Tạp chí Nội Nha tháng 10 2013 Vol 6 No5

clinical articles • management advice • practice profiles • technology reviews
October 2013 – Vol 6 No 5

Top ten tips

9

#

Preparation
techniques

Dr. Tony Druttman

Endodontic
treatment of
curved root
canal systems
Dr. John Bogle

Practice profile
Dr. Peter A. Morgan

Corporate profile
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No. 3 in a Series


ASSOCIATE EDITORS
Julian Webber BDS, MS, DGDP, FICD
Pierre Machtou DDS, FICD
Richard Mounce DDS
Clifford J Ruddle DDS
John West DDS, MSD

D

EDITORIAL ADVISORS
Paul Abbott BDSc, MDS, FRACDS, FPFA, FADI, FIVCD
Professor Michael A Baumann
Dennis G Brave DDS
David C Brown BDS, MDS, MSD
L Stephen Buchanan DDS, FICD, FACD
Gary B Carr DDS
Arnaldo Castellucci MD, DDS
Gordon J Christensen DDS, MSD, PhD
B David Cohen PhD, MSc, BDS, DGDP, LDS RCS
Stephen Cohen MS, DDS, FACD, FICD
Simon Cunnington BDS, LDS RCS, MS
Samuel O Dorn DDS
Josef Dovgan DDS, MS

Tony Druttman MSc, BSc, BChD
Chris Emery BDS, MSc. MRD, MDGDS
Luiz R Fava DDS
Robert Fleisher DMD
Stephen Frais BDS, MSc
Marcela Fridland DDS
Gerald N Glickman DDS, MS
Kishor Gulabivala BDS, MSc, FDS, PhD
Anthony E Hoskinson BDS, MSc
Jeffrey W Hutter DMD, MEd
Syngcuk Kim DDS, PhD
Kenneth A Koch DMD
Peter F Kurer LDS, MGDS, RCS
Gregori M. Kurtzman DDS, MAGD, FPFA, FACD, DICOI
Howard Lloyd BDS, MSc, FDS RCS, MRD RCS
Stephen Manning BDS, MDSc, FRACDS
Joshua Moshonov DMD
Carlos Murgel CD
Yosef Nahmias DDS, MS
Garry Nervo BDSc, LDS, MDSc, FRACDS, FICD, FPFA
Wilhelm Pertot DCSD, DEA, PhD
David L Pitts DDS, MDSD
Alison Qualtrough BChD, MSc, PhD, FDS, MRD RCS
John Regan BDentSc, MSC, DGDP
Jeremy Rees BDS, MScD, FDS RCS, PhD
Louis E. Rossman DMD
Stephen F Schwartz DDS, MS
Ken Serota DDS, MMSc
E Steve Senia DDS, MS, BS
Michael Tagger DMD, MS

Martin Trope, BDS, DMD
Peter Velvart DMD
Rick Walton DMD, MS
John Whitworth BchD, PhD, FDS RCS

oes your endodontics leave the footprints you want? Does your endodontics
distinguish who you are? Do your clinical endodontic skills set you apart? Are you
the endodontist that you would want to go to? What are your “measurables?”

NATIONAL SALES/MARKETING MANAGER
Drew Thornley
Email:
Tel: (619) 459-9595

In today’s marketplace, it’s not good enough to be good enough, to have convenient
hours, or to send referring doctors staff lunches. In order to earn the transfer of referral
trust, we have to do something different. We have to deliver something that exceeds
expectation. How is this done? Listed below are 10 measurables that influence the
endodontic referral and create endodontic value:
1. Quality. The first step in becoming a masterful endodontic clinician is to slow down.
When we slow down, we do better endodontic finishes, and we create more value
to our patients and referring doctors. With greater value, we are worth more to the
community, and a higher fee has been earned. If your fees are justifiably higher, you
have a choice to slow down. The successful cycle then continues. Slowing down
and skillful endodontic mechanics have been the focus and hallmark of my current
Endodontic Practice US series entitled Anatomy Matters. What is your finishing
checklist? What matters to you?
2. Only start what you can finish well. Most of us attempt to finish everything we
start. This is the risk of the growth phase of endodontics. We have no time to finish
anything well. Our quality and standards go down, and what once set us apart has

been lost.
3. Be your dentists’ advocate/ally. Let them know they can be safe with you no
matter how bad they may have had technical difficulties. Tell them their success is
your job. You have their back.
4. Transfer of trust. Your referring dentists and their patients have granted you trust.
Now you have to earn it.
5. Be accountable for your results. Referring dentists want an endodontist who has
no excuses. Take full responsibility for a successful patient experience and treatment
outcome.
6. Present alternate treatment plans. Sometimes endodontists have tunnel vision
or diagnose based on their own needs. Dentists need the security and confidence
that you will tell them and their patients WWIDIIWM (What would I do if it were me?).
Learn the parts of the endodontic interdisciplinary mind: biology, structure, function,
and esthetics. Know these domains as well as, if not better, than your referring
dentists.
7. Practice team endodontics. Discover what it is in your day that you enjoy the
most, and do more of that and less of what you don’t enjoy. For me, I am lost in the
moment or in the Flow when I am Cleaning, Shaping, Packing, or in Surgery (Flow,
Mihaly Csikszentmihalyi, 1991 by Harper Perennial). Delegate tasks that you enjoy
less to trained and skilled hands.
8. Exceed your referring doctors’ and patients’ expectations. Perform at a level
of competence, consistency, and confidence that exceeds the expectations of the
dentist and patients.
9. Mentor an Endodontic Study Club. This study club should be designed to
collaboratively learn knowledge and to make consensus diagnoses and treatment
plans. It should not be about “getting referrals.”
10. Lead. Leaders take people where they have never gone before. Leaders keep their
focus on the outcome they want in spite of pressure to do otherwise. They start with
the answer.

PRODUCTION ASST./SUBSCRIPTION COORD.
Lauren Peyton
Email:
Tel: (480) 621-8955

Summary

CE QUALITY ASSURANCE ADVISORY BOARD
Dr. Alexandra Day BDS, VT
Julian English BA (Hons), editorial director FMC
Dr. Paul Langmaid CBE, BDS, ex chief dental officer to the Government
for Wales
Dr. Ellis Paul BDS, LDS, FFGDP (UK), FICD, editor-in-chief Private
Dentistry
Dr. Chris Potts BDS, DGDP (UK), business advisor and ex-head of
Boots Dental, BUPA Dentalcover, Virgin
Dr. Harry Shiers BDS, MSc (implant surgery), MGDS, MFDS, Harley St
referral implant surgeon

PUBLISHER | Lisa Moler
Email:

Tel: (480) 403-1505

MANAGING EDITOR | Mali Schantz-Feld
Email:

Tel: (727) 515-5118

ASSISTANT EDITOR | Kay Harwell Fernández

Email:

Tel: (386) 212-0413

EDITORIAL ASSISTANT | Mandi Gross
Email:

Tel: (727) 393-3394

DIRECTOR OF SALES | Michelle Manning
Email:

Tel: (480) 621-8955

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printed herein, or in any consequence arising from it. The views expressed herein are those of the
author(s) and not necessarily the opinion of either Endodontic Practice or the publisher.

Volume 6 Number 5

If your endodontic practice is waning, does not represent you, if you are not as busy as
you want to be, or you have lost the respect of your dentists, then commit to one, some,
or all of these guidelines, and then observe the difference.

John West, DDS, MSD
Founder and Director, Center for Endodontics, Tacoma, Washington
Past President Academy of Microscope Enhanced Dentistry
Past President of American Academy of Esthetic Dentistry
Endodontic practice 1

INTRODUCTION

You are an endodontist: “how do you
measure up?”

