iene OMe nat Mae ie Om nee RCA ae Ween oo | Bpeed pa base i rndoadontc Aicbeisl U PROMOTING EXCELLENCE IN ENDODONTICS \\ Clinical management Diallo ac ler Pama) ww Clit gle incomplete root glide path afedcuut lcd) DS Cem Cun ESR Imran Cassim, and Aconservative perigee comer leaching of a vital Aer ked anterior tooth with calcified pulp chamber Pee Cue) ern IS Errno oie MN onsessen sansa ies CONTINUING EDUCATION CREDITS PER YEAR! ry company that aims to redefine a revolutio ™ and transform Visit: Page 6 nal root canal therapy adiOBTURA | The Gold SENN Seeeige Use for Access Refinement, Retreatment, and Restorative procedures, There's a BUC tip ready to accomplish a multitude of endodontic treatment challenges. Call (800) 344-1321 today to receive 20% off your next ultrasonic tip order!Endodontic Rear ee Me ned Fhe) MeciMark, te Se pegs Dental medicine in an age of change TTrteaing tte Now Ye vous ngs an rat hte kara fn past {and a preicton of what es ahead, and such exatnations are cra o maintaiig a taard of excelenice In ow dacpine ith regard to our endodonte pacts, I's Gear at he noreasig ace of innovation i revotstonzing the way we precios, ast il change evry form of heaitroae Practce. Tha areas of mest rap incation writin endodordcs wil ruse cane-boam computed tomography with new algorithms to improve assessmets and facktste surgeal guidance, enhanced \fsinfoion and ehaping tectniques, nanotechnology, imorabve ackanoes in cbtration that promise sale treatment, improved worklow, ard betler outcomes and regenerate procedes, Skingent lsborator and inal evasion wl be yalcatng these innovations at en noessing pace, and more sophisticated studies wil present chicas wi ngoroudy examined imation opport.ites tat wl prove very sgniient improvements othe practice of endodenics. Asn most ors of medicine, isnot only th rata of chango ut the dyes of ference thats increasing, Th adoption of such innovations ls becoming ever mere compaling. Consereay, gnarng novation is becoming a ever Increasing professional ak (Over te past 80 years, change menagement nas evcved asa recogized dlsclpine. ft wes once a vial le hat specials coud achieve success oy using the sare eaters and buses Stalag forthe rae part of har ciel carer. For he curert commun of ensodortt, such ‘a noten seiousy Raves. Tock, there are new produts, eehnolgial developments, nreased competion, and a changing wcrkorco that requra us to change course nord prod ho met sugcessid outcomes forour patients ant slay competi. Most successful compan under maderate organizaionalchange yearend major changes ‘every 4 to § years" Bu nspte of al this management attention, most tudes show enly moderate suocess for rgonzatonal change. This woud suggest tht Kote csc echt success fects abo flawed, Whats gong on hers? Pehaps hwo acchonal acters neo to be conscare, both ot which may conrad other nations hat served us the past * Change should not be episodic. Rather tran conscering change as a planned and dened part of ow busness plan, we shoud miegrate chenge ino the way wre execute our business plan, “This means that new approaches to eatment and Guiness operations need 0 be examined on ‘contra! bass and that wo, as leaders of our practicas, shoud adopt behairal patioms that ‘ransorm rather than maintain. Tis requtes chengrg the fundamental vues and principles of ‘our crganizalon andthe indica witht. Each member ecotuously asking beter ways to ‘operate as pat ofa team fo mprove resus. But conscer such a cencept early, because Fis Jel of arsformation doas ot raqure management requires leadership ‘+ Change shoud rot be hierrctica, Change ftom the ap can never be adequate to the challenges ‘of making the mal of changes eqiked to improve a comglexerganicatio, Rate than dking {and dictating change, the bet paces fdr vil nape and coach change — stuctung th ‘xgenizators to actualy breed teas for improvement Ina recent case tidy, Kote Tak about ‘he need to accelerate change by using a al orgarizatal sructire, The prablem stat most busmesses have a herarchicl stucre that mehans processes very wel, bu resists cheng. How many of ourpractces opereteths way? Kite proposes a paral sructirewhereempioyess at alll ar ited to content ta changa na cflrent, but complementary, way. He tated hat ‘eating sence of urgency around 8 enge opportunity fo prebiem 6a good way to tar” end tj got people accustomed io confrbuing eas rdopondonty of maragement les and suc, ‘ny se practice can bewet fom suct a paral concept: Daly management of patent fow end procedures can be managed by a herercry of prottes and team memos oes, but ideas for ‘mprovement shold fown para, unimpeded by hearty ‘Soas the New Year begins, we ms conde squats review o ou perspesves on westerns and the orgarzational aiture of cur practic. Mest success chango ers raqura creating a ‘hhnge-aatle ouarizaon thet i ays realy fo examine ancl aac to na eaten protocols fand ofce opercoral demands, al supported by the evidence and mets, reepactvey. Tis means ‘establishing a sense ot upeney and eeatng a ststegy tha 8 supple and read fr madienton es constons change ‘Abe Harerd Meccal Schad 2018 Class Day adie Dr. Brice Dono, dan ofthe Hana Shoo of Dental Medone, said, “We edicated you na way that doesnot simply repeat the fetes otha pec bt prepara ou fo undetard and ee ne kxoniadge nthe contri charg fk fas wel aso the wer wei Ihwould encourage ust imorove cur haa, taf and pacie iis to benefit tem the ‘engsing atveam of innovation that wl enable ue to continuously improve patent eae san ext ‘age in which tobe practong denta meciche, Best wishes or this New Year and years ahead, Manin D. Lean, OND. Doma, Ararican Boer of Edodontos Cina Associate Professor of Endodonts, Univer o Pemba nw endonet.com and van erdce.ccm B Endodontic pactce 1TABLE OF CONTENTS Clinical Clinical guidelines for the use of ProTaper Next” instruments: \ — st Ope Pee. vn cer Yea — Michael J. Scianambio discuss the = cine ges fr an AT THE SPEED OF SOUND ProTaper Next” instruments vou 12 BT-Race— Biologic and conservative root canal Instrumentation withthe fal Fat restoration in mind