Contemporary Endodontics

Contemporary Endodontics
Preface
Frederic Barnett, DMD

Guest Editor
The focus of this issue is on contemporary clinical endodontics. As there have been
several fundamental changes in the specialty of endodontics over the last years, the
purpose of this issue is to inform our dental colleagues about these changes. Each
article offers realistic information, most of which can be put to immediate use in clinical
practice. As such, the clinician will benefit directly from the up-to-date information in
this issue.
The authors include leading national and international authorities in their field. A
broad and diversified range of topics has been chosen for this issue. The topics range
from advanced techniques for detecting bone lesions, anesthesia for the hot tooth,
contemporary access designs, root filling with resin materials, access restoration,
and endodontic surgery. Additionally, an article on the endodontic–implant decision
tree has been included.
I would like to thank the authors for generously contributing their knowledge,
passion, and expertise to this issue. It is my hope that reading this issue of Dental
Clinics of North America will enhance the level of skill and understanding of endodon-
tics for our dental colleagues.
Frederic Barnett, DMD

IB Bender Division of Endodontics
Albert Einstein Medical Center
Philadelphia, PA, USA
E-mail address:
barnettf@einstein.edu
Dent Clin N Am 54 (2010) xi

doi:10.1016/j.cden.2010.01.004 dental.theclinics.com
0011-8532/10/$ – see front matter ª 2010 Elsevier Inc. All rights reserved.
The Use of the
Operating
M i c ro s c o p e i n
Endodontics
a,b,c,d, a,e,f,g
Gary B. Carr, DDS *, Carlos A.F. Murgel, DDS, PhD
KEYWORDS
Operating microscope Magnification Endodontics
Endodontists have frequently boasted that they can do much of their work blindfolded
simply because there is ‘‘nothing to see.’’ The truth is that there is a great deal to see
with the right tools.1
In the last 15 years, for nonsurgical and surgical endodontics, there has been an
explosion in the development of new technologies, instruments, and materials. These
developments have improved the precision with which endodontics is performed.
These advances have enabled clinicians to complete procedures that were once
considered impossible or that could be performed only by talented or lucky clinicians.
The most important revolution has been the introduction and widespread adoption of
the operating microscope (OM).
OMs have been used for decades in other medical disciplines: ophthalmology,
neurosurgery, reconstructive surgery, otorhinolaryngology, and vascular surgery. Its
introduction into dentistry in the last 15 years, particularly in endodontics, has revolu-
tionized how endodontics is practiced worldwide.
Until recently, endodontic therapy was performed using tactile sensitivity, and the
only way to see inside the root canal system was to take a radiograph. Performing
a
Pacific Endodontic Research Foundation, 6235 Lusk Boulevard, San Diego, CA 92121, USA
b
Department of Endodontics, University of Texas Health Science Center, 7703 Floyd Curl Drive,
San Antonio, TX 78229, USA
c
Department of Endodontics, University of Southern California, 925 West 34th Street,
Los Angeles, CA 90089-0641, USA
d
Private Practice, San Diego, CA 92121, USA
e
Brazilian Micro Dentistry Association, Brazil
f
Department of Endodontics and Microdentistry, Campinas Dental Association, Rua Francisco
Bueno de Lacerda 30, Pq. Italia, Campinas - SP 13030-900, Brazil
g
Private Practice, Rua Dr Sampaio Peixoto, 206, Campinas, SP, Cep 13024-420, Brazil
* Corresponding author. Pacific Endodontic Research Foundation, 6235 Lusk Boulevard, San
Diego, CA 92121.
E-mail address: gary@tdo4endo.com
Dent Clin N Am 54 (2010) 191–214

0011-8532/10/$ – see front matter ª 2010 Published by Elsevier Inc.
192 Carr & Murgel
endodontic therapy entailed ‘‘working blind,’’ that is, most of the effort was taken
using only tactile skills with minimum visual information available. Before the OM,
the presence of a problem (a ledge, a perforation, a blockage, a broken instrument)
was only ‘‘felt,’’ and the clinical management of the problem was never predictable
and depended on happenstance. Most endodontic procedures occurred in a visual
void, which placed a premium on the doctor’s tactile dexterity, mental imaging, and
perseverance.
The OM has changed both nonsurgical and surgical endodontics. In nonsurgical
endodontics, every challenge existing in the straight portion of the root canal system,
even if located in the most apical part, can be easily seen and competently managed
under the OM. In surgical endodontics, it is possible to carefully examine the apical
segment of the root end and perform an apical resection of the root without an exag-
gerated bevel, thereby making class I cavity preparations along the longitudinal axis of
the root easy to perform.
This article provides basic information on how an OM is used in clinical endodontic
practice and an overview of its clinical and surgical applications.
ON THE RELATIVE SIZE OF THINGS
It is difficult, even for a scientist, to have an intuitive understanding of size. Specifically,

a dentist must have an accurate understanding of the relationship between the gross
dimensions involved in restorative procedures and the dimensions of deleterious
elements that cause restoration failure, such as bacteria, open margins, and imperfec-
tion in restorative materials. A filling or a crown may appear well placed, but if bacteria
can leak through the junction between the tooth and the restorative material, then
treatment is compromised.
A brief review of relative size may be helpful. Cell size is measured in microns
(millionths of a meter, mm), and a single bacterial cell is about 1 mm in diameter.
One cubic inch of bacteria can hold about a billion cells. A typical human (eukaryotic)
cell is 25 mm in diameter, so an average cell can hold more than 10,000 bacteria. By
comparison, viruses are so small that thousands can fit within a single bacterial cell.
Simple calculations show that 1 in3 can contain millions of billions of viruses.These
calculations do not end there. For example, the size of macromolecules (eg, bacterial
toxins) is measured in nanometers, or one-billionth of a meter (Fig. 1).
Some of these bacterial toxins are so potent that even nanogram quantities can
cause serious complications and even death. Clearly, dentists are at a severe disad-
vantage in their attempts to replace natural tooth structure with artificial materials that
do not leak, in view of the virtually invisible microbiologic threats to restoration
integrity.2
THE LIMITS OF HUMAN VISION
Webster defines resolution as the ability of an optical system to make clear and distin-
guishable 2 separate entities. Although clinicians have routinely strived to create
bacteria-free seals, the resolving power of the unaided human eye is only 0.2 mm.
Most people who view 2 points closer than 0.2 mm will see only 1 point. For example,
Fig. 2 shows an image of a dollar bill. The lines making up George Washington’s face
are 0.2mm apart. If the bill is held close enough, one can probably just barely make out
the separation between these lines. If they were any closer together, you would not be
able to discern that they were separate lines. The square boxes behind Washington’s
head are 0.1 mm apart and not discernible as separate boxes by most people. The
The Use of the Operating Microscope in Endodontics 193
Fig. 1. (A) Bacterial blebbing from gram-negative biofilm bacteria. (B) Membrane-enclosed
bleb. (C) Higher magnification of bleb. (From Carr GB, Schwartz RS, Schaudinn C, et al. Ultra-
structural examination of failed molar retreatment with secondary apical periodontitis: an
examination of endodontic biofilms in an endodontic retreatment failure. J Endod
2009;35(9):1303–9; with permission.) (Pacific Endodontic Research Foundation.)
boxes are beyond the resolving power of the unaided human eye. For the sake of
comparison, it would take about 100 bacteria to span that square. Clinically, most
dental practitioners will not be able to see an open margin smaller than 0.2 mm.
The film thickness of most crown and bridge cements is 25 mm (0.025 mm), well
beyond the resolving power of the naked eye.
Fig. 2. A dollar bill without magnification. Note that the lines that make George Washing-
ton’s face cannot be seen in detail.
194 Carr & Murgel
Optical aids (eg, loupes, OMs, surgical headlamps, fiberoptic handpiece lights) can
improve resolution by many orders of magnitude. For example, a common OM can
raise the resolving limit from 0.2 mm to 0.006 mm (6 mm), a dramatic improvement.
Fig. 3 shows the improvement in resolution obtained by the standard OM used in
dentistry today. A clinical example is that at the highest power a restoration margin
opening of only 0.006 mm is essentially sealed and this is beyond the common cement
thickness film used in restorative dentistry.
WHY ENHANCED VISION IS NECESSARY IN DENTISTRY
Any device that enhances or improves a clinician’s resolving power is extremely bene-
ficial in producing precision dentistry. Restorative dentists, periodontists, and
endodontists routinely perform procedures requiring resolution well beyond the 0.2-
mm limit of human sight. Crown margins, scaling procedures, incisions, root canal
location, caries removal, furcation and perforation repair, postplacement or removal,
and bone- and soft-tissue grafting procedures are only a few of the procedures that
demand tolerances well beyond the 0.2-mm limit.
OPTICAL PRINCIPLES
Because all clinicians must construct 3-dimensional structures in a patient’s mouth,

stereopsis, or 3-dimensional perception, is critical to achieving precision dentistry.
Dentists appreciate that the human mouth is a small space to operate in, especially
considering the size of the available instruments (eg, burs, handpieces) and the
comparatively large size of the operator’s hands. Attempts have been made to use
the magnifying endoscopes used in artroscopic procedures, but these devices require
viewing on a 2-dimensional (2D) monitor, and the limitations of working in 2D space
are too restrictive to be useful.
Several elements are important for consideration in improving clinical visualization.
Included are factors such as
Stereopsis
Magnification range
Depth of field
Resolving power
Working distance
Spherical and chromatic distortion (ie, aberration)
Ergonomics
Eyestrain
Head and neck fatigue
Cost.
Dentists can increase their resolving ability without using any supplemental device
by simply moving closer to the object of observation. This movement is accomplished
in dentistry by raising the patient up in the dental chair to be closer to the operator or
by the operator bending down to be closer to the patient.2 This method is limited,
however, by the eye’s ability to refocus at the diminished distance.
Most people cannot refocus at distances closer than 10 to 12 cm. Furthermore, as
the eye-subject distance (ie, focal length) decreases, the eyes must converge,
creating eyestrain. As one ages, the ability to focus at closer distances is compro-
mised. This phenomenon is called presbyopia and is caused by the lens of the eye
losing flexibility with age. The eye (lens) becomes unable to accommodate and
Fig. 3. Different magnifications of a dollar bill as seen through an OM. (A) Magnification 3.
(B) Magnification 5. (C) Magnification 8. (D) Magnification 10. (E) Magnification 18.
196 Carr & Murgel
produce clear images of near objects. The nearest point that the eye can accurately
focus on exceeds ideal working distance.3
As the focal distance decreases, depth of field decreases. Considering the
problem of the uncomfortable proximity of the practitioner’s face to the patient,
moving closer to the patient is not a satisfactory solution for increasing a clinician’s
resolution. Alternatively, image size and resolving power can be increased by using
lenses for magnification, with no need for the position of the object or the operator to
change.
LOUPES
Magnifying loupes were developed to address the problem of proximity, decreased

depth of field, and eyestrain occasioned by moving closer to the subject. (Depth of
field is the ability of the lens system to focus on objects that are near or far without
having to change the loupe position. As magnification increases, depth of field
decreases. Also, the smaller the field of view, the shallower the depth of field. For
a loupe of magnification 2, the depth of field is approximately 5 in [12.5 cm]; for
a loupe of magnification 3.25, it is 2 in [6 cm]; and for a loupe of magnification
4.5, it is 1 in [2.5 cm].)
Loupes are classified by the optical method by which they produce magnification.
There are 3 types of binocular magnifying loupes: (1) a diopter, flat-plane, single-
lens loupe, (2) a surgical telescope with a Galilean system configuration (2-lens
system), and (3) a surgical telescope with a Keplerian system configuration (prism-
roof design that folds the path of light).
The diopter system relies on a simple magnifying lens. The degree of magnification
is usually measured in diopters. One diopter (D) means that a ray of light that would be
focused at infinity would now be focused at 1 meter (100 cm or 40 in). A lens with 2 D
designation would focus light at 50 cm (19 in); a 5 D lens would focus light at 20 cm (8
in). Confusion occurs when a diopter single-lens magnifying system is described as 5
D. This designation does not mean 5 power (ie, 5 times the image size). Rather, it
signifies that the focusing distance between the eye and the object is 20 cm (<8 in),
with an increased image size of approximate magnification 2 (2 times actual size).
The only advantage of the diopter system is that it is the most inexpensive system.
But it is less desirable because the plastic lenses that it uses are not always optically
correct. Furthermore, the increased image size depends on being closer to the viewed
object, which can compromise posture and create stresses and abnormalities in the
musculoskeletal system.3
The surgical telescope of either the Galilean or the Keplerian design produces an
enlarged viewing image with a multiple-lens system that is positioned at a working
distance between 11 and 20 in (28–51 cm). The most used and suggested working
distance is between 11 and 15 in (28–38 cm).
The Galilean system provides a magnification range from 2 to 4.5 and is a small,
light, and compact system (Fig. 4).
The prism loupes (Keplarian system) use refractive prisms and are actually tele-
scopes with complicated light paths, which provide magnifications up to 6 (Fig. 5).
Both systems produce superior magnification and correct spherical and chromatic
aberrations, have excellent depth of field, and are capable of increased focal length
(30–45 cm), thereby reducing eyestrain and head and neck fatigue. These loupes offer
significant advantages over simple magnification eyeglasses.
The disadvantage of loupes is that the practical maximum magnification is only about
4.5. Loupes with higher magnification are available, but they are heavy and unwieldy,
Fig. 4. An example of a Galilean system. (Courtesy of Designs for Visions, Inc, Ronkonkoma,
NY, USA.)
with a limited field of view. Using computerized techniques, some manufacturers can
provide magnifications from 2.5 to 6 with an expanded field. Nevertheless, such
loupes require a constrained physical posture and cannot be worn for long periods of
time without producing significant head, neck, and back strain.
Fig. 5. An example of a Galilean system. (A) Prism loupes. These loupes have sophisticated
optics, which rely on internal prisms to bend the light. (Courtesy of Designs for Visions, Inc,
Ronkonkoma, NY, USA.) (B) Headset and prism loupes. (Courtesy of Carl Zeiss, Inc, Germany.)
198 Carr & Murgel
THE PROBLEM OF LIGHT
By increasing light levels, one can increase apparent resolution (the ability to distin-
guish 2 objects close to each other as separate and distinct). Light intensity is deter-
mined by the inverse square law, which states that the amount of light received from
a source is inversely proportional to the square of the distance. For example, if the
distance between the source of light and the subject is decreased by half, the amount
of light at the subject increases 4 times. Based on the law, therefore, most standard
dental operatory lights are too far away to provide the adequate light levels required
for many dental procedures.
Surgical headlamps have a much shorter working distance (13 in or 35 cm) and use
fiberoptic cables to transmit light, thereby reducing heat to minimal levels. Another
advantage is that the fiberoptic cable is attached to the doctor’s headband so that
any head movement moves the light accordingly. Surgical headlamps can increase
light levels up to 4 times that of conventional dental lights (Fig. 6).
THE OM IN ENDODONTICS
Apotheker introduced the dental OM in 1981.1 The first OM was poorly configured and
ergonomically difficult to use. It was capable of only 1 magnification (8), was posi-
tioned on a floor stand and poorly balanced, had only straight binoculars, and had
a fixed focal length of 250 mm. This OM used angled illumination instead of confocal
illumination. It did not gain wide acceptance, and the manufacturer ceased
Fig. 6. Surgical headlight and loupes. Together, these devices can greatly increase a clini-
cian’s resolution. (Courtesy of Designs for Visions, Inc, Ronkonkoma, NY, USA.)
manufacturing it shortly after its introduction.4 Its market failure was more a function of
its poor ergonomic design than its optical properties, which were actually good.
Howard Selden5 was the first endodontist to publish an article on the use of the OM
in endodontics. He discussed its use in the conventional treatment of a tooth, not in
surgical endodontics.
In 1999, Gary Carr6,7 introduced an OM that had Galilean optics and that was ergo-
nomically configured for dentistry, with several advantages that allowed for easy use
of the scope for nearly all endodontic and restorative procedures. This OM had
a magnification changer that allowed for 5 discrete magnifications (magnification
3.5–30), had a stable mounting on either the wall or ceiling, had angled binoculars
allowing for sit-down dentistry, and was configured with adapters for an assistant’s
scope and video or 35-mm cameras (Fig. 7).
It used a confocal illumination module so that the light path was in the same optical
path as the visual path, and this arrangement gave far superior illumination than the
angled light path of the earlier scope. This OM gained rapid acceptance within the
endodontic community, and is now the instrument of choice not only for endodontics
but for periodontics and restorative dentistry as well. The optical principles of the
dental OM are seen in Fig. 8.
The efficient use of the OM requires advanced training. Many endodontic procedures
are performed at magnification 10 to 15, and some require a magnification as high as
30. Operating comfortably at these magnifications requires accommodation to new
skills that were not taught until recently in dental schools. Among other things, working
at these higher-power magnifications brings the clinician into the realm where even
slight hand movements are disruptive, and physiologic hand tremor is a problem.
In 1995, the American Association of Endodontists formally recommended to the
Commission on Dental Accreditation of the American Dental Association that micros-
copy training be included in the new Accreditation Standards for Advanced Specialty
Education Programs in Endodontics. At the commission’s meeting in January 1996,
the proposal was agreed on, and in January 1997, the new standards, making micros-
copy training mandatory, became effective.8
EFFICIENT USE OF AN OM IN ENDODONTICS
Although the OM is now recognized as a powerful adjunct in endodontics, it has not

been adopted universally by all endodontists. It is seen by many endodontists as
simply another tool and not as a way of practice that defines how an endodontist
works. Although cost is frequently cited as the major impediment, in truth, it is not
Fig. 7. Today’s OM allows the doctor and the assistant to ergonomically view the same field.
This OM is fitted with a 3CCD (charge coupled device) video camera and an assistant scope.
200 Carr & Murgel
Fig. 8. Galilean optics. Parallel optics enables the observer to focus at infinity, relieving
eyestrain.
cost but a failure to understand and implement the positional and ergonomic skills
necessary to effectively use an OM. This failure has restricted its universal use in all
endodontic cases.
The occasional or intermittent use of an OM on a patient results in the inefficient use
of a clinician’s time. It represents a disruption in the flow of treatment of the patient,
which can only negatively affect the final result. Clinicians who practice this way
seldom realize the full advantage of a microscopic approach and never develop the
visual and ergonomic skills necessary to operate at the highest level.
The skillful use of an OM entails its use for the entire procedure from start to finish.
Working in such a way depends on refinement of ergonomic and visual skills to a high
level.
THE LAWS OF ERGONOMICS
An understanding of efficient workflow using an OM entails knowledge of the basics of

ergonomic motion. Ergonomic motion is divided into 5 classes of motion:
Class I motion: moving only the fingers (Fig. 9)

Class II motion: moving only the fingers and wrists (Fig. 10)
Class III motion: movement originating from the elbow (Fig. 11)
Class IV motion: movement originating from the shoulder (Fig. 12)
Class V motion: movement that involves twisting or bending at the waist.
Fig. 9. (A) Fingers waiting for the file. (B) File placed in between fingers. (C) Fingers capturing
file.
Fig. 10. (A) Hand waiting for the instrument. (B) Fingers and wrist movement receiving the
instrument. (C) Fingers movement receiving the instrument.
Fig. 11. (A) Elbow rested at the stool support. (B) Supported elbow rotation and instrument
apprehension. (C) Supported elbow rotation to working position.
Fig. 12. (A) Professional at the neutral position. (B) Shoulders, arms, elbows, and hands
moving to reach the OM. (C) OM moved to the ideal position without rotational movement
of the waist.
202 Carr & Murgel
No clinical example of the Class V motion movement is shown because this move-
ment is the most prejudicial of all (unfortunately, this is the most common movement
used by dentists and dental assistants with or without the OM).
POSITIONING THE OM
The introduction of the OM in a dental office requires significant forethought, planning,

and an understanding of the required ergonomic skills necessary to use the OM effi-
ciently. Proper positioning for the clinician, patient, and assistant is absolutely neces-
sary. Most problems in using an OM in a clinical setting are related to either positioning
errors or lack of ergonomic skills in the clinician. If proper ergonomic guidelines are
followed, it is possible to work with the OM in complete comfort with little or no muscle
tension.
In chronologic order, the preparation of the OM involves the following maneuvers:
Operator positioning
Rough positioning of the patient
Positioning of the OM and focusing
Adjustment of the interpupillary distance
Fine positioning of the patient
Parfocal adjustment
Fine focus adjustment
Assistant scope adjustment.
OPERATOR POSITIONING
The correct operator position for nearly all endodontic procedures is directly behind
the patient, at the 11- or 12-o’clock position. Positions other than the 11- or 12-o’clock
position (eg, 9-o’clock position) may seem more comfortable when first learning to use
an OM, but as greater skills are acquired, changing to other positions rarely serves any
purpose. Clinicians who constantly change their positions around the scope are
extremely inefficient in their procedures.
The operator should adjust the seating position so that the hips are 90 to the floor,
the knees are 90 to the hips, and the forearms are 90 to the upper arms.9 The oper-
ator’s forearms should lie comfortably on the armrest of the operator’s chair, and feet
should be placed flat on the floor. The back should be in a neutral position, erect and
perpendicular to the floor, with the natural lordosis of the back being supported by the
lumbar support of the chair. The eyepiece is inclined so that the head and neck are
held at an angle that can be comfortably sustained. This position is maintained re-
gardless of the arch or quadrant being worked on. The patient is moved to accom-
modate this position. After the patient has been positioned correctly, the armrests
of the doctor’s and assistant’s chairs are adjusted so that the hands can be comfort-
ably placed at the level of the patient’s mouth. The trapezius, sternocleidomastoid,
and erector spinae muscles of the neck and back are completely at rest in this
position.
Once the ideal position is established, the operator places the OM on one of the
lower magnifications to locate the working area in its proper angle of orientation.
The image is focused and stepped up to higher magnifications if desired.10
Fig. 13. Examples of traditional operatory designs with large side cabinets, sinks, and so
forth. A design such as this makes efficient OM use problematic.
OPERATORY DESIGN PRINCIPLES FOR USING OM
The OM was originally introduced into standard dental operatories that have been
designed in the conventional way, with outdated ergonomic concepts using the tradi-
tional operatory side cabinets, dual sinks, over-the-patient delivery systems, and so
forth. This historical design turned out to be extremely inefficient because of the ergo-
nomic constraints imposed by the way the OM is actually used in endodontic proce-
dures. There is an ergonomic flow to using an OM efficiently, and careful operatory
design is critical in enabling this flow. One of the main reasons clinicians struggle
with using the OM for all procedures is that the ergonomic design of the operatory
prohibits it. Clinicians who attempt to use the OM for all procedures but do not
have appropriate ergonomic designs to their operatories experience significant frus-
trations (Fig. 13).
The organizing design principle using the OM in the dental operatory should revolve
around an ergonomic principle called circle of influence (Fig. 14). The principle posits
that all instruments and equipment needed for a procedure are within reach of either
the clinician or the assistant, requiring no more than a class IV motion, and that most
endodontic procedures are performed with class I or class II motions only (Fig. 15).
The principle assumes that the most ergonomic way to work is to perform all proce-
dures under the OM, including the diagnostic examination, oral cancer screening,
anesthesia, and rubber dam placement.
Therefore, the circle of influence design principle places the OM at the center of the
operatory design, and all the ergonomic movements necessary to work with this tech-
nology are centered within those circles. Simplicity and efficiency are the guiding prin-
ciples of this innovative design. This innovative concept allows for the constant
evolution of the operatory design while maintaining its ergonomic parameters and
permitting the incorporation of new technologies as they become available.
Fig. 14. The circle of influence design takes into consideration the 3 participants of the
dental team: doctor, assistant, and patient. Maximum ergonomics, efficiency, and comfort
for all members are achieved with this office design.
204 Carr & Murgel
Fig. 15. The circle of influence principle can be implemented into private practice (A) and in
the academic environment (B) (Einstein Medical Center, Philadelphia, PA, USA).
The design has been improved to make it even simpler to implement and less
expensive by adopting off-shelf solutions from IKEA (PA, USA). This design is
extremely valuable, especially because of its availability and ease of setup. In a few
hours, one can construct an ideal OM operatory back wall using all the circle of influ-
ence design principles for a fraction of the cost of a traditional operatory with custom
cabinets (Fig. 16).
Fig. 16. (A) The circle of influence design concept using different IKEA cabinets. Note how
spacious and clean this design is, in contrast to traditional ones. The key elements here are
rear-mounted or ceiling mounted OM, cart, back wall, assistant table, stool with arm
support, computer integration, and rotational chair. (B) Ease of construction using modular
design principles. (C) Efficient IKEA delivery cabinets.
Fig. 17. (A) Team work development: doctor and assistant working erect and muscularly
relaxed. (B) Adjustable cart allowing access to all instruments, using only a class III motion.
KEY ELEMENTS OF THE NEW DESIGN
This new design assumes a teamwork approach to the delivery of endodontic care.
The doctor and assistant are placed at the scope in upright and comfortable positions
(Fig. 17A). The scope is positioned so that the doctor and the assistant are muscularly
at rest through all treatment phases (see Fig. 17A). This configuration places some
constraints on the design of the back wall and on the cart systems used. Computers,
scanners, digital radiographs, and monitors are ergonomically placed according to the
circle of influence principle and are easily reached by either the doctor or the assistant
with only class III motions (Fig. 17B). The cart must be easily movable and adjustable
and at the correct height to be ergonomically positioned (see Fig. 17B).
The dental chair is freely rotatable with the doctor’s legs, so that the patient, not the
OM, is moved when a field of view needs to be changed. Patient movement, and not
OM movement, is a paradigm shift in understanding how to use an OM efficiently. The
small rotational movement of the dental chair should be done using the practitioner’s
legs and not hands (Fig. 18). This simple principle can change the way one practices.
In this position, the patient faces the ceiling, and the practitioner works around at the
11-o’clock position for nearly every procedure. Doctor and assistant stools with arm
support are critical (Fig. 19). Because fine motor skills are necessary to work under
Fig. 18. (A) Small movement of the chair to the left (note that patient’s head is tilted a little
to the left). (B) If necessary, the patient’s head is moved slightly to the right to compensate
chair movement (note that the OM was not touched at any time).
206 Carr & Murgel
Fig. 19. Elbow support for doctor and assistant is mandatory to allow the necessary fine
motor skills under constant magnification and muscular comfort throughout the day.
constant magnification, it is mandatory that both members have adequate elbow and
arm support. Without either support, fine motor skills with either hand become more
problematic for the practitioner and for the dental assistant (Fig. 20).
THE OM AND CLINICAL PROCEDURES
The efficient use of an OM for all clinical procedures requires not only ergonomic
sophistication but also special clinical skills that are not required in nonmicroscopic
endodontics. When one tries to use conventional concepts with magnification, frustra-
tion and inefficiency are the usual results (Fig. 21). Specifically, in microendodontics,
the use of specialized micromirrors vastly improves efficiency and capability (Fig. 22).
The skills needed to manipulate much smaller mirrors at higher magnification are
easily acquired by dentists, but not without some effort. The use of smaller mirrors
results in the mirror being placed further away from its usual location, and even minor
hand movements can make such use frustrating for the novice (Fig. 23). Proper ergo-
nomic form and a well-trained assistant can mitigate some of this frustration, but it
takes practice and repetition to master the skills required (Fig. 24).
Removing canal or pulp chamber obstructions is also greatly facilitated by the use of
an OM. Even obstructions such as separated instruments deep within canals can be
addressed, given the proper training and level of persistence. Examining fractures,
Fig. 20. A simple exchange of instruments demands fine motor skills once the doctor and
assistant are going to ideally use class I, II, and III movements (note how the doctor’s hands
does not leave the reference point at patient’s cheek).
207
Fig. 21. Image with intermediate magnification (6) of access on tooth No.15. Nothing is
seen besides the high-speed head and parts of the tooth. Such image when using the
OM, causes frustration and introduces inefficiency and significant clinical impairment.
Fig. 22. (A) A selection of flexible mirrors in different sizes and shapes. (B) Detail of highly
reflective mirrors with flexible and flat shafts. (Courtesy of EIE2, San Diego, USA.)
Fig. 23. (A) Inadequate level of magnification and mirror position. (B) Adequate magnifica-
tion to position mirror. (C) Adequate mirror position. Notice the flex of the mirror staff. (D)
Adequate magnification level with clear view of the operatory field.
208 Carr & Murgel
Fig. 24. (A) The use of smaller mirrors positioned further away. Adequate level of magnifi-
cation and mirror position. (B–E) Higher magnifications of occlusal surface. (F) Clear view of
occlusal surface ready to initiate clinical work with high speed and suction well position.
Fig. 25. Clinical diagnosis of prosthetic margins. (A) Low magnification of crown on tooth
No. 2. (B) Intermediary magnification of crown margin. (C) High magnification of crown
margin.
Fig. 26. Clinical diagnosis of cracks. (A) Intermediary magnification of occlusal surface of
tooth No. 2. (B) Higher magnification showing cracks on distal area.
Fig. 27. Clinical diagnosis of caries. (A) Intermediary magnification of occlusal surface on
tooth No. 14. (B) Higher magnification showing gross microleakage and an open margin
on cervical area.
Fig. 28. (A) Intermediary magnification of endodontic access on tooth No. 15 (note there is
no sign of canals). (B) Dentin smear resulted from ultrasonic instrumentation (Pearl dia-
mond, EIE2 Excellence in Endodontics, GBC Innovations, Inc, San Diego, CA, USA) of pulp
floor. (C) Groove produced after ultrasonic usage. (D) Mesiobuccal (MB) and second MB
(MB2) canals located after ultrasonic usage. (E) Files inserted on MB and MB2 canals.
210 Carr & Murgel
Fig. 29. (A) Preoperative radiograph of teeth Nos. 13, 14 and 15 showing inadequate
previous root canal treatment (teeth 14 and 15) with incomplete shaping and obturation
of the root canal system. (B) Intermediary magnification of 06 file at MB2. (C) Higher magni-
fication showing MB and MB2, cleaned and shaped. (D) Immediately postoperation. (E, F)
Long-term recall.
crown margins, cement layers, subgingival defects, and caries extension are all
enhanced by a microscopic approach.
To discuss the uses of the OM in endodontics is beyond the scope of this article, but
several examples of its use serve to illustrate its permanent place in endodontics.
Fig. 30. Intermediate magnification of tooth No. 2 with an extra distal lingual canal (white
spot dehydrated with air).
Fig. 31. Intermediate magnification of tooth No. 3 with an MB2 canal way under the mesial
ridge.
212 Carr & Murgel
Fig. 32. (A) Preoperative radiograph of tooth No. 18 showing the presence of chronic apical
periodontitis, but no sign of aberrant anatomy. (B) Low magnification of mesial canals,
cleaned and shaped. (C) Higher magnification showing extra mesial lingual canal (arrow).
(D) Low magnification of mesial lingual canal, cleaned and shaped. (E) Immediate postop-
erative radiograph, (F) Immediate postoperative inverted radiograph.
Clinical Diagnosis
In endodontics, clinical diagnosis has a greater need for enhanced vision. With the
advent of implant dentistry, a more accurate diagnosis is necessary to select only
viable and long-lasting teeth that will withstand the test of time (Figs. 25–27).
Fig. 33. (A) Regular and retro mirror comparison. (B) Apical exploration after root resection.
(C, D) Microsurgery technique. (E) Ultrasonic retro preparation. (F) Retro preparation filled.
(G) Immediately postoperation. (H) Long-term recall.
Fig. 34. (A) Before operation. (B) Ultrasonic root preparation with moderated bevel, (C) Mi-
cromirror view of retropreparation, (D) Immediately postoperation. (E) 5-year recall. (F) 10-
year recall.
Locating Canals
Locating canals is perhaps the most obvious use of the OM in endodontics. Calcified
canals (Fig. 28), missed canals (Fig. 29), aberrant canals (Figs. 30–32), dilacerated
canals, and canals blocked by restorative materials are all addressed easily by the
skillful use of an OM.
Operators quickly learn the visual skills necessary to distinguish dentin from calci-
fied pulp, relying on changes in color, translucency, and refractive indexes to identify
remnants of pulpal tissues. Such searches have historically resulted in perforations or
gross destruction of tooth structure, but with the advent of the OM, such misadven-
tures are uncommon.
Surgical Endodontics
Modern endodontic surgical procedures demand a microscopic approach. Use of the
smaller retro mirrors allow for a more moderated bevel of the root resection and permit
a coaxial ultrasonic preparation into the root (Figs. 33 and 34).6
Surgical soft-tissue management is also greatly enhanced by a microscopic
approach, leading to faster healing, less traumatic soft-tissue management, and the
advent of microsurgical suturing techniques that minimize trauma and lead to rapid,
primary intention wound healing (Fig. 35).
These are only a few of the endodontic applications of a microscopic approach, but
there are others such as lateral root repairs, perforation repairs, external cervical
Fig. 35. (A) Immediately postoperation. (B) 48 hours postoperation. (C) 21 days postopera-
tion. Incision scar barely visible.
214 Carr & Murgel
invasive resorption repairs, and other resorptive repairs that also benefit from a micro-
scopic approach. In reality, all clinical endodontic procedures should be done under
constant illumination, magnification, and ergonomics. This requirement applies even
for implant dentistry, which needs special attention to fine details to achieve
excellence.10
As the OM gains widespread acceptance in endodontics, the advantages of its use
in providing precision care will carry over into restorative dentistry, and it will eventu-
ally become a universal approach for all phases of dentistry.4,10–15
REFERENCES
1. Apotheker H. A microscope for use in dentistry. J Microsurg 1981;3(1):7–10.