October 2013 - Volume 6 Number 5

TABLE OF CONTENTS

Clinical
Systematic adhesive core

Practice profile

6

Dr. Peter A. Morgan
Hard work and attention to detail lead to smooth sailing in endodontics.

build-up
Dr. Ludwig Hermeler presents a
clinical case using the Rebilda Post
system........................................ 14

Case study
Management of root resorptive
lesions in maxillary incisors
using computed tomography and
MTA: 1-year follow-up
Drs. Anil Dhingra and Marisha
Bhandari delve into the advantages
of MTA and CBCT imaging ......... 18

Endodontics in
focus
Top ten tips: Tip number 9 Preparation techniques
Continuing his series on

endodontics, Dr. Tony Druttman
shows the importance of preparation
................................................... 24

Corporate profile

12

Carestream Dental

ON THE COVER

A history of proven technology, a future dedicated to innovation.

Cover photo courtesy of Dr. Ludwig
Hermeler. Article begins on page 14.
For the August/September issue, the
cover photo was courtesy of Dr. Stanislav
Geranin from Poltava, Ukraine.

2 Endodontic practice

Volume 6 Number 5


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TABLE OF CONTENTS

Practice
management
Growing the money tree
William H. Black, Jr. discusses the
financial advantages of having a good
plan in place .................................48

Endospective
One clinician’s means of obtaining
patency and preparing the glide

The big
debate

Continuing
education
Endodontic treatment of curved
root canal systems
Dr. John Bogle offers some cases
to treatment plan success for tooth
retention .......................................28
Root canal preparation: the path
to success
Dr. Omar Ikram explains the principles

of taper and apical preparation and
how they relate to clinical practice
.....................................................32

Endo essentials
The big debate
Drs. Michael Norton and Julian
Webber discuss — implants or
endodontics?................................36

4 Endodontic practice

36

Legal matters
Harassment – crossing the
professional line
Dr. Bruce H. Seidberg discusses the
consequences and complications of
harassment...................................38

Product profile
PROTAPER NEXT™ delivers
performance refined .................42

path
Dr. Rich Mounce discusses a method
for obtaining patency and preparing
the glide path with hand files ........50

Anatomy matters
“Could it all simply be a
coincidence?” Part 8
Dr. John West considers the
mysteries of endodontic success or
failure ...........................................52

Industry news.............56
Materials &
equipment ......................56

Air Techniques’ all new ScanX
Swift™
Digital imaging without limits .........44

Practice
development
Apply current tax laws to improve
patient care
Bob Creamer explains Section 179
and Bonus Depreciation ...............46
Volume 6 Number 5


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my treatment process is a lot less stressful. My patients benefit from the technology and my
referrals appreciate the value.” ~ Dr. Kathryn Stuart, Endodontist - Fishers, Indiana

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PRACTICE PROFILE

Dr. Peter A. Morgan
Hard work and attention to detail lead to smooth sailing in endodontics
What can you tell us about your
background?
I grew up in a small town on the Allegheny
River in Western Pennsylvania just 20
miles outside of Pittsburgh. I attended the
University of Pittsburgh for college and
dental school. Because it was during the
Vietnam War, I had been deferred from
military service, and so I entered the U.S.
Army after I graduated from dental school.

I was fortunate to have a very good dental
internship at Fort Bragg in North Carolina
and then spent 2 additional years as a
Captain in the U.S. Army Dental Corps
doing general dentistry at Fort McNair in
Washington DC.

Why did you decide to focus on
endodontics?
Because of extensive exposure to oral
surgery in the military, I originally thought
of specializing in oral surgery. However, as
I approached the end of my Army service,
I began to think about endodontics as I
enjoyed saving teeth over extracting them.

I visited what was then the School of
Graduate Dentistry at Boston University
(BU) and met Dr. Harold Levin. He
eventually became a mentor and my
partner in practice. We first met by chance
when I walked into the school, and he was
kind enough to take considerable time
to explain the school and the specialty
of endodontics to me. I left that meeting
with tremendous excitement about the
possibility of having a career in endodontics
and training at BU. Not long after that, I
was fortunate to have an interview with Dr.
Herb Schilder. That led to a residency at

BU, training under Dr. Schilder and many
other talented and dedicated endodontists
who were teaching there at the time.

What
training
undertaken?

have

you

I received a Certificate in Endodontics
and a Masters of Science and served as
Associate Clinical Professor at the school
for many years. I am a Diplomate of the
American Board of Endodontics (AAE).
I have served two terms as a Trustee to
the American Association of Endodontics
and am currently serving as a Trustee to
6 Endodontic practice

In sailboat racing and in practice, all members of the crew need to focus on every detail to get a good
outcome

the American Association of Endodontics
Foundation. I am currently the managing
partner of North Shore Endodontics and
Brookline Endodontics in Boston and
suburbs.

It is my association with the AAE
Foundation that has been a real eye opener
to me on the real world of endodontics. I
have seen that there is a tremendous need
for endodontic teachers in all of the dental
schools and an equally important need
for research to further our understanding
of the biological and technical processes
that affect the outcome of the care we
deliver. This revelation has only been
topped by the fact that the Foundation
funding to date has been a result of a
tremendous outpouring of support from
endodontists and from corporate partners
who see the commitment our endodontist
members make and value their judgment.
The Foundation is the only organization
exclusively dedicated to supporting
endodontic research and education. It
provides support to every endodontic
residency program in the U.S. and
Canada. The Foundation provides over 1
million dollars yearly to support research
and faculty positions in endodontics.

Who has inspired you?
Dr. Schilder was the best teacher I have

ever encountered. He was exceptionally
smart, very demanding, and capable of

explaining complex concepts in a clear
way. His educational protocol allowed
for little deviation from his prescribed
technique. I have realized the tremendous
value of this approach on countless
occasions in my career when faced with
difficult diagnostic and treatment cases.
Herb knew that the oddities of anatomy
and biology were looming out there. By
giving his residents a solid understanding
of diagnosis and disciplined treatment
objectives, he equipped us for the real
world of endodontic practice. Herb trained
clinicians in an era when the specialty of
endodontics was just beginning to grow.
Dr. Schilder’s legacy continues at BU
through the BU Endo Alumni Association,
which provides a forum for all BU trained
endodontists to collaborate.

Tell us about your practice.
My career in practice began when I
joined Dr. Harold Levin and Dr. Robert
Rosenkranz. Over many years together, we
grew the practice to a multi-office, multidoctor practice. Both of those doctors
have retired from practice, and I am now
fortunate to have Dr. Yuri Shamritsky and
Dr. Fiza Singh as partners. Together we
have continued to grow the practice, which
Volume 6 Number 5

What is the most satisfying aspect
of your practice?
There are many aspects of Endodontic
Volume 6 Number 5

practice that I find satisfying. The most
rewarding feeling by far is the satisfaction of
meeting a patient with significant symptoms
that are life-interrupting and reversing those
symptoms quickly and painlessly. Every
endodontist experiences this, and I hope
they all realize what a unique service it is
in the health care world. It is very common
in our offices for an emergency patient to
be seen very soon after we get the call
from his/her dentist. Not long after that,

members to take responsible roles in the
practice. We have a great team, and I am
very proud of them.
The leader of our staff team is our
Practice Manager, Michele Whitley.
Michele and other staff members have
taken an active role in continuing education
by presenting courses at the AAE Annual
Session and at other CE venues. Holly
LeBlanc, another staff member, has
served as a consultant to EndoVision.

Dr. Andrew Bradley

Dr. Andrea Chung Shah

Partners: Dr. Yuri Shamritsky, Dr. Fixa Singh, and
Dr. Peter Morgan

Dr. Paul Talkov

we complete the emergency treatment.
At a subsequent appointment, the patient
returns with gratitude for having had his/
her very significant problem resolved
painlessly. Patients benefit greatly from the
skill of their endodontist, and the model of
how we move patients between offices in
response to patient need is a model that
should be more frequently found in health
care.

