j CHES / @ (An innovative technique to safely perform active cleaning in teeth with open apices: CAB technique) ¢ Alfredo landolo, Alessandra Ainato, Dn Abaena Giuseppe Pantaleo, Alberto Dagna’, Luca Ivaldi, Federica di Spirito, Se eae and Surery. Univesity of Salerno, Saleen, ‘Department of Clinical, Surgical Diagnostic and Pediatric Sciences, Seen oT perv: Enda Ut, Uri a a, te ces Gonna epee of Enodories, Fayo University of Alexandria, ATSXaNaee-Eaype bstract The cbrrent study cims to evcluce in vio the exrusion of NOOCI,vsing on arifcal root conal with an open opeX, using Aiferontednalirigation protocols. For this sud, @ woneporent ofc root canal wor used. The opex wos shoped fo be ‘oversized and ifeguarin form. Alter roo conel mechanical shaping, he oniicalofindscal chamber, which wos mode below the lorge epical fordmeg, wos filed with fuchsinestined bovine pup tssve, Alerward, igation protocols were cortied 01 and compored regarding their slay wih regrds To inigant extrusion. Subsequently the examiner ceoled two grOUPS, Group A: inemal heating eSodoted with ulesonic activation ond, Group 6: inlemal heating ossoccied with yliasonic aaivaon_uning the CAB ecnigiselt batter geese 8.25% solo hypocHonie TauFOn War Used % the iigont “Engvunieestnat pace vobeactne eee Te ocake ar aS war taken ond onaeed. Forte statistical nats Fes for ped semplee nor used Duan ot rigon beyond he ep ag acne aah bjeclveof endodontic reament she remove of Setined fons td basta. Forth rearon atv cleoing i cuca In endadontewostnent covey. feel Rctee eee a caeen scrotan wil ning he CAB technique wes en ffective ond safe technique to ensure no irigonexrusion beyond the SBenaper. Keywords: Internal heating, irigants, NoOCI, open opex, safety, ultrasonic tivation 5 a) INTRODUCTION to access or even completely inaccessible {Those areas can Boca ae erige oe aera (Nina tanger suas pens’ getecucuaed dents oe ang ‘significantly on adequate three-dimensional (3D) cleaning “canal mechanical shaping alone is incapable of reaching all ‘of the complex endodontic space alongside the root areas ofthe root canal system, regardless of the fechnique ‘anal shaping}ffollowing that, he complete obturation of tilized, leaving parts of the canal untreated, {{herefore, the complex ‘Oot canal system*(Possibly, a significant ix ig essential to carry out the endodontic biochemical 3D bereentagecfrootcanaureseanbetasedbythepresnct _jeaning for both accesible and inaccessible spac at ae eocly aces Sble to of deaned, it can be filled an iaand. “areas that age easily acceasible to hand and rotary les (main Gcaneds it can be filled and obturaved with gutta-percha and _. a ase.) “root-canals)(On the other hand (as confirmed by"many— _Sesler during the obturation phase.) J nical and hi cudies), some parts can be difficule : : Ny anc fstological z Re Bacteria and their woducts are the major cause of SITET done! (tess i ote Gon in The pulp. ané the. peapical tasue™ An PiOf. Alfredo landolo, ‘untreated root canal or improperly cleaned, shaped, and obturated can lead to the development or the persistence of a periapical lesion. \) of aperiapical lesion.) _ “isi pen aces Jounal anda dba nde eee ofthe Creve Commons Atributlon-NonCominrca- ShareAlike 40 License, which allows others to remix, weak, and tid pon te work ‘or-commercially, 3 long as approprite ered is given and the new creations ar Hisense under the identical erm For reprints contact: WKIILRPMedknow reprinis@weherskuwercom [Pies wenTandolo, etal: Collagen apical bartier technique (lone case often with uid oxapes ais, advisable tthe shaping must be minial)lecove, gation cannot be done actively = there'is a risk of irrigant extrusion beyond the apex."*fOne of the proposed safe irrigation techniques for tect with immature or open the pulp tissue at a hig 7a apices is_negative apical pressure\{This technique may Sotisane rit coon compere) avoid excrusion of irrigants beyond’tNe apex, but itis not inside the lateral anatomies and den inal tuba) hen treating tecth with immature apices associated with, Periapical lesions, the resistant biofilms can be formed in the main canal and dgep inside the lateral anatomies ‘and dentinal tubules!"@[For this reason, it is critical to, Asse high-performance activation techniques for irrigants. Consequently, 7 mcg ne me 1as been developedXThis technique permits irrigants’ activation, y case of an open apex, without risking the extrusion. seconds,flandolo at al. also showed tha at che apical and middle chieds, "he temperature never exceeds AO*C.ERIc is well proven sodium hypochlorice-at boling-temiperacure.can break Up ‘peed up to 210 times compared stabil sed on that, thisrecentirgantacivationeecbriqu, interna) featng conned with lego ac sage nic activation isan effective 3D ‘leaning technique that allows a deeper cleaning inside lateral natomies and even inside the dentinal ubules.