Tạp chí nội nha EPUS tháng 3&4/2013 Vol6 No 2

clinical articles • management advice • practice profiles • technology reviews

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March/April 2013 – Vol 6 No 2

PROMOTING EXCELLENCE IN ENDODONTICS

New instruments
for root canal
negotiation and
preparation
Drs. Peet van der Vyver
and Casper Jonker

Top ten tips

6

#

Magnification and
illumination

Drs. Jozef Mincík and
Marián Tulenko

CBCT within
endodontics:
an introduction

Dr. Navid Saberi

Corporate profile
Coltene: Growth helps fund innovation

Practice profile
Dr. John R. Hughes

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Dr. Tony Druttman


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

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

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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

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Should endodontics remain a specialty?
Of course we endodontists would all reply with a resounding “Yes!” but it’s not quite that
easy — in fact, we were almost decertified back in the late 1980s! As you probably know,
every 10 years, the American Dental Association (ADA) requires that each dental specialty
submits the reasons why the specialty is necessary. Fortunately, we were recertified a
couple of years ago due, in part, to the generous efforts of our AAE Foundation, which
has funded research to expand the envelope of endodontic knowledge. On a more
personal level, what are we endodontists doing (or should be doing) to reaffirm the need
for our specialty?

Our AAE appoints a committee to prepare a document that will be sent to the ADA
highlighting the distinguishing practice guidelines that justify our specialty existence;
these guidelines have to reflect what all endodontists are capable of performing. In fact,
the AAE has position papers on the breadth and depth of what general dentists and the
public should expect from a practicing endodontist. With this introduction, I have a few
questions for my endodontic colleagues:

Are we all using CBCT (cone beam) when periapical radiographic images are
insufficient to make an accurate diagnosis? We don’t necessarily need to buy a CBCT

(they are costly) because there are so many dental X-ray centers so nearby. By employing
CBCT, when appropriate, we can make more sophisticated and accurate diagnoses.
After all, who but we endodontists are better trained to diagnose vertical root fractures?
How about the more elusive (occult) incomplete vertical root fractures? But the subtext of
this question about CBCT leads to another question: do we endodontists have sufficient
training acquired either through a rigorous post-graduate endodontic program or through
continuing education programs to interpret CBCT findings? In 2013, there is a reasonable
expectation by general dentists and the patients we serve that endodontists should know
when to employ and how to interpret CBCT.

When it comes to a complex diagnosis (e.g., atypical facial pain) that presents
ostensibly as “toothache,” our advanced training in history gathering and testing enables
us to recognize this uncommon entity. We endodontists must reaffirm through our clinical
diagnostic acumen that recognizing complex diagnostic entities is another area that
distinguishes our specialty from general dentistry.

Accurate diagnosis is part of the foundation of our specialty, and this in turn, leads
to accurate and appropriate treatment planning. All of us have seen countless cases
that were misdiagnosed which, of course, led to inappropriate treatment or even worse,
mistreatment. If an injured patient files a complaint against an endodontist alleging
negligent treatment, it is quite likely Plaintiff’s counsel will inquire if the endodontist used
CBCT leading to the diagnosis and treatment plan — and if not, why not? Of course,
not every case we treat requires CBCT; however, if we fail to employ CBCT when it is
indicated for diagnosis or treatment planning, we may expose ourselves to claims of
negligent care.

Pulp regeneration is not merely science fiction, it’s a science fact based on many
fine studies published in our peer-reviewed endodontic journals. Are we endodontists
prepared to employ pulp regeneration when an appropriate case presents in our office?
After all, our ability to stimulate pulp regeneration is another distinguishing feature that

sets us apart from the general dentists’ skill-set. When symptoms subside, patients
may become dilatory about returning to their general dentist for a final restoration, or the
general dentist may delay restoring the endodontically-treated tooth. Thus, I would submit
that we endodontists should also place final restorations in our access openings because
we know, through many papers published in endodontic journals, that there are countless
failures due to coronal leakage around provisional restorations.

Every day we are in practice, we must demonstrate our sophisticated Standard of
Endodontic Excellence to justify endodontics as a specialty!

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held responsible for the accuracy of the information 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 2

Stephen Cohen, MA, DDS, FICD, FACD
Diplomate, American Board of Endodontics
www.cohenendodontics.com

Endodontic practice 1

INTRODUCTION

March/April 2013 - Volume 6 Number 2


TABLE OF CONTENTS

Practice profile

6

Dr. John R. Hughes: Privileged to serve
Dr. John Hughes discusses restorative dentistry, the importance of sharing with
colleagues, and his fulfilling humanitarian efforts.

Clinical
Electronic root canal
measurements using Endo-Eze
Quill, Root ZX mini, Root
ZX II, and SybronEndo Mini
apex locators — an in vitro
comparison with actual canal
length
Drs. Carlos A. Spironelli Ramos,
Renato de Toledo Leonardo,
Richard D. Tuttle, and Bruno Shindi
Hirata, study the location of the

suitable apical file position........... 12
Long-term treatment of root
fractures
Drs. Jozef Mincík and Marián
Tulenko discuss the long-term
treatment of root fractures with
Rebilda Post System................... 16

Corporate profile

10

Coltene®: Growth helps fund innovation
The COLTENE ENDO group offers a complete product lineup, ranging from
diagnostics, isolation, drying and filling products, to post and core build-up
materials.

2 Endodontic practice

Endodontics in
focus
Tip number 6 – Magnification and
illumination
Dr. Tony Druttman looks at the
importance of magnification and
illumination in the practice of
endodontics................................ 20

Volume 6 Number 2

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TABLE OF CONTENTS
Cone beam computed
tomography

24

Research
Effect of repeated sterilization
and simulated clinical use on the
heating capacity of System B™

Continuing
education
CBCT within endodontics: an
introduction
Dr. Navid Saberi presents a guide to
cone beam computed tomography
.....................................................24
New instruments for root canal
negotiation and preparation

Drs. Peet van der Vyver and Casper
Jonker introduce X-plorer canal
navigation nickel-titanuim files for glide
path preparation followed by Typhoon
Infinite Flex nickel-titanium files for
root canal preparation...................32

Case study
Preoperative risk assessment and
endodontic treatment planning:
examination of a complex clinical
endodontic case
Dr. Rich Mounce looks at some
common challenges in endodontic
therapy..........................................38
4 Endodontic practice

