite rare and normally done by my colleagues), in which case I really appreciate the deep disinfection with Nd:YAG, which offers the highest bac- terial reduction in comparison with other wavelengths, and the Er:YAG SWEEPS (shock wave-enhanced emission photoacoustic streaming) procedure, which provides the most effective cleaning and disinfection. With surgical treatments, I use both wavelengths in almost all cases. Even when performing an easy and fast tooth extraction, I can use Er:YAG for granulation tissue removal, followed by Nd:YAG for disinfection, clot stabilisation and finally photo-biomodulation. Of course, I use laser before im- plant insertion, as well as when complications appear. Dr Michał Nawrocki Laser is becoming essential for every modern dental practice. Moreover, from an educational standpoint, there are many benefits in terms of the personal and pro- fessional development of the practitioner. In this inter- view, Dr Michał Nawrocki explains how laser dentistry has helped to advance his practice and career and why dental laser, and Fotona’s LightWalker in particular, has become an essential part of his daily practice. Dr Nawrocki, you have been using laser technology since 2016. Looking back at your journey as a laser dentist, how has LightWalker impacted your every- day practice? I started my great adventure with Fotona’s LightWalker in 2016. Before that I had used a diode laser, but it was 42 roots 1 2022

| interview 1 4 8 10 2 3 5 6 7 Fig. 1: Initial situation. Fig. 2: Pocket depth measurements. Fig. 3: Bleeding on probing. Figs. 4 & 5: Use of the Er:YAG laser Varian tip for granulation tissue removal, implant surface decontamination and surface ablation of infected bone. Fig. 6: Photo-biomodulation with the Nd:YAG laser. Fig. 7: Final results after three months. No sign of inflammation. of the implant surface with Er:YAG; (3) surface ablation of infected bone with Er:YAG; (4) reduction of bacteria in the bone with the Nd:YAG laser; and (5) photo-biomodulation with the Nd:YAG laser (after flap closure). In our non-surgical procedure, there are only four steps—I skip deep disinfection with the Nd:YAG laser owing to the 1,064 nm wavelength’s high absorption in titanium (it’s not possible without elevating a flap to disinfect only the bone and not harm the implant surface). As I mentioned, the flapless pro- cedure is most often my first option, and when the defect is severe, I decide on a surgical procedure as the second stage. After the procedure, the same restoration is generally placed in the mouth (after corrections if necessary). Some- times, depending on the type of bone defect, I decide to conduct bone regeneration with the use of bone substitute and collagen membranes. In such cases, I have to remove the restoration and, after peri-implantitis treatment with the use of laser and bone augmentation, close the flap with cover screws, leaving the patient with no restoration (pos- teriorly), not even a temporary one, for two to three months. What are the benefits of LightWalker for the treatment of peri-implantitis in your everyday practice? As I mentioned, the treatment of peri-implantitis is a huge challenge nowadays; statistically, in 20% of cases peri- implantitis develops and in 40% of cases mucositis develops around inserted implants. Treatment with the use of Er:YAG and Nd:YAG lasers is very effective, fast and comfortable 9 11 12 Fig. 8: Initial situation. Fig. 9: Granulation tissue visible after flap elevation. Fig. 10: Granulation tissue removal with Er:YAG laser. Fig. 11: Bone augmentation. Fig. 12: Final results with restoration two years post-op. 44 roots 1 2022

| interview “The correct choice of an animal model is vital” An interview with Dr Alexis Gaudin By Iveta Ramonaite, Dental Tribune International As in other medical fi elds, both dental research and the pharmaceutical industry aim to identify therapeutic strategies that can decrease pain, that can make den- tal therapeutics more effi cient, faster and more com- fortable, and that can make more predictable results possible. The use of animal models can accurately replicate many oral diseases and dental issues. Their use makes it possible for scientists to conduct re- search into the effect of new drugs and therapeutic proposals. 