Professional Documents
Culture Documents
Roots
Roots
1 2009
_working length
Endodontic success and
working length: thinking
three-dimensionally
_clinical
Nonsurgical therapy of
mucosal and cutaneous
fistulae
_trends
Ceramics-based sealers as
new alternative to currently
used endodontic sealers
an innovation in
efficiency, simplicity and safety
Want information ?
Obturated canal
Detector wire
(PVC-covered electrical wire)
To power source
I trends I trends
4 Endodontic success and working length: thinking 32 Nonsurgical therapy of mucosal and cutaneous fistulae
three-dimensionally _ Arnaldo Castellucci
_ E. Steve Senia
I research
I research
42 Ceramics-based sealers as new alternative to currently
12 The leakage resistance of endodontic fiber obturator used endodontic sealers
_ Gregori M. Kurtzman & J. A. von Fraunhofer _ Deyan Kossev & Valeri Stefanov
I trends
26 Answering two frequently asked clinical endodontic I on the cover
questions: How much taper? How do I troubleshoot my The cover image for this issue of Roots magazine is courtesy of
apex locator? Dr. Eric Herbranson, 3D Interactive Tooth Atlas, Brown and
_ Richard Mounce Herbranson Imaging, eHuman.com.
roots
1 _ 2009 I 03
RO0109_1-52.indd 3 3/5/09 1:14:12 PM
I trends_ working length
I
n the article “Endodontic success: it’s all about actly where working length (WL) should terminate.
the apical third” (Roots magazine, Vol. 4, Issue Let’s explore the reasons and try to make sense of it
1, 2008, pages 14–19), we introduced the all. The American Association of Endodontists’ Glos-
term working width (WW). Don’t be surprised sary of Endodontic Terms states: “working length is
if you have never heard this term — it’s quite the distance from a coronal reference point to the
new and warrants a brief description. WW is the point at which canal preparation and obturation
canal’s pre-instrumented diameter, adjacent and should terminate.”1 Where is the disagreement? The
coronal to the apical constriction (Fig. 1). I like this definition doesn’t tell us where WL should terminate.
term very much, because it is a valuable reminder Exactly where should it be? Our forefathers hotly
that canals are three-dimensional. Instrumenta- debated the question for many years, and the issue
tion should address a working length and a working appeared to be resolved. Unfortunately, WL is once
width. My last article focused on working width, this again embroiled in controversy.
article focuses on working length. Our forefathers concluded that instrumenta-
tion should end at the cementodentinal junction
Definition of working length (CDJ) (Fig. 1), which is approximately co-located
There is considerable disagreement regarding ex- with the apical constriction. Most agree with that
04 I roots 1_ 2009
Trust the number one in the class! We would be happy to advise you.
Phone +49 (6074) 836-0 or visit our website at www.jmoritaeurope.com
location because the pulp makes dentin and the “usually 0.5 to 1.0 mm short of the center of the api-
periodontium makes cementum. Instrumentation cal foramen,” but positions the CDJ “ranging from
should remove pulp tissue and not invade the peri- 0.5 to 3.0 mm from the anatomic apex.”1 The last
odontium. That’s not to say that I’m against passing a word, apex, is very important. If the CDJ can be as
patency file past the CDJ or even slightly beyond the much as 3 mm from the apex, it means that the apex
foramen. However, remember the formula, Area = p is not a precise reference point for WL determination
(pi) times the radius squared. This means that a #15 and should not be used. Clearly, apex and foramen
(0.15 mm) patency file’s tip occupies only 5 percent can’t be used interchangeably, and evaluating the
of the average foramen’s cross-sectional area (0.60 quality of an obturation by its distance from the
mm) and only 25 percent of the average constric- apex is wrong.
tion’s area (0.30 mm)!2 A meaningful discussion of WL can only take
I suspect patency files are used more for warning place when it is understood to be measured in mil-
of an impending ledge than for maintaining patency. limeters from the foramen and not the apex. So let’s
The downsides are the likelihood of a patency file not talk about the apex because it’s irrelevant, and
lacerating vital tissue beyond the constriction and let’s not pretend that the apex is the same as the
possibly causing postoperative pain in an asympto- foramen. It’s all about the foramen, which is usually
matic vital case. A clean cut of the pulp at its narrow- not at the apex.2,3 Gutierrez and Aguayo3 examined
est point (apical constriction) is a more biologically 140 teeth with a scanning electron microscope. They
acceptable approach. In necrotic cases it would likely found no foramina located exactly at the apex, and
push infected material into the periapical tissue and the average distance of the foramen from the apex
possibly cause a “flare-up.” ranged from 0.2 mm to 3.8 mm. The foramen gives
a precise reference point for WL determination — the
Termination point apex does not.
Where to terminate WL (our clinical target) re- If we use the foramen, rather than CDJ/constric-
quires two reference points. The first one is the coro- tion or apex, as a firm reference point, we can really
nal reference point on the crown, and the second is in narrow down the best locations for WL. I purposely
the apical part of the canal. The AAE Glossary states use the plural to emphasize the two acceptable loca-
that a root canal is: “a passage or channel in the root tions — 0.5 mm from the foramen or 1.0 mm from the
of a tooth extending from the pulp chamber to the foramen. Why not agree on a WL that ranges from
apical foramen.”1 Note that the foramen defines the 0.5 mm to 1.0 mm short of the foramen? I think that’s
end of the canal. This narrows the choices for WL reasonable, and here’s why. Let’s say that I believe WL
to somewhere between the foramen and the CDJ/ should be 0.5 mm short of the foramen, whereas you
constriction. think it should be 1.0 mm short of it. Could I say that
The Glossary positions the apical constriction my choice is correct, whereas yours is not and your
roots
1 _ 2009 I 07
08 I roots 1_ 2009
SybronEndo Europe, Basicweg 20, 3821 BR Amersfoort, The Netherlands Tel: +31 33 4536 159 fax: +31 33 4536 153
email: endo@sybrondental.com ©2008 SybronEndo
I trends_ working length
10 I roots 1_ 2009
F
Abstract into each tooth in contact with the obturation mate-
iber obturators have been introduced into rial and sealed in place with sticky wax. The exteriors
endodontics, but there are few reports of of the teeth and the wax-wire junctions were sealed
their efficacy compared with standard with three layers of nail varnish with care taken to en-
obturation materials. This study evalu- sure that the apices were patent. The teeth then were
ated the leakage resistance of fiber obtu- immersed in 0.9 percent NaCl solution together with
rators compared with other obturation materials. a stainless steel counter electrode. A 20 V dc voltage
Sixty-four human single-rooted teeth, with 20 was connected between the stainless steel and each
mm average working length, were used for the study. tooth in turn, and current flow determined by voltage
Access was prepared coronally and patency confirmed drop across a standard resistor (100 Ω) in the circuit.
with a hand file. The canals were instrumented to Current flow in the circuit was observed for 30 days
apical size ISO #40 with NaOCl irrigation, paper point and ANOVA and Scheffé testing were used to compare
dried, rinsed with 17 percent EDTA solution, re-dried the leakage currents and identify any statistically sig-
and divided into eight groups of N=8. They were ob- nificant differences in the leakage behavior.
turated as follows: 1) InnoEndo fiber obturator with All specimens showed a progressive increase in
InnoEndo adhesive and resin sealer. 2) InnoEndo fiber leakage with time. The specimen leakage fell into three
obturator with a self-adhesive resin sealer. 3) Fibrefill groups; the least leakage was found with obturations
fiber obturator with Fibrefill adhesive and resin sealer. 1, 2, 3 and 5, the greatest leakage with obturations 4
Fig. 1_After preparation and 4) Gutta-percha with Endorez resin sealer. 5) Endorez and 8, with obturations 6 and 7 being intermediate.
obturation, a length of PVC-covered
cone with Endorez resin sealer. 6) Resilon cone with The data indicate that fiber obturation and a new
copper wire was placed coronally
into each tooth in contact with the Endorez resin sealer. 7) Gutta-percha with ZOE sealer. cone/sealer system provide the best canal obturation
obturation material and sealed in 8) Gutta-percha with AH26 sealer. as evidenced by the leakage behavior.
