Tạp chí nội nha tháng 11 & 12 /2013 Vol6 No 6

clinical articles • management advice • practice profiles • technology reviews

PROMOTING

EXCELLENCE

Top ten tips

10

#

When things
go wrong

IN

ENDODONTICS

TO SHARPEN YOUR VISIBILITY

November/December 2013 – Vol 6 No 6

Fiber posts
and tooth
reinforcement

Drs. Leendert Boksman,
Gary Glassman,
Gildo Santos, and
Manfred Friedman

Corporate profile
Planmeca

Practice profile
Dr. Brian Trava

Pride Institute
“Best of Class”
special awards tribute

PAYING SUBSCRIBERS EARN 24
CONTINUING EDUCATION CREDITS
PER YEAR!

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Dr. Tony Druttman


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IMAGING

UTILITY ROOM

MERCHANDISE

No. 4 in a Series


“And ye shall know the truth and the truth shall make you free…” ~ JOHN VIII-XXXII

ASSOCIATE EDITORS
Julian Webber BDS, MS, DGDP, FICD
Pierre Machtou DDS, FICD
Richard Mounce DDS
Clifford J Ruddle DDS
John West DDS, MSD
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
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
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Tel: (727) 515-5118

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Email:

Tel: (386) 212-0413

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Tel: (727) 393-3394

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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 6

This quote from the book of John is inscribed on the lobby wall of the Central Intelligence Agency
headquarters in Langley, Virginia, and I think of it often while treating patients.

In clinical endodontics, as with all science, few things are as important as truth.

Our essential sworn duty is to “do no harm.” We risk no greater harm to our patients than when
we proceed on the basis of assumption, presumption, or habit, without first doing everything we can
to ascertain the truth of our patient’s condition.

Fortunately, we have tools today that allow us to see more, appreciate more, and evaluate more
of a patient’s condition than ever before.

My first epiphany in this realm was while still practicing general dentistry. My insatiable quest for
continuing education took me to Santa Barbara, California, under the guidance of Dr. Cliff Ruddle. It
was there that I first looked through a dental operating microscope. I was literally AMAZED!

French author Marcel Proust once observed, “The true voyage of discovery consists not in
seeking new landscapes, but in having new eyes.” As soon as I integrated a dental microscope into
my general practice and peered through the lenses, I understood the truth of Proust’s wisdom.

Thanks to the lighting and magnification of the scope, I was seeing the closest thing possible to
the truth of my patient’s condition. Now I could see, with vivid clarity, every tooth margin. I looked, in
intimate detail, at things that I saw clinically…but had not really seen.

Shortly, I came to realize another truth: we cannot treat what we cannot see. And the better we
can see it, the better we can treat it.

Proper use of the microscope impacts everyone involved in patient care: the clinician who
immediately gains confidence, the assistant (hopefully utilizing the assistant’s binoculars) who can
better anticipate and understand the clinical conditions and needs, the office staff who know that
their clinicians are providing the most well-informed care possible, and of course, the patients
themselves who benefit from potentially reduced chair time, reduced pain and discomfort, decreased
recovery times, and less risk of the need for future treatment.

While attending graduate school at Boston University, my mentor, Dr. Herb Schilder, sometimes
referred to me as “The Virus,” because I was so excited about new dental technologies — and I was
all too eager to share that enthusiasm with my classmates, my teachers, and anyone else who would
listen. But the truth is that my love affair is not really with technology itself, but with what I can do with
it. And that still holds true today. The things that we are able to do today with technology in dentistry

are truly amazing.

Without question, I consider the dental operating microscope the single most important piece of
technology that I have incorporated into my practice.

Like the microscope, which I discovered purely by accident, more recently, Cone Beam
Computed Tomography (CBCT) has proven to be a practice game changer for me. And like the
microscope, it has transformed both the way that I practice and the way that I think about truth.

I never anticipated the impact that visualizing dental anatomy in 3D would have on my staff,
my patients, my practice, and me. CBCT has literally changed the way that I approach clinical
endodontics.

This technology is the epitome of John’s verse: it represents three-dimensional truth, and the
freedom to treat patients confidently, creatively, and effectively because of the truth it provides.

CBCT allows me to visually strategize the clinical execution of a procedure before I actually do
it, whether it’s endodontic therapy, a careful manipulation of the Schniderian membrane for a sinus
lift, or the placement of a dental implant — either done “free hand” or utilizing CBCT’s DICOM data to
create a computer-generated surgical guide.

Beyond visualizing the anatomy prior to the procedure, having the 3D scan on a large highresolution monitor chairside provides a true representation of the operating space, and an incredible
level of pretreatment confidence along with it.

Procedures that once were difficult and created significant pretreatment anxiety for doctor, staff,
and patient are now commonplace and are executed with ease. To the benefit of all, with CBCT we
can digitally document the entire scope of a procedure, from initial evaluation, through treatment
planning, and eventually, years of follow-up. This gives us the great luxury of going back to review
past cases and learn from our own experiences, as well as to provide extensive treatment feedback
to our referring doctors and the colleagues with whom we consult.

With today’s technologies, endodontic professionals are closer than ever to attaining that
ultimate scientific pursuit of truth. New tools and ever-evolving technologies add limitless stimulation
to the practice careers of those who embrace them, and ultimately set us free in the greatest way
imaginable: by giving us the freedom to continue to grow at what we do best, for our patients, our
colleagues, and ourselves.
Thomas V. McClammy, DMD, MS
aka: Clamdawg
North Scottsdale Endodontics & Implantology (Arizona)
Foundational Dental Seminars

Endodontic practice 1

INTRODUCTION

Few things are as important as truth
November/December 2013 - Volume 6 Number 6


TABLE OF CONTENTS
Corporate profile
Planmeca®
Innovative, upgradeable imaging
technology................................... 10

Practice profile

6

Dr. Brian Trava

Continually learning and training, Dr. Trava discusses the joys of being a “tooth
saver.”