Professionally, what are you most
proud of?
I am very proud of our practice. While I know
that group practice is not for everyone, it
has been a very favorable format for my
partners and me. Because we have a
group of doctors, we have the opportunity
to share ideas and to collaborate on cases.
Because we are bigger, we have more

staff, and they also bring new ideas and
capabilities to the table. The biggest gains
in our business management have come
about as a result of empowering our staff

Dr. Morgan and two of his key team members, Cheryl
Bennet-Delong and Jennifer Hamlett

This involvement in the larger world of
endodontics outside our practice walls
empowers our staff to bring back to our
practice innovative ideas they develop
in collaboration with colleagues at these
educational sessions. As AAE Annual
Session chair some years ago, I stressed
Endodontic practice 7

PRACTICE PROFILE

now includes six offices.

Dr. Yuri Shamritsky began his dental
career with a Doctor of Dental Science
from the University of Moscow. In the
U.S., he continued his dental education
at Boston University Goldman School
of Dental Medicine where he received
a DMD and a Certificate of Advanced
Graduate Studies. He served for over 10
years as Associate Clinical Professor and

Director of the Microendodontic Surgical
Program. Yuri has inspired many students
by his dedication to precise microsurgical
techniques, and he has applied his skills to
resolve many problems for his patients in
our practice.
Dr. Singh received her Doctorate of
Dental Surgery from New York University
College of Dentistry. She holds a Certificate
in Endodontics, a 3-year specialty
fellowship from The Harvard School of
Dental Medicine, and Masters of Medical
Sciences from Harvard Medical School,
including 2 years of research at The
Forsyth Institute. Her specialized training
includes Oral Implantology and Oro-Facial
Musculoskeletal
Pain/TMD
Disorders
from the New York University College of
Dentistry. Dr. Singh is also board certified
in Endodontics in Canada, where she is
a member of the Royal College of Dental
Surgeons.
We are also fortunate to have the
following doctors in our practice:
Dr. Paul Talkov, who completed his
dental school at Tufts University and endo
residency at Boston University Goldman
School of Dental Medicine.

Dr. Andrea Shah, who completed her
dental school at Harvard University and
endo residency at Tufts University. While a
resident, she was recipient of a Research
Grant from the AAE Foundation.

Dr. Andrew Bradley, who completed
his dental school at Tufts University and
endo residency at Boston University
Goldman School of Dental Medicine.

We are very proud to have Dr. Schilder
and Dr. Joe William’s former practice,
Brookline Endodontics, as a part of our
current practice. Many of the doctors in our
practice had the benefit of Dr. Schilder’s
teaching during their training. Continuing
his treatment philosophy in the office where
he practiced has been very professionally
rewarding for us.


PRACTICE PROFILE

Michele Whitley, practice manager and Dr. Peter Morgan, managing
partner

Dr. Morgan and his team taking a break at the EndoVision booth, from presenting at the AAE Annual Session
in San Antonio

the need to incorporate more staff
educational courses in our programs to
fulfill this objective.

What is
practice?

unique

about

your

I believe our practice is unique. It was
started in Lynn, Massachusetts in 1962
by Dr. Harold Levin. At that time he was
the only endodontist between Boston and
Montreal, Canada. That has changed of
course, and now there is competition for
almost every endodontist no matter where
they practice. What makes us unique is our
multi-office format. Because of this, while
we do face competition, we stay busy
in many locations. The key to business
success is having a full appointment book.
This is our way of helping that to be true.

What systems do you use?
I have been fortunate to practice in the

time of the evolution of technology in
endodontics. We all appreciate the teaching
and patient education advantage of digital
X-ray. However, to really appreciate it, you
have to have worked for years with film. As
I tell my patients, in the past I would look at
the little X-ray films and tell the patients that
they needed a root canal. Now I enter the
room and the image is already on the big
monitor, and the patient often says to me,
“I guess I need a root canal.”
We started with Schick digital X-ray
in 1998. We made a big commitment to
equip all of our locations at that time. It
was immediately very helpful clinically and
provided a “WOW factor” for patients as
they had never seen such a thing before.
8 Endodontic practice

Our relationship with Schick continues
today and has led us to an equally
rewarding relationship with Sirona. We
followed the integration of digital X-ray with
conversion to EndoVision and an Electronic
Health Record (EHR). EHR is certainly the
current standard for records, and we find it
to be essential for a multi-location practice.
Because we have multiple doctors, we
have loyalties to both Global and Zeiss
operating microscopes, and surprisingly

we have all become comfortable with
both. More recently, we have opened our
eyes even wider with the incorporation
of the Sirona XG3D CT scan machine.
This technology has provided exceptional
value to our patients by giving us more
information than ever before from which
to make treatment decisions. The XG3D
by Sirona provides a remarkably clear
5 cm X 5 cm focused field which is truly
the current “WOW!” in 3D imaging. The
availability of this technology has enhanced
our relationship with referring dentists
because they repeatedly see the value of
the informed treatment decisions we can
make in retreatment, surgical, resorption,
and unusual anatomy cases.
My partner, Dr. Shamritsky and I
recently had the opportunity to attend a
Sirona/Sicat opinion leaders conference in
Bonn, Germany. I was very impressed with
the application of the XG3D CT technology
to the creation of surgical guides. This has
the potential for application in endodontics
as well as in implant placement and the
creation of precision prostheses.

Another recent addition to our practice
is a marketing tool, the Endofone App.

This is essentially an electronic business
card that uses smart phone technology
to inform our patients about our practice.
Accessed via a QR code, patients can
instantly learn about us and get all of the
essential information about us on their
smart phone without having to go to the
web site.
These technologies help us, but I
believe it is more important than ever for all
endodontists to focus on true clinical skills.
There is a saying, “It is a poor carpenter
who blames his tools.” Herb Schilder and
many of the great early endodontists did
not use a microscope or digital X-ray.
Yet they were instrumental in establishing
many of the treatment methods we still use
today. They showed cases then that would
rival any case done today with enhanced
vision and rotary instrumentation. I believe
the future of endodontics will depend
on endodontists defining the value of
consistent predictably successful cases
for their patients. If endodontics is defined
by equipment and technology, it will
allow anyone with that equipment and
technology to claim the high ground.

What has been your biggest
challenge?

I think the most successful practices are
those that know how to change to meet the
challenge of the changing market for our
services. The model used by my partner,
Dr. Levin, when he started the practice, may
not be the model for success today. The
single practitioner then had more patients
than the doctor could manage. They
were often begging the endo department
chairs to send them their next graduate.
Today’s single practitioners had better
find an area in need of an endodontist,
or they will not have a busy schedule. In
addition, starting a practice today requires
Volume 6 Number 5


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Side Delivery
An ASI cart positioned at the doctor’s
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Foot Control Placement
The foot control tubing of an ASI system can
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from the junction box to the patient dental
chair. The end result creates easy access to
the foot control without tubing running
across the floor.

The Junction Box
In addition to attractively concealing the standard
connections of compressed air, suction and electricity,
ASI’s unique in-wall junction box allows computer
connections such as video, USB, network and other
IT connections throughout the office to be easily
organized and safely hidden from view.