™ ) (rater dentinal tubule penetration of NaOCl and ot canal cleanliness were improved significantly by ut intracanal-heated NaOCl. Gutrentstudy aimsto evaluate, in vitro using an arcificial ot canal with an irregular and open apex the extrusion of NaOCi through different protocols of canal irigation,) ¢ Hence, it is used after sufficient and minimal mechanical C\MATERIALS AND METHODS (of collagen beyond the apex in teeth with open apices. Cree ushed beyond the apex with suitable hand pluggen(only then, the irrigant activation can be inducted safelf"and ‘afecivey.) Gorer gue completion of irgang avon, the collagen canbe Tel Bajond the apex. Or canbe removed using 3 ‘modified small suction tp (Surgidp-endo, Clene, Sis) after cutting the first millimeters to guarantee its suction,) li shaping. The CAB technique Pag 1 \ 2 free are, several irrigant activation techniques, and the _ fost commonly used methods are the subsonic, sonic, and tragonic activation and the preheating joo etal. showed how sodium hypachloite preheated eA Artificial oot canal with large and irregular apex ‘was cred buwitowasing the CABtecnique’) 3 tn_Group_B, (in (ater sapng the oot canal the ai ates (3.4 mm in diameter and.6.75.mm-thick-wich-a— feeder aie wane oeaa” wie periapical lesion and covered with a histological slide." (an artical root canal 17 mm in length was used for this reseachifle was shaped using a ProTaper F330, 09, tapers (Protaper Gold, Dentsply Mailleer, Swiss), beyond the apex, then from the external sie of che apex, a hand file type K 0.80 was used to enlarge the foramen and fo create an irregular area. (major diameter 1.62 mm and Sterne orSmn)Pue TE yy” gine hee Ateruad, rue poupavere eaaraup An Cro.) Tera pvp, een) caperiners Sere cao or et otal for eperinnts Tne tne ae tot cat) was a standard in all the experiments, rc Grp sGeup (emaesigoowesy trae, rernal_ heating followed by ultrasonic activation was tone with the CAB technique. ) L_oulindies 6:98 mm below the apical foramen was filed with fuchsine-sined bovine pulp tissue to_simufatFigure3: Endodontic treatment of tooth number 2.1 with an open CAB technique, (c) Postoperative radiograph showing obturation For Group A (without CAB technique), the irrigant was -aitaly deivered with 3 30G, side-vented needle (CanalPro Figure 4: Group A showing color change resulted from irrigant extrusionirrigant extrusion. Figure 5: Group B showing no color change resulted from no irrigant extrusionirrigant extrusion y Ge each experiment, the fuchsine-stained bovine pulp ~ Ntissue was changediffne insertion of the fuchsine-stained ~ bovine pulp tissue was done using a x20 magnification to =. ensure Precision.) the two groups, room temperature 5.25% sodium pochlorite solution (CanalPro, Coltene, Swiss) was used ‘as the irtigant{The irrigant extrusion was calculated by evaluating the Oo “ eylindrical chamber. (ne duration of each test for all the twenty experiments Nwas 10 ssn amount ofirigantforeach testwas6 ccs. “The same operator performed all the trials foto, eal: Collagen apical barrier technique apex. (a) Preoperative radiograph, (b) Insertion of collagen for (a) Follow-up at T-year showing healing, ee orn otyed by nal Retna chen ne aaah 5 ee en, 2 Ne source (Syste, KA, USA) wes set ce carrer used was the tip X-Fine 30/04 reach from the main canals engl During this phase, up-ané-down invementsf aout Samu eheXFne ip waremd) itvigation tips for Swiss), 2mm away from the heating was (« cach activation gee, 8s of internal Iternated with, 3¢ yLultrasonic_activation. (EndoUitra, See oung te servation ce, thet of the Gwnidenp wes fa hemi e.) Sees ettvaton le that and then aso. seine of pose wor allowed, and then, NeOCl W2s Teesheda ttl tive gles was performed) (eae Group B (CAB technique), the same protocol in Group, Twas used but before each experiment, a small part of collagen (Spongostan, Ethicon, USA) soaked in saline solution was positigned beyond the apex using a plugger calibrated at 17 tun) [Figure 2) ‘To ensure precision, the ten parts of collagen were cut under x20 magnification{After each testing, the collagen was removed and a new piece was inserted) For the forty experiments, the operator did potos of the ‘rtifcial cylindrical chamjer at_%20 before and after each ign ation gree pots were ag ws 2 ‘operating microscope \Kaps Som 32, Germany), Pvoughthe _ color change, the captured photos demonstrated hedge _-OF not chere-Was An exttusion of irrigant beyond the apex.) The photos were taken frog the same v Gl the Same distance and witht he same intensity of light. uring takigg each picture, the _sample-was.fixed in the sante pasion ptos of Grou > ‘A and Group B were analyzed to ev « jo the presence or absence of inrigant extrusion beyond the apex. > @ (cr of Conservative Dentistry | Volume 24 | Issue2 | March-April 2) 163Tandoo, ea: Collagen apical bares technique s for paired samples was used to assess the differences Corn ‘the test and control groups. The statistically significant eitference was evaluated berween the 80 groups, [C86 tenor, root canal feet ent of tooth number 2.1 with ‘pen apex was done using thy CAB technique [Figure 3) ‘A22year-old male patient was presented at ourcinie with Pain associated with the afeeriar maxillary aree. Upon ‘alographic examination, 4 periapical lesion was noticed nego he tooth had an open aifex caused ty ‘was performedy{tne shaping|phase was minimally done Using only @ hand Kee 0.20)QYcerward, a collagen barrier as inserted through the “ode canal beyond the apical foramen hen, the aD.iigatioh protocol was carried out using infernal heating fallowed fon, as Breviousiyexpainedfsing an ehdodenicsonation tp wth viendo, Catene) the Jon cit pe thet.)'S obverved Figure 3} Inthe 1-year Follow-up, healing RESULTS ‘In-Group A, all the experiments caus eyond the apex. In contrast, Grou in any of the tests, sed extrusion ofirrigant Apical extrusion ‘Only Group A was associated with extrusion ofthe itigant jeyond the apex. The CAB technique suggests that it was __Safe under the experimental conditions [Figures 4 and 3 EE ere caperimental conditions teria and their by-products are the major etiological “Lalisative factors of pulp and periapical infection, Modern, be to completely ove all the pulp tissue and Seer Fem ne we Wom the whore terature shows how problematic it ca mplex endodontic space Pa Ujtiermore, fo gain short- and long-term positive At is necessary t0 Use techniques and imply esiilts ( Ya jp Bshowedno extrusion _( The CAB technique explained in the curre technologies that increase the profundity of root canal leaning. Subsequently, itis crucial to perform icrigant activation, in all root canal treatment cases, abo¥e all in Open apex _ based) oweve a safe inigation technique for teeth with immacurlopen apices ea be the negative apical pressure and this cecnigue will not cause extrusion OF Wigane beyond the apedDespte this techniques safety, i lacks the force co pushe ltigant inside the lateral anatomies sve denn) J (The situation can be further complicated in teeth with immature ot open apices associated with periapical — sions The later case cam be accompanied by biofiims TNGIAE the main cangl and inside the lateral anatomies /— and dentinal tubules For this reason, it is essential to use high-performance uetvation techniques for ierigants, Consequently, the CAB technique, barrier technigu > collagen apical has been developed, which allows the activation of irrigants in case of an open apex withoure the tisk of extrusion beyond the apex. ) t ont study appears ~“to yield promising results 5 Irrigant activation techniques are many and vary.'%42 fonetheless, an effective and welltested 3D cleaning technique involves internal heating of sodium hypoct followed by ultrasonic act ‘technique, this powerful technique in cases of teeth with open apices. chlorice_ ith the sid of the CAB “can be used safely even, nuns, Crowes, the results ghined in this study should be ‘onfiemed by prospective clinical tals, \ > ¥) CoNcLUsions SONCLUSIONS __ (Goiy the protocol o niga sctivaton associated with the ie €0 avoid apical extrusion) Without ‘extruded béyond the Cu te ease of o “ Pen apices, the CAB technique allows ‘performing iri gan ne activation safely;Declaration of patient consent Te autos crt that thy hn bined a prop atient consent forms. In the form the patient(s) : sive hist consee for fisher soaps so other clinical information to be oun ; reported inthe our The ptenes understand at the nanes a all pled ah de flrs wl be made to coz their identity, but anonymity cannot be guaranteed Financial support and sponsorship Conflicts of interest ‘There are no conflicts of interest. _REFERENCES 1. van dor Sas LW, Vos, Wu MK, essai PR, Pastve axons Imegetion of te rock canal A rvow of fa iret. Int Endod J 2007401415: landoio A Artrano G, Ama M,Rengo $, Simeone M. 1-e:Anov too! to improve root cana ceaning ahd measurement of te apc foramen, Gal Endod a011-2572.81 ‘Konstanind Pema 2, Chater 60 Paz LE, Bousiouks ©. tea hepato preseueigaon versus syinge wigation A systematic Tovow of Gearing end Gsinbaton atthe estan etm, In Endod) mio. tandelo A, Patao G, Atal D, Sraone Mt, Lo A, ‘Trot eo to guage tne tcl arate endodontic: Ani wo ‘Suuy Open bent 20te-120046 ‘Siyaone Vela A Gusos Al Lorenzo landole A. 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