4 12 DAYS OF ENDODONTICS Dr Alexis Gaudin LECTURES “The correct choice of an animal model 14 is vital in order to minimise suffering and cost while maximising effi ciency HANDS-ON-COURSES and the success of the research.” Dr Alexis Gaudin believes that novel diagnostic tools, such as the use of biological markers, could be an alternative to studying pulpitis on animal models in the future. (Image: © Alexis Gaudin) register at www.roots-summit.com Dr Alexis Gaudin is an associate professor in the Department of Endodontics at Nantes Université in France. In 2021, together with fi ve other researchers, he published a review article that sought to provide a thor- ough understanding of the different animal models used in dental research to study pulp infl ammation. In this inter- view with Dental Tribune International, Dr Gaudin dis- cusses the ideal animal model for studying pulpitis, talks about the increasing popularity of non-animal methods in dental research and considers the possibility of studying artifi cially generated caries-inducing models in the future. The correct choice of an animal model is vital in order to minimise suffering and cost while maximising effi ciency and the success of the research. Scientifi c and practical decisions govern the selection of the animal model. For example, the animal model used must be as close as possible to humans from an anatomical, biological and physiological point of view. The operating condi- tions for inducing pulpitis, including accessibility and dental dam installation, must be technically simple, and the infl ammatory conditions obtained must be equiva- lent to those found in humans. Dr Gaudin, why is it important to choose the most appropriate animal model in dental research, and how would you describe the ideal animal model for studying pulp infl ammation? The animal model should give the most precise and scientifi cally interpretable results while presenting the least serious biological risk for the research team. The results should be reproducible, and the animal model 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. 46 roots 1 2022

| research The key role of vitamin D in immune health and regeneration The evidence for supplementation Prof. Shahram Ghanaati, Dr Karl Ulrich Volz & Dr Sarah Al-Maawi, Germany & Switzerland A healthy immune system is the basis of general good health and a good immune defence. It has been proved that individual habits, nutrition and the environment have an influence on our health.1 A balanced and healthy diet in particular is the key to a healthy human body. An un- balanced diet can seriously impair the immune system and increase the risk of chronic disease as a result.1 In the last decade, chronic diseases such as diabetes mellitus, Endogenous synthesis Exogenous intake 7-dehydrocholesterol Vitamin D3 cholecalciferol Calcidiol (25-hydroxycholecalciferol) Calcitriol (1,25-dihydroxycholecalciferol) 1 Fig. 1: Diagram for endogenous synthesis and exogenous vitamin D3 intake. 48 roots 1 2022 obesity and cardiovascular disease have surged sharply in various countries. A major reason for this is an in- creasingly unhealthy living environment and increasingly unhealthy lifestyle choices, especially in industrialised countries.2 The role of food components and especially vitamins has become increasingly important in various areas. In 1928, the German biochemist Adolf Windaus was awarded the Nobel Prize in Chemistry for his work on the correlation between sterols and vitamins, which sparked further research interest in vitamin D.3 Vitamin D can be produced in a physiological way in the human body. Sunlight is essential for this endogenous synthesis, which takes place primarily in the skin, where 7-dehydrocholesterol is converted into cholecalciferol (vitamin D3) by UVB rays. In order to reach its biologically active form, cholecalciferol undergoes further conversion steps in the liver (calcidiol) and in the kidney (calcitriol). The latter is the biologically active form of vitamin D and acts as a transcription factor. After binding to the vitamin D recep- tor, calcitriol regulates the expression of various proteins in the cell. The physiological mode of action of calcitriol therefore resembles that of a hormone and not that of a vitamin. That is why vitamin D, as a precursor of calcitriol, should rather be regarded as a prohormone (Fig. 1).4, 5 The connection between vitamin D and parathyroid hor- mone was recognised shortly after its discovery. Within this context, the regulatory effect of vitamin D on the min- eral balance of the body and in particular the regulation of calcium and phosphate levels was emphasised.6–8 Fur- thermore, it was established quite early on that vitamin D plays an important role in mineralisation and bone forma- tion. Consequently, many studies have focused on the in- fluence of vitamin D on skeletal health and the treatment of diseases such as osteoporosis. These findings have contributed to vitamin D being primarily associated with bone health in the public perception. However, some studies have shown the positive effect of vitamin D on the immune system too and thus on the gen- eral health of the body. Several studies have shown that vitamin D has a preventive effect on chronic diseases such as diabetes mellitus, hypertension and cardiovascular dis-