Product profile
The TF Adaptive System
The TF Adaptive System by Axis |
SybronEndo is a new NiTi file system
designed to work with the Elements
motor which features Adaptive Motion
Technology....................................42
PIPS™ Laser Endo
PIPS™ Laser Endo harnesses the
power of the Lightwalker Dual
Wavelength Laser: improving clinical
results and patient treatment
acceptance...................................44

Vista SOLUTIONS
Tested and proven for superior
outcomes......................................46
Vari™-Tip
Engineered Endodontics™ is
revolutionizing the ultrasonic tip
market with the Vari™-Tip, the first
customizable, cost efficient, all-metal
ultrasonic tip..................................48

Heat Source pluggers
Drs. Steven W. Black, Brian E.
Bergeron, Mark D. Roberts, Jacob
P. Bitoun, Zezhang T. Wen, Van T.
Himel, and Joseph L. Hagan, MSPH,
explore possible degradation and
pathogens related to routine heat
activation.......................................50

Anatomy matters
Root canal system anatomy only
matters when it matters
Dr. John West explains the
importance of educating referring
dentists about endodontic diagnosis
and technique...............................56
Diary.............................................59
AAE Preview................................60
Materials & equipment...............63

Ruddle on the radar
Thrill of the fill
Avoiding apical and lateral blocks
.....................................................64
Volume 6 Number 2



PRACTICE PROFILE

Dr. John R. Hughes
Privileged to serve

Alexi, an orphan, and I in an orphanage in Tijuana, Mexico

What can you tell us about your
background?

Is your practice
endodontics?

I was born in the back bedroom of the
church parsonage of the First Baptist
Church, Gene Autry, Oklahoma. My father
was a minister, my mother was a full-time
mom, and both were the children of dirt
farmers in Oklahoma and Texas. We were
poor as church mice, but I did not know it!
I was the second of four, a total nerd, and
moved to different locations every 4 to 5

years. I took 18 to 21 hours per semester
at Oklahoma Baptist University where I
majored in chemistry and math with a
physics minor. I applied to one dental
school at the end of my junior year and
graduated from The University of Missouri
at Kansas City 4 years later. I married my
wife, Thompson, a designer for Hallmark
Cards, a month later. Still married to the
same wonderful woman after 46 years! I
was a restorative dentist in Kansas City for
15 years and dealt with my mid-life crisis
by going to Boston University to study
endodontics under Dr. Herb Schilder. Two
years later, at the end of the residency,
we decided we didn’t want to be cold any
more. We came to Tucson, Arizona, where
I started Southern Arizona Endodontics
(SAE) 30 years ago, a practice with 12
endodontists (one retired), four locations
and 55 of the best employees in southern
Arizona.

SAE is an endodontics-only specialty
practice. I think most endodontists’
drift toward implants represent a lack of
busyness rather than a love of implants.
We would rather be great at endo than
good at endo and implants.

6 Endodontic practice

limited

to

Why did you decide to focus on
endodontics?
My initial interest in endodontics was
driven by a hope for more control of the
result of my efforts. There is no tougher
professional task in my mind than being
a good restorative dentist. Great longterm success depends on the lab and
patient attention to detail. The greatest
effort of the dentist is compromised by
too many things outside of his control.
Endodontics is certainly one of dentistry’s
most predictable procedures and one that
is most dependent on operator excellence.

How long have you been
practicing, and what systems do
you use?
I started restorative dentistry in 1966 and
endodontics in 1983. Endodontics has
seen many changes in that span. The
growth of new products and procedures
has been almost exponential. In our office,
we have all of the bells and whistles. There

is probably nothing one of us has not
tried. There is a wide variety of the types
of rotary instruments we use. We all end
up using vertical compaction of warm
gutta percha for stuffing the root system.
While we have a lot of great systems at our
disposal, most that are advertised to make
the process easier also lend themselves to
misuse. Faster and easier rarely translate
to more predictable and better outcomes.
Regardless of the systems you use, they
require knowledge of the root canal system
you are invading, an understanding of
the complexity of that system, and the
determination to seal it well. Ninety-nine
percent of today’s graduates are wellinformed and well-trained endodontists.
The systems they are most deficient in are
the systems associated with the attraction
and nurturing of referral sources. That is an
area that spells success or failure for many
offices. Failure to thrive with today’s high
debt loads is not uncommon.

What
training
undertaken?

have

you

I was fortunate to train under the firm
control of Dr. Herb Schilder. I was
fortunate to also study with a group of
33 exceptional residents; 11 in my class,
11 in the class before me, and 11 in the
class behind. The majority of my training
came from the residents around me. We
Volume 6 Number 2


Who has inspired you?
It would be impossible to be around Dr.
Herb Schilder without being inspired. His
commitment to the mastery of endodontics
was and is a frequent reflection. The
rest of the dental list is rather long, but
includes Drs. Pankey, West, Ruddle,
Pannkuk, Melnick, Stropko, Yu, and Sam
Marescalco, the best restorative dentist I
ever knew. My wife, Thompson, is also a
source of great inspiration to me. Though
visually impaired, her outlook on life, her
commitment to the joy of others, and her
love of her grandchildren bring a smile to
my mind.

Professionally, what are you most
proud of?
For many years, we have maintained a

relationship with over 350 different dentists
who refer to our group. We track our
referrals very closely. If we see a decline,
we are quick to see where we are failing
them. We are in the relationship business.
The lengths we travel to maintain that
connection and the service we perform
for their patients consistently is the result
of systems we have had in place for many
years. We do good endo, but most offices
do good endo. We really excel before and
after treatment, from our followup to our
commitment to see all patients who are in
pain that same day.

What would you have become if
you had not become a dentist?
We are in the widget business. If we are
not making widgets, our income stream is
threatened. I would have been fascinated
with the challenges of management/
leadership of a company or service that
allowed delegation of responsibilities
without affecting the outcome. I think an
attorney with an MBA would allow for a
great latitude of opportunities.

What is the future of endodontics
and dentistry?

These may look like young fillies, but they are workhorses
I have worked with for a combined total of over 65 years!

I am excited about the challenges that lay
before us. When I look at where dentistry
has come during my watch, I would
hesitate to guess where it is going. Just
15 years ago, implants were considered
risky business. Now, in the right hands,
they are predictable. I don’t see them
replacing endodontics, but it has allowed
us an alternative to treating marginal teeth.
We will continue to be faced with access
to care issues. Products and solutions
will continue to evolve. I think success will
always follow quality of care, especially in
dentistry.