place with sticky wax. A PVC-covered copper wire was placed coronally
Introduction
Leakage can be a hidden factor in endodontic
failure in that percolation at the margins of a res-
toration may be long standing before its effects are
apparent to the patient or the dentist. In fact, various
studies indicate that significant leakage may occur
within two days following exposure of teeth with
endodontically treated root canals to artificial and
natural saliva, leading to complete bacterial leakage.1
In vitro studies likewise indicate that dye leakage
can occur in as few as three days.1 It has also been
shown that gutta-percha does not offer an effective
barrier to crown-down leakage when exposed to the
oral environment due to poor bonding with various
sealers.1 Additional studies have indicated that gutta-
percha will allow bacterial leakage, although the use
of adhesive obturation materials can significantly
slow or stop coronal-apical bacterial migration.1
Nevertheless, despite its limitations, gutta-percha in
combination with various sealers traditionally have
12 I roots 1_ 2009
Fig. 2_The teeth were immersed in been used for endodontic obturation. time to completely seal the canal system and prevent
0.9 percent NaCl solution together In recent years, however, novel adhesive systems coronal leakage issues is at the time of canal obtura-
with a stainless steel counter have been developed in an attempt to improve leak- tion when a rubber dam is already in place.
electrode. A 20 V DC voltage was age resistance. Fiber obturators were introduced to The present study compared the leakage behavior
connected between the stainless
the market several years ago as a method to address of the recently introduced InnoEndo fiber obtura-
steel and each tooth in turn, and
current flow was determined by the separate steps of obturation and post placement. tion system compared to that found with traditional
voltage drop across a standard These unique obturators allow the practitioner to materials (gutta-percha used in combination with
resistor (100 Ω) in the circuit. obturate the canal and place a fiber post in a single both AH26 and zinc oxide eugenol [ZOE] sealants) and
the newer resin obturation materials. Leakage was
assessed using an electrochemical methodology,1,2,3
this approach being adopted because of its accuracy,
convenience and high correlation with traditional dye
leakage studies.1
14 I roots 1_ 2009
ER-RES: Resilon cone with Endorez resin sealer. The greatest leakage was found in teeth obturated
GP-ZOE: Gutta-percha with ZOE sealer. with gutta-percha with Endorez resin sealer and those
GP-AH26: Gutta-percha with AH26 sealer obturated with gutta-percha and AH26 sealer — that
(DENTSPLY DeTrey GmbH, Konstanz, is, obturations 4 and 8.
Germany). The least leakage was found with teeth obturated
After preparation and obturation, a length of PVC- with an InnoEndo fiber obturator and InnoEndo ad-
covered copper wire was placed coronally into each hesive and resin sealer, an InnoEndo fiber obturator
tooth in contact with the obturation material and with a self-adhesive resin sealer, an Endorez cone
sealed in place with sticky wax (Fig. 1). Thereafter, the with Endorez resin sealer and a Fibrefill fiber obturator
tooth/wax junction and all external surfaces of the with Fibrefill adhesive and resin sealer — specifically,
teeth were sealed and insulated with three layers of obturations 1, 2, 3 and 5. Teeth obturated with gutta-
nail varnish. Care was taken to ensure that the apices percha with Endorez resin sealer and those obturated
of the teeth remained patent. with a Resilon cone with Endorez resin sealer — obtu-
The teeth then were immersed in 0.9 percent NaCl rations 6 and 7 — were intermediate in behavior.
solution together with a stainless steel counter elec-
trode. A 20 V DC voltage was connected between the Discussion
stainless steel and each tooth in turn, and current flow Methods for the study of leakage may be divided
was determined by voltage drop across a standard into three methods — dye penetration, bacterial
resistor (100 Ω) in the circuit (Fig. 2). Current flow in penetration and electrophoresis. Both dye and bacte-
the circuit was observed for 30 days. One way ANOVA rial penetration methodology provide a qualitative
with post hoc Scheffé testing at an a priori = 0.05 was result. The results observed are either black or white,
used to compare the data and identify any statistically the material leaks or it doesn’t leak. These methods
significant differences in the leakage behavior. don’t inform us to what degree the material leaks. Dye
penetration studies will tell us there was dye leakage
Results along the canal, but to what degree this is clinically
All specimens showed a progressive increase in significant has been debated as the dye molecule is
leakage over time (Fig. 3). Statistical analysis indicated larger than the bacteria associated with endodontic
that there were no differences (p>0.05) between the leakage seen clinically. Bacterial leakage studies were
groups, primarily because of the large standard devia- an answer to that question. If the solution in the api-
tions within the sets of data (Fig. 4). Nevertheless, the cal chamber of a two-chamber model became turbid,
trends in behavior indicated that specimen leakage fell then it was an indication that bacteria penetrated the
into three groups. canal system. But again, this is a qualitative result that
roots
1 _ 2009 I 15
does not inform us how leakage compares between The findings of this limited in vitro study indicate
materials, only that it did leak and when leakage was that the use of fiber obturators combined with newer
visible to the eye. Electrophoresis is currently the only adhesives holds great promise for achieving consis-
method testing leakage behavior that is able to provide tent leak-free root canal obturation.
a quantitative result, allowing the determination how
much different materials leak. This methodology also References
removes viewer bias as seen with the other meth- 1. Khayat A, Lee SJ, Torabinejad M. Human saliva penetration of
coronally unsealed obturated root canals. J Endod. (1993) 19(9):
odologies. Leakage is measured with an electronic
458–461.
apparatus and is not dependant on the viewer saying 2. Swanson K, Madison S. An evaluation of coronal microleakage in
he or she could see a result (visible dye shown along endodontically treated teeth. Part I. Time periods. J Endod (1987)
the canal’s length when the specimen was sectioned 13(2): 56–59.
or turbidity seen on the media solution). 3. Cohen S, Burns R. Pathways to the Pulp. 8th edition, CV Mosby,
New York, 2001.
Endodontic leakage studies invariably show a 4. Britto LR, Grimaudo NJ, Vertucci FJ. Coronal microleakage as-
scatter in leakage behavior, as evidenced by the large sessed by polymicrobial markers. J Contemp Dent Pract. (2003)
standard deviations in the leakage data. All materials 4(3):1–10.
will leak more over the initial period, and leakage be- 5. Jacobson SM, von Fraunhofer JA. The investigation of microleak-
age in root canal therapy. Oral Surg Oral Med Oral Path (1976)
havior will plateau during the first 30 days then remain 42: 817–823.
fairly consistent thereafter. Nevertheless, the leakage 6. Mattison GD, von Fraunhofer JA. Electrochemical microleakage
found in the present study for gutta-percha with study of endodontic sealer/cements. Oral Surg Oral Med Oral Path
Endorez resin sealer obturation and teeth obturated (1983) 55: 402–407.
7. von Fraunhofer JA, Fagundes DK, McDonald NJ, Dumsha TC. The
with gutta-percha and AH26 sealer was comparable,
effect of root canal preparation on microleakage within endo-
if somewhat greater than, the findings of other leak- dontically treated teeth: an in vitro study. Int Endodont J (2000)
age studies.1 33: 355–360.
The leakage found for fiber-obturated teeth was 8. von Fraunhofer JA, Adachi EI, Barnes DM, Romberg E. Effect of
similar to that observed with other modern obtura- tooth preparation on microleakage behavior. Oper Dent (2000)
25: 526–533.
tion techniques and showed a significantly better 9. von Fraunhofer JA, Klotz DA, Jones OJ. Microleakage within endo-
leakage resistance than gutta-percha with either ZOE dontically treated teeth using a simplified root canal preparation
or AH26 sealers. technique: an in vitro study. Gen Dent (2005) 53: 439–443.
16 I roots 1_ 2009
No cord. Full power. Entran sets new standards in the area of cordless endodontics and
combines the highest level of ergonomics with consistent W&H quality. For root canal
preparation, there are a number of features at your disposal e.g. torque control, automatic
direction change and 5 preset torque levels for NiTi files. Simple to operate, so you can
concentrate on the treatment. With Entran you can enjoy complete freedom of movement
inside the entire mouth - even in the most inaccessible posterior molar area.
wh.com
Endodontics. Cordless!