“The ASI Endodontic carts are a great convenience. This space
saving design allows me to be organized and efficient with only one
foot control and without all of the cords draped over my counters.”
– Dr. Kelly Jones

1-800-566-9953 • asimedical.net


PRACTICE PROFILE
a much larger capital investment than
before the days of high-powered software

and technology. This increases the risk of
a practice venture, and as a result, many
endodontists choose to avoid this risk and
work in the offices of general dentists, or
for corporate dental centers. Naturally, this
puts more competitive pressure on the
more traditionally situated endodontist.
Changing to meet these market realities
is challenging. It requires constantly
adapting to meet the needs of the referring
dentists and their patients. Having younger
endodontists in the practice helps us
adapt, as they have a closer understanding
of the needs and wishes of their peers.

our group, we schedule new doctors in a
way to allow for them to meet patients and
referring doctors at a reasonable pace. We
do not require that all partners’ schedules
are filled before associates get patients
on their schedule. We invest a lot of time
and energy in the process of selecting an
associate and integrating him/her into the
practice. The new associates make a big
commitment also. Our goal is to give this
combined effort the best possible chance
for success.

What would you have become if
you had not become a dentist?

When I was making the final decision to

team in sailboat racing has many parallels
to developing a successful practice team.
Both require dedicated talented individuals
who are willing to work hard to achieve
success. And in both, others are trying to
win too. So, in order to win, you must pay
attention to every detail.

I often say to our doctors and staff at
the office, “We want our patients to realize
that they have been referred to the right
place for endodontic care.” To accomplish
this, we apply the same rule that I have
used with my racing crew to prepare for a
sailboat race. Every detail is important and
essential to give us the best opportunity
for a good outcome. In our offices, this

What advice would you give to
budding endodontists?
I have had the advantage of working with
young endodontists in our practice over the
years. They have all taught me more than
I have taught them. However, in general, I
would advise the young graduate to find a
mentor to reach out to when needed. Also,
in challenging diagnostic cases, I would
advise remembering that you can almost

always wait a day to make a treatment
decision rather than making a decision
immediately that you may regret later.
In talks to endo resident groups,
I always stress that success for any
endodontist requires you to make yourself
indispensable to the practice. By this I
mean that it is essential to commit to an
“all in” approach. The residents I see
who achieve the greatest success begin
by working hard in their training and in
their practice to continually improve their
clinical skills. Then they must also learn
to integrate successfully into the group of
individuals they work with. This is extremely
important as the daily challenge of practice
necessitates a team approach to be
successful. Also, new doctors in a practice
need to recognize the absolute requirement
to grow the practice. This means you,
the new person, need to become the
recognized established person in the
practice ASAP. In addition, every doctor
in a practice must accept responsibility for
special projects. This means recognizing
that there is more to being a successful
endodontist than just doing good cases.

What are some tips for maintaining
a successful practice?

To help associates succeed, the partners
in a practice also need to work hard to
give them every opportunity to succeed. In
10 Endodontic practice

Our practice continually strives to
incorporate advanced technology, such
as the Sirona XG3D Cone-Beam CT
machine shown above

go on to dental school, I briefly considered
going to law school. I had minored in
Political Science and had some good
friends going on to law school. In the end,
I decided that dentistry was right for me,
and it has turned out to be a very satisfying
career.

Tell us some more about yourself.
What are your hobbies, and what
do you do in your spare time?
When I came to Boston, in addition to
finding Boston University and an area to
practice, I also met my wife, Jessie Morgan.
Jessie is an accomplished painter with a
studio near our home. Her abstract works
can be seen in contemporary galleries, and
on her website. Her paintings are held in
corporate and private collections nationally
and internationally. I love that her abstract

work is so different from what I do.

I have come to love New England. I am
fortunate to live in a New England coastal
community with a beautiful natural harbor.
I became interested in sailboat racing
and have spent many years competing
in one-design sailboat racing in this area.
I learned that developing a competitive

means that we will always strive to have
everything from doctor and staff continuing
education to incorporating the appropriate
technology up to a very high standard. And
it means that every contact with patients
and every detail about our offices reflect
our commitment to the highest standard of
care. By putting our patients first, we are
in essence putting our referring doctors
first as well. It is a simple but powerful
philosophy.
We appreciate the trust referring
doctors put in our practice every time
they refer a patient. Our doctors and
staff members work hard to exceed
expectations so that the patients return
with respect for their dentists for having
referred them to us. EP
Top favorites
• Schick: A real company with great people, a

great product, and great support.
• Sirona: Another great company with a
long history of bringing great products to
dentistry.
• Endovision: Henry Schein. Leading the way
with practice management software for multioffice locations.
• Brasseler: Great products for endodontists.
• Endofone: An innovative new way to inform
referred patients and referring dentists.

Volume 6 Number 5


ARE YOU A DINODONTIST?
You might have the slickest looking office in town, but is your software still from the Stone Ages? At TDO,
we believe you deserve a software system that helps your practice grow, not one that gets in your way.
TDO Software allows you to provide the best possible patient care. Only TDO enables your staff to be their
best by eliminating time-wasting inefficiencies in the office. TDO makes it easy to keep current with the
latest technology, terminology, materials and techniques. With TDO
you can create professional-looking referral and CBCT reports and
print, email or publish them on your website with just one click.
Take your practice out of the museum and into the
world of modern endodontics. Evolve today with
TDO Software.

This EHR Module is 2011 compliant and has been certified by an ONCDATCB in accordance with the applicable certification criteria adopted by the Secretary of Health and
Human Services. This certification does not represent an endorsement by the U.S. Department of Health and Human Services or guarantee the receipt of incentive payments.


CORPORATE PROFILE

A history of proven technology, a future dedicated to innovation

W

ith roots that can be traced back to
the 19th century, Carestream Dental
certainly has a long history of innovation
when it comes to dental specialties —
including endodontics. This legacy carries
on still, as the company continues to
develop imaging systems and software
and enter new markets. It’s because of
this proud tradition that more than 800
million images are captured each year on
products from the company’s imaging
portfolio. Today, Carestream Dental is
focused on providing endodontists with the
products they need to facilitate treatment
planning and improve patient care.

Endodontic clinical image captured with an RVG 6100 sensor

RVG 6100 sensor

History of Carestream Dental
The Carestream Dental of today was
built on the shoulders of major industry
leaders of the past — starting in 1896
when Eastman Kodak introduced the first

photographic paper designed specifically
for dental X-rays. As technology improved
and became more digitalized, Trophy
Radiologie filed a patent for the world’s
first digital intraoral sensor in 1983. Already
known for producing intraoral X-ray
generators, the digital intraoral sensor
earned Trophy a reputation as the world’s
leader in dental digital radiography.

In 2000, PracticeWorks emerged as a
dominant dental software company when it
acquired several other software companies.
PracticeWorks went on to acquire Trophy
Radiologie in 2002, and was purchased
the next year by Eastman Kodak to expand
their presence in the dental business. With
the integration of PracticeWorks/Trophy,
Eastman Kodak built the industry’s leading
portfolio of film, digital imaging systems,
and practice management software. Then,
in 2007, Onex Corporation purchased
Kodak’s Health Group, and Carestream
Dental was born.

The Carestream Dental Factor
“We exist to make your practice better,”
said Marc Gordon, Carestream Dental’s
General Manager, U.S. Equipment and
Software. “Our number one goal is to make

user-friendly, yet sophisticated, technology
12 Endodontic practice

to put our customers’ practices at the
forefront.”
Carestream Dental’s dedication to
advancing endodontics can be summed
up by the Carestream Dental Factor; three
pillars on which the company bases all of its
products and services.  Incorporating the
key elements at the heart of Carestream
Dental’s philosophy, the company’s main
focus is on delivering workflow integration,
humanized technology, and diagnostic
excellence.
Workflow integration: Administrative
tasks cut into time that can be better spent
communicating with and treating patients.
For this reason, Carestream Dental designs
systems and software to enhance treatment
planning and fit seamlessly into busy
endodontic practices. Ensuring that every
link in the chain fits and contributes to the
workflow as a whole allows endodontists
to increase productivity and efficiency.
Intuitive technology and software
are the hallmarks of Carestream Dental.
By developing imaging systems that can
be quickly utilized by practitioners —
and easily integrated with leading thirdparty endodontic practice management

software, such as TDO — users can
eliminate time that would have been spent
troubleshooting problems and instead
focus on patients.