| research its potential preventive influence in chronic and infectious diseases. However, these mechanisms of action still re- main largely unexplained for the respective indications. The correlation between vitamin D levels and the prev- alence of various chronic diseases has been shown in several clinical studies. A meta-analysis of 25 prospec- tive cohort studies has shown that low vitamin D levels increase the risk of developing cardiovascular disease. In about 10,000 patients, the risk of cardiovascular dis- ease was about 44 % higher than in people with healthy vitamin D levels.15 Another study showed a correlation between vitamin D levels and the development of hyper- tension. It examined 8,155 patients suffering from hy- pertension and vitamin D deficiency. After the vitamin D deficiency had been eliminated, 71 % of the patients no longer showed any symptoms or had measurably high blood pressure.16 A positive influence of vitamin D has also been demonstrated in the development of Type 2 diabetes mellitus. It was shown that the number of pa- tients in a prediabetic stage and with a vitamin D defi- ciency was significantly lower than in the untreated group, once the vitamin D deficiency had been eliminated.17 Furthermore, the potential of an anti-infectious or anti- viral effect of vitamin D has been increasingly investigated in recent years. As a result, vitamin D has gained greater significance as a preventive or adjuvant therapy.11, 18 A systematic review has shown that a vitamin D deficiency is associated with a higher viral load in hepatitis B pa- tients.19 Furthermore, it was shown that vitamin D can in- hibit a herpesvirus infection through its anti-inflammatory and supportive defence effect.20 In addition, studies have shown that vitamin D supplementation reduces the prev- alence of influenza infections during influenza outbreaks.21 Another meta-analysis showed that the number of certain vitamin D receptor polymorphisms involved in processing of vitamin D correlates with an increased risk of a viral in- Vitamin D deficiency: 85.7 % 45.8 % 20.8 % 20.8 % 12.5 % > 30 ng/ml 20–30 ng/ml 10–20 ng/ml 0–10 ng/ml 15 10 5 0 s n o s r e p t s e t f o r e b m u N 2 Fig. 2: Distribution of vitamin D levels according to a pilot study conducted by the Clinic for Oral and Maxillofacial Plastic Surgery at Goethe University Frankfurt am Main. 50 roots 1 2022 fection. Based on the vitamin D-mediated improved im- mune defence and its potential role as an antiviral agent, its importance in the prevention of viral diseases is in- creasingly being investigated. Especially in the COVID-19 pandemic, vitamin D supplementation can play an im- portant role in preventing and defeating infection.22 Determination of vitamin D levels and definition of hypovitaminosis Vitamin D is a lipophilic molecule that is transported in the blood by carrier proteins. Approximately 80 % of these molecules are bound to the vitamin D binding protein in this manner. A further 10–15 % are bound to albumin and the rest circulates freely in the blood. The determination of the vitamin D level as part of a routine examination involves measuring the total concentration of all these forms. The 25(OH)D serum concentration is widely rec- ognised as a reliable marker of vitamin D levels.12 Similar to other vitamins and blood components, the vitamin D concentration is usually expressed in nanograms per mil- lilitre (ng/ml) or in nanomoles per litre (nmol/l). Both units are used, depending on the individual testing laboratory. Here, it must be noted that 1 nmol/l equals 0.4 ng/ml. The definition of a healthy vitamin D level and thus hypovita- minosis is a matter of much debate. In the literature, a vitamin D level of less than 30 ng/ml (75 nmol/l) is con- sidered a vitamin D deficiency (hypovitaminosis).13, 19, 23, 24 In various