Corporate insight © Ge cero Donan ana Sonendo® — A new paradigm in endodontics Martin Trope explore the Atthe 2014 AAE Annual Session, Sonendo is debuting ts Mulisonic hereon tll Utracleaning System thal uses a miu of igang ids and sound waves to clean nese the oot of tet, A eisoaroitvs spina Interal bleaching ofa vital anterior tooth with calcified pulp chamber Drs. David Kelnan and Eugene AA Pantera ut. solve a common endodontic problem in a CCONSEVALIVE WAY sneer Clinical 7 Accuracy of a new apex locator in ex-vivo teeth using Cres scanning electron microscopy ‘Gover photo courtesy ore. Pet J. an Drs. Marla Bonila, Taner Cem Sayin, Brenda Schobert, and Patrick Hardigan compare the accuracy of root canal working lengths in 200 ex-vivo teeth determined using a fourth-generation electronic apex locator and a new fith- generation electronic apex locator 2 Endodontic parce Volume 7 Number 4Perfect delivery. Optimal performance. Easy removal. Use NaviTip® tip to place Don't change your technique. UltraCal® XS in the canal, and Make it easier with UltraCal® XS use Citric Acid with the NaviTip® and Citric Acid 20%. FX® tip to easily remove it. eee TS, 800.552.5512 ultradent.comTABLE OF CONTENTS Continuing education ‘The Importance of a reproducible glide path Drs, Yosef Nahmias, Inran Cassin, and Gary Glassman discuss how rolary and reciprocating instruments that follow a designated route wil result in more successful outcomes and minimal latrogenic mishaps ...28 Clinical management of teeth with Incomplete root formation Dr. Siu Jacob discusses treatment techniques for teeth with incomplete rool formation 34 Abstracts The latest in endodontic research Or. Kishor Gulabhvala presents the latest Iterature, keeping you up-to- Gite with the most relevant research st 4 Endodontic pace Anatomy matters Endodontic accountability: The “9¢* factor, part 9 Dr. John West discusses knowledge, stl, and vilingness in endodintios A Endospective The cookbook's not working — what's next? Dr. Fich Mounce discusses a superior method for cleaning canals... 48 Product insight What Is the Ideal endodontic interappointment medicament, its most effective placement and removal technique? Dis. Carlos AS. Ramos, Richard D. Tulle, and Mr. Danial C, White explain the benefits of UtraCal® XS .0nn50 Practice management Feedback - lateral thinking «Jaequ Goss explans now to gather rebabe patient feedbACK en nusS2 Materials & SQUIPMENE ....ervnnnnned Diary 56 Vouane 7 Numberimplantologists Creer Er larae 1 . ene Endodontists Cem OR Cus Ae See bee eee ace) De and measuring canal ‘Orthodontists bos pas Sea bata Peer ca eae) OSE Og General Practitioners Pee Porte Sarto Ee eee COSUIs(01a 10> (Ce ng cee oee rer piven remem tyres tert v ‘Combine that with the metal artfact reduction software that reduces distortions from metal object, Boe ee rerec ere ere Perera tare erre een The advantages of 20 & 30 in ane comprehensiestal Cee Ce erate ce Se enn eee on ee ee eet ey ieee ee ee eter ee STATON (OCU (OL a Clg<-|/ iC, sae BR wonefacebook com/sirona3D ay r O n | |CORPORATE INSIGHT Anew paradigm in endodontics So-nen-do: a revolutionary company that aims to redefine and transform traditional root canal therapy. Company History The mission of Sonendo® is to lead the transformation of andodontics. through Sound Science” Atitscore, Sound Science means that we are committed to ensuring that our product development is based on sound scientife research, and extensive proof souroe. Furthermore, we wil continue to leverage our innovative approach to sound — and ts use in endodontcs — as we work to bring tis csruptve new technology to the endodontic community. “Our goal Is to transform endodontics by improving the clinical quality and business performance of practices performing root canal therapy,” sald Bjarne Berghelm, President and Chief Executive Officer of Sonendo. ‘Sonendo is a privately held company located in Laguna Hills, Calforia, and ‘employs over 50 peopia, Sonendo was founded in 2008 with co-founders. wha Include arector Olay Berghelm; Calforia Institute of Technology professor Morteza Gari; retred dntist Erk Ha; and Bil Neman. As President and CEO, Blame Bergheim collaborates with a scertiic advisory board that includes Scott Ame, DDS, FAGD; Gerald Gickman, DDS; ‘Markus Hasso, DDS, PhD; and Ove eters, DMD, MS, PAD, 6 Endodontic practice Multisonic Ultracleaning”™ The Mulsonic Urtraclearing System, currenty scheduled! to debut at tho 2014 ‘AAE Annual Session, is designed to be a lstuptive technology that uses a mitre of iigating fuids and sound waves to clean inside the roots of teeth. It quicky, easly, and safely loosons and removes all the pulp tissue, debris, decay, and bacteria ror the entre root canal system vithin minutes. The system is designed to automaticaly and simultaneously dean al canals in about 5 minutes, as well as improve the cinical quality and business Performance of root canal therapy New paradigm SSonendo's desqn goals allow forte no tactonal instrumentation (endodontic ie) requie, ith procadure time cramataly reduoed. Tre Mutiserio Utraceaning Sysiem does not remove structural dein, preserving the stuctualintogrty of the tooth, Sonendo le focused to bring to market a device that wil provide an ene: crt treatment thats highly prodictablo for every procedure, mere conorabl for the patent faster and mor ficient forthe practice, ofeng a sinftant cleaner and ioinfected treatment area compared to curent standard. Sonendo'ssytsm isnot yt commer. cily avaiable forsale or dstrbuton. For moe inormatn, vist ‘wor. sonandlo.com. This information was provided by Sonende, SEN borg neal demig veh Sirens Uhasoneg” Som SEN Bog dein aes ‘Sed Raden” sien SEM Borg dein es ‘Sed Uncen sen @}@ 2 SONENDO Volume 7 Number 1Accuracy of a new apex locator in ex-vivo teeth using scanning electron microscopy Drs, Maria Bonilla, Taner Cam Sayin, Brenda Schobert, and Patrick Hardigan compare the accuracy of root canal working lengths in 200 ex-vivo teeth determined using a fourth-generation electronic apex locator and a new fifth-generation electronic apex locator Introduction