Humanized technology: Patients are an
integral part of every endodontic practice,
so Carestream Dental is committed
to providing solutions that facilitate
communication between the endodontist
and patient. When communication is
optimized, patients are happier and
healthier — allowing them to make better,
more informed decisions regarding their
proposed treatment plan and, in turn,
increasing case acceptance.
Diagnostic excellence: When evaluating
canal morphology and endodontic
pathology, details are everything. To
facilitate faster, more reliable treatment
planning, Carestream Dental has created
a number of cutting-edge diagnostic tools
that enable endodontists to capture sharp,
high-quality images quickly. From industryleading 3D imaging systems to highresolution intraoral sensors, Carestream
Dental offers a range of solutions that allow
endodontists to identify areas of concern
and determine the best course of action.

Technology developed for clinicians, by clinicians
The Carestream Dental Factor isn’t the only

thing driving user-focused and innovative
products and services — the clinicians at
the heart of the company also play a large
role. Through meetings and forums with
doctors in the field, Carestream Dental
Volume 6 Number 5


CORPORATE PROFILE

CS 9000 3D
Root resorption image as seen on Carestream Dental’s 3D Imaging software

is better able to understand the needs of
endodontists in order to develop — and
modify — products. In fact, the voice of the
customer (VOC) is critical throughout the
development process.

To ensure quality, Carestream Dental
also manages every aspect of the products
they develop. “By controlling each step
in the process — from development and
manufacturing all the way to support — we
make it easier for endodontists to deliver
better patient outcomes,” said Mr. Gordon.

Innovative products to facilitate
endodontic treatment planning
Endodontists

require
high-resolution
images to evaluate the morphology of the
dental pulp and view the most intricate
details of canals — something that
Carestream Dental certainly delivers. The
following is just a sample of the imaging
products Carestream Dental has designed
to meet the specific needs of endodontic
practices:
CS 9000 3D: Combining focused-field
3D technology with dedicated panoramic
imaging, the affordable two-in-one CS
9000 3D system delivers the best of both
worlds, offering the highest resolution and
lowest radiation dose. Users can capture
anatomically correct images with 1:1
measurements as well as view all of the
necessary angles and slices, making it the
ideal unit for root canals and procedures
limited to a focused area, while the available
3D stitching module combines up to three
volumes for full-arch reconstruction.
Volume 6 Number 5

CS 3D Imaging Software: Included
with Carestream Dental’s CBCT imaging
units, CS 3D Imaging software allows
practitioners to view images slice by slice
in axial, coronal, sagittal, cross-sectional,

and oblique views to enhance diagnostic
interpretation. In addition, the images can
be saved to a CD/DVD or USB drive with
a complimentary copy of the software to
share with the referring doctor — improving
the colleague collaboration process.
RVG 6100: With greater than 20 lp/
mm resolution per image, Carestream
Dental’s RVG 6100 sensors deliver the
highest image resolution in the industry.
Each sensor undergoes rigorous testing to
provide maximum durability and flexibility,
and the RVG 6100 features a rear-entry
cable, three different sizes, and rounded
corners to improve comfort for patients
and make positioning easier for users.

Comprehensive education
When endodontists understand how to
fully maximize their imaging capabilities,
they are better able to get the most of
out of their equipment. For this reason,
Carestream Dental is committed to
providing thorough training and education
to ensure their customers have the skill and
knowledge necessary to use their imaging
products and software.
In addition to providing web-based
and in-person training, Carestream Dental
holds 3D symposiums, where practitioners

can learn how to use 3D imaging
equipment in their daily practice. This event

features leaders in the industry who share
advice and insights, as well as information
on the latest industry trends in 3D, to make
participants’ practices more efficient and
successful.

Next steps
With the launch of CS Solutions, a oneappointment CAD/CAM restoration system,
Carestream Dental will once again enter an
entirely new market — and it certainly will
not be the last. As an integrated, openarchitecture system, practitioners can scan
an impression with a CBCT unit or scan the
patient’s mouth directly with the CS 3500
intraoral scanner, design the crown, inlay,
or onlay using the CS Restore software,
and mill the crown in-office with the CS
3000 milling machine. For doctors who
would rather send the design or milling
off to the lab, they can easily submit the
information electronically to their dental lab
of choice.
As always, Carestream Dental will
continue to focus on customer service.
“Our number one goal is to provide superior
customer experience through best-in-class
products and best-in-class support,” said
Mr. Gordon.

To learn more about Carestream
Dental’s portfolio of imaging products
and software for endodontic practices,
please call 800-944-6365 or visit
carestreamdental.com today. EP
This information was
Carestream Dental.

provided

by

Endodontic practice 13


CLINICAL

Systematic adhesive core build-up
Dr. Ludwig Hermeler presents a clinical case using the Rebilda Post system

A

s early as 1995, the study conducted
by Ray and Trope confirmed the
relevance of a good post-endodontic
restoration for the successful preservation
of teeth where the root canals have been
treated. In today’s age of adhesive dentistry,
considerable importance is awarded to
preventing “leakage” and, accordingly, the

risk of reinfection of the canal system (Fox,
Gutteridge, 1997). The post-endodontic,
adhesive core build-up with simultaneous
glass fiber post luting satisfies both of
these indispensable requirements for a
certain long-term prognosis of severely
damaged teeth.
The Rebilda Post system from
Voco offers a user-friendly concept in an
optimally coordinated set, featuring all the
necessary components.

Up-to-date post treatments
The consensus today is that a root post
is used to retain the coronal build-up
and, consequently, for creating sufficient
retention. The degree of coronal dental
hard tissue loss and the expected loads
on the tooth determine the type of postendodontic treatment on a case-by-case
basis.

In cases of low to medium levels of
destruction, treatment with a plastically
processed composite without postretained build-up is usually indicated. If the
clinical crown displays severe substance
loss, a post construction system should
be employed to guarantee secure retention
(taken from the shared scientific opinion
of the German Academic Association
of Dentistry, the German Association of

Prosthodontics and Dental Materials, and
the German Association of Dentists in

Ludwig Hermeler, Dr med dent, established
his practice in Rheine, Germany, in 1991. He
is licenced to practice medicine and gained
his doctorate in 1988 at the Westfälische
Wilhelms-Universität Münster. He has
national and international publications in the fields
of endodontics, esthetic dentistry, bleaching, and
implantology. He is a member of the German Association
for Oral Implantology (DGOI) and International Congress
of Oral Implantologists (ICOI).

14 Endodontic practice

Figure 1: The Rebilda Post system (Voco) in its practical drawer insert

‘Aufbau endodontisch behandelter Zähne’
(2003) [English translation: Build-up of
endodontically treated teeth]).

A dentin margin of no less than 2 mm
width is later prepared apical to the buildup in the so-called “ferrule design” in order
to increase fracture resistance (Hemmings,
et al., 1990; Torbjörner, Karlsson, Ödman,
1995). Root canal posts affixed with
adhesives allow consistently minimally
invasive preservation of intact dental hard
tissue, whereby retentive areas in the

region of the build-up can also be used as
additional retentive surfaces.
In contrast to metal, zirconium
and
carbon
posts,
glass
fiberreinforced composite root posts display
biomechanical behavior similar to that of
dentin. Thanks to their dentin-like elasticity,
arising forces can be distributed over the
surrounding tooth substance without the
development of punctiform force peaks
in the root as in the alternatives named
above. The physiological distribution of the
forces, to apical and coronal, of the total
adhesive composite of glass fiber, build-up
composite, and preserved tooth substance
reduces the risk of fractures.