I trends_K3 rotary nickel titanium instrumentation
A
mong the options available, since the a. Number of recommended uses.
introduction of rotary nickel titanium b. Type of tactile insertion (pecking motion, single
(RNT) instrumentation, choosing be- insertion, multiple insertion, etc.)
tween many existing RNT systems c. Method of use, i.e., crown down method, step
has, largely, been a decision between back method, and/or using a hybrid technique
safety and efficiency. Some instruments cut well employing both concepts.
but tended to transport canals. Others created less d. Recommended rotational speeds. Recom-
transportation and are relatively safer, but also less mended rotational speeds vary from approxi-
effective at shaping dentin. mately 300 to 2,000 rpm.
Complicating matters, there is no literature-based Coincident to the above, there is debate in the
proven superiority of one RNT file system over an- endodontic community as to the ideal master apical
other available at this time. As a result, selection of file (MAF) size, a debate that has a direct relationship
one RNT file system over another has been primarily to the capabilities and limitations of the given RNT
empirical and, for many, been based more on tactile file system. Some file systems may not be flexible
feel and ease of cone fit after preparation than any enough to get around severe curvatures in larger
measurable scientific parameters. Each file has its tapers. With some systems, the MAF possible may
own learning curve, some steeper than others. Mak- be limited by the available file sizes. For example, if a
ing decisions even more complex, various file systems file system is available to only a #40 tip size (or some
have been introduced with different technique and similar diameter) that is the limiting factor imposed
Fig. 1_The cross section tactile recommendations. In essence, each RNT file is onto the clinician, irrespective of what the literature
of the K3 RNT. unique in many ways based on a number of factors, might suggest as optimal.
including design, use recommendations, etc. For RNT file systems also differ based on the following
Fig. 2_K3 in longitudinal example, there are variations among some systems attributes (among others):
cross section. (among many things) in the: 1. Cross-sectional design and degree of sym-
metry.
2. Presence or absence of radial lands.
3. Presence or absence of a positive, neutral or
negative cutting and rake angle.
4. Whether the file was ground, stamped, or
manufactured via a different method.
5. Flute width and flute depth.
6. Helical angle.
7. Presence or absence of reliefs behind the radial
lands.
8. Electro polishing.
9. Active versus non-cutting tips.
18 I roots 1_ 2009
roots
1 _ 2009 I 19
non-tapered RNT file at this time, which is stamped. a 25-tip size and are generally used as orifice openers.
All other RNT files are ground with the limitations that The 0.02 K3 is available in tip sizes of #15 to 45. The
microcracks are created. K3 overcomes many of the 0.04 is available from #15 to 60. The 0.06 K3 is avail-
limitations imposed by these microcracks due to the able from 15 to 60. K3 is packed into three different
design characteristics of the file (lack of symmetry, pack configurations, the Procedure Pack, the G Pack
radial lands, non-cutting tip, etc.) and the VTVT Pack.
5) Flute width and flute depth. Flute width and
depth increases for K3 as the clinician moves away The Procedure Pack contains either a 0.06 or 0.04
from the tip of the file. Such increasing width and taper:
depth provides space for chips derived from cutting. 0.10 .25 tip 17 mm
Such channeling of debris reduces torsion. 0.08 .25 tip 17 mm
6) Helical angle. K3 has a greater number of flutes 0.06 (.04) 40 tip 21 or 25 mm
at the distal 8 mm of the file that makes the apical 0.06 (.04) 35 tip 21 or 25 mm
portion of the file as flexible as possible and resistant 0.06 (.04) 30 tip 21 or 25 mm
to fracture. This also provides more cutting flutes at 0.06 (.04) 25 tip 21 or 25 mm
the portion of the file where they are needed most
during function. The G Pack contains:
7) Presence or absence of reliefs behind the radial 0.12 25 tip 17 mm
lands. Two of the three radial lands of K3 are relieved 0.10 25 tip 21 or 25 mm
to reduce the friction of the file against the canal 0.08 25 tip 21 or 25 mm
walls and to allow more room for chip debris as it is 0.06 25 tip 21 or 25 mm
formed. 0.04 25 tip 21 or 25 mm
8) Electro polishing. K3 is not electropolished. 0.02 25 tip 21 or 25 mm
While advocated by some, electropolishing can dull
the cutting edges of the file as well as change the The VTVT (variable taper, variable tip) Pack contains:
surface structure of the metal to varying degrees. 0.10 25 tip 21 or 25 mm
9) Active versus non-cutting tips. K3 has a non- 0.08 25 tip 21 or 25 mm
cutting tip. Any RNT file can fracture when used 0.06 35 tip 21 or 25 mm
inappropriately. Empirically, a lack of cutting at the 0.04 30 tip 21 or 25 mm
tip of K3 is borne out by the fact that although rare, 0.06 25 tip 21 or 25 mm
when K3 might fracture, it usually does not fracture 0.04 20 tip 21 or 25 mm
3–4 mm at the tip.
10) Fixed tapered, non-tapered, or viable tapers. There is no inherent or functional superiority
K3 is a fixed tapered instrument. This means that the of any one given pack configuration over another.
final prepared taper and tip size is inherently built Choosing any particular pack configuration over any
into the file. This is significant because some other file other is a matter of clinician preference. The above
designs require that the clinician blend several (po- statement notwithstanding, common empirical rea-
tentially many) RNT files to create a continuous taper sons for favoring one pack over another are listed here
from the orifice to the apex. With K3, if a 0.06 #30 or in discussion of the configurations.
35 file is taken to the true working length (TWL), the 1) The Procedure Pack is generally used in a
preparation is final and ready to obturate for an aver- straight crown down method, in essence using the
age molar tooth (unless the clinician desires to create files from larger tapers to smaller and from larger tip
larger apical diameters) and blending with additional sizes to smaller. Because of the diminishing tip sizes,
RNT files is not necessary to create the final ideal each K3 file should and does advance slightly api-
prepared canal shape. cally relative to its precursor as it is inserted (which is
K3 is available in six tapers: 0.12, 0.10, 0.08, 0.06, inherently crown down). For straight canals and mild
0.04, and 0.02. The 0.12, 0.10, and 0.08 are available in to moderate curvatures, as would be treated by most
20 I roots 1_ 2009
Tactile control
1) Passive gentle insertion. If the file resists ad-
vancement, undue pressure is not put on the file to
move apically.
2) Minimal engagement to avoid taper lock. Ide-
ally, each K3 insertion will cut 1–2 mm of dentin and
after irrigation and recapitulation, the next K3 in the
sequence is inserted.
3) Creation of a glide with hand files. Manual pre-
flaring of a canal with hand files give the K3 (and all
RNT files) a path to track to avoid debris blockage and
locking of the tip in a previously unexplored portion
of the canal.
4) K3 is never left stationary in the canal. The file is
either inserted or withdrawn, but never left rotating
at the same level.