Endodontics in
focus
Top ten tips: Tip number 10 When things go wrong
In the last article in this series, Dr.
Tony Druttman focuses what to do
when things do not go according to
plan ............................................ 18

Case study

12

Endodontics in 3D
Drs. Derek Chu, David Jaramillo, Chad Gustafson, and Dwight Rice study the
benefits of CBCT, and its role in helping to diagnose and treat endodontic
problems

2 Endodontic practice

Volume 6 Number 6


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endodontic solutions

A decade of success

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Unmatched hydrophilicity and adaptability
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EndoREZ

đ


TABLE OF CONTENTS

Abstracts
The latest in endodontic research
Dr. Kishor Gulabivala presents the
latest literature, keeping you up-todate with the most relevant research
.....................................................48

Product insight
The rationale and use of electronic

Fiber posts and
tooth reinforcement

22

apex locators
Dr. L. Stephen Buchanan offers
advice on getting to the root of the
matter ...........................................50

Endospective
The martensitic transformation:

Continuing
education

Fiber posts and tooth
reinforcement: evidence in the
literature
Drs. Leendert Boksman, Gary
Glassman, Gildo Santos, and Manfred
Friedman look at the literature for fiber
posts and the best techniques for
placement ....................................22
Management of an upper first
molar with three mesiobuccal root
canals
Dr. Peet van der Vyver presents a
case report to illustrate the clinical
management of an upper first
maxillary molar tooth with three
mesiobuccal root canals, using the
ProTaper Next system ..................28

4 Endodontic practice

Special section
Tribute to Pride Institute’s “Best of
Class” Technology Awards .......34

Legal matters
Upholding the Endodontist’s
Standard of Care
Drs. Stephen Cohen and Edwin
Zinman discuss how to avoid patient
distrust..........................................44

Technology
Endodontics made more efficient
with the ScanX Swift™
Dr. Howard Golan discusses a
different type of imaging technology
.....................................................46

still transforming endodontics
Dr. Rich Mounce discusses the
second generation of heat-treated
nickel-titanium alloys .....................53

Practice
management
Technology leads the charge for
improved patient experience,
increased cash flow
Jena McCoy-Lovern tackles some
challenges to establishing and
maintaining a positive relationship with
patients ........................................54

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

Volume 6 Number 6

ORTHOPHOS XG 3D
The right solution for
your diagnostic needs.

Implantologists

Endodontists

Orthodontists
will benefit from highquality pan and ceph
images for optimized
therapy planning.

will enjoy instantly
viewable 3D volumetric
images for revealing
and measuring canal
shapes, depths
and anatomies.

will appreciate the
seamless clinical
workflow from initial
diagnostics, to treatment
planning, to ordering
surgical guides and final
implant placement.

General Practitioners
will achieve greater

diagnostic accuracy
for routine cases.

ORTHOPHOS XG 3D

“With my Sirona 3D unit, I can see the anatomy of canals, calcification, extent of resorption, fractures, and sizes of periapical radiolucencies, all of which influence treatment plans for my patients.
Combine that with the metal artifact reduction software that reduces distortions from metal objects,
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

The advantages of 2D & 3D in one comprehensive unit
ORTHOPHOS XG 3D is a hybrid system that provides clinical
workflow advantages, along with the lowest possible effective
dose for the patient. Its 3D function provides diagnostic accuracy
when you need it most: for implants, surgical procedures and
volumetric imaging of the jaws, sinuses and other dental anatomy.

For more information, visit www.Sirona3D.com
or call Sirona at: 800.659.5977
www.facebook.com/Sirona3D


PRACTICE PROFILE

Dr. Brian Trava
Multidimensional endodontics
What can you tell us about your
background?
I grew up in Northern New Jersey, and would
like to say I spent endless summers hanging

at the shore, but I actually spent summers
working with my father doing construction
since the fourth grade. I benefited from a
liberal arts education and graduated from
Lycoming College with honors. I attended
the University of Medicine and Dentistry,
receiving both graduate and postgraduate
degrees. I also enjoyed being an Associate
Clinical Professor for 10 years. I started my
first practice right out of school and have
opened five offices in New Jersey since
then.

Is your practice
endodontics?

limited

to

I am often asked if our practice is just
limited to endodontics. My answer is we
are limited to comprehensive endodontics.
We limit ourselves to root canals, surgical
endodontics, facial pain diagnosis,
occlusion, TMD, and patients with special
needs. A complete postgraduate program
touches upon many areas of endodontics,
and it is up to individuals what they limit
themselves to.

What
training
undertaken?

have

you

You are never done training and learning.
Take continuing education courses that
are not endodontic in nature. Anatomy,
microbiology, restorative, and pathology
helps you communicate with your peers on
a more thorough comprehensive basis.

Why did you decide to focus on
endodontics?
So, why endodontics? At first, I thought
it was fun, I had an aptitude for it, and
loved doing it. I had a deep respect for the
instructors in my department. To this day, I
still love going to work.

How long have you been
practicing, and what systems do
you use?
I have been fortunate to be practicing for
close to 25 years. There was once a time
when I use to say: “We have to be able to

6 Endodontic practice

do this on computers!” Careful for what
you wish for. Plumber, move over on my
speed dial, computer technician, step
right in. We review radiographs from many
different software systems. We have been
exceptionally pleased with companies such
as Adec, Schick, and Planmeca. The detail
and support we feel has been consistent
and dependable.

Who has inspired you?

Professionally, what are you most
proud of?
On a professional level, I am most proud
of my fellow colleagues in the office, both
doctors and staff. “I’d rather be having a
root canal.” Guess what? — you are! We
work hard to make our patients want to
come back.

What has been your biggest
challenge?

I was first and still inspired by my family
dentist, Dr. Anthony Cipriano. I could tell as
a teenager he really enjoyed what he did.
Patients can sense that, young to old. That

may be the tip of the day.