A key factor affecting the success of fendadartic treatment isthe establishment of an accurate rast canal working length. The ideal cleaning, shaping, and dlainfzction of the root canal system dopands on the accurate detarminaion of the root canal anatomy rom cana office to the cara-dantinaloement (CDC) junction. ‘The apical anatomy ofroat canalshas boon investigated in several research studies and review acl (Kuler, 1985; Rlcucc, 19098; Groen, 1956; Pda, Kuta, 1972) The apical CDC junction, also defined fa the minor diamatet, i@ the anatomical lancmark that seqregates the pulp tissu from periodontal tissues. Dummer, et al, dseribed the morphological variations (of apical CDC junctions in 1984. Mary of these variations cannot be determined radiographicaly. The distance betwean the ‘major dlameter and the minor ameter of the apex can vary, but usually itis between (05 mm to 1 mm (Rico, 1998; Green, 1956; Pada, Kuler 1972), Topreserve the vitality of the periapical tissues, the ideal cloaning, shaping, and rot canalfling materials hav ta be ited to the aoical CDC junction. Therefore, i hhas become the prefered landmark for the apical endpoint for root canal therapy (Nekoofe, et al, 2002) ‘Maia Sona, DDS, GAGS, works tne Department ot Encocein, Now Seteatn Una Cala “are Cam Sash, DOS, PRD, te an sascitepoteasor at he Deparment of Ercodentes, Nova Sutrwaster Univers), Catage of Dental Median, Fert Lauder, ‘renca Schober, DDS, CAGS, wrk atthe Deparment tt Endodonts, Nova Souham Unies, Colage Patnexc. Haraiga, Phos prtessr of pubic ean athe Deparmant of Erdodontes, Nowa Soueasern vary cotgeot Get esene Fort Luce, Volare 7 Numbart Procedural erors — such as over Instumentation orunder-nstumentatlon— ‘can ocour because of inaccurate estates (of root canal langth. Over instrumentation ‘can damage the anatomy ofthe root end and also injure the periodontal tissues, On the other hand, under-instrumantation may create @ sulle environment for bacteria that might cause a less favorabie outcome of the endodontic treatment. Therefor, the accurate determination of the working lenath is an portant goal or the sucess ‘of the root canal treatment, Several methods can be used to measure the root ‘canal working lena. Radiographs can visualza tha root ‘canal but are limited to two dimensions and are technique-senstve to apetator input (Cox, at al, 1901). A study by Brunten, et al, (2002) showed that electronic apex locators (EALS) could be used to reduce the radiation exposurs te to the patients by requiing less radiographs. Some studi found that there were no significant differences ketwoen tha accuracy of EALS ‘and raciographs Hoe, Attn, 2004; Vieyra, Acosta, 2011}. A study by Real, ot a (2011) found that EALs wore sigricanly mere accurate than dig sensors. “The use of EAL for datermnining the root canal working length has became an indispensable part of endodontic treatment. Mora acourala EALS have avoWad in recent years by Improving tha basic principles upon which the measurements are pariormad. In 1918, Custer proposed the development of electronic devices to determine the working length. in 1942, Suzudl presented the et ganeration of EAL 10 use the aoctical rasistance propertias Cf the root canal to determine is working longi. Sunada (1962) determined the ‘lectrcal rsistanca value consiantiy at 65 ‘ohms. This theory considered the electrical resistance between the od tissues ane! the Perodortal gament to remain constant “The second generation of EAL had the peculiarity of working wih impedance Principles. An axampla of the thi Fu Ape prin ol ho speinon ‘generation EAL i the Root ZX° (J, Mora} which worked with a constant frequency Principle. A fourh-ganeraion EAL was created by Gordon and Chancler 2004), Tha fist varsion of Rost ZX EAL used tho averago measurements of two frequencies of O.4KHiz and ek Kobayashi and Suda (1994) described this method as the EAL frequency rat. The most recent version of Root ZX uses ‘multiple frequencies and can be classified as a fourth-generation EAL (Kobayashi Suda, 1994), The fh generation of EAL also uses muttpio frequencies, in action to calculating the root mean square (FMS) vaies of the olectic signas. The RMS represents the energy of the olectic signals, and therefore, it is claimed to ba loss affected) by. oloctrcal noises affocting other physical parameters such as amplitude or phase of electrical signal that aro used by othar EALS. An example of a fith-generation EAL is the Propex Pix”, which is a newer version of recently dosigned EAL Propex (Dentsoly Mailer, ‘Svitzerand Endodontic prction 7CLINICAL, 15 = Px = Figwe2Temsan dace ram fal wating lenght tp Aims and objectives “The aim of tis study was to compare the accuracy of root canal working lengths In 200 ex-ino teein determined using @ fourth-ganeration EAL tho Root ZX I) with 2 fith-generation EAL the Propex Pb) “The Propex Phx and Root ZX use signals at two dlforent frequencies to calculate the fle tip postion relatively to root apex. Furthermore, the technology utlized. in Prope Pitas ram the technology uses in Root ZK Propex Pid by measuring te RMS of the electri signal, which is further Used ‘for calculations. Bacause of these technology cierences, there is a need to ‘compare the accuracy of the Propex Pix withthe Root 2X10 determine root canal working lengths. Materials and methods Aer IAB approval was obtained, an archive of 200 sound human pexmanent toath with completly formed aplcos was used in this study. The teeth were disinfected by submerging them in a 6% sealum hypochiofta (NOC) solution for 18 minutes. They were then rinsed for 10 minutes with disilled water. This tlsinfection eyela was repeated 2 tras for teach tooth. The teeth were stored in 20- 1 tere sctlation vals led wth distiled water n a raigeratr at °C unt use, Porto inclusion in ths stu, the root surfaces and apices of each tooth were ‘ezamined under x18 magnificaten using {surgical microscope (Global Surgical 8 Endodontic practice Corp, for a possible fracture or resorpive seas, If ny defects were observed in a tooth it was discarded from this study. The