2. Friedman S, Lustmann J, Shahardany V. Treatment results of apical surgery in
premolar and molar teeth. J Endod 1991;17(1):30–3.
3. Weller N, Niemczyk S, Kim S. The incidence and position of the canal isthmus:
part 1. The mesiobuccal root of the maxillary first molar. J Endod 1995;21(7):
380–3.
4. Carr GB. Magnification and illumination in endodontics. In: Hardin FJ, editor.
Clark’s clinical dentistry, vol. 4. St Louis, MO: Mosby; 1998. p. 1–14.
5. Selden HS. The role of a dental operating microscope in improved nonsurgical
treatment of ‘‘calcified’’ canals. Oral Surg Oral Med Oral Pathol 1989;68(1):93–8.
6. Carr GB. Common errors in periradicular surgery. Endod Rep 1993;8(1):12–8.
7. Carr GB. Microscopes in endodontics. J Calif Dent Assoc 1992;20(11):55–61.
8. Selden HS. The dental-operating microscope and its slow acceptance. J Endod
2002;28(3):206–7.
9. Michaelides PL. Use of the operating microscope in dentistry. J Calif Dent Assoc
1996;24(6):45–50.
10. Sheets CG, Paquette JM. The magic of magnification. Dent Today 1998;17(12):
60–3, 65–7.
11. Worschech CC, Murgel CAF. Micro-odontologia: visão e precisão em tempo real.
Londrina: Dental Press International; 2008. p. 31–81.
12. Carr GB. Endodontics at the crossroads. J Calif Dent Assoc 1996;24(12):20–6.
13. Carr GB. Ultrasonic root end preparation. Dent Clin North Am 1997;41(3):541–54.
14. Castellucci A. Magnification in endodontics: the use of the operating microscope.
Pract Proced Aesthet Dent 2003;15(5):377–84.
15. Murgel CAF, Gondim E Jr, Souza Filho FJ. Microsco pio Ciru
rgico: a busca da ex-
celência na Clınica Odontolo gica [Surgical Microscope: the search for excel-
lence on clinical dentistry]. Rev da Assoc Paul Cir Dent 1997;51:31–5 [in
Portuguese].
A d v a n c e d Tec h n i q u e s
f o r De t e c t i n g L e s i o n s
in Bone
Elisabetta Cotti, DDS, MS
KEYWORDS
Radiologic techniques CBVT CT Echography
Periapical lesions
Apical periodontitis (AP) is an infectious disease caused by bacteria (in association

with viruses and fungi) residing in the root canal system (endodontium) of the affected
teeth, and organized in a biofilm as a consequence of pulpal infection and necrosis.1–3
The pathogenesis of AP is due to the initiation of a nonspecific inflammatory response
and a specific immunologic reaction of the host in the periradicular tissues (cementum
of the tooth, periodontal ligament, and alveolar bone) in response to the infection
coming from the endodontium. The establishment of this response is considered an
attempt from the body to prevent the spread of the infection deep into the bone. As
the disease proceeds it causes resorption of the periapical bone and its substitution
with the inflammatory tissue.1,4,5 Clinical signs and symptoms that may be associated
with the different stages of this pathologic condition are represented by soft tissue
swelling, presence of a sinus tract, and pain on percussion of the tooth and on palpa-
tion of the periapical area. However, it is the presence of osteolytic lesions in the peri-
apical/periradicular area of the maxillary bones that represents the clinical landmark of
AP.4,5
The changes in the mineralization and structure of the periapical bone that can be
seen by radiographic techniques are the major indicator of the presence of AP and
the progression of its healing (Fig. 1).5,6
From a histopathologic perspective, bone radiolucencies caused by AP may be
distinguished as periapical cysts and granulomas.7,8 Furthermore, two kinds of lesions
can be identified among periapical cysts; the true cyst (a cavity completely enclosed in
its epithelial lining with no direct connection to the apical portion of the root canal) and
the periapical pocket cyst (a cavity lined by epithelium that forms a collar around the
apex of the involved tooth and that is consequently open to the root canal).7,8 Accord-
ing to the results from the most reliable studies in the recent literature, the prevalence
of cysts among AP is 15% of which 9% are true cysts and 6% are pocket cysts.9 It has
Department of Conservative Dentistry and Endodontics, School of Dentistry, University of Cagliari,

Via Binaghi # 4, 09100, Cagliari, Italy
E-mail address: Cottiend@tin.it
Dent Clin N Am 54 (2010) 215–235

216 Cotti
Fig. 1. Digital periapical radiographs (regular and color-coded) showing a lesion of

endodontic origin.
been suggested that true cysts may sustain persistent AP, therefore it is important to
make a differential diagnosis between periapical lesions using clinical and radio-
graphic techniques,9–12 even though histologic serial or semiserial sectioning of the
whole lesion is considered the only reliable diagnostic method to date.9 Thus, diag-
nostic information will directly influence the clinical decisions on the management of
periapical bone lesions.
An effective imaging system is required for the following purposes:
1. Detection of all the lesions present in the maxillary bones.
2. Disclosure of the anatomic coordinates of the lesions in the three spatial dimen-
sions for diagnostic and treatment purposes (determine shape and measures of
a lesion; determine the amount of cortical bone involved; visualize the relationship
of a lesion with the root tip(s) and the anatomic landmarks in the bones).
3. Orientation toward a differential diagnosis of the lesions of endodontic origin (ie,
cysts vs granulomas) and of endodontic lesions versus other radiolucencies.
4. Follow-up evaluation of the outcome of the treatment.
The information may be obtained by traditional radiology (intraoral periapical radio-

graphs and panoramic radiographs), which has the limitation of being a two-dimen-
sional representation of three-dimensional structures.13,14 Whenever further
information is required, advanced imaging systems are needed.6,15
ADVANCED IMAGING TECHNIQUES
Advanced imaging systems that have become more and more helpful in the manage-
ment of endodontic lesions are computed tomography (CT), cone beam volumetric
tomography and ultrasound real-time echotomography. Each of these techniques
Advanced Techniques for Detecting Lesions in Bone 217
has the specificity to enhance the diagnostic potential, increase the awareness of the
anatomic details, make better differential diagnoses or investigate protocols.
CT and Dental CT
CT was introduced by Hunsfield16 in the 1970s and it provides imaging of soft tissues,
bone, and vessels.17 With this technique the part of the body to be examined is divided
into slices by fanning out of collimated roentgen rays. As the x-ray source rotates
around the region of interest, multiple sensors detect the beam. These slices are
layers consisting of volume elements known as voxels, whose height is determined
by the selected thickness of the layer. The system measures the attenuation of the
rays entering the anatomic structures located within these voxels from many different
angles. The attenuation coefficients encountered by the rays passing through the
anatomic structures (depending on the thickness and on the atomic number of the
tissue elements) are detected and transformed into images. The values of attenuation
coming from a linear or tangential direction are referred to as projections. The
computer then reconstructs the part under observation into a series of cross sections
or planes.
CT is widely used for the diagnosis of pathologic conditions in the maxillary bones.17
Using a specific protocol of investigation and software, dental CT is a procedure that
permits a metric analysis of transverse sections of the jaws in three dimensions.18–20 In
dental CT direct axial scans of the jaws are acquired using the highest possible reso-
lution, and then secondary curved and orthoradial multiplanar tomograms are recon-
structed by data computation. To avoid the influence of artifacts generated from metal
restorations, the field of measurement can be positioned inferior to the occlusal plane
in the jaw of interest.20 Conventional CT, spiral CT or multislice CT can be used for
dental CT. A standard protocol for dental CT in the diagnosis of pathologic conditions
of the jaws should use: slice thickness of 1.5 mm, table feed of 1.0, field of view (FOV,
mandible) of 120 mm, FOV (maxilla) of 100 mm, scan time of 2 seconds, voltage of 80
to 120 kV, current of 25 to 100 mA, mandible base, and hard palate as scan planes.21
The data accumulated from the primary axial tomograms are transformed into multi-
planar reconstructions using dental software. The indirect orthoradial reconstructions
are calculated perpendicular to a planning line along the centreline of the jaw arch. The
distance between each of the 40 to 60 cuts is 1.5 to 3.0 mm.20 The panoramic views
and cross sections of the jaws reconstructed from the axial slices make it possible to
measure distances and diameters, and to determine the thickness of the osseous
structures. In each single jaw examination the axial scans are displayed followed by
the dental reconstructions on a 1:1 scale including the planning line, the orthoradial
lines, and the dental scans, which are numbered and correlated to the orthoradial
reconstructions (Figs. 2 and 3).
Tissue density is measured in Hounsfield units (HU) on a scale from 1000 to 13000
HU (water 5 0 HU; air 5 1000 HU). Bone ranges from 500 to 1300 HU (compact
bone) to 100 to 240 HU (cancellous bone); soft tissue is approximately 40 HU.20
The major concern related to dental CT is the high radiation dose required for
average examinations; in the last few years dose reduction methods have been estab-
lished.20,22 Reducing the tube current is an important step, followed by using 1.5-mm
slice thickness. The spiral CTs (if used with pitch higher than 1), provide an optimum
data set while drastically reducing the amount of radiation because they use contin-
uous scanning to generate cross-sectional slices. In this examination the pitch indi-
cates the slice thickness (in millimeters) and the rate at which the table is advanced
(layers per rotation 5 mm/360 ). By increasing the rotation speed and exposing
several layers simultaneously, the exposure time and the radiation dose is reduced.
218 Cotti
Fig. 2. (A) Details from a panoramic radiograph showing an extensive lesion (white arrow)
of endodontic origin related to tooth no. 22. (B) Clinical photograph of the same tooth,
showing the swelling in the buccal-periapical area.
An additional suggestion for dose reduction is to be specific about the area of interest
for the investigation, selecting the upper or lower jaw and excluding all the occlusal
scans.20–22
Cone Beam Volumetric Tomography

Cone beam volumetric tomography (CBVT),20,23–25 also called digital volume tomog-
raphy or cone beam CT, was developed to produce three-dimensional images of the
maxillofacial region with scan time reduction and lower radiation dosage than
medical-grade CT. The examination is produced using a narrow cone-shaped x-ray
beam. The x-ray source and the sensor rotate synchronously between 180 and
360 around the head of the patient only once. The sensor can be either an image
intensifier or a flat panel. The image intensifier can be coupled with a charged coupled
device or with a complementary oxide semiconductor; the flat panel (thin film tran-
sistor) is the newest image receptor for solid large area arrays and it produces less
distortion with a wider scale of contrast. The method of acquiring images in CBVT is
different from medical CT. In CBVT, a single scan captures projection data in a volume
and the voxels are consequently isotropic. A reconstruction algorithm then calculates
the three-dimensional image of the original object. From this volume, tomographic sli-
ces from 0.125 mm thickness are displayed in 3 orthogonal planes. New slices can be
also made in any direction. Three-dimensional image volume is represented in
a cylinder or a sphere greater than 100 million voxels; some CBVT machines acquire
larger data volumes than others. Depending on the FOV, limited CBVT can be distin-
guished from full CBVT. Limited CBVT creates a three-dimensional image volume in
the range of 4 4 to 10 10 cm2 with smaller isotropic voxels (0.125–0.2 mm),
thus increasing the resolution and the accuracy of measurements. Image volumes
in full CBVT range from 10 10 to 20 20 cm2 (voxels 5 0.2–0.4 mm). The dedicated
viewer software of the CBVT system allows the clinician to examine the full volume
together with the simultaneous axial, sagittal, and coronal views of the area of interest.
The CBVT system obtained US Food and Drug Administration approval for dental use
in the United States in 2000.25 There are now several CBVT systems on the market.
The major difference between the systems is in the detector used and in the FOV.
Depending on the CBVT, the patient can be examined in a seated, standing, or supine
position. CBVT uses ionizing radiation and therefore the most common concern
arising is the effective radiation dose on the patient. Most of the time CBVT yields
a lower effective radiation dose than traditional CT. Exposure time can be reduced
Fig. 3. (A) Axial scans of the previous lesion (white arrows) showing its extension and the
involvement of the cortical plates. (B) Dentascan of the same lesion (white arrows). Involve-
ment of the sinus is visible. (C) Surgical excision of the same lesion.
by using pulsating technology (making the beam-on time shorter than the scan time).
The effective dose from digital panoramic radiographs ranges from 4.7 to 14.9 micro-
Sieverts (mSv), and the effective dose for a full mouth series is from 33 to 84 mSv.
According to the literature, not all CBVT machines deliver the same radiation dose
220 Cotti
Fig. 3. (continued)
per examination. The amount of radiation can range from 2% to 23% of medical-grade
CT and can be 4 to 42 times higher than a single panoramic radiograph (from 4.70 mSv
to 134 mSv).26–30
To minimize the radiation dose and depending on the region of interest, the clinician
might use either a smaller FOV with betters details, thus requiring a higher mA, or
a bigger FOV with lower resolution, thus requiring a lower mA.28 CBVT has been the
object of numerous applications in the field of endodontics.25,31
Ultrasound Real-time Echotomography

This widely used imaging system is based on the reflection of ultrasound waves.32
Ultrasound waves are generated as a consequence of the piezoelectric effect by
a quartz or synthetic ceramic crystal when it is exposed to an alternating electric
current of 3 to 10 MHz. Ultrasound waves oscillating at the same frequency are colli-
mated by an acoustic lens and sent toward the area of interest in the body using
a transducer, which is called an ultrasonic probe and contains a crystal.
Because the different biologic tissues in the body possess different mechanical and
acoustic properties, the ultrasound waves at the interface between 2 tissues with
different acoustic impedance undergo the phenomena of reflection and refraction.
The echo is the part of the ultrasound wave that is reflected back from the tissue inter-
face toward the transducer.
The transducer transforms the reflected ultrasound waves (echo) into electromag-
netic waves of the same frequency, which are then transformed into images in
a computer. The greater the difference in acoustic properties between 2 adjacent
tissues, the higher is the intensity of the echoes originating from them. The ultrasound
images seen on the computer monitor are produced by the movement of the crystal
over the tissue of interest, which appear as a sequence of moving images (an average
of 30 images per second). When the operator moves the probe on the examination
area a change is created on the sector plane, thus producing a real-time three-dimen-
sional image of that particular space.
If an area in a given tissue has high echo intensity, it is called hyperechoic and will
appear as a white bright spot. Bone exhibits total reflection and is therefore hypere-
choic. An area that has low echo intensity is called hypoechoic and appears as
a darker image. An area that has no echo intensity it is called anechoic and appears
very dark in the examination. Fluid-filled areas exhibit no reflection and are anechoic.
Areas that contain different types of tissues show a dishomogeneous echo.
When applied to ultrasound examination, color power Doppler (CPD) flowmetry33
allows the presence and direction of the blood flow within the tissue of interest to
be observed. The intensity of the Doppler signal is represented by changes in real time
on a graph (Doppler) and is also shown in the form of color spots on the gray scale
image (color). Positive Doppler shifts are caused by the blood moving toward the
transducer and are represented in red, whereas negative Doppler shifts are caused
by blood moving in the opposite direction and are represented in blue. Power Doppler
is associated with color Doppler to improve its sensitivity to low flow rates. It is based
on the integrated power spectrum, and can disclose the minor vessels.11 The use of
contrast media by intravenous (IV) injections increases the echogenicity of the blood
making the color power Doppler examination more sensitive.32,33 Ultrasound imaging
is a safe technique; the biologic risk is much lower than that associated with radio-
graphs because it does not use ionizing radiations.34–36 Potential adverse effects of
ultrasound (caused by cavitation and vibration) depend on the length of time the ultra-
sound energy is applied; safety measures therefore limit the number of examinations.
REQUIREMENTS FOR THE DETECTION AND MANAGEMET

OF ENDODONTIC LESIONS
Detection of the Lesions in the Maxillary Bone and in the Mandible
A two-dimensional digital panoramic radiograph can often be enough for the prelim-
inary visualization of the patient’s dentition and related bone pathosis, in particular,
if the general condition of the teeth (caries, previous restorations) is within average.
Periapical radiographs, taken in at least 2 different projections, will follow through to
have a close up on selected teeth, check for the presence and extension of caries,
view the condition of restorative work, and diagnose the possible lesion.6 Treatment
of the affected tooth can thus be planned.
When the overall condition of the dentition is complex because of the existence of
numerous caries, restorations, and root canal treatments, then the presence of unde-
tected periapical pathosis might be suspected and an examination that will eliminate
superimposition of teeth or surrounding structures in the area of interest is required.
The same consideration is valid whenever there are periapical symptoms but the
lesion(s) cannot be seen with conventional two-dimensional images. CT and CBVT
are then indicated.
As a result of the high resolution achieved, dental CT and then CBVT have become
significantly more effective than radiographs for the detection of periapical lesions in
bone.6,37
Velvart and colleagues38 correlated the presence of lesions diagnosed with CT and
radiographs to the actual findings in the surgical field on 50 teeth selected for
endodontic surgery. The 78 lesions found during the surgical procedure were visible
on the CT scans, whereas only 61 of them were seen using conventional radiographs.
Stavropoulos and Wenzel39 used CBVT to examine experimental bone defects in
pig jaws, and showed that this examination has a higher diagnostic accuracy than
intraoral radiography, conventional and digital. Nakata and colleagues40 reported
a case in which, only using CBVT, they were able to detect the presence of a periapical
lesion in the root of a symptomatic maxillary molar, which had not been diagnosed
with intraoral and panoramic radiographs.
Lofthag-Hansen and colleagues41 in a very comprehensive clinical work conducted
at the Public Dental Health Service in Goteborg reported that CBVT provided addi-
tional information not found on periapical radiographs. In particular, in 36 patients
and a total of 46 teeth analyzed, periapical lesions were diagnosed in the same 32 teeth
with both examinations. However, lesions were diagnosed in 10 more teeth with the
CBVT images. Among these 10, 3 undetected lesions were considerably large,
222 Cotti
crossing the alveolar bone in the bucco-palatal direction and expanding into the maxil-
lary sinus (Fig. 4). Furthermore, when the lesions were correlated to individual roots,
the same 53 lesions were diagnosed with both techniques and 33 more roots with
lesions were seen using the volumetric tomography.
In another report 34% more lesions, particularly related to maxillary second molars
or to roots in close proximity with the maxillary sinus, were seen using CBVT.42
Fig. 4. (A) Periapical radiograph showing tooth no. 27 with what appears as a small lesion
on the mesial root. (B) CBVT (Courtesy of Professor Carlo Prati [3D Accuitomo, J Morita, Mfg
Corp. Kyoto, Japan].) of the same tooth no. 27 with the 3 projections: axial (upper left),
sagittal (lower right), and coronal (lower left). In this image set, it is possible to see the
huge lesion within the sinus (arrows), is not visible in the periapical radiograph. The volume
of the examination is represented on the upper right.
Similar results were found by Estrela and his group in 2 consecutive papers. In the
first study on 888 patients, they compared the accuracy of CBVT, and panoramic and
periapical radiographs for the detection of AP, finding that the overall sensitivity of
periapical and panoramic radiographs was 0.55 and 0.28, respectively.43 In the
second study, on 569 patients and 1014 teeth, AP was detected in 39.5% of the cases
examined with the radiographs and in 60.9% of the cases screened with CBVT.44
Disclosure of the Anatomic Coordinates of the Lesions in 3 Spatial Dimensions

Knowing the anatomic coordinates of a lesion in 3 spatial dimensions means:
(a) To be aware of the size of a lesion at different levels in the bone and in the multiple
spatial projections
(b) To understand whether and where the cortical plates are involved or perforated by
the inflammatory process
(c) To determine the position and divergence of the roots within the alveolar process
of the maxillary bones and their involvement in a lesion
(d) To know the proximity of a lesion/root to vital anatomic landmarks such as the
mandibular canal, mental foramen, incisal canal, and maxillary sinus.
An average of 70% more clinically relevant information (of outmost importance in
endodontic presurgical planning) can be gathered with CT and CBVT than with tradi-
tional radiographs (Figs. 1–6).38,41–44
CT has been advocated as a preferential imaging system when looking for details
not achievable using two-dimensional examinations such as the relation of the lesions
to the buccal and the lingual cortical plates, and their size. The periphery of the osteo-
litic lesion can be easily identified and measured on the cross-sectional reconstruc-
tions.45 In the in vivo clinical study by Velvart and colleagues38 mentioned earlier, all
the information achieved with high-resolution CT scans made it possible to evaluate
the extent of the lesions and their precise position within the bone. The oblique cuts
of the same CT scans also provided the predictable identification of the mandibular
canal and its relationship with the lesions and the roots. The same information was
not predictably obtained in all the cases examined using radiographs. The inferior
alveolar nerve and the mental foramen in relation to the apex of mandibular premolars
can also be precisely located with CBVT (see Fig. 5).25 The involvement of the roots/
lesions with the sinus floor and their expansion into the maxillary sinus is another
important concern when planning surgery, which can be overcome only using CT or
CBVT (see Fig. 2 and 3).42,46,47 From these examinations it was possible to show
that in 76% of first molars and in 50% of second molars the sinus floor was intertwined
with the roots,42 and that it was approached by 30% of second premolar roots. The
sinus was found between the buccal and the palatal root of the first molar in 25% of
cases.47 In 32% of cases, maxillary root lesions perforate the sinus, and in 30% of
the cases they are separated from the sinus by 1 mm of bone or less.42 The position
and the size of the incisive foramen/canal have been determined with CT and CBVT
with equal success.25,48
The linear and three-dimensional measurements for the anatomic structures49,50
and volumetric measurements of osseous lesions51 taken with CBVT are considered
accurate in vitro and in vivo. The mean horizontal distance of the palatal root of the first
maxillary molars from the buccal cortical plate (mean distance 5 9.73 mm) has been
measured by CBVT to assess surgical access.47 Apico-marginal communications,
which can be an important indication of the presence of a radicular fracture, are
also more frequently detected by CBVT.42
224 Cotti
Fig. 5. (A) Periapical radiograph of tooth no. 36 showing a periapical lesion, a previous root
canal treatment, and crown restoration. (B) Axial scans from CBVT (3D Accuitomo) of the
same tooth in the widest portion of the lesion, showing its relationships with the cortical
plates and the roots of the tooth (arrows). (C) CBVT coronal scan of the same tooth. (D)
Sagittal scan of the same tooth. The progressive relation of the lesion with the mandibular
canal is clearly visible (arrows).
Fig. 6. (A) Presurgical CBVT coronal scan on tooth no. 46 (Promax, Planmeca Oy, Helsinki,
Finland). It is possible to select the surgical access by assessing the slice where the cortical plate
is thinner (arrow). (B) Sagittal scan showing the lesion with respect to the mandibular canal
(arrow). (C) Surgical field on the same tooth. (D) Postsurgical radiograph.
CBVT has been successfully used to evaluate the position of an instrument fractured
in the maxillary sinus between the 2 buccal roots of an upper molar, and to plan ortho-
grade and surgical treatment.52
Some authors have even built a CBVT computer-aided design/computer-aided
manufacturing guidance system for surgical endodontics.53
Orientation Toward a Differential Diagnosis of Lesions of Endodontic Origin

Nonendodontic lesions in the jaws that may need to be differentially diagnosed from
AP54 are lateral periodontal cysts, odontogenic keratocysts, dentigerous cysts, devel-
opmental cysts, central giant cell granuloma, traumatic bone cysts, and some forms of
ameloblastoma. The differential morphology of radicular cysts, keratocysts, and den-
tigerous cysts55 has been described using CT examinations and might help in the
diagnosis. Keratocysts and dentigerous cysts can exhibit multilocular or unilocular
patterns. Dentigerous cysts are more frequently unilocular, but they are usually in
association with the crown of an unerupted tooth.54 When unilocular, these lesions
are more difficult to differentiate from endodontic lesions. On CT, keratocysts and
dentigerous cysts tend to develop more into an oval shape and in a direction parallel
to the long axis of the mandible. Dentigerous cysts may present with a local expansion
of the cortical plate; keratocysts tend to show a discontinuity in the lingual cortex more
often than radicular cysts, and are preferably located in the posterior body and ramus
of the mandible. Radicular cysts are almost always unilocular, show discontinuity of
the lingual cortex of the mandible less often, have a rounder shape, and can be sur-
rounded by a sclerotic bone rim. Giant cell granuloma more often involves the
mandible (anterior) and has the radiographic appearance of an irregular radiolucent
area that may be unilocular or multilocular, and tends to resorb the roots of the
involved teeth. When the lesions are small and unilocular they may simulate AP.
They are distinguishable on CT because they are noncorticated (Fig. 7).54
226 Cotti
Fig. 7. (A) Panoramic radiograph detail of teeth no. 34 and no. 35 showing a periapical
bone lesion (arrow). (B, C) Dentascan of the same area (arrows) showing the extensive
involvement of the cortical plates and the scalloping of the bone. The lesion turned out
to be a giant cell granuloma.
Nasopalatine canal cysts and static bone cysts (Stafne cyst) are developmental
nonodontogenic cysts.54 The nasopalatine canal cyst on panoramic radiographs is
an oval- or heart-shaped radiolucent lesion located between the roots of maxillary
central incisors. CT shows an enlargement of the nasopalatine canal on axial or
coronal sections. Multiplanar and three-dimensional imaging may be important to
show the extent of the lesion.25,54
Static bone cyst54,56 is a depression in the lingual surface of the mandible between
its angle and the first molar, below the mandibular canal. The cyst is occasionally
found in the anterior mandible. It is caused by aberrant tissue of the submandibular
gland, and on CT shows a well-circumscribed radiolucency in the lingual aspect of
the mandible with the associated glandular tissue.56 The traumatic bone cyst is a pseu-
docyst, probably due to an infrabone hematoma.54,57 If detected early it contains
blood, if later it appears as an empty cavity. On radiographs it is a well-defined radio-
lucent area, which does not cause interruption of the lamina dura of the teeth involved.
On CT (axial scans) it shows expansion with scalloping of the cortical plate and, if
present, its fluid content.
The ameloblastoma, more often found in the posterior mandible, appears as a well-
defined multilocular or unilocular radiolucent area, which may be associated with
resorption or displacement of the roots of the teeth involved. The differential diagnosis
of periapical lesions is difficult if the lesion is unilocular. CT shows the expansion of the
bone and it becomes important as a differential diagnostic tool in the follow-up of the
lesion after an interval of 6 months to 1 year (Fig. 8).54,55 Periapical cemental dysplasia
(cemento-osseous dysplastic/reactive lesion) has an initial radiolucent phase, which
makes it difficult to be distinguished from periapical lesions. Periapical cemental
Fig. 8. (A) Panoramic radiograph detail of teeth no. 46 and no. 47 showing a wide multiloc-
ular bone lesion (arrow). (B, C) Dentascan of the same area (arrows) showing the extensive
involvement of the cortical plates and the thinning of the bone. The lesion was an
ameloblastoma.
dysplasia is predominantly located in the mandible, and on axial CT scans they show
radiopaque masses surrounded by low-density areas with no continuity with the
cortical plate and the root of the teeth.54,58
When diagnostic doubt refers to the possible presence of a malignancy, then CT is
indicated and used in association with contrast media. If the differential diagnosis is
between endodontic lesions, then the requirement is to make a distinction between
a cyst and a granuloma.7,8,15 The pioneer application of CT to endodontic lesions
came from Trope and colleagues59 in 1989. These authors selected 8 periapical
lesions from human cadavers, which were divided into 4 cysts and 4 granulomas
based on the diagnosis made by an oral radiologist. They examined the lesions in
the jaws with a CT scan and axial slices, and used a densitometric processor to
read the lesions and the surrounding tissues. The CT scan readings were then corre-
lated to the histopathology. Of the 8 periapical lesions studied, 7 were granulomas and
only 1 was a cyst. It was concluded that cystic cavities could be differentiated from
granulomas based on their CT appearance. A cyst on axial CT scans displays an
area with a density reading similar to the background, darker than a granuloma or
the fibrous tissue of an apical scar. Granuloma has a cloudy appearance with a density
similar to that of the surrounding soft tissues. In 1 case, within the same lesion it was
possible to distinguish the granulomatous tissue from the cystic cavity inside it.
228 Cotti
Controversial reports arise from the application of CBVT to the differential diagnosis
of cystic lesions from granulomas. Simon and colleagues60 examined 17 lesions (1 cm
1 cm or more) using CVBT to attempt a differential diagnosis between cysts and gran-
ulomas based on the measurement of gray values ( 4096 gray scale) of the
imaged lesion areas. The CBVT diagnosis and the traditional biopsy results coin-
cided only in 13 cases out of 17; 4 cases had a split diagnosis. Frisbie and
colleagues61 used CBVT to make a differential diagnosis between cysts and gran-
ulomas in 55 lesions. They based the study on the following parameters: (1) agree-
ment between radiologists as to whether the CBVT image represented a cyst or
a granuloma (gray values), (2) agreement between pathologists in deciding if the histo-
pathologic specimen was a cyst or a granuloma, and (3) accuracy of the diagnostic
assessment of radiologists using histopathology as the gold standard. The results
showed that the pathologists were in high agreement whereas the radiologists were
in low agreement and hence, differed in accuracy regarding the diagnosis. The authors
concluded that CBVT is not sensitive enough to provide an accurate differential diag-
nosis among endodontic lesions. Schultze and colleagues62 reported that CBVT is
helpful in the diagnosis of osteomyelitis of the mandible.
Ultrasound real-time echotomography has been used predictably to examine
endodontic lesions in the jaws.63 In an initial study, the differential diagnosis between
cystic lesions and granulomas was attempted based on an ultrasound examination
complemented by CPD on 11 patients. The patients were diagnosed with periapical
lesions and scheduled for endodontic surgery and biopsy. The established criteria
to distinguish the 2 lesions were as follows: cyst, annaechoic/transonic, contoured
cavity with reinforced walls (pasterior enhancement), fluid content, and no internal
vascularization; granuloma, echogenic lesions of different shapes and contours
showing vascular supply on CPD.
The provisional echographic diagnosis was compared with the results from the
histopathologic examination, which was done after surgical excision of the lesions
and semiserial sectioning. The histopathologic reports confirmed the ultrasound diag-
nosis in all 11 cases. The sensitivity of the technique was particularly enhanced in one
case, which showed a mixed echographic appearance, mostly echogenic and vascu-
larized with a well-contoured transonic area in the upper central area. The lesion
turned out to be a granuloma containing a small cyst.64 This study was replicated
by a group of researchers who analyzed 15 periapical lesions with echography,
conventional and digital radiology, and routine biopsies. Their histology confirmed
the ultrasound observations with respect to the underlying lesions, and the authors
concluded that ultrasound unequivocally identified the contents and nature of the peri-
apical lesions.65 A subsequent report on 2 lesions on the same patient, for which the
initial diagnosis was done with ultrasound and then validated by the histology
confirmed these findings (Figs. 9 and 10).66 In a more recent paper67 another 22 radio-
lucent lesions of the jaws were examined with ultrasound and CPD, and with routine
histopathology. The diagnosis of periapical granuloma made with the ultrasound was
consistent with the biopsy reports. The lesions that were defined as cysts after the
biopsy showed a more varied ultrasound appearance in this report. They were tran-
sonic in 5 cases, had a complex and semisolid appearance in 9 specimens (all without
internal vascularization), and 1 case appeared as a vascularized solid lesion. Among
the lesions histologically classified as cysts there were actually 4 keratocysts, 2 den-
tigerous cysts, 4 residual cysts, and 7 radicular cysts. These findings might explain
why some of the cysts had a mixed fluid and solid content. Furthermore the one
cyst that exhibited a solid appearance with internal vascular supply had a very thick
capsule and extensive inflammatory content.
Fig. 9. (A) Panoramic radiograph showing an extensive periapical lesion in the area of teeth
no. 11 and no. 12. (B) The ultrasound examination of the area (circled) showing a fluid-filled
cavity without internal vascularization. The lesion was diagnosed as a cyst.
Ultrasound with CPD can provide accurate information regarding the content of
intraosseous lesions of the jaws before surgery, but it does not eliminate the need
for a biopsy for histopathologic diagnosis.
Evaluation in Follow-up of the Outcome of Treatment

Periapical radiographs have been used as the gold standard to evaluate healing of
endodontic lesions6,15 and the Periapical Index (PAI) has been used as the scoring
system for radiographic assessment of AP.68 The PAI offers a visual reference scale
(scores related to reference radiographs and histologic evaluation of AP) and assigns
a health status to the root, based on the changes in the mineral bone content in the
periapical area. The score ranges from 1 (absence of pathosis) to 5 (spread of the
lesion within the bone) (Fig. 11).
In a case report,48 the authors did the diagnosis and follow-up of an extensive lesion
of the maxillary bone using a CT scan and panoramic radiograph. The 18-month
follow-up of the panoramic radiograph disclosed a lesion that could be considered
healed for about 70% of its extension. The second CT done at the same time showed
that the appearance of healing was mostly obtained because the external cortical
plate, previously resorbed, had been regenerated. Yet, the size of the lesion was
Fig. 10. (A) Periapical lesion on tooth no. 17, (B) Ultrasound and CPD examination of the
same lesion (squared). The lesion is echogenic and has a rich internal vascularization (arrow)
and is diagnosed as a granuloma.
230 Cotti
Fig. 11. Representation of the PAI, from the beginning of the pathosis to its spreading in
the bone. (The case has been observed in reverse, from the recall to the pretreatment
radiograph.)
not reduced to the same extent that could be seen from the radiograph. CT was useful
to provide the information on the actual progress of the healing process, which started
with the reconstruction of the external cortical plate, and on the necessity to continue
to follow-up the case.
Recently, a new PAI system has been developed using criteria established from
measurements of periapical lesions as interpreted on CBVT scans, and has been
named the CBCT PAI.44 The index is a scoring system based on the measurement
of the lesions in three dimensions (bucco-lingual, mesio-distal, and diagonal) and is
determined by the largest extension of that lesion. The scores range from 1 to 6
depending on the largest measure and include the two variables, expansion and
destruction of the cortical bone. Radiolucencies measuring more than 8 mm in their
largest diameter are given the score 6, whereas 1 is the score for lesions having a larger
diameter of 0.5 to 1 mm (Fig. 12). The clinical advantages of this system are related to
the possibility of assessing the lesions in the 3 planes of space, obtaining more accu-
rate measurements, eliminating false-negative readings, and minimizing the interfer-
ence of the observers.
With regard to the short-term follow-up of endodontic lesions, in a recent pilot
project the authors evaluated the possibility of monitoring the inflammatory changes
in diseased bone in response to endodontic treatment. Ultrasound examination asso-
ciated with CPD was used as a clinical follow-up. In 6 teeth with periapical lesions, the
endodontic treatment was completed in 2 appointments using calcium hydroxide as
an intermediate medication. Besides periapical radiographs, each case was examined
with ultrasound and CPD before treatment (to assess the content of the lesion and its
vascularization), 1 week after root canal cleaning and disinfection, and 1 month after
the completion of treatment. When the ultrasound/CPD examinations of the same
case were compared, a change in the vascularization within the lesions, after the first
appointment and after the completion of treatment was observed in all cases. These
preliminary data open up new possibilities to follow up endodontic treatment with
regard to initial and short-term reactions of lesions at the different stages (and types)
of treatment.69
Fig. 12. Representation of CBCT PAI on tooth no. 46, with the measurements of the mesio-
distal (A), bucco-lingual (B), and diagonal diameters (C).
SUMMARY
Even if traditional radiology still represents the backbone of everyday endodontic

treatment,6,15 the adjunct of advanced techniques is always indicated when there is
a need for more detailed information.15,25,31 The clinician should be responsible for
choosing the most appropriate and convenient examinations for a given investigation.
Every time a three-dimensional image is required, either CT or CBVT should be
considered. CT is still the best choice for the diagnostic challenges of bone lesions
in the jaws. It must be prescribed and used with care to minimize the dose of radia-
tion.54–59,70 CT can be substituted by CBVT, if available, for most endodontic situa-
tions.25,31 CBVT should not be considered as a substitute for a panoramic
radiograph, if this is an adequate examination for a specific case. Not all CBVT inves-
tigations and machines dispense the same dose of radiation; some examinations
present even more risk than a medical-grade CT.26–30
To date, ultrasound imaging is the most sensible technique to address the differential
diagnosis of endodontic lesions and to specify their vascular/fluid/solid content in the
absence of histopathologic evaluation. It is also valuable for the immediate and
short-term clinical follow-up. Ultrasound real-time echotomography is more convenient
than computerized tomographs because it entails lower biologic adverse effects.63–68
When choosing such advanced imaging techniques the clinician should be aware of
and responsible for all the extra information that can be included in these examinations.25
Indications on the use of CT for the imaging of AP:
1. Need for predictable information concerning the presence of AP
2. Diagnostic challenges (possible nonodontogenic lesions, different kind of cysts,
suspected tumors; need for IV contrast medium)
232 Cotti
3. Surgical approach toward very extensive lesions

4. Need for soft tissue examination.
Indications on the use of CBVT for the imaging of AP:
1. Need for predictable information concerning the presence of AP in the jaws

2. Need for additional information useful in the diagnosis and treatment plan of AP (ie,
specific roots/teeth involved, additional roots/canals foreign objects, relationship
to important anatomic landmarks)
3. Need for specific information on the anatomic coordinates in the surgical approach
to endodontic lesions
4. Need for reproducible data for the follow-up of AP (CBCT PAI).
Indications on the use of ultrasound for the imaging of AP:
1. Need for very low risk examination
2. Interest in assessing the content (fluid vs mixed or solid) and vascularization of
a lesion
3. Interest in documenting the immediate response to treatment of a lesion (for clinical
and scientific purposes).
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Local Anesthesia
Strategies for the
P a t i e n t W i t h a ‘‘ H o t ’’
To o t h
John M. Nusstein, DDS, MSa,*, Al Reader, b
DDS, MS ,
Melissa Drum, DDS, MSc
KEYWORDS
Local anesthesia Intraosseous injection Irreversible pulpitis
Achieving profound pulpal anesthesia is a corner stone in endodontic practice and

dentistry. Profound pulpal anesthesia during the root canal procedure benefits not
only the patient, for obvious reasons, but also the dentist who will be less stressed
worrying about patient reactions or sudden movement during therapy. Achieving
adequate anesthesia in patients can, at times, be a challenge. But when one adds
the condition of a ‘‘hot’’ tooth, the challenges increase. This article describes some
strategies that the endodontist can use when treating patients with teeth having
moderate-to-severe pain.
To begin, it is necessary to define what a ‘‘hot’’ tooth really is. In endodontic terms, it
certainly does not mean a tooth of extreme attractiveness or even a tooth that is
undergoing an exothermic reaction in which its temperature is well above normal
body temperature. The term ‘‘hot’’ tooth generally refers to a pulp that has been diag-
nosed with irreversible pulpitis, with spontaneous, moderate-to-severe pain. A classic
example of one type of hot tooth is a patient who is sitting in the waiting room, sipping
on a large glass of ice water to help control the pain.
Inflammatory changes within the pulp progressively worsen as a carious lesion
nears the pulp. Chronic inflammation takes on an acute exacerbation with an influx
Financial disclosure: The authors have no relationship or direct financial interest with any
company mentioned in this article. Nor do they have any direct financial interest in the subject
matter or materials discussed in this article.
a
Division of Endodontics, The Ohio State University College of Dentistry, 305 West 12th
Avenue, Room 3058, Columbus, OH 43210, USA
b
Division of Endodontics, The Ohio State University College of Dentistry, 305 West 12th
c
Department of Endodontics, The Ohio State University College of Dentistry, 305 West 12th
* Corresponding author.
E-mail address: nusstein.1@osu.edu
Dent Clin N Am 54 (2010) 237–247

238 Nusstein et al
of neutrophils and the release of inflammatory mediators (such as prostaglandins and

interleukins) and proinflammatory neuropeptides1 (such as substance P, bradykinin,
and calcitonin gene-related peptide). These mediators, in turn, sensitize the peripheral
nociceptors within the pulp of the affected tooth, which increases pain production and
neuronal excitability.2 All of this leads to the pain that patients report as they sit in the
dental chair.
In dealing with teeth diagnosed with irreversible pulpitis, determining whether
adequate local anesthesia has been achieved before treatment is important. Mandib-
ular anesthesia via the inferior alveolar nerve block (IANB) has traditionally been
confirmed by asking the patient if their lip feels numb, probing or sticking the gingiva
around the mandibular tooth to be treated, or simply starting treatment and waiting for
a patient response. However these techniques are not very effective in determining if
pulpal anesthesia has been achieved.3–6 Objective tests can be used to better assess
the level of pulpal anesthesia for all teeth. The use of an electric pulp tester (EPT) and/
or the application of a cold refrigerant have been shown to accurately determine pulpal
anesthesia in teeth with a normal pulp before treatment. If the patient responds nega-
tively to the stimulus (cold or electric current), then pulpal anesthesia has been
attained and the patient should not experience pain during treatment. However, in
teeth diagnosed with a hot irreversible pulpitis, a failure to respond to the stimulus
may not necessarily guarantee pulpal anesthesia.7–9 The patient may still report
pain during treatment. Teeth with necrotic pulp chambers but whose root canals
contain vital tissue may not be tested using the above means. In these cases, testing
for pulpal anesthesia of the neighboring teeth may give the clinician an indication of the
anesthetic status of the tooth to be treated.9
When one considers the challenges of local anesthesia in dentistry, mandibular
teeth pose the most severe challenge. The IANB must be delivered accurately (indi-
cated by soft tissue and lip numbness) to attain pulpal anesthesia. Missed blocks
(lack of lip numbness) occur about 5% of the time and should prompt the provider
to re-administer the injection before beginning treatment. When dentists review the
literature to determine what injection techniques or anesthetic solutions can offer,
they need to be cognizant of the definition of anesthetic success that is used in
the research. One way to define anesthetic success for mandibular anesthesia is
by the percentage of subjects who achieve 2 consecutive EPT readings of 80 within
15 minutes and sustain these readings for 60 minutes. Clinically, this translates into
being able to work on the patient no later than 15 minutes after giving the IANB and
having pulpal anesthesia for 1 hour. This duration of anesthesia would be valuable to
the endodontist and the restorative dentist. In the available clinical literature it is
reported that after administration of a successful IANB (lip numbness achieved) using
2% lidocaine with 1:100,000 epinephrine, success occurs (1) 53% of the time for the
mandibular first molar, (2) 61% of the time for the first premolar and (3) 35% of the
time for the lateral incisor.3–6,10–14 Anesthetic failure (the percentage of patients who
never achieve 2 consecutive 80 readings with the EPT during 60 minutes of testing)
for the mandibular first molar is 17%, 11% for the first premolar, and 32% for the
lateral incisor. Patients may also be subject to anesthesia of slow onset. These
patients generally do not achieve pulpal anesthesia until after 16 minutes following
the IANB, which has been reported to occur in mandibular teeth approximately
19% to 27% of the time, with some patients (8%) having onset after 30
minutes.3–6,10–14
When the clinician is confronted with the case of a severe irreversible pulpitis in
which the conventional IANB using 2% lidocaine with 1:100,000 epinephrine achieves
lip numbness but not pulpal anesthesia (per testing), the question arises as to what
Local Anesthesia Strategies 239
strategies can be used to get the patient numb so that the root canal treatment can be
done as comfortably as possible.
The first consideration could be to change the local anesthetic agents. Research
comparing various local anesthetic agents such as 3% mepivacaine plain (Carbo-
caine, Polocaine, Scandonest),4 4% prilocaine (Citanest Plain),4 4% prilocaine with
1:200,000 epinephrine (Citanest Forte),6 2% mepivacaine with 1:20,000 levonordefrin
(Carbocaine with Neo-Cobefrin),6 and 4% articaine with 1:100,000 epinephrine (Sep-
tocaine)15 to 2% lidocaine with 1:100,000 epinephrine for the IANB in patients with
normal pulps showed that there was no difference in success rates. Therefore,
changing local anesthetic agents may not be of benefit. Clinical studies involving
patients diagnosed with irreversible pulpitis also failed to show any superiority of
3% mepivacine16 or 4% articaine with 1:100,000 epinephrine17 over 2% lidocaine
with 1:100,000 epinephrine for the IANB.
The next strategy would be to change the injection technique in attempting to block
the inferior alveolar nerve. The Gow-Gates technique18 has been reported to have
a higher success rate than the conventional IANB, but controlled clinical studies
have failed to prove its superiority.19–23 The Vazirani-Akinosi technique (closed mouth)
also has not been shown to be superior to the conventional IANB technique.20,24–26
Therefore, replacing the conventional IANB injection with these techniques will not
improve success in attaining pulpal anesthesia in mandibular teeth.
Inaccuracy of the IANB injection has been cited as a contributor to failed mandibular
pulpal anesthesia. Hannan and colleagues10 used medical ultrasound to guide an
anesthetic needle to its target for the IANB. They found that although accurate injec-
tions could be attained by this method, it did not result in more successful pulpal anes-
thesia. Therefore, the accuracy of the injection technique (needle placement) was
not the primary reason for anesthetic failure with the IANB. Needle deflection as
related to the needle bevel direction (toward or away from the mandibular ramus)
has also been shown not to affect the anesthetic success rate of the IANB.27
Accessory nerves have also been implicated as a potential reason for the failure of
the IANB. The incisive nerve block at the mental foramen has been shown to improve
anesthetic success of the IANB in first molars and premolars,28 but the success rate
was not as good as other supplemental anesthetic techniques. The mylohyoid nerve
is the accessory nerve most often implicated as the cause for mandibular anesthesia
failure.29,30 However, Clark and colleagues,31 when combining the IANB with a mylo-
hyoid injection after locating the mylohyoid nerve with a peripheral nerve stimulator,
found no significant improvement in mandibular anesthesia when the mylohyoid
injection was added.
Increasing the volume of the local anesthetic delivered during the IANB has also
been found not to increase the incidence of pulpal anesthesia.3,14,31–33 Increasing
the concentration of epinephrine (1:50,000), with the hopes of keeping the anesthetic
agent at the injection site longer, also showed no advantage in the IANB.11,34
So why then is it so difficult to achieve adequate pulpal anesthesia in mandibular
teeth, even if the patient is asymptomatic? The central core theory may be the best
explanation.35,36 This theory states that the outer nerves of the inferior alveolar nerve
bundle supply the molar teeth, whereas the nerves for the anterior teeth lie deeper.
Anesthetic solutions that are currently used may not be able to diffuse into the nerve
trunk to reach all the nerves and provide an adequate block, which explains the diffi-
culty in achieving successful anesthesia for mandibular anterior teeth.2–6,10–14,19
Patients in pain as a result of a tooth diagnosed with irreversible pulpitis have addi-
tional difficulties attaining pulpal anesthesia. One theory to explain this is that the
inflamed tissue has a lowered pH, which reduces the amount of the base form of
240 Nusstein et al
the anesthetic needed to penetrate the nerve sheath and membrane. Therefore, there
is less ionized form of the anesthetic within the nerve to produce anesthesia. This
theory may explain only the local effects of inflammation on the nerve and not why
an IANB injection is less successful when given at a distance from the area of inflam-
mation (the hot tooth). Another theory is that the nerves arising from the inflamed
tissue have altered resting potentials and reduced thresholds of excitability.37,38 It
was shown that anesthetic agents were not able to prevent the transmission of nerve
impulses because of the lowered excitability thresholds37,39 of inflamed nerves. Other
theories have looked at the presence of anesthetic-resistant sodium channels40 and
the upregulation of sodium channels in pulps diagnosed with irreversible pulpitis.41
SUPPLEMENTAL INJECTIONS
Failure of the traditional IANB in asymptomatic and symptomatic patients requires that
a clinician have fall-back strategies to attain good pulpal anesthesia, especially when
a patient complains of pain too severe for the clinician to proceed with treatment, as is
often the case of patients with hot teeth. There are several supplemental injection
techniques available to help the dentist/endodontist, which are reviewed in this article.
It should be reiterated that these supplemental techniques are used best after attain-
ing a clinically successful IANB (lip numbness).
Intraligamentary (Periodontal Ligament) Injection