The biggest challenge we face is to
have others understand that many teeth
indicated for extraction can be saved.
Quality CBCT imaging makes diagnosing
and treatment more predictable.

What is the most satisfying aspect
of your practice?

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

We are tooth savers! When told the tooth
can’t be saved, nothing is more satisfying
then keeping that tooth right where it
erupted. Origin of facial pain, yes, we have
it figured out; let’s put you in the right
direction. The practice’s scope of treatment
expands as well as the opportunity to
collaborate with many of our colleagues
from medicine to dentistry.

I was fortunate to choose my profession.
As a child growing up, I wanted to be an
astronaut. My career would have ended
early; I have to take Dramamine before I go
on carnival rides with my daughter.

What is the future of endodontics
and dentistry?
The future of endodontics is found in
Volume 6 Number 6


Achieve the Optimal Treatment Room with ASI
The Cart, With Only One Foot Control
The versatility of ASI’s custom integrated cart system
allows for infinite positioning of the cart
to easily maneuver within close reach
during procedures and then out of patient
view after procedures. Adding a monitor
mount creates an intimate environment for
both patient education and clinical use.

Side Delivery
An ASI cart positioned at the doctor’s
dominant side requires the least amount of
tasking movements during a procedure and
works efficiently with microscope dentistry.

Foot Control Placement
The foot control tubing of an ASI system can
be run underneath the floor through a conduit
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

research and technology. Endodontic
research has given us a much more
comprehensive understanding of microbial
infections, biofilm, and anatomy. Our
practice has been the first to incorporate
both CBCT and lasers in many ways to treat
our patients. Patients are more educated,
they want to save their natural teeth, and
we have the tools available to us.

endodontist is twofold. Look beyond the
tooth. Take what you learned in school,

and use it to treat the whole patient. To
make it easier, invest in quality equipment
backed by quality companies. Do your
research. Look for a quality CBCT machine,
a machine that allows you to study and
diagnose the oral maxillary complex, TMJ,
and sinus with great detail.

What are your top tips for maintaining a successful practice?

What are your hobbies, and what
do you do in your spare time?

1. Listen to the patient
2. Be fair to the patient
3.Make sure the patient understands
what you’re doing and why you’re
doing it
4. Communicate with the patient and the
dentists

Endodontics can be demanding. It is best
to have distractions to take your mind away
from the office. So, I became a soccer
mom with my wife. There is nothing like
kids to help you forget about the office for
a weekend. Typically, when I am asked to
lecture across the country, the first place
I look for is a National Park to incorporate
into our trip. It’s a great way to really

appreciate what we work for. EP

What advice would you give to
budding endodontists?
The best advice that I can give to a budding
8 Endodontic practice

TOP 10 FAVORITES LIST
1. My number one most indispensible piece of
equipment in my office, our Promax 3D.
2. Explaining to patients how their CBCT image
has given me the detail I need to help them.
3. Being the first to use the Waterlase MD to
treat lesions without making a surgical flap.
4. Working with the NBA in Africa to help
children.
5. Treating kids and special needs individuals
when they were turned away from other
practices.
6. Telling patients at 3 a.m. that it is normal;
everybody calls me at this time to tell me
they had a toothache for 2 weeks.
7. Having the opportunity to learn from other
colleagues while lecturing in different areas
of the country.
8. Enjoying problem solving and interacting
with my colleagues.
9. Watching my daughter’s athletic ability and
realizing it does skip a generation.
10. Finally, being able to hang at the shore.

Volume 6 Number 6


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

Planmeca®: innovative, upgradeable imaging technology
Company history
Planmeca is the world’s largest privately
held dental imaging company and one of
the industry’s leading manufacturers of
panoramic and cephalometric X-rays. Over
the past four decades, it has expanded its
sales network in more than 100 countries

worldwide. Planmeca’s imaging units
offer superior image quality, reduced
radiation during routine procedures, easy
upgradeabililty, and advanced, userfriendly imaging software. Planmeca
has been a leader in digital imaging and
advanced computer-integrated dental
care concepts for years and remains in
the forefront of technology as the field of
dentistry evolves.
Since the company’s establishment,
Planmeca’s developers have worked
closely with dentists and leading universities
to anticipate future trends, using this data
to design an advanced line of high-tech
products. From the introduction of the
first microprocessor-controlled chair, to
the development of the ProMax™ line of
imaging units with SCARA (Selectively
Compliant Articulated Robotic Arm)
technology, Planmeca has always led the
way with new technology. The company’s
goal is to supply dental professionals with
the highest quality dental equipment that
is uniquely designed for today’s modern,
technologically advanced practice.

Patented SCARA technology
What truly sets Planmeca apart from the
competition is the company’s patented,
exclusive SCARA technology. This robotic

arm, which comes standard on all ProMax
units, enables free geometry based on
image formation and can produce any
movement pattern required. The precise,
free-flowing arm movements allow for
a wide variety of imaging programs not
possible with any other X-ray unit on the
market; this allows the dental professional
to take images based on diagnostic needs,
not machine limitations.

Anatomically accurate extraoral
bitewing program
Planmeca’s ProMax
Mid imaging units
extraoral bitewing
only with SCARA
innovative program

S3, 3D, and 3D
offer an exclusive
program, possible
technology. This
consistently opens

10 Endodontic practice

interproximal contacts, eliminates patient
positioning errors, and is more diagnostic
than other intraoral modalities. ProMax

extraoral bitewings are ideal for a number
of patients, from the elderly and those
requiring periodontal work to those with
claustrophobia, sensitive gag reflexes, or
those in pain. All of this comes in a true
bitewing program that enhances clinical
efficiency and takes less time and effort
than a conventional intraoral bitewing.