cuter surfaces of the teeth were cleaned by removing tssues with a 150 scalpel [Aspen Surgical. Photographs wore taken of each tooth in a buccoingual as wel as a mesodstal view Figue 1), Digtal racioaraps (Schick Technologie) fr each tooth in a buccolingual andl a mesiocstal ‘rection were also taken as pre-operatory procedure (Figure 2) ‘Access caviles were prepared with a high-speed handpiece andl a fesure bur (Mailefor, Switzrand) vith watar coolant, Under the surgical operating microscope. Pre-fing of the root canals was not performed. The roct canals wore inigatod vith 6% NaOCi before the introduction of any fle. Patency was established by Introducing 2 No. 6 of No. 8 hand fle (Mailer, Swizerand) unt it emerged in the apical foramen, and this was corroborated by visualization using the surgical microscope. Each ol the taeth was ‘embeded in a dental device for taining purposes with alginate. The 200 teath wore randomly assigned to the Propex Pin = 100} group or the Foot 2X, Mor (1 100) group. The root canal working length measurements were cared aut according to the manufacturers’ instructions. Tha Ip ip electrode was altached to the device, 1nd the other electrode was atlached to 2 fla that ft snugly in the apical portion of the root canal. Digital radiographs foreach tooth in @ buccolngual and a mesiodstal direction were taken 10 corroborate radiographicaly thet the working length had been estabished. The fles were then vuthdrawm from the canals to. measure them with an endodontic ruler (Mailer, Swilzeiand). The reference pots were marked with siicone stoppers. All the working lengths were measured using ‘he same endodontic ruer. The working lengihs were recorded on a spreadsheet, The files were reinserted inlo the root canal and cemented with @ flowable composite resin to avoid any movements ‘rom within the root canal, The apioal 4mm portion of the root cenals was carefully shaved in a longtudnal drecton using @ fine diamond bur (Mallefer, Switzetiand) ‘and @ scalpel under a Olympus SZX7* stereomicroscope at x8 magnifcation to prevent touching the les with the clamond bur. ‘The apical portion of the teeth and ‘les were observed in micrograhs at x40 ‘magnification using an FEI Quanta 200 FEG Environmental Scanning Electron Microscope in the ow-vacuum mode, and the distance from the fie tip to the CDC Iunetion was measured with Scandium image software FEI Company) igure 3, A Welch's test test was used to compare the accuracy of the working lengths determined by the two EALs at @ significance eve of Pe.05, Results The mean distance from the fa working length to the fla tp was. 0.21 = 0.25 mm for the Propex Poo EAL whi it was 0.08 + 0.22 mm forthe Foot ZX1 EAL (Table 1, Fqure 2), A ference of 0.13 mm (95%: 0.23 to 10.47) was found between the Propex Pix ‘and Root ZX IIEALs. The Propex Pi was ‘accurate 88% of tho tima ta + 0.5 mm and 198% acourate within = 1.00 rm (Table 2), The Root 2X Il was accurate 97% of ‘he tine to 40.50 mm and 99% ancurate within 21.00 mm (Table 2). There was no significant ference inthe accuracy of the working lengths determined by tho two EALS P > 005). Discussion This study is the fist to investigate the scouracy of the root canal workrig length measurements of a naw ffth-geneeation EAL called the Propex Pix Given the importance of accurate oot canal working length measurements to the outcome of Volume 7 Number 1Table: Desperate ont “Tol reny of ite fom on eh prt re font Cee ea ee a a ‘endodontic treatment, itis essential that al 975 of the time within 0.5 mm of the new EALS be evaluated forthe accuracy. actual root canal anath, These high levels. ‘The multole frequency processing of accuracy appear to be benefcia to the tecinology, and use of RMS incorporated practice of endodonties, and since both Into the Propex Pixi may have theovatical ALS had similar lavels of accuracy, both ‘advantages for increasing the accuracy the Propex Px and Root ZXIl EAL can be ‘of the working length measurements, by recommended for use in endodontic. reducing the olectical noises affecting “Traditional, a radiographic evaluation ‘ther physical parameters lke ammpituce hasbeentheprimarytechniquetocietemine for phase of eleclical signal that are thevertcalimitofinstrumentation,irigaion, used by other EALs. But the technology and obturation in endodontic therapy Improvements were not enough to make (Fouad, Rivera, Kel, 1999), However, the Propex Pxisignicanty more accurete El yout, et al, (2005) concluded that than the Root ZX IP > 006), whica _radograchlc evaluation was net accurate ‘appears to be an extremely accurate encugh and causes over-instrumertation, fourh-generation EAL, especialy in 90% of premolars, Wis, “Tho Propax Pixi and Root ZX Il qave ot al, (2006) concluded thatthe files that root canal working lengins of 0:21 and seem to be beyend the apex were longer (0.08 mm, which were accurate 88% and by an average of 1.2 mm. In contrast, Hes Volume 7 Number {hat seemed to be short ofthe apex onthe radiographs were 0.47 mm closer 10 the ‘apical foramen. ‘The new technologies in EAL appear omake tham more accurate; thay are more ‘accurate than raciographs, wtich are only useful fo corroborate the EAL readings. Radiographs are useful for vsualing the ‘existence of paltiology, the amount of root {0 teat, and the direction of curvatures In the root canal system (Rcuec, 1988; Dummer, McGinn, Rees, 1984; Gordon, ‘Chanoler, 2008), The use of EAL relerence pponts has been controversial. The malor 0,05), which appears to be an extremely accurate fourth-generation EAL. These high levels of accuracy apacar to be boncficlal tothe practice of endodontes, and since both EAL had similar levels of accuracy, both ‘ho Propex Psi and Root 2X EALS can be recommend for use in endodontios ‘Acknowledgments The authors thank Dr. Armando Lora from Universty of Taxcala, Mexico. Ed rae soae cee eisroueaseterce Eearescsaeeete tees ‘sect prt reve ea ‘eonanioses es ‘oomaai nee (ee tenn aot 705, ocealJOwner ieee Tet saan ht eon Encoa anon oro ——— ee eee Wo AR Bunga JC Maha J. An > ‘mors wo ferry seo (eer Jeno sears, ama ce, oj