Bangerter and colleagues42 reported that the periodontal ligament (PDL) supple-
mental injection is still one of the most widely taught and used supplemental tech-
niques. The success of supplemental PDL injections in helping achieve anesthesia
for endodontic procedures has been reported to be 50% to 96%.16,43,44 Often reinjec-
tion is required because of failure of the initial PDL injection. Walton and Abbott43
reported an initial success rate of 71%, and when reinjection was used, the overall
success rate was 92%. Smith and colleagues44 also reported an increase in success
when a second PDL injection was required. In patients with irreversible pulpitis, Cohen
and colleagues16 reported that the supplemental PDL injections were successful 74%
of the time, whereas reinjection boosted success to 96%. The key to giving a success-
ful PDL injection remains the attainment of back-pressure during the injection.43,45
Failure to get back-pressure will most likely lead to failure.43,46
PDL injections are usually given using either a standard dental anesthetic syringe or
a high-pressure syringe. The development of computer-controlled anesthetic delivery
systems (the Wand or the Single Tooth Anesthesia [Milestone Scientific, Livingston,
NJ, USA] devices) have been found to be able to deliver a PDL injection. Berlin and
colleagues,47 using the Wand, found that with a primary PDL injection, successful
anesthesia (2 consecutive 80/80 readings) was attained in mandibular first molars
86% of the time with 4% articaine with 1:100,000 epinephrine and 74% of the time
with 2% lidocaine with 1:100,000 epinephrine. No significant difference was found
between the 2 solutions. The Wand system was able to deliver 1.4 mL of the anesthetic
over the course of the injection. When this system was used, the duration of anes-
thesia for the first molar averaged from 31 to 34 minutes, which was longer than the
10 minutes reported by White and colleagues48 when they used a pressure syringe
and delivered only 0.4 mL of 2% lidocaine with 1:100,000 epinephrine. No research
on the Single Tooth Anesthesia device is currently available for review.
In patients diagnosed with irreversible pulpitis and experiencing moderate-to-
severe pain, when a supplemental PDL injection was delivered using the Wand,
the rate of success of the injection was 56%.49 Success in this study was defined
as no pain or mild pain on access and instrumentation of the canals of the affected
tooth. The PDL injections used 2% lidocaine with 1:100,000 epinephrine and were
limited to mandibular posterior teeth after successful IANB injections (lip numbness
only).
Intraosseous Injection
The use of the intraosseous (IO) injection allows the practitioner to deliver local anes-
thetic solutions directly into the cancellous bone surrounding the affected tooth. There
are several IO systems available in the market, including the Stabident system (Fairfax
Dental Inc, Wimbledon, UK), X-Tip system (Dentsply, York, PA, USA), and IntraFlow
handpiece (Pro-Dex Inc, Santa Ana, CA, USA). The Stabident system consists of
a 27-gauge beveled wire that is driven by a slow-speed handpiece, which perforates
the cortical bone. Anesthetic solution is then delivered into the cancellous bone with
a 27-gauge ultrashort needle through the perforation using a standard anesthetic
syringe. The X-Tip system consists of a 2-part perforator/guide sleeve component,
which is also driven by a slow-speed handpiece. The perforator leads the guide sleeve
through the cortical bone and then is separated from it and removed. This leaves the
guide sleeve in place and allows for a 27-gauge needle to be inserted for injecting the
anesthetic solution. The guide sleeve is then removed with a hemostat at the end of
the appointment. The IntraFlow handpiece holds and drives a perforating needle
and an anesthetic cartridge, which is engaged via an internal clutch to deliver the local
anesthetic through the perforation.
One of the benefits of the IO injection is the reported immediate onset of anes-
thesia.50–58 The injection is recommended to be given distal to the tooth to be anes-
thetized.50–58 The exception to this rule would be the maxillary and mandibular
second molars, for which a mesial site injection would be needed. The perforation
site for the IO injection should be equidistant between the teeth and in the attached
gingiva to allow for the perforation to be made through a minimal thickness of tissue
and cortical bone and to prevent damage to the roots of the teeth. Perforation in
the attached tissue also allows for easier location of the perforation site with the Sta-
bident system. The X-Tip could be used in a more apical area below the mucogingival
junction if needed because the guide sleeve remains in place and therefore, there is no
difficulty in locating the perforation hole. This may also be attempted with the IntraFlow
system. The apical location of the injection would be advisable if the patient has no
attached tissue around the affected tooth, if there is a lack of interproximal space
between adjacent roots, or if the Stabident IO injection did not achieve adequate
anesthesia.
Research on the supplemental IO injection for patients diagnosed with irreversible
pulpitis has shown good results. Nusstein and colleagues8 found that a supplemental
mandibular IO injection using 1.8 mL of 2% lidocaine with 1:100,000 epinephrine had
a 91% success rate in attaining complete pulpal anesthesia when used after the IANB
injection failed. Parente and colleagues59 reported a success rate of 79% when they
used 0.45 to 0.9 mL of 2% lidocaine with 1:100,000 epinephrine. The addition of
a second IO injection increased their reported success to 91%. Reisman and
colleagues60 used 1.8 mL of 3% mepivacaine as a supplemental injection in mandib-
ular, posterior teeth diagnosed with irreversible pulpitis. They reported 80% success
with an initial IO injection and 98% success when a second IO injection of mepivacaine
was delivered. Bigby and colleagues61 studied 4% articaine with 1:100,000 epineph-
rine as an IO supplemental injection in posterior mandibular teeth diagnosed with irre-
versible pulpitis and reported an 86% success rate when the IANB injection failed. The
Stabident system was used in all these 4 studies.
242 Nusstein et al
Using the X-Tip system for the supplemental IO injection in patients diagnosed with
irreversible pulpitis, Nusstein and colleagues50 reported an 82% success rate when
using 1.8 mL of 2% lidocaine with 1:100,000 epinephrine in mandibular posterior
teeth. In this study, the injection site was 3 to 7 mm apical to the mucogingival junction.
The failures of the injection were attributed to backflow of the anesthetic out of the
guide sleeve during the injection. This backflow usually indicates an incomplete perfo-
ration or blockage of the guide sleeve. Remmers and colleagues62 used the IntraFlow
system as a primary IO injection in 15 patients diagnosed with irreversible pulpitis and
reported an 87% success rate. Their definition of success was 2 consecutive 80/80
readings with the EPT. They reported that failures were because of clogging of the
perforating needle and subsequent leakage of the anesthetic around the transducer
assembly. However, the study sampled a very small number of patients, and further
research is needed on the Intraflow system.
The duration of anesthesia for a supplemental IO injection in patients with irrevers-
ible pulpitis has been reported to last the entire debridement appointment of approx-
imately 45 minutes.8,49,60 The duration will be shorter with the 3% mepivacaine
solution.59
One of the concerns when using the IO injection is the reported transient increase in
heart rate with both the Stabident and X-Tip systems when injecting epinephrine- and
levonordefrin-containing anesthetic solutions.8,50–57,61,63 Replogle and colleagues63
reported that 67% of subjects had an increase in heart rate as measured on an elec-
trocardiograph when 1.8 mL of 2% lidocaine with 1:100,000 epinephrine was used.
The increase in heart rate ranged from 12 to 32 beats per minute.51,53,61,63,64 The
use of 3% mepivacaine has been reported not to cause any significant increase in
the heart rate63,65 and may be an excellent alternative when a patient’s medical history
or drug therapies contraindicate the use of epinephrine or levonordefrin.
Mandibular Buccal Infiltration Injection with Articaine

Recent research has looked at the use of a mandibular buccal infiltration injection of
4% articaine with 1:100,000 epinephrine as a supplemental injection to increase the
success of the IANB injection. In asymptomatic patients, the use of the articaine solu-
tion was found to be superior to the lidocaine solution (88% vs 71%, respectively,
when success was defined as achieving 2 consecutive readings of 80 with the EPT
and maintaining anesthesia for 60 minutes).66 Kanaa and colleagues67 reported
a success rate of 91% (2 consecutive readings of 80 during the test period) with
4% articaine with 1:100,000 epinephrine. However, when the buccal infiltration injec-
tion was used as a supplement to the IANB in patients diagnosed with irreversible
pulpitis, success was reported as only 58%.68 This result was much less than that
attained with the IO and PDL injections.
Intrapulpal Injection
In approximately 5% to 10% of mandibular teeth diagnosed with irreversible pulpitis,
supplemental injections (PDL and IO) do not produce adequate anesthesia, even when
repeated, to enter the pulp chamber painlessly. This is a prime indication that an intra-
pulpal injection may be necessary.
The intrapulpal injection works well when it is given under back-pressure.69,70 Onset
of anesthesia is immediate. Various techniques have been advocated in giving the
injection; however, the key factor is giving the injection under strong back-pressure.
Simply placing local anesthetic solution in the pulp chamber will not achieve adequate
pulpal anesthesia.
A disadvantage of the intrapulpal injection is its short duration of action (approxi-

mately 15–20 minutes). Once anesthesia is achieved, the practitioner must work
quickly to remove all the tissue from the pulp chamber and the canals. The intrapulpal
injection also requires that the pulp tissue be exposed to permit the injection to be
given. Achieving a pulpal exposure could be very painful to the patient because the
pain of treatment may begin when the dentin is exposed.8,50,60,61,70 The injection
can be very painful for the patient. The patient should be warned to expect moderate
to severe pain during the initial phase of the injection.
Preemptive Strategies to Improve Success of the IANB Injection
Recent clinical studies have looked at the use of oral medications before treatment of
a patient with a tooth diagnosed with irreversible pulpitis in hopes of improving the
success rate of the IANB injection. Ianiro and colleagues71 used pretreatment oral doses
of acetaminophen or a combination of acetaminophen and ibuprofen versus placebo in
patients undergoing endodontic therapy. They reported a trend toward higher success
rates (defined as no pain upon entering the pulp chamber) of 71% to 76%, respectively,
as compared with placebo (46%). These differences, however, were not found to be
significant. Galatin and colleagues72 used an IO injection of 40 mg of methylprednisolone
(Depo-Medrol) and found that it significantly reduced pain and use of medication in
untreated patients diagnosed with irreversible pulpitis when compared with patients
who received a placebo injection. Unfortunately, follow-up studies by Agarwala and
colleagues73 and Stein and colleagues74 using similar doses of methylprednisolone
failed to improve the success of the IANB injection.
Anxiety is believed to play a role in lowering pain thresholds, and the use of a seda-
tive agent to help increase the success of the IANB injection in patients diagnosed with
irreversible pulpitis was studied by Lindemann and colleagues75 This group used
sublingual triazolam and found that a dose of 0.25 mg given 30 minutes before treat-
ment failed to improve the success rate of the IANB as compared with placebo. They
concluded that, with conscious sedation, profound pulpal anesthesia was still required
to eliminate pain during endodontic treatment of a hot tooth.
SUMMARY
The dentist who treats patients diagnosed with a mandibular hot tooth (irreversible
pulpitis) will often find achieving adequate pulpal anesthesia to be a challenge. It
behooves each provider to develop a plan to deal with the eventual failures found
with the IANB injection. This plan needs to include the use of supplemental anesthesia
techniques. Whether the clinician’s training or preference is the PDL or IO injection,
these supplemental techniques have been shown to be quite effective in achieving
pulpal anesthesia for teeth with irreversible pulpitis. Being able to fall back on both
sets of techniques provides the dentist the confidence to provide relatively pain-free
treatment for the patient having a hot tooth.
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J Endod 2008;34(10):1167–70.
Modern Molar
Endodontic Access
a n d D i re c t e d D e n t i n
Conservation
a, b
David Clark, DDS *, John Khademi, DDS, MS
KEYWORDS
Molar Endodontic Access Dentin
During patient treatment, the clinician needs to consider many factors that will affect
the ultimate outcome. In simple terms, these factors can be grouped into 3 categories:
the operator needs, the restoration needs, and the tooth needs. The operator needs
are the conditions the clinician needs to treat the tooth. The restoration needs are
the prep dimensions and tooth conditions for optimal strength and longevity. The tooth
needs are the biologic and structural limitations for a treated tooth to remain predict-
ably functional. This article discusses molar access and failures of endodontically
treated teeth that occur not because of chronic or acute apical lesions but because
of structural compromises to the teeth that ultimately renders them useless. What
both authors have discovered in their respective practices through careful observa-
tions of failing cases and modes of failure, and observation of the truly long-term
(decades) successful cases, is that the current models of endodontic treatment do
not lead to long-term success. The authors want to coronally shift the focus to the
cervical area of the tooth and create awareness for an endorestorative interface.
This article introduces a set of criteria that will guide the clinician in treatment deci-
sions to maintain optimal functionality of the tooth and help in deciding whether the
treatment prognosis is poor and alternatives should be considered. This article is
not an update on traditional endodontic access, as the authors believe the traditional
approach to endodontic access is fundamentally flawed. Traditional endodontic
access has been endodontic centric, primarily focused on operator needs, and has
been decoupled from the restorative needs and tooth needs. Central to our philosophy
is that balance needs to be restored to these 3 needs, which are almost always in
conflict when performing complete cusp-tip to root-tip treatment.
Disclosure: Drs Clark and Khademi will receive a royalty from the sales of CK Endodontic Access
burs. http://www.sswhiteburs.com.
a
3402 South 38th Street, Tacoma, WA 98409, USA
b
2277 West 2nd Avenue, Durango, CO 81301-4658, USA
E-mail address: drclark@microscopedentistry.com
Dent Clin N Am 54 (2010) 249–273

250 Clark & Khademi
SETTING THE STAGE FOR CONTEMPORARY MOLAR ENDODONTIC ACCESS
Modern clinicians must factor the unique and dramatically higher biting force of the
molar tooth when designing the endodontic portion of the endo-endorestorative-pros-
thodontic (EERP) continuum. The occlusal forces created by the attachment position
of the elevator muscles to the mandible generate occlusal forces that vary dramatically
throughout the dentition, with light biting force in the front of the mouth to increasingly
heavier forces at the back of the mouth. In physics, the mandible with its hinged
access (the temporomandibular joint) is classified as a moment arm. The closer to
the hinge, the higher the moment, or force, applied. The ability of the incisor to splay
forward when loaded occlusally also comes into play when evaluating tooth stresses
during occlusal loading. However, the molar absorbs a more vertical force and, there-
fore, a significantly higher net compressive force. When these 2 factors are combined
(moment arm and splay), the overall compressive forces on the molar create a situation
that requires a different set of rules for the calculation of ferrule, post and core design,
resistance to fracturing, and (of utmost importance) endodontic access and removal of
radicular dentin during endodontic shaping.
There are also different forces. The incisor must withstand milder, but more oblique,
shearing forces. Most of the in vitro and in vivo research of post and core design has
been conducted on maxillary incisor teeth, and attempting to extrapolate these find-
ings to the molar tooth is not feasible. Placing a post in a round, husky maxillary ante-
rior root and subjecting it to mild shearing force has little relevance to placing a post in
a delicate, ovoid root in a mandibular molar and subjecting it to heavy compressive
force.
Box 1 presents a compelling argument for change, or, perhaps, a return to the pre-
Schilder era of directed dentin conservation. Many people were hopeful that the
promise of point number 1, the endodontic monoblock of bonded endodontic obtu-
rants, posts, and cores, could revitalize a hollowed-out tooth. This has not reached
fruition. Most restorative dentists are unaware of point number 2. Most have always
assumed that coronal composite restorations, especially those that are bonded to
enamel, strengthen the crown of the tooth and prevent coronal fracturing. This
common notion has created a false hope, as no such intracoronal splinting benefit
exists. Point number 4 eliminates posts as a reconstructive asset in molars. Point 5
presents the troubling fact that altering the thickness of radicular dentin, especially
in the ovoid and fluted root, predisposes the root to fracture. Yet the dentin in the
endodontically treated tooth has virtually the same strength and moisture content
as a tooth with intact pulp. Root fractures in endodontically treated teeth should be
considered as iatrogenically generated, not because of any fault of the tooth. The
authors have exhausted the means to reinforce the endodontically treated molar
stump, and now realize that dentin is the key.
Box 1
Current research and restorative trends
(1) The failure of the endodontic monoblock1

(2) The failure of intracoronal splinting using adhesive dentistry2
(3) The resurgence of partial coverage posterior restorations
(4) The recognition that molars do not benefit from placement of posts3
(5) Crack initiation in stress tests of endodontically treated roots4,5
Molar Endodontic Access and Dentin Conservation 251
Endodontic accesses are traditionally conservative to the occlusal/incisal tooth

structure. However, with the changes that occur in restorative dentistry, this technique
is unnecessarily restrictive for the operator and potentially damaging to the more crit-
ical cervical area of the tooth.
The following case is representative of a large percentage of endodontic accesses
performed by general dentists and endodontists. This story is replayed each day in the
United States and Canada. Fig. 1 shows a lower first molar of a 20-year-old woman.
These young teeth are dangerously hollow to begin with. By the time that both of these
well-meaning dentists had finished with the tooth, the molar was nearly worthless. The
most important structures were so badly compromised that the tooth was perma-
nently crippled.
The general dentist created the first access using fissure burs and with the type of
dentin removal that is the standard today (Fig. 2A). The tooth was then reaccessed by
an internationally recognized endodontist (Fig. 2B, C). This model for generous
removal of pericervical dentin is common in many specialty practices. Eighteen
months later, the lesion on the mesial root continues to enlarge (Fig. 3). In the authors’
practices, such a tooth does not warrant endodontic retreatment. The wholesale loss
of PCD has reduced the value of this tooth to the point that, when the tooth becomes
symptomatic, extraction and replacement with an implant is a better option. In fairness
to their patients, dentists must change the process, or make implants a first option
instead of the eventual option. The new model of endodontic access is superimposed
over the tooth in Fig. 4.
In summary, directed dentin and enamel conservation is the best and only proven
method to buttress the endodontically treated molar. No man-made material or tech-
nique can compensate for tooth structure lost in key areas of the PCD. Molar access,
key to endodontic success, should also be considered as the key to restorative
success and to long-term retention of the molar tooth. The primary purpose of the
redesigned access is to avoid the fracturing potential of the endodontically treated
molar.7 For expediency, molar fracturing can be described as retrograde vertical
root fracture; midroot vertical root fracturing; oblique root/crown fracturing; and hori-
zontal, oblique, and vertical coronal fracturing.
A NEW MODEL FOR ENDODONTIC ACCESS
As endodontic access is deconstructed, it is crucial to understand the 5 catalyst

forces that will change the future of endodontic access and coronal shaping. They are:
Fig. 1. Preoperative view of tooth #19 in a 20-year-old woman.

252 Clark & Khademi
Fig. 2. (A) The deroofing problem. The likely bur used by the referring general dentist is
a 56 carbide; one of the most popular burs in dentistry,6 it is possibly the most iatrogenic
instrument in modern medicine. Red arrow delineates the typical gouging. (B) Postoperative
view provided by the endodontist. Blue arrow indicates the grossly excessive dentin removal
of pericervical dentin (PCD). This serious gouging is typical of round bur access. Yellow
arrow indicates the large canal flaring with unacceptable dentin removal (blind funneling).
(C) Green circle highlights worsening lesion on mesial root ends.
1. Implant success rates

2. Operating microscopes and micro-endodontics
3. Biomimetic dentistry
4. Minimally invasive dentistry
5. Esthetic demands of patients.
In both of the authors’ practices, the endodontic goals and armamentarium have
been in a constant state of flux for nearly a decade as we have collaborated to bring
the EERP continuum to maturity. The goal is to satisfy the demands of the big 5 forces
for change mentioned earlier. In so doing, we have come to realize that, when cutting
endodontic access, our previous needs as dentists were often in conflict with the
needs of the tooth.
Table 1 presents the hierarchy of needs to maintain optimal strength, fracture resis-
tance, and several other characteristics needed for long-term full function of the
endodontically treated tooth. Banking of tooth structure is key and is age- and
case-sensitive. For example, in the case of the importance of pericervical enamel,
the cementoenamel junction (CEJ) is an invaluable asset in the physiologically young
molar. Margins of direct and indirect restorations placed on enamel have been shown
Fig. 3. Eighteen-month follow-up. Despite generous access and aggressive canal enlarge-
ment, the lesion on the mesial root continues to enlarge.
Fig. 4. A more appropriate access shape is overlayed. Partial deroofing and maintenance of
a robust amount of PCD is demonstrated. A soffit that includes pulp horns on mesial and
distal is depicted.
to be more caries resistant than margins on dentin. The CEJ is also the most ideal
vehicle to transition the stress from crown to apex.
Three-dimensional Ferrule
Three-dimensional ferrule is the backbone of prosthetic dentistry and has historically
been described as axial wall dentin covered by the axial wall of the crown or bridge
abutment. Ferrules are frequently used outside of dentistry. For example, in musical
instruments, a ferule is a metal band used to prevent the ends of wooden instruments
from splitting. Compression fittings for attaching tubing (piping) commonly have
ferrules in them. A swaged termination type for wire rope or the cap at the end of
a cane or umbrella are ferrules. In pool and billiards, the portion of a cue that tops
the shaft and to which the leather tip is bonded is a ferrule. In fishing, the male and
female joints that join one section of a rod to the next are known as ferrules.
Research varies on the minimal vertical amount required, but the range of absolute
minimums is from 1.5 mm to 2.5 mm.8–23 The clinician must remember that buildup
material, although necessary, does not count toward ferrules. A more comprehensive
view of ferrules is needed, and is embodied in the term three-dimensional ferrule (3DF).
There are 3 components of the new ferrule; first is the vertical component, which was
Table 1
The hierarchy of tooth needs for posterior teeth
Value to the Tooth Tissue Type

High PCD
Undermined dentin
The D2J
Axial wall DEJ
Cervical enamel in the physiologic young tooth
Medium Coronal enamel
Low 2 dentin
No value or liability 3 Dentin
Undermined enamel
Inflamed pulp in mature teeth
Cementoenamel junction in physiologically aged tooth
or in root caries–prone patient
254 Clark & Khademi
described earlier, and is the traditional ferrule. The second component is dentin girth
(thickness). The absolute minimum thickness is 1 mm; however, 2 mm is obviously
a safer number. Girth becomes more important closer to the finish lines of the prepa-
ration. The thickness of the remaining dentin (the wall thickness) between the external
surface of the tooth at the finish line and the endodontic access is more important
apically. Further, progressing apically down onto the root surface in the endodontically
treated tooth, the wall thickness can vary considerably and can become thin in places,
especially if large coronal shaping or flaring was done during the endodontic treat-
ment. Thus, axially deep finish lines on root structure can be extremely damaging to
3DF. Gutta percha is an exceptionally poor core material. The third component is total
occlusal convergence (TOC) or net taper. TOC is the total draw of the 2 opposing axial
walls of the prepared tooth to receive a fixed crown. A net taper or TOC of 10 requires
3 mm of vertical ferrule; a TOC of 20 requires 4 mm of vertical ferrule.24–37 Deep
chamfer marginal zones, common with modern porcelain crowns, typically have
a net taper of 50 or more, and therefore many modern esthetic margins lose a milli-
meter or more of their original potential 3DF at the crown margin interface. In short,
typical modern porcelain crown prep has less 3DF than the corresponding gold crown
prep. Hence, the need for directed dentin conservation during endodontic access
becomes even more crucial, and, at the same time, the volume of dentin removed
in the axial direction should be questioned in the modern era of high-strength zirconia
core crowns that actually allow minimal axiomarginal reduction. In certain case types
and finish line designs, the degree of apical placement of the finish line can affect the
ferrule quality, as mentioned earlier. Light axiomarginal reduction coupled with apically
placed finish lines and a nonzero-degree emergence profile of the restoration can
provide high 3DF. The concept of 3DF incorporates an interplay between these factors
that, in sum, indicate the true ferrule quality.
Undermined Enamel Versus Undermined Dentin

Because undermined enamel has not been shown to be strengthened by resin resto-
rations, it becomes a liability because of fracture potential, poor C factor, and as
a physical and visual obstruction to the endodontic operator. Conversely, because
dentin acts as a trimodal composite, it can be of great value to the tooth whether
the undermined dentin occurs naturally, such as the soffit, or from previous restor-
ative/endodontic treatment. It is important to clarify that the act of purposely under-
mining dentin for mechanical retention of restorative materials or when using round
burs in endodontic access is no longer indicated in contemporary restorative and
endodontic dentistry. Enamel is essentially a crystalline structure and is therefore
naturally supported 100% by dentin. Dentin, by contrast, is a multilevel composite
that can stand alone and acts ideally as a semirigid pipe.
PCD
PCD is the dentin near the alveolar crest. Although the apex of the root can be ampu-
tated, and the coronal third of the clinical crown removed and replaced prosthetically,
the dentin near the alveolar crest is irreplaceable. This critical zone, roughly 4 mm
above the crestal bone and extending 4 mm apical to the crestal bone, is important
for 3 reasons: ferrule, fracturing, and dentin tubule orifice proximity from inside to
out. The research is unequivocal; long-term retention of the tooth and resistance to
fracturing are directly related to the amount of residual tooth structure.9,11 The more
dentin is kept, the longer the tooth is kept.
SACRIFICE VERSUS COMPROMISE
In the featured case, significant dentin was sacrificed to facilitate expedient and safe
(avoidance of rotary file separation) instrumentation. No compromise was made in
creating a direct pathway to the apices allowing copious irrigation and full vertical
compaction of heated gutta percha, and yet the endodontic treatment was failing.
Contrast that case with the tooth in Fig. 5. There was a significant compromise
when the dentist, 20 years ago, stopped removing dentin when he or she could not
find the canal systems and filled less than half of the distal root. Yet the poor
endodontic result is successful, the well-preserved PCD has buttressed the tooth,
and the overall case is a still a success after 20 years. The authors have seen many
cases of seemingly poor endodontic results that have defied current and conventional
endodontic wisdom. Without detracting from the Schilder Objectives, the case types
that seem to be lacking in the long-term are those with the appearance of high-quality
endodontics, namely generous endodontic access, continuous taper, and large
shape, facilitating the compaction of warm gutta percha.
LOOK, GROOM, AND FOLLOW: SHAPING VERSUS MACHINING

(1) Why are Gates Glidden (GG) burs so problematic? Since the introduction of
rotary files, GG burs have been used more aggressively and with more reliance
on larger sizes (4, 5 and 6) to reduce binding and fracture of rotary files. Gates
burs have always been considered safe because they do not end cut and are
self-centering. There is a significant problem here, which is cervical self
centering. Because the shank of the GG is so thin, it is difficult to steer the
GG away from high-risk anatomy. As the GG straightens the coronal or high
curve, it can shortcut across a fluting or furcation and weaken or even create
strip perforations (Fig. 6). Dr Clark has abandoned, and Dr Khademi has
severely curtailed, the use of GG burs in their respective practices.
(2) Why are round burs so destructive? The traditional method of initiating
endodontic access is predicated on mental models that do not represent the
day-to-day clinical reality presented to the clinician. Many texts shows the
same round bur technique relying on tactile feedback as the round bur drops
into the chamber (Fig. 7).
Fig. 5. Radiographically ugly but clinically successful (20 years) endodontic treatment. This
case was likely done on a vital tooth. Residual PCD has buttressed this tooth to avoid
fracture.
256 Clark & Khademi
Fig. 6. Extensive coronal flaring results in extrusion of obturation material in the furcation.
The furcal strip perforation is a perfect example of the dangers of blind funneling with GG
burs.
These kinds of images, so frequently shown in dental school, textbooks, and

lectures, are predicated on mental models based on occlusal decay in children. If
the pulp chamber is sufficiently large, then a round bur can truly drop in to the pulp
chamber, as shown in Fig. 8, with a #6 round bur superimposed on the lower molar
of an 11-year-old child.
The reality of day-to-day clinical practice is far removed from this, and these deeply
ingrained mental models are a setup for occult iatrogenic trauma. More realistically,
Fig. 7. Texts frequently show the same round bur technique relying on tactile feedback as
the round bur drops into the chamber. (From Ingle JI, Beveridge EE. Endodontics. 2nd
edition. Lea and Febiger; 1976. p. 132 (plate XII), 148 (plate XX), 157 (plate XXIV); with
permission.)
Fig. 8. If the pulp chamber is sufficiently large, then a round bur can drop in to the pulp
chamber, as shown here with a #6 round bur superimposed on the lower molar of this
11-year-old child.
the case shown in Fig. 9 is more representative of the spectrum of cases typically pre-
senting for endodontic treatment. Clearly, trying to drop a round bur into the scant or
nonexistent chamber is not going to lead to the desired outcome even for a skilled
clinician. Instead, the size of the burs relative to the chambers, the omnidirectional
cutting blades (which side cut aggressively), and chatter common with this bur design
are much more likely to lead to the kinds of outcomes seen in Figs. 2 and 3.
Fig. 9. The case shown here is more representative of the spectrum of cases typically pre-
senting for endodontic treatment. Trying to drop a round bur into the scant or nonexistent
chamber is not going to lead to the desired outcome even for a skilled clinician.
258 Clark & Khademi
So although round burs are destructive because they contribute to, or exacerbate,
these problems, it is really the tactile-based mental models predicated on these kinds
of drawings showing round burs dropping into the pulp that are the ultimate problem.
Care and magnification can compensate, but only to a degree (Fig. 10).
(3) Why is complete deroofing so dangerous? When the authors first began to main-
tain a soffit, which is a small piece of roof around the entire coronal portion of the
pulp chamber, it seemed sloppy and contradicted the compulsive nature of
traditional dentistry that has made complete deroofing a mark of a thorough
clinician. The pulp seemed difficult to remove under the tiny eve and the removal
of sealer and gutta percha was equally difficult. It just seemed wrong. Today it
makes perfect sense; cleanup is easier and the authors take pride in this impor-
tant advance in minimally invasive access. It is a perfect example of banked
tooth structure. However, it is the attempts at removing the soffit that are far
more damaging to the surrounding PCD. The idea that a round bur can be drop-
ped below this soffit and drawn coronally to unroof the chamber is predicated on
large pulp chambers and exceptional hand skills. Clinically, it is impossible. At-
tempting to remove the pulp chamber roof does not accomplish any real
endodontic objective, and invariably gouges the walls that are responsible for
long-term survival of the tooth. The primary reason to maintain the soffit is to
avoid the collateral damage that usually occurs, namely the gouging of the
lateral walls. Research will certainly need to be done to validate the strength
attributes of the roof strut or soffit. However, in the absence of a compelling
Fig. 10. Blue arrows indicate gouges. Red arrows indicate perforations. Essentially, all previ-
ously accessed molars were gouged to some degree. The first upper and lower molar cases
show what many might consider acceptable access extension, and were obviously cut with
round burs. Both are gouged. The third upper and lower cases have frighteningly thin
pulpal floors with blushing dentin. The upper fourth case is deceptive in that it is perfo-
rated, whereas the worse-looking lower case is not, but the pulpal floor is thin. The last
upper molar case (which has a class V resorption repair) shows what is possible with practice,
microscope level magnification, an assistant, and the right instruments. The lower molar
shows the type of access that should be routinely achievable with high-powered loupes
and the right instruments. (JK indicates that the case was done by John Khademi with
adherence to the modern model of directed dentin conservation.)
reason to remove dentin, our default position should always be conservative.

This 360 soffit or roof-wall interface can also be compared with the metal
ring that stabilizes a wooden barrel. Inference to the second moment of inertia
in structural engineering deserves analysis. The second potential benefit, as
described earlier, is embodied in the physics model of the second moment of
inertia. An ideal example of second moment of inertia is the I beam. The second
moment or furthest point of the I portion away from the center of the beam, or
centroid, determines the resistance to bending. Maintaining dentin as it rounds
a corner places it far from the cervical area, which is often where fracturing initi-
ates in the endodontically accessed molar. More important than the soffit itself,
however, is the preservation of axial wall dentin near the soffit.
Presuming one could drop into the pulp chamber in the way described earlier (see
Fig. 7), the chamber roof is now to be removed by scooping it up and away with
a round carbide. A two-dimensional drawing with the small size of the bur and
chamber roof overhanging a large pulp chamber makes this seem like a reasonable
proposition. The chamber walls are always drawn flat even though they are cut by
a round bur.
In practice, it is impossible to cut flat walls in 3 dimensions with a round instrument.
The chamber is not unroofed in some areas, leaving pulpal and necrotic debris with no
specific subsequent step to address the debris, yet the walls are overextended and
gouged in other areas. Further, the internal radius of curvature at many of the pulp
chamber line angles is simply too small for all but the smallest of round burs.
In the final analysis, round burs point cut in an endodontic access application,
whereas what is needed is planing. What is needed is a new set of mental models
based on vision, and a new set of instruments reflective of the task at hand and the
desired shaping outcomes. The new vision-based mental model is Look, Groom,
Follow. The new burs are all round-ended tapers (Fig. 11).
It is appropriate to provide updated cavosurface outlines and cross-sectional illus-
trations for initial access for the maxillary and mandibular molars (Table 2).
CAVOSURFACE AND CROSS-SECTIONAL ILLUSTRATIONS

FOR MAXILLARY MOLAR ACCESS
Traditional textbooks devote considerable length and effort on drawing access outline
forms that are done on restoration-free, caries-free teeth. The authors hesitate to
provide access outline drawings as there are so many variables that enter into the
formula on real clinical cases. Within this context, the authors provide these drawings
as a guideline for accessing full coverage gold or porcelain for cases in which the
underlying restorative materials, the presence or absence of decay, and the locations
of sound dentin cannot be ascertained. When in doubt, a larger outline form through
the restorative should be cut, but only to the level at which dentin is encountered.
Then, the access should be vision based, cuing from the color map and the presence
of any PTRs that can be identified. This method is a stepped access, in which an inten-
tionally over-enlarged access is made through the cavosurface of a restored tooth
(typically a crowned tooth) to the level at which dentin is encountered, then the access
steps in to the size of the pulp chamber outline.
The occlusal view drawing shows an inner outline form in black, requiring the most
sophistication in skill and magnification. Suggested extensions for clinicians at
different points along the experience/magnification curve in blue and green show
extension and enlargement, primarily toward the mesial and buccal. These should
be primarily interpreted as the direction to strategically extend the access based on
260 Clark & Khademi
Fig. 11. Comparison of the CK endodontic access bur with the corresponding round bur. The
tip size of these burs is less than half as wide as the corresponding round bur. One of the
prototype CK endodontic access burs (right) is shown and contrasted with the correspond-
ing surgical length round bur (left). These burs, designed by Drs Clark and Khademi, will be
available from SS White Burs, Inc.
experience/magnification and case difficulty as opposed to absolute outline forms.