5) K3 is inserted in 2–3 seconds to resistance and
then withdrawn, the file is not arbitrarily pushed api-
cally if it does not want to progress. The motion is con-
tinuous and controlled and engagement of the flutes
Figs. 5a–7b_Clinical cases treated general practitioners, this is an excellent choice for a of the file should be minimized to the greatest extent
with the K3 as described. single pack configuration (Fig. 3a). possible, ideally to 1–2 mm per insertion. The same K3
2) The G Pack is preferred by some because the is never reinserted repeatedly to the same level in the
files may progress more rapidly toward the apex than canal. There is no value in such a motion.
with some of the other configurations. Diminishing 6) The M4 Safety handpiece is an excellent adjunct
taper (as opposed to diminishing tip sizes) allows the to the K3. The M4 is a reciprocating handpiece attach-
K3 file to move apically with efficiency. Some believe, ment that can take hand K-file, reamer, or Hedström
with various tapers, that this pack can treat a slightly files (among others) and move the files alternatively
greater range of anatomy than with the Procedure 30 degrees clockwise and 30 degrees counterclock-
Pack (Fig. 3b). wise. The M4 fits onto any E type attachment of an
3) The VTVT Pack is favored by some because with electric motor. The M4 saves time, hand fatigue and
the variation in taper, with progressive insertions, makes predictability a hallmark of initial hand file
torsional stresses on subsequent files decrease due negation of canals. For example, if a MB2 canal is
to minimized engagement relative to a reinsertion of narrow, has multiplanar curvature and is difficult to
the taper. Many endodontists favor the VTVT Pack for initially negotiate to the EWL, use of the M4 can make
this reason (Fig. 3c). enlargement of this space simple and predictable to
4) K3 is used either crown down or step back. When the size needed for a glide path. In clinical practice,
using K3 crown down, the file is used from larger the #6 hand K file is placed to the EWL, which clinically
tapers to smaller or from larger tip sizes to smaller. can often be felt as a pop as the hand K file exits the
Moving down the root, the given K3 files are advanced apical foramen just beyond the minor constriction.
until the clinician reaches the estimated working Once the #6 drops to length, the file is left in the tooth
length (EWL), and then the TWL is taken with an elec- and the M4 is placed onto the hand file under the
tronic apex locator and the preparation finalized. rubber dam and in the tooth. With a full depression
If K3 is used step back, the clinician uses smaller of the foot pedal and the motor set on 900 rpm and
K3 files initially in an attempt to reach the EWL and the 18:1 setting, the M4 is activated and the file will
establish TWL as rapidly as possible with an electronic reciprocate clockwise and counterclockwise as noted
22 I roots 1_ 2009
above. With amplitude of 1-3 mm for approximately with any RNT brand desired.
15 seconds, the file is moved vertically and apically
with a gentle and passive motion. Usually, in ap- What is the most common sequence of K3 use?
proximately this period the initially restrained #6 is Common sequences of K3 include:
able to move freely in the canal. The orifice of the a. crown down from larger tapers to smaller and
canal is irrigated and the canal recapitulated. Then a from larger tip sizes to smaller, if the tactile control
#8 is placed and the process repeated, a #10 is then is correct.
used, etc. until the desired initial diameter is present. b. Step back, using K3 from smaller to larger
If the ideal initial negotiating file is a #8 or #10 based tapers.
on the initial anatomy of the canals, these files can Literally, for both of these techniques, the K3 files
certainly be used first instead of the #6. It is difficult can be placed from the pack configurations into the
to fracture a file with an M4; the technique is very safe sponge in the same order they were packaged and
and highly effective (Fig. 4). the files are used in this order, crown down (primarily
larger to smaller) or step back (primarily smaller to
Expanded K3 functionality larger) as described here.
1) 0.02 tapered K3 files offer a powerful arsenal In both of these techniques, initial negotiation and
of options, especially in negotiating several apical creation of a glide path with hand files is essential to
third curvatures. Clinically, if, for example, a canal precede the K3 in the given portion of the canal being
has a glide path created with the M4, the 0.02 #15 K3 enlarged.
can be brought into the canal to the EWL or TWL. The
initial enlargement of the canal path that is made in Is K3 stiff?
this manner with the 0.02 #15 can be enlarged to a K3 is not inherently stiff. The “feel” of K3 in one’s
#20 with the 0.02 #20 K3. This creates an excellent hand has no translation to its clinical function. Clini-
pathway for the subsequent sequence of K3 instru- cally, if K3 is used appropriately (correct rotational
ments that will be used, irrespective of the pack con- speed, method of insertion, engagement, etc.) it is
figuration or whether the sequence is crown down or more than flexible enough to handle even the most
step back in nature. challenging curvatures.
2) K3 can create larger apical diameters as desired.
Since the 0.04 tapers are available to a #60, the 0.06 How many times can I use a K3 file?
is available to a #60, and the 0.02 is viable to a #45, Individual preferences vary. I generally use my
K3 can be used to prepare apical diameters of virtu- K3 from 3–5 molar teeth. If there are any wear
ally any diameter short of an open apex (i.e., 60 and marks, stretches, kinks, bends, etc., it is discarded im-
above). This flexibility is not a common feature of the mediately. Smaller taper and tip sized K3s might be
RNT systems available on the market. The value of this discarded after a single use (0.02 #15 and #20 files)
functionality cannot be overstated as the endodontic and the larger tapers, a 0.04 and 0.06 above a #20 can
literature is very clear that larger final prepared api- be used more often.
cal diameters create cleaner canals relative to smaller
ones. Can I match my K3 preparation with gutta- percha
3) K3 can be rotated at a wide variety of speeds points?
depending on the wishes of the clinician. SybronEndo Matched K3 gutta-percha is available. The final
recommends that K3 be rotated at approximately 350 prepared taper and tip size of the K3 file is matched
rpm, but some have advocated its use at up to 900 rpm by a gutta-percha point with little if any adjustment
and faster for removal of gutta-percha in retreatment of the cone being necessary.
(up to 1,500 rpm). What is clear is that if the tactile
control over K3 is correct, the files can be rotated at What do I do if I can’t get a hand file beyond some
higher speeds than 350 and done so very efficiently. level in the canal? Do I use K3 to the level of the block-
age and then fill at that level? Will this reduce my
K3 FAQ success?
Can you run K3 with any type of electric motor? Part of the answer depends on whether the area
Does K3 have to be used with torque control? of blockage could once be bypassed or not. If the
K3 can be used with any brand of electric motor, blockage could never be bypassed from the start of
corded or cordless. K3 can be used with torque con- treatment, it may or may not be negotiable. If the
trol, but it does not have to be. Many endodontists use level of the canal that is now impassable was once
K3 (and other RNT files) with the torque control off. negotiable, the blockage has obviously been created
by the clinician and the chances improve somewhat
Can K3 files be used in coordination with other RNT that bypassing can be achieved.
file brands? If referral is an option, such an event is often an
While K3 is a complete system, K3 can be combined indication for referral, especially, if the given block-
roots
1
_ 2009 I 23
age was not present earlier in treatment. Precurving ideal position for obturation might be short of the
hand files for use in such situations is essential. Such minor constriction and others make a distinction be-
bending (a small J bend at the tip of the file) allows tween vital and necrotic cases, with vital cases filled to
the hand file to negotiate the canal more easily, espe- just short of the minor constriction and necrotic cases
cially a curved canal. The EndoBender (SybronEndo, obturated to the minor constriction. It is beyond the
Orange, Calif.) is an excellent instrument for this pur- scope of this paper to comprehensively review these
pose. In a canal filled with irrigant and a precurved concepts. With tactile control, the use of a bleeding
hand file, the clinician should make every effort to point determination, the electronic apex locator and
bypass the blockage to regain canal patency. This possibly radiographic information, the position of
effort to bypass the blockage may take many hand the minor constriction of the apical foramen can be
files and repeated insertions from different orienta- determined very accurately. With K3’s functionality,
tions to determine if there is any negotatible canal preparations can be made with enhanced MAFs to the
space. There is value, of course, in taking a radiograph minor constriction as needed.
to see if visible canal transportation has occurred
or perhaps a separated file is blocking the canal, What do I do if I want to advance the K3 file in my
amongst other possible sources of obstruction. If sequence and it does not want to advance?
the canal can be subsequently negotiated by hand As with all RNT files, the K3 should never be forced
and the blockage bypassed, the glide path should be to move apically. If, for example, using a G Pack, the
reestablished (an M4 would be very helpful for such 0.08 orifice opener has been used to the point of the
a task) and the smaller tapers and tip sizes of K3 used first curvature and the 0.06 does not want to progress
first to create a minimal diameter. Subsequently, the passively beyond this first curvature, the clinician
final apical preparation of the desired taper and tip would go to the 0.04 25. This should progress slightly
size can be created. beyond the initial root curvature. If the 0.04 will not
allow initial engagement beyond the desired level,
How do I know when to stop the preparation? the clinician can then move to the 0.02 tapered K3 25,
When am I done with K3? which should easily advance beyond all but the most
Globally, most clinicians will finish their apical severe curvatures.
preparation to approximately a #25 or 30, but the Alternatively, the clinician can create more taper
rationale and methodology for creating master apical above the point of resistance (by using the 0.12, 0.10
diameters varies widely. There is strong evidence in the and 0.08 tapered 25 K3) and then attempt to place the
endodontic literature that larger apical preparations .06 again into the root beyond the curvature.