Am atta 8 compan Sireninntrndnpns wy Volume ? Nuntor +THE CART, WITH ONLY ONE FOOT CONTROL The versatility of ASI’s custom cart system allows for the integration of common instruments ~ all of which are operated from just one foot control. Positioning of the cart is infinite. It can be easily maneuvered within close reach for procedures, and then out of patient view when finished Adding a monitor mount creates an intimate environment for both patient education and clinical use Additional electrical outlets and foot pedal quick connect ensure added versatility and easy upgradability. WASI The Leader In Advanced Systems Integration Contact ASI for More Infomation 1-800-566-9953 * asimedical.netCLINICAL, Clinical guidelines for the use of ProTaper Next™ instruments: part one Drs. Peet J. van der Vyver and Michael J. Scianamblo discuss the clinical guidelines for using Protaper Next instruments Introduction According to Bird, Chambers, and Peters 2008), rotary nioke-teanium (NT) Instruments have become a_ standard tool for shaping root canal systems. These Insttuments provide the clinician with several achantages compared. to Conventional stainless steel instruments. They are more flexible, have increased cutting oficlency Kim, a a, 2012; Peters, 2004; Wala, Brantoy, Gerstein, 1988), can Create osntered preparations more rapidly (Shor, Morgan, Baumgartnor, 1907; Gossen, ot al, 1995), and can produc tapered root canal preparations with @ reduced tendancy of canal transportation (Chen, Messer, 2002; Kim, eta, 2012). However, nicke-tanium Instruments ‘appear to have a. high isk of fracture (rans, otal, 2008; Sattapan, et al, 2000) ‘mainly because of flexural and torsional ‘Sresses during rotation in tha root canal systom Boru, et al, 2008; Parashos, ‘Messer, 2006), When there isa wide area Of contact atween the cuting edge of the instrument and the canal wall during rotation, the instrument wil be subjected to ‘an increase in torsional srass Pater, ot 2004; Blum, t al. 1999). The preparation Co areoroduele gice path can reduce the torsional sts on rect canal instruments. A glida path is a smooth passage that extends from the canal orice in the pulp chamber to ts opening at tho apex of the root (West, 2006). This wil provide a Continuous, uninterupied pathway for the rotary nicke-ttanum instrument to fentor and to move freely to the root canal terminus. Dr Peat J. van der yr extraordinary profesor st ‘he Department ot Oaontalogy, Senoal of Dents, Univeraty of Pretona ond Prvste Practice, Sandton ‘South Anica (68 winwstudotendo.com fr mete ‘ha devetpar of Clic Paty Tecnology He fe 3 Postyraduate antelow oftne Harare Senoo| ot Dena Mectine ante oer ea 2 tcuy member of the Univraty tne Pacts na tne Unerty ot cairn ‘Schools of Denis in San Francie, 12 Endodontic practi “The main purpose ofa glide path isto create a rect canal ameter the same siza 83, of ldsaly @ sze bigger than, the tst rotaryinatrument invoiced anit el, 2004; Varea-Pati, t al, 2008; Borut, ct a, 2009). Another way to reduce torsional stress tncerporate multipia prograsale tapers to the lnstrumant design, for example, the ProTaper® universal system DentsplyAdallefer. According 10. Wast (2001), the progressive taper lows for only sral areas of dentin to be engaged. “This design concept also contriautes 10 maintaining the orignal canal curvature (un, Kim, 2003), ProTaper Next Recently, the ProTapar Next system CentsolyAalefr) was launched into tho dental market, (ProTaper NEXT? Is ny avaiable in North America trough DENTSPLY Tulsa Dental Species) “There are fv instruments inthe system, but most canals can be prepared by Using nly the frst two Instruments, This system also makos use of the mute progressive taper concept, Each tle presents with an increasing and decreasing percentage tapored dasign on a single fle concept (Pudoe, Machiou, West, 2013), The desin nour that there is’ reduced contact batwean the cuting futes ofthe instrument and the dentin wall, thus reducing the change for tapar lock (Screwsn effec). At tha same time, i also horeases fexbiity and outing etfoency Rude, 2001) ‘The fst instrument inthe system is ProTapar Next X1 (Figure 1), wth a tp sze of 0.17 mm and a 4% taper. This instument is used after creation of a reproducibi gla path by means of hand instruments orrotary Pathe instruments, This instruments always folowed by the second instumert, the ProTaper Next 2 (0.25 mm tp and 6% tape) (Fgure 2 ProTaper Next X2 can be regarded asthe frst finishing fle in the system, as it lnaves the prepared root canal with adequate shape and taper for optimal inigation and roct canal cbturtion. ProTaper Next X1 and X2 have an neeasing and decreasing Se Fire tigen 179 aa a Fue taper 2 2509 rumor Ces Fur: taper 8 6087 ear lett Fire tae aX HO arma SE Figue: Tp 5 6006) issue percentage tanerad design aver the active portion ofthe instruments. ‘The last three finishing instruments are ProTaper Next X3 (0.30 mm tp with 7% taper) (Figure 4), ProTapar Naxt X4 (0.40 mm tip with 89 taper) (gure 9) and PraTaper Newt X6 (0.5 mm tip with 6% taper (Figure 6). These instruments have 2 decreasing percentage taper from the tip fo the shank. ProTapor Next XS, X4, and XS can be used to atheroraate mara tance In a root canal or to prepare larger root canal systems. ‘Another boneft of this systam isthe fact thatthe instruments are manutactured ‘rom M.Wre and not traditional nical: ‘tanium alloy. Research by Johnson, et al, (2008) demonstrated that the W-Wire aloy could reduce cyclic fatigue by 400% compared to simfar instruments ‘manulactured ‘tom conventional rickel titanium alloys. The added: metalurgical benefit cortrbutas toward more fxbie instruments, increased safely, and Volume 7 Number 1Fata Nod inst ae ir rite egress (na te aa hentai oct ‘aon fg ea 3 mn of a ie reunsns, ARE tr sens ne ret fossa peorenothoin a Freehotnor neage Te svgtetry naener reba bp revue wet le nepe onton (elim compe acm sas neve nh Syuetiatnsanaisa ater = )) i Figue7: tar Notre or cre epaon tet wang Ero Kehr aero Ste or he fat de at? als sro lian sao he sng cs & rae Slrraly na hep fe natu aioe