The angles of entry into the canal system are unlikely to be perpendicular to the
occlusal surface. The access rarely needs to be significantly extended to the distal
or palatal, as the angle of entry to the palatal canal is out to the mesio-buccal (MB)
(Fig. 12), and the distal is toward the mesio-palatal (MP) (Fig. 13). The MB and MB2
angles of entry are generally from the distal, and can also be from the palatal (Figs.
14 and 15).
Table 2
The 6 types of molar cavosurface and chamber access
Restorative Case Type Cavosurface Angle (To Occlusal Table)

Nonmutilated molar to receive bonded 1 mm of anatomic flattening (2 mm cusp tip
indirect onlay or composite onlay flattening); then 45 angle of penetration
until reaching the dentinal map (Fig. 20)
Nonmutilated molar to receive full crown 1.5 mm of anatomic flattening (2.5 mm cusp
tip flattening); then 45 angle of
penetration until reaching the dentin map
Mutilated molar to receive full crown 2–3 mm of flattening
Gold crown to be retained 80 angle of penetration until reaching the
dentin map
PFM crown to be retained 45 angle of penetration through the crown
until reaching the dentin map
Zirconia based porcelain crown* to be 70–90 angle of penetration until reaching
maintained the dentin map
* As of date of publish, most zirconia based crowns including Lava tm and Procera tm have non
etchable cores and non etchable stacked porcelains.
Fig. 12. The angle of entry to the palatal canal is out to the MB.
An access extension or modification that is frequently needed is the fluting or notch-

ing of the mesial wall in the area of the MB2. This requirement is due to the pattern of
calcification that often places the angle of entry to the MB2 at an untenable distal
angle. This notching can be performed in dentin with a BUC-1 ultrasonic tip, and, if
need be, extended into restorative using an LAAxxess nipple-tipped diamond. This
case (Fig. 16) shows a preliminary access with a slight amount of fluting (Fig. 17). A
closeup shows the finished fluting in the prepared case, and the overall sizes of the
access through the porcelain fused to metal (PFM) (crown) and the dentin (Figs. 18
Fig. 13. The angle of entry to the distal canal is out to the MP.
262 Clark & Khademi
Fig. 14. The MB angles of entry are generally from the distal side.
and 19). A frequent criticism of the techniques demonstrated here is that these more
precise shapes preclude the discovery of coronal points of negotiation (PONs), and
deep anatomy, and preclude the development of condensation hydraulics. The
authors have not found this to be the case. In this case with an apparent confluent
MB/MB2, precurved files were introduced with intent on the palatal aspect of the
MB2, which often contains a deep split. The wire radiograph shows the 2 larger files,
1 in the MB orifice and 1 in the MB2 orifice joining, and a smaller file, also in the MB2
Fig. 15. The MB2 angles of entry can also be from the palatal side.
Fig. 16. Preoperative condition.
orifice branching deep to a separate portal of exit (Fig. 20). The completed case is
shown in Fig. 21.
As discussed earlier, these should be interpreted more as guides on how and where
to extend, rather than as absolute extension guidelines. The first 2 buccal views show
a large pulp chamber (Fig. 22), and a raw Clark/Khademi (CK)-style access with small
Fig. 17. Initial access, slight fluting.

264 Clark & Khademi
Fig. 18. Closeup fluting (arrow).
soffits of chamber roof left to be debrided later (Fig. 23). The next buccal view is an
overlay of the CK-style access, a more traditional occlusally divergent access, and
an access taken from a recent text showing fairly parallel walls, but grossly overex-
tended cervically (Fig. 24). The second set of overlays shows the CK-style access
with blue and green extensions, with cavosurface finish lines appropriate for a bonded
Fig. 19. Access with probe.

Fig. 20. Working radiograph.
substrate with a bonded restorative, which are described later (Fig. 25). The mesial
view shows the various extensions, again emphasizing the directions to extend as
opposed to exact amounts and locations (Fig. 26). The extension is not balanced
equally between buccal and palatal, but favors the buccal.
The guiding principles and strategy on access and access extension should recog-
nize the hierarchy of tooth needs listed in Table 1. Restorative materials should almost
Fig. 21. Final radiograph.

266 Clark & Khademi
Fig. 22. Buccal view with normal pulp.
always be sacrificed before tooth structure. More occlusal tooth structure should be
sacrificed for more cervical tooth structure. The key pericerivcal tooth structure should
remain as untouched as possible.
Final cavosurface outline extension at the finish appointment (which may be the
start appointment on a 1-step case) hinges on the existing restorative, and the restor-
ative plan. If abundant highly bondable substrate such as etchable porcelain or
Fig. 23. Buccal view with CK access and soffit (arrows).

Fig. 24. Buccal view with access overlays.
enamel is available, and a bondable restorative material such as a heavily filled

composite resin is planned, the cavosurface should be Cala Lillied (Fig. 27), or gener-
ously beveled on those areas. If the bondability of the substrate is of low, or a bond
cannot be established between the substrate and restorative material, a butt joint or
70 to 90 interface at the cavosurface should be the objective. On multiple visit cases
in which an unbonded temporary restoration is placed, the cavosurface should be
maintained at 70 to 90 until the completion visit.
Fig. 25. Buccal view with various extensions.

268 Clark & Khademi
Fig. 26. Mesial view with various extensions.
CAVOSURFACE AND CROSS-SECTIONAL ILLUSTRATIONS

FOR MANDIBULAR MOLAR ACCESS
These illustrations are consistent with the style of access demonstrated in the maxil-
lary molar section earlier (generously flared and flattened when appropriate in the
coronal third of the tooth, then conservative in the middle and apical portion of the
coronal portion of the tooth).
The first step in contemporary molar access in the noncrowned tooth is flattening. It
is a step that is ignored or overdone in most practices.
GUIDELINES FOR TREATMENT DECISIONS
There have been some consistent patterns in what the authors have observed in their
practices with the long-term successful cases. These observations are important for
Fig. 27. Traditional parallel-sided access (left), compared with the Cala Lilly enamel prepa-
ration (right). (Left) Unfavorable C factor and poor enamel rod engagement are typically
present when removing old amalgam or composite restorations or with traditional
endodontic access of 90 to the occlusal table. (Right) The enamel is cut back at 45 with
the Cala Lilly shape. This modified preparation will now allow engagement of nearly the
entire occlusal surface.
2 reasons: (1) they can serve to direct how virgin endo/restorative cases planned for
treatment are managed; (2) they can help the endodontist quickly decide whether
retreating failing prior treatment is even worth investigating. Although it would be
advantageous for the treating clinician to have objective randomized clinical trials
(RCTs) on the factors related to long-term endodontic success, there is a dearth of
RCTs of longer than 20 years to guide the clinician with the real variables related to
long-term success. The authors are, however, able to observe the cases presenting
to their practices. These observations contradict contemporary endodontic thinking,
yet, when put to the test, remain essentially unchallenged. They are certain to cause
controversy in the endodontic community:
(1) Long-term, that is, 20- to 40-year, success of the endodontically treated tooth has
little to do with what would be traditionally characterized as the quality of the
endodontic result.
(2) Preservation of dentin trumps quality endodontics when evaluated over a time
frame of 20 to 40 years.
The Three Strikes Rule

In endodontically treated cases from 20 to 40 years ago, the authors have observed
consistently that these teeth are violated in less than 3 ways. The cases that truly
go the distance have damage in 2 or less of the following clinically controllable
variables:
(1) Excessive axial reduction (consistent with PFM or all-porcelain restorations)

(2) Gouged endodontic access
(3) Large and arbitrarily round endodontic shape.
The authors would contend that teeth that are violated in 3 or more ways simply do
not go the distance. All 3 of these violations are insults to the PCD, and if all 3 are
present, the loss of PCD is irreparable and the tooth is permanently compromised
or destroyed. When the clinician is evaluating a case for possible treatment, it is far
more advantageous and expedient to evaluate the restorative aspects of the case first.
One should ask: ‘‘Presuming successful endodontic treatment, what is left to work
with?’’ For instance, if the distal half of the tooth is severely decayed, but the patient
has adequate opening, the access can be distalized, directing dentin conservation to
the mesial half of the tooth, leaving the opportunity for enough 3DF.
With retreatment cases, the rationale is the same, and the question to ask, before
even considering the endodontic issues, is: ‘‘How many ways has this tooth been
violated?’’ If the tooth has been violated 2 or more ways (ie, 3 strikes), it is exception-
ally unlikely that a long-term result can be delivered to the patient with even the most
exceptional endodontic care.
GLOSSARY OF TERMS FOR CONTEMPORARY MOLAR ENDODONTIC ACCESS
The endodontic-endorestorative-prosthodontic (EERP) continuum
The EERP is a restoratively driven view of the endodontics as simply a servant to the
restoration and preservation of the tooth, concurrent with a complete integration of
endodontic design as part of an interlocking series of components. From crown to
apex an outside fortress of fracture resistance, and from inside to outside a set of fire-
walls for leakage prevention. Biomimetics and minimally invasive dentistry are guiding
270 Clark & Khademi
principles. Each component must compliment, not compromise, the other compo-
nents. If at any point in the diagnosis, access, endodontic shaping, or obturation a crit-
ical compromise is discovered, the ethical directive demands that extraction and
implant placement must be considered in lieu of continuation of the attempt to retain
the tooth.
Three-dimensional ferrule (3DF)
3DF is an evaluation of the available dentin that will buttress the crown. The 3
components are dentin height, dentin girth (dentin thickness), and TOC (total draw
of the opposing axial walls; buccal-lingual and mesial-distal).
Pericervical dentin (PCD)
PCD is defined as the dentin near the alveolar crest. This critical zone, roughly 4 mm
coronal to the crestal bone and extending 4 mm apical to crestal bone, is crucial to
transferring load from the occlusal table to the root, and much of the PCD is
irreplaceable.
Banked tooth structure
The approach of banking of tooth structure in restorative dentistry dictates that

whenever possible, more tooth structure should be left in place than is needed for
the procedure at hand. It may involve a less expedient, but more conservative,
approach. This banked tooth structure may serve as a valuable future asset in the
advent of unforeseen future trauma or disease, coupled with the reality that a tooth
will need to last for decades and potentially be restored and then rerestored in the
patient’s lifetime.
The inverse funnel
An undesirable endodontic access shape in which the size of the access becomes
wider as it progresses deeper into the tooth. It is a common occurrence when con-
stricted cavosurface access opening size is paired with round bur use. It is exacer-
bated when advanced magnification is not used during tooth cutting.
Blind tunneling
Blind tunneling is another undesirable endodontic access approach and shape that
creates a parallel sided access when performed without advanced magnification,
relying on tactile feedback rather than on microscopic visualization and following
the dentinal maps of primary, secondary, and tertiary dentin and microscopic traces
of residual pulp tissue. Typically performed with round burs.
Blind funneling
Blind funneling is another undesirable access shape, common in generalist and

endodontic specialist practices. This popular practice obliterates significant tooth
structure to facilitate rapid and safe (avoidance of file separation) machining of the
roots with rotary files.
Filling and caries leveraged access
Partial deroofing
Soffit
Stepped access
Secondary dentin (2 dentin)
Tertiary dentin (3 dentin)

Biomimetic endodontic shaping (BES)
Arbitrary round shaping (ARS)
The dentinal map
The dentinoenamel junction (DEJ)
The junction of primary and secondary dentin (D2J)
The junction of primary and tertiary dentin (D3J)
Pulp tissue remnants (PTRs)
The Cala Lilly
Fig. 27 highlights the creation of the Cala Lilly cavity shape. The Cala Lilly is a flower
and is the new model for composite preparations.
Points of negotiation (PONs)
PONs are statistically predictable anatomic areas that may serve as starting points
during the access portion of endodontic therapy.
Italicized points indicate an undesirable outcome or technique.
ACKNOWLEDGMENTS
Dr Clark would like to thank Dr Jihyon Kim, Dr Eric Herbransen and Dr Marc Balson,
for their input and unwavering support.
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C a s e S t u d i e s in
Modern Molar
Endodontic Access
a n d D i re c t e d D e n t i n
Conservation
a, b
David Clark, DDS *, John A. Khademi, DDS, MS
KEYWORDS
Maxillary Composite Pulp horn Molar
The following case studies provide insight into the integration of the principles set
forward in the preceding article. Each case is evaluated first on the endorestorative
principles that form the basis of the modern endo-endorestorative–prosthodontic
continuum. Endorestorative needs should, whenever possible, trump previous notions
of endodontic needs.
Case 1 is provided by Dr Clark, and cases 2 to 6 are provided by Dr Khademi. Dr
Clark’s provides a stark contrast between the old and new models of endodontic
access and shaping. Dr Clark then risks avoiding postplacement but also avoids the
mutilating effects of a full crown by instead providing a minimally invasive restorative
technique using direct composite to permanently splint the tooth for ideal function.
Case 2 shows the possibilities in a maxillary molar when an emphasis is made on
banking of coronal and pericervical dentin (PCD). The conscientious preservation of
tooth structure during access and endodontic shaping allows a second, and possibly
third, prosthesis (crown) during the patient’s lifetime.
Case 3 is an ideal study of the realities of day to day endodontic access. This
thought provoking access teaches that the authors are not accessing a crown, but
accessing the root through the crown. This tipped and rotated maxillary molar; is
also mutilated and coronally altered with a PFM crown creating a mirage that could
easily lead to gouging and even perforation unless the operator follows the disciplined
approach outlined in the text.
Case 4 is an access through another PFM crown. The importance of proper access-
ing through full crowns should not be underestimated, as the pulpal death rate from
a full crown procedure has been documented in some studies to be well over 20%.
a
3402 South 38th Street, Tacoma, WA 98409, USA
b
2277 West 2nd Avenue, Durango, CO 81301-4658, USA
E-mail address: drclark@microscopedentistry.com
Dent Clin N Am 54 (2010) 275–289

276 Clark & Khademi
Fig. 1. (A–T) Case 1, the nonmutilated lower first molar to receive a direct composite onlay.
This maxillary first molar demonstrates 6 canal systems, three in the mesio-buccal root
alone. The aggressive lateral removal of PCD to access the MB-2 canal system is the
only such example shown in the chapter, and is warranted because the enormous
amount of dentin present in this unique zone and the dangers associated with the
extremely high curve of the MB-2.
Case 5 is a hallmark of both non traditional and carefully individualized access. It is
the best example of capitulation to the hierarchy of tooth needs of all the cases pre-
sented in the chapter.
Case 6 demonstrates the futility of the round bur in endodontic access. The roof of
the calcified lower molar chamber is sawed off and broken loose with a tapering
Case Studies 277
Fig. 1. (continued)
diamond or carbide followed by a prying excavator, not blindly and clumsily burrowed
into with a round bur.
The reader is encouraged to visit and revisit these cases to fully absorb the anatomic
and restorative techniques that are simultaneously presented in this very unique
method of case presentation.
CASE 1: THE NONMUTILATED LOWER FIRST MOLAR TO RECEIVE A DIRECT

COMPOSITE ONLAY
The preoperative bitewing (Fig. 1A) depicts what seems to be a very shallow and
minimally invasive class I composite, but the periapical radiograph reveals periapical
278 Clark & Khademi
Fig. 1. (continued)
infections, indicating that the pulp must have been exposed at the time of treatment.
Fig. 1B shows a low-magnification view of the occlusal surface of tooth No. 30.
Fig. 1C is a high-magnification view (8) of the occlusal surface. The composite resto-
ration seems to be minimally invasive and relatively well sealed. Fig. 1D shows that as
a saucer-shaped cut is made to explore the composite restoration and to begin
endodontic access, the bur is angled at 45 instead of being parallel to the long
axis of the tooth. There was a lack of bond and carious invasion along the wall of
the composite restoration. This is an extremely common problem for the parallel-sided
composite preparations of today. Previously exposed mesiolingual (ML) pulp horn is
highlighted with red arrow.
Fig. 1E shows a 24 magnification view, revealing that there is no such thing as
a small pulp exposure. The pulp chamber is now accessed by leveraging into the
chamber through the filling and caries base of operation. A small sacrifice of additional
enamel with a 45 enamel wall would have allowed an ideal restorative seal and could
have aided the clinician to avoid burrowing into and subsequently failing to recognize
the pulp horn. Similarly, a 45 opening through the enamel for endodontic access
allows better visualization, better enamel engagement, improved C factor, and
improved ability to splint the tooth with direct composite. Fig. 1F–J were captured
with a traditional flash (as opposed to coaxial microscopic light) to demonstrate the
good access and lighting that is possible when delicate flattening and a 45 initial
penetration is performed. In spite of what initially seems to be an insufficient cervical
enlargement of the chamber, the cavosurface preparation allows reasonable
endodontic access and light while maintaining generous cervical dentin.
Multiple angles of the anatomic shortening of the corona of the tooth are shown in
Fig. 1K, L. As discussed later, it is of utmost importance to retain large islands of
enamel on the occlusal of the molar tooth to avoid overreliance on dentin bonding
to retain the bonded onlay. A clearance range of 1 to 2 mm is adequate for proper
strength of modern microfilled composites. The rough polish of the composite onlay
is demonstrated in Fig. 1O. Fig. 1P, Q shows the final polish after occlusal adjustment.
Dr Clark is confident that the patient would enjoy a 10- to 20-year service from the
Case Studies 279
restoration. It is the least invasive of all of the options required to splint the endodon-
tically treated molar.
Three differently angled radiographs of the finished cusp tip-to-apex endodontic treat-
ment are shown in Fig. 1R. Fig. 1S shows the first angled radiograph. The green arrow
marks the 1.25-mm cuspal coverage, whereas the yellow arrow marks the soffit of dentin
that was maintained and the filled pulp horn. The blue arrow marks the 45 cut through
the enamel, and the large red arrow marks the mesialized access angle, which is situa-
tionally correct because the caries and filling material were encountered in the mesial
portion of the tooth—a perfect example of the filling- and caries-leveraged access.
Fig. 1T shows the second angled radiograph with the yellow arrow marking the
mesial soffit. After a 6-week calcium hydroxide treatment, there was an improvement
(decrease) in the size of the radiographic lesions, especially the distal ones. The series
of photographs, Fig. 1A–Q, shows an ideal bucco-occlusal-lingual composite onlay
preparation, composite placement, matte finish, and final finish after occlusion was
adjusted.
The chamber was carefully layered with flowable composite (Filtek Supreme Flow
A-1; 3M, St Paul, MN, USA), mitigating the difficult C-factor problems by allowing
the layers (2-mm increments) to touch only 1 or 2 cavity walls and never all the 4 walls
at once. The cusps were built carefully with paste composite (Filtek Supreme Plus A-1
body [3M] was used with patient consent to show contrast for the photographs for
a bright result) to avoid cross tooth contact during photo-polymerization of the
composite. The distobuccal (DB) and distal cusps were built together with the ML
cusp then photo polymerized. Then the distolingual (DL) cusp was built with the mesio-
buccal (MB) cusp then photo polymerized. Although a discussion of restoratives is
beyond the scope of this article, the modern version of endodontic access is
constantly mindful of the restorative needs of the tooth, and that is why this brief
synopsis on the composite onlay is included, to demonstrate how the ideal access
leads to the ideal restoration.
CASE 2
This case demonstrates the access and restorative technique for an upper molar
deemed suitable for final restoration with a bonded porcelain onlay or a composite
onlay (Fig. 2A, B). The initial presentation of the case was a somewhat calcified molar
with some slight cracking and ditching of the enamel, coincident with the natural
anatomic grooves. The cusps were flattened 2 mm with wheel diamond, and the
central groove area was slightly flattened. This was planned to be a 2-step procedure,
which presents temporization issues if a 45 initial penetration is made, because
nonbonded materials generally need to be at a 90 angle. Thus, the calla lily–shaped
portion of the access is delayed until the final restorative is placed. After removing the
amalgam, a residual pulp horn is noted at the MB (Fig. 2C). The chamber is troughed
out as previously described, using Clark/Khademi (CK) burs (SS White burs Inc, NJ,
USA) or ultrasonics, and 3 initial point of negotiations (PONs) are located, and an initial
trough for the MB2 is made using a CK bur (Fig. 2D). If the opening permits, the notch-
ing for access to the MB2 can be reduced, or as in this case, nearly eliminated
(Fig. 2E). Calcium hydroxide is placed, Cavit (3M, St Paul, MN, USA) is placed deeply
with no sponge or cotton pellet, and 2–3-mm unbonded flowable composite veneer is
placed over the Cavit (Fig. 2F). At the second visit, the procedure is completed, the
chamber is cleaned up, and the calla lily portion of the access is completed
(Fig. 2G). Separate dentin- and enamel-bonding steps are then performed (Fig. 2H).
A small amount of flowable composite is placed over the gutta-percha and worked
280 Clark & Khademi
Fig. 2. (A–O) Case 2, the access and restorative technique for an upper molar deemed suit-
able for final restoration with a bonded porcelain onlay or composite onlay restoration.
Case Studies 281
Fig. 2. (continued)
into the enamel periphery and cured (Fig. 2I). PhotoCore (Kuraray America, Inc, New
York, NY, USA) is placed in the cervical portion of the access and cured (Fig. 2J). A
second increment of PhotoCore is placed with the objective of creating a nearly C-
factor–1 bowl for the final increment of PhotoCore (Fig. 2K); Fig. 2L shows a different
view of the bowl configuration of the final increment of PhotoCore. The final increment
of PhotoCore is placed and brushed to the enamel periphery (Fig. 2M). Occlusion is
adjusted to completely eliminate any excursive contacts. Ideal occlusion in this type
of case is a light single centric stop on restorative (Fig. 2N). The final radiograph shows
282 Clark & Khademi
a narrow ‘‘waist’’ to the access, which constricts from the level of the alveolar crest
until it steps out to where the original amalgam was and then reflares again for maximal
enamel engagement at the cavosurface (Fig. 2O). The flattening and the calla lily cav-
osurface have made this tooth safer than in the traditional methods; however, it is not
safe until the cusps are physically onlayed with restorative material.
CASE 3: THE UPPER FIRST MOLAR WITH A PORCELAIN-FUSED-TO-METAL CROWN
This case of the upper molar (Fig. 3A) highlights several issues encountered in real
clinical cases. The tooth in this case has rotated and drifted mesially, has a PFM
Fig. 3. (A–P) Case 3, the upper first molar with a PFM crown.
Case Studies 283
Fig. 3. (continued)
that obscures many of the normal anatomic landmarks, and has moderate calcifica-
tion. The MB root has a cervical bend and a concurrent distal angle of entry to the
MB system.
The preoperative occlusal view gives almost no indication of the underlying rotation
or the multiplanar inclination of the underlying tooth (Fig. 3B). It is only through exam-
ination of the cervical outline that the clinician can gain some hints to the true orienta-
tion and inclination of the tooth and the modifications to the access that will be
required. By observing the palatal view (Fig. 3C), the bulge of the palatal root can
284 Clark & Khademi
be prominently seen, and a hint as to the mesial inclination can be gained by observing
the contour of the mesial contact reaching for the distal part of tooth No. 13. The
preoperative buccal view (Fig. 3D) shows a reversal of the root prominences, with
no evidence of the normally more prominent MB, yet a marked prominence of the
DB, which is reflected both in the alveolar housing and the cervical contour of the
PFM. This evidence suggests that the mesial of the tooth has rotated inward as it
has drifted mesially. In the preoperative occlusal view, the translucency of the porce-
lain can often allow the clinician to look through to the opaque layer and better ascer-
tain where at least the occlusal portion of the tooth mass is. The yellow outline form
(Fig. 3E) shows a normal orientation on a maxillary first molar, with the mesial roughly
paralleling the mesial of the crown, but authors are not accessing the crown; authors
are accessing the root structure through the crown. The blue outline shows an appro-
priate rotation of the outline form along with a mesial and buccal translation in an
attempt to compensate for the rotation and tipping of the underlying tooth structure.
It is also increased in size to reflect the lower confidence in the true locations of the
underlying tooth mass. The smaller black outline represents the expected outline
form that is obtained once the clinician gains access to the underlying dentin map,
and it is reflective of the more oval shape of the maxillary second molar pulp chamber.
There is no green outline for this difficult type of case. The initial cut through porcelain
and metal and slightly into dentin is oriented along the anticipated line connecting the
MB and palatal (P) horns, generally the largest of the pulp horns (Fig. 3F). The access
is liberally extended in the crown without progressing apically (Fig. 3G). A close-up
shows a color change, whereby it would be reasonable to expect a P pulp horn
(Fig. 3H). Careful apical progression through dentin exposes the chamber through
the P horn, and the color map gives a visual cue as to the location of the MB horn
as well (Fig. 3I). The tip of a CK bur is barely placed through the exposed P horn, drop-
ping through the chamber roof, and is drawn around using the visual cues filtered
through the expected chamber outline (black outline form mentioned earlier,
Fig. 3J). Fig. 3K shows a considerable soffit over the P horn, less over the MB, and
almost none over the DB. The buccal-most extent of the MB is carefully partially
unroofed and troughed out to ensure that an additional MB canal is not present to
the buccal, and a small amount of troughing and fluting slightly buccal of the palatal
canal is done, because maxillary second molars occasionally harbors the MB2 canals
in or near the P orifice (Fig. 3L). Fig. 3M shows the completed outline form ready for
instrumentation. If the angle of entry to the DB is too constricted, a CK bur can be used
to remove the small lip of dentin. The old residual DB horn can be seen when observed
carefully. Fig. 3N shows the absolute sizes of the outline form through the PFM and the
step in once the dentin is reached. Fig. 3O shows a slightly different view with a fairly
dramatic step at the distal and palatal and a little-to-no step toward the MB. Thus,
even with a fairly dramatic rotation and translation of the outline form, the access
through the PFM was barely buccal and mesial enough. The final radiograph is shown
in Fig. 3P.
CASE 4: MAXILLARY FIRST MOLAR WITH TYPICAL COMPLEXITY OF THE MB ROOT
A common criticism of these more-precise endodontic accesses is that they preclude

PON location and discovery of deep anatomy. Yet there is no real evidence that
generous outline forms actually facilitate discovery of coronal or deep anatomy.
This can be confirmed by reviewing endodontic texts that continue to present clinical
cases such as this fairly routine upper molar as anatomic oddities.
Case Studies 285
Fig. 4. (A–F) Maxillary first molar with a typical complexity of the MB root.
This case presents a stepped access on a somewhat calcific maxillary molar

through a PFM (Fig. 4A). The initial outline form is on the larger side until the dentin
is reached (Fig. 4B). Once the dentin is reached, the visual cues are followed as shown
in case 6, slowly dissecting away just enough dentin to gain access. In this case,
a cervical bulge shrouds the MB2 orifice, which is a fairly common finding in a maxillary
molar. Instead of extending the entire mesial wall and unnecessarily removing irre-
placeable PCD to gain access to the MB2 orifice, the mesial wall is slightly fluted as
the MB2 is chased mesially before finally diving down the root (Fig. 4C). Fig. 4D shows
the dimensions of the finished outline form using a 3-mm Marquis probe.
The canals are prepared, and a confluent MB/MB2 is noted. With this canal config-
uration, a deep split off the MB2 reaching the palatal is not an infrequent finding. This
deep split is picked up by using a precurved file with a marked stopper, with the tip of
the file directed along the palatal aspect of the MB2-prepared MB2 wall. Fig. 4E
shows 3 instruments in the MB root: a No. 20 hand file in the MB orifice and 2 files
(Nos. 20 and 10) in the MB2 orifice. The 2 No. 20 files can be seen to join, while the
smaller No. 10 file curves off to a separate portal of exit. The final radiograph demon-
strates the confluent prepared canals and the deep split likely filled with sealer
(Fig. 4F).
Endodontic treatment is a balancing act. In the final analysis, the endodontic
anatomy needs to be adequately addressed, requiring removal of dentin, which
cannot possibly result in a stronger tooth. The authors believe that the endodontic
286 Clark & Khademi
Fig. 5. (A–E) Caries-leveraged access in a lower first molar.
access has probed too far and that teeth are being needlessly weakened because of
these larger outline forms, shapes, and the occult gouging that accompanies the tradi-
tional access technique and instrumentation. The clinician needs to be acutely aware
of the biologic price of dentin removal and should always ask the question ‘‘Do I really
need to cut here?’’
CASE 5: CARIES-LEVERAGED ACCESS IN A LOWER FIRST MOLAR
Traditional endodontic access has paid little importance to the concept of directed
dentin conservation, placing the operator’s needs for facile access to the canal
systems above the restoration needs and the tooth needs, when it is really a balance
between these needs that is the objective. Traditionally, a case like this lower molar
would have an endodontic access cut paying no importance to the decay on the distal,
but instead, removing a substantial amount of the remaining healthy tooth structure (in
the mesial region) to aid in accomplishing the endodontic objectives (Fig. 5A, B).
To avoid such a situation, the authors introduce the concept of caries- and filling-
leveraged access, whereby existing restorative materials, decay, and less-strategic
tooth structure are preferentially removed in favor of keeping tooth structure farther
up on the hierarchy of tooth needs. Creativity and resourcefulness are the new direc-
tives. This concept leverages the availability of low- or zero-value tooth or restorative
materials to skew the access and direct the conservation of dentin to where it is most
important. In this case, there is distal decay, which is of zero value. The access is
skewed distally, being almost entirely in the distal half of the tooth (Fig. 5C). A
close-up of the chamber shows that the mesial wall, the mesial portion of the chamber
Case Studies 287
Fig. 6. (A–O) Case 6, the calcific lower first molar with a gold crown.
roof or soffit, as well as the mesial pulp horns are untouched and are left in their natural
anatomic state (Fig. 5D). The undercut areas are cleaned out with prebent Maillefer
micro-openers and Shepherd hook explorers. The final radiograph shows the
completed case with an amalgam core that has been driven up into the mesial pulp
horns (Fig. 5E). If traditional access had been cut in this tooth, the 3-dimensional
ferrule in the most important walls, buccal and lingual, would have been insufficient
to retain the tooth long term.
288 Clark & Khademi
Fig. 6. (continued)
CASE 6: THE CALCIFIC LOWER FIRST MOLAR WITH A GOLD CROWN
The idea of using a round bur to drop in to a pulp chamber was put to test on a case
such as a fairly routine lower molar (Fig. 6A). After a wide access was cut through the
gold crown to the level at which dentin is encountered, the access was stepped in, and
Case Studies 289
the color map was followed, leading to the first pulp tissue remnant (PTR) (Fig. 6B).
The framework through which the color map and PTRs were interpreted was the
outline of the pulp chamber when the patient was young (Fig. 6C). In this case,
a pulp stone had been growing for decades and had obliterated the bulk of the lumen
of the pulp chamber, leaving a periphery of PTRs that could be traced out with ultra-
sonics or CK burs.
Exploration is worthless with this case type because the bulk of the periphery
sticks, leading to innumerable false positives, wasted time, and unnecessary
digging that results in occult damage to the PCD. Instead, a moat is cut around
the pulp stone. Fig. 6D shows the moat troughing around 3 of the 4 sides of
this roughly trapezoidal chamber. The partial trough starts at the ML line angle
and moves buccal to the MB line angle, turns about 90 distal toward the DB,
turns another 90 at the DB line angle proceeding lingually, and terminates at
the DL line angle. Fig. 6E shows the last leg of the moat connecting the DL to
the ML.
A spoon excavator can usually pop the stone free (Fig. 6F). The chamber floor is
inspected, revealing a small piece of necrotic pulp emanating from the MB and
some residual stone stuck to the pulpal floor flowing down the distal system occluding
access to that system (Fig. 6G). A mild amount of troughing reveals a fairly tenacious
stone stuck partway down the distal system (Fig. 6H). Continued troughing begins to
eliminate PTRs around several parts of the chamber periphery (Fig. 6I).
Troughing the distal system reveals a PTR surrounding the stone lodged in the distal
system similar to the way in which the initial pulp stone occluded the pulp chamber
(Fig. 6J). Again, the mental model is to identify the periphery of the stone by looking
for color changes and PTRs that match the expected shape of lumen of the distal
canal (Fig. 6K).
The cleaned-up and prepared chamber is shown in Fig. 6L. The obturated case was
planned for a bonded amalgam repair of the access. As gold is not an etchable
substrate, the cavosurface was left as a butt joint (Fig. 6M, N). The final radiograph
is presented in Fig. 6O.
The strategy is to cut a larger-than-needed access through the dispensable restor-
ative material only to the depth at which dentin is encountered. First cues in the color
map should then be used to find the first PTRs, and slowly and carefully the dentin,
pulp stones, and restoratives are dissected away to find the extent of the pulp
chamber floor. By carefully tracing around the chamber floor, the PONs, which are
almost invariably located at the periphery of the chamber floor, can be identified.
Endodontic explorers are relics from the tactile-based world and have little value in
the vision-based world in a case such as this.
FINAL NOTES: LOGISTICS OF THE CK APPROACH TO MOLAR ACCESS

1. You will notice that your measurement reference points may change; for example,
in the past, the reference for the mesial canals was often the corresponding MB
cusp. You may now find the reference more to the distal as you have preserved
PCD and soffit dentin.
2. The simultaneous placement of 4 or 5 gutta-percha points for a cone fit radiograph
in this more constricted access may require that some of the cones be cut back into
the chamber to eliminate binding.
3. We recommend not removing the pulp tissue under the soffit until the obturation is
finished; that way you only have to clean it up once.
Irrigation in
Endodontics
Markus Haapasalo, DDS, PhDa,*, Ya Shen, DDS, PhD
a
,
Wei Qian, DDS, PhDb, Yuan Gao, DDS, PhDc
KEYWORDS
Endodontics Irrigation Root canal Irrigant
The success of endodontic treatment depends on the eradication of microbes

(if present) from the root-canal system and prevention of reinfection. The root canal
is shaped with hand and rotary instruments under constant irrigation to remove the
inflamed and necrotic tissue, microbes/biofilms, and other debris from the root-canal
space. The main goal of instrumentation is to facilitate effective irrigation, disinfection,
and filling. Several studies using advanced techniques such as microcomputed
tomography (CT) scanning have demonstrated that proportionally large areas of the
main root-canal wall remain untouched by the instruments,1 emphasizing the impor-
tance of chemical means of cleaning and disinfecting all areas of the root canal
(Figs. 1 and 2). There is no single irrigating solution that alone sufficiently covers all
of the functions required from an irrigant. Optimal irrigation is based on the combined
use of 2 or several irrigating solutions, in a specific sequence, to predictably obtain the
goals of safe and effective irrigation. Irrigants have traditionally been delivered into the
root-canal space using syringes and metal needles of different size and tip design.
Clinical experience and research have shown, however, that this classic approach
typically results in ineffective irrigation, particularly in peripheral areas such as anasto-
moses between canals, fins, and the most apical part of the main root canal. There-
fore, many of the compounds used for irrigation have been chemically modified and
several mechanical devices have been developed to improve the penetration and
effectiveness of irrigation. This article summarizes the chemistry, biology, and proce-
dures for safe and efficient irrigation and provides cutting-edge information on the
most recent developments.
a
Division of Endodontics, Department of Oral Biological & Medical Sciences, UBC Faculty of
Dentistry, The University of British Columbia, 2199 Wesbrook Mall, Vancouver, BC, Canada
V6T 1Z3
b
Graduate Endodontics Program, Faculty of Dentistry, The University of British Columbia, 2199
Wesbrook Mall, Vancouver, BC, Canada V6T 1Z3
c
State Key Laboratory of Oral Diseases, West China College & Hospital of Stomatology, Sichuan
University, Chengdu, China
E-mail address: markush@interchange.ubc.ca
Dent Clin N Am 54 (2010) 291–312

292 Haapasalo et al
Fig. 1. A scanning electron microscopy image of dentin surface covered by predentin and
other organic debris in an uninstrumented canal area.
GOALS OF IRRIGATION
Irrigation has a central role in endodontic treatment. During and after instrumentation,
the irrigants facilitate removal of microorganisms, tissue remnants, and dentin chips
from the root canal through a flushing mechanism (Box 1). Irrigants can also help
prevent packing of the hard and soft tissue in the apical root canal and extrusion of in-
fected material into the periapical area. Some irrigating solutions dissolve either organic
or inorganic tissue in the root canal. In addition, several irrigating solutions have antimi-
crobial activity and actively kill bacteria and yeasts when introduced in direct contact
with the microorganisms. However, several irrigating solutions also have cytotoxic
potential, and they may cause severe pain if they gain access into the periapical
tissues.2 An optimal irrigant should have all or most of the positive characteristics listed
in Box 1, but none of the negative or harmful properties. None of the available irrigating
solutions can be regarded as optimal. Using a combination of products in the correct
irrigation sequence contributes to a successful treatment outcome.
IRRIGATING SOLUTIONS
Sodium Hypochlorite
Sodium hypochlorite (NaOCl) is the most popular irrigating solution. NaOCl ionizes in
water into Na1 and the hypochlorite ion, OCl , establishing an equilibrium with
Fig. 2. Area of uninstrumented root-canal wall.