What are your top tips for maintaining a successful practice?

Dr. Hughes and his colleagues at Southern Arizona
Endodontics

What is the most satisfying aspect
of your practice?

What do you think is unique about
your practice?

I would say the growth of those I work with.

We have had dental assistants who have
decided to go back to school and on to
dental school. Two of our staff leaders have
been with SAE for over 20 years, and many
have excelled with us for 10 years or more.
The strength of our culture is the result of
the commitment our workforce has to treat
patients and each other with kindness,
courtesy, and respect. I have never seen
a staff more aligned in the pursuit of
excellence both in and out of the tooth.

The quality of care we extend to our
patients from the time of their contact
with us to follow up after they leave our
office. We work hard to treat every one as
if he/she is a guest in our home; a special
person we are privileged to serve.

Volume 6 Number 2

and maintaining our office culture became
a priority. We are fortunate to have a firstrate administrator to manage our systems,
culture, and priorities. Michael Austin
allows us to stay in the operatory with the
confidence that outside the operatory,
everything is under control.

What has been your biggest
challenge?

Early on, the biggest challenge was to
control our growth to allow us to maintain
quality of care in a caring environment.
Once our systems were in place, developing

You never get a second chance to make
a good first impression. Always have your
best telephone personality answering the
phone. There is no position in your practice
for a person with a bad attitude. A person
with average skills and a great attitude
always trumps a very skilled person with
poor attitude. We hire attitude and train
skills. You must be very intolerant of poor
culture. We work very closely with patients
who are our guests at a challenging time in
their life. They do not need to be exposed to
staff that is not harmonious and supportive
of each other. Kindness, courtesy, and
respect rules the day. Your office requires
management and leadership. Managers
focus on systems and structure, leaders on
development. Managers push; leaders pull.
Management involves efficiency; leadership
involves effectiveness. Peter Drucker once
commented that “with the emergence
Endodontic practice 7

PRACTICE PROFILE

saw more, learned more, and experienced
more by the shear numbers of endodontic
procedures we were exposed to. Some of
the best endodontists I have known came
out of those 33 people.

I also was involved with a mastermind
group of 10 or 12 endodontists from all over
the United States for many years that met
every 6 months to compare successes,
frustrations, and challenges. That really
shortened the learning curve for all of us
and exposed us to a lot of the movers and
shakers in the profession. In addition, I
have been a student of business systems
and applications. Part of our success has
been our attention to detail outside of the
root system.

Henry Wadsworth Longfellow wrote:
The heights of great men, reached and
kept
Were not obtained by sudden flight,
But they, while their companions slept,
Were toiling upwards in the night.
Success or mastery is not a 9-to5 endeavor. Success favors those who
entertain the thoughts and wisdom of
others. We all drink from wells others have
dug.

PRACTICE PROFILE

A pro bono work in progress, we built in 3 1/2 days

Getting ready to raise a home for another family

Last project’s work crew

of the knowledge worker, the challenge
is not to manage people; the task is to
lead them.” That involves allowing staff to
contribute to the decision-making process.
They work harder to implement ideas when
they are included in the process. A staff
that is in alignment with decisions they help
develop, “buy in” to the success of the
office.

5) Emergency practice: See all people in
pain.
6)Make the experience so compelling,
exceeding the expectations of the
patient and the referring office.

SAE combines the last two. We strive
to be able to say, “Send them right over!”
We know that frequently the patient isn’t
hurting, the dentist is! We don’t judge
whether he made a good decision in

sending them; we are happy to triage the
patient. Rarely does the patient require
immediate treatment. If you are swamped,
you medicate them. You can say, “My, my,
my, I bet that hurts. We are going to get
you on some antibiotics that will make you
feel better in a day or two. In the meantime,
we will give you something for the pain
to get you some rest. If we tried to do
something today, I am afraid we would not
be friends afterward! We will first get the
swelling down and get you comfortable.”
Or you can incise and drain or open the
tooth. None of that takes a long time. Then,
schedule them in the next week. They will
be happy that you saw them.
There are three great things about
emergency patients; 1) They are thrilled to
be seen, 2) they are referred, not because
of the degree of difficulty, but because of
the referring dentist’s lack of time, and 3)
the dentist feels like he is a stud, and he
can say, “they will see you today.”

Once they are in our office, it is our
chance. It is our job to pamper them from
the moment they step in our office to
the time they leave. You can say it is not
necessary, I know it is not necessary! You
do it because you are building a practice

that is exceptional. People do not know
good endo, but they know how they were
treated, and how they felt when they left.
When they think of your office, it should put
a smile on their face!
Third, don’t get too full of yourself.
When was the last time you were impressed
by someone who introduced himself/

herself as “doctor?” Your patient knows
that you are a doctor…your assistant can
introduce you as doctor…but you, use your
name. “Hello, I am John Hughes.” That is
much more powerful, whether in the office
or in social settings. They will find out soon
enough that you are a doctor. Charles
DeGaulle, former general and president of
France, once said, “Graveyards are full of
indispensable people.”

Keep your eye on possibilities!
You must be a rainmaker. Referrals
don’t just come; they must be earned.

What advice would you give to
budding endodontists?
First, join or start a mastermind group.
It should be comprised of endodontists
outside of your geographic area. Our group
met twice a year for many years. We each

brought copies of all of the current printed
material in our office (such as referral pads,
letterheads, post-op correspondence)
and distributed them with the agreement
that we could mimic anything in our office.
Sharing and discussing challenges and
solutions greatly reduces the learning
curve. We spent Friday on tooth stuff and
Saturday on management, leadership, and
interface with referring offices.