Figure 2: X-ray taken prior to removal of telescopic tooth
LR4

Volume 6 Number 5


The Rebilda Post system fits in dental
cabinets as a complete drawer insert
(Figure 1) and contains all the necessary
components for stable, coronal build-ups –

with or without a root post – in a maximum
of five steps: dual-curing Rebilda® DC
as a luting and build-up composite;
Futurabond® DC as a dual-curing selfetch bond; Rebilda Post, the glass fiberreinforced composite root post with the
precisely coordinated pilot and root canal
drills, and Ceramic Bond, a coupling silane
that strengthens the bond between Rebilda
DC and Rebilda Post.

Voco has complemented the existing
post sizes of 1.2 mm, 1.5 mm, and 2.0
mm diameters with the new 1.0 mm post
size. As a result, the available range is now
perfectly suited to treating all anatomical
root canal sizes safely and with minimal
substance loss.

CLINICAL

The Rebilda Post system

THE FUTURE HAS RETURNED.

NO EQUIPMENT TO BUY,
NO EQUIPMENT TO SET UP,
NO BATTERIES REQUIRED.
MANUFACTURER DIRECT.

MADE IN THE U.S.A.

effective
is the most cost
The Finishing File
nal!
ca
a
an
to cle
and simplest way

Clinical case
The patient is a 75-year-old male. The
telescopic tooth LR4 (Figure 2) was
extracted and a curved clip placed on
tooth LR3 (Figure 3) as an interim solution.
Following adequate healing of the wound,
the terminal tooth LR3 should be furnished
with a telescopic crown and the existing
restoration suitably reproduced on the
right-hand side. Tooth LR3 is extensively
filled on all sides, and its loading as a
terminal abutment tooth is not insignificant.
Consequently, it is equipped with a glass
fiber post for the fixation of the adhesive
build-up. After application of a rubber dam,
removal of the fillings and a check with
Caries Marker (Voco), it becomes evident
that the remaining healthy substance
requires an adhesive, preprosthetic
restoration (Figure 4).

Tooth LR3 was treated with a root
canal filling in 2001, subjected to regular
X-ray controls ever since, and has not
displayed any symptoms at all over the
whole period. Following removal of the
root canal filling using a Gates-Glidden bur
to achieve the planned depth, precision
drilling is performed with the drill from the
system corresponding to the respective
post size (Figure 5).
The X-ray image for measurement
is performed with the Rebilda Post drill
with a diameter of 2 mm (Figure 6). The
image displays the correct fit with apical
preservation of the root canal filling of
approximately 5 mm. Optimal drilling
performance is ensured by intermediate
Volume 6 Number 5



www.engineeredendo.com

Figure 3: Initial clinical situation following extraction of telescopic tooth LR4 with already
accordingly expanded partial prosthesis

Figure 4: Healthy remaining substance of tooth LR3 prior
to adhesive build-up

Figure 5: Preparation of post canal with the drills of the

Rebilda Post system
Endodontic practice 15


CLINICAL

Figure 7: Checking the position with the Rebilda Post
glass fiber post

Figure 8: Silanization with Ceramic Bond (Voco) for 60
seconds

Figure 6: X-ray image for measurement with Rebilda Post
drill (diameter 2 mm)

Figure 9: Mixing of Futurabond DC (Voco) with the Single
Tim applicator in the Single Dose

Figure 10: Rubbing in of the self-etch bond in the post
hole with Endo Tim

Figure 11: Introduction of composite Rebilda DC (Voco)
with the pliable application tip of the Quickmix syringe

Figure 12: Introduced Rebilda Post with excess composite
forced out in the process

Figure 13: Fixation of the post via primary light-curing for
40 seconds

cleaning of the canal and the drill by rinsing
away dentin remnants.
The Rebilda Post is cleaned with
alcohol before the trial insertion. During the
position check in the mouth, the root post
fills the canal precisely without becoming
wedged (Figure 7). The post is shortened
to the required length extraorally using a
fine-grain diamond (not forceps or scissors
due to the risk of delamination). The glass
fiber post is cleaned again with alcohol,
dried, and silanized for 60 seconds with
the Ceramic Bond included in the system
(Figure 8) before being dried with oil-free air
again. Prior to the adhesive luting, the root
canal is rinsed out with water and dried
using paper points.
Futurabond DC is activated by
pressing on the marked area of the Single
Dose and then mixed by piercing the film

and making circular movements with the
Single Tim (Figure 9).

The self-etch bond is rubbed into the
canal with the fine Endo Tim (Figure 10)
and over the rest of the tooth surface with
the Single Tim for 20 seconds, the solvent
dried with oil-free air for seconds, and
any excess liquid in the channel removed

using paper points. A shiny bonding layer
is created, which is not light-cured.
Rebilda DC is introduced directly
into the root canal using the thin, pliable
application tip of the Quickmix syringe
(Figure 11), starting apically and keeping
the cannula tip emerged in the luting
composite throughout the application.
The Rebilda Post is inserted with a rotary
movement, with small amounts of excess
material being forced out in the process.
Light-curing is performed for 40 seconds to

fix the post (Figure 13), and then additional
Rebilda layers are applied. The core buildup can then be light-cured for a further 40
seconds per layer; the chemical curing
takes 5 minutes.
Thanks to its consistency, Rebilda
DC is easy to apply, and Voco also offers
shaping aids for designing the build-up,
which can be individually cut to size for the
tooth shape using scissors. The build-up is
also easy to process thanks to the dentinlike hardness of Rebilda DC. Figure 14
shows the prepared tooth; the preparation
employs the ferrule effect in order to stabilize
the abutment tooth and the subsequent
restoration. The high radiopacity of Rebilda
Post impresses in the X-ray image, and it is
clear that the post and build-up composite
form a homogeneous, adhesive build-up

block (Figure 15). The functionality of the

16 Endodontic practice

Volume 6 Number 5


CLINICAL
Figure 14: Finished, prepared tooth with Rebilda Post and
Rebilda DC build-up

Figure 15: X-ray image of the homogeneous adhesive
build-up block

telescopic restoration, expanded with the
telescopic LR3 and then rebased, and the
familiar wearing comfort are restored for
the patient (Figure 16 and 17).

Conclusion
Figure 16: Inserted telescopic crown tooth LR3

Modern composites and adhesive systems
are of decisive importance for long-term
tooth conservation in the post-endodontic
treatment of severely damaged teeth.
Voco’s Rebilda Post system is a
sophisticated, optimally coordinated, and
complete set with materials that satisfy the
high requirements for a stress-free, coronal

build-up with a root post. EP

References
Fox K, Gutteridge DL. An in vitro study
of coronal microleakage in root-canaltreated teeth restored by the post and core
technique. Int Endod J. 1997;30(6):361-368.
Hemmings KW, King PA, Setchell DJ.
Resistance to torsional forces of various
post and core designs. J Prosthet Dent.
1991;66(3):325-329.
Ray HA, Trope M. Periapical status of
endodontically treated teeth in relation to the
technical quality of the root filling and the
coronal restoration. Int Endod J. 1995;28(1):
12-18.
Torbjörner A, Karlsson S, Odman PA. Survival
rate and failure characteristics for two post
designs. J Prosthet Dent. 1995;73(5):439-444.

