This report describes root canal treatment through cone beam computed tomography and magnification through a surgical microscope of C-shaped mandibular second premolars in the same patient. The mandibular left second premolar with Sert and Bayirli type XV classification was treated for symptomatic irreversible pulpitis and apical periodontitis. The mandibular right second premolar with Vertucci type V classification was re-treated because of a deficient previous root canal treatment, which also involved buccal canal transportation, furcal perforation and two separated instruments in the lingual canal besides symptomatic apical periodontitis. During the root canal re-treatment, buccal canal transportation and furcal perforation were sealed with mineral trioxide aggregate (MTA-Angelus, Londrina, PR, Brazil), separated instruments were removed and a better obturation was achieved. In the 6-month follow-up the patient reported no symptoms, the radiographs of both teeth showed no apical radiolucencies and the percussion tests were negative. For this case, cone beam computed tomography and magnification were essential to identify this unusual root canal morphology, allowing successful endodontic treatment to be achieved.
With the advent of three-dimensional (3D) printing, there has been an enhanced focus on the creation of models in dental education. These models range all the way from simple teeth for predoctoral educational programmes to more sophisticated models that can be used in both continuing educational settings and in postgraduate/graduate specialty programmes. In this article, the development of a model to teach the decompression technique is described along with a case report that demonstrates the application of this procedure.
Hydraulic calcium silicate-based sealers have been available to dentists for over a decade. How have these materials changed views on root canal treatment? Is there demand for a change in the standard treatment protocols that are accepted when using common sealers? Do hydraulic calcium silicate-based sealers offer a new understanding of the root canal filling material, developing its properties from sealing abilities to healing abilities? A number of issues must be addressed when using hydraulic calcium silicate-based sealers for root canal obturation. This narrative review provides an overview of the clinically relevant aspects of root canal obturation with hydraulic calcium silicate-based sealers.
Background Hydraulic materials are used in Endodontics due to their hydration characteristics namely the formation of calcium hydroxide when mixing with water and also because of their hydraulic properties. These materials are presented in various consistencies and delivery methods. They are composed primarily of tricalcium and dicalcium silicate, and also include a radiopacifier, additives and an aqueous or a non-aqueous vehicle. Only materials whose primary reaction is with water can be classified as hydraulic. Objectives Review of the classification of hydraulic materials by Camilleri and the literature pertaining to specific uses of hydraulic cements in endodontics namely intra-coronal, intra-radicular and extra-radicular. Review of the literature on the material properties linked to specific uses providing the current status of these materials after which future trends and gaps in knowledge could be identified. Methods The literature was reviewed using PUBMED, and for each clinical use, the in vitro properties such as physical, chemical, biological and antimicrobial characteristics and clinical data were extracted and evaluated. Results A large number of publications were retrieved for each clinical use and these were grouped depending on the property type being investigated. Conclusions The hydraulic cements have made a difference in clinical outcomes. The main shortcoming is the poor testing methodologies employed which provide very limited information and also inhibits adequate clinical translation. Furthermore, the clinical protocols need to be updated to enable the materials to be employed effectively.
Nowadays, in order to prevent the early loss of cariously or traumatically damaged teeth in paediatric dentistry, different types of endodontic treatments are considered. Over the past decade, paediatric dentistry has primarily shifted its focus towards the preservation of vital tissues and improvement of treatment outcomes, and has benefitted immensely from the introduction of effective and safe bioactive endodontic materials. Since 1993, the year in which mineral trioxide aggregate was introduced, hydraulic calcium silicate-based biomaterials have made a significant impact on endodontic treatments. There is a growing body of evidence demonstrating that hydraulic calcium silicate cements are beneficial for both the least aggressive and most invasive type of vital pulp therapies, as well as for the management of non-vital primary/permanent young teeth. Moreover, clinicians' skills and knowledge regarding the applications of hydraulic calcium silicate-based biomaterials play a crucial role in achieving success with the applied methods. The objective of this review is to summarise the recent developments concerning hydraulic calcium silicate-based biomaterials and provide an overview of some existing trends alongside current theories that have significantly influenced the art and science of paediatric endodontics.