Irrigation in Endodontics 293
Box 1
Desired functions of irrigating solutions
Washing action (helps remove debris)

Reduce instrument friction during preparation (lubricant)
Facilitate dentin removal (lubricant)
Dissolve inorganic tissue (dentin)
Penetrate to canal periphery
Dissolve organic matter (dentin collagen, pulp tissue, biofilm)
Kill bacteria and yeasts (also in biofilm)
Do not irritate or damage vital periapical tissue, no caustic or cytotoxic effects
Do not weaken tooth structure
hypochlorous acid (HOCl). At acidic and neutral pH, chlorine exists predominantly
as HOCl, whereas at high pH of 9 and above, OCl predominates.3 Hypochlorous
acid is responsible for the antibacterial activity; the OCl ion is less effective
than the undissolved HOCl. Hypochloric acid disrupts several vital functions of the
microbial cell, resulting in cell death.4,5
NaOCl is commonly used in concentrations between 0.5% and 6%. It is a potent
antimicrobial agent, killing most bacteria instantly on direct contact. It also effectively
dissolves pulpal remnants and collagen, the main organic components of dentin.
Hypochlorite is the only root-canal irrigant of those in general use that dissolves
necrotic and vital organic tissue. It is difficult to imagine successful irrigation of the
root canal without hypochlorite. Although hypochlorite alone does not remove the
smear layer, it affects the organic part of the smear layer, making its complete removal
possible by subsequent irrigation with EDTA or citric acid (CA). It is used as an unbuf-
fered solution at pH 11 in the various concentrations mentioned earlier, or buffered
with bicarbonate buffer (pH 9.0), usually as a 0.5% (Dakin solution) or 1% solution.3
However, buffering does not seem to have any major effect on the properties of
NaOCl, contrary to earlier belief.6
There is considerable variation in the literature regarding the antibacterial effect of
NaOCl. In some articles hypochlorite is reported to kill the target microorganisms in
seconds, even at low concentrations, although other reports have published consid-
erably longer times for the killing of the same species.7–10 Such differences are a result
of confounding factors in some of the studies. The presence of organic matter during
the killing experiments has a great effect on the antibacterial activity of NaOCl.
Haapasalo and colleagues11 showed that the presence of dentin caused marked
delays in the killing of Enterococcus faecalis by 1% NaOCl. Many of the earlier studies
were performed in the presence of an unknown amount of organic matter (eg, nutrient
broth) or without controlling the pH of the culture, both of which affect the result. When
the confounding factors are eliminated, it has been shown that NaOCl kills the target
microorganisms rapidly even at low concentrations of less than 0.1%.9,12 However, in
vivo the presence of organic matter (inflammatory exudate, tissue remnants, microbial
biomass) consumes NaOCl and weakens its effect. Therefore, continuous irrigation
and time are important factors for the effectiveness of hypochlorite.
Byström and Sundqvist13,14 studied the irrigation of root canals that were necrotic
and contained a mixture of anaerobic bacteria. These investigators showed that using
294 Haapasalo et al
0.5% or 5% NaOCl, with or without EDTA for irrigation, resulted in considerable reduc-
tion of bacterial counts in the canal when compared with irrigation with saline.
However, it was difficult to render the canals completely free from bacteria, even after
repeated sessions. Siqueira and colleagues15 reported similar results using root
canals infected with E faecalis. Both studies failed to show a significant difference in
the antibacterial efficacy between the low and high concentrations of NaOCl. Contrary
to these results, Clegg and colleagues,16 in an ex vivo biofilm study, demonstrated
a strong difference in the effectiveness against biofilm bacteria by 6% and 3% NaOCl,
the higher concentration being more effective.
The weaknesses of NaOCl include the unpleasant taste, toxicity, and its inability to
remove the smear layer (Fig. 3) by itself, as it dissolves only organic material.17
The limited antimicrobial effectiveness of NaOCl in vivo is also disappointing. The
poorer in vivo performance compared with in vitro is probably caused by problems
in penetration to the most peripheral parts of the root-canal system such as fins,
anastomoses, apical canal, lateral canals, and dentin canals. Also, the presence of
inactivating substances such as exudate from the periapical area, pulp tissue, dentin
collagen, and microbial biomass counteract the effectiveness of NaOCl.11 Recently, it
has been shown by in vitro studies that long-term exposure of dentin to a high concen-
tration sodium hypochlorite can have a detrimental effect on dentin elasticity and
flexural strength.18,19 Although there are no clinical data on this phenomenon, it raises
the question of whether hypochlorite in some situations may increase the risk of
vertical root fracture.
In summary, sodium hypochlorite is the most important irrigating solution and the
only one capable of dissolving organic tissue, including biofilm and the organic part
of the smear layer. It should be used throughout the instrumentation phase. However,
use of hypochlorite as the final rinse following EDTA or CA rapidly produces severe
erosion of the canal-wall dentin and should probably be avoided.20
EDTA and CA
Complete cleaning of the root-canal system requires the use of irrigants that dissolve
organic and inorganic material. As hypochlorite is active only against the former, other
substances must be used to complete the removal of the smear layer and dentin
debris. EDTA and CA effectively dissolve inorganic material, including hydroxyapa-
tite.21–24 They have little or no effect on organic tissue and alone they do not have anti-
bacterial activity, despite some conflicting reports on EDTA. EDTA is most commonly
Fig. 3. Cross section of root dentin covered by the smear layer created by instrumentation.
Notice smear plugs in dentin canals.
used as a 17% neutralized solution (disodium EDTA, pH 7), but a few reports have indi-
cated that solutions with lower concentrations (eg, 10%, 5%, and even 1%) remove
the smear layer equally well after NaOCl irrigation. Considering the high cost of
EDTA, it may be worthwhile to consider using diluted EDTA. CA is also marketed
and used in various concentrations, ranging from 1% to 50%, with a 10% solution
being the most common. EDTA and CA are used for 2 to 3 minutes at the end of instru-
mentation and after NaOCl irrigation. Removal of the smear layer by EDTA or CA
improves the antibacterial effect of locally used disinfecting agents in deeper layers
of dentin.25,26 EDTA and CA are manufactured as liquids and gels. Although there
are no comparative studies about the effectiveness of liquid and gel products to
demineralize dentin, it is possible that the small volume of the root canal (only a few
microliters) contributes to a rapid saturation of the chemical and thereby loss of effec-
tiveness. In such situations, the use of liquid products and continuous irrigation should
be recommended.27,28
Chlorhexidine Digluconate
Chlorhexidine digluconate (CHX) is widely used in disinfection in dentistry because of
its good antimicrobial activity.29–31 It has gained considerable popularity in endodon-
tics as an irrigating solution and as an intracanal medicament. CHX does not possess
some of the undesired characteristics of sodium hypochlorite (ie, bad smell and strong
irritation to periapical tissues). However, CHX has no tissue-dissolving capability and
therefore it cannot replace sodium hypochlorite.
CHX permeates the microbial cell wall or outer membrane and attacks the bacterial
cytoplasmic or inner membrane or the yeast plasma membrane. In high concentra-
tions, CHX causes coagulation of intracellular components.3 One of the reasons for
the popularity of CHX is its substantivity (ie, continued antimicrobial effect), because
CHX binds to hard tissue and remains antimicrobial. However, similar to other
endodontic disinfecting agents, the activity of CHX depends on the pH and is also
greatly reduced in the presence of organic matter.31
Several studies have compared the antibacterial effect of NaOCl and 2% CHX
against intracanal infection and have shown little or no difference between
their antimicrobial effectiveness.32–35 Although bacteria may be killed by CHX, the bio-
film and other organic debris are not removed by it. Residual organic tissue may have
a negative effect on the quality of the seal by the permanent root filling, necessitating
the use of NaOCl during instrumentation. However, CHX does not cause erosion of
dentin like NaOCl does as the final rinse after EDTA, and therefore 2% CHX may be
a good choice for maximized antibacterial effect at the end of the chemomechanical
preparation.36
Most of the research on the use of CHX in endodontics is carried out using in vitro
and ex vivo models and gram-positive test organisms, mostly E faecalis. It is therefore
possible that the studies have given an overpositive picture of the usefulness of CHX
as an antimicrobial agent in endodontics. More research is needed to identify the
optimal irrigation regimen for various types of endodontic treatments. CHX is
marketed as a water-based solution and as a gel (with Natrosol). Some studies
have indicated that the CHX gel has a slightly better performance than the CHX liquid
but the reasons for possible differences are not known.37
Other Irrigating Solutions

Other irrigating solutions used in endodontics have included sterile water, physiologic
saline, hydrogen peroxide, urea peroxide, and iodine compounds. All of these except
iodine compounds lack antibacterial activity when used alone, and they do not
296 Haapasalo et al
dissolve tissue either. Therefore there is no good reason for their use in canal irrigation
in routine cases. In addition, water and saline solutions bear the risk of contamination if
used from containers that have been opened more than once. Iodine potassium iodide
(eg, 2% and 4%, respectively) has considerable antimicrobial activity but no tissue-
dissolving capability38,39 and it could be used at the end of the chemomechanical
preparation like CHX. However, some patients are allergic to iodine, which must be
taken into consideration.
Interactions Between Irrigating Solutions

Hypochlorite and EDTA are the 2 most commonly used irrigating solutions. As they
have different characteristics and tasks, it has been tempting to use them as a mixture.
However, EDTA (and CA) instantaneously reduces the amount of chlorine when mixed
with sodium hypochlorite, resulting in the loss of NaOCl activity. Thus, these solutions
should not be mixed.40
CHX has no tissue-dissolving activity and there have been efforts to combine CHX
with hypochlorite for added benefits from the 2 solutions. However, CHX and NaOCl
are not soluble in each other; a brownish-orange precipitate is formed when they are
mixed (Fig. 4). The characteristics of the precipitate and the liquid phase have not
been thoroughly examined, but the precipitate prevents the clinical use of the mixture.
Atomic absorption spectrophotometry has indicated that the precipitate contains iron,
which may be the reason for the orange development.41 Presence of parachloroani-
line, which may have mutagenic potential, has also been demonstrated in the
precipitate.42,43
Mixing CHX and EDTA immediately produces a white precipitate (Fig. 5). Although
the properties of the mixture and the cleared supernatant have not been thoroughly
studied, it seems that the ability of EDTA to remove the smear layer is reduced.
Many clinicians mix NaOCl with hydrogen peroxide for root-canal irrigation. Despite
more vigorous bubbling, the effectiveness of the mixture has not been shown to be
Fig. 4. Orange precipitate formed by mixing chlorhexidine with sodium hypochlorite.

Fig. 5. Mixing sodium chlorhexidine with EDTA produces a white cloud and some
precipitation.
better than that of NaOCl alone.32 However, combining hydrogen peroxide with CHX
in an ex vivo model32,44 resulted in a considerable increase in the antibacterial activity
of the mixture compared with the components alone in an infected dentin block.
However, there are no data concerning the use or effectiveness of the mixture in
clinical use.
Combination Products
Although some of the main irrigating solutions cannot be mixed without loss of activity
or development of potentially toxic by-products, several combination products are on
the market, many with some evidence of improved activity and function. Surface-
active agents have been added to several different types of irrigants to lower their
surface tension and to improve their penetration in the root canal. In the hope of better
smear-layer removal, detergents have been added to some EDTA preparations
(eg, SmearClear (Fig. 6))45 and hypoclorite (eg, Chlor-XTRA (Fig. 7) and White King).
Detergent addition has been shown to increase the speed of tissue dissolution by
hypochlorite.46 No data are available on whether dentin penetration is also improved.
Recently, a few studies have been published in which the antibacterial activity of
a chlorhexidine product with surface-active agents (CHX-Plus; see Fig. 7) has been
compared with regular CHX, both with 2% chlorhexidine concentrations. The
studies47,48 have shown superior killing of planktonic and biofilm bacteria by the
combination product. There are no studies about whether adding surface-active
agents increases the risk of the irrigants escaping to the periapical area in clinical use.
MTAD (a mixture of tetracycline isomer, acid, and detergent, Biopure, Tulsa Dents-
ply, Tulsa, OK, USA) and Tetraclean are new combination products for root-canal
irrigation that contain an antibiotic, doxycycline.49–51 MTAD and Tetraclean are
298 Haapasalo et al
Fig. 6. SmearClear is a combination product containing EDTA and a detergent.
designed primarily for smear-layer removal with added antimicrobial activity. Both
contain CA, doxycycline, and a detergent. They differ from each other in CA concen-
tration and type of detergent included. They do not dissolve organic tissue and are in-
tended for use at the end of chemomechanical preparation after sodium hypochlorite.
Although earlier studies showed promising antibacterial effects by MTAD,52,53 recent
studies have indicated that an NaOCl/EDTA combination is equally or more effective
Fig. 7. Chlor-XTRA and CHX-Plus are combination products whose tissue dissolution or
antibacterial properties have been improved by specific surface-active agents.
than NaOCl/MTAD.54,55 Comparative studies on MATD and Tetraclean have indicated

better antibacterial effects by the latter.56 Although a mixture containing an antibiotic
may have good short-term and long-term effects, concerns have been expressed
regarding the use of tetracycline (doxycycline) because of possible resistance to the
antibiotic and staining of the tooth hard tissue, which has been demonstrated by expo-
sure to light in an in vitro expreriment.57 However, no report of in vivo staining has been
published.
CHALLENGES OF IRRIGATION
Smear Layer
Removal of the smear layer is straightforward and predictable when the correct
irrigants are used. Relying on EDTA alone or other irrigants with activity against the
inorganic matter only, however, results in incomplete removal of the layer. Therefore,
use of hypochlorite during instrumentation cannot be omitted (Fig. 8). The smear layer
is created only on areas touched by the instruments. Delivery of irrigants to these
areas is usually unproblematic, with the possible exception of the most apical canal,
depending on canal morphology and the techniques/equipment used for irrigation.
However, careless irrigation, with needles introduced only to the coronal and middle
parts of the root canal, is likely to result in incomplete removal of the smear layer in
the apical root canal.
Dentin Erosion
One of the goals of endodontic treatment is to protect the tooth structure so that the
physical procedures and chemical treatments do not cause weakening of the dentin/
root. Erosion of dentin has not been studied much; however, there is a general
consensus that dentin erosion may be harmful and should be avoided. A few studies
have shown that long-term exposure to high concentrations of hypochlorite can lead
to considerable reduction in the flexural strength and elastic modus of dentin.19 These
studies have been performed in vitro using dentin blocks, which may allow artificially
deep penetration of hypoclorite into dentin. However, even short-term irrigation with
hypochlorite after EDTA or CA at the end of chemomechanical preparation causes
strong erosion of the canal-wall surface dentin (Fig. 9).20 Although it is not known
for sure whether surface erosion is a negative issue or if, for example, it could improve
dentin bonding for posts, it is the authors’ opinion that hypochlorite irrigation after
Fig. 8. Instrumented canal wall after removal of the smear layer by NaOCl and EDTA.
300 Haapasalo et al
Fig. 9. Considerable erosion of canal-wall dentin occurs when hypochlorite is used after
EDTA or CA.
demineralization agents should be avoided. Instead, chlorhexidine irrigation could be

used for additional disinfection at the end of the treatment.
Cleaning of Uninstrumented Parts of the Root-canal System
Irrigation is most feasible in the instrumented areas because the irrigation needle can
follow the smooth path created by the instruments. Cleaning and removing of necrotic
tissue, debris, and biofilms from untouched areas rely completely on chemical means,
and sufficient use of sodium hypochlorite is the key factor in obtaining the desired
results in these areas (Fig. 10). A recent study showed that untouched areas, in
particular anastomoses between canals, are frequently packed with debris during
instrumentation.58 Visibility in micro-CT scans indicates that the debris also contain
a considerable proportion of inorganic material (Fig. 11). Although at present it is
not known how these debris can best be removed (if at all), it is likely that physical
agitation (eg, ultrasound) and the use of demineralizing agents are needed in addition
to hypochlorite.
Biofilm
Biofilm (Fig. 12) can be removed or eliminated through the following methods:
mechanical removal by instruments (effective only in some areas of the root canal);
Fig. 10. Canal-wall dentin in an uninstrumented area after hypochlorite irrigation has
removed (dissolved) tissue remnants and predentin, revealing the large calcospherites
that have already joined mineralized dentin.
Fig. 11. An anastomosis between 2 joining canals has been packed with debris during rotary
instrumentation.
dissolution by hypochlorite; and detachment by ultrasonic energy. Other chemical

means, such as chlorhexidine, can kill biofilm bacteria if allowed a long enough
contact time. However, as they lack tissue-dissolving ability, the dead microbial
biomass stays in the canal if not removed mechanically or dissolved by hypochlorite.
Any remaining organic matter, microbes, or vital or necrotic tissue jeopardizes the
integrity of the seal of the root filling. Therefore the goal of the treatment is not only
to kill the microbes in the root canal but also to remove them as completely as
possible.
Safety versus Effectiveness in the Apical Root Canal

Irrigation must maintain a balance between 2 important goals: safety and effective-
ness. This point is particularly true with the most important irrigant, sodium hypochlo-
rite, but other irrigants can also cause pain and other problems if they gain access to
the periapical tissues. Effectiveness is often jeopardized in the apical root canal by
restricting anatomy and valid safety concerns. However, the eradication of the
microbes in the apical canal should be of key importance to the success of endodontic
Fig. 12. Bacteria growing on dentin surface; early stages of biofilm formation.
302 Haapasalo et al
treatment. Sufficient exchange of hypochlorite and other irrigants in this area while
keeping the apical pressure of the solutions minimal is the obvious goal of irrigation
of the apical root canal. A better understanding of fluid dynamics and the development
of new needle designs and equipment for irrigant delivery are the 2 important areas to
deal with in the challenges of irrigating the most apical part of the canal. These areas
are discussed in the following sections.
COMPUTATIONAL FLUID DYNAMICS IN THE ROOT-CANAL SPACE
Computational fluid dynamics (CFD) is a new approach in endodontic research to

improve our understanding of fluid dynamics in the special anatomic environment of
the root canal. Fluid flow is commonly studied in 1 of 3 ways: experimental fluid
dynamics; theoretic fluid dynamics; and computational fluid dynamics (Fig. 13).
CFD is the science that focuses on predicting fluid flow and related phenomena by
solving the mathematical equations that govern these processes. Numerical and
experimental approaches play complementary roles in the investigation of fluid flow.
Experimental studies have the advantage of physical realism; once the numerical
model is experimentally validated, it can be used to theoretically simulate various
conditions and perform parametric investigations. CFD can be used to evaluate and
predict specific parameters, such as the streamline (Fig. 14), velocity distribution of
irrigant flow in the root canal (Fig. 15), wall flow pressure, and wall shear stress on
the root-canal wall, which are difficult to measure in vivo because of the microscopic
size of the root canals.
In CFD studies, no single turbulence model is universally accepted for different
types of flow environments. The use of an unsuitable turbulence model may lead to
potential numerical errors and affect CFD results.59 Gao and colleagues60 found
that CFD analysis based on a shear stress transport (SST) k-u turbulence model
Fig. 13. Particle tracking during irrigation simulated by a CFD model.

Fig. 14. Streamline provides visualization of the irrigant flow in the canal.
was in close agreement with the in vitro irrigation model. CFD based on an SST k-u
turbulence model has the potential to serve as a platform for the study of root-canal
irrigation.
The irrigant velocity on the canal wall is considered a highly significant factor in
determining the replacement of the irrigant in certain parts of the root canal and
Fig. 15. Velocity contour and vectors colored by velocity magnitude in an SST k-u turbulence
model. High-velocity flow seen in the needle lumen and in the area of the side vent.
304 Haapasalo et al
in the flush effect, therefore directly influencing the effectiveness of irrigation.61 In

a turbulent flow, there is a viscous sublayer that is a thin region next to a wall, typically
only 1% of the boundary-layer thickness, in which turbulent mixing is impeded and
transport occurs partly or, as the limit of the wall is approached, entirely by viscous
diffusion.62 From turbulent structure measurements of pipe flow, the regions of
maximum production and maximum dissipation are just outside the viscous sub-
layer.63 Hence, the fastest flow is found in the turbulent boundary, whereas the
minimum velocity is observed on the wall of all root-canal irrigations. Some of the
goals of CFD studies in endodontics are to improve needle-tip design for effective
and safe delivery of the irrigant and to optimize the exchange of irrigating solutions
in the peripheral parts of the canal system.
IRRIGATION DEVICES AND TECHNIQUES
The effectiveness and safety of irrigation depends on the means of delivery. Tradition-
ally, irrigation has been performed with a plastic syringe and an open-ended needle
into the canal space. An increasing number of novel needle-tip designs and equipment
are emerging in an effort to better address the challenges of irrigation.
Syringes
Plastic syringes of different sizes (1–20 mL) are most commonly used for irrigation
(Fig. 16). Although large-volume syringes potentially allow some time-savings, they
are more difficult to control for pressure and accidents may happen. Therefore, to
maximize safety and control, use of 1- to 5-mL syringes is recommended instead of
the larger ones. All syringes for endodontic irrigation must have a Luer-Lok design.
Because of the chemical reactions between many irrigants, separate syringes should
be used for each solution.
Needles
Although 25-gauge needles were commonplace for endodontic irrigation a few years
ago, they were first replaced by 27-G needles, now 30-G and even 31-G needles are
taking over for routine use in irrigation. As 27 G corresponds to International Standards
Fig. 16. Plastic syringes for irrigation.

Organization size 0.42 and 30 G to size 0.31, smaller needle sizes are preferred.
Several studies have shown that the irrigant has only a limited effect beyond the tip
of the needle because of the dead-water zone or sometimes air bubbles in the apical
root canal, which prevent apical penetration of the solution. However, although the
smaller needles allow delivery of the irrigant close to the apex, this is not without safety
concerns. Several modifications of the needle-tip design have been introduced in
recent years to facilitate effectiveness and minimize safety risks (Figs. 17 and 18).
There are few comparative data about the effect of needle design on irrigation effec-
tiveness; it is hoped that ongoing CFD and clinical studies will change this situation.
Gutta-percha Points
The recognition of the difficulty of apical canal irrigation has led to various innovative
techniques to facilitate the penetration of solutions in the canal. One of these includes
the use of apically fitting gutta-percha cones in an up-and-down motion at the working
length. Although this facilitates the exchange of the apical solution, the overall volume
of fresh solution in the apical canal is likely to remain small. However, the benefits of
gutta-percha point assisted irrigation have been shown in 2 recent studies.64,65
EndoActivator
EndoActivator (Advanced Endodontics, Santa Barbara, CA, USA) is a new type of
irrigation facilitator. It is based on sonic vibration (up to 10,000 cpm) of a plastic tip
in the root canal. The system has 3 different sizes of tips that are easily attached
(snap-on) to the handpiece that creates the sonic vibrations (Fig. 19). EndoActivator
does not deliver new irrigant to the canal but it facilitates the penetration and renewal
of the irrigant in the canal. Two recent studies have indicated that the use of EndoAc-
tivator facilitates irrigant penetration and mechanical cleansing compared with needle
irrigation, with no increase in the risk of irrigant extrusion through the apex.66,67
Fig. 17. Four different needle designs, produced by computerized mesh models based on
true and virtual needles.
306 Haapasalo et al
Fig. 18. Flexiglide needle for irrigation also easily follows curved canals.
Vibringe
Vibringe (Vibringe BV, Amsterdam, The Netherlands) is a new sonic irrigation system
that combines battery-driven vibrations (9000 cpm) with manually operated irrigation
of the root canal (Fig. 20). Vibringe uses the traditional type of syringe/needle delivery
but adds sonic vibration. No studies can be found on Medline.
RinsEndo
The RinsEndo system (Durr Dental Co) is based on a pressure-suction mechanism
with approximately 100 cycles per minute.68 A study of the safety of several irrigation
systems reported that the risk of overirrigation was comparable with manual and
RinsEndo irrigation, but higher than with EndoActivator or the EndoVac system.67
Not enough data are available to draw conclusions about the benefits and possible
risks of the RinsEndo system.
EndoVac
EndoVac (Discus Dental, Culver City, CA, USA) represents a novel approach to irriga-
tion as, instead of delivering the irrigant through the needle, the EndoVac system is
based on a negative-pressure approach whereby the irrigant placed in the pulp
chamber is sucked down the root canal and back up again through a thin needle with
a special design (Fig. 21). There is evidence that, compared with traditional needle
irrigation and some other systems, the EndoVac system lowers the risks associated
with irrigation close to the apical foramen considerably.67 Another advantage of the
reversed flow of irrigants may be good apical cleaning at the 1-mm level and a strong
antibacterial effect when hypochlorite is used, as shown by recent studies.69,70
Fig. 19. (A) EndoActivator with the large (blue) plastic tip. (B) Same tip in sonic motion.
Fig. 20. Vibringe irrigator creates sonic vibrations in the syringe and needle.
Ultrasound
The use of ultrasonic energy for cleaning of the root canal and to facilitate disinfection
has a long history in endodontics. The comparative effectiveness of ultrasonics and
hand-instrumentation techniques has been evaluated in several earlier studies.71–74
Most of these studies concluded that ultrasonics, together with an irrigant, contributed
to a better cleaning of the root-canal system than irrigation and hand-instrumentation
alone. Cavitation and acoustic streaming of the irrigant contribute to the biologic-
chemical activity for maximum effectiveness.75 Analysis of the physical mechanisms
of the hydrodynamic response of an oscillating ultrasonic file suggested that stable
and transient cavitation of a file, steady streaming, and cavitation microstreaming all
contribute to the cleaning of the root canal.76 Ultrasonic files must have free move-
ment in the canal without making contact with the canal wall to work effectively.77
Several studies have indicated the importance of ultrasonic preparation for optimal
Fig. 21. EndoVac system uses negative pressure to make safe and effective irrigation of the
most apical canal possible. The irrigant in the pulp chamber is sucked down the root canal
and back up again via the needle, opposite to the classic method of irrigation.
308 Haapasalo et al
debridement of anastomoses between double canals, isthmuses, and fins.78–80 The

effectiveness of ultrasonics in the elimination of bacteria and dentin debris from
the canals has been shown by several studies.81–85 However, not all studies have
supported these findings.80
Van der Sluis and colleagues84 suggested that a smooth wire during ultrasonic
irrigation is as effective as a size 15 K-file in the removal of artificially placed dentin
debris in grooves in simulated root canals in resin blocks. It is possible that preparation
complications are less likely to occur with an ultrasonic tip with a smooth, inactive
surface.
SUMMARY
Irrigation has a key role in successful endodontic treatment. Although hypochlorite is

the most important irrigating solution, no single irrigant can accomplish all the tasks
required by irrigation. Detailed understanding of the mode of action of various
solutions is important for optimal irrigation. New developments such as CFD and
mechanical devices will help to advance safe and effective irrigation.
ACKNOWLEDGMENTS
The authors would like to thank Ingrid Ellis for her editorial assistance in the final
preparation of this manuscript.
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tion techniques in tapered and nontapered canal preparations: an in vitro study.
J Endod 2008;34:1374–7.
70. Nielsen BA, Craig Baumgartner J. Comparison of the EndoVac system to needle
irrigation of root canals. J Endod 2007;33:611–5.
71. Plotino G, Pameijer CH, Grande NM, et al. Ultrasonics in endodontics: a review of
the literature. J Endod 2007;33:81–95.
72. Martin H. Ultrasonic disinfection of the root canal. Oral Surg Oral Med Oral Pathol
1976;42:92–9.
312 Haapasalo et al
73. Cunningham W, Martin H, Forrest W. Evaluation of root canal debridement by the

endosonic ultrasonic synergistic system. Oral Surg Oral Med Oral Pathol 1982;
53:401–4.
74. Cunningham W, Martin H, Pelleu G, et al. A comparison of antimicrobial effective-
ness of endosonic and hand root canal therapy. Oral Surg Oral Med Oral Pathol
1982;54:238–41.
75. Martin H, Cunningham W. Endosonics–the ultrasonic synergistic system of
endodontics. Endod Dent Traumatol 1985;1:201–6.
76. Roy RA, Ahmad M, Crum LA. Physical mechanisms governing the hydrodynamic
response of an oscillating ultrasonic file. Int Endod J 1994;27:197–207.
77. Lumley PJ, Walmsley AD, Walton RE, et al. Effect of pre-curving endosonic files
on the amount of debris and smear layer remaining in curved root canals.
J Endod 1992;18:616–9.
78. Goodman A, Reader A, Beck M, et al. An in vitro comparison of the efficacy of the
step-back technique versus a step-back ultrasonic technique in human mandib-
ular molars. J Endod 1985;11:249–56.
79. Archer R, Reader A, Nist R, et al. An in vivo evaluation of the efficacy of ultra-
sound after stepback preparation in mandibular molars. J Endod 1992;18:
549–52.
80. Sjögren U, Sundqvist G. Bacteriologic evaluation of ultrasonic root canal instru-
mentation. Oral Surg Oral Med Oral Pathol 1987;63:366–70.
81. Spoleti P, Siragusa M, Spoleti MJ. Bacteriological evaluation of passive ultrasonic
activation. J Endod 2002;29:12–4.
82. Sabins RA, Johnson JD, Hellstein JW. A comparison of the cleaning efficacy of
short term sonic and ultrasonic passive irrigation after hand instrumentation in
molar root canals. J Endod 2003;29:674–8.
83. Lee SJ, Wu MK, Wesselink PR. The effectiveness of syringe irrigation and ultra-
sonics to remove debris from simulated irregularities within prepared root canal
walls. Int Endod J 2004;37:672–8.
84. Van der Sluis LW, Wu MK, Wesselink PR. A comparison between a smooth wire
and a K-file in removing artificially placed dentine debris from root canals in resin
blocks during ultrasonic irrigation. Int Endod J 2005;38:593–6.
85. Van der Sluis LW, Wu MK, Wesselink PR. The evaluation of removal of calcium
hydroxide paste from an artificial standardized groove in the apical root canal
using different irrigation methodologies. Int Endod J 2007;40:52–7.
Tre a t m e n t o f t h e
I m m a t u re Too t h wi t h
a Non–Vital Pulp and
Apical Periodontitis
a,b,
Martin Trope, DMD *
KEYWORDS
Sodium hypochlorite Calcium hydroxide
Revascularization Periodontitis Mineral trioxide aggregate
The immature root with a necrotic pulp and apical periodontitis (Fig. 1) presents
multiple challenges to successful treatment.
1. The infected root canal space cannot be disinfected with the standard root canal
protocol with the aggressive use of endodontic files.
2. Once the microbial phase of the treatment is complete, filling the root canal is diffi-
cult because the open apex provides no barrier for stopping the root filling material
before impinging on the periodontal tissues.
3. Even when the challenges described earlier are overcome, the roots of these teeth
are thin with a higher susceptibility to fracture.
These problems are overcome by using a disinfection protocol that does not include
root canal instrumentation, stimulating the formation of a hard tissue barrier or
providing an artificial apical barrier to allow for optimal filling of the canal, and reinforc-
ing the weakened root against fracture during and after an apical stop is provided.
TRADITIONAL TECHNIQUE
Disinfection of the Canal
Because in most cases nonvital teeth are infected,1,2 the first phase of treatment is to
disinfect the root canal system to ensure periapical healing.2,3 The canal length is esti-
mated with a parallel preoperative radiograph, and after access to the canal is made,
a file is placed to this length. After the length has been confirmed radiographically, de-
pending on the thickness of the remaining dentinal walls either a very light filing or no
a
University of Pennsylvania, Philadelphia, PA 19104, USA
b
University of North Carolina School of Dentistry, Chapel Hill, NC 27599, USA
* 1601 Walnut Street, Suite 401, Philadelphia, PA 19102.
E-mail address: martintrope@gmail.com
Dent Clin N Am 54 (2010) 313–324

314 Trope
Fig. 1. The immature root with a necrotic pulp and apical periodontitis presents multiple
challenges to successful treatment. (1) The infected root canal space cannot be disinfected
with the standard root canal protocol with the aggressive use of endodontic files. (2) Once
the microbial phase of treatment is complete, filling the root canal is difficult because the
open apex provides no barrier for stopping the root filling material before impinging on
the periodontal tissues. (3) Even if the challenges described earlier are overcome, the roots
of these teeth are thin with a higher-than-normal susceptibility to fracture.
filing is performed with copious irrigation with 0.5% sodium hypochlorite.4,5 A lower
strength of sodium hypochlorite is used because of the danger of placing it through
the apex of immature teeth. The lower strength of sodium hypochlorite is compen-
sated by the volume of the irrigant used. An irrigation needle that can passively reach
close to the apical length is useful in disinfecting the canals of immature teeth. The
intra-canal medication is placed when the irrigant leaving the canal is clean of debris.
Newer irrigation protocols such as EndoVac6 (Discus Dental, Culver City, CA, USA) or
use of ultrasound7 may be useful in immature canals.
The canal is dried with paper points, and a creamy mix of calcium hydroxide is spun
into the canal with a lentulospiral instrument. The disinfecting action of calcium
hydroxide (in addition to instrumentation and irrigation) is effective after its application
for at least 1 week,8 so that the continuation of treatment can take place any time after
1 week. Further treatment should not be delayed for more than 1 month because the
calcium hydroxide could be washed out by tissue fluids through the open apex,
leaving the canal susceptible to reinfection.
A new disinfection medicament has been used when revascularization is attempted
(discussed in later section). This medicament has been extensively studied by Sato
and colleagues9 and Hoshino and colleagues.10 It comprises metronidazole, ciproflox-
acin, and minocycline in a saline or glycerin vehicle. A recent study by Windley and
colleagues11 showed the effectiveness of the tri-antibiotic paste when used for
a month on immature infected dog teeth that had been irrigated with only sodium
hypochlorite.
Treatment of the Immature Tooth 315
Hard Tissue Apical Barrier

Traditional method
The formation of the hard tissue barrier at the apex requires an environment similar to
that required for hard tissue formation in vital pulp therapy, that is a mild inflammatory
stimulus to initiate healing and a bacteria-free environment to ensure that the inflam-
mation is not progressive.
As with vital pulp therapy, calcium hydroxide is used for this procedure.12–14 Pure
calcium hydroxide powder is mixed with sterile saline (or anesthetic solution) to a thick
(powdery) consistency (Fig. 2). Ready mixed commercially available calcium
hydroxide can also be used. The calcium hydroxide is packed against the apical
soft tissue with a plugger or a thick point to initiate hard tissue formation. This step
is followed by backfilling with calcium hydroxide to completely fill the canal thus
ensuring a bacteria-free canal with little chance of reinfection during the 6 to 18
months required for the hard tissue formation at the apex. The calcium hydroxide is
meticulously removed from the access cavity to the level of the root orifices, and
a well-sealing temporary filling is placed. When a radiograph is taken, the canal should
seem to have become calcified, indicating that the entire canal has been filled with the
calcium hydroxide (Fig. 3). Because calcium hydroxide washout is evaluated by its
relative radiodensity in the canal, it is prudent to use a calcium hydroxide mixture
without the addition of a radiopaque substance such as barium sulfate. These addi-
tives do not wash out as readily as calcium hydroxide, so if they are present in the
canal, evaluation of washout is not possible.
At 3 months’ interval a radiograph is taken to evaluate if a hard tissue barrier has
formed and if the calcium hydroxide has washed out of the canal. This is assessed
to have occurred if the canal can be seen again radiographically. If calcium hydroxide
washout is seen, it is replaced as before. If no washout is evident, it can be left intact
for another 3 months. Excessive calcium hydroxide dressing changes should be
avoided if possible because the initial toxicity of the material is believed to delay
healing.15
When completion of a hard tissue barrier is suspected, the calcium hydroxide is
washed out of the canal with sodium hypochlorite and a radiograph is taken to eval-
uate the radiodensity of the apical stop. A file that can easily reach the apex is used
to gently probe for a stop at the apex. The canal is filled after the presence of
Fig. 2. Pure calcium hydroxide powder mixed with sterile saline (or anesthetic solution) to
a thick (powdery) consistency.
316 Trope
Fig. 3. The canal seems to have become calcified, indicating that the entire canal has been
adequately filled with the calcium hydroxide. (Courtesy of Frederic Barnett, DMD, Philadel-
phia, PA.)
a hard tissue barrier is indicated radiographically and the barrier is probed with an
instrument.
The hard tissue barrier that forms has been described as ‘‘Swiss cheese–like’’
(Fig. 4) because many soft tissue inclusions are still present inside the hard tissue
during the time a barrier that can resist a filling material is formed. The soft filling mate-
rial therefore often passes through the apex in the form of a sealer or filling material
puff. The hard tissue barrier is formed at the site of healing of the periodontal granu-
lation tissue. This site does not always conform to the radiographic apex of the tooth.
Therefore when the presence of the hard tissue is felt with a point or file, it may be short
of the radiographic apex of the tooth. It is important not to force the file to the radio-
graphic apex so as to avoid destruction of the formed barrier.
Fig. 4. Histologic appearance of a ‘‘Swiss cheese–like’’ apical hard tissue barrier. Note the soft
tissue inclusions inside the hard tissue.
The traditional calcium hydroxide apexification technique has been extensively

studied and is proved to have a high success rate.16,17 However, the technique has
some disadvantages. The primary disadvantage is that it typically takes between 6
and 18 months for the body to form the hard tissue barrier. The patient needs to report
every 3 months to evaluate whether the calcium hydroxide has washed out and/or the
barrier is complete enough to provide a stop to a filling material. This requires patient
compliance for up to 6 visits before the procedure is completed. It has also been
shown that the use of calcium hydroxide weakens the resistance of the dentin to frac-
ture.18 Thus it is common for the patient to sustain another injury and also fracture the
root before the hard tissue barrier is formed (Fig. 5).
Mineral trioxide aggregate barrier
Mineral trioxide aggregate (MTA) is used to create a hard tissue barrier after the disin-
fection of the canal (Fig. 6). Calcium sulfate (or similar material) is pushed through the
apex to provide a resorbable extraradicular barrier against which the MTA is packed.
The MTA is mixed and placed into the apical 3 to 4 mm of the canal in a manner similar
to the placement of calcium hydroxide. A wet cotton pellet can be placed against the
MTA and left for at least 6 hours and then the entire canal filled with a root filling mate-
rial or the filling can be placed immediately because the tissue fluids of the open apex
may provide enough moisture to ensure that the MTA sets sufficiently. The cervical
canal is then reinforced with composite resin to below the level of the marginal
bone as described later in the article (see Fig. 6).
Several case reports have been published using this MTA apical barrier tech-
nique,19,20 and it has steadily gained popularity with clinicians. At present, there is
no prospective long-term outcome study that compares the success rate of this tech-
nique with that of the traditional calcium hydroxide technique.
Fig. 5. Root that suffered a horizontal root fracture soon after root filling (left) and during
the long-term calcium hydroxide treatment (right). (From Andreasen JO, Farik B, Munks-
gaard EC. Long-term calcium hydroxide as a root dressing may increase risk of root fracture.
Dent Traumatol 2002;18(3):134–7; with permission.)
318 Trope
Fig. 6. Apexification with MTA. The canal is disinfected with light instrumentation, copious
irrigation, and a creamy mix of calcium hydroxide for 1 month, calcium sulfate is placed
through the apex as a barrier to the placement of MTA, and 4-mm MTA plug is placed at
the apex. The body of the canal is filled with Resilon obturation system (Pentron Clinical
Technologies, Wallingford, CT, USA), and a bonded resin is placed to below the cementoe-
namel junction to strengthen the root. (Courtesy of Marga Ree, DDS, MSc, Purmerend,
Netherlands.)
Because the apical diameter is larger than the coronal diameter of most of the
canals, a softened filling technique is indicated for these teeth. Care must be taken
to avoid excessive lateral force during filling because of the thin walls of the root.
The apexification procedure has become a predictably successful procedure.16,17
However, the thin dentinal walls still present a clinical problem. Should secondary
injuries occur, teeth with thin dentinal walls are more susceptible to fractures that render
them nonrestorable. It has been reported that approximately 30% of these teeth will
fracture during or after endodontic treatment (see Fig. 5).16 Some clinicians have there-
fore questioned the advisability of the apexification procedure and have opted for more
radical treatment procedures, including extraction followed by extensive restorative
procedures such as dental implants. Studies have shown that intracoronal bonded
restorations can internally strengthen endodontically treated teeth and increase their
resistance to fracture.21,22 Thus after root filling, the material should be removed to
below the level of marginal bone and a bonded resin filling placed (see Fig. 6).
Routine recall evaluation should be performed to determine the success in the
prevention or treatment of apical periodontitis. Restorative procedures should be as-
sessed to ensure that they do not promote root fractures.
Periapical healing and the formation of a hard tissue barrier occurs predictably with
long-term calcium hydroxide treatment (79%–96%).14 However, long-term survival is
jeopardized by the fracture potential of the thin dentinal walls of these teeth. It is ex-
pected that the newer techniques of internally strengthening the teeth described
earlier will increase their long-term survivability.
PULP REVASCULARIZATION
Revascularization of a necrotic pulp is considered possible only after avulsion of an