countries, studies have reported a general vitamin D deficiency. Observational studies have docu- mented that the prevalence of vitamin D levels of below 20 ng/ml (50 nmol/l) is as much as 24 % in the US, 37 % in Canada and 40 % in Europe.13, 24 The German Robert Koch Institute reported that 58 % of 18- to 79-year-olds in Germany have a level of below 20 ng/ml (50 nmol/l).25 This vitamin D deficiency pandemic was recognised as such several years ago. However, not much has been done in terms of supplementation and defining a sufficient dose. A pilot study examined the vitamin D levels of medical staff in the clinic for oral and maxillofacial plastic surgery at Goethe University in Frankfurt am Main in Germany. Out of 24 participants, 85.7 % had a vitamin D deficiency with a value below 30 ng/ml, whereas 45.8 % even had a value of below 10 ng/ml (Fig. 2). It is important to empha- sise that a healthy vitamin D value is considered to be between 40 ng/ml and 60 ng/ml. Current guidelines for vitamin D supplementation Given that, in most cases, endogenous synthesis of vitamin D is insufficient owing to limited exposure to sun- light, the body’s vitamin D intake should also come from food or dietary supplements. The amount of vitamin D absorbed can be expressed in two units: micrograms (µg) and international units (IU). One microgram equals 40 international units (1 µg equals 40 IU). These units

| research Vitamin D test < 40 ng/ml ≥ 40 ≤ 80 ng/ml > 80 ng/ml 10,000 IU/day 5,000 IU/day 1,000 IU/day Monitoring after three months 3 Fig. 3: Vitamin D3 dose recommendation of the authors for healthy adults. Nutrition Society estimate the need at 400 IU/day for chil- dren and 800 IU/day for adults.25 The US research insti- tute GrassrootsHealth collected data on the safety of a dose of 10,000 IU/day and found no undesirable side ef- fects.24, 29 The European Food Safety Authority also clas- sifies a dose of 10,000 IU/day as safe, but recommends no more than 4,000 IU/day.22 Clinical supplementation protocols in randomised controlled clinical studies As opposed to the recommendations of various author- ities and institutions, relatively high doses of vitamin D have been administered in randomised controlled clinical trials, and these have in most cases led to the support of therapy. Various clinical supplementation protocols have been used with doses ranging from 1,000 IU/day to 100,000 IU/day. Two different strategies have been pur- sued: one option is to administer a relatively high dose, such as 100,000 IU, once a month to raise and maintain vitamin D levels; and the other option is to supplement with an adequate daily dose (between 5,000 IU/day and 10,000 IU/day) to cover the body’s daily requirements. Most studies have documented an observation period of up to one year and have paid particular attention to the analysis of the dreaded side effect of vitamin D intoxica- tion. However, no vitamin D intoxication was observed in any of these studies. A detailed overview of the respec- tive studies is given in Table 1. Not long after the discov- ery of vitamin D and the recognition of its role in main- taining mineral balance, many diseases, such as asthma, rickets and tuberculosis, were treated in the 1930s and 1940s with extremely high daily doses of vitamin D (be- tween 60,000 IU/day and 600,000 IU/day). These studies reported hypercalcaemia as a result of over-physiological vitamin D concentrations, which led to growing concern regarding vitamin D supplementation. It is important to note that these studies were carried out with much higher doses than the ones currently administered. 52 roots 1 2022 Authors’ dose recommendation for healthy adults Today, the importance of vitamin D for the general health of the body and the immune system is well documented. A vitamin D value of between 40 ng/ml and 80 ng/ml should be aimed for. In contrast to the doses recommended by various associations, there is increasing evidence in cur- rent research that a relatively high daily dose is neces- sary to reach these values. However, there are no uniform guidelines at this point. Based on the investigated data, we recommend a daily dose that is adapted to the indi- vidual needs of the patient. In the case of a vitamin D de- ficiency (< 40 ng/ml), a dose of 10,000 IU/day should be administered for three months to compensate for the de- ficiency. As a maintenance dose for a vitamin D level in the range of 40–80 ng/ml, a dose of 5,000 IU/day is recom- mended. If