Endodontic success is based on the eradication of root canal infections and prevention of recontamination. The presence of any form of communication between the endodontium and surrounding tissue, in particular the oral cavity, provokes prompt infection relapse. Most of these communications are represented by iatrogenic perforation caused during endodontic procedures. The use of CBCT has significantly improved diagnosis and treatment planning when facing such clinical situations. The introduction of the surgical operating microscope has been another major improvement, allowing precise application of the repair material. Finally, the introduction of biocompatible and even bioactive hydraulic cements, including mineral trioxide aggregate, has been a significant development in improving the outcome of perforation repair, allowing a predictable and perduring seal that prevents further bacterial contamination. Some confusion persists regarding the clinical steps required to treat the different presentations. The present article illustrates the main techniques for repairing perforations based on their position. Suborifice perforation repair requires use of an appropriate sandwich technique.
Regenerative endodontic treatment is a biologically based approach for the treatment of immature teeth with pulp necrosis. In this approach, a sequence of procedural steps, such as disinfection of the root canal space, introduction of a scaffold into the root canal, sealing of the scaffold with an intracanal coronal barrier and restoration of crowns, is followed. Most commonly, hydraulic calcium silicate cements such as mineral trioxide aggregate have been used as the coronal barrier in regenerative endodontic treatment. Although there is still much to be known regarding the details of each step, the procedures performed before and after establishment of the coronal barrier may interact with hydraulic calcium silicate cements and play a role in some of the outcomes of regenerative endodontic treatment. Tooth discolouration has been reported as a common unwanted patient-orientated outcome. This review provides an overview of the probable impact of each procedural step on hydraulic calcium silicate cements in regenerative endodontic treatment, with special attention paid to tooth discolouration.
The recent development of new biomaterials and improved understanding of pulp biology have allowed a reconsideration of the systematisation of endodontic treatments in the case of pulp exposure. The importance of tissue conservation for the durability of treatments has been demonstrated.Pulp capping corresponds to the placement of a biomaterial in direct contact with the pulp. The objective of the treatment is to obtain a biological seal of the site. The prognosis of pulp capping depends on the material used, the age of the patient, the topographical location of the exposure and, above all, the inflammatory status of the pulp.Clinical evaluation of the inflammatory status of the pulp has proven to be the main limiting constraint to systematisation of this procedure. To mitigate this difficulty, in coming years, chamber pulpotomy could be considered as an alternative therapeutic option to endodontic treatment. Clinical implications: The objective of this article is to review the knowledge required for optimisation of therapeutics for pulp vitality conservation and to detail the factors that influence the prognosis.
Aim: Tri Auto ZX2 (Morita, Saitama, Japan), an endodontic motor with an inbuilt apex locator, claims to offer the new feature of monitoring canal length in real time to facilitate working length control during root canal preparation. As such, the present study aimed to evaluate its applicability and features in clinical settings, especially in curved canals as these tend to straighten during preparation, leading to iatrogenic errors and postoperative pain and requiring continuous monitoring of working length. This study also aimed to determine the impact of simultaneous working length determination on postoperative pain in curved canals. Materials and methods: Sixty patients with mandibular molars with curved canals as per the eligibility criteria were randomly divided into two groups: Group 1, the control group (separate working length determination and root canal preparation, n = 29), and Group 2, the intervention group (simultaneous working length determination during root canal preparation, n = 31). Single-sitting root canal treatment was performed using Tri Auto ZX2. Patients' age, sex, tooth number, root canal curvature, preoperative and postoperative pain assessed on the Heft-Parker visual analogue scale and analgesic intake were recorded. The data were analysed using a chisquare test, independent-samples t test and paired t test. Results: There was a significant reduction in postoperative pain in Group 2 on days 1, 5 and 7 ( P < 0.05). Group 2 showed a significant reduction in postoperative pain irrespective of canal curvature as compared to Group 1, with a significant difference in moderately curved canals (P < 0.05). Only two patients from Group 2 required analgesics, whereas nine patients required them in Group 1. Conclusion: Working length determination during root canal preparation provides real-time canal measurement and kinematic features that help to reduce postoperative pain. The new feature of Tri Auto ZX2 can be clinically applied for single-sitting root canal treatment irrespective of canal curvature and severity of preoperative pain.