ote ee armed Iron orcad ose Eh nay mp als om nb te ea nd pc fats dni Wangs setng hao iin ok protection against instrument fracture (Gutmann, Gao, 2012), The last major advantage towards root canal proparation with the ProTapar Next system is the fact that most of the instruments present with a biateral symmetrical rectangular cross section (Pgue 6) with an offset from the central axis of rotation (except in the lst 8 mm of the instrument, 0-03). The exception is ProTaper X1 that has @ square cross sect in last 3 mm to give the instruments bit more core strength in the rarow apical par. This design characteristic allows tho instrument to experenca a rotational Phenomenon known as_precession or ‘swagger (Scianarrblo, 2017). The benefits of tis design characteristic incude: ‘it turmer reduces yn adatton 12 me progressive tapered design) engagement between the instrument ‘and the dentin walls, This wal conriout to a reduction in taper lock, screw-in cfect, and stress onthe flo. Vome 7. Number ‘+ Removal of debres in a coronal direction (Figure 7) because the oft-center crass section allows for more space around the files of the instrument. This wil lead! to improved cutting effelrey, as the blades wil stay in contact with the surrounding dentin wals. Root canal preparation Is done in a vety fast and ffotiess manner ‘The swaggering mation of the instrument Intates activation o re irigation solution during canal preparation, improving debris removal reduces te tsk of inarumentracture because there is lass stress on the fle and more efficient debris removal Every instrument & capable of cuting a larger envelope of motion Varger canal preparation size) (Figure 6) compared to a similarly sized instrument with a syimetical mass and axis of rotation This allows the clinician to use fewer instuments to prepare a root canal to adequate shape and taoer to alow for ‘plimal ingation and obturation. ge 8 Peer ratogah of mata i et a wir so wars ‘There s.a smooth tanston between the differant ezas of instruments bacause the design ensizes thatthe instrument sequence itself expands exponential. Clinical guidelines for ProTaper Next instruments ‘Tho clinical technique for ProTaper Next wilbe discussed by means of case reports, The fst case repert wil outine the basic sidelines for the use of ProTaper Next instruments The palit, a 48yearcid male, presented wth a. previous emergency rool canal treaiment on his upper le rst premolar. A periapical raiograph shoved ‘evidence of thea separate roots and ange pesiapcal lesion (Faure 8). According to the patint, the tooth was left open by his previous dentists that performed the ergency root canal treaiment to alow for drainage. Guideline one: Create straight- line access and remove triangles of dentin iis very important to prepare an adequate acess cavty that wil ensure stralg- line access ito each roat canal sytem. However, nthe present cial case thee was sil @ dentin tangle obscurng direct access into the dstobucaal root canal system Figures 9A and 96), The Starx tip No. 3 Centsoy/Mallien was used to romovasomeotthls dentin onthe pulp foor Endodontic pracce 19CLINICAL Fue 10 Sar-xtoo3 syle Busia nncisuim bw ‘en i Morompee DenkeyMales) soe. c9er6% ue TZAPolpe gua 18 Dest stag ine ass oh an rie eae (oe Eetumert iusto “ cre mos sa freradnay ss Guemartcvasei i ie (2srm erin = pee (Faure 10), alowing more dract access to. Guideline two: Negotiate canal to a glide path is a smooth passage that the dstobuccal root canal orice, patency and createa reproducible extends trom the canal orice in the pulp ‘A Micro-opener (Dantspy/Mailte, glide path chamber to its opening at the root apex. ‘820 10, 06% taper instrument was used The authors prefer to negotiate tho root Most authors recommend that the glide to locate and enlarge the distob ‘and mesicbuccal canal oriicas (Figure patency is esta cal canal with sie 08 or 10 K-fles nt shed (Figure cal path should Apical —asbobiag the same size as, or deally than ta frst rotary instrument 11), For improved radicular access, tho patency is tho ality to pass smal Kfles that wll bo Invocuced into the root canal ‘SX instrument (Dentsply/Mailete) the ProTapor Universal system was used) _constiction, beyond the (Figure 124). The reccmmended mathod of uithout widening (Buck fom 0.5mm 1 mmpassivey trough tie apical system (Berut, etal, 2004; Varela Patio, minor damier et al, 2005; Berti et a, 2000), hanan, 1960), Ils recommenda to uso the stahloss seis to introduce the fle into the coronal Length determination was done using steel K-fles in vertical in and. out motion portion ofthe rect canal eneuring that the a Propex xi Apex Locator (Dentsply/ with an amplitude of 1 ram and gradually fos ablotofredlyrotato, Restrcthe dentin Mallon, Predictablo readings wero is then removed by using backstroke, achieved by using two size 10 K- outward brushing motion. This stap wil mesiobuc ‘also relocate the canal odfices more and a se 20 Kf int asing the amplitude asthe dentin wall ssinthe wears away and the fle achances apicaly cal and distobuocal root canals Most, 2006), West (2010) racemwmands larger palatal a “super locso” sizo 10 K-flo as the ‘mesial or Gta (avay for furcal danger) root canal and confirmed rasiographicaly minimum requirement. To confirm that @ and ia the canal orfloas, ensurng Figure 138). roproduciol gid path s prosent, the ze ‘complete stalght ne access into the root ‘After working longth determination, 10 fips taken to fll working langth gure canal system (Figure 125) +4 Endodonti practoe iherewn 1mm and Jide back to working ‘glde path should be 148), The files then ding 10 (2010), should be able ume? Numberpe7TecT. APEX LOCATOR Sharpen Your Clinician’s Root Canal Visibility Introducing the new Detect” Apex Locator from Maillefer. Det ct" Apex Locator is innovative, aesthetically pleasing, and Gelivers successful root canal theraoy. Other Features include: + Large color display to facilitate file tracking + Progressive sound control for dual contral + Fully automatic device + Powered by rechargeable battery + Latest multi-frequency technology enables