Upgradeable innovation
One of Planmeca’s greatest contributions
to dental imaging is its innovative,
upgradeable product platform — all based
on exclusive, patented SCARA technology.
Since
it’s
software-driven,
SCARA
technology enables limitless possibilities
to upgrade existing equipment, allowing
the new dentist on a smaller budget to
grow while making only appropriate and
necessary equipment investments. For
example, Planmeca products can be
upgraded from a 2D panoramic X-ray to a
combination of pan/ceph capabilities, which
can be further upgraded to accommodate
3D imaging needs. Whether it is the
transformation of a film to a 3D unit, or the
addition of a cephalometric arm, Planmeca

offers solutions for every upgrade need.
This single piece of technology makes the
ProMax the most versatile all-in-one X-ray
unit available on the market.

Reduced radiation
procedures

for

safer

All Planmeca products are designed around
the ALARA radiation principle (As Low As
Reasonably Achievable). Through specially
designed programs, such as horizontal
and vertical segmenting, autofocus, and
pediatric pans, dental professionals are
able to provide their patients with excellent
care without compromising their safety.
Horizontal and vertical segmenting
options limit the exposure to diagnostic
areas of interest. By selecting these
options, patient dosage can be reduced by
up to 93%, which is highly advantageous
when follow-up images are needed.

Autofocus automatically positions the
focal layer using a low-dose scout image
of the patient’s central incisors, and uses

landmarks within the patient’s anatomy
to calculate placement. The result is a

“The company’s goal is to
supply dental professionals
with the highest quality
dental equipment that is
uniquely designed for today’s
modern, technologically
advanced practice.”

fast, diagnostic pan every time, which
drastically reduces retakes caused by false
positioning.

Pediatric programs further lower the
dose by automatically selecting the narrow
focal layer of young patients, adjusting
the collimator, and reducing the area of
exposure from the top and the sides.
This reduces the dosage area while still
providing full diagnostic information.

Digital Perfection™:
standard

the

new

Building on the well-established all-in-one
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Volume 6 Number 6


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CASE STUDY

Endodontics in 3D
Drs. Derek Chu, David Jaramillo, Chad Gustafson, and Dwight Rice study the benefits of CBCT, and its role
in helping to diagnose and treat endodontic problems

E

ndodontic therapy is performed millions
of times a year with relatively high
success rates. Success is based on an
accurate diagnosis and execution of the
indicated treatment plan. Advancements
in the treatment and diagnosis of root
canal therapy (apex locators, development
of NiTi instruments, rotary instrumentation,
new irrigating solutions, evolving technique,
and cone beam computed tomography
(CBCT) all play important roles in treatment
success. The application of new technology
has made major advances in diagnosis
and treatment, particularly in the area of
radiography.

Radiographic assessment and clinical
tests are essential in making an accurate
diagnosis. Radiographic interpretation
allows evaluation for the presence of
periapical pathosis, hard and soft tissue
configurations, and other contributing

factors in patient care. High quality
radiographic evaluation is an essential
component in objectively diagnosing teeth
with suspected endodontic problems
(Patel, et al., Ozen, 2009, and Yoshioka,
2011).

It is well established that conventional
periapical radiographs have limitations such
as anatomical noise, two-dimensional and
geometric distortions (Humonen & Orstavik,
2002, Patel, 2009). Conventional intraoral
radiographs image a three-dimensional
structure and display it onto a twodimensional surface, causing the image
to have overlaps, distortion, and blockage
of key anatomical structures. This results

Referral PA

Endodontist’s PAs

Possible involvement of tooth No. 12 but could also be thin buccal plate
Derek Chu, DDS, is Assistant Professor, Department
of Endodontics, Loma Linda University School of
Dentistry, California.
David E. Jaramillo, DDS, is Associate Professor,
Department of Endodontics, Loma Linda University
School of Dentistry.
Chad Gustafson, DDS, is in Private practice in
Endodontics in Central California.

Dwight Rice, DDS, is Associate Professor, Department
of Oral Diagnosis Radiology and Pathology, Loma Linda
University School of Dentistry.

12 Endodontic practice

in more radiopaque structures masking or
blocking more radiolucent structures. With
the development of CBCT, it is now possible
to overcome some of these limitations.
CBCT technology is significantly more
sensitive than conventional radiography in
detection of apical periodontitis (Estrela,
2008). CBCT scans are now able to aid in
difficult endodontic diagnostic cases where
clinical tests and conventional radiology are

Postoperative radiographs

inconclusive.

Detection of apical periodontitis can be
accomplished earlier with CBCT than with
conventional radiography because CBCT
detects bone loss prior to the involvement
of cortical bone. Earlier detection and
diagnosis of bony involvement associated
with apical periodontitis may allow earlier
intervention, if appropriate, which can
result in superior treatment outcomes.

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CASE STUDY

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CBCT technology has been shown to
detect 28% more periapical pathosis
versus conventional radiography (Patel, et
al.).

The following three case reports will
demonstrate the benefits of CBCT, and
its role in helping to diagnose and treat
endodontic problems.

Pano Scout

Case report No. 1
The patient presented to the Loma Linda
University School of Dentistry graduate
endodontic clinic for endodontic evaluation
of tooth Nos. 11 and 12. The patient had
mild tenderness when pressing below his
eye on the left side for several months. He
had no pain on chewing, and it had never
awakened him. The oral exam revealed
Volume 6 Number 6

Endodontic practice 13


CASE STUDY

6/18/2012

extensive crown and bridge reconstructive
dentistry. Tooth Nos. 11-13 were restored
with porcelain-fused-to-metal crowns with
tooth No. 11 serving as an abutment for
a multiunit bridge. There was no sinus
tract, and probing depths were 2-3 mm
around tooth Nos. 11-13. There was no
tenderness to percussion.
14 Endodontic practice