Aim: Dental bleaching could adversely affect dentine hardness. The aim of the present study was to evaluate the effect of cervical dentine thickness on hardness reduction of outer dentine following intracoronal bleaching. Materials and methods: Thirty-six intact anterior teeth were selected and the root segments were separated 2 mm below the cementoenamel junction. Using a diamond fissure bar, dentine substrate was removed so that cervical dentine thickness in one part of the separated tooth was twice that in the other half. A resin-modified glass-ionomer cement plug was placed in 2-mm thickness from the apical side. Teeth were randomly divided into three groups (n = 12) to be treated with bleaching agents containing 35% hydrogen peroxide, sodium perborate, and distilled water in the control group. Vickers hardness numbers were measured for outer and inner dentine in each tooth sample. Data were analysed using Mann-Whitney U tests. Results: The mean Vickers hardness number between the two dentine thicknesses showed a statistically significant difference only in the sodium perborate bleaching group (P = 0.000). The mean Vickers hardness number of inner dentine was significantly higher in the small dentine thickness in comparison to the large dentine thickness (P = 0.000). The mean Vickers hardness number of outer dentine was significantly higher in the large dentine thickness in comparison to the small dentine thickness (P = 0.000). Conclusions: Within the limitations of this laboratory study, even in the presence of an orifice barrier, removal of excessive dentine from the root canal walls during root canal preparation could increase the damaging effect of bleaching materials on outer dentine microhardness.
Aim: To compare the cyclic fatigue resistance of three thermomechanically treated rotary nickel-titanium instruments, 2Shape (TS; Micro-Mega, Besancon, France), ProTaper Gold (PTG; Dentsply Maillefer, Baillagues, Switzerland) and Vortex Blue (VB; Dentsply Tulsa Dental Specialties, Tulsa, OK, USA), under intracanal conditions. Materials and methods: A total of 36 rotary nickel-titanium instruments of (12 TS [25/0.06]; 12 PTG [25/0.08]; 12 VB [25/0.06]) were rotated in a custom-made model with a 60-degree angle of curvature and 5-mm radius of curvature until fracture occurred. The model was immersed in an acrylic resin container filled with 2.5% sodium hypochlorite (NaOCl) solution set at intracanal temperature (35 degrees C +/- 2 degrees C). Time to fracture was recorded, then the number of cycles to failure was calculated. The length of the fractured segments was measured using a digital caliper and scanning electron microscopy was also performed. The data were statistically analysed using a Kruskal-Wallis and Dunn test with the significance level set at P <= 0.05. Results: The PTG group showed the highest statistically significant number of cycles to failure followed by the VB and TS groups, respectively (P <= 0.001). Both the PTG and TS groups exhibited no statistically significant difference regarding the length of the fractured segments (P >= 0.05); however, they had statistically significant longer fragments compared to the VB group (P <= 0.007). Scanning electron microscopy analysis revealed typical features of cyclic fatigue failure. Conclusions: The PTG system had the highest cyclic fatigue resistance followed by the VB system. The T-wire technology of the TS system showed the lowest resistance to cyclic fatigue.