Figure 17: The restored telescopic restoration
Volume 6 Number 5

Endodontic practice 17


CASE STUDY

Management of root resorptive lesions in maxillary
incisors using computed tomography and MTA:
1-year follow-up

Drs. Anil Dhingra and Marisha Bhandari delve into the advantages of MTA and CBCT imaging
Abstract
This case presented with periapical
radiolucencies and external root resorptions
in maxillary incisors, tooth Nos. 11, 12, 21,
22 (FDI). To determine the exact extent
of the lesions, as periapical radiographs
tend to underestimate the size of the
resorptive lesions, cone beam computed
tomography (CBCT) was performed.
Revision of root canals was performed and
nonsurgical management initiated using
mineral trioxide aggregrate (MTA) [Dentsply
Maillefer Ballaigues, Switzerland] and
thermoplasticized gutta percha (Obtura,
Obtura Spartan® Endodontics). Followup radiographs after regular intervals
showed healing of the periradicular tissues,
demonstrating the effectiveness of MTA as
a clinical filling material of choice.

Figure 2

Figure 1

Introduction
The management of endodontic problems
is reliant on radiographs to assess the
anatomy of the tooth and its surrounding
anatomy. Such radiographic images have
inherent limitations, the major limitation

being the lack of the three-dimensional
nature of the radiographs and masking
of areas of interest by overlying anatomic
(anatomic noise), which are of relevance
in endodontics (S. Patel, 2009).
Resorptive defects are challenging
to diagnose correctly, which may result in
inappropriate treatment being carried out
(Chapnick L,1989). Cone beam computed
tomography reconstructed images have

Anil Dhingra, BDS, MDS, FAGE, is a Professor in the
Department of Conservative Dentistry & Endodontics,
Subharti Dental College, Subharti University, Meerut,
India. Dr. Dhingra can be reached at anildhingra5000@
yahoo.co.in.
Marisha Bhandari, BDS, is from the Post Graduate
Department of Conservative Dentistry and Endodontics,
Subharti Dental College, Subharti University, Meerut,
India.

18 Endodontic practice

Figure 3

Figure 4

been successfully used in diagnosis and
management of resorptive lesions (Maini A,
Durning P, Drage N, Resorption 2008). It

is able to reveal the true nature and exact
location of the lesion, determine the “portal
of entry” of the resorptive lesion, and also
reveal previously undetected resorptive
lesions (Cohenca N, Simon JH, Marthur
A, Malfaz JM, 2007). Root resorption is
inhibited by the protective unmineralized
innermost pre-dentin and outermost
pre-cementum surfaces of the root
(Lindskog S, Blomlof L, Hammarstrom

L, 1983). Channels extend into dentin
and interconnect within the periodontal
ligament. As the lesion advances, bonelike material (replacement resorption) might
also become deposited within the lesion
and also in direct contact with the adjacent
dentin; this indicates that the lesion is not
destructive but attempting to repair itself
(Shanon Patel, Shalini Kanagasingam,
Thomas Pitt Ford, 2005). Few studies
have determined the ability of cone
beam computed tomography to improve
diagnosis of root resorptive lesions.
Volume 6 Number 5


CASE STUDY

Figure 5

Figure 6

Figure 7

Figure 9

Figure 10

dimensional reconstruction, a diagnosis of
severe external root resorption in relation to
tooth Nos. 11, 12 and periradicular lesions
in relation to tooth Nos. 11, 12, 21, 22 (FDI)
was determined (Figures 2 and 3).
The patient was informed of the
diagnosis, treatment plan alternatives,
and prognosis of the case. An informed
consent was obtained from the patient,
and nonsurgical root canal therapy was
initiated.

On the basis of tomography findings,
revision of root canal was carried out
using ProTaper® Retreatment files D1,
D2, D3 (Dentsply Maillefer, Ballaigues,
Switzerland) [Figures 4, 5, 6, 7]. The root
canals were cleaned and shaped using
the ProTaper system (Dentsply Maillefer,
Ballaigues, Switzerland). Tooth Nos. 11
and 12 (FDI) were cleaned and shaped
up to a F5 ProTaper (Dentsply Maillefer,

Ballaigues, Switzerland). Tooth Nos. 12
and 22 were cleaned and shaped up to F3
ProTaper (Dentsply Maillefer, Ballaigues,
Switzerland). Intracanal irrigation was
performed with 1ml 1.25% sodium

hypochlorite in between every instrument,
and two final irrigations of 1ml 17%
EDTA, followed by 1.25% NaOCl were
performed before drying the canal with
paper point (Dentsply Maillefer Ballaigues,
Switzerland).The canals were obturated
with white ProRoot® MTA (Dentsply
Maillefer, Ballaigues, Switzerland), to
obtain an apical stop of 5-6 mm with some
extrusion of the material apically. The apical
stop method involved size 50 MAF with
5/7 endodontic pluggers. After drying the
coronal aspect of the MTA plug with paper
points, the canals were further obturated
with thermoplasticized gutta percha,
Obtura (Obtura Spartan Endodontics) and
the sealer.
AH
Plus™
(Dentsply
Maillefer,
Ballaigues, Switzerland) was restored with
composite. An X-ray film was recorded,
which showed that the resorptive defects

were filled with MTA (Dentsply Maillefer,
Ballaigues, Switzerland) [Figures 8, 9,
10, 11]. An occlusal radiographic film
recorded after a 2-month, 6-month, and
12-month interval showed the teeth had

Figure 8

Case report
A 30-year-old male patient reported to
the Department of Conservative Dentistry
and Endodontics, Subharti Dental College,
Meerut, Uttar Pradesh, India with the
chief complaint of pain and mobility in the
upper anterior tooth region for the past
12 months. The patient’s medical history
was noncontributory. The patient reported
trauma to his upper anterior teeth more
than 15 years ago, for which root canal
treatment was performed. On examination,
it was observed that tooth Nos. 11, 12, 21,
22 (FDI) were tender on percussion, with
Grade II mobility in relation to tooth Nos.
11 and 21 (FDI) with no discoloration.
Radiographic
examination
revealed
incomplete root canal treated teeth with
overextended obturation and
multiple

periradicular lesions in relation to tooth
Nos. 11, 12, 21, 22 (FDI) [Figure 1].

In order to determine the extent and
depth of the lesion in three spatial levels, we
decided to opt for CBCT imaging in relation
to the maxillary anterior tooth region.
Based on the CBCT images and threeVolume 6 Number 5

Endodontic practice 19


CASE STUDY

Figure 11

Figure 12

Figure 13

Figure 14

Figure 15

Figure 16

remained completely asymptomatic, and
the periapical lesion showed healing or
healing in progress of the lesion present at
the beginning of the treatment procedure

(Figures 12-18).

Discussion
Root resorption in this case may have
been produced by the trauma to the
teeth reported by the patient during his
childhood and due to incomplete root canal
therapy. Root resorption is the loss of hard
tissue (i.e., cementum and dentin) as a
result of odontoclastic action. Cone beam
computed tomography appears to be a
promising diagnostic tool for confirming the
presence, appreciating the true nature, and
managing external root resorption (Shanon
Patel, Shalini Kanagasingam, Thomas
Pitt Ford, 2005). As with CBCT, a threedimensional volume of data is acquired
in the course of a single sweep of the
scanner, using a simple, direct relationship
between the sensor and source, which
rotates synchronously 180-360 degrees
around the patient’s head. The X-ray
beam is cone-shaped (hence the name of
the technique) and captures a cylindrical
or spherical volume of data. This has an
advantage of reducing the patient radiation
dose. The radiographic outcome of root
20 Endodontic practice

Figure 17

Figure 18

canal treatment is more successful when
teeth are treated and obvious radiographic
signs of periapical disease are detected
(S. Patel, 2009). Thus, earlier identification
of periradicular radiolucent changes with
CBCT may result in earlier diagnosis and
more effective management of endodontic
disease (Cotton TP, Geisler TM, Holden
DT, et al., 2007). In situations where
patients have poorly localized symptoms
associated with an untreated or previously
root treated tooth and clinical and
periapical examination show no evidence
of disease, CBCT may reveal the presence
of previously undiagnosed pathosis.