Preoperative radiographs
Palpation over the buccal apical area of
tooth Nos. 11 and 12 was consistent
with the patient’s chief complaint and a
hard, bony-like swelling was noted in the
vestibule, which was not present on the
contralateral area of tooth Nos. 5 and 6.
Tooth Nos. 11-13 responded to cold,
but the response was delayed. Two PA

radiographs were taken, but no definitive
periapical pathosis was noted, and the
PDL appeared normal around all apices.
No endodontic cause could be found.
A small field of view CBCT scan was
recommended to identify location and size
of expansive lesion.
The CBCT indicated a periapical
radiolucency surrounding the apex of

Volume 6 Number 6


CASE STUDY

tooth No. 11. The apical bone surrounding
tooth No. 12 appears to be normal. The
radiolucency is consistent with a periapical
granuloma or cyst related to a necrotic
pulp tooth No. 11. A tentative diagnosis
No. 11 necrotic pulp/symptomatic apical
periodontitis was determined. Root canal
treatment was recommended for tooth No.
11. The canal was cleaned and shaped to
length. The canal was obturated with warm
vertical compaction and GP. The access
was sealed with a bonded composite
restoration. A 6-month follow-up visit was
recommended to evaluate apical healing.

Case significance
Clinical signs and symptoms did not
provide enough information for a conclusive
endodontic diagnosis for tooth No. 11,
and no definitive lesion could be detected
with two-dimensional radiographs. CBCT
allowed for the detection of apical pathosis
and aided in the diagnosis.

Case report No. 2

A male patient presented in the Loma Linda
School of Dentistry graduate endodontic
clinic referred for endodontic evaluation
of tooth No. 3. He reported having pain
on the upper right side of his mouth. He
had mild tenderness when palpating
around the buccal mucosa of tooth No.
3. Clinical evaluation showed a sinus tract

Pano Scout

present along with purulent discharged
after palpating the swelling. The clinical
exam revealed mobility, the periodontal
probings were within normal limits, and
there was no pain to percussion. The
radiographs revealed that tooth No. 3 had
been previously treated, and the sinus tract
was traced with GP leading to tooth No. 3.
He recalled that the tooth was previously
Volume 6 Number 6

treated 2 to 3 years prior. Tooth No. 3 was
diagnosed having a recurring/persistent
infection and treatment planned for nonsurgical retreatment.
During retreatment, a missed MB2
canal was located, cleaned, and shaped
to length. Calcium hydroxide was placed in
the canals, and the patient was scheduled
to return in 1 week to complete treatment.

Final obturation was performed using warm
vertical compaction of GP.
At a 5-month follow-up, patient
reports having tenderness recur when
palpating over the area where the previous
swelling was. Clinical exam reveals slight
tenderness to palpation on buccal mucosa
of tooth No. 3 again. Tooth mobility,
percussion, and periodontal probing were
Endodontic practice 15


CASE STUDY

within normal limits. Patient was referred
for CBCT scan for further evaluation.

Evaluation of CBCT scan confirmed the
presence of an apical lesion of endodontic
origin, and the patient was scheduled for
endodontic surgery. CBCT provided the
opportunity to determine the size of the
lesion and establish the location of the
sinus in preparation for the osteotomy to
be performed. The surgery was completed,
and a biopsy sample taken. Biopsy report:
periapical granuloma.

At 2-month recall, the patient reported

that the pain had subsided. The clinical
exam revealed no signs of swelling or sinus
tract. All the tests were within normal limits.

Case report No. 3
A male patient presented in the Loma Linda
School of Dentistry dental hygiene clinic
for routine dental maintenance. A firm,
localized, solitary 5 mm swelling on the
inside of the left upper lip (buccal to tooth
No. 9) was noted. There was also a sinus
tract present associated with the swelling.
He reported no pain, and was not aware of
16 Endodontic practice

the findings. The PA radiographs revealed
an impacted canine superimposed over
the apex of tooth No. 9.

The buccal mucosa above tooth No.
9 was red with a slight swelling where
the apex of tooth No. 9 would be. The
patient had a CBCT scan to establish the
orientation and proximity of tooth No. 11
in regards to the apex of tooth No. 9. The
CBCT scan also showed the presence
of apical periodontitis on tooth No. 9,
establishing tooth No. 9 as the source
of infection. Endodontic evaluation and
treatment was done prior to evaluation for

surgical removal of tooth No. 11.
CBCT technology demonstrated its
important value in these presented cases.
CBCT scans provide additional information
for visualizing the anatomic features
present and for overcoming the limitations
of conventional dental radiography. EP

References
Patel S. New dimensions in endodontic imaging:
Part 2. Cone beam computed tomography. Int
Endod J. 2009;42(6):463–475.
Patel S, Horner K. The use of cone beam
computed tomography in endodontics. Int Endod
J. 2009;42(9):755–756.
Patel S, Dawood A, Whaites E, Pitt Ford T.
New dimensions in endodontic imaging: part
1. Conventional and alternative radiographic
systems. Int Endod J. 2009;42(6):447–462.
Patel S, Dawood A, Mannocci F, Wilson R, Pitt
Ford T. Detection of periapical bone defects
in human jaws using cone beam computed
tomography and intraoral radiography. Int Endod
J. 2009;42(6):507-515.
Yoshioka T, Kikuchi I, Adorno CG, Suda H.
Periapical bone defects of root filled teeth
with persistent lesions evaluated by conebeam computed tomography. Int Endod J.
2011;44(3):245–252.
Ozen T, Kamburoğlu K, Cebeci AR, Yüksel SP,
Paksoy CS. Interpretation of chemically created

periapical lesions using 2 different dental
cone-beam computerized tomography units,
an intraoral digital sensor, and conventional
film. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod. 2009;107(3):426–432.
Huumonen S, Ørstavik D. Radiological aspects of
apical periodontitis. Endod Topics. 2002;1(1):3–
25.

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ENDODONTICS IN FOCUS

Tip number 10 — When things go wrong
In the last article in this series, Dr. Tony Druttman focuses what to do when things do not go according to

plan.