Second, know what your gift is, what
your strengths and weaknesses are. Those
affect how you can best thrive. There are
really just five or six ways you can practice.
Each has pluses and minuses; some
attract specific personality types, or fill
specific needs and wishes of the dentist.
Most practices are a combination of one or
two of the following.
1)
Government
services:
Veterans
Administration, Indian Health Service,
armed services, etc. These involve
somewhat of an 8-to-5 group
involvement with retirement after a fixed
number of years.
2) Education/Research, with an intermural

practice: Schools need endodontists.
3)Develop products and/or systems,
lecture, become an “authority.”
4) Underserved area: These are becoming
hard to find.
8 Endodontic practice

What are your hobbies, and what
do you do in your spare time?
I really enjoy pro bono construction in
Mexico. When I retire, I hope to build
a home every month or so. I now build
every March with a group of students
from Westmont College during their spring
break. It greatly changes the lives of the
givers and the receivers. EP

TOP FAVORITES
My wife, Thompson
My two sons, Justin and Cole, and my daughter
Wendy
My four grandchildren, Hailey, Tanner, Tenley,
and Britney
My partner of 25 years, Dean Hauseman
DEXIS®: There are several good digital
radiograph systems available. I think DEXIS is
the cream of the crop.
Dentrix: We have over 75 work stations, 67
users, over four locations. This software system
gives us real time access to any chart in any

location. It also works seamlessly with DEXIS. A
great pairing.
Tulsa Dental: We are, I assume, one of Tulsa’s
largest accounts and biggest fans! They seem
to always be there when the “next big thing” is
introduced. They have a large variety of rotary
instruments that fit our group perfectly!
Roydent™ Dental Products: We have used
Roydent’s files and reamers forever.
Smart Practice®: The best, most economical,
suppliers of gloves. Very service oriented.

Volume 6 Number 2


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Ultrasonic Irrigator
• Distributes and ultrasonically activates sodium
hypochlorite to increase debridement of lateral
canals and isthmuses
• Ratcheting syringe permits controlled delivery
of 0.2 ml of solution with each audible click
Benefits of Continuous Ultrasonic Irrigation:
• Removes significantly more debris from narrow
isthmuses better than conventional needle irrigation*
• Significantly increases the penetration of
irrigation solutions into lateral canals**
*Adcock et al, J.Endod. 2011; 37 (4) **Castelo-Baz et al, J. Endod. 2012; 38 (5)

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235 Ascot Parkway | Cuyahoga Falls, OH 44223
Tel. USA & Canada 800.221.3046 | 330.916.8800 | coltene.com
PATENT PENDING


CORPORATE PROFILE

Growth helps fund innovation

I

n May 2011, the COLTENE ENDO group
formed to consolidate some of the most
widely known endodontic brands under
one umbrella, allowing clinicians simplified
access to product information. Bringing
many widely known brands under one
umbrella enables greater focus. The
COLTENE ENDO group is comprised
of three sites: Altstatten, Switzerland,
Langenau, Germany, and Cuyahoga
Falls, USA. The American headquarters in
Cuyahoga Falls, Ohio is one of the main
manufacturing locations for several of the
products and the home site for divisional
management. Operating as an international
team allows the COLTENE ENDO group
to cross-pollinate ideas, making products
more relevant and uncompromising based
on feedback from a broad, multinational
group of dentists, universities, and opinion
leaders.
The COLTENE ENDO group has
brought together products from four
product lines; Alpen®, ROEKO, Hygenic®
and Whaledent. Alpen®, a complete line
of diamond and carbide burs, offers endo

access products to gain entry into the canal.
Celebrating its 100th birthday, ROEKO
products like ROEKOSeal continue to be
used by a wide dental audience. Another
brand of products that performs day in and
day out is Hygenic® Endo-Ice®, paper and
gutta-percha points.
Helping to ensure better isolation
with latex and non-latex choices are the
industry’s gold standards, Hygenic® Dental
Dams and Clamps. For the past 50 years,
the ParaPost® and ParaCore have been
used in millions of post and core buildups. Within the COLTENE ENDO product
portfolio are everyday endo products used
for a wide range of therapies. The merger of
brands into one globally managed portfolio
allows greater focus on the endodontic
field, thereby enhancing customer service
and expediting innovation forces.

Endodontic products continue to
grow
The focus of COLTENE ENDO, to
concentrate on bringing together all the
products needed to perform endodontic
treatment, is helping fuel the overall growth
of the entire company. The COLTENE
ENDO group has tapped into an ongoing
10 Endodontic practice

Coltene North American headquarters, Cuyahoga Falls, Ohio

History of COLTENE ENDO firsts
First high volume casting and metal post manufacturer
First to introduce a silicone endo sealer
First cold flowable root canal sealer
First core build-up material and post cement (ParaCore) to be
indicated as a crown cement

trend within dental — patients are living
longer, thereby necessitating more
treatment. In general, older patients have
more money, resulting in geriatric dental
patients being treated for endodontic
ailments like root canals. Moreover, the
mission of the COLTENE ENDO group is
to focus on filling out their portfolio to offer
a wide selection of endodontic products.
The Strategic Dental Marketing group
agrees that endo product sales are on
the rise. Richard Fishbane, Vice President
of Strategic Dental Marketing states, “In
2012, the endodontic category of products
saw a growth rate that was substantially
higher than the overall growth rate for
dental products in the U.S. Coltene’s Endo

Division was a major factor in that growth
and posted the strongest annualized
sales growth of any major endodontic

manufacturer in the U.S.” The success of
Coltene in 2012 was aided by the strong
performance of the endo division.

Investment in R&D
Even during the economic downturn of
2008 and 2009, Coltene funded research
and development projects, keeping the
pipeline full. The COLTENE ENDO group’s
development process is collaborative
gathering cross-functional input from Asia,
Europe, and the Americas. The process
starts with investigation of market needs
and trends. Customer input enters the
Volume 6 Number 2


CORPORATE PROFILE

Operating as an international team allows the COLTENE ENDO group to cross-pollinate
ideas, making products more relevant and uncompromising based on feedback from a
broad, multinational group of dentists, universities, and opinion leaders.

development process through opinion
leaders, universities, R&D staff, and sales
and marketing personnel. Winning ideas
are formulated and tested following a
rigorous process that ensures new key
benefits are included. Validation occurs by
testing the product’s properties through

internal and external means that also
includes giving products to universities and
key opinion leaders to test.