result in cleaner canals. One method to determine
what the ideal master apical diameter might be is to How are irrigation and patency maintenance in-
gauge the canal, i.e., determine the initial diameter serted into the K3 sequence?
of the minor constriction of the apical foramen. To Irrigation and maintenance of patency with hand
gauge the apex, the clinician can determine the hand files (0.08 file size, slightly past the apical constric-
file that meets resistance at the minor constriction for tion) are ideally performed after every K3 insertion.
the apical foramen and from this measurement make Frequent irrigation and patency maintence keeps the
a determination of the ideal final prepared diameter. canal open and negotiable, thereby preventing apical
For example, if a #30 hand K file meets resistance at debris blockages and minimizes the possibility for
the minor constriction and will not pass with mild iatrogenic events. The importance of such irrigation
pressure, the master apical preparation can be taken and patency maintenance cannot be overstated in the
to a 45. While this is certainly not an exact science, this context of prevention of iatrongic events of all types
allows the canal to dictate the final preparation rather (separated instruments, ledging, perforation, etc.).
than imposing onto the canal an arbitrary MAF. Blockages can easily lead to deflection of instruments
away from the true canal path and cause iatrogenic
Where should I stop the preparation exactly and issues.
how is this influenced by K3? Enlargement should take place with a sequence of
There is no universal agreement about the ideal insertion, irrigation and patency maintenance. Ide-
filling point of obturation. Rationales and method- ally, and especially in difficult curvatures and calci-
ologies vary as to the ideal filling point. In practical fied canals, this irrigation and patency maintenance
clinical terms, the minor constriction of the apical should optimally take place after every K3 insertion.
foramen is the natural termination point for instru-
mentation, irrigation and obturation. The position How do I know when it is time to throw a K3 file
of the narrowest diameter of the minor constriction away?
is accurately determined by the use of an electronic If a kink, bend or deformation should appear with
apex locator and often confirmed with a bleeding K3, it should be immediately discarded. Torsional
point determination. Some would argue that the stresses and cyclic fatigue stresses on files are cu-
24 I roots 1_ 2009
mulative; when in doubt, the file should always be clinician may place each RNT into a handpiece at-
discarded. tachment. Exchanging the attachments into the
handpiece (corded or cordless) is far more efficient
Can I use K3 to remove gutta-percha, pastes and than replacing each single RNT into the attachment.
warm carrier based products? While there is an initial investment in attachments,
Yes. Usually, such procedures are performed by these multiple attachments can save valuable time
endodontists and done so at enhanced rotational between instrument switches.
speeds, from 900 rpm to 1,500 rpm. Use of such 7) Preoperatively the tooth should be evaluated
enhanced speeds requires experience, caution and for all foreseeable risks of possible iatrogenic events.
clinical judgment. Coincident to this evaluation, the clinician should de-
termine what the anticipated final taper and tip size
All RNT systems are optimized by the following of the preparation might be. The final prepared taper
strategies. is generally a 0.06 taper throughout the length of
1) Use of a surgical operating microscope (SOM) the preparation for most of the teeth treated in both
(Global Surgical, St. Louis, MO, USA). A clinician can specialty and general practice. Thus, it is certainly
never have enough lighting, magnification and visu- possible that the final prepared taper and anticipated
alization in endodontics. tip size can change after the tooth is opened. It must
2) Manual preflaring of the canal to create a mini- be remembered that the tooth dictates the shape of
mum #15 sized glide path before RNT insertion. In the final preparation. The final and taper and tip size
essence, before a K3 is placed into any canal, the canal are not dictated onto the tooth by the clinician (Figs.
has an initial diameter of at least a #15 hand file. 5a–7b).
3) Lubrication is essential before insertion of a RNT
file. In vital cases with a great deal of pulp, a viscous A comprehensive view of the K3 RNT system has
EDTA gel (File Eze, Ultradent, South Jordan, Utah) is been discussed to allow the clinician to utilize the
appropriate until at least the greatest bulk of pulp instrument in clinical practice. Emphasis has been
is removed from the canals. After removal of the placed on:
majority of pulp and the chamber is cleaned, sodium 1) The instrument is asymmetrical in all of its
hypochlorite can be used as the primary irrigant in design characteristics and and, as a result, has little if
vital cases. In non-vital cases and retreatment, gener- any tendency to “screw in” as do many designs that
ally chlorhexidine is more commonly used. are more symmetrical.
4) Straight-line access is ideal. All files, hand and 2) As with all RNT files, a glide path is advised. The
RNTs, should not deflect on insertion into the canals. M4 safety handpiece is a very useful adjunct to K3
5) The clinician must appreciate at all stages of the technique in creating the glide path.
enlargement process the EWL (and TWL once known) 3) K3 can be used crown down or step back. In
to correlate the position of the RNT file tip to minimize either event, insertion of the file is gentle, passive and
the chances for apical transportation via inadvertent should minimize engagement of dentin.
insertion through the minor constriction. 4) K3 is a complete system from which enhanced
6) The RNT files should be lined up on the sponge master apical diameters can be created for a wide
in the expected order of use or, alternatively, the range of clinical anatomies.
roots
1
_ 2009 I 25
G
lobally, the endodontic questions asked clean and shape the canal space from the orifice to
by general practitioners are very com- the minor constriction (MC) of the apical foramen
mon. Two of the most frequent are ad- and do so in a way that minimizes or eliminates the
dressed here. While the specific instru- risk of subsequent vertical fracture. Inherent to safe
ments used to accomplish a root canal may vary, the and efficient canal enlargement is adherence to the
principles advised in the answers are universal. At primary principles of canal preparation (maintain-
the heart of each of the answers is a goal to remove ing the MC in its original position and size, keeping
bacteria to the greatest extent possible from the root the canal in its original position and only enlarging
canal system, obturate the canal system in three it in the shape of a tapered funnel with narrowing
dimensions and create a post endodontic coronal cross-sectional diameters). Secondary goals of
seal as soon as possible after treatment. These goals canal preparation are to prepare a canal that has a
are consistent with the goals of endodontic canal taper and size to optimize irrigation and obturation.
enlargement, which are to: three-dimensionally With these goals as a foundation, the following two
clinical questions are answered.
26 I roots 1_ 2009
roots
1 _ 2009 I 27
28 I roots 1_ 2009
30 I roots 1_ 2009
several common challenges when using EALs. While can negotiate the canal by hand to this level with a
electronic apex locators are marketed as though small hand file.
they can be used with blood, purulence and sodium 2) Once a hand file reaches the EWL, TWL is taken
hypochlorite in the canal (among other solutions), with the EDU for the first time and instrumentation
empirically I have found that their accuracy is not as commences with the TF, using a taper as described
favorable with liquid in the canals — i.e., they func- above. After canal enlargement is completed, the
tion better in a dry canal. In addition, in the event of a TWL is taken again with the EDU and canal prepara-
faulty reading, the largest file that can reach the MC tion finalized. After the preparation is finished, the
should be used, the file should not touch the metal of EDU is used to reconfirm the TWL. This second deter-
the crown (if one is present), and the first thing that mination of TWL is made because the canal will get
should be done in the event of a faulty reading is for slightly shorter during preparation, although the loss
the clinician to check all of the unit connections to of length is generally fairly small, 0.5 to 1 mm.
make certain that they are inserted correctly. 3) After canal preparation is finalized and the EDU
It is essential to appreciate that an EAL reading is used as noted above, the EDU measurements are
should be one of a number of various pieces of con- confirmed with a bleeding point. The bleeding point
firming information to alert the clinician as to the is taken with paper points and the position of the MC
true position of the MC of the apical foramen. First of the apical foramen is finalized for the purposes
off, the clinician should appreciate that the hand file, of obturation using this method in my hands. The
which just passes the MC, often gives the clinician the bleeding point is determined using a paper point that
feeling of a “pop” as it passes out the apical foramen. just spots with moisture or haemorrhage at the tip,
The hand file used to accomplish this is small, #6, 8, generally about 1 mm at the position of the MC. This
10, and is precurved during negotiation of the canal. spotting is consistent and reproducible.