T

he causes of endodontic failure are
predominantly of bacterial origin
resulting either from retained microbes or
from those reintroduced into the root canal
space:
1.
Untreated and or contaminated canal
space. This will include inadequately
cleaned, missed, or ledged canals.
2.Instrument separation preventing proper
shaping, cleaning, and obturation of
canal space.
3.Perforation.
4.
Leakage resulting from an inadequate
coronal seal.
The successful management of an
endodontic failure depends on many
different factors. The correct diagnosis is
of major importance and reference to the
earlier article in this series may be helpful.
As CBCT technology becomes more
established, we come to depend more
heavily on it to help diagnose endodontic
failure. Even the best quality digital
periapical images will sometimes hide the

truth (Figures 1A and 1B).

When things do not go according to
plan, the best thing to do is to stop and reevaluate before making things worse. With
experience, correct case assessment can
often prevent pitfalls during treatment.

Failure of endodontic treatment

Figure 1A: Tooth No. 15 appears on a periapical to be well
root treated

Figure 1B: The equivalent CBCT image shows an
endodontic lesion associated with the MB root

Figure 2A: Endodontic lesion of the mesiobuccal root of tooth No. 14

No treatment can be guaranteed to be
100% successful, and endodontics is no
exception, even though success rates of
over 90% can be achieved. If an endodontic
failure is diagnosed, it is important to know
why it has failed. A very good knowledge of
root canal anatomy is important as well as
an understanding of the techniques used
in endodontic procedures. This is why very
often endodontic retreatments are carried
out by specialists and form a significant
proportion of their work.

Tony Druttman, MSc, BChD, BSc, is an
endodontist working in central London. He
is also a part-time teacher at the Eastman
Dental Institute, University of London, and
lectures in the UK and abroad.

18 Endodontic practice

Figure 2B: Retreatment of tooth No. 14 including the MB2 canal

Volume 6 Number 6


Figure 3B: Tooth No. 30 has been retreated. A second distal canal has been identified

Figure 4: Sectioned root tip of root filled showing a round preparation in an oval canal


Case assessment should include the
following:
Degree of treatment complexity
Restorability of the tooth
Periodontal status
Medical status
Cost
Skill of the practitioner
Patient’s wishes

Missed canals
Most endodontic failures are due to the

presence of residual infection. This is
caused by canals that have been missed
or canals that have been inadequately
cleaned. The most common cause of
failure of upper molars is due to untreated
MB2 canals (Figures 2A and 2B). These
are often missed because they are very
Volume 6 Number 6

Figure 5: Rotary nickel-titanium instrument fracture due to
coronal binding

small and difficult to identify without
magnification. Canal anatomy can be
diverse, and it is important to identify all
the canals that are present, rather than
just the ones that one expects to find. It
is also important to appreciate that canals
sclerose from coronal to apical, and that
the entrance to a canal can be some way
apical to the pulp chamber. The operating
microscope is invaluable in this respect.


Often a symptomatic root-filled tooth
will look fine on a radiograph, and a
diagnosis may be difficult to establish. It is
important to remember that a radiograph is
only a two-dimensional image of a threedimensional object. Tissue remnants may
be left in the root canal after obturation

(Figures 3A and 3B). An oval cross section
and a circular cross section can look
exactly the same on a radiograph.

Inadequately cleaned canals

Fractured instruments

Conventional understanding is that files
shape, and irrigants clean. If a canal is
oval in cross section, then very often canal
debris is packed into the lateral extensions
of the canal, and it is difficult for the irrigants
to remove the debris. This is particularly the
case in the isthmus region of molar teeth.

Instrument fracture occurs either through
torsional stress or flexural failure. Fracture
due to torsion occurs when the tip or
any other part of the instrument binds
in the canal while the handpiece keeps
turning. When the elastic limit of the metal
is exceeded, fracture of the instrument
Endodontic practice 19

ENDODONTICS IN FOCUS

Figure 3A: Tooth No. 30 appears to be well root treated, and yet has symptoms

ENDODONTICS IN FOCUS

Figure 6: Instrument fracture due to flexural fatigue in the
mesiobuccal canal of tooth No. 15

Figure 7A: Fractured instrument in the distal root of a
symptomatic tooth 30

Figure 7B: Tooth 30 fractured instrument removed and the
tooth retreated

Perforation

Figure 8: Fractured instrument in the mesial root 8 years
after treatment

Figure 9: Perforation of the mesiobuccal root during root
canal preparation

Figure 10A: Failed endodontic treatment of tooth No.19

Figure 10B: Endodontic retreatment. Note the sealer in the
mesial root beyond the blockage

Figure 10C: Six-month review of tooth 19 shows healing
of the endodontic lesion associated with the blocked
canals

becomes inevitable (Figure 5). This is often
due to the application of excessive apical

force on the handpiece and can occur
coronally as well as apically.
Flexural failure occurs because of
metal fatigue. The instrument does not
bind in the canal, but rotates freely until the
fracture occurs at the point of maximum
flexure. This type of failure is due to their
use in curved canals (Figure 6). Incorrect
rotational speeds and torque settings may
also contribute to this type of failure.

The presence of a fractured instrument
does not necessarily cause a failure.
The question has to be asked, “At what
point in the procedure did the instrument

separate?” If the mishap has occurred early
in the cleaning and shaping process, and
the instrument has blocked the access to
the more apical part of the canal, then failure
is likely to occur. This is because bacteria
left behind are inaccessible to disinfection
procedures (Figures 7A and 7B). On the
other hand, if the last instrument in the
sequence has separated at the working
length, then the likelihood is that the canal
has already been debrided adequately,
and the presence of the fragment may not
affect the prognosis of the tooth (Figure 8).
Either way, it is important that the patient

is informed. Fracturing an instrument in a
canal is not negligent, but failing to inform

the patient is. Removal of the instrument is
often possible with the aid of the operating
microscope and ultrasonics; however, a
great deal of care has to be taken not to
remove excessive amounts of the tooth
structure (Figure 7B).