immature permanent tooth. Skoglund and colleagues23 showed in dog teeth that
pulp revascularization was possible and took approximately 45 days (Fig. 7). The
advantages of pulp revascularization lie in the possibility of further root development
and reinforcement of dentinal walls by deposition of hard tissue thus strengthening the
root against fracture. After reimplantation of an avulsed immature tooth, a unique set
of circumstances exists that allows revascularization to take place. The young tooth
has an open apex and is short; this allows new tissue to grow into the pulp space
quickly. The pulp is necrotic but usually not degenerated and infected; thus it acts
as a scaffold into which the new tissue can grow. The apical part of a pulp may remain
vital and after reimplantation may proliferate coronally, replacing the necrotized
portion of the pulp.23–26 In most cases, the crown of the tooth is intact and caries-
free, ensuring that bacterial penetration into the pulp space through cracks27 and
defects is slow. Thus the race between the new tissue formation and infection of
the pulp space favors the new tissue.
Revascularization of the pulp space in a necrotic infected tooth with apical perio-
dontitis has been considered to be impossible. Nygaard Ostby28 successfully regen-
erated pulps after vital pulp removal in immature teeth, but he was unsuccessful when
the pulp space was infected. However, if the canal is effectively disinfected, a scaffold
into which new tissue can grow is provided, and the coronal access is effectively
sealed, revascularization should occur as in an avulsed immature tooth.
Fig. 7. Revascularization of immature dog teeth during a period of 45 days. The teeth were
extracted and immediately replanted. Over the course of 45 days, the blood supply moved
into the pulp space. (From Skoglund A, Tronstad L, Wallenius K. A microradiographic study
of vascular changes in replanted and autotransplanted teeth in young dogs. Oral Surg Oral
Med Oral Pathol 1978;45(1):23; with permission.)
320 Trope
A case report by Banchs and Trope29 has reproduced results in cases reported by
others that indicate that it may be possible to replicate the unique circumstances of an
avulsed tooth to revascularize the pulp in infected necrotic immature roots.25,26
The case (Fig. 8) describes the treatment of an immature second lower right
premolar tooth with radiographic and clinical signs of apical periodontitis with the
presence of a sinus tract. The canal was disinfected without mechanical instrumenta-
tion but with copious irrigation with 5.25% sodium hypochlorite and the use of
a tri-antibiotic mixture.9,11
A blood clot was produced to the level of the cementoenamel junction to provide
a scaffold for the ingrowth of new tissue, followed by a double seal of MTA in the
cervical area and a bonded resin coronal restoration above it. With clinical and radio-
graphic evidence of healing at 22 days, the large radiolucency had disappeared within
7 months, and at the 24th month recall it was obvious that the root walls were thick and
the development of the root below the restoration was similar to the adjacent and
contralateral teeth. The author’s group has confirmed the potent antibacterial proper-
ties of the tri-antibiotic paste used in this case.11
Some variations on the original tri-antibiotic paste mixture have been used with
good success (Fig. 9).30 These variations were tried because of the staining of the
dentin by the antibiotic minocycline (Fig. 10). Either the minocycline is left out thus
using a bi-antibiotic paste or cefaclor is used as a substitute for the minocycline.30
A recent study on dogs demonstrated the potential for revascularization using
a collagen-enhanced scaffold (Fig. 11). This study also indicated that it was the blood
clot with or without the addition of the collagen-enhanced scaffold that seemed impor-
tant for the stimulation of the revascularization process.31 The study also confirmed
Fig. 8. Immature tooth with a necrotic infected canal with apical periodontitis. The canal is
disinfected with copious irrigation with sodium hypochlorite and tri-antibiotic paste. After 4
weeks the antibiotic is removed, and a blood clot created in the canal space. The access is
filled with an MTA base, and bonded resin above it. At 7 months the patient is asymptom-
atic, and the apex shows healing the apical periodontitis and some closure of the apex. At
24 months apical healing is obvious, and root wall thickening and root lengthening have
occurred, indicating that the root canal has been revascularized with vital tissue. (Adapted
from Banchs F, Trope M. Revascularization of immature permanent teeth with apical perio-
dontitis: new treatment protocol? J Endod 2004;30:196; with permission.)
Fig. 9. Successful revascularization after failed Cvek pulpotomy. Cefaclor was substituted for
minocycline in the tri-antibiotic paste. (Courtesy of Blayne Thibodeau, DMD, Saskatoon,
Canada.)
that only in a few cases the pulp is actually the tissue that revascularizes the pulp
space (see Fig. 11). Case-based studies have confirmed the viability of this proce-
dure.32,33 Further studies are underway to find other potential synthetic matrices
that will act as a more predictable scaffold for new ingrowth of tissue than the blood
Fig. 10. Discoloration after antibiotic placement. Minocycline in the tri-antibiotic paste seems
to be the cause of the discoloration. The color of the root after placement of the paste
including minocycline is shown (first from left). If Arestin (OraPharma, Inc, Warminster, PA,
USA) is used as a substitute for the minocycline, the discoloration is markedly reduced (third
from left). However cefaclor (second from left) or no additional antibiotic (extreme right)
results in the least discoloration. (Courtesy of Dr Jared Buck, Philadelphia, PA.)
322 Trope
Fig. 11. Experimental confirmation that revascularization is possible. Radiograph on the left
is after successful revascularization and root wall thickening. The histologic picture on the
right shows cementum on the inner root wall, which is the reason for the thickening of
the root. (From Thibodeau B, Teixeira F, Yamauchi M, et al. Pulp revascularization of imma-
ture dog teeth with apical periodontitis. J Endod 2007;33(6):680–9; with permission.)
clot that was used in previous cases. In addition, a synthetic matrix may allow easier
and more predictable placement of the coronal seal than that provided by a fresh
blood clot. The procedure described in this section can be attempted in most cases,
and if after 3 months no signs of regeneration are present, the more traditional
treatment methods can be initiated.
DISCUSSION POINTS
Regeneration Versus Revascularization
Cases such as those presented in this article have been described as examples of
pulp regeneration and the beginning of stem cell technology in endodontics. It is
important to distinguish between revascularization and pulp regeneration. At present,
it is certain that the pulp space has returned to a vital state, but based on research in
avulsed teeth and on a recent study on infected teeth, it is likely that the tissue in the
pulp space is more similar to periodontal ligament than to pulp tissue (see Fig. 11).31 It
seems that there is about a 30% chance of pulp tissue reentering the pulp space.34
Future research will be needed to stimulate pulp regeneration from the pluripotential
cells in the periapical region. Also, in an irreversible pulpitis case, instead of removing
the entire pulp and replacing it with a synthetic filling material, partial resection of the
pulp and regrowth with the help of a synthetic scaffold would be better.
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2. Shuping G, Ørstavik D, Sigurdsson A, et al. Reduction of intracanal bacteria
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5. Spangberg L, Rutberg M, Rydinge E. Biologic effects of endodontic antimicrobial
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6. Nielsen BA, Craig Baumgartner J. Comparison of the EndoVac system to needle
irrigation of root canals. J Endod 2007;33(5):611–5.
7. Carver K, Nusstein J, Reader A, et al. In vivo antibacterial efficacy of ultrasound
after hand and rotary instrumentation in human mandibular molars. J Endod
2007;33(9):1038–43.
8. Bystrom A, Claesson R, Sundqvist G. The antibacterial effect of camphorated
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ment of infected root canals. Endod Dent Traumatol 1985;1:170.
9. Sato T, Hoshino E, Uematsu H, et al. In-vitro anti-microbial susceptibility to combi-
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11. Windley W 3rd, Teixeira F, Levin L, et al. Disinfection of immature teeth with a triple
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15. Lengheden A, Blomlof L, Lindskog S. Effect of delayed calcium hydroxide treat-
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16. Kerekes K, Heide S, Jacobsen I. Follow-up examination of endodontic treatment
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18. Andreasen JO, Farik B, Munksgaard EC. Long-term calcium hydroxide as a root
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22. Goldberg F, Kaplan A, Roitman M, et al. Reinforcing effect of a resin glass
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23. Skoglund A, Tronstad L, Wallenius K. A microradiographic study of vascular

changes in replanted and autotransplanted teeth in young dogs. Oral Surg
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Resin Materials
for Root Canal
Obturation
Cornelis H. Pameijer, DMD, MScD, DSc, PhDa,b,*,
Osvaldo Zmener, DDS, Dr Odontc
KEYWORDS
Methacrylate resins Obturation Biocompatibility
Leakage Cytotoxicity
DEVELOPMENT LEADING TO RESIN SEALERS
The concept of resin bonding in dentistry was introduced in the mid-1950s by Buono-
core,1 who advocated the use of an acid to demineralize enamel. Skepticism slowly
gave way to general acceptance. However, bonding materials and techniques have
completely changed over the course of 50 years. During the initial development only
hydrophobic resins were available; these have been replaced by hydrophilic resins
over time. Furthermore, about 30 years of research resulted in a change from using
85% phosphoric acid liquid for 60 seconds to etch enamel to 35% phosphoric acid
gels for 15 seconds to etch dentin and enamel. Although early attempts were strictly
focused on preventive and restorative dentistry, it was only a matter of time before
orthodontics and then endodontics embraced this concept. Usually, when new mate-
rials and techniques are introduced, there is an initial reluctance on the part of prac-
titioners to abandon trusted and proven methods until evidence that is sufficiently
convincing to change established techniques is generated.
The objective of this article is to provide information about methacrylate-based resin
sealers (MBRS) on which practitioners can base their decision to consider changing
established techniques and embrace a new one. This decision cannot be made by
presenting empiric data, but by offering an analysis of scientific evidence from ex
vivo and in vivo research. Based on their successful long-track record, gutta-percha
and zinc oxide, eugenol, and other conventional sealers, have served as the gold stan-
dard for comparison.
a
Department of Reconstructive Sciences, University of Connecticut, Health Center, Farmington,
CT 06030, USA
b
DLC International, 10 Highwood, Simsbury CT 06070, USA
c
Post Graduate Program for Specialized Endodontics, Faculty of Medical Sciences, School of
Dentistry, University of El Salvador, Buenos Aires, Argentina
* Corresponding author. Department of Reconstructive Sciences, University of Connecticut,
Health Center, Farmington, CT 06030.
E-mail address: cornelis@pameijer.com
Dent Clin N Am 54 (2010) 325–344

326 Pameijer & Zmener
One of the factors that was instrumental in the development of resin-based sealers
was the recognition that gutta-percha does not bond to dentin or to any conventionally
used sealer, such as zinc oxide-eugenol (ZOE)-based cements and epoxy resins such
as AH-26 or AH Plus. Although these materials are being used successfully, an ideal
root canal sealer should be capable of bonding to root canal dentin and to gutta-per-
cha, thus preventing microleakage. Recent advances in adhesive technology have led
to the introduction of a new generation of endodontic sealers and filling materials, that
are based on adhesive properties and polymer resin technology. These materials are
capable of forming a hybrid layer and penetrating deep into dentinal tubules by virtue
of their hydrophilic properties.
Early attempts at using resins were reported in 1978 by Tidmarsh,2 who suggested
that a low-viscosity resin could have the potential to be used in root canal obturation.
Of the bonding agents that were used in restorative dentistry, the early generations did
not use an acid to remove the smear layer and therefore bonded to it. This resulted in
a weak bond and did not prevent bacterial leakage. Later generations that used 35%
phosphoric acid gels for the removal of the smear layer were more promising. Further-
more, the early resins were hydrophobic and therefore their interaction was adversely
affected by moisture in the dentin. The latest bonding agents are hydrophilic and they
derive their adhesive properties from micromechanical interlocking by penetrating into
dentinal tubules, thus creating an attachment mechanism along with an intimate
hybrid layer when they come in direct contact with the surrounding collagen fibrillar
intertubular network. The latter requires careful treatment and it has been shown
that the collagen network of dentin can be best preserved using 17% to 19%
EDTA3 or low concentrations of citric acid solution as the final rinse. Effective removal
of the smear layer before filling the canals will enhance the ability of these bonding
agents to enter the dentinal tubules and improve the sealing of the root canal system
by increasing the contact surface area. The presence of organic debris along with
bacteria within the matrix of the smear layer represents an undesirable interface
between filling material and dentin. Furthermore, the sequence of the irrigating solu-
tions has been shown to be a factor. A 5% sodium hypochlorite (NaOCl) solution fol-
lowed by 17% EDTA or 50% citric acid seems to be the most effective combination.4,5
Zidan and El Deeb6 were among the first to attempt to establish adhesion to dentin
walls in vitro with the use of Scotchbond (3M ESPE, St Paul, MN, USA). Apical micro-
leakage with gutta-percha and the bonding agent was significantly less than in root
canals obturated with gutta-percha and Tubli-Seal (SybronEndo, West Collins,
Orange, CA, USA), a ZOE-based root canal sealer. Handling properties, radiopacity,
and the difficulty of removing the sealer in case of retreatment were some of the draw-
backs that were experienced. Other possible bonding systems have subsequently
been reported in the literature. Leonard and colleagues7 compared the effectiveness
of a combination of the dentin bonding agent 4-methacryloyloxyethy trimellitate anhy-
dride (4-META) and the resin C&B Metabond (Parkell Inc, Edgewood, NY, USA), which
was commercialized a few years later as MetaSEAL (Parkell Inc, Edgewood, NY, USA),
and the glass ionomer cement Ketac-Endo (3M ESPE, St Paul, MN, USA) for sealing of
the root canal system. The coronal and apical seals were tested by means of dye
penetration, and both materials showed some evidence of dye leakage. However,
the sealing ability of the bonding agent and resin was significantly better. This was
further supported by scanning electron microscopy (SEM) of the interface sealer
and dentin, indicating the presence of a hybrid layer and resin tags penetrating into
the dentinal tubules. Despite these positive features, the materials seemed to be tech-
nique sensitive. Nikaido and colleagues,8 Morris and colleagues,9 and Erdemir and
colleagues,10 showed that the use of sodium hypochlorite and hydrogen peroxide
Resin Materials for Root Canal Obturation 327
or a combination of both irrigants, decreased the bond strength to dentin by adversely

affecting the tensile bond strength to bovine dentin. Hydrogen peroxide breaks down
to water and oxygen, whereas the combination of sodium hypochlorite and hydrogen
peroxide allows for the formation of oxygen, which inhibits polymerization of the adhe-
sive materials. However, irrigation with chlorhexidine did not exhibit these adverse
effects.
ALL-BOND 2 adhesive (Bisco, Itasca, IL) and Scotchbond Multi-purpose Plus adhe-
sive in combination with gutta-percha and an epoxy resin–based root canal sealer
AH-26 (Dentsply-Maillefer, Switzerland) was also tested for leakage with a 2% methy-
lene blue solution.11 It was reported that root canals that had the combination of
bonding agents with gutta-percha and the epoxy resin sealer leaked significantly
less than the controls in which the root canals were obturated with gutta-percha and
AH-26. Although no problems were experienced with respect to the working time of
the bonding agents, the complexity of the technique (it required many steps) made
the use of bonding agents impractical for root canal obturation. Of additional concern
is the use of bonding agents containing 2-hydroxyethyl methacrylate (HEMA), which,
when extruded beyond the apex into bone, could sensitize patients, particularly if
they are from Nordic countries or have genetic make-up that originates there.
Ahlberg and Tay12 tested a methacrylate-based bone cement normally used in
orthopedic surgery, in which the monomer from N-butyl methacrylate was changed
to tetrahydrofurfuryl methacrylate with 1% N’N’-dimethyl p-toluidine as the activator.
The powder consisted of poly(ethyl methacrylate) with a molecular weight of 150,000
to 1,500,000 and a particle size of 15 to 100 mm. They used this formulation to obturate
in vitro root canals of human teeth with gutta-percha cones; the control canals were
filled with gutta-percha only. The root canals filled with the resin and gutta-percha
leaked significantly less than the controls. Scanning electron microscope observation
of the interface revealed a bond not only between the resin-based sealer and the root
canal walls but also between the sealer and gutta-percha. With respect to their
handling properties, the material was found to be easy to place in the root canal
and the working time was approximately 50 minutes. The investigators postulated
that, because the smear layer was not effectively removed, bonding to the root canal
walls may be attributed to the low viscosity of the resin itself, whereas the ability to
bond to gutta-percha was attributed to dissolution of the gutta-percha surface.
Kataoka and colleagues13 analyzed the coronal and apical sealing properties of
a newly developed resin-based root canal sealer composed of vinylidine fluoride/hex-
afluoropropylene copolymer, methyl methacrylate, zirconia, and tributylborane as the
catalyst, used in conjunction with gutta-percha cones in root canals, which were pre-
treated with dentin conditioners and primers. They also analyzed the tensile bond
strength and used SEM to analyze the interfaces. The test material revealed a signifi-
cantly higher sealing ability than Pulp Canal Sealer EWT (Sybron Kerr, Romulus, MI,
USA) and Sealapex (Sybron Kerr, Romulus, MI, USA), which were used as controls.
When the canal walls were pretreated with EDTA and further application of glutaralde-
hyde/2-hydroxyethyl methacrylate primers, higher bond strength values were
recorded. SEM observation revealed the presence of a hybrid layer approximately
2 mm thick, formed by the penetration of the resin into the dentin with only a few
gaps at the interface between the sealer and the root canal walls. Based on these
observations, the investigators suggested that the tested resin-based sealer had
many useful properties for root canal obturation, such as adhesiveness to dentin
and gutta-percha while exhibiting good sealing properties.
According to the above information these experimental formulations have the
potential to bond to the root canal walls provided the smear layer is removed.
METHACRYLATE-BASED RESIN SEALERS
MBRS are new in endodontics and are derived from polymer chemistry technology
initially developed for adhesive restorative dentistry, albeit in modified formulations
and viscosities as determined by the specific demands in endodontics. This article
focuses on 2 systems as they dominate the market:
1. EndoREZ (Ultradent Products Inc, South Jordan, UT, USA) and

2. RealSeal (Sybron Dental Specialties, Orange, CA, USA).
Pentron Clinical Technologies (Wallingford, CT, USA) was recently acquired by Syb-
ron Dental Specialties, which includes the Resilon-Epiphany system, now marketed as
RealSeal. Therefore products such as SimpliFill (LightSpeed Technology Inc, San
Antonio, TX, USA), InnoEndo (Heraeus Kulzer, Armonk, NJ, USA), and Resinate
(Obtura Spartan, Fenton, MO, USA) and Resilon-Epiphany are now all categorized
under the name RealSeal.
ENDOREZ
EndoREZ (ER) is a hydrophilic, two-component (base and catalysts), dual-curing self-

priming sealer. The formulation can be described as follows:
The EndoREZ base contains:

a bismuth compound as the radiopaque filler
small amounts of other fillers
diurethane dimethacrylate
triethylene glycol dimethacrylate
a peroxide initiator
a photo initiator (not chamfer quinone).
The EndoREZ catalyst contains:
a bismuth compound as the radiopaque filler
small amounts of other fillers
diurethane dimethacrylate
triethylene glycol dimethacrylate.
The sealer can be used with gutta-percha or with resin-coated gutta-percha cones,
the latter with the objective of establishing continuous adhesion (uniblock or mono-
bloc) between all materials. The sealer is supplied in a double barrel auto mixing
and delivery syringe and meets the basic requirements of an endodontic sealer. The
manufacturer recommends that after preparation the root canal walls should remain
slightly moist to take maximum advantage of the hydrophilic properties of the sealer,
thus allowing for resin tags to penetrate into the dentinal tubules and the formation of
a hybrid layer with the collagen fiber network.14 However, too much water can cause
water permeation during the polymerization process and results in the entrapment of
water droplets in the sealer, resulting in bond disruption and an increase in leakage.15
Delivery through the tiny opening and the hydraulics involved when using a NaviTip
(Ultradent Products Inc, South Jordan, UT, USA) produces a sealer free from air
bubbles that fills the canal with a homogeneous layer. The sealer is radiopaque and
has favorable low viscosity properties. Low viscosity plays a significant role in the
handling properties and makes it useful for placement in wide or narrow root canals;
it provides a good adaptation to the intricacies of the dentin walls. EndoREZ bonds
well to root canal walls but not to gutta-percha, which constitutes a potential weak-
ness, as a path for bacterial leakage may exist.16 To address this issue and to establish
a bond between sealer and dentin and between sealer and gutta-percha, resin-coated
gutta-percha cones (RCGP) cones (Ultradent Products Inc, South Jordan, UT, USA)
were introduced.
The combination of these materials establishes the so-called monobloc and is the
reason for the superior sealing properties of the system. The objective of the EndoREZ
sealer is to establish a hermetic seal, rather than high bond strength adhesion, that is,
optimum softness or hardness while providing a maximum seal.
The RCGP cones can be used with an accelerator, which serves a dual purpose.
The polymerization reaction of the EndoREZ is accelerated (within 4–5 minutes) allow-
ing for immediate continuation of the restorative phase should the practitioner choose
to do so and bonding of the EndoREZ to the RCGP cones is promoted, thus establish-
ing a monobloc.
REALSEAL (RESILON/EPIPHANY)
Resilon is composed of a polymer-based resin (polycaprolactone), bioactive glass,

bismuth oxide, barium sulfate and coloring agents. The sealer is a dual-cure sealer,
composed of urethane dimethacrylate (UDMA), poly dimethacrylate (PEGDMA),
ethoxylated bisphenol A dimethacrylate (EBPADMA) and bisphenol A glycidyl methac-
rylate (BIS-GMA), barium borosilicate, barium sulfate (BaSO4), bismuth oxychloride,
calcium hydroxide, photo initiators, and a thinning resin. In addition the system comes
with a self-etching primer. The premise behind the material is the formation of a mono-
bloc, that is, the primer forms a hybrid layer with dentin, which bonds to sealer, and
then bonds to the Resilon core. The ability of Resilon to bond to methacrylate-based
root canal sealers has also been questioned because the amount of dimethacrylate in
the thermoplastic composite may not be optimum for chemical coupling.17 However,
when surface roughness was established, the micromechanical interlocking increased
the mean bond strength significantly.
BIOCOMPATIBILITY
Several early publications (2001 and 2003) have reported on the biocompatibility and
adhesiveness of EndoREZ.18–20 Since then numerous publications have appeared,
testing different MBRS formulations and using a variety of techniques, which to a large
extent have caused more controversy and confusion than answering the following
basic questions:
1. Are resin-based sealers safe?
2. Can they be used successfully in patients?
3. Will they ultimately replace gutta-percha and conventional sealers?
4. Will they last as long as conventional materials?
5. Are they easier to use than conventional materials?
TOXICOLOGY STUDIES IN VITRO
One of the requirements of any dental material for use in humans is that it should be
biocompatible. Numerous investigators have conducted cytotoxicity studies ex vivo
using cell cultures and in vivo in laboratory animals. The results between investigators
are contradictory. Huang and colleagues21 showed that the elution compounds from
MBRS, zinc oxide-eugenol and calcium hydroxide-based sealers were cytotoxic to
primary human periodontal ligament cultures and V79 cells, with calcium hydroxide
being the least toxic. Huang and co-workers,22 reported that the highest level of
DNA damage was induced by epoxy resin–based sealers, in this case Topseal (Dents-
ply, Konstanz, Switzerland), AH-26, and AH Plus. Koulaouzidou and colleagues23
reported similar results. AH-26 had a severe cytotoxic effect, whereas Topseal and
AH Plus had markedly lower effects. These findings are surprising as the basic formu-
lation of AH-26 and Topseal is the same. Bouillaguet and colleagues,24 reported that:
‘‘Most materials pose significant cytotoxic risks and that cytotoxicity generally
decreased with time.’’ At 72 hours, GuttaFlow became significantly less toxic than
AH Plus, Epiphany sealer, and Resilon. Other investigators, such as Key and
colleagues25 found Epiphany to be less toxic than Grossman’s sealer. However,
Epiphany was more cytotoxic than Sealapex after 1 hour, but less after 24 hours.
Epiphany was more cytotoxic than conventional materials. In a more recent publica-
tion26 similar findings were reported. According to Lodiene and colleagues27 the
multi-methacrylate-based resin (Epiphany) root canal sealer was significantly more
toxic to L-929 cells than the silicone-based RoekoSeal and the single methacrylate-
based EndoREZ root canal sealers. AH Plus showed intermediate toxicity.
Based on the these findings it seems that no sealer is universally accepted as being
nontoxic. Furthermore, the investigators mentioned earlier have reported completely
opposite findings, which makes selection of a sealer without drawbacks difficult, if
not impossible. Therefore it is necessary to conduct a careful and critical analysis of
the various ex vivo research methodologies to reach a consensus. It is also important
to correlate the results of the various techniques with the clinical performance of the
same material or materials. Oliver and Abbott28 reported that clinical and in vitro
data frequently contradict each other.
TOXICOLOGY STUDIES IN VIVO
The early studies on which the launch of EndoREZ was based were conducted by
Louw and colleagues18 and Becce and Pameijer20 who reported that EndoREZ was
mildly irritating, but within acceptable standards (1.5 is the acceptable limit). Further
evidence of biocompatibility was published by Zmener29 and Zmener and
colleagues.30 In other related studies (Pameijer, 2002, unpublished data), EndoREZ
and Epiphany/Resilon reacted more favorably than the control AH Plus. Preoperative
and postoperative radiographs were made and root canal treatment was performed
according to a standardized protocol using a rubber dam in subhuman primates.
Histologic observations were made at various time periods: 30 days to determine
an early reaction and from 3 months to 6 months posttreatment for long-term reac-
tions. The results can be summarized as follows. Ten EndoREZ root canal treated
teeth scored a mean inflammatory reaction after 26 days of 1.5 . After 90 days, out
of 21 root fills, 4 had extruded sealer with an inflammatory mean of 0.8 . Good apical
adaptation scored a lower mean inflammation of 0.4 . None of the periapical areas of
the roots at either time period showed bone resorption. The control sealer (AH Plus)
had a mean inflammatory reaction of 1.3 after 26 days and 1.0 after 90 days.
Epiphany, which was tested according to the same protocol, scored a mean inflam-
matory reaction of all root fills of 1.2 after 120 days (13 teeth), whereas the inflamma-
tion of bone was 0.4 . Control teeth (AH Plus) had a mean inflammatory reaction of 2 ,
and a bone inflammation of 1 .
Both materials clearly reacted more favorably than the control AH Plus.
These results were confirmed by Zmener.29 The severity of the reaction decreased
over time. Zmener and colleagues30 conducted a histologic and histometric study in
which silicone tubes filled with EndoREZ were implanted in the tibias of rats for a period
of 10 days and 60 days. At the 10-day observation period, the number of inflammatory
cells in contact with the sealer was significantly higher. After 60 days, the initial inflam-
matory reaction was resolved and newly formed healthy bone was observed
surrounding the implants. Thus, after early mild irritation the material reacted in
a biocompatible fashion allowing healing of bone. In contrast Sousa and colleagues31
tested AH Plus, EndoREZ, and Epiphany in guinea pigs over 4 and 12 weeks. They
reported a severe reaction for EndoREZ; AH Plus was also severe after 4 weeks
and moderate after 12 weeks. Only Epiphany showed intraosseous biocompatibility.
EXAMPLES OF SEALER AND POINT BIOCOMPATIBILITY TESTING
The periapical tissues can react to extrusion of a sealer and/or point in several ways:
1. It can cause an inflammatory reaction
2. It can be regarded as a foreign body and be encapsulated
3. A sealer can be present without causing inflammatory reactions and is not
encapsulated
4. The sealer can be resorbed over time, with or without an inflammatory reaction.
As mentioned earlier, a material causing an inflammatory reaction is not necessarily

bad and the outcome depends on the intensity and duration of the inflammatory
process and the ability of the natural defense mechanisms of the body to manage
the reaction. Biocompatibility should be construed in a broader sense. If over a reason-
able period of time (30–60 days) healing occurs after an initial irritating reaction,
a material can still be considered biocompatible. None of the endodontic sealers
that are currently being used are totally nonirritating, yet without doubt they are being
used with clinical success.
If over a short period of time (up to 30 days) a mild inflammation is present and it
diminishes over time, a material with otherwise favorable properties can be consid-
ered biocompatible.29 Eluation of components was recognized by Ferracane and
Condon32 and the inflammatory process as a result of this is the body’s response to
irritation. Fibrous encapsulation without inflammation is the body’s response to isolate
an otherwise biocompatible material. Furthermore, a material, usually small size parti-
cles, can be present in periapical tissues, cause no inflammation, and be present
without encapsulation.
Fig. 1 is a representative radiograph of experimental sealers in 4 central incisors.
After 113 days 2 reactions were observed for 2 different experimental sealers.
Fig. 2 is an example of extrusion (intentional to determine biocompatibility) of the
sealer into periapical tissues. The sealer particles are not encapsulated and no inflam-
matory reaction was observed. The periapical tissues reacted differently to the other
sealer. After 113 days the histologic features of the apical area (Fig. 3) showed slight
extrusion into the periapical tissues. A fibrous encapsulation of the material can be
observed, however, without the presence of inflammatory cells (magnification 64,
hematoxylin and eosin stain).
LEAKAGE STUDIES
Leakage of MBRS, whether coronal or apical, has been studied by numerous investi-
gators, resulting in the publication of contradictory data that have generated more
questions than answers.
It has been established that selection of an appropriate sealer will influence the
outcome of endodontic therapy.33,34 For that reason many investigators have focused
on this important aspect using techniques such as fluid filtration, dye penetration, and
Fig. 1. At 113 days post treatment, the endodontic radiograph of 4 central incisors shows
extrusion of sealer (intentional) into the periapical tissues.
bacterial leakage tests. Frequently AH Plus or AH-26 are used as control materials. In
one of the first published leakage tests using India ink, Zmener and Banegas35
reported no statistically significant difference between EndoREZ and AH Plus. Oruco-
glu and colleagues,36 using the fluid filtration method, reported that Diaket with cold
lateral condensation leaked less apically than EndoREZ and AH Plus. However,
Fig. 2. Histologic reaction of an experimental sealer (black) extruded into periapical tissues.
The white space was occupied by the Resilon point and disappeared during processing for
histology. Ingrowth of connective tissue into apical root space adjacent to the point can be
observed. Despite the presence of numerous sealer particles beyond the apex, no inflamma-
tory cells were present (hematoxylin and eosin stain, original magnification 64).
Fig. 3. At 113 days post endodontic treatment, the sealer (dark brown) is surrounded by
a fibrous capsule in the periodontal ligament space. No inflammatory reaction is present
as a result of the extruded material, point, and sealer (hematoxylin and eosin stain, original
magnification 200).
others37 reported that AH Plus leaked less than EndoREZ and AH-26 using a single
cone technique. Compared with zinc oxide-eugenol,38 MBRS was found to be more
effective in sealing. These investigators also used the fluid filtration method. Using
similar techniques,39 it was found that the apical seal of Epiphany and Resilon was
not different from AH Plus and gutta-percha, AH Plus and Resilon, and Epiphany
and gutta-percha. In contrast, using a fluid-transport method, Tunga and Bodrumlu40
concluded that Epiphany and Resilon leaked significantly less (P<.05) than gutta-per-
cha and AH-26. Others reached a similar conclusion when comparing Resilon and
gutta-percha and AH Plus,41 and in bacterial leakage tests42,43; Epiphany and Resilon
were superior to gutta-percha and various other sealers. Pitout and colleagues44 also
used a bacterial leakage test and a dye penetration method and Biggs and
colleagues45 did not observe a difference between Resilon and gutta-percha. Several
investigators have used the dye penetration technique to demonstrate that MBRSs
are superior or inferior to conventional materials.46–48 One explanation for the differ-
ence in results between the various MBRS materials can most likely be attributed to
the presence or absence of moisture in the root canal at the time of obturation.
To put leakage studies in context, in 2001 Oliver and Abbott28 conducted a study to
determine if there was a correlation between apical dye penetration and clinical perfor-
mance of root fillings. They tested the length of apical dye penetration using a vacuum
technique ex vivo in 116 human roots that had been root-filled at least 6 months before
extraction. Endodontic treatment was classified as clinically successful or unsuccess-
ful and the results for these groups were compared using an analysis of variance and
the Student t-test. Positive and negative controls were used to test the experimental
system. In unsuccessful cases the dye penetrated significantly further although the
raw data suggested little difference. Overall, the dye penetrated in 99.5% of the spec-
imens, and this indicates that the presence of dye in a canal is a poor indicator of
whether a technique or material will succeed clinically. However, the extent of dye
penetration may be related to the clinical outcome. The investigators concluded
that clinically placed root canal fillings do not provide an apical seal that prevents fluid
penetration and therefore the outcome of treatment cannot be predicted based on the
results of apical dye leakage studies. In 1993 Wu and Wesselink49 reviewed the
shortcomings of various tests reported in the literature. However, dye leakage studies
may be useful to determine the performance of a new material or technique by con-
ducting comparative studies with existing systems. An electrochemical technique
that seems to be sensitive and has generated findings that correlate with bacterial
leakage tests, has been published by von Fraunhofer and colleagues.50 Fig. 4 illus-
trates a comparison between resin sealers and conventional sealers.
Independent of the technique used (fluid filtration or bacterial leakage test or other
tests), there is no general agreement on whether there is reduced or more leakage
when using MBRS. In addition ex vivo tests frequently do not correlate with clinical
performance.
WHEN TO DRY AND WHEN NOT TO DRY
The contradictory data of several of the leakage studies can be explained and are
most likely the result of the ingrained belief in endodontics that root canals after a final
rinse need to be dried thoroughly. Many articles reviewed stated in the materials and
methods section that ‘‘the canals were dried’’ (eg, Biggs and colleagues45 and Kardon
and colleagues51). Several of the articles did not specify in sufficient detail the condi-
tion of the root canal. Based on established endodontic techniques we can speculate
with a fair amount of certainty that the canals were thoroughly dried. Thorough drying
will create a hydrophobic environment while a hydrophilic material is being used. Field
emission scanning electron microscopy (FESEM) and SEM have provided excellent
examples of the potential of EndoREZ when proper moist conditions are adhered to
and the recommended insertion technique is followed (Fig. 5) and show what happens
when the canal is thoroughly dried according to well-established endodontic tech-
niques (Fig. 6). The concept of moist bonding has always been difficult to explain in
restorative dentistry, and endodontics has not been exempt from the same misinter-
pretations and misconceptions. For MBRS, whether EndoREZ or Epiphany, to estab-
lish a proper seal, the dentin needs to be moist to allow for the penetration of resin tags
into the opened dentinal tubules and the formation of a hybrid layer, thus taking advan-
tage of the hydrophilicity of these materials, whether bonding agent or sealer. In the
case of EndoREZ this allows for deep penetration of resin tags, up to 500 to 1000 mm
and more, and for Epiphany it allows bonding of the adhesive by means of a hybrid
layer and resin tags into the dentin. Unlike restorative dentistry, where a reflection
100
75
Relative leakage (%)
50
25
0
Conventional Thermoplastic Resin system
Fig. 4. Relative leakage behavior of endodontic obturation techniques. (From Von

Fraunhofer JA. Dental materials at a glance. Oxford: Wiley-Blackwell; 2009; with permission.)
Fig. 5. FESE micrograph of EndoREZ tags extruding from the root filling material extending
distances of at least 400 to 600 mm. The foreground shows fractured resin tags (caused
by polymerization shrinkage) or resin tags that have partially entered the dentinal tubules.
(From http://www.ineedce.com. Pameijer CH, Barnett F, Zmener O, Schein B. Methacrylate
based resin endodontic sealers: a paradigm shift in endodontics? ENDO0710DE; 2008:1–11;
with permission.)
of light from the moisture on the surface of a preparation can be visualized, in a root
canal this is not possible, thus making clinical judgment more difficult.
In a study by Zmener and colleagues14 4 scenarios of dentin wetness or dryness
were tested for apical and coronal dye leakage. In Group 1, 95% ethanol was used
followed by paper points to dry the canals. In Group 2, the canals were blot dried
with several paper points. In Group 3, a luer vacuum adaptor with low vacuum for 5
seconds followed by 1 paper point for only 1 to 2 seconds was used. In Group 4,
the root canal remained flooded and no effort was made to remove excess distilled
water. It was theorized that perhaps the hydrophilic properties of EndoREZ with the
scenario in Group 4 would displace excess water.
Positive and negative controls were also tested. Dye leakage as determined by
methylene blue, showed that EndoREZ and Epiphany/Resilon in Groups 2 and 3
Fig. 6. Scanning electron micrograph of a gutta-percha point partially covered with EndoR-
EZ. The space between point and adjacent dentin wall is filled with EndoREZ; however, no
penetration into the dentinal tubules was observed. This is the result of over drying. (From
Becce, C, Pameijer CH. SEM study of a new endodontic root canal sealer. J Dent Res
2001;79(AADR issue):abstract #866; with permission.)
exhibited significantly less coronal and apical leakage (P<.05) than Groups 1 and 4.
The method with a low vacuum luer adaptor and paper point drying for 1 to 2 seconds
(Group 3) scored the lowest leakage. There was no statistically significant difference
between EndoREZ and Epiphany/Resilon. Another clinical technique to maintain moist
dentin is to make sure that when excess water (or EDTA, saline or chlorhexidine) is
removed with paper points, the last paper point shows at least 3 mm of moisture.
OXYGEN-INHIBITED LAYER
When conducting biocompatibility studies using subcutaneous implantation or intra-

osseous bone implants, specimen preparation of MBRS may result in the formation
of an oxygen-inhibited layer, which depends on the method of sample preparation.
The presence of an oxygen-inhibited layer plays a significant role in the outcome of
tissue reactions, because resin, whether chemical, light, or dual cured, does not poly-
merize at its surface when in contact with air. This surface layer contains unreacted
monomers that are highly toxic. However, this does not mean that polymerized sealers
cannot cause irritation. Conversion of monomer in a typical polymerization reaction is
at best less than 70%.52 It is important to thoroughly flush the root canal with EDTA
after using NaOCl, followed by an optional final flush with sterile saline or 2% chlorhex-
idine (Consepsis, Ultradent Products Inc), because oxygen left behind from the NaOCl
inhibits polymerization, thus forming an oxygen-inhibited layer. The effect of this was
demonstrated by the following study dealing with irrigation.
IRRIGATION PROTOCOL
Bond strength values of MBRS using different intracanal irrigation scenarios vary
depending on the sequence of rinses and the composition of the last rinse. To deter-
mine the importance of an irrigation protocol that does not interfere with dentin
bonding of a sealer, an experiment using a modification of the thin-slice push-out
test design was used by Pameijer and Zmener.53 Intact human teeth were instru-
mented according to a standardized protocol and subsequently prepared to produce
18 standardized dentin tubes (n 5 6 per group for 3 groups), with a 3 mm internal
diameter. The irrigation protocol was as follows:
Group 1 (n 5 6): irrigation for 1 minute with 10 mL of 17% EDTA to remove the smear
layer followed by a continuous flow of 10 mL of 5.25% NaOCl. The canal was then
dried with a luer low vacuum tip for 2 seconds followed by sterile cotton pellets leaving
the dentin slightly moist with NaOCl.
Group 2 (n 5 6): irrigation with a continuous flow of 10 mL of 5.25% NaOCl followed
by 10 mL of 17% EDTA (1 minute each) followed by drying with a luer low vacuum tip
for 2 seconds followed by sterile cotton pellets leaving the dentinal walls slightly moist
with EDTA.
Group 3 (n 5 6): irrigation with a continuous flow of 10 mL of 5.25% NaOCl followed
by 10 mL of 17% EDTA (1 minute each) and a final 2-minute rinse with 10 mL sterile
distilled water. The canals were dried with a luer low vacuum tip for 2 seconds followed
by sterile paper points leaving the dentinal walls slightly moist with distilled water.
All samples were then obturated with EndoREZ as per the manufacturer’ instruc-
tions and prepared for the push-out test. Fig. 7 shows the setup of the custom-
made equipment used. Data were recorded in megaPascals (Table 1). The results
of the push-out tests revealed that all groups had measurable adhesive properties.
Group 1 showed the lowest bond strength values, whereas the values for Groups 2
and 3 were much higher. Although the results in Group 3 were slightly better, no statis-
tically significant differences were demonstrated compared with Group 2 (P>.05).
Fig. 7. The push-out test setup. A, space for displaced sealer; B, metal base of apparatus for
sample fixation; F, direction of force; P, cylindrical plunger; D, 3 mm high root dentin cylinder;
ER, EndoRez sealer; E and M, lateral sides of acrylic resin; R, remaining root; C, cylindrical prep-
aration of the root canal (6 mm long with a 3 mm internal diameter); S, 3 mm high root section
embedded in acrylic resin. The black line below E and S represent the cut through the samples
perpendicular to the long axis of the tooth. (From http://www.ineedce.com. Pameijer CH,
Barnett F, Zmener O, Schein B. Methacrylate based resin endodontic sealers: a paradigm
shift in endodontics? ENDO0710DE; 2008:1–11; with permission.)
Visualization of the presence or absence of an oxygen-inhibited layer at the interface

of dentin and EndoREZ sealer was demonstrated in cross sections (Figs. 8 and 9).
Fig. 8 shows a sample of Group 1. The light blue color represents dentin, the narrow
gold colored band is the oxygen-inhibited layer, and the dark blue color represent fully
polymerized EndoREZ. A photograph of Group 2 is significant (see Fig. 9) for the
absence of a halo of unpolymerized resin. The dentin is light blue in color, and the
dark blue represents fully polymerized EndoREZ. When EDTA was used as a final
rinse, only polymerized (dark blue) EndoREZ was present at the dentin (light blue)
interface and the cross sections were similar to the Group 2 samples.
It is obvious that unpolymerized resin at the interface dentin and sealer offers
a pathway for leakage and has to be prevented at all cost.
CLINICAL EVIDENCE
More reports of reasonably long-term clinical studies have appeared in the literature
that make it easier for the practitioner to evaluate the benefits and success of
MBRS. EndoREZ was first reported on by Zmener and Pameijer.54,55 One intermediate
clinical study on Epiphany/Resilon56 followed by a long-term clinical study have been
published by Barnett and Debelian.57
Table 1
Mean push-out bond strength value
Group n Mean Bond Strength, MPa (SD) Range