Coming out of the COLTENE ENDO
group are three market-focused products
helping the endodontist and general
practice dentist drive successful clinical
outcomes. The Coltene Hyflex® CM™
NiTi files offer clinicians up to 300% more
resistance to cyclical fatigue, helping reduce
the incidence of file separation. HyFlex® CM
NiTi files have been manufactured utilizing a
unique process that controls the material’s
memory, making the files extremely flexible
but without the shape memory of other NiTi
files. This gives the file the ability to follow
the anatomy of the canal very closely,
reducing the risk of ledging, transportation,
or perforation.
CanalPro™ is another new complete
Volume 6 Number 2

grouping of products introduced by the
COLTENE ENDO team. The complete
system of color-coded syringes provides an
easy way to organize and identify different
types of irrigants and solutions, helping to
increase safety and minimize the chance of
syringe swap. The CanalPro™ line offers a

complete selection of endodontic irrigation
tips.
CanalPro™ endodontic solutions are
engineered to optimize the time spent
on irrigation, giving the clinician the
best approach for cleansing canals and
achieving the best outcomes. CanalPro™
irrigation solutions come in four formulas:
CanalPro™ NaOCl EXTRA, NaOCl, EDTA
and CHX-Ultra. CanalPro™ helps complete
the COLTENE ENDO lineup, allowing the
practitioner four separate products to help
cleanse the canal and eliminate debris.

Newly introduced GuttaFlow®2 is the
second generation of the first cold flowable
root canal filling system that combines
gutta percha with a sealer. The delivery
system is an industry standard 5ml syringe
making dispensing convenient and simple.
GutttaFlow®2 requires no heating, no

condensation, and no plastic carriers to
transport material into the canal.
The COLTENE ENDO group offers
a complete product lineup, ranging from
diagnostics, isolation, drying and filling
products, to post and core build-up
materials. What makes the mission of the
newly formed COLTENE ENDO group

more relevant than ever, is discovery
of new techniques and products to
solve everyday problems. New product
innovation that saves valuable chair time
while driving improved patient outcomes
is what matters most. Successful triedand-true products are being surrounded
with incremental product innovations to
make the endodontist and general practice
dentist’s job faster to complete, freeing up
valuable time for everyone. EP
Coltene/Whaledent, Inc.
235 Ascot Parkway
Cuyahoga Falls, OH 44223
800-221-3046
This information was provided by Coltene
Endo.
Endodontic practice 11


CLINICAL

Electronic root canal measurements using Endo-Eze
Quill, Root ZX mini, Root ZX II, and SybronEndo Mini
apex locators — an in vitro comparison with actual
canal length
Drs. Carlos A. Spironelli Ramos, Renato de Toledo Leonardo, Richard D. Tuttle, and Bruno Shindi Hirata,
study the location of the suitable apical file position
Summary
The purpose of this study was to determine
the ability of four apex locator devices to

1) indicate precisely the foramen exit
position correctly, 2) provide fundamental
data for working length determination,
and 3) indicate intermediate points. Thirty
extracted maxillary central incisors were
used in this study. Measurements were
taken using the new Endo-Eze® Quill
(Ultradent, USA), Root ZX® mini (J. Morita,
Japan), Root ZX® II (J. Morita, Japan),
and SybronEndo Mini (Sybron Dental
Specialties, USA) apex locators. An analysis
of variance (ANOVA) was used to evaluate
the measurements, and no statistically
significant differences were found between
the electronic measurements of the devices
and the actual canal length at the foramen
point. This study also showed that none
of the devices demonstrated accurate
measurements at intermediate points.

Introduction
The establishment of the correct apical limit
of instrumentation is accepted as one of
the most important operative procedures

Carlos A. Spironelli Ramos, DDS, MSc, PhD, is
a specialist in Endodontics; Professor, Roseman
University of Health Sciences, College of Dental
Medicine, South Jordan, Utah; and Master and PhD in
Endodontics, University of São Paulo, and Ultradent

R&D Endodontic Segment Manager.
Renato de Toledo Leonardo, DDS, MSc, PhD, is a
specialist in Endodontics; former Head and Chairman,
Department of Restorative Dentistry, Araraquara
Dental School-UNESP; Master in Endodontics, PhD in
Pathology, University of São Paulo; Visiting Professor,
University of Texas at San Antonio, Texas; and Invited
Professor, Universitat Internacional de Catalunya,
Spain.
Richard D. Tuttle, DDS, is Col. USAF Ret., R&D Clinical
Division Manager, and Clinical Applications Advisor.
Bruno Shindi Hirata, DDS, MSc, is a specialist in
Endodontics and Master in Endodontics, State
University of Londrina, Brazil.

12 Endodontic practice

in endodontics. Determination of accurate
working length has a profound influence on
ideal canal cleaning and shaping, microbial
disinfection, and appropriate sealing of
the root canal system. The location of the
suitable apical file position has constituted a
persistent challenge in clinical endodontics.
Radiographs are commonly used to
determine the working length. However,
radiographic assessments of the working
length may prove inaccurate, depending
on the direction and the extent of the root
curvature, and the position of the apical

foramen in association with the anatomic
apex.

By measuring the electrical properties
of the apical third of the root canal, such
as capacitance and impedance, it should
be possible to detect the canal terminus.
The root canal system is surrounded by
dentin and cementum, which are insulators
to electrical current. At the apical foramen,
there is a small orifice in which conductive
materials within the canal space (e.g.,
tissue and fluid) are electrically connected
to the periodontal ligament that is itself a
conductor of electric current.
Thus, dentin, along with the tissue
and fluid inside the canal, forms a resistor,
the value of which depends on their
dimensions and inherent resistivity. When
an endodontic file penetrates inside the
canal and approaches the apical foramen,
the resistance between the endodontic file
and the foramen decreases because the
effective length of the resistive material
(dentin, tissue, and fluid) decreases. Along
with resistive properties, the structure of the
tooth root has capacitive characteristics.
Therefore, various electronic methods
have been developed that use a variety of
methods to detect the canal terminus. While

the simplest devices measure resistance,
other devices measure impedance using
one high frequency, two frequencies, or
more than two frequencies. In addition,

Figure 1: Endo EZE Quill Apex locator, Ultradent, USA

some systems use low frequency oscillation
and/or a voltage gradient method to detect
the canal terminus.

Many new electronic foramen locators
have become available, resulting in the
need to have their accuracies ascertained
and compared. Some techniques for
determining the endodontic working
length have been described and verified
scientifically, including the digital tactile
sensibility, methods based in radiographic
analysis, and electronic methods. The third
generation of apex locators are based on
analysis of relative impedance changes
over frequency, and preliminary published
studies indicated reliable and accurate
measurements of the position of apical
foramen. Despite being based on the same
third generation method of operation, the
different models to be tested differ as to the
number of frequencies used to calculate
the impedance variation. The current

study’s aim is to determine if the new
Endo-Eze Quill, Root ZX II, Root ZX mini,
and SybronEndo Mini present accurate
measurements of foramen position (canal
length) and intermediate positions to
calculate working length.