location of the _apex in most types of canal conditions CCheck out our website for a short technique and product educational video perfect for customer demonstrations: maillefercom The cursor onthe tooth ion Incicates the progression of the fle in the canal Asolid tone will emit sen the apex s eazted The OVER icon indicates when the fl passes the apex DENSPLY _enrsriysaieren 1-000 520-7290 1-000 24-709 maeren oenrseur.com EBERT Prin, DENI ADDLCLINICAL eg gh ‘ol eg engh length by using light tinger pressure ‘Thorcafar, the fais withdrawn 2 mm and should be able to side back to working lanath, using the same protocol. When tha fle can ba withdrawn 4 mm to S mm and slide back to working length Figure 148) 2 reproducible ale path is confined (Van ‘dor Ver, 2011) ‘The reproductle gide path is then cnlarged using rotay Paths (Dents Malloy}, PathFice” are only avalabo in Notth America trough DENTSPLY Tulsa Dantal Spaciaties) PathFlo No. 1 (0.13 im tip ize} Is taken to full working length rating at 300 rpm and 5 Nicm torque (Fgura 1A), As soon as the flo reaches working length, the authors recormmand to brush ightly outwards against one side of the canal wall. Tha le is pushed back to working longth and brushed outward ‘agaist another part ofthe canal wall. This procedure is rapeated four times (touching tho canalwallinamesta, distal, cuccal and ingual rection). Pathe No. 2(0.16 mm tip sizes usod folowing the same protocol Figur 1 in) as the fest preparation Instrument, the X1 of the ProTaper Next system has 3 tip ‘staofl80 17. However, tis recommended to use PathFio No. 3 (0.19 mm tip size) when deaing with challenging root canal systems. Guideline three: ProTaper Next preparation sequence ProTapor Next X1 (shaping instrument only) Inoduce sodium hypochlorite end the 16 Endodontic pation SAPAIeNa eben FayetSh Flee 2 en Fowes 116: eqns car. 1 ela NeXt epg a farts 28m sid own e gle pa ani aa ear wre ee Theft ull bad apa 28 wm stl many eng a cab baste eu ut a sre gy eae (cle mre arene ct spctd ool ce TE Pray fete al Senang eh ants sh svt Bah emg ce up tenes meses carpe esa cutest ng a ihe Pept trae dlr es, ‘Rebel 178 rseal r rr Shas wee tes wae oem nm da ca rd wa cyte having gee eed 7 sxnese cnet ines bean Profaper Net X1 instrument into the root canal, The authors found that four scenarios can present itself when using ProTaper Nox X1 instrument: Easy oot canals 2. Mors atic and longer root canals 8. Vary long/saveraly curved root canals 4, Larger diameter root canals and fetreatmant cases root canals where tha use of ProTapar Next X1 Is not necessary and canal preparation can be Inte with ProTaper Next 2, X3, X4 or XS. The last two scenarios wil be cdacussed later in this aricle. For easy canals (mesiobuccal root canal in this case report), alow the ProTaper Next Xt instrument (operating at 200 rem and tarque of 2 8Nicm) to slide cown the aide je ores ekg ag eu ant sapere path up to working enath Fue 16A). I this 1s possible, pul the instrument back to approximately 2-3 mm short of working lent and incerporate a delberate stroke, outward brushing motion (away from any extemal root cancavities) to ts mora spaca in the coronal aspoct of the root canal gure 168). Final, take the fle to full working length and “touch the ‘apex and brush outwards (coronaly) wth the fle in the apical thed ofthe root canal This “touch-andbush” sequence can be repeated up to 8 or 4 times 60), For more alfcut and longer canals [eistobuceal oat canal in tis case report alow the ProTapor Next X1 to sic down the glide path unth re is met gure 178). incorporate a delberate backstrcke, outward brushing motionin erdertoremove Vohme 7 NumberIrrigate coer Fuh See 202 1B: kat non eps I te ot carl ete a tag fe seo aac he but bu ii 2 3 es wh Figure 18 Pope Net nk gu 0 Se 25/0 Nae ata ah Oe dordpel cues feped otwinieah —iltmtany eat tteaaeagrt Besa Ue pape Olieren canal erect sng | ren te pepe cna cucu sb Heiss) ra ng eg ible used oqeigethe — Fqae71B: Asie 002M] Fre 22h AS002MTiNnd Fg Figs 220 Gage asain th catrarena/fe arms bane tran aetna rerumen ten and shows rele het SRG hihennsrent Glcwraterd tiacze — leyehemnimsttehesae — tetulwonhglen enon ‘ofl oak ne items pad Yeslundiaibe 2atzle eee ws oe tlt cd restrictive dentin at ths level (avy from any exteinal rool concave). This mation enabling the Fie to sie a few mere milimeters down the root canal towards working lenath (Figure B) (i the fle ceases to progress apically, remove the fie, clean the flutes, inigate, ral before you progress withthe shaping procedur ‘The above procedure is repeated unt the fig reaches ful working length. Final, take the fe to full working length (Figure 1170) and the “touch-and-brush” sequence Is done 3 t to complete canal preparation Alter the use of ProTaper Neat XI, Is recommended to inate with sodium hypochiotte, recapiuiaie with a small patency file to dislodge cutting debris, and to re-igate to fush out al the dstodged willoreate more lateral spat Number debris trom the root canal Figure 18) ProTaper Next X2 first finishing instrument) ProTaper Next X2 (25/06) to ful working length, using the same protocol as prevously desorbed. However, itis ioueand- brush’ sequence in the epical part of the root cara ony 2 to 3 times asa fal step (Figure 19) Excessive “touch-and-brustt sequences in the apical pat of the root canal can lee! to transportation ofthe rot, caral, The toot cana is aga ingated, pitted, and re-rigated, Gauging of apical foramen to determine if the preparation is complete Inoduoe a se 25/02 NTI hand fie Niven iawn the to (Denisply/Mailefer| to full working length (Figure 20), ifthe fle Is snug at working Fength, it means tat the apical foramen fs prepared to a size 'S0 25, andthe carl is adequately shaped The palatal rool canal in the present case report was prepared with the ProTaper Next X1 and X2 accorting to the Protocol previously outined. In ths case it was foun that the 25/02 NIT hand fle was filing loose at lengtn, and it could be pushed past working length (Figure 218) ater canal preparation with the X2 Instrument, This Indicated that the apical foramen was