Aim: Endodontic-periodontal disease is difficult to treat. The difficulty is related to establishing which component of the inflammation is of endodontic origin and which is periodontal. It is therefore crucial to reveal the origin of endodontic-periodontal disease before initialising root canal treatment. It is important to realise that if the root canal treatment will lead to a severe periodontal condition, the necessary efforts to save the tooth will be ccomplex and expensive and the outcome will be uncertain. This article describes the cases of two patients diagnosed with endodontic-periodontal lesions. Materials and methods: Two teeth with different types of endodontic-periodontal lesions were treated and followed up. The first was a type II endodontic-periodontal lesion (according to Messing and Stock's classification) and the second was a type IV lesion. In case 1, root canal treatment was carried out over two visits with calcium hydroxide as an intracanal dressing, and in case 2, the appropriate treatment was provided for a type IV lesion. Results: In case 1, complete healing was observed after root canal treatment. In case 2, progressive bone reconstruction was visible around the treated tooth after 1 year of observation. The following year, a decision was made to extract the tooth due to the patient's lack of cooperation with the dental practitioner. Conclusion: It is important to properly diagnose and reveal the origin of endodontic-periodontal disease before initialising root canal treatment, but the patient's cooperation with the dental practitioner is also crucial, and can contribute to successful treatment outcomes.
Aim: The aim of the present case series was to present three methods of conservative instrument fragment removal. Materials and methods: Different removal techniques were applied; ultrasonic tips, injection needles, small-size hand files and a dental operating microscope were used. Ultrasonic tips were used for the removal of stainless steel files. In one of the cases, removal occurred after loosening the fragment and activating the rinsing solution (citric add). In another, due to the earlier separation and shortening of the removed fragment using ultrasonics, an injection needle and dental cement were employed. For nickel-titanium rotary file removal, the access to and exposure of the corona' fragment were achieved using an injection needle mounted on an endomotor, then the file was removed using cement and an injection needle. Results: In all three cases, the instrument fragments were removed successfully. The success of removal could be influenced by the length of the broken part of the file or the lack of extrusion into the periapical tissues. Conclusions: The file removal procedure is complicated. It requires an experienced operator, specialised equipment and knowledge of treatment and management protocols depending on the treatment case.
An effective irrigant delivery system is mandatory for successful endodontic treatment. The endodontic delivery systems developed in recent years rely on various mechanisms and philosophies for cleaning root canal systems. In general, newer endodontic delivery systems lead to improved canal cleanliness in comparison with conventional syringe needle irrigation. Despite the existence of numerous studies aiming to assess these systems, there are currently no evidence-based studies available to correlate their clinical efficacy. As in daily practice, ergonomics is a crucial factor when choosing an endodontic delivery system; it is necessary to determine how these devices are perceived in terms of practicality and ease of use. The present study provides an overview of the endodontic delivery systems currently available. Based on a new ergonomic index, endodontic delivery systems were assessed in terms of volume, working principle and practicality. While effectiveness in cleaning and disinfecting the root canal system is an aspect to consider when selecting a proper irrigation system, this new ergonomic index may help clinicians to select the appropriate endodontic delivery system.
Aim: This study aimed to investigate whether a conservative endodontic access cavity design results in an identical assessment of the number and shape of root canals compared to a traditional endodontic access cavity design.Materials and methods: A total of 84 extracted human molars were examined by 28 students studying for a master's degree in endodontics, with each student examining three molars. The students were divided into pairs. A conservative endodontic access cavity was prepared in each molar, and the teeth were evaluated independently by both students in the pair to determine the number and shape of the canal orifices. The access cavity was then extended to a traditional endodontic access cavity and independently evaluated again by the same persons. The data were then statistically evaluated using a Wilcoxon signed rank test, chi-square test and McNemar test with the level of significance set at P < 0.05.Results: For 30 teeth (35.7% total; 37.9% maxillary, 30.8% mandibular), the number of canals detected varied between conservative and traditional endodontic access cavities (P < 0.001). For 152 canals (28.5% total; 26.6% maxillary, 33.6% mandibular), the evaluation of the canal geometry changed (P < 0.001). There were no significant differences in absolute value between the two types of access in terms of the number of canals and the round geometry of the canal orifices, although more oval canals were detected with traditional endodontic access cavities. No absolute difference was found in detected second mesiobuccal root canals in maxillary molars or in the middle mesial canal in mandibular molars.Conclusion: The conservative endodontic access cavity approach is more susceptible to misinterpretation of the number and shape of canal orifices than the traditional approach.