Volume 6 Number 2


Materials and methods
Selection of extracted teeth
This study was performed in accordance
with the guidelines issued by the
Department of Health, State of Paraná,
Brazil, and after approval by the State
University of Londrina’s Ethics in Research
Committee.

Figure 3: Cross section showing the placement of the file
in the specimen during the measurements and the distance measured (line AB) from the base of the file handle
to the top of the rubber stop

Recently extracted human maxillary
central incisors stored in 2.5% glutaraldehyde solution were used in this study.
After evaluating the canal shape with
mesiodistal and buccolingual radiograph
films, teeth with previous endodontic
treatment, complicated anatomy, external
root resorption, immature root, and apical

Visual determination of the actual
canal length
In order to determine a value corresponding
to actual canal length of the specimens, a
No. 10 K-File (Maillefer, Switzerland) was
introduced into the canal until the tip of the
file reached an imaginary line connecting
the edges of the foramen exit. The silicon
stop was lowered to the cemento-enamel

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Volume 6 Number 2

Endodontic practice 13

CLINICAL

Figure 2: A digital caliper (Mitutoyo, Japan) showing a
value corresponding to the actual length of the canal and
the electronic measurements of the canal. The measurements were taken from the top of the rubber stopper to
the base of the handle

foramen diameter up to 4.0X10-2 mm
were excluded, leaving 30 teeth to be used
for this study. The selected teeth were
immersed in 5.25% sodium hypochlorite
solution for 15 minutes. Calculus and soft
tissue debris were removed with a scaler,
and the teeth were washed thoroughly with
tap water. The teeth were then stored in
100% humidity at a temperature of 36ºC
until the tests were conducted.
All teeth specimens were cut
horizontally at the cemento-enamel junction
with a diamond disc (Extec® 12205, Extec
Corp.) mounted in a precision saw (IsoMet®
1000, Buehler Ltd). The canal orifice at the
cemento-enamel junction cut was used as
the reference point for all measurements.

CLINICAL
junction cut position. Using a digital caliper
(Mitutoyo, Japan), measurements were
made from the silicon stop to the base of
the handle (Figures 2 and 3). The same
methodology was used to determine the
electronic measurement’s values.
Electronic determination of the canal
length
After locating the canal opening
using an endodontic probe, the initial
instrumentation was made with a No.
10 or 15 K-File (Maillefer, Switzerland),
stopping approximately 3 mm short of the
temporary working length. In all cases,
instrumentation was made using the
crown-down technique. All specimens
were irrigated abundantly with 2.5%
sodium hypochlorite, and the excess liquid
was evacuated from the canal before any
electronic measurements were taken,
according to the device manufacturer’s
instructions.
(Alginplus®,
Alginate
Major,
Torino, Italy) was mixed following the
manufacturer’s instructions, and all of the
specimens were individually embedded in
alginate. Before electronic measurements

were taken, the teeth were removed from
the alginate to verify the regularity of the
reproduction and the absence of bubbles.
Within 2 hours after alginate preparation,
the root canal electronic measurements
were taken. Each specimen was tested
with the four devices by the same operator,
and the measurements were recorded.
The four devices: Endo-Eze Quill
(serial number F1, Figure 1); Root ZX mini,
(serial number ZJ062); Root ZX II (serial
number VA8025); and SybronEndo Mini,
(serial number SC3456) were set up with
the contrary electrode in the alginate and
the file electrode attached to the file to
be introduced into the canal. The devices
would determine the canal length from the
reference point to the “0” mark (foramen
position, 0.5, 1.0, 1.5, 2.0, 2.5, and 3.0), as
indicated on the devices. Although some
devices were designed to measure canal
lengths at varying distances from the apical
foramen, measurements to the “foramen”
mark were taken first and compared with
the actual length’s relative value in order
to standardize the procedure for the four
devices.
For the electronic measurements, a
K-File sized for the foramen’s anatomical
diameter was introduced gently towards

the radicular apical third, until the EndoEze Quill showed the green LED indication
14 Endodontic practice

Table 1: Mean and standard deviation of the distances between the electronic measurements at
point 0.0 (foramen exit) and actual length

Table 2: Mean of the distances and standard deviations (SD) between the points measured (point
0.0, 0.5, 1.0, 1.5, 2.0, 2.5, and 3.0) and actual lengths. NS means with no statistical difference
between the compared values (ANOVA). SS means statistical difference between groups

Table 3: Mean of the distances between the intermediate points measured (0.5, 1.0, 1.5, 2.0, 2.5,
and 3.0). NS means with no statistical difference between the compared values (ANOVA, p<0.05).
SS means statistical difference between groups. There were no differences among the devices
studied at 0.0, 0.5, and 1.0. At points 1.5 and 2.0, SybronEndo Mini showed statistical different
results comparing with the others

(0.0), the Root ZX mini and Root ZX
II showed the last green mark before
“APEX,” and the SybronEndo Mini showed
the green LED indication “APEX.” The
same procedure was performed two times
for each device. After the foramen position
measurements were taken, intermediate
point measurements were taken with
the four devices. Using a digital caliper
(Mitutoyo, Japan), measurements were
made between the silicon stop and the
base of the handle (Figures 2 and 3).

From

these
measurements,
calculations were made of the differences
between the relative values corresponding
to the actual canal lengths and the
electronic device’s measurements of the
canal lengths at the foramen position (0.0),
and the other positions of (0.5), (1.0), (1.5),

(2.0), (2.5), and (3.0). The statistical analysis
for each device was made from this data.

Results
Because the specimen sample size was
greater than 20, the Kolmogorov-Smirnov
nonparametric test was used to compare
the sample distribution. It was found that
the significance was 0.200, showing a
normal distribution of the results.
As the distribution was normal,
the ANOVA parametric test was used,
analyzing the data from the four devices.
The significance was 0.066, (p<0.05),
showing that there was no statistical
difference between the values found
comparing electronic measurements at the
point 0.0 (foramen positions) and canal’s
actual length. Intermediate points, from
Volume 6 Number 2

CLINICAL

0.5 to 3.0, showed statistical differences
between electronically measured points
and actual corresponding points in all
devices studied.