the level is higher than 80 ng/ml, it is advisable to reduce the dose to 1,000 IU/day. The vitamin D level should be checked every three months in order to ad- just the dose to the individual needs of the patient (Fig. 3). When supplementing vitamin D, it is equally important to take the patient’s medical history into consideration and, in the case of compromised organ function or metabolic disease, to individualise the dose accordingly. Editorial note: A list of references is available from the publisher. This article was first published in implants—international magazine of oral implantology, vol. 22, issue 1/2021. about Prof. Shahram Ghanaati is a specialist in maxillofacial surgery and oncology, based in Frankfurt am Main, Germany. In 2013, he was appointed Director of the University Cancer Center of the Frankfurt University Hospital. He is the Senior Physician and Deputy Director of the Department of Oral and Maxillofacial Plastic Surgery of the Frankfurt University Hospital. In addition, he is the Director of the research laboratory FORM-Lab (Frankfurt Orofacial Regenerative Medicine). contact Prof. Shahram Ghanaati Universitätsklinikum Frankfurt Theodor-Stern-Kai 7 60590 Frankfurt am Main, Germany +49 69 6301-3744 shahram.ghanaati@kgu.de

| manufacturer news Seiler Instrument celebrates its 77th anniversary this year US-based Seiler Instrument came from humble origins When Seiler Instrument launched in September 1945, the staff included just its founders: husband and wife duo Eric H. and Dora Seiler. Operations ran out of a small rented manufacturing and offi ce space located in downtown St Louis in Missouri. The company has come a long way since. Today, Seiler Instrument has about 240 employees, does business around the globe and boasts a nearly 13,800 m2 headquarters in the Kirkwood suburb of St Louis. Seiler Instrument was founded with a focus on repairing micro- scopes and surveying equipment. Eric H. Seiler, who was trained in Germany as an instrument maker, came to the US in 1923. “He was not only able to build instruments, but was also able to train people. That was the double benefi t from him. He was a master of optics and able to train,” said his grandson Tom Seiler, executive vice president of the company’s geospatial and medical divisions. Even during its subsequent expansion, Seiler Instrument’s focus on optical instruments has not wavered. The company operates fi ve major divisions: manufacturing, geospatial, medical, plane- tarium and design solutions. The company serves as a contract manufacturer for precision machining and optical instrument as- sembly and sells surveying software and instruments, microscopes, ZEISS planetarium equipment and theatre equipment for astrology and related fi elds. Key to the company’s long tenure has been a “strong family unit”, according to Tom. The company is led by its third generation, which includes Tom, his brother Eric (Rick) Seiler Jr, who is president and CEO, and their sister Louise Schaper, director of compliance and planetarium division manager. Of the second generation, Eric P. Seiler remains chairman of the company and his wife, Hazel Elaine, is a board member. Four members of the family’s fourth generation are also involved in the company. Perhaps the greatest challenge for Seiler Instrument since its founding has been managing its growth and fi nances without straying from the family-owned and closely held vision of the company, said Tom. “We have benefi ted greatly from our strong relationships and support from UMB Bank over 40 years,” he said. Seiler Instrument celebrates its 77th anniversary this year, but Tom said the family is not slowing down. It is targeting several growth channels, including in its medical division, where execu- tives see opportunity for long-term strategic growth with 3D micro- scopes. The company hopes to achieve that through existing vendor relationships throughout the world. According to Dane Carlson, medical division manager, “Dentistry does not lend itself to good posture, causing injury. The dental microscope is a wonderful ergonomic tool, but Seiler’s new 3D microscope provides an even better ergonomic opportunity for the dentist. While using the 3D microscope, the dentist is not in a static position, and the 3D microscope allows the end user to manipulate the optical pod in a 360° rotation while the monitor stays directly in front of the dentist. This is the fi rst 3D dental surgical microscope built with this unique design. This distinctive design allows the end user to learn the microscope quicker and be able to provide many direct vision angles not achievable with the traditional microscope.” While Seiler Instrument has grown signifi cantly since its founding in the 1940s, Tom said it has not strayed from its roots. A point of pride for the company, he said, is a high number of fi rst-generation immigrant employees “working to achieve the American dream”. “That’s exactly what our grandparents were. Our founder was a fi rst-generation immigrant,” said Tom. www.seilerinst.com