Aim: Many factors can affect the cyclic fatigue resistance of nickel-titanium files. Nickel-titanium can exist in a soft martensitic state, which improves its cyclic fatigue resistance. The alloy transforms from the austenite to martensite state at a certain temperature, and various factors can modify this transition temperature. Temperature affects the state of the metal; therefore, the way the file behaves at intracanal temperature is significant. The present review aims to gather evidence to show that martensitic files display increased cyclic fatigue resistance compared to conventional files. Materials and methods: A population, intervention, comparison, outcomes and study framework was used to formulate the review question and develop the inclusion and exclusion criteria. The search was conducted using the databases Science Direct, Wiley, PubMed and Google Scholar. A single reviewer screened the results, applying the inclusion and exclusion criteria. The results were analysed. The Joanna Briggs Institute Checklist for Cohort Studies was used to assess the quality of the studies. The primary studies and review process were assessed for bias. Results: A total of 642 studies were screened and 22 studies were included. The overall quality of the included studies was judged as moderate. Conclusions: Within the limitations of this study, it was found that the Hyflex EDM file (Coltene/Whaledent, Altstatten, Switzerland) is martensitic at intracanal temperature and has higher cyclic fatigue resistance than the other martensitic phase files.
The advent of guided endodontics, combining 3D imaging techniques with digitally designed guides, has led to its utilisation in surgical and nonsurgical root canal treatment. To date, however, guided endodontics has focused mainly on static guidance, with dynamic guidance receiving limited attention. In the present case report, a dynamic navigation implant system was used for guided endodontics. The safe and accurate access cavity preparation, location and negotiation of the calcified canals of a maxillary second premolar demonstrate the successful clinical, application of dynamic guided endodontics in everyday endodontic practice.
Aim: The aim of this study was to evaluate the number of bacteria extruded from the tooth apex after root canal instrumentation using three nickel-titanium rotary systems. Materials and methods: A total of 55 mandibular premolars were extirpated and inserted into glass bottles. The root canals were contaminated with Enterococcus faecalis. The teeth were divided into four groups: ProTaper Universal, ProTaper Next, ProTaper Gold (all Dentsply Sirona, Charlotte, NC, USA) and the control group. For the first three groups, comprised of 15 teeth each, preparation was implemented with ProTaper Universal, ProTaper Next and ProTaper Gold files, respectively. No instrumentation was performed in the control group, comprised of 10 teeth. The solution in the bottles was investigated using the classical bacteria-counting technique. Data were analysed using a Kruskal-Wallis one-way analysis of variance and Mann-Whitney U tests. Results: The mean number of colony-forming units in the ProTaper Universal and ProTaper Gold groups was significantly higher than in the ProTaper Next group (P < 0.05). The difference between the ProTaper Universal and ProTaper Gold groups was not statistically significant (P > 0.05). Conclusions: All instrumentation techniques caused extrusion of intracanal bacteria. The ProTaper Universal and ProTaper Gold groups produced significantly more bacterial extrusion than the ProTaper Next group.
Root-end surgery is necessary when primary endodontic treatment fails and the tooth cannot be managed successfully by conventional retreatment strategies. Over the last two decades, root-end surgical techniques have changed considerably due to the introduction of microscopes, ultrasonic instruments and dedicated root-end filling materials. This clinical perspective focuses on the development and use of hydraulic calcium silicate materials for root-end surgery.