Table 1 shows the mean and standard
deviation of the distances between the
electronic measurement at point 0.0 of
each device and the actual length.
Table 2 shows the mean of the
distances between all points measured
(point 0.0, 0.5, 1.0, 1.5, 2.0, 2.5, and 3.0)
and relative actual length values. There
was no difference between all device’s
electronic measurements at point 0.0
and the actual root canal length (p<0.05).
Statistical analysis showed differences
(p<0.05) between all the intermediate
points electronically measured by all
devices tested and the actual intermediate
values.
Table 3 shows the mean of the
distances between intermediate points
measured using the tested devices (point
0.5, 1.0, 1.5, 2.0, 2.5, and 3.0). Comparing
results among the intermediate electronic
measurements of Endo-Eze Quill, Root ZX

mini, and Root ZX II showed there were
no statistical differences between the
results. Nevertheless, at points 1.5 and
2.0, SybronEndo Mini showed statistically
different results when compared with the
other devices.

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Conclusion
It was observed that no electronic
measurement of any of the devices used in
this study was beyond the real position of
the apical foramen, maintaining the apical
biological limit parameters. The results are
in agreement with studies that used similar
third-generation apex locators.
Comparing the electronic measurements at the foramen positions, indicated
by the four apex locators studied (EndoEze Quill, Root ZX mini, Root ZX II, and
SybronEndo Mini) with the actual root
canal’s lengths found no statistically
significant differences.
The intermediate points do not
appear to be accurate because they
showed statistically significant differences

as compared to the actual intermediate
points. These results are in agreement with
the Rambo, et al., study, which showed
that electronic apex locators are accurate
when used at the foramen reference point
only. EP

Volume 6 Number 2

References
1. Wu MK, Wesselink PR, Walton RE. Apical
terminus location of root canal treatment procedures.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod.
2000;89(1):99-103.
2. Rambo MV, Gamba HR, Ratzke AS, Schneider
FK, Maia JM, Ramos CA. In vivo determination
of the frequency response of the tooth root canal
impedance versus distance from the apical foramen.
Conf Proc IEEE Eng Med Biol Soc. 2007;570-573.
3. 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.
4. Ricucci D. Apical limit of root canal
instrumentation and obturation, part 1. Literature
review. Int Endod J. 1998;31(6):384-393.
5. Stein TJ, Corcoran JF. Radiographic “working
length” revisited. Oral Surg Oral Med Oral Pathol.
1992;74(6):796-800.
6. Nekoofar MH, Ghandi MM, Hayes SJ, Dummer
PM. The fundamental operating principles of

electronic root canal length measurement devices. Int
Endod J. 2006;39(8):595–609.
7. Carneiro E, Bramante CM, Picoli F, Letra
A, da Silva Neto UX, Menezes R. Accuracy of
root length determination using Tri Auto ZX and
ProTaper instruments: an in vitro study. J Endod.
2006;32(2):142-144.

8. Welk AR, Baumgartner JC, Marshall JG. An in
vivo comparison of two frequency-based electronic
apex locators. J Endod. 2003;29(8):497–500.
9. Ponce EH, Vilar Fernández JA. The cementodentino-canal junction, the apical foramen, and the
apical constriction: evaluation by optical microscopy.
J Endod. 2003;29(3):214–219.
10. Herrera M, Abalos C, Planas AJ, Llamas R.
Influence of apical constriction diameter on Root ZX
apex locator precision. J Endod. 2007;33(8):995–998.
11. Olson DG, Roberts S, Joyce AP, Collins DE,
McPherson JC III. Unevenness of the apical
constriction in human maxillary central incisors. J
Endod. 2008;34(2):157–159.
12. ElAyouti A, Lost C. A simple mounting model
for consistent determination of the accuracy
and repeatability of apex locators. Int Endod J.
2006;39(2):108–112.
13. Venturi M, Breschi L. A comparison between two
electronic apex locators: an ex vivo investigation. Int
Endod J. 2007;40(5):362-373.
14. Ounsi HF, Naaman A. In vitro evaluation of the
reliability of the Root ZX electronic apex locator. Int

Endod J. 1999;32(2):120-123.

Endodontic practice 15


CLINICAL

Long-term treatment of root fractures
Drs. Jozef Mincík and Marián Tulenko discuss the long-term treatment of root fractures with Rebilda Post
System

R

oot fractures must be regarded as a
form of complex trauma because they
affect both the dental hard tissue, and the
periodontal and pulpal tissue. They result
from powerful forces with compression
zones acting in the root region. The
consequence of fractures is that the
tooth is split into a coronal and an apical
fragment.
In regards to the level at which the
fracture occurs, a distinction is made
between fractures in the apical, middle,
and cervical third of the root. It is known
that young patients, in whom root growth is
not yet complete, have the best prospects
of the fracture healing.
Other factors that are favorable to

the healing process include a positive
sensitivity test at the time of the accident,
no dislocation, and no pronounced mobility
of the coronal fragment. In the absence of
dislocation, there is a danger of the fracture
not being detected, and therefore, imaging
at two levels is necessary for the purpose
of diagnosis (von Arx, Chappuis, Hänni,
2007).
The recommendation that a root
fracture should be treated with rigid
splinting for several months has long since
become obsolete. No positive effect on the
healing pattern in the region of the fracture
gap was demonstrated with splinting for
longer than 4 weeks (Cvek, Andreasen,
Borum, 2001).

The factors determining the choice of
treatment are the location of the fracture,

Dr. Jozef Mincík studied dentistry at the University of
Košice in Slovakia, and from 1980 to 1989 assisted
in the Department of Conservative Dentistry at the
1st Department of Stomatology Clinic of the Košice
University Hospital. He has had his own dental practice
in Košice since 1990, and has been head of the
Conservative Dentistry section of the Slovakian Dental
Association since 2000. His key areas of expertise
include esthetic-restorative dentistry, endodontics,

and dental traumatology. He is the author of numerous
publications and presentations on these subjects.
Dr. Marián Tulenko studied dentistry at the University
of Košice and has worked at Dr. Mincík’s practice
since 2008. He is a member of the Young Dentists
section of the Slovakian Dental Association, and in his
publications and presentations he specializes in the
areas of esthetic-restorative dentistry, endodontics, and
dental traumatology.