If the clinician is careful to make note of the position 4) Some clinicians will place the master cone back
of the initial “pop” of a hand file (if one is detected), from the MC by 0.5 to 1 mm to prevent the extrusion
he or she will find that this is virtually identical to of sealer and obturation material. If the position of
the position determined by a subsequent “bleeding the MC has been determined accurately, it is optional
point” with a paper point and the EAL reading. Feel- and not a step that I personally take. Aside from
ing a tactile “pop” at the MC also has value in telling creating the correct shape of preparation to the MC,
the clinician that he or she can negotiate the canal to applying the correct amount of sealer and achieving
the MC and that if the canal patency is subsequently excellent cone fit and tugback are all methods to
lost, this was due to something that the clinician prevent extrusion.
did rather than being due to a calcification or other
blockage that is related to an anatomical challenge The answers to two clinically relevant questions
in the root canal system. have been discussed to help guide clinicians when
making decisions with regard to the final taper of
While there are as many methods to determina- their canal preparation as well as to aid in the preci-
tion of true working length as there are clinicians, sion of the termination point of that obturation.
what follows are my common methods. Emphasis has been placed on creating a taper that
1) I do not take radiographs during treatment allows adequate irrigation and obturation, but that
unless there is an imperative reason to do so. From does not put the root at risk of a subsequent vertical
the initial radiographs, an estimate is made of the fracture or strip perforation. In addition, determining
true working length (TWL), this estimated working TWL in a dry canal and understanding the limitations
length (EWL) is usually very close to the true working and capabilities of electronic means of electronic
length. The EWL is held in mind until the clinician TWL determination are essential (Fig. 8).
roots
1
_ 2009 I 31
Nonsurgical therapy
of mucosal and
cutaneous fistulae
Author_Arnaldo Castellucci, Italy
O
nce the pulp tissue has become A slow inflammatory process thus begins in the
necrotic, the products of cellular tissue contained within the periodontal ligament. Left
degeneration, bacterial toxins and to itself, it may manifest in a variety of ways ranging
occasionally the bacteria themselves from simple widening or thickening of the ligament
within the canal, spread through the to granuloma or cyst.
apical foramen or the various lateral foramina into The increased space of the periodontal ligament in
the surrounding periradicular tissue. this area is due to resorption of the surrounding bony
trabeculae with secondary fusion of the connective
tissue of the periodontal ligament with the inter-
trabecular connective tissue of the medullary spaces.
The fibers of the periodontal ligament, which become
disordered and dysfunctional, lose their insertions
in the surrounding bone. However, their insertions
in the cementum, particularly in the periphery of
the lesion, are preserved. The pathological entity
commonly known as a granuloma develops in this
way. Sometimes, the inflammatory process also in-
volves other cellular elements within the periodontal
ligament, namely epithelial rests of Malassez, which,
when stimulated to proliferate, give rise to a cavity
and a radicular cyst.25
In its various clinical manifestations, chronic
apical periodontitis is generally asymptomatic. It is
usually discovered on routine radiographic checkups,
which on occasion is prompted by suspicious discol-
oration of the dental crown. The patient may relate a
history of acute (pulpitic) pain that spontaneously re-
solved or a history of trauma, but he may also present
with a completely unrevealing history. Sometimes,
Fig. 1a_Preoperative radiograph of
the upper left central incisor with a
a fistula may be present, through which the patient
necrotic pulp caused by preceding reports having noticed an intermittent discharge of
trauma. pus (Figs. 1a–f).
32 I roots 1_ 2009
Fig. 1f
Fig. 1e Fig. 1f_One year recall.
roots
1 _ 2009 I 33
Fig. 2a Fig. 2b
34 I roots 1_ 2009
online
now!
www.dental-tribune.com
I trends_ fistulae
Fig. 2g
Fig. 2h Fig. 2i
Fig. 2i_Six-month recall.
36 I roots 1_ 2009
Fig. 4e Fig. 4f
Fig. 4f_Two-year recall.
roots
1 _ 2009 I 37
Fig. 6c
Figs. 6d_Postoperative radiograph.
38 I roots 1_ 2009
W ctinomycosis.
Conclusion
Endodontic lesions with a fistulous tract should
always be welcome in our office. And this is true for
many reasons:
W The tooth responsible is necrotic, therefore the
fistulous tract will help in the diagnosis: the the right treatment.
radiograph will immediately show the tooth
responsible. The presence of a fistula, in conclusion, is not an in-
W The patient will never have a flare up. The re- dication for extraction, is not an indication for surgery,
crudescence after treatment or retreatment is is not an indication for any specific medication: it is
nothing more than one little drop of pus coming just an indication for a correct root canal treatment.
out from the fistula, and the patient is not even
aware of it. References:
W One week after cleaning and shaping of the root 1. Baumgartner, J.C., Picket, A.B., Muller, J.T.: Microscopic examina-
tion of oral sinus tracts and their associated periapical lesions.
canal system, the fistula is gone, and this will J. Endod. 10:146, 1984.
confirm that we made the right diagnosis and 2. Bella, G., Russo, S., Messina, G., Badalà, A.: Considerazioni sulle
roots
1 _ 2009 I 39
40 I roots 1_ 2009
_About the author roots
Dr. Arnaldo Castellucci
Dr. Castellucci graduated in
medicine at the University of
Florence in 1973 and special-
ized in dentistry at the same
University in 1977. From 1978
to 1980 he attended continuing
education courses in endodon-
tics at Boston University School
of Graduate dentistry with Prof.
Herbert Schilder. As well as running a practice limited to en-
dodontics in Florence, Italy, Castellucci is past president of the
Italian Endodontic Society, past president of the International
Federation of Endodontic Associations, an active member of
the European Society of Endodontology, an active member
of the American Association of Endodontists, and a visiting
professor of endodontics at the University of Florence Dental
School. He is editor of The Italian Journal of Endodontics and of
The Endodontic Informer, founder and president of The Warm
Gutta Percha Study Club and The Micro-Endodontic Training
Center, and he is international editor of Endo Tribune. An in-
ternational lecturer, he is the author of the text “Endodontics,”
which is now available in English.
!
,
!"#! !$ %$!"
-
(.'/0,0,
,
#&!'! ()** $!
1
"!# !"$%
&' 0
,
*%# *"!
This article is an excerpt from !"%
&
'
Dr. Arnaldo Castellucci’s textbook
“Endodontics,” which is divided into
three volumes and 35 chapters.
!"#$$%&''#(' )*&$+&+(+%&%
Volumes 1 and 2 of this endodontic
textbook are now available for the
first time in English, completely
revised with new chapters and many
more color illustrations. Each volume
( ) *
comes complete with its own CD-
+*
ROM, which includes the complete
text and illustrations in PDF files.
To order, contact Il Tridente S.R.L.,
,
Viale dei Mille 60, 50131 Firenze,
Italy, Tel. +39 055 500 1312,
"!# !+-
&'.