| meetings International events ROOTS SUMMIT 2022 26–29 May 2022 Prague, Czech Republic www.roots-summit.com 17th IDEX Istanbul 2022 26–29 May 2022 Istanbul, Turkey https://cnridex.com SIDEX Seoul International Dental Exhibition & Scientifi c Congress 2022 27–29 May 2022 Seoul, South Korea https://eng.sidex.or.kr DENTAL BERN 2022 9–11 June 2022 Bern, Switzerland https://dental2022.ch EuroPerio10 15–18 June 2022 Copenhagen, Denmark www.efp.org/europerio 56 roots 1 2022 AAID Annual Conference 2022 21–24 September 2022 Dallas, USA www.aaid.com Dental World Budapest 2022 13–15 October 2022 Budapest, Hungary https://dentalworld.hu/ dental-world-2022-en 19th ESCD Annual Meeting 13–15 October 2022 Rome, Italy https://escdonline.eu Formnext 2022 15–18 November 2022 Frankfurt am Main, Germany https://formnext.mesago.com/ events/en.html IDS 2023 14–18 March 2023 Cologne, Germany www.ids-cologne.de m o c . k c o t s r e t t u h S / o t o h p 6 0 ©

| about the publisher Imprint Publisher and Chief Executive Officer Torsten R. Oemus t.oemus@dental-tribune.com Managing Editor Magda Wojtkiewicz m.wojtkiewicz@dental-tribune.com Designers Franziska Schmid Copy Editors Sabrina Raaff Ann-Katrin Paulick Editorial Board Fernando Goldberg, Argentina Markus Haapasalo, Canada Clemens Bargholz, Germany Michael Baumann, Germany Benjamin Briseno, Germany Heike Steffen, Germany Gary Cheung, Hong Kong Asgeir Sigurdsson, Iceland Adam Stabholz, Israel Philippe Sleiman, Lebanon Jorge Vera, Mexico Unni Endal, Norway Esteban Brau, Spain José Pumarola, Spain Kishor Gulabivala, United Kingdom William P. Saunders, United Kingdom Fred Barnett, USA L. Stephan Buchanan, USA James Gutmann, USA Ben Johnson, USA Kenneth Koch, USA Sergio Kuttler, USA John Nusstein, USA Ove Peters, USA International Administration International Headquarters Dental Tribune International GmbH Holbeinstr. 29, 04229 Leipzig, Germany Tel.: +49 341 48474-302 Fax: +49 341 48474-173 General requests: info@dental-tribune.com Sales requests: mediasales@dental-tribune.com www.dental-tribune.com Printed by Löhnert Druck Handelsstraße 12 04420 Markranstädt, Germany Chief Financial Officer Dan Wunderlich Chief Content Officer Claudia Duschek Clinical Editors Nathalie Schüller Magda Wojtkiewicz Editors Franziska Beier Jeremy Booth Brendan Day Iveta Ramonaite Executive Producer Gernot Meyer Advertising Disposition Marius Mezger Art Director Alexander Jahn Copyright Regulations All rights reserved. © 2022 Dental Tribune International GmbH. Reproduction in any manner in any language, in whole or in part, without the prior written permission of Dental Tribune International GmbH is expressly prohibited. Dental Tribune International GmbH makes every effort to report clinical information and manufacturers’ product news accurately but cannot assume responsibility for the validity of product claims or for typographical errors. The publisher also does not assume responsibility for product names, claims or statements made by advertisers. Opinions expressed by authors are their own and may not reflect those of Dental Tribune International GmbH. 58 roots 1 2022

CanalPro™ Jeni Digital assistance system for canal preparation Jeni - ready - go! • • Digital assistance system for canal preparation • • Irrigation recommendation is indicated by controls the file movement at millisecond an acoustic signal intervals • • Due to the integrated apex locator and fully • • Movement profile of the file continuously insulated angled handpiece, continuous adapts to the individual root canal measurement of the working length is possible anatomy in real time Perfectly matched to four file systems Four NiTi file systems are pre-programmed especially for use in the Jeni-Move. Due to Doctor‘s Choice function, flexible use with individual file sequences is also possible. HyFlex™ EDM HyFlex™ CM MicroMega One Curve MicroMega 2Shape www.coltene.com 1 2 0 1 . 6 7 0 7 0 0