CBCT images are geometrically
accurate (Murmulla R, Wortche R,
Muhling J, et al., 2005) and the problem
of anatomical noise seen with periapical
eliminated. Serial sets of linear and
volumetric measurements obtained with
CBCT technology could therefore be used
to provide a more objective and accurate
representation of osseous changes
(healing) over time (Pinky HM, Dyda A, et
al., 2006). Future research may show that
periapical tissues, which appear to have

“healed” on conventional radiographs, may
still have signs of periapical diseases when
imaged using CBCT (S. Patel, 2009).
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CASE STUDY

Mineral trioxide aggregrate has
emerged as a reliable bioactive material
with extended applications in endodontics
that include the obturation of the root
canal space. It provides an effective seal
against dentin and cementum, and also
promotes biologic repair and regeneration
of the periodontal ligament. The chemical
composition of MTA was determined by
Torabinejad, et al. The material consisted
of fine hydrophilic particles, and the main
components were tricalcium silicate,
tricalcium aluminate, tricalcium oxide, and
silicate oxides. Bismuth oxide acts as a
radiopacifier. They declared that calcium
and phosphorus were the main ions in
MTA (Hashem Ahmed Adel Rahman, et al.,
2008). It appears that teeth obturated with
MTA might not only increase their fracture
resistance with time, but bacteria might
be effectively entombed and neutralized
in severely infected teeth. Unsuccessful
root canal treatments compromised by
microleakage, large periapical lesions,
perforations, and inadequate cleaning
and shaping can demonstrate superior

healing rates when this osteoinductive and
cementogenic material is used to restore
the root canal system.

MTA provides an effective seal against
dentin and cementum and also promotes
biologic repair and regeneration of the
periodontal ligament. It not only fulfills the
ideal requirement of being baceriostatic,
but might have potential bactericidal
properties. The release of hydroxyl

References
Patel S. New dimensions in endodontic imaging: Part
2. Cone beam computed tomography. Int Endod J.
2009;42(6):463-475.
Chapnick L. External root resorption: an experimental
radiographic evaluation. Oral Surg Oral Med Oral
Pathol. 1989;67(5):578-582.
Maini A, Durning P, Drage N. Resorption: within
or without? The benefit of cone-beam computed
tomography when diagnosing a case of an internal/
external resorption defect. Br Dent J. 2008;204(3):135137.

ions, a sustained high pH for extended
periods, and the formation of a mineralized
interstitial layer might provide a challenging
environment for bacterial survival. The
cured cement creates a potentially
impervious seal that might be difficult for

microorganisms to penetrate. This unique
sealing property, combined with an initially
high pH that increases to 12.5 after curing,
might provide a suitable mechanism for
bacterial entombment, neutralization, and
inhibition within the canal system. These
factors are important when considering
nonsurgical patients with large periapical
lesions associated with initial root canal
treatment or in cases presenting with
refractory endodontic disease diagnosed
for retreatment (George Bogen, et al.,
2009). There are many factors involved
in the healing of periapical lesions, such as
the apical limit of root canal instrumentation
and obturation (Riccuci D, Langeland K,
2005) and follow-up time (Leonardo MR,
Barnett F, Debelian G, et al., 2007) It is
necessary to perform further recall in this
case to confirm total healing of the lesion.

Estrela, et al., tested the reliability of
a periapical X-ray film, and the images
obtained by CBCT to detect periapical
lesions; they found that the best results
were obtained with the CBCT group.
In the clinical case presented here,
we observed that the extent of resorption
could not be detected in conventional
X-ray film, hence, the need for the use of

CBCT.

Schindler WG. Endodontic applications of cone-beam
volumetric tomography. J Endod. 2007;33:1121-1132.
Marmulla R, Wörtche R, Mühling J, Hassfeld S.
Geometric accuracy of the NewTom 9000 Cone Beam
CT. Dentomaxillofac Radiol. 2005;34(1):28-31.
Pinsky HM, Dyda S, Pinsky RW, Misch KA, Sarment
DP. Accuracy of three-dimensional measurements
using cone-beam CT. Dentomaxillofac Radiol.
2006;35(6):410-416.
Patel S. New dimensions in endodontic imaging: Part
2. Cone beam computed tomography. Int Endod J.
2009;42(6):463-475.

Cohenca N, Simon JH, Mathur A, Malfaz JM. Clinical
indications for digital imaging in dento-alveolar trauma.
Part 2: root resorption. Dent Traumatol. 2007;23(2):105113.

Hashem AA, Hassanien EE. ProRoot MTA, MTAAngelus and IRM used to repair large furcation
perforations: sealability study. J Endod. 2008;34(1):5961.

Lindskog S, Blomlöf L, Hammarström L. Repair
of periodontal tissues in vivo and in vitro. J Clin
Periodontol. 1983;10(2):188-205.

Bogen G, Kuttler S. Mineral trioxide aggregate
obturation: a review and case series. J Endod.
2009;35(6):777-790.

Patel S, Kanagasingam S, Pitt Ford T. External cervical
resorption: a review. J Endod. 2009;35(5):616-625.

Estrela C, Bueno MR, Leles CR, Azevedo B, Azevedo
JR. Accuracy of cone beam computed tomography and
panoramic and periapical radiography for detection of
apical periodontitis. J Endod. 2008;34(3):273-279.

Cotton TP, Geisler TM, Holden DT, Schwartz SA,

22 Endodontic practice

Conclusion
Cone beam computed tomography
technology is improving at a rapid pace. It
overcomes most of limitations of intraoral
radiography. The increased diagnostic data
should result in more accurate diagnosis
and monitoring, and therefore, improved
decision making for the management
of complex endodontic problems. It is a
desirable addition to the endodontist’s
armamentarium. When indicated, threedimensional CBCT scans may supplement
conventional two-dimensional radiographic
techniques, which at present have higher
resolution than CBCT images. In this
way, the benefits of each system may be
harnessed.

In this case, the patient tried to save

his teeth and accepted the treatment
accordingly.
Twelve
months
after
treatment, the teeth were asymptomatic,
there was no periapical radiolucency, and
the conventional X-ray film showed healing
or healing in progress of the periapical
lesion present at the beginning of the
treatment procedure.

Acknowledgement
The authors thank Dr. Shibani Grover,
Professor and Head of the Department,
Department of Conservative Dentistry and
Endodontics, Subharti Dental College,
Meerut, India for her eminent support and
guidance. EP

Ricucci D, Langeland K. Apical limit of root canal
instrumentation and obturation, part 2. A histological
study. Int Endod J. 1998;31(6):394-409.
Holland R, Mazuqueli L, de Souza V, Murata SS, Dezan
Júnior E, Suzuki P. Influence of the type of vehicle
and limit of obturation on apical and periapical tissue
response in dogs’ teeth after root canal filling with
mineral trioxide aggregrate. J Endod. 2007;33(6):693697.
Leonardo MR, Barnett F, Debelian GJ, de Pontes
Lima RK, Bezerra da Silva LA. Root canal adhesive

fillings in dogs’ teeth with or without coronal
restoration: a histopathological evaluation. J Endod.
2007;33(11):1299-1303.
American Association of Endodontists. Appropriateness
of care and quality assurance guidelines of the
American Association of Endodontists. Chicago, IL:
1994.
Holland R, Sant’Anna Júnior A, Souza Vd, Dezan Junior
E, Otoboni Filho JA, Bernabé PF, Nery MJ, Murata
SS. Influence of apical patency and filling material on
healing process of dogs’ teeth with vital pulp after root
canal therapy. Braz Dent J. 2005;16(1):9-16

Volume 6 Number 5


Sharpen Your Root Canal Visibility
Introducing the new Detect™ Apex Locator from Maillefer.
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