!+-"/
& '
Ceramics-based sealers
as new alternative
to currently used
endodontic sealers
Authors_ Deyan Kossev & Valeri Stefanov, Bulgaria
T
he most ideal outcome of an endodon- This equilibrium can easily be destroyed when due to
tic treatment is hard tissue closure, different reasons human body’s reactivity is changed
which permanently separates the root and existing balance is “pushed” toward appearance of
canal content — the root filling — from pathologic periapical changes.
the periapical tissues and prevents That is why the quest for endodontic sealers that
chronic irritation and foreign body reactions by adhesively and chemically bond to root canal walls
material components.7 Good instrumentation and continues. Clinical use of Bis-GMA based sealers in
cleaning of root canal combined with perfect combination with polycaprolactone made cones is a
hermetic closure of its apical third are decisive promising step ahead,5,10 but in the area of the root
preconditions for achieving of full closure of root canal apical third these materials are in constant
canal apical orifice with cementoid tissue. Closure of contact with wet environment of periodontium and
the root canal in this way ensures non-problematic are subjected to action of enzyme systems there.
and long-term function of the root in naturally wet Reported data about alkaline and enzyme hydrolysis
environment surrounding it. of polycaprolactone and the shrinkage of Bis-GMA
Today’s “golden” standard for endodontic treat- based sealer question the long-term stability of api-
ment are warm condensation multi phase (gutta- cal third hermetic seal achieved by these endodontic
percha — sealer ) techniques. These techniques, sealers.2,8,9
however, result in a friction fit, “cork-in-the-bottle”
type sealing only. In the era of adhesive techniques ‘Endodontic grafting’
in dentistry we have an endodontic standard, which Filling of the root canal apical third must be looked
lacks adhesion and chemical bond between root canal upon separately from the filling of the rest of the canal
dentin walls and root canal filling materials. Visualiza- having under consideration the active and constant
tion of sealer “puff” in periapical space on radiography metabolic processes occurring in the periapical area.
does not give enough grounds to say that seemingly Special attention must be paid to the interface formed
adequate root canal filling is an absolute guarantee of between dentinal root canal walls, gutta-percha and
successful healing result.1 Shrinking of gutta-percha sealer on one side and periodontium and body fluids
after the end of warm condensation and lack of adhe- on the other side. Long-term hermetic sealing of apical
sion of the root filling materials to dentinal root canal third achieved in constantly wet environment is an ob-
walls are factors creating enough predispositions ligatory condition to ensure lack of microbial growth.
for micro leakage. The known fact is that the hu- Another extremely important factor promoting hard
Fig. 1_Polarisation microscopy.
Horizontal cut. Dark green — dentin,
man body’s immune system can easily deal with this tissue closure of the canal is presence of osseocon-
white — bioceramic-based sealer situation when titer of microorganisms is low. That ductivity as sealer’s feature. Perfect and lasting in wet
iRoot SP, orange — gutta-percha capability of immune system is demonstrated by lack environment hermetic seal of apical third combined
cone. of periapical pathology and subjective complaints. with osseoconductivity of endodontic sealer ensure
42 I roots 1_ 2009
conditions for hard tissue closure of root canal apical I. Preparation of “coronal reservoir” from which
orifice in time. Filling of the root canal with ceramic ceramic sealer to be condensed aside to canal walls
sealer, which due to its osseoconductivity action and toward and into canal’s apical third so that to seal
promotes the physiological closure of the canal by the canal’s apical orifice.
cementoid hard tissue, can be called “endodontic Using RGG or GG drills, the coronal third of the
grafting.” Such endodontic grafting can ensure the root canal is conically widened to form a “coronal
lasting root’s health while it constantly remains in reservoir,” which is subsequently to be filled with MTA,
contact with body fluids. BioAggregate, iRoot SP or iRoot BP material.
The use of bioceramic-based sealers with their fea- From this point on, there are two different ap-
tures — osseoconductivity, hydrophylity, adhesiveness proaches:
and chemical bonding to root canal dentinal walls — A. “Coronal reservoir” is filled directly with ready-
Fig. 2_Plastic applicator inside
appears to be an effective approach to eliminate (Fig. to-use material packed into syringes (iRoot SP or iRoot simulated root canal “coronal
1) on long term, the microspace, otherwise remaining BP). Mini applicators included in the package are used reservoir.”
between the root canal walls and the materials filling for direct filling of reservoir with factory premixed
the root canal. Such microspace is a potential place for material.
possible microbial growth, because of microleakage B. Powder-like ceramic material (MTA or biocer-
observed with other kind of sealers. amic-based BioAggregate) is mixed with distilled wa-
ter to form a paste with suitable viscosity to allow car-
Sealers for ‘endodontic grafting’ rying it into the “reservoir” by plastic carrier designed
Endodontic sealers that set hard and are stable in by the author. Micro applicator handle, with “fluffy”
constantly wet environment are : head cut, may be used instead, too. (Fig. 2)
a. Recently created calcium — silicate — phos- The dentist can fold the plastic carrier as needed
phate-based bioceramic nano-compositions — Bio- to make it suitable to easily get inside the “coronal
Aggregate, iRoot SP and iRoot BP (IBC, Canada). reservoir.” Small portions of “ex tempore” mixed sealer
b. MTA-based products — “MTA — Angelus” (AN- are carried into the “reservoir” until it gets full. It is im-
GELUS, Brazil), ProRoot (Dentsply, USA), Aureoseal portant to work in constantly slightly wet root canal.
(OGNA, Italy). Before putting next small portion of MTA or BioAggre-
The common feature of all these products is that gate sealer into reservoir, the dentist visually controls
when used to fill the apical third of the root canal, they the moisture of the sealer mass. If necessary the tip of
guarantee adhesive hermetic seal.4 They do not get the plastic carrier is wetted with distilled water and
destroyed during their hardening and afterward while put inside the reservoir to increase the humidity of the
being constantly in contact with the wet periapical sealer mass inside. Thus the risk of drying of material
environment. They are very stable in time. Ceramic- at the bottom of the reservoir is avoided and ceramic Fig. 3_Condensor inside simulated
based sealers ensure much better apical seal than IRM, sealer is prepared for condensation further inside the root canal down to 1 mm less than
amalgam or Super EBA materials, and this excellent root canal. WL.
seal is combined with excellent biocompatibility and
significant stimulation of periodontal regeneration.5,6 II. “Capillary condensation” of the sealer to fill the
Until recently the application of all these materials, root canal
except for iRoot SP and iRoot BP, required significant This stage is valid for both (A and B) types of ce-
widening of the root canal apical third — up to #60–70 ramic sealers. Condensation of the sealer is made with
— and use of specially developed instruments to carry “condensor” — an instrument designed by the authors
the materials to apical third of the canal. These purely (Fig. 3). The basic rule is correctly chosen instrument
technological limitations were reducing ceramic- to get freely inside into root canal within 1 mm less
based materials use as regular antegrade root canal than canal’s measured working length (WL). In case of
filling materials. straight canals the number (#) of the instrument must
The first author has developed an innovative be one number (#) less than MAF. In slightly or severely
method for filling of apical third of the root canal with curved canals the number (#) of the used instrument
MTA- and bioceramic-based sealers he has called the must be two to three numbers (#) less than MAF. It is
“capillary condensation” technique. This new tech- preferable to use NiTi made instruments, especially in
nique does not require enlargement of the canal’s curved canals.
apical third more than # 35-40 / 04. Apical third of By pushing the condensor slowly in and then get-
canal space is widened based on its original size and ting it out, without taking it totally out of “coronal
shape only. reservoir,” the sealer is condensed inside the canal,
aside to canal’s walls and at the same time toward its
Method for ‘capillary condensation’ of apical orifice, down to previously defined depth of 1
ceramics-based endodontic sealers to fill mm less than WL. Condensation must be done slowly Fig. 4_Condensor in the moment of
the root canal and with maximum possible amplitude of the “push- “take-out” movement start (compare
Method comprises of several stages: in” and “take-out” movements (Fig. 4). to Fig. 3).
roots
1 _ 2009 I 43
When condensing the powder-like ceramic seal- densor, the dentist must also choose the same size
ers (MTA-based or BioAggregate) that are mixed “ex gutta-percha master cone. Inserting of the gutta-
tempore” before use, there should not be a tactile percha cone inside the canal will serve three functions
feeling of “tightening” of the instrument inside the simultaneously.
canal during condensation. If such a feeling appears,
the dentist must take the condensor totally out of the A. It will finish the condensation of the sealer
canal and must wet the tip of the instrument with wa- inside the root canal and will make sealer layer along
ter before inserting it inside the canal again. The total the canal’s length even. It will eliminate any air still
time for the sealer’s condensation is approximately entrapped inside the canal, too.
10–15 seconds. Between 12 and 15 “push-in/take out”
movements are needed to achieve a good filling of the B. It will create a pliable space inside the canal with
canal’s apical third and to ensure good adhesion of the which to accommodate the stress created by expan-
sealer to canal’s walls, too. Ten seconds after the start sion of the ceramic sealers during their hardening.
of condensation (approximately 10 “push-in” move- Bioceramic-based sealers BioAggregate, iRoot SP and
ments) the dentist must take the instrument out of iRoot BP have significant expansion of 0.20 percent.
canal. There should not be hardened aggregates on
the instrument’s surface, but only liquid white solu- C. By inserting the gutta-percha cones the pos-
tion. Then one must look at the bottom of the “coronal sibility for re-entering the canal is maintained, and
reservoir.” If there is a “black hole,” this means more easier preparation of calibrated “bed,” for cementing
water must be added to the sealer inside the reservoir. a fiberglass post inside, is ensured.