1 6 1.33 (0.45) 0.69–1.73
2 6 7.95 (0.60) 8.67–7.11
3 6 8.09 (0.49) 8.67–7.28
Fig. 8. Group 1 showing a cross section of dentin (light blue), an oxygen-inhibited layer
(gold colored halo) and polymerized EndoREZ (dark blue).
In a retrospective study on 180 patients a total of 295 root canals were treated with
laterally condensed gutta-percha cones in conjunction with EndoREZ. Root canal
therapy was performed in 1 visit using standardized techniques. The results were
assessed clinically and radiographically 14 to 24 months postoperatively54 and after
5 years.55 A comparison with baseline radiographs was made. Parameters for success
were based on the absence of clinical symptoms, a normal or slightly widened peri-
odontal ligament, and resolution of periapical radiolucencies with an absence of
pain in patients who had pre-existing lesions associated with pain. After 2 years the
overall success rate was 91.03%. In the subsequent 5-year follow-up that examined
the same pool of patients, 129 responded to a recall request. Root canals had been
adequately filled to the working length in 92 teeth (76.66%) and short in 13
(10.83%). Fifteen cases (12.50%), filled flush at the initiation of the experiment,
showed slight resorption of the filling material at the apex within the lumen of the
root canal. Of the 10 roots with extrusion, none had radiographic evidence of sealer
in the periradicular tissues after 5 years. All patients were free of clinical symptoms.
A life table analysis revealed a cumulative probability of success of 86.3% at the 5-
Fig. 9. A cross section of dentin (light blue), adjacent to fully polymerized ER (dark blue). No
oxygen-inhibited layer is present.
year recall with a 95% confidence interval of 79.7 to 91.0. This percentage compares
favorably with the literature34,58,59 on the use of conventional sealers.
An example from the 5-year study is shown in the following 3 radiographs. Preop-
erative (Fig. 10A) and immediate postoperative view (Fig. 10B), and a 5-year follow-
up (Fig. 10C) on tooth number 8 filled with EndoREZ and gutta-percha. Extruded
sealer was resorbed during the interim and new bone was deposited. The patient
has been free of symptoms since completion of treatment.
The results of Resilon/Epiphany in a 2-year prospective study have been reported
by Debelian.56 A total of 67 vital teeth were treated in 1 visit and 53 necrotic pulps
in 2 visits (n 5 120). After 2 years 108 cases were evaluated by 3 evaluators and the
mean of the Periapical Index Scores (PAI) was calculated. When PAI 1 and 2 were
combined (PAI 1 5 healed; PAI 2 5 in the process of healing), the success rate after
24 months was 91.6% (a similar success rate, ie, 91.3%, was reported by Zmener and
Pameijer).54
Results after 4 years:

86 of 102 teeth (93.1%) were scored as successful (PAI 1, 2). 53 of 56 teeth (94.6%)
that were without preoperative apical periodontitis were scored as successful.
42 of 46 teeth (91.3%) that were diagnosed as nonvital pulps with apical periodon-
titis were scored as successful.
Comparison between EndoREZ and Resilon is not feasible here because of the
difference in evaluation periods (4 and 5 years, respectively). However, the
Fig. 10. (A) Upper incisor with pulpal involvement caused by leaking anterior restoration. (B)
Immediate postoperative view. (C) After 5 years, the incisor, restored with a post and core and
porcelain fused to metal is functional and completely asymptomatic. (From http://www.
ineedce.com. Pameijer CH, Barnett F, Zmener O, Schein B. Methacrylate based resin endodontic
sealers: a paradigm shift in endodontics? ENDO0710DE; 2008:1–11; with permission.)
percentages seem to indicate that both perform equally well and compare favorably
with conventional sealers that have been reported in the literature.60–62
Ideally, more prospective clinical studies are needed to confirm these studies.
DO RESIN-BASED SEALERS REINFORCE ROOTS?
Intraradicular dentin bond strength tests have been conducted by means of a push-
out test evaluating various sealers and combinations of sealers and points.
Some investigators reported higher values with resin-based sealers,63,64 whereas
others reported a lack of reinforcement.65,66 Furthermore some experimental designs
are suspect because of the drying of the root canal technique that has been discussed
previously or the lack of standardization of the samples. Optimum standardization by
Grande and colleagues66 led to the following conclusion: the currently available
endodontic filling materials and their recommended adhesive procedures are not
able to influence the mechanical properties of root canal dentin. The flexural properties
of Resilon and gutta-percha or EndoREZ and gutta-percha are too low to reinforce
roots.
RETREATMENT OF MBRS
One of the requirements of a root canal sealer is that, in case of failure, the root canals
can be retreated. According to de Oliveira and colleagues67 and Ezzie and
colleagues,68 Epiphany/Resilon could be removed faster and with less residual filling
material when K3 files,67 or ProFile 0.06 combined with heat and chloroform68 were
used compared with gutta-percha and AH Plus. Automated69 instrumentation can
also be used to remove resin-based, zinc oxide, and eugenol endodontic sealers
when retreating root canals. Straight canals obturated with gutta-percha and sealer
may be negotiated with engine-driven stainless steel Anatomic Endodontic Tech-
nology (Ultradent Products Inc) instruments. The flute design with sharp cutting edges
resulted in efficient cutting of the gutta-percha, aided by the softening of the material
caused by frictional heat. Each individual instrument was discarded after instrumenta-
tion of 2 teeth, thus reducing the possibility of instrument breakage. The recommen-
dation to use new instruments had been reported previously.70 However, only teeth
with straight canals were tested and consequently no conclusions can be drawn about
the retreatment efficacy of AET instruments in curved root canals.
FUTURE EXPECTATIONS
It is anticipated that the MBRS will continue to appeal to the dental profession. New
techniques and modifications of existing ones will be developed and introduced.
For instance, the EndoREZ system recommends harpooning of catalyst-coated
accessory cones after placement of the master cone into the sealer. This not only
accelerates the setting reaction but also reduces the amount of sealer, thus reducing
polymerization shrinkage; consequently a reduction in leakage can be accomplished.
Because the accessory cones are placed after the master cone has been seated, there
is no risk of pressing unreacted catalyst beyond the apex potentially causing damage
to the periradicular tissues.
Bonding in endodontics is gaining recognition as reflected in a statement by
Mounce71: ‘‘Given the long-term trends in dentistry there can be little, if any, doubt
that the future of endodontics is bonded. The goal of being able to bond a canal
from the minor constriction to the canal orifice to the occlusal surface is a desirable
one.’’
On the challenging side of the positive ex vivo and in vivo studies and clinical
success are publications that underscore the complexity of chemical compositions
and their biologic interaction of currently available dental materials; these publications
cannot be ignored. Material composition seems to be a critical factor.72,73 It has been
established that the co-monomer triethylene glycol dimethacrylate (TEGDMA) causes
gene mutations in vitro. Formation of micronuclei indicates chromosomal damage and
the induction of DNA strand breaks detected with monomers, such as TEGDMA and
HEMA. New findings indicate that increased oxidative stress results in impairment of
the cellular pro- and antioxidant redox balance caused by monomers. Monomers
reduce the levels of the natural radical scavenger glutathione (GSH), which protects
cell structures from damage caused by reactive oxygen species (ROS). Depletion of
the intracellular GSH pool may then significantly contribute to cytotoxicity, because
a related increase in ROS levels can activate pathways leading to apoptosis. Neither
EndoREZ nor Epiphany contain these components.
After a thorough review of the available data and despite the contradicting ex vivo
and in vivo tests, it seems that MBRS are here to stay. EndoREZ and Resilon are
now being used successfully, about 10 years after their inception. The only conclusive
evidence is long-term clinical success. Therefore more long-term data are needed to
determine whether they will eventually replace conventional sealers or will be used in
parallel as an alternative choice when filling root canals.
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T h e En d o - R e s t o r a t i v e
I n t e r f a c e : C u r ren t
Concepts
a b,c,
Marga Ree, DDS, MSc , Richard S. Schwartz, DDS *
KEYWORDS
Endodontics Restorative dentistry
Adhesive dentistry Posts
The primary goals of endodontic treatment are straightforward: to debride and disin-
fect the root canal space to the greatest possible extent, and then seal the canals as
effectively as possible. The materials and techniques change somewhat over time, but
not the ultimate goals. The primary goals of restorative treatment are to restore teeth
to function and comfort and in some cases, aesthetics. Once again, the materials and
techniques change, but not the ultimate goals of treatment. Successful endodontic
treatment depends on the restorative treatment that follows. The connection between
endodontic treatment and restorative dentistry is well accepted, but the best restor-
ative approaches for endodontically treated teeth have always been somewhat
controversial. The topic is no less controversial today, despite the massive (and
ever growing) amount of information available from research, journal articles, courses,
‘‘expert’’ opinions, and various sources from the Internet. In fact, information overload
contributes to the controversy because so much of it is contradictory.
With the emergence of implants into the mainstream of dentistry, there has been
more emphasis on long-term outcomes and on evaluating the ‘‘restorability’’ of teeth
prior to endodontic treatment. Patients are not well served if the endodontic treatment
is successful but the tooth fails. The long-term viability of endodontically treated teeth
is no longer a ‘‘given’’ in the implant era. In consequence, some teeth that might have
received endodontic treatment in the past are now extracted and replaced with
implant-supported prostheses if they are marginally restorable or it makes more sense
in the overall treatment plan. It is not possible to review in one article all the literature
on the restoration of endodontically treated teeth. This article therefore focuses
primarily on current concepts based on the literature from the past 10 years or so,
and provides treatment guidelines based on that research.
a
Meeuwstraat 110, 1444 VH Purmerend, Netherlands
b
1130 East Sonterra Boulevard, Suite 140, San Antonio, TX 78258, USA
c
University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
* Corresponding author. 1130 East Sonterra Boulevard, Suite 140, San Antonio, TX 78258.
E-mail address: sasunny@satx.rr.com
Dent Clin N Am 54 (2010) 345–374

346 Ree & Schwartz
THE RELATIONSHIP BETWEEN ENDODONTICS AND RESTORATIVE DENTISTRY
Long-term success of endodontic treatment is highly dependent on the restorative

treatment that follows. Once restored, the tooth must be structurally sound and the
disinfected status of the root canal system must be maintained. Because microorgan-
isms are known to be the primary etiologic factor for apical periodontitis1 and
endodontic failure,2 contamination of the root canal system during or after restorative
treatment is considered an important factor in the ultimate success or failure. Expo-
sure of gutta-percha to saliva in the pulp chamber results in migration of bacteria to
the apex in a matter of days.3 Endotoxin reaches the apex even faster.4 The impor-
tance of the coronal restoration in successful endodontic treatment has been shown
in several studies.5,6 Delayed restoration has been show to result in lower success
rates.7
Successful restorative treatment is also greatly influenced by the execution of the
endodontic procedures. Radicular and coronal tooth structure should be preserved
to the greatest possible extent during endodontic procedures.8–10 Root canal prepa-
rations should attempt to preserve dentin in the coronal one-third of the root. There is
no reason to prepare a ‘‘coke bottle’’ type of canal preparation (Fig. 1) that weakens
the tooth unnecessarily. Access preparations similarly should be made in such a way
that cervical dentin is preserved. The roof of the pulp chamber should be removed
carefully, preserving the walls of the chamber as much as possible. The chamber walls
should be prepared only to the extent that is necessary for adequate access for
endodontic treatment.
Many, if not most endodontically treated teeth today are restored with adhesive
materials. Adhesive materials provide an immediate seal and some immediate
strengthening of the tooth. These materials are generally not dependent on gross
mechanical retention, so tooth structure can be preserved. The sections that follow
discuss basic principles of adhesive dentistry and some of the limitations, pitfalls,
and special problems presented by endodontically treated teeth.
BONDING TO ENAMEL
Enamel is a highly mineralized tissue that is often present along the margins of access
preparations of anterior teeth and sometimes in posterior teeth. Effective bonding
Fig. 1. This radiograph shows canals prepared with a ‘‘coke bottle’’ design. Excessive dentin
was removed in the cervical one-third of the root and the apical preparations are thin.
Endo-Restorative Interface: Current Concepts 347
procedures for enamel were first reported in 1955.11 An acid, such as 30% to 40%
phosphoric acid, when applied to enamel will cause selective dissolution of the
enamel prisms. Microporosities are created within and around the enamel prisms,
which can be infiltrated with a low-viscosity resin and polymerized,12 creating resin
‘‘tags’’ that provide micromechanical retention and a strong, durable bond. It is impor-
tant to prevent contamination of etched enamel with blood, saliva, or moisture that will
interfere with bonding.13 Poorly etched enamel leads to staining at the margins of the
restoration.14 A good enamel bond protects the less durable underlying dentin bond.15
BONDING TO METAL-CERAMIC AND ALL-CERAMIC RESTORATIONS
Access cavities are often made through metal-ceramic or all-ceramic materials, so at-
taining an effective, durable bond is important. Like enamel, the porcelain margins can
be etched (usually with a 1-minute etch of 10% hydrofluoric acid) to create micropo-
rosities, which may be infiltrated with resin and polymerized. Application of silane to
the etched porcelain surface enhances the bond.16 Etched ceramic materials form
a strong, durable bond with resin.17
BONDING TO DENTIN: RESIN-BASED MATERIALS
A smear layer is formed when the dentin surface is cut or abraded with hand or rotary
instruments. The smear layer adheres to the dentin surface and plugs the dentinal
tubules; it consists of ground-up collagen and hydroxyapatite and other substances
that might be present such as bacteria, salivary components, or pulpal remnants.18
The smear layer cannot be rinsed or rubbed off,19 but can be removed with an acid
or chelating agent. Some dentin adhesives remove the smear layer, whereas others
penetrate through the layer and incorporate it into the bond. Both approaches may
be used successfully.12
Bonding to dentin is more complex than bonding to enamel or ceramic. Dentin is
a wet substrate and restorative resins are hydrophobic (‘‘water hating’’). Dentin
consists of approximately 50% inorganic mineral (hydroxyapatite) by volume, 30%
organic components (primarily type 1 collagen), and 20% fluid.20 The wet environment
and relative lack of a mineralized surface made the development of effective dentin
adhesives a challenge.
The first successful strategy for dentin adhesion was reported by Nakabayashi and
colleagues in 1982.21 Their ideas were not widely accepted until later in the decade.
Nakabayashi showed that resin could be bonded to dentin by demineralizing the
dentin surface and applying an intermediate layer that would bond to dentin and
restorative materials. Although not as durable and reliable as enamel bonding, dentin
bonding forms the foundation for many of today’s restorative procedures. Nakabaya-
shi’s technique was later simplified by combining some of the steps.
THE LIMITATIONS OF DENTIN BONDING
From the restorative literature it is known that dentin bonding materials have limita-
tions, many of which are related to polymerization shrinkage. When resin-based mate-
rials polymerize, individual monomer molecules join to form chains that contract as the
chains grow and intertwine, and the mass undergoes volumetric shrinkage.22 Resin-
based restorative materials shrink from 2% to 7%, depending on the volume occupied
by filler particles and the test method.23–25 The force of polymerization contraction
often exceeds the bond strength of dentin adhesives to dentin, resulting in gap
348 Ree & Schwartz
formation along the surfaces with the weakest bonds.26 Resins, even in thin layers,
generate very high forces from polymerization contraction.27,28
Another limitation of dentin bonding is deterioration of the resin bond over time. This
process is well documented in vitro15,29–31 and in vivo.32,33 Loss of bond strength is
first detectable in the laboratory at 3 months.30 Interfacial leakage increases as the
bond degrades.22,34 Functional forces have been shown to contribute to the degrada-
tion of the resin bond in restorative applications.30,35
THE LIMITATIONS OF BONDING IN THE ROOT CANAL SYSTEM
The root canal system has an unfavorable geometry for resin bonding.36 Configuration
factor or C-Factor, the ratio of bonded to unbonded resin surfaces,23 is often used as
a quantitative measure of the geometry of the cavity preparation for bonding. The
greater the percentage of unbonded surfaces, the less stress is placed on the bonded
surfaces from polymerization contraction. The unbonded surfaces allow plastic defor-
mation or flow within the resin mass during polymerization.23,37 A Class 4 cavity prep-
aration, for example, has a favorable geometry with a ratio of less than 1:1. There are
few if any walls that directly oppose each other, and more than half of the resin
surfaces are not bonded. In the root canal system the ratio might be 100:1,23 because
virtually every dentin wall has an opposing wall and there are minimal unbonded
surfaces. Any ratio greater than 3:1 is considered unfavorable for bonding.38 Because
of this unfavorable geometry, it is not possible to achieve the gap-free interface with
current materials. Interfacial gaps are virtually always present in bonded restorations
in restorative dentistry,39 obturating materials,40 and bonded posts,41,42 and gap
formation increases with time.43
THE POTENTIAL PROBLEMS OF USING ADHESIVE MATERIALS DEEP

IN THE ROOT CANAL SYSTEM
Performing the bonding steps is problematic deep in the root canal system. Uniform
application of a primer or adhesive can be difficult. Once the primer is applied, the
volatile carrier must be evaporated. This process can also be problematic deep in
the canal. If the acetone or alcohol carrier is not completely removed, the bond is
adversely affected.44 An in vitro post study by Bouillaguet and colleagues45 reported
lower bond strengths were achieved bonding in the root canal system than bonding to
flat prepared samples of radicular dentin.
COMPATIBILITY PROBLEMS WITH DUAL-CURE AND SELF-CURE RESINS
Because penetration with a curing light is limited in the root canal system, dual-cure or
self-cure resin adhesives must be used. Dual-cure resins contain components that
provide rapid light polymerization in those areas where the curing light penetrates
effectively and a slower chemical polymerization in those areas where the light is
not effective. Adhesives and sealers that contain a self-cure component have compat-
ibility problems with self-etching dentin adhesive systems (ie, sixth and seventh genera-
tion), so they should be used with ‘‘fourth generation’’ etch-and-rinse adhesives.41,46,47
IRRIGATING SOLUTIONS AND MEDICAMENTS
Sodium hypochlorite is commonly used as an endodontic irrigant because of its anti-

microbial and tissue dissolving properties. The antimicrobial properties of sodium
hypochlorite are largely due to it being a strong oxidizing agent, but as a result it leaves
behind an oxygen-rich layer on the dentin surface. The same applies to chelating agents
that contain hydrogen peroxide. Oxygen is one of the many substances that inhibit
the polymerization of resins. When dentin bonding agents are applied to an oxygen-
rich surface, low bond strengths are achieved48–50 and microleakage is increased.51
A reducing agent, such as ascorbic acid and sodium ascorbate, applied to the dentin
surface will reverse the negative affects of sodium hypochlorite.48,51 A final soak with
ethylenediamine tetra-acetic acid (EDTA) has also been reported to be effective.52
BASIC PRINCIPLES FOR RESTORING ENDODONTICALLY TREATED TEETH
Although many aspects of the restoration of endodontically treated remain controver-

sial, there are several areas of general agreement. One of the best documented prin-
ciples is cuspal coverage. Several studies evaluated factors that affected the survival
of endodontically treated teeth. Cuspal coverage was the most consistent finding.53–55
In one study, teeth with cuspal coverage had a 6 times greater survival rate than teeth
without cuspal coverage.56 Another study showed teeth without cuspal coverage had
only a 36% survival rate after 5 years.57
Another important principle is preservation of tooth structure. Coronal tooth struc-
ture should be preserved to support the core buildup.9,10 Several studies identify
remaining coronal tooth structure as the most important factor in tooth survival in teeth
with posts.8,9,58
As stated previously, radicular tooth structure should also be preserved. For most
teeth that are to receive posts, no additional dentin should be removed beyond
what is necessary to complete the endodontic treatment. If a tooth is prepared for
a 0.06 tapered preparation, a 0.06 tapered post should ‘‘drop right in’’ without
removing additional radicular dentin.
There is wide general agreement that the ‘‘ferrule effect’’ is important. In dentistry,
the ferrule refers to the cervical tooth structure that provides retention and resistance
form to the restoration and protects it from fracture. In one study, teeth with a ferrule of
1 mm of vertical tooth structure doubled the resistance to fracture compared with
teeth restored without a ferrule.59 Other studies have shown maximum beneficial
effects from a ferrule of 1.5 to 2 mm.60–62 The ‘‘ferrule effect’’ is important to long-
term success when a post is used.61 In anterior teeth, the lingual aspect of the ferrule
is the most important part.63 If the height of the remaining dentin is not sufficient to
create an adequate ferrule, crown lengthening, orthodontic extrusion, or extraction
may be indicated.
TEETH RESTORED WITH POSTS
Endodontically treated teeth often have substantial loss of tooth structure and require
a core buildup. If retention and resistance of the core are compromised, a post may
also be necessary. Custom cast posts and cores or prefabricated metal posts were
the standard for many years. In the past 10 years or so, fiber-reinforced composite
posts have gained popularity.
INDICATIONS FOR A POST
The primary function of a post is to retain a core in a tooth with extensive loss of
coronal tooth structure.64 Posts should not be placed arbitrarily, however, because
preparation of a post channel adds a degree of risk to a restorative procedure:
Disturbing the seal of the root canal filling, which may lead to microleakage65,66
350 Ree & Schwartz
Removal of sound tooth structure, which weakens the root and may result in
premature loss due to root fracture67,68
Increased risk of perforation.69
Some studies report higher failure rates in endodontically treated teeth with posts
than without.7,70 The finding was not universal, however.71
Traditional thought has been that posts do not ‘‘reinforce’’ the root; this was appar-
ently true for metal posts,72,73 but there is a growing body of evidence that fiber posts
may strengthen the root and make it more resistant to fracture. To date, 9 studies have
shown a strengthening effect74–82 while 3 have shown no effect.10,83,84
Metal posts have a high modulus of elasticity, which means that they are stiff and
able to withstand forces without distortion. When a force is placed on a tooth contain-
ing a stiff post, it is transmitted to the less rigid root dentin, and concentrates at the
apex of the post. Stress concentration in the post/root complex increases the chances
of fracture.
To overcome the concerns about unfavorable stress distribution generated by metal
posts, fiber-reinforced composite resin posts were introduced in 1990, with the aim of
providing more elastic support to the core. The reduced stress transfer to tooth struc-
ture was claimed to reduce the likelihood of root fracture.85 Posts made of materials
with a modulus of elasticity similar to dentin are more resilient, absorb more impact
force, and distribute the forces better than stiffer posts.36
TYPES OF POSTS
Posts can be categorized by modulus of elasticity, composition, fabrication process,

shape, and surface texture.
Rigid Post Systems

Metal
– custom cast
– prefabricated
Zirconium and ceramic.
Posts traditionally were made of metal, and were either custom cast or prefabri-
cated. Custom cast posts and cores are made of precious or nonprecious casting
alloys; prefabricated posts are typically made of stainless steel, nickel chromium alloy,
or titanium alloy. With the exception of the titanium alloys, they are very strong.
Parallel metal posts are more retentive than tapered posts86 and induce less stress
into the root, because they have less wedging effect and are reported to be less likely
to cause root fractures than tapered posts.59,87 In a retrospective study, Sorensen and
Martinoff 53 reported a higher success rate with parallel metal posts than tapered
posts. Tapered posts, on the other hand, require less dentin removal because most
roots are tapered.
Prefabricated posts can be further divided in active or passive posts. Most active
posts are threaded and intended to engage the walls of the canal, whereas passive
posts are retained primarily by the frictional retention of the luting agent. Active posts
are more retentive than passive posts, but introduce more stress into the root than
passive posts.88 Active posts have very limited indications, and are only recommen-
ded when the need for retention is the overriding factor.
One factor that has reduced the use of metal posts is aesthetics. Metal posts may
be visible through translucent all-ceramic restorations, and even with less translucent
restorations may cause the marginal gingiva to appear dark. These concerns have led
to the development of posts that are white or translucent. Among the materials used
for ‘‘aesthetic’’ posts are zirconium and other ceramic materials. These posts will work
clinically, but have several disadvantages.
Among rigid posts, zirconium is stiffer and more brittle than metal. Zirconium posts
were shown to cause significantly more root fractures than fiber posts in vitro.89,90
When compared with custom cast and fiber posts, ceramic posts had a lower failure
load in vivo91 and in vitro.92–94 As a group, they tend to be weaker than metal posts, so
a thicker post is necessary, which may require removal of additional radicular tooth
structure. Zirconium posts cannot be etched, therefore it is not possible to bond
a composite core material to the post, making core retention a problem.92 Retrieval
of zirconium and ceramic posts is very difficult if endodontic retreatment is necessary
or if the post fractures. Some ceramic materials can be removed by grinding away the
remaining post material with a bur, but this is a tedious and risky procedure. It is
impossible to grind away a zirconium post. In many cases, excessive removal of
dentin is necessary to remove a zirconium post. For these reasons, ceramic and zirco-
nium posts should be avoided.
Metal and zirconium posts are all radiopaque and clearly visible on a radiograph
(Figs. 2 and 3). The radiopacity of titanium is similar to that of gutta-percha, and there-
fore sometimes the presence of a titanium post is difficult to detect on radiographs
(Fig. 4).
Fig. 2. Radiographic appearance of custom cast metal posts.

352 Ree & Schwartz
Fig. 3. Radiographic appearance of zirconium posts.
Nonrigid Post Systems: Fiber Posts

Carbon fiber
Glass fiber
Quartz fiber
Silicon fiber.
The first composite reinforced fiber posts were made with carbon fibers, which were
arranged longitudinally and embedded in an epoxy resin matrix.85 The black carbon
fibers were rapidly replaced by more esthetic white and translucent glass and quartz
fibers, which are now the standard components in fiber posts. These posts are
commonly used in aesthetically demanding areas.
The main advantage of fiber posts is the uniform distribution of forces in the root,
which results in fewer catastrophic failures than occur with metal posts if an adequate
ferrule is present.95 Several in vitro studies report that teeth restored with nonrigid
posts have fewer catastrophic, irreparable root fractures when tested to failure.96,97
Clinical studies of fiber post systems also report successful multiyear service with
few or no root fractures.8,98,99 A retrospective clinical study of carbon fiber posts
and custom cast posts reported root fractures in 9% of teeth restored with cast posts,
and no root fractures in teeth restored with fiber posts after 4 years.100 In a long-term
retrospective study of the clinical performance of fiber posts by Ferrari and
colleagues,8 a 7% to 11% failure rate was reported for 3 different types of fiber posts
after a service period of 7 to 11 years. Half of the failures were classified as endodontic
failures, the other half were mechanical failures. Out of 985 posts evaluated, the nonen-
dodontic failures consisted of one root fracture, one fiber post fracture, 17 crown
Fig. 4. Radiographic appearance of a titanium post. Note that the radiopacity of gutta-
percha and titanium is very similar.
dislodgements, and 21 failures due to post debonding. The mechanical failures were
always related to the lack of coronal tooth structure. In a review by Dietschi and
colleagues101 it was concluded that nonvital teeth restored with composite resin or
composite resin combined with fiber posts currently represent the best treatment option.
Although fiber posts offer several advantages, they do have limitations. Posts and
core foundations are subjected to repeated lateral forces in clinical function. Because
nonrigid posts have a modulus of elasticity and flexural strength close to that of dentin,
they flex under occlusal load. When there is an adequate ferrule, the cervical tooth
structure itself resists lateral flexion.95 However, in structurally compromised teeth
that lack cervical stiffness from dentin walls and an adequate ferrule, a flexible post
may result in micro-movement of the core and coronal leakage,102,103 which in turn
may lead to caries or loss of the core and crown.
Fiber posts were shown to lose flexural strength if they are submitted to cyclic
loading or to thermocycling104,105 due to degradation of the matrix in which the fibers
are embedded. The strength of fiber posts varied between brands, but was directly
related to post diameter and was reduced by thermocycling.106
Parallel fiber posts are more retentive than tapered posts.107,108 However, in a clin-
ical study by Signore and colleagues99 no difference was found in the long-term
survival rate of maxillary anterior teeth restored with tapered or parallel-sided glass-
fiber posts and full-ceramic crown coverage. The overall survival rate was reported
to be 98.5%. Most fiber posts are relatively radiolucent and have a different radio-
graphic appearance than traditional metal posts (Fig. 5).
It has been shown that the retention of fiber posts relies mainly on mechanical (fric-
tional) retention rather than bonding, similar to metal posts.41,42,109,110 Several in vitro
354 Ree & Schwartz
Fig. 5. Radiographic appearance of a glass-fiber post. The post is radiolucent, but the radi-
opaque composite clearly reveals its outline.
studies have confirmed the presence of gaps in the interface between the luting
composite resin of the fiber post and the root canal wall,42,110 and that the bond
strengths between fiber posts and dentin are low, about 5 to 6 MPa.109,111 This situ-
ation is due primarily to the unfavorable bonding environment of the root canal system,
as discussed earlier.
POST LENGTH AND REMAINING ROOT CANAL FILLING
The length of a post is dictated by several factors, some of which are conflicting. Most
of the studies on optimum post length were done with metal posts, but there is no
compelling evidence that the principles of post length are different for fiber posts.
Braga and colleagues112 evaluated the force required to remove glass fiber and
metallic cast posts with different lengths. Irrespective the post type, posts with
10-mm length had higher retention values than posts with 6-mm length. In a study
by Büttel and colleagues,113 teeth restored with glass-fiber posts with insertion
depths of 6 mm resulted in significantly higher mean failure than teeth with post
space preparation of 3 mm. The retention of fiber posts was shown to be directly
proportional to the insertion length in resin cubes.114
Several ‘‘rules’’ have been suggested for passively fitting posts:
The post length below the alveolar crest should be at least equal to the length
above the alveolar crest.64,115 Sorensen and Martinoff 53 reported 97% success
if post length at least equaled the crown height.
The post should end halfway between the crestal bone and the root apex.64
A post should extend at least apical to the crest of the alveolar bone.67
Another factor that influences post length is the length of the remaining apical root
canal filling. Several studies have investigated apical seal following post space prep-
aration and have reported that 3 to 5 mm of gutta-percha is the minimum recommen-
ded,116–118 and longer is better117,118; this is sometimes dictated by the length of the
canal. Post placement in a long root, for example, a canine of 28 mm, allows more
apical root canal filling, as placing a 23-mm post is unnecessary. When using the crite-
rion that the post should extend beyond the apical crest, teeth with bone loss need
longer posts than teeth with normal bone height.
LIGHT-TRANSMITTING FIBER POSTS
Although it seems logical that translucent posts would transmit light for enhancement
of cure deeper in the canal, there seems to be no consensus in the literature on this
issue. The use of a light-transmitting translucent fiber post was reported to increase
the depth of resin cure in several in vitro studies,119–121 but other studies reported
minimal or no benefits from translucent posts. One study evaluated the influence of
fiber-post translucency on the degree of conversion of a dual-cure composite. Low
degrees of conversion were found for the medium and deep depths.122 Another in vitro
study measured light transmission through 4 different posts of a standard length of 10
mm. All posts evaluated showed some light transmission capacity, but with values
lower than 40% of incident light. One post demonstrated less than 1% light transmis-
sion.108 Goracci and colleagues evaluated the light transmission of several fiber posts.
These investigators reported no light transmission through 2 posts, and for all other
posts light intensity decreased from coronal to apical, and rose again at the apical
tip. Light transmission was significantly higher at the coronal level.123 Another study
showed that even without a post, the luminous intensity inside the canal decreased
to levels that are insufficient for polymerization, especially in the apical third.124 Based
on these findings, the use of light-cured resin cements for post placement cannot be
recommended. The benefits of light-transmitting posts are unclear.
IS THERE BENEFIT TO PLACING A POST AFTER ENDODONTIC TREATMENT

OF A TOOTH WITH A CROWN?
In most cases, when preparing endodontic access through a crown there is no way of
knowing the amount or strength of the underlying tooth structure, which is a particular
concern in small teeth and bridge abutments.
When an access preparation is made through a crown, retention is lost.125 When the
access opening is restored with amalgam or composite resin, the retention values are
restored.125,126 When the access opening is restored with a post, the retention is
greater than before the access was prepared.125
There is growing evidence that the insertion of a fiber post can also increase fracture
resistance of teeth with crowns. An in vitro study has shown that placement of fiber
posts can improve fracture resistance in maxillary premolars under full-coverage
crowns.76 The use of fiber posts in endodontically treated maxillary incisors with
different types of full-coverage crowns increased their resistance to fracture81,82
and improved the prognosis in case of fracture.81 The type of crown was not a signif-
icant factor affecting fracture resistance, whereas the presence of a post was. D’Ar-
cangelo and colleagues80 showed that fiber posts significantly increased mean load
values for maxillary central incisors prepared for veneers.
Based on these findings, it seems retention will be enhanced by a post, and fracture
resistance will probably be improved as long as no additional tooth structure is
356 Ree & Schwartz
removed. The authors routinely place fiber posts in bridge abutments and small teeth
with crowns (Fig. 6).
POST PLACEMENT
Advantages of Immediate Post Placement
The literature on the timing of the post space preparation is inconclusive. Some
studies showed less leakage after immediate post space preparation,127,128 whereas
other articles showed no difference 118,129 Some in vitro studies showed that delayed
cementation of a fiber post resulted in higher retentive strengths.130,131 Scanning elec-
tron microscopy examination revealed a more conspicuous presence of sealer
remnants on the walls of immediately prepared post spaces.131 Remnants of sealer
and gutta-percha may impair adhesive bonding and resin cementation of fiber
posts.132,133 Therefore, it is important to clean the root canal walls before conditioning
the dentin for post placement. Acid-etching of the prepared post space and EDTA irri-
gation combined with ultrasonics are reported to be an effective method.134,135 The
use of magnification can facilitate inspection of the post space for cleanliness.
Immediate preparation for post placement following obturation has several advan-
tages. The operator has a great familiarity with the root canal morphology, working
lengths, and reference points of the root canal system. In addition, placement of
a temporary post and restoration can be avoided, as maintaining the temporary seal
can be difficult. In vitro studies by Fox and Gutteridge136 and by Demarchi and
Sato137 showed that teeth restored with temporary posts leaked extensively.
LUTING FIBER POSTS
Fiber posts are usually luted with lightly filled composite resins. Light penetration is
limited, so dual-cure of self-cure luting resins must be used. Some luting resins are
used with a separate etchant and primer (total-etch method), whereas others contain
an acidic primer in the luting cement (self-etching method). More recently a third cate-
gory has been added (self-adhesive method), in which there is no etching and no
primer. Several studies have evaluated these luting cements.
Goracci and colleagues138 reported that the values achieved by total-etch method
were significantly higher than self-etch resin cements. Transmission electron
Fig. 6. The authors routinely use fiber posts when restoring access openings through crowns
on bridge abutments or small teeth.
microscopy analysis revealed that the acidic resin monomers responsible for
substrate conditioning in self-etch and self-adhesive resin cements did not effectively
remove the thick smear layer created on root dentin during post space preparation.
Valandro and colleagues139 similarly concluded that more reliable bond strengths in
the dowel space might be achieved when using total-etch adhesive systems instead
of self-etching adhesives. A study by Radovic and colleagues140 concluded that the
use of self-etching resin luting systems offer less favorable adhesion to root canal
dentin in comparison with the total-etch and self-adhesive approaches.
Self-adhesive cements were introduced in 2002 as a new subgroup of resin
cements. Self-adhesive cements do not require any pretreatment of the tooth
substrate. The cement is mixed and applied in a single clinical step. The application
of self-adhesive cements to radicular dentin does not result in the formation of hybrid
layer or resin tags.138 Lührs and colleagues141 found the shear bond strength of self-
adhesive resin cements to be inferior compared with conventional composite resin
cements. The sealing ability of 2 self-adhesive resin cements was shown to be signif-
icantly lower than a self-etching and 2 conventional dual-cure resin cements. The
investigators concluded that although the bonding effectiveness of self-adhesive
cements seems promising, their interaction with root dentin might be too weak to mini-
mize microleakage at the post-cement-dentin interface.142 In another study by Vro-
chari and coworkers, the degree of cure of 4 self-etching or self-adhesive resin
cements in their self-curing mode was very low. The values obtained in the dual-curing
mode were also low.143
Self-adhesive cements offer a new, simpler approach, but the efficacy of many
recently marketed products is not known, and there are few data in the literature
regarding their in vitro or clinical performance. At this point in their development,
the literature generally shows them to be inferior to the total-etch method.
THE POST/RESIN INTERFACE
In addition to the interface between the resin cement and dentin, the post/resin inter-
face is also important. Several surface treatments of the post have been recommen-
ded for improving the bonding of resin cements or core materials to fiber posts.
Silane Application
The literature is mixed on the value of application of silane to fiber posts. In one study,
pretreatment of fiber posts with silane did not result in an enhanced bonding between
post and 6 different resin cements144 and the effect of silanization was reported to be
clinically negligible.145,146 Perdigão and colleagues147 showed that the use of a silane
coupling agent did not increase the push-out bond strengths of 3 different fiber posts.
On the contrary, Goracci and colleagues148 reported an improvement in bond strength
between silanized fiber posts and flowable composite cores. Aksornmuang and
colleagues149 similarly confirmed the benefit of silane application in enhancing the mi-
crotensile bond strength of a dual-cure resin core material to translucent fiber posts.
Air Abrasion
It is well accepted that sandblasting with alumina particles results in an increased
surface roughness and surface area, but it also provided mixed results when used
with fiber posts. A study by Valandro and colleagues150 showed that air abrasion
with silica-coated aluminum oxide particles, followed by silanization, improved the
bond strength between quartz fiber posts and resin cements. Sandblasting was
also shown to improve the retention of fiber posts in 2 other studies.151,152 The
358 Ree & Schwartz
mechanical action of sandblasting probably removes of the superficial layer of

resinous matrix, creating micro-retentive spaces on the post surface. On the other
hand, Bitter and colleagues144 reported little influence of sandblasting on the bond
strength between fiber posts and resinous cements. Sahafi and colleagues106 evalu-
ated the efficacy of sand blasting the surface of zirconium and fiber posts with silica
oxide. Despite the satisfactory bond strengths, the treatment was considered too
aggressive for fiber posts, with the risk of significantly modifying their shape and fit
within the root canals. Air abrasion should be used with caution, as it is difficult to stan-
dardize the procedure.
Alternative Etching Techniques