sil larger than 0.25 mm. in these situations, itis recommenced to gauge the foramen with a size 30:02 NT hand fle (Figure 216}. I the 9002 fle is snug at length, the shape is complete, fit Is found thal the 30/02 instrument fs tint Endodontic prasice 17CLINICAL ' r Fique2%Fhaleuttetchvaten, —Fgve 23: Prapeatieraioyaph Fue 25 css coy partion heh gue 26 Length dterbaten oye las al hvac Unt eral snc eed haan habe eas ‘ado hug a ne aes (Geena) Tedmuncunge (eal mroerieg —citwastmnsycen tomas pose ha tuk sia Pero cand Hraytlnoaset a fe mel ik el ones Syate Fgeta helps FyaeZaMtnnsin, Fyne et Fare ZA Mifueete. eames (Prana Rata Steger, fanede,, anmenmaae Come n , Pome Geemarc Sizaliwcroae Potrero e te eine ised esi manne mseare econo Sareea but short ofthe ful working length figure root canal in the present case report, length. This preparaton sequence wil 22), tis recommended to cantnue canal The canals were obtuated wth ProTaper create enough lateral space inthe coronal Preparation with the ProTaper Next XS Next X2- gutta-percha points inthe two-thirds of he root canal to ensuro that (0007) gue 228) and gauge agan with —mesiobuccal and dstobuccal root canals ProTaper Nex X1 can now be taken 1 ul 1/02 NIT hand isument (Figure anelaProTaner Net XSgutle-pecha pom working Ingth without any cffculy 220 {Donispy/Mallefn in tho palatal root canal as master cones using the Calamus Dual Case report Guideline four: Shaping recom- Obiuration Unt Dentsph/Meiletey. Figure The patient, « 80-year-old female, presents mendations for ProTaper Next X3, 23 demonstrates the fal result tar canal wthpainon ber mancularrigth fest molar x4, and XS cbturation vith 2 history of @ previous emergency ProTaper Next XB and X8 and x6 i root can treatment, Cirical examination necessary is used inthe same mamer as Preparation sequence for very reveded a broken down and leaking ProTaper X1 o X2 with te exception that long and curved root canals temporary restoration possibly resuitng in pica preparation is dane by using the In selected nical cases, the cnician coronal leakage. A periapical radiograph “touch-and:-brush” sequence only once er might ind that ProTapor Naxt X1 does not revealed very long and curved mosia twice in the apical fit of the root canal. progress to ful working length even after roots. Also visible on the radiograph was ‘Apical gauging is done according to the a few coronal circumferential brushing evidence of dentn triangles preventing previously mentioned protaca using asiza mations. The authors than recommend —straigh-ine access info the masta roct 30/02, 40/02, or 50/02 NiTiinstruments. to create more coronal shape by using canal (Figure 24) The 30/02 instrument was iting ProTaper Next X1 followed by ProTaper The defective temporay restoration snugly at working length in the palatal Next X2 up to two-thids of te canal and caries wero removed before tne tooth 18 Endodontic pactes Volume ? Nuntor +Fue 2a ave fpr 2a wae eit whiny Ur ecaras ee dared adage nay ‘tt ie Figue294 Peapre Aegiio sion cer” win Gusto cece Fagen nce rove arate be earthen ate rag pena wh Fae tee was restored with composite and a new ‘ac0ess caviy prepared. Note tha evdenca ff dentin tangles on the mesial aspect of the canal orfices (Figuie 25, arrows. ‘The dantn tangles were removed with 2 ProTaper Sx instrument, ensuring straight line access int all he root canals. Figura 26 shows the rachographic viow of the length deterrination confirming straight line access nta tha root canals ‘As mentioned before, the clinical protocol for cases with very long. and Ccuned toot canals wauld be to aon ProTaper Newt Xt to progress to about twothirds of the canal length Figure 27. This is flowed by inigation, Fecapitulation, and ro-lrigation sequence with sodium hypochionte, ProTaper Next 2 is than used in tha same manner (wit ‘creumferential oustrake rushing mations) to the same lenglh Figure 278). ProTaper Nae XI is then used again to progress with canal preparation to fll working natn (Figure 270) using the "Youch-and-brust sequence as desaried Defore, ProTaner [Next X2 is then taken to full working length (using the same protocol as described before) Figure 27D) after_inigation, recapitulation, and re-rigation of tho root cana, Canals were gauged according 10 the technique described before, and final preparation was dane up to ProTaper Next X2 nthe mesial raat canals and up ta PProTaper Next Xin the distal roct canal GutiaCore™ veriiers were fited Figure 28 to working length to confirm the siza Voluma? Number 1 erat ssid ot ‘arlene ate ae ens aa ig poten 1028 Legh rar ang ae FqueSDU Prtaper Rea 4 Fer 08 peal gaa wth 20 cal aac wth lnsumes blero lng AUP feo! oem SO Wl hr as lea thaerod mete otlose (rate rores™ hl wry Meng aida orav ext bron preva matt 2 egeaemned wihng™ Mtetwa enn of oblurators for each canal before the cals were oblirated wth corresponding GuttaCore obturator. Figure 288 shows the postoperative resut ater obturation, Shaping recommendations for large diameter root canals or retreatment of root canals ithe fat fe to working length is a size 20, ie aa it loose up to working length, the shaping proosdure can be inated by Using ProTaper Next X2 (25/06) the st fies to length ae a size 25/30, 3035, or 40/45, and they are found to be loose in the canal up to working eng, tne shaping procedure can be inated wit ProTaper Nat 3 (007), X4 (40/06, and X5 (50/06) respective. Case report The palient, a 44-year-old female presented with paln and discomfort on her maxilaryrght-cental incisor. Radiographic examination revealed that the tooth was poorly rool treated, and there was ‘evidence of a large periapical area Figure 298), After removal of the previous gutta, percha, it was possible to take a sue 35 fle to working angth (Figure 298, oot canal preparation was inated by preparing the root canal to workng length wth the ProTapor Next X4 (40/06) instrument (Figue SOAJ. Apical gaugng wih @ 40/02 NIT hand fle revealed that tho tip of tho fle was loose at length and able to travel past the predetermined ‘working length (Figure 308) and that a size Endodontic practce 19