20 Endodontic practice

Perforations
Perforations (Figure 9) can occur when
looking for sclerosed canals, and
sometimes it is hard to know if the true
canal has been located, or if a perforation
has been created, even when using
magnification. Apex locators are very
useful in helping to distinguish between the
two, and this is recommended as soon as
Volume 6 Number 6


blocked in spite of our best efforts. These
teeth should not be condemned, as very
often the lesions will heal. This may be due
to the lesion being associated with other
canals in the tooth or because the majority
of the bacteria have been removed, and

any remaining are entombed and denied
access to nutrients (Figure 8). Canals
that are apparently blocked to even the
smallest of endodontic instruments are
often patent, and this is only determined
on the postoperative radiograph, when
cement is forced into the uninstrumented
part of the canal during obturation (Figures
9A and 9B).

Blocked canals

With technologies, such as the operating
microscope, ultrasonics, CBCT, high
quality digital radiography, and materials

There are situations where teeth with
endodontic lesions have canals that remain

Conclusions

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extraction. These include the teeth where

previous endodontic treatment has failed,
and where there have been procedural
errors during treatment.

There is an increasing preoccupation
within the profession with dental implants
driven by the efforts of the industry. When
a tooth has to be extracted or has been
lost, there is no better substitute than an
implant; however, there is nothing better
than the natural dentition. Endodontics
plays a vital role in maintaining the natural
tooth, keeping or restoring it to health and
function. It is important that the skills and
knowledge required to do so are not lost.
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Volume 6 Number 6

Endodontic practice 21

ENDODONTICS IN FOCUS

the canal wall has been breached. Strip
perforations occur when canals have been
over enlarged, often by using Gates Glidden
drills too far apically or when the access
cavity has not been shaped correctly.
Perforations should be repaired as
soon as possible, preferably at the same
appointment. If they are left, bone loss
around the perforation can occur, and

it may not heal if left too long. MTA has
proved to be an excellent repair material,
although because it is a material based
on Portland cement, it can be difficult to
control. The new bioceramic materials that
are coming onto the market show promise
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CONTINUING EDUCATION

Fiber posts and tooth reinforcement: evidence in the
literature
Drs. Leendert Boksman, Gary Glassman, Gildo Santos, and Manfred Friedman look at the literature for fiber
posts and the best techniques for placement

T

raditional thinking that a post is only
placed to retain a core and serves
no other purpose may no longer be valid
(Hajizadeh, et al., 2009).
The preservation of dentin during access
opening, shaping the canal, preparing the
root for placement of a post, and during
restoration with an onlay, or full coverage
preparation is critical to the clinical longevity
and success of the final restoration (Pilo,
Shapenco, Lewinstein, 2008). It is now well
recognized that excess removal of dentinal

support, not only in the root but also
coronally, changes the flexural behavior and
resistance to failure, and that overflaring the
canal for straightline access to the canals
weakens the dentinal complex (Trope,
Ray, 1992; Reeh, Messer, 1989; Linn,
Messer, 1994; Panitvisai, Messer, 1995).
Dentin coronally must be maintained, not
only to give support to the core build-up
(Fokkinga, et al., 2005; Creugers, et al.,
2005), but as well, because clinical and in

Educational aims and objectives
This clinical article aims to explain why the literature should be scoured to find
the best fiber post available and the best techniques for placement.
Expected outcomes
Correctly answering the questions on page 32, worth 2 hours of CE, will
demonstrate the reader can realize that materials and techniques for fiber post
restoration of endodontically treated teeth are continuously evolving with the
inevitable outcome of better clinical results for patients.

Figure 1: Especially in ovoid canals (which are the norm),
post preparation can needlessly remove dentin and
result in weakening the remaining tooth structure, while
leaving lateral gutta percha that compromises bonding/
cementation

Leendert (Len) Boksman, DDS, BSc, FADI, FICD, graduated from the Faculty of Dentistry, University of Western
Ontario, Canada, with a DDS in 1972. After 7 years in private practice, he joined the Faculty of Dentistry
at Western as an assistant professor of operative dentistry, shortly thereafter attaining the tenured position

of associate professor. He has authored more than 100 articles and several chapters in textbooks and was
awarded the Ontario Dental Association Award of Merit in 2005. He has recently been appointed as adjunct
professor in the University of Technology Dental School, Jamaica, where he donates his time. Dr. Boksman is a
paid part-time consultant to Clinical Research Dental and Clinician’s Choice.
Gary Glassman, DDS, FRCD(C), graduated from the University of Toronto, Faculty of Dentistry in 1984. The
author of numerous publications, Dr. Glassman lectures globally on endodontics, is on staff at the University of
Toronto, Faculty of Dentistry in the graduate department of endodontics, and is adjunct professor of dentistry
and director of endodontic programming for the University of Technology, Jamaica. Dr. Glassman is a fellow of
the Royal College of Dentists of Canada, and the endodontic editor for Oral Health dental journal. He maintains
a private practice, Endodontic Specialists, in Toronto, Canada.
Gildo Coelho Santos Jr., DDS, MSc, PhD, received his DDS (1986) and MSc in dental clinics (1999) from Federal
University of Bahia, and PhD in prosthodontics (2003) from University of São Paulo (Brazil). Dr. Santos was
appointed as assistant professor, division of restorative dentistry at the University of Western Ontario Schulich
School of Medicine and Dentistry in 2006, and in 2011 was appointed chair of the division of restorative
dentistry. Dr. Santos is a part-time consultant (research and development) for Clinical Research Dental and
Clinician’s Choice.
Manfred Friedman, BDS, BChD, graduated from the University of Witwatersrand and Johannesburg (South
Africa) in 1971 and then obtained his BChD Honours at the University of Pretoria in 1980. He immigrated
to Canada in 1987 where he took up a full-time position at the University of Western Ontario (UWO) and
was appointed as director of dentistry at the Southwestern Regional Center for developmentally challenged
adults from 1987 to 1994. He currently has a full-time practice in London, Ontario, restricting his practice to
endodontics, and is a major part-time adjunct professor at Schulich School of Medicine and Dentistry at UWO.
Dr. Friedman has given numerous courses on endodontics, with particular interests in rotary instrumentation,
endodontic materials, apex locators, and restoring the endodontically treated tooth.