The tip of plastic carrier is wetted with water and is put
inside the reservoir. This is to be immediately followed The master gutta-percha cone is inserted slowly
by adding one more small portion of the mixed sealer with “push-in” and “take-out” motions down to 1
into the reservoir. Important note: Do not add water mm less than WL. Additional smaller diameter gutta-
when using bioceramic-based iRoot SP and iRoot BP percha cones may be added, if necessary. The ends of
sealers! Only the additional portion of sealer must be gutta-percha cones extending out of the root canal
added when using iRoot SP or iRoot BP! These two are cut and cones are condensed with round head
sealers are supplied premixed and “ready to use” and metal instrument. During gutta-percha condensa-
do not need additional water, they have already been tion excessive water and excessive sealer remnants
factory mixed to optimal viscosity to fill the canal are also pushed outside and are wiped out with small
properly. cotton pellet. A temporary filling is placed in the tooth
cavity. After the ceramic sealer is hardened, preferably
III. Insertion of gutta-percha cones 24 hours after canals are filled, the final restoration
At the moment of choosing the correct size con- is made.
44 I roots 1_ 2009
Fig. 9a Fig. 9b
roots
1 _ 2009 I 45
46 I roots 1_ 2009
roots
1 _ 2009 I 47
A
The VDW.ULTRA ultrasonic device is able to deliver a constant and efficient performance
enhances endodontic treatment. n ultrasonic device in endodontics — why is for every application. The piezo-electric handpiece
it necessary? It is a fact that today’s endo- weighs only 50g and can be sterilized in the autoclave.
dontists can no longer think of endodontic Also classic periodontal and scaling applications can
treatments without ultrasound, not because they be carried out efficiently.
want high standard equipment, but because they VDW provides a high-quality tailor-made tip
know about the essential advantages the ultrasonic assortment for use in endodontics: irrigation files
technique provides for their endodontic treatments. for thorough ultrasonic cleaning and the removal
The increasing demand comes mostly from practices of bio film, diamond-coated tips for efficient fine-
that are either interested or specializing in endodon- preparation of the access cavity, fine tips made of
tics. For this reason VDW, the expert in endodontics, the novel (innovative) titanium-niobium alloy for
has developed an ultrasonic device especially for root delicate retreatments, as well as a robust tip to remove
canal treatment: the VDW.ULTRA®. metal posts with high intensity.
The main function of this device surely is the For more information, visit VDW online at www.
activation of irrigation: vibrations create air bubbles vdw-dental.com.
48 I roots 1_ 2009
must be combined into one Word document. If you need to make a list, or add footnotes You may submit images through a zipped
Please do not submit multiple files for each or endnotes, please let the Word processing file via E-mail, unzipped individual files
of these items. program do it for you automatically. There via E-mail, or post a CD containing your
are menus in every program that will help images directly to us (please contact
In addition, images (tables, charts, photo- you to do this. The fact is that no matter how us for the mailing address as this will
graphs, etc.) must not be embedded into the careful one might be, errors have a way of depend upon where in the world you will
Word document. All images must be submit- creeping in when you try to hand number be mailing them from).
ted separately, and details about how to do footnotes and literature lists.
this appear below. Please do not forget to send us a head
Image requirements shot photo of yourself that also fits
Text length Please number images consecutively the parameters above so that it can be
Article lengths can vary greatly—from a throughout the article by using a new printed along with your article.
mere 1,500 to 5,500 words—depending on number for each image. If it is imperative
the subject matter. Our approach is that if that certain images are grouped together, Abstracts
you need more or less words to do the topic then use lowercase letters to designate the An abstract of your article is not re-
justice then please make the article as long or images in a group (ie, 2a, 2b, 2c). quired. However, if you choose to pro-
as short as necessary. vide us with one, we will print it in a
Please put figure references in your article separate box.
We can run an extra long article in multiple wherever they are appropriate, whether that
parts, but this is usually discussing a subject is in the middle or end of a sentence. If you Contact info
matter where each part can stand alone are not directly mentioning the figure in the At the end of every article is a Contact Info
because it contains so much information. body of your article, when it appears at the box with contact information along with
In addition, we do run multi-part series on end of the sentence the figure reference a head shot of the author. Please note at
various topics. should be enclosed within parenthesis and the end of your article the exact informa-
be inside the sentence, meaning before the tion you would like to appear in this box
In short, we do not want to limit you in terms period. and format it according to the previously
of article length, so please use the word mentioned standards. A short bio may
count above as a general guideline and if In addition, please note: precede the contact info if you provide
you have specific questions, please do not us with the necessary information (60
hesitate to contact us. _We require images in TIF or JPEG format. words or less).
_These images must be no smaller than
Text formatting 6 x 6 cm in size at 300 DPI. Questions?
Please use single spacing and un-indented _Images cannot be any smaller than 80 KB in Please contact us for our Author Kit, or if you
paragraphs for your text. Just place an extra size (or they will print the size of a postage have other questions:
blank line between paragraphs. stamp!).
Managing Editor
We also ask that you forego any special Larger images are always better, and some- Fred Michmershuizen
formatting beyond the use of italics and thing on the order of 1 MB is best. Thus, if f.michmershuizen@dtamerica.com
boldface, and make sure that all text is left you have an image in a large size, do not
justified. bother sizing it down to meet our require-
roots
1 _ 2009 I 49
roots
the international magazine of endodontics
International Administration
President/CEO
Torsten R. Oemus
t.oemus@dtamerica.com
roots_Copyright Regulations
_the international magazine of endodontics is published by Dental Tribune America LLC and will appear in 2009 with one issue every quarter.
The magazine and all articles and illustrations therein are protected by copyright. Any utilization without the prior consent of editor and
publisher is inadmissible and liable to prosecution. This applies in particular to duplicate copies, translations, microfilms, and storage and
processing in electronic systems.
Reproductions, including extracts, may only be made with the permission of the publisher. Given no statement to the contrary, any
submissions to the editorial department are understood to be in agreement with a full or partial publishing of said submission. The editorial
department reserves the right to check all submitted articles for formal errors and factual authority, and to make amendments if necessary.
No responsibility shall be taken for unsolicited books and manuscripts. Articles bearing symbols other than that of the editorial department,
or which are distinguished by the name of the author, represent the opinion of the afore-mentioned, and do not have to comply with the
views of Dental Tribune America LLC. Responsibility for such articles shall be borne by the author. Responsibility for advertisements and other
specially labeled items shall not be borne by the editorial department. Likewise, no responsibility shall be assumed for information published
about associations, companies and commercial markets. All cases of consequential liability arising from inaccurate or faulty representation
are excluded. General terms and conditions apply, legal venue is New York, NY, U.S.A.
50 I roots 1_ 2009
❏ PayPal Name
subscriptions@dental-tribune.com Position
Organisation
Commerzbank Leipzig
Account No.: 11 40 201 Address
Fax form to: +49 341 484 74 173 or subscribe online at www.dental-tribune.com
Anschnitt DIN A4 06.03.2009 12:05 Uhr Seite 1
/ N . 5 8
a l l 1 0 . 2
ID S - H
Rotary NiTi instruments
FKG RaCe
NON-CUTTING SAFETY TIP
• Perfect control of the instrument
NON-THREADING DESIGN
• Alternating cutting edges
IMPROVED EFFICIENCY
• Sharp cutting edges
ELECTRO-CHEMICAL TREATMENT
• Better resistance to torsion and metal fatigue
Crêt-du-Locle 4 • CH-2304 La Chaux-de-Fonds - Switzerland • Tél.: +41 (0)32 924 22 44 • Fax: +41 (0)32 924 22 55 • info@fkg.ch • www.fkg.ch