16 Endodontic practice

Figure 1: The radiograph shows the
root fractures of the upper right lateral
incisor (UR2) [root region], the maxillary central incisors (UR1, UR2) [apical
region], and the upper right lateral
incisor (UR2) after trepanation and
temporary restoration. The partially
erupted upper right canine (UR3) was
undamaged

Figure 2: Permanent root canal filling
of the upper right lateral incisor
(UR2). The maxillary central incisors
(UR1, UR2) are vital. No resorption is
recognizable at the fracture lines

Figure 3: External root resorption of
the coronal fragment of the upper left
central incisor (UL1) in the fracture

line

Figure 4: The permanent endodontic
treatment of the upper left central
incisor (UL1). External resorption
in the fracture line was diagnosed,
while the apical region was found to
be normal

Figure 5: Considerable healing of the
resorption of the fracture gap on the
upper left central incisor (UL1) 2 years
after endodontic treatment. External
resorption of the upper right central
incisor (UR1)

Figure 6: The radiograph taken after
the root canal filling on the upper right
central incisor (UR1)

the nature and degree of dislocation of
the coronal fragment, and the stage of
root growth. In the case of root fractures
located entirely in the intra-alveolar region,
the outcome is often favorable. With a
root fracture, only the coronal fragment
is treated as a rule because the apical
portion generally remains vital (Andreasen,
Hjorting-Hansen, 1967).

The specific case
In 1999, an 11-year-old patient came to
our practice after a bicycle accident. During
the intraoral examination, we found greatly
increased mobility of the upper right lateral
incisor (UR2) and less pronounced mobility
of the maxillary central incisors (UR1, UL1)

without dislocation. The teeth were treated
with a wire splint, which was adhesively
bonded to the labial surfaces. Two weeks
after the initial treatment, the percussion
test on the upper right lateral incisor (UR2)
was negative. At the same time, sensitivity
to percussion was detected. Following
trepanation and pulp extirpation, the tooth
was filled with calcium hydroxide (Figure 1).

Two months after the trepanation, a
permanent root canal filling was placed
in the upper right lateral incisor (UR2).
Incipient obliteration in the apical region,
a symptom that often accompanies root
fractures, prevented the apex being
reached (Figure 2).
At the patient’s regular visits to our
Volume 6 Number 2


CLINICAL

Figures 7A-7C: The coronal fragment of the upper right lateral incisor (UR2) is adhesively luted to the apical fragment with the aid of the composite post Rebilda Post (Voco)

Figure 8A: Resection of the apical fragment of the upper right lateral incisor (UR2)
and restoration of the bone defect with bone substitute material

INVENTIONS

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Figure 8B: Situation after resection of the upper right lateral incisor (UR2)

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Endodontic practice 17


CLINICAL

Figure 9: The latest

check-up in summer
2011: the fracture lines
on the maxillary central
incisors (UR1, UL2) have
become filled with hard
tissue. The periapical
process of the upper
right lateral incisor (UR2)
has healed fully

Figure 10: Palatal view of the affected teeth 12 years after
the accident

Figure 11: Labial view of the affected teeth 12 years after the accident

practice, the clinical and radiographic
check-ups revealed no pathological
changes up to 2008. However, 9 years after
the accident, the pulp test on the upper
left central incisor (UL1) was negative. The
radiograph shows an external inflammatory
root resorption of this tooth in the fracture
line (Figure 3).

Following a temporary calcium hydroxide dressing, a permanent restoration was
placed in the affected upper left central
incisor (UL1). The restoration extended
as far as the fracture line because the
apical region displayed no changes, and
therefore, was most probably vital, as is

typical with root fractures (Figure 4).

The next check-up was 2 years later.
The patient complained of discomfort at
the upper right central incisor (UR1). The
radiograph showed considerable healing
of the external resorption of the fracture
gap on the upper left central incisor (UL1);
however, on the other hand, we diagnosed
external resorption on the upper right
central incisor (UR1), similar to the upper
left central incisor (UL1) [Figure 5].

The upper right central incisor (UR1)
received endodontic treatment similar to
the upper left central incisor (UL1). The root
canal filling extended as far as the fracture
gap (Figure 6).
This check-up revealed a periapical
process on the upper right lateral incisor
(UR2), which was not filled up to the apex

because of an obliteration. In our opinion,
the infection extended to the periapex,
and therefore to the fracture line via the
gingival sulcus. Consequently, we decided
to secure both fragments of the tooth
with the aid of the glass fiber-reinforced
composite post Rebilda Post (Voco) and to
seal the gap with composite. In this way, it

was possible to save the tooth. We use the
fiber-reinforced composite (FRC) Rebilda
Post because this system has proven
very successful in our experience. One
of the benefits of this post is that it has a
modulus of elasticity similar to that of the
tooth. In this particular case, securing the
fragments assists the treatment of the root
fracture, and the adhesive luting creates a
barrier against ingress of bacteria into the
periodontium (Figures 7A-C).
Subsequently,
we
treated
the
periapical process surgically by performing
a resection and retrograde restoration.
We restored the bone defect with bone
substitute material (Figures 8A and 8B).

The latest check-up in June 2011, 12
years after the accident, shows formation
of new bone in both fracture lines following
the endodontic treatment. Furthermore,
the radiograph confirms that the periapical
process of the upper right lateral incisor
(UR2) has healed following the resection
(Figure 9).
Thanks to this treatment, the teeth
are fully functional in spite of root fractures.

18 Endodontic practice

With the exception of the discoloration on
the upper right lateral and upper left central
incisors (UR2, UL1), the patient has been
free of all symptoms for 12 years after the
accident (Figures 10 and 11).

Conclusion
Our experience confirms that the prognosis
for root fractures is very good in most
cases. This may be linked to the fact that,
in comparison with apical interruption of the
blood supply, the revascularization area is
large, and the distances to be bridged are
small.
As mentioned at the beginning, the
treatment is determined by the location
of the fracture, the nature and degree of
dislocation of the coronal fragment, and
the stage of root growth. EP

References
Andreasen JO, Hjorting-Hansen E. Intraalveolar root
fractures: radiographic and histologic Study of 50
cases. J Oral Surg. 1967;25:414-426.
von Arx T, Chappuis V, Hänni S. Verletzungen
der bleibenden zähne - teil 3: therapie der
wurzelfrakturen. Schweiz Monatsschr Zahnmed.

2007;117(2):135-144.
Cvek M, Andreasen JO, Borum MK. Healing of 208
intra-alveolar root fractures in patients aged 7-17
years. Dent Traumatol. 2001;17:53-62.

Volume 6 Number 2