22 Endodontic practice

vitro studies support the fact that survival of
endodontically treated teeth restored with
posts is directly proportional to the residual

coronal dentin that remains (Ferrari, et al.,
2007; Oliveira, Denehy, Boyer, 1987).
Post preparation of the root canal space
must not remove additional dentin, as this
contributes to a reduced fracture toughness
(Figure 1). Ree, et al., (2010) state that,
“No additional dentin should be removed
beyond what is necessary to complete the
endodontic treatment.” If this concept is to
be adhered to clinically, then, of course,
the use of parallel-sided posts must be
eliminated from our clinical protocol, as
these posts usually require removal of
sound apical radicular dentin, creating
sharper internal line angles, resulting in a
weakened root and a higher root fracture
risk (Figure 2) [Sorensen, Mito, 1998]. As
well, the parallel post does not complement
the tapered shape of the prepared canal,
resulting in excess luting composite in the
coronal aspect of the canal, which can
decrease bonding efficacy and decrease
dislocation resistance (Figure 3) [Boksman,
2011].
If we adhere to the concept of minimal
dentin removal in the root, and if we
recognize that most root canals are ovoid
in shape, then a wholly different treatment
approach than what we have been taught
in the past is indicated. Boksman, et al.,

(2013) have recommended utilizing a
tapered master quartz fiber post (MacroLock Post™ X-RO™ Illusion™, Clinician’s
Choice Dental Products) with additional
FiberCones™ placed into the irregularity
(lateral spaces) of the canal (Figures 4 and
5). This technique is similar to using a master
Volume 6 Number 6


Figure 3: The taper of the Macro-Lock post allows respect
for the dentin, and ensures a more even and minimal
amount of surrounding composite resin, thereby reducing
polymerization contraction forces

Figure 5: A clinical photograph showing the placement of FiberCones laterally to the main Macro-Lock Post, which
decreases composite volume, adds anti-rotational elements, and decreases microleakage

gutta-percha point with accessory guttapercha points, which is well understood.
Utilizing this approach provides several
clinical advantages (Akkayan, et al., 2010;
Maceri, Martignoni, Vairo, 2008; Li et al.,
2011; Mossavi, Maleknejad, Kimyai, 2008;
Porciani, et al., 2008) including:
• More anti-rotational resistance
• Decreased volume of composite or
cement lateral to the post to decrease the
“C” and “S” factor constraints (volumetric
shrinkage)
• Better adhesion to the root canal walls,
resulting in decreased microleakage and

increasing resistance to dislodgement,
as well as decreased likelihood for lateral
perforation.

Choosing the right fiber post
The combination of a post (or multiple posts)
Volume 6 Number 6

that transmits light efficiently, with sufficient
extended light-curing time/output, results
in better composite polymerization.
The indirect cast gold/metal/zirconia
post and core has been largely replaced
with a single appointment restoration of a
direct post and core. Fiber posts such as
the UniCore® Post (Ultradent), the quartz
fiber posts manufactured by RTD (St
Egreve, France), the Macro-Lock X-RO,
and the DT Light-Post® (Bisco Canada,
BC) have many physical characteristics
that make them more desirable clinically,
rather than metal and zirconia posts:
1. The elastic modulus (or a material’s
stiffness) of fiber posts more closely
approximates that of dentin (18.6GPa),
allowing some slight flex in function,
dissipating stress, and reducing the
likelihood of damage to the root (Ferrari,

Figure 4: In irregular or ovoid canals, the use of

FiberCones lateral to the Macro-Lock X-RO has many
clinical advantages, increasing longevity

Scotti, 2002; Duret, Duret, Reynaud,
1996). Stainless steel has an elastic
modulus of about 200GPa, titanium alloy
110GPa and zirconia 300GPa (Goracci,
Ferrari, 2011). The stiffness of metal and
zirconia posts creates more internal stress,
zones of tension and shear during function
and parafunction (Rodrigues-Cervantes, et
al., 2007), which can result in unrestorable
catastrophic root fractures.
2. Fiber posts have a high flexural strength,
and according to a study by Stewardson,
et al., (2004): “The flexural strength of
fiber-reinforced composite endodontic
post materials exceeds the yield strength
of gold and stainless steel, and two of the
FRC (fiber reinforced composite) posts
were comparable to the yield strength of
titanium.”
It must be noted here that not all
fiber posts are created equal. There
are differences in fracture load, flexural
strength, fiber diameter, fiber/matrix ratio,
type of fiber (with quartz fiber posts having
higher failure resistance), light transmission,
shape, post surface adhesion, quality
of fiber, structural defects/voids, and

manufacturing quality, which all affect the
clinical outcome and longevity (Seefeld, et
al., 2007; Freedman, Jain, 2008; Bassi,
2001; Boudrias, Sakkal, Petrova, 2001;
Maceri, Martignoni, Vairo, 2008).
The clinician must make an informed
choice for choosing a fiber post – looking
for the best attributes – in order to select
the post with superior properties based
on independent research. The dental
practitioner must also be aware of the best
adhesive combinations and techniques, as
there are some incompatibilities between
dual-cure core materials and simplified
acidic adhesives due to residual acidity.
There is a variation in the results of
the scientific literature when evaluating
fiber posts, not only because of the
differences in the posts themselves,
but also because of the cementing/
Endodontic practice 23

CONTINUING EDUCATION

Figure 2: To seat the inserted parallel-sided post into the
tapered canal would require more apical removal of vital
dentinal structure needlessly weakening the root and
creating an apical stress point