Hydrogen peroxide and sodium ethoxide are commonly employed for conditioning
epoxy resin surfaces. The etching effect of these chemicals depends on partial
resinous matrix dissolution, breaking epoxy resin bonds through substrate oxida-
tion.153 A similar approach has been proposed for pretreatment of fiber posts to
increase their responsiveness to silanization, achieving satisfactory results for both
chemicals.154,155 The conditioning treatment consisted of fiber posts immersion in
the solutions for 10 to 20 minutes. By removing a surface layer of epoxy resin, a larger
surface area of exposed quartz fibers is available for silanization. The spaces between
these fibers provide additional sites for micromechanical retention of the resin
composites. Similar results were obtained by pretreating methacrylate-based posts
with either hydrogen peroxide or hydrofluoric acid.156
Pretreatment with 24% H2O2 for 10 minutes, followed by silane application, seems
to be a clinically feasible, inexpensive, and effective method for enhancing interfacial
strengths between both methacrylate-based and epoxy resin-based fiber posts and
resin composites.155,156 Pretreatment with H2O2 can be performed well in advance
of the clinical use.
CLINICAL PROCEDURES FOR FIBER POST CEMENTATION AND CORE BUILDUP
As discussed earlier, there are a lot of advantages to immediate post placement after
finishing the endodontic treatment. The use of rubber dam, magnification, and good
illumination are essential to carry out root canal treatment to a consistently high stan-
dard. Similar conditions are also required for all clinical procedures involving an adhe-
sive bonding.
Gutta-percha can be removed with the aid of heat or chemicals, but most often the
easiest and most efficient method is with rotary instruments. If the clinician who has
performed the root canal treatment is going to place the post as well, obturation
can be completed only in the apical portion of the canal.
There is a direct correlation between the diameter of the fiber post and fracture
strength.157 Büttel and colleagues113 showed that post fit did not have a significant
influence on fracture resistance, irrespective of the post length. Their results suggest
that excessive post space preparation aimed at producing an optimal circumferential
post fit is not required to improve fracture resistance of roots.
All remnants of gutta-percha, Resilon, sealer, and temporary filling materials should
be removed using small micro-brushes with alcohol or a detergent. Acid-etching of the
post space and an EDTA irrigation combined with ultrasonics are effective in obtaining
a clean post space.134,135 Air abrasion is an effective way the clean the pulp floor.
The use of a matrix helps confine the core material, enhances the adaptation of the
composite to the remaining tooth structure and post, and prevents bonding core
material to adjacent teeth. However, the use of a matrix is not essential.158
As discussed earlier, the use of a fourth-generation, 3-step etch-and-rinse adhe-

sive with self-cure and dual-cure composites is recommended. If a self-etching
adhesive is used, no rinsing takes place, which might result in dentin walls that
are less clean. Moreover, when using a ZOE sealer, a self-etching adhesive incorpo-
rates Eugenol in the hybrid layer, which inhibits the polymerization of resins. After
the etch-and-rinse step, paper points are recommended to dry the canal before
the application of the primer and adhesive. The use of small micro-brushes has
been shown to promote higher bond strength values than other brushes tested.159
In the same study, the use of paper points to remove excess adhesive resulted in
higher bond strengths.
A self-cure or dual-cure resin composite may be used rather than a separate luting
cement for cementation of the post and the subsequent buildup. These composites
may be bulk-filled because they do not require deep penetration with a curing light.
Self-cure and dual-cure composites polymerize more slowly than light-cure materials,
allowing the material to flow during polymerization contraction, and placing less stress
on the adhesive bond.24
To minimize void formation, the composite is injected into the conditioned post
channel using a syringe with a specially designed small tip, a so-called needle tube.
The tip is inserted until it reaches the coronal part of the root canal filling, and is
then applied from the base of the post channel coronally until the post space is filled
to the brim. Then the pretreated post is immediately inserted into the composite filling
the post space, without the need to further cover the post itself with composite.
Finally, the composite core is added to the newly placed post, using the same self-
cure or dual-cure composite applied into the post space. This procedure can be
done immediately or after the composite in the post channel has completely set. A
Fig. 7. Mandibular second premolar is treatment planned for an endodontic retreatment,

post, core, and crown.
360 Ree & Schwartz
Fig. 8. Cone-fit.
Fig. 9. Obturation is complete and the post channel is free of remnants of root canal filling.
The obturating material is seen at the base of the post channel.
light-cured composite may also be used for the buildup. It is critical that the post is
fully embedded in composite to avoid the uptake of moisture, which may compromise
its mechanical properties.160–162 Embedding can be obtained by cutting back the post
a few millimeters below the cavo-surface margin before placement or after the
composite of the core has completely set. If a matrix has been used, the core needs
to be contoured and the occlusion needs to be adjusted. Another option is to complete
the crown preparation at the same session.
CLINICAL SEQUENCE
1. Isolate the tooth with rubber dam and carry out root canal treatment (Figs. 7 and 8).
2. Remove all remnants of root filling and temporary filling materials using small
micro-brushes with alcohol (Fig. 9).
3. Clean the floor with air abrasion.
4. Select a post that passively fits into the available canal space (Fig. 10).
5. Pre-fit the post and cut it back at the coronal or apical end to accommodate the
existing post channel. In oval shaped canals, or premolars with 2 canals, consider
placing 2 posts.
6. Confirm the fit of the post with a radiograph if necessary.
7. Air abrade the post surface with 50-mm alumina particles for 5 seconds, or use
a pretreated post that has been immersed in 24% H2O2 for 10 minutes. Clean
the post surface by acid-etching the surface with 37% phosphoric acid, rinse
and air-dry.
8. Apply silane to the post surface according to the manufacturer’s instructions.
Fig. 10. The largest post that fits passively in the available post space is selected. After fin-
ishing the root canal treatment, no additional dentin is removed to accommodate the post.
362 Ree & Schwartz
Fig. 11. Phosphoric acid 37% is applied to the dentin of the post channel and the remaining
tooth structure.
Fig. 12. The use of a small micro-brush greatly facilitates the application of dentin primer
and adhesive into the post channel.
Fig. 13. A shiny surface confirms an even distribution of the dentin adhesive.
9. Acid-etch the enamel (if present) with 37% phosphoric acid for 30 seconds, and
dentin for 15 seconds (Fig. 11).
10. Rinse and air-dry.
11. Use a small micro-brush to apply a primer that can be used with a self-cure or
dual-cure core material to the dentin according to the manufacturer’s instructions
(Fig. 12). Gently air-dry.
Fig. 14. The use of a needle tube for delivering composite into the post space minimizes
void formation. The tip of the needle tube is inserted until it reaches the root canal filling.
Then the composite is applied from the base of the post channel coronally, and the post
space is filled to the brim. The post is immediately inserted into the composite.
364 Ree & Schwartz
Fig. 15. A composite core is added to the newly placed post. To prevent bonding core mate-
rial to adjacent teeth, as well as to enhance the adaptation of the composite to the remain-
ing tooth structure, a core form is used as a matrix.
12. Apply a self-cure or dual-cure dental adhesive that can be used with a self-cure or
dual-cure core material to the dentin according to the manufacturer’s instructions
(Fig. 13).
13. Inject a self-cure or dual-cure composite in the post space by using a needle tube
(Fig. 14).
14. Insert the post into the post channel filled with composite.
15. Use a matrix to prevent bonding core material to adjacent teeth, as well as to
enhance the adaptation of the composite to the remaining tooth structure
(Fig. 15).
Fig. 16. The composite core is added to the newly placed post in a bulk fill, using the same
self-curing composite placed in the post channel.
Fig. 17. The composite core is contoured and finished.
16. Add the remaining composite to the newly placed post or use a light-cure
composite for that purpose in increments (Fig. 16).
17. Light-cure if necessary, or wait for at least 5 minutes until the self-cure composite
has completely set.
18. Contour and adjust the occlusion (Fig. 17).
19. Finish and polish the restoration.
20. Take a final radiograph (Fig. 18).
Fig. 18. The radiograph shows a well-adapted fiber post and composite buildup without
voids, which is ready to be prepared for a crown.
366 Ree & Schwartz
SUMMARY AND RECOMMENDATIONS
Evaluate restorability carefully before considering endodontic and restorative

treatment.
Preserve radicular and coronal dentin, especially in the cervical area, to maximize
the long-term restorative result.
Use adhesive procedures at both radicular and coronal levels to strengthen
remaining tooth structure and optimize restoration stability and retention.
Use post and core materials with physical properties similar to those of natural
dentin.
Use a rubber dam when performing clinical procedures involving adhesive
bonding.
Choose a post that fits passively into the canal preparation.
Preserve an apical root canal filling of at least 4 to 5 mm.
Use a post length that equals at least the crown height, and that extends apically
beyond the crest of bone.
Consider placing 2 posts in oval-shaped canals.
Consider placing a fiber post through the existing crown in bridge abutments
or small teeth. The post will increase crown retention and may improve resis-
tance to fracture as long as no additional radicular dentin is removed in the
process.
With an adequate ferrule and canal thickness, use a fiber post to distribute forces
more evenly in the root and reduce the chances of root fracture.
If there is an inadequate ferrule, longevity may be compromised, no matter which
post is used.
Metal posts are stronger and more resistant to flexure, but the stress distribu-
tion is unfavorable, with higher risk of root fracture.
The stress distribution in fiber posts is more favorable, but these posts are
more susceptible to fracture and more likely to flex under load, which may
result in micro-movements of the core, and subsequent leakage, caries, and
retention loss.
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J Esthet Restor Dent 2003;15(5):313–8.
Essentials
of Endodontic
M i c ro s u r g e r y
a,b,c,d,e,
Stephen P. Niemczyk, DMD *
KEYWORDS
Endodontic microsurgery Ergonomics Root end resection
Root end preparation Root end filling
In his book Working in a Small Place Mark Shelton chronicles the efforts of a young
neurosurgeon, Dr Peter Jannetta, to introduce a radically new microsurgical technique
for cranial nerve decompression. Pivotal to the technique was the use of the surgical
operating microscope (SOM) for precise visualization and manipulation of the delicate
structures. What Dr Jannetta discovered was that not only was the use of the SOM in
neurosurgery a rare event but also this particular piece of armamentarium was re-
garded with disdain by the ‘‘Grand Old Men’’ of the profession. Programs were hesi-
tant to implement this technology, and their residents were discouraged in its use
because the senior staff members either felt estranged by the unfamiliarity with the
SOM, or threatened by its presence. What Dr Jannetta realized was that, rather
than trying to convince the grand old men of the merits of the SOM, he would work
from within the system, slowly teaching his residents and wait for a new generation,
his generation, to assume the role of senior staff members. He is quoted in the
book as saying ‘‘It takes twenty years for anything new to really catch on, not because
it takes that long to convince the establishment, but because it takes that long for there
to be a changeover to people who have grown up with the new idea as being
accepted.’’1 Today, all residency programs in neurosurgery require proficiency with
the SOM and microsurgery.
An interesting parallel is drawn when one examines the progression of the dental
operating microscope (DOM) use in dentistry and, specifically, endodontics. Although
Movies can be viewed within this article at http://www.dental.theclinics.com, April 2010 issue.
a
Post Graduate Endodontic Program, Harvard School of Dental Medicine, Boston, MA, USA
b
Post Graduate Endodontic Program, Dental Division, Albert Einstein Medical Center,
Philadelphia, PA, USA
c
Graduate Endodontic Program, National Naval Medical Center, Bethesda, MD, USA
d
United States Army Endodontic Program, Fort Gordon, GA, USA
e
5100 Township Line Road, Drexel Hill, PA 19026, USA
* 5100 Township Line Road, Drexel Hill, PA 19026.
E-mail address: spndo@comcast.net
Dent Clin N Am 54 (2010) 375–399

376 Niemczyk
presented as early as 1986 by Selden,2 it was not until the early 1990s that the DOM
was introduced to the profession and graduate-level endodontic programs.3–6 The
usefulness of the DOM in endodontics was viewed with similar skepticism by the
senior attendings of most programs for all the same reasons of their counterparts in
neurosurgery. However, a concerted effort was made by a few enlightened individuals
with foresight enough to recognize the advantages that microscopy could afford, and
they lobbied their cause until the late 1990s, when it was mandated that all graduate
programs and students demonstrate a proficiency in the use of the DOM. Before 1999,
only 52% of the endodontists surveyed reported using the DOM.7 Compare that to
a more recent survey,8 in which the age of the operator was compared with their usage
of the DOM and it was found that the younger respondents (35 years old or younger)
used the DOM 97% of the time for surgical and nonsurgical treatment. It is clear that
the recent graduates are not only more comfortable with its use, but are also more
accustomed to rendering treatment with the DOM. What is an interesting coincidence
is that endodontics is approaching the 20-year mark of the inception of the DOM into
practice; it would seem that Dr Jannetta’s prophecies extend to the dental profession
as well!
Although the basic principles of endodontic surgery have not been dramatically
changed, advances in armamentarium and microtechniques have attempted to
keep pace with the demands of today’s endodontic microsurgical environment:
greater ergonomic flexibility, more efficient preparation and placement of the root
end filling (REF), and more biocompatibility of the materials used.
ANESTHESIA AND HEMOSTASIS
These 2 facets are inexorably linked because the effectiveness of the surgeon’s
administration preoperatively not only influences the comfort of the patient during
the procedure but also the control of hemorrhage at the surgical site. Standard
protocol is divided into regional and local injections and are as follows:
1. The administration of a long-acting anesthetic agent such as bupivicaine (Mar-
caine) as a block technique to obtain a sustained level of anesthesia beyond the
duration of the surgery. For posterior surgeries this entails, for maxillary sites,
a posterior superior and middle superior alveolar block; for posterior mandibular
sites, an inferior alveolar nerve block supplemented with a mental nerve trunk
block. Maxillary anterior teeth are blocked using bilateral anterior superior alveolar
or infraorbital injections, while mandibular anterior teeth receive bilateral mental
nerve blocks. All of these can be supplemented, as need be, with corresponding
palatal or lingual infiltrations of the same anesthetic.
In studies examining the effectiveness of lidocaine versus bupivicaine, it was shown
that lidocaine was faster in onset of lip numbness while bupivicaine resulted in longer
duration.9 However, Gordon and colleagues10 have shown that administration of bu-
pivicaine following surgical extractions resulted in decreased pain for longer periods of
time. By minimizing the peripheral barrage of peripheral nociceptive neurons, it
reduced the development of central sensitization, thought to mediate partially the
central component of allodynia and hyperalgesia. This postoperative effect can be
further enhanced by the preoperative administration of a nonsteroidal anti-inflamma-
tory drug, resulting in statistically less postoperative discomfort and delay of onset of
pain.11,12 This peripheral block should be allowed to take effect (8–10 minutes) and
signs of adequate anesthesia noted before the next phase.
Essentials of Endodontic Microsurgery 377
2. Once regional anesthesia has been achieved, then a local infiltration of lidocaine
1:50,000 epinephrine is injected over the intended flap extent, concentrating the
bulk of the infiltration over the surgical site. The injection speed is slow and steady
(1–2 min/mL), allowing time for diffusion of the fluid and avoiding the formation of
a bolus accumulating in the submucosa.13 Done correctly, blanching will be evident
in the surrounding tissues, spreading throughout the flap and its perimeter. Care
should be taken to avoid injecting into skeletal muscle. Doing so will activate the
b-adrenergic receptors, triggering vasodilation instead of constriction, causing
undue hemorrhage on flap reflection and subsequent limited visibility of the surgical
site.13,14
The outlined protocol is, of course, predicated on the systemic health of the patient
and their ability to tolerate not only the surgical stress but also the cardiovascular
impact of the epinephrine in the selected anesthetic. Even in healthy patients a tran-
sient tachycardia of short duration is not uncommon, but is usually well tolerated if
the patient has been forewarned. However, in cases where underlying cardiovascular
diseases such as uncontrolled hypertension or history of recent cardiac surgery place
these patients at a higher risk, the surgeon would be prudent to consult with their
physician before the procedure.
FLAP DESIGN
There are 3 basic flap designs; 2 are traditional mainstays (Triangular, Ochsenbein-
Luebke) and the third a variation of a periodontal surgical incision, the papilla-base
flap.
The triangular flap design entails a full sulcular incision at least one tooth mesial and
distal of the intended surgical field. The blade tip is in contact with the crest of alveolar
bone throughout the incision, severing the periosteum, and carried through the sulcus
and into each interdental papilla. As each papilla is incised, it can be gently reflected
using the scalpel blade to ensure that a complete cut has been made. A vertical
releasing incision is then made, originating at the line angle of the most anterior tooth
of the flap, and drawn apically parallel to the long axis of the adjacent roots (Fig. 1).
Fig. 1. Triangular (sulcular) flap. The solid red line indicates the sulcular incision from the
mesial of tooth #12 to the distal of tooth #15; the dotted line represents the vertical
releasing incision parallel to the root of tooth #11. Note the swelling in the mucobuccal
fold near the MB apex of tooth #14.
378 Niemczyk
The soft tissue of the flap is then reflected, starting in the vertical releasing incision and
proceeding coronally/distally/apically, undermining and releasing the periosteum until
full reflection is achieved and the surgical site is uncovered.
The Ochsenbein-Luebke flap was the design of choice in the maxillary anterior when
there were concerns about exposure of crown margins or gingival recession following
apical surgery (Fig. 2). This flap requires that the incision be contained within the
attached gingiva, with at least 2 mm between the depth of the sulcus and the incision
line. The band of attached gingiva should also be wide enough so that the incision line
does not cross the mucogingival junction into the alveolar mucosa. It is imperative that
the sulcus depths be mapped, and there are specific instruments made for this
purpose called pocket markers, designed like college pliers, with one jaw configured
like a periodontal probe and the other having a small ‘‘tooth’’ or projection on the
tissue side of the jaw. These instruments are available in left- and right-side models
to allow for correct orientation and adaptation to the tooth. The periodontal jaw is
placed against the facial surface of the crown of each tooth, inserted to the depth
of the facial sulcus at 3 points, and the handles are gently squeezed to bring the
pointed end of the opposite jaw into contact with the facial gingival; this creates
a series of bleeding points apical to each crown, representative of the depth of
each individual sulcus. The incision is made 2 to 3 mm apical to these bleeding points,
in a scalloped fashion to mimic the contour of the respective gingival crests. The inci-
sion is carried at least 1 to 2 teeth mesial and distal to the intended surgical site, with
a vertical releasing incision terminating at both ends. The flap is reflected as with the
triangular design, starting at one end of the incision and progressing to the opposite
side. Although chosen to reduce the potential for exposed crown margins, this design
is contraindicated in cases where a large apical lesion is present or there is an
inadequate band of attached gingiva.15–20
The papilla-base flap could be best termed a hybrid variation of a full sulcular and
split-thickness incisions, and has been suggested to prevent the gingival recession
seen with the aforementioned 2 flap designs.21 This flap consists of 2 vertical releasing
incisions, connected by intrasulcular incisions in the cervical areas of the planned
reflection concomitant with the papilla-based split-thickness variation. The split-thick-
ness incision is accomplished in 2 steps: the first is a shallow cut, meant to sever the
Fig. 2. (A) Ochsenbein-Luebke flap. The solid red line is the scalloped incision in the
attached gingiva. The purple dots, made with a Gentian Violet stick, denote the probing
depth plus 2 mm at the facial surface of each tooth in the proposed flap. The incision
connects these dots together as one line, with vertical releasing incisions (dotted lines) at
the terminal ends of the flap. (B) Ochsenbein-Luebke flap. The suturing of the coapted
‘‘points’’ of the flap correctly readapt the tissues. More sutures will be added to secure
the flap (arrows).
epithelium and connective tissue to a depth of 1.5 mm from the surface of the gingiva,
subscribing a curved line, perpendicular to the gingival margin, and connecting one
side of the papilla to the other. The second cut is more vertical in nature, tracing the
original incision but deep enough to contact the alveolar bone margin (Fig. 3). This
cut will produce a split-thickness flap at the apical third of the base of the papilla.
This split-thickness incision is joined by the intrasulcular cut(s) at the cervical
margin, completing the release of the marginal gingival complex. The intended flap
is then reflected as a full-thickness mucoperiosteal event, apically positioned as
dictated by the intended operative site. The one crucial caveat is the choice of
scalpel blade; it should not exceed 2.5 mm in width, to allow for the delicate course
of the incision and minimize inadvertent overcutting of the tissue. Although very
predictable in terms of minimizing soft tissue recession, this is a very challenging
flap design to execute and, if the tissues are mishandled, primary coaptation of
the epithelial margins will be compromised; necrosis of the affected sections will
occur and lead to formation of a surgical scar.22 Also incumbent in this flap design
is the size of the sutures used in closure; 7-0 to 8-0 polypropylene monofilament,
at least 2 placed per papilla.
ERGONOMICS AND POSITIONING (PATIENT/SURGEON)
One of the most frustrating aspects of microscopic surgery is the correct positioning of
the DOM relative to the patient and operative field. Indeed, a recent survey indicated
almost 77% of those responding claimed some difficulty in access and visualization
using the operating microscope.23 Improper positional technique has long been
recognized in the medical field, and guidelines to enhance performance and limit
fatigue have been presented.24,25 In endodontic surgery, the position of the patient
is not as important as the position of the root apex and the immediate surgical field.
This orientation forms the foundation on which the remainder of the microsurgical
procedures is based. To begin, the patient is positioned in a supine to slightly Trende-
lenberg attitude so that the surgical osteotomy site is most superior in the operating
field. This position can vary from the patient simply turning their head to actually laying
on their side. The patient can then be stabilized for comfort in this new position using
rolled-up surgical towels, ‘‘donut’’ style headrests, or memory foam pillows. The
Fig. 3. (A) Papilla-based flap. The green lines denote the full sulcular portion of the incision
around the cervical of each tooth, the red lines are the split-thickness incisions for the
papillas involved, and the dotted green line is the vertical releasing incision. Note from
the text that the papilla incisions are made with 2 different angles and depths. (B)
Papilla-based flap reflection. The arrows point to the split-thickness reflection of each
papilla. Note the long tissue bed of each papilla, especially between the 2 premolars.
380 Niemczyk
surgeon then takes position at the head of the patient, the 11 to 12 O’clock orientation.
The operator’s chair height is adjusted so that the angle formed between the thigh and
lower part of the foot is a minimum of 90 , and the spine is comfortably straight. The
patient’s chair is then raised or lowered so that the surgeon can maintain his or her
elbows close to his body, passively bent at a neutral 90 . There are several companies
that manufacture surgeon’s chairs that have elbow rests incorporated into them, af-
fording support of the forearms and elbows. Once positioned, the surgeon’s arms
and hands should not deviate from the core-centric position; this affords the greatest
dexterity and precise micro-control, while limiting fatigue and strain trembling.26,27 The
microscope is last positioned with the line of sight axis perpendicular to the soft tissue
field of the intended flap, and the binocular eyepieces adjusted to a comfortable height
relative to the operator.
The selected flap design is then incised, the soft tissue reflected, and the retractor(s)
stabilized on the cortical plate. The retractors must be in contact with the bone to
avoid inadvertent impingement of the reflected soft tissue or other vital structures
such as the mental nerve. The retractors must also be positioned at some distance
from the surgical site to afford access for visualization and manipulation of the instru-
ments. However, the extent of the reflection is not as broad as with other oral surgical
procedures; rather, the reflection forms a narrow corridor bordered by the edges of the
flap. This corridor not only minimizes the trauma to the soft tissues but desiccation of
the cortical plate as well. This retraction can be augmented by the assistant using
a second retraction instrument such as a Seldin or Pritchard style periosteal elevator
to gently redirect a lip or section of the flap that has prolapsed into the field, especially
during the osteotomy and root end resection phases of the procedure. Once retraction
is complete and stable, the patient is readjusted so that the cortical plate/tooth long
axis of the surgical site is parallel to the floor and most superior in the field (Fig. 4).
ERGONOMICS AND POSITIONING (PATIENT/SURGEON/DOM): SITE SPECIFIC
Although there is no one correct way to position the microscope relative to the field, an
excellent guide would be to visualize what a direct line of sight to the field would be,
Fig. 4. The correct positioning (left) for the tooth long axis relative to the floor on the left.
Positioning in this manner allows for the resection to be ‘‘gravity driven,’’ dropping straight
down toward the floor, making a right angle cut with regard to the facial-palatal direction.
On the right, because the angle is incorrect, the osteotomy is larger and the resection is
angled from facial to palatal.
then position the line of sight of the microscope along that imaginary line. Inclinable
optics allow for the microscope to assume different vertical attitudes relative to 90 ,
and a shift of as little as 20 in either direction will enable the surgeon to look past
the head of the handpiece to the end of a burr, or use direct vision to examine a re-
sected root end. It is also imperative to have the microscope visual axis (MVA) parallel
to the root long axis (RLA) at the selected resection level; if the observation position is
skewed off-angle, the resection will mimic that angle (Fig. 5). This section explains the
basics of positioning for the microscope; more details concerning the actual root end
procedures follow in later sections. For the 4 major quadrants, the respective position
guidelines are presented.
MAXILLARY ANTERIOR
The head of the microscope is tilted slightly off from direct vertical, angling from the
crown of the tooth toward the apex (Fig. 6). This angle will alleviate the superimposi-
tion effect of the head of the handpiece; bring the tip of the selected burr into view.
Decortication of the intended apical site, if not already exposed by pathologic fenes-
tration, is affected by a small round bur (#2–4) or other specialized bone bur (Lindeman
Bone Bur). Care should be taken not to unintentionally gouge the selected root surface
during this discovery phase. Use of a nonaerosol producing handpiece, such as an
Fig. 5. The relationship of the root long axis (RLA) and the microscope visual axis (MVA). If
the microscope and, by extension, the surgeon are positioned in the same line as the long
axis of the root at the selected resection site, then the line of resection will be parallel to the
surgeon’s chest, an ergonomically reproducible path. This positioning will ensure the correct
mesial-distal angulation. When a disparity exists, as shown on the right, the surgeon is
guided by their body position and line of sight, not the position of the root tip, and an
angled resection is made.
382 Niemczyk
Fig. 6. The correct inclination of the microscope and patient for maxillary anterior surgery.
Position A and Movie 1 are for the resection; position B and Movie 2 are for the inspection,
root end preparation (REP), and root end filling (REF).
Impact Air (Palisades Dental, Englewood, NJ, USA) will reduce the amount of occult
spray in the field and improve visibility without compromising cooling of the bur and
bone. Following identification of the selected apex, the osteotomy is enlarged to
enable curettage of any lesion present and isolate the root tip from the surrounding
surgical crypt. How large an osteotomy should be is predicated on the native size
of the lesion, adequate access for the armamentarium, and proximity to vital structure
such as the mental nerve, mandibular canal, or maxillary sinus. In a phrase: it should
be as small as possible but as large as practical.
Once the root tip is isolated, the surgeon and DOM are repositioned so that they are
parallel to the long axis of the root at the selected level of the resection, not the long
axis of the tooth, and the coronal-apical inclination is reestablished. With the direct line
of sight to the bur tip restored, the root end is resected (Movie 1, available along with
all other movies cited here in the on-line version of this article at: http://www.dental.
theclinics.com). Once resection is complete, the microscope is then angled from
apex to crown to allow for inspection of the resected root surface with direct vision
(Movie 2). The angle will, of course, depend on the extent and quality of the retraction.
Following the resection, the operator will be using micromirrors to more accurately
assess the accuracy and completeness of the resected surface. This same angle
will also be used to visualize the root end preparation (see Movie 2).
MANDIBULAR ANTERIOR
The positioning is relatively the same, with a few notable exceptions:
(a) Positioning of the cortical plate parallel to the floor may not be possible; this should
be taken into account during the root end resection and preparation phases. In
many instances, rather than recline the patient to an uncomfortable angle, it may
be enough to have them elevate their chin slightly to affect this parallel position
(Fig. 7) (Movies 3 and 4).
(b) The second angle, coming from the apex to the crown, again may be compro-
mised by the limitations of the reflection and the angle of the patient, but the solu-
tion may again be as simple as having the patient elevate the chin for a short period
of time to enable the correct line of sight.
MAXILLARY AND MANDIBULAR POSTERIOR
The limiting factor here is the ability of the patient to present the cortical plate parallel
to the floor. Using rolled surgical towels or pillows to prop the back of the patient will
allow them to comfortably lie on their side in the dental chair, affording a more favor-
able attitude to the surgical site. An anesthesiologist’s ‘‘donut’’ or small pillow can also
be placed under the patient’s head to gently cushion it in this new position. Failure to
achieve this presentation of the surgical field often results in a misdirected ‘‘tunneling’’
of the osteotomy, with the potential for inadvertently damaging adjacent roots or
structures (Fig. 8). Also, retraction in the most posterior of sites is inhibited by the
xygoma or external oblique ridge, and may require repositioning of the retractor(s).
Otherwise, the previous rules of positioning of the microscope hold true with respect
to the osteotomy, root end resection/inspection, and preparation (Figs. 9 and 10)
(Movies 5–8).
Fig. 7. The correct inclination of the microscope and patient for the mandibular anterior
surgery. Position A and Movie 3 are for the resection; position B and Movie 4 are for the
inspection, REP, and REF.
384 Niemczyk
Fig. 8. The magnified area of root apices teeth #13, #14, and #15 shows the correct osteot-
omy approach (green arrow) for the distobuccal root of tooth #14. However, if the patient is
facing straight forward, the field of view is distorted at higher magnification, and the
approach angle is often too far mesial, resulting in a grazing or gouging of the MB root
(red arrow). Turning the patient so that the cortical plate of the site is superior in the field
alleviates this difficulty.
Fig. 9. The correct inclination of the microscope and patient for the maxillary posterior
inspection, REP, and REF. Note the bow-tie effect on the resected root surface of this MB
root.
Fig. 10. The correct inclination of the microscope and patient for the mandibular posterior
inspection, REP, and REF. Note the harvesting of the root apex after resection, and the 2
canals it demonstrates (one filled, one uninstrumented/filled).
ROOT END RESECTION
This phase is perhaps the most pivotal of the surgical procedure, as errors here are
magnified with respect to the subsequent root end preparation and successful sealing
of the apical extent of the root canal system. The carpenters’ axiom of ‘‘measure
twice, cut once’’ has great significance, as root structure cannot be replaced once
it has been removed, so careful consideration must be given to the length and angle
of the resection process.
LENGTH
First and foremost are the restorative implications of the resection with regard to
crown-root ratio. There are histologic guidelines for how much of the root end should
be removed but if, in doing so, the integrity and stability of the remaining tooth is
compromised, alternative treatment options should be explored. If there is sufficient
root length in sound bone, then the amount of root apex that is removed is dictated
by the prevalence and distribution of the apical ramifications the surgeon hopes to
eliminate. As the accompanying diagram shows (Fig. 11), a resection level of 3 mm
from the anatomic apex will eliminate 93% of lateral canals and 98% of any other rami-
fications such as deltas, fins, and so forth.28 Coupled with a root end preparation
depth of 3 mm, 6 mm of infectious etiology in the canal space will have been effectively
treated. There are, however, 2 notable exceptions to this rule. First, if the level of
resection is such that it leaves a root geometry that is significantly curved at that level,
then the root end preparation will be compromised (Fig. 12). The preparation tips, by
design, are 3 mm long, and are not designed to follow curves like a root canal file.
386 Niemczyk
Fig. 11. The relationship of resection level and canal ramifications eliminated in this canine
apex. (Data from Kim S, Kratchman S. Modern endodontic surgery concepts and practice:
a review. J Endod 2006;32:601–23.)
Hence, the preparation will be shallower than required because of the tip’s impact on
the curve or, if forced longer, can in fact perforate the external root surface. This situ-
ation can be remedied by increasing the length of the resection past the curve,
provided the overall length of the remaining portion of the root does not compromise
the crown-root ratio.
The other exception occurs when the root in question has undergone a resorptive
process, and is shorter than normal. In this instance, part of that ideal 3-mm length
Fig. 12. The preoperative radiograph of tooth #3 demonstrates the dissimilar curves of the
roots, and the correspondingly different angles of resection for each root apex. Note that
the resection of the MB apex is slightly shorter so as not to impact the REP into the curve.
The postoperative radiograph shows the REF to be well centered and to the correct depth.
has been eliminated involuntarily. Comparison of the root length of the contralateral
tooth can assist in determining how much more of the apex needs to be removed, if
any. At the very least, the resorbed root apex would likely need to be flattened some-
what to allow for efficient root end preparation and filling/finishing.
ANGLE
Before the introduction of the microscope, resected root ends were routinely beveled to
enable the surgeon to visualize the resected surface(s). It was not uncommon for bevels
of 30 , 45 , or even greater to be placed because of ‘‘convenience.’’ This beveling was
most often rendered by with a #4 to #6 round burr attached to a large, straight nose cone
handpiece, such as a Stryker, or with a fissure burr in a conventional slow-speed hand-
piece. This severe angle contributed to gross apical leakage and often failure of the
apical surgery. In 1989, Tidmarsh and Arrowsmith29 examined the implications of the
beveled resection (45 –60 ) with regard to dentinal tubule concentration in young and
old teeth, and the depth of the effective retrograde seal. These investigators concluded
that the potential for leakage was greatest when the bevel was steep and the retrograde
filling did not extend deeper than the coronal aspect of the beveled surface. This concept
was elaborated upon with the work of Gilheany and colleagues 1994.30 Twenty-seven
single-rooted teeth were selected and their root apices were resected at 0 , 30 , and
45 . Apical preparations were created and sequentially filled with a glass ionomer (Ketac
Silver). The apical microleakage and dentin permeability were measured by observing
and quantifying the fluid flow in a hydraulic conductance apparatus as described by
Derkson and colleagues in 1986.31 Gilheaney and colleagues concluded that: (1) the
amount of leakage increased as the slope of the bevel increased; (2) increasing the
depth of the retrograde filling decreased the microleakage; and (3) optimum/
minimum depths for the retrogrades were as follows: 0 5 1 mm, 30 5 2.1 mm,
45 5 2.5 mm (Fig. 13).
Bur selection for the root apex removal is almost a matter of personal choice.
However, here are some guidelines based on the literature32–34:
Fig. 13. The impact of different bevel angles, and the amount of lateral leakage through
the exposed dentinal tubules to the REF (blue triangles). The red triangle in the 45 bevel
would represent contaminated tubules left after such a resection in an infected root
apex. (Data from Gilheany PA, Figdor D, Tyas MJ. Apical dentin permeability and microleak-
age associated with root end resection and retrograde filling. J Endod 1994;20:22–6.)
388 Niemczyk
(a) Straight or tapered carbide fissure configuration, long enough to span the depth of
the apex, is advised. If a tapered fissure is chosen, the angle created by the taper
should be taken into account during the resection to maintain as close of a 0 bevel
as possible.
(b) Avoid coarse diamond or crosscut fissure configurations as these create surface
roughness and irregularities, making it difficult to finish the REF properly.
(c) Use of the bur in a high-speed handpiece with copious coolant is advised. It is also
recommended that this coolant stream not be air driven, as this could potentially
induce an air embolism effect in the soft tissues of the surgical field. An example
of such a handpiece is the Impact Air, available with or without fiber optic
capability.
The technique of the resection is not the ‘‘chainsaw’’ cutting of a tree trunk, but
rather akin to the slicing of a piece of bread. In the former action, the coolant would
fail to effectively reach the interface of the bur and tooth surface being cut, allowing
for the dentinal surface to become overheated and burned. By using the tip of the
bur and making progressively deeper passes across the root tip surface, not only
will the coolant flush and cool the resection cut but also the first few passes will create
a ‘‘guide slot’’ in the root. If any adjustments to length or angle are required, they are
easily corrected at this time without undue, and irreversible, damage to the root. This
guide slot also serves as a ‘‘pilot reference’’ to maintain the correct angle throughout
the resection. Some operators prefer to shave the root end rather than resect it. The
author feels that this has the potential to cloud the issue of how much has really
been removed, and the shaving of an infected root end disperses just that much
more pathogenic material into the surrounding crypt.
Once the apex (ices) has been removed, the first observation made should be of the
resected tip cut surface (Fig. 14). This view will very often mirror the cut surface of the
remaining root, offering a preview of what the surgeon is to expect in terms of number
of canals, filled or unfilled, isthmuses, fractures, and so forth. Such observations can
also reveal the smoothness of the cut, and whether the resection was complete;
a jagged edge along the perimeter of the root usually indicates that portion of the
root being broken off, rather than cut cleanly. The situation is confirmed clinically by
examining the remaining root surface, either directly or in a micromirror.
Fig. 14. The picture on the left shows a root tip harvested after resection in this surgical re-
treatment. The black stain near the MB canal is from the amalgam retrograde. Note the
long isthmus seen in this tip; it is the mirror image of what can be expected when the re-
sected surface of the root is viewed. The picture on the right is the micromirror view of
the resected surface; an exact replica of the observation made from the harvested root tip.
Fig. 15. (A, B) The radial dentin pattern in an anterior and posterior tooth, respectively.
(C, D) The bow-tie effect. (C) The dentinal tubules of the transitional lines as they appear
naturally; (D) the tubules stained at the transitional line angles from a coronally leaking
obturation.
The remainder of the crypt is curetted to remove any remnants of soft tissue, sufficient
hemostasis is either maintained or attained (explained in the following section), and the
resected root end is disclosed with methylene blue, caries indicator, or other nontoxic
dye. Subsequent observations of the root end(s) with a micromirror are made to assess
the conditions of the site: are there incomplete resections, indicated by an irregular peri-
odontal ligament perimeter or ‘‘dog-eared’’ projection of dentin? Are there extra roots/
canals present, evident by the staining or lack of it? Are there fractures or isthmuses,
and what is their location and extent? All of these points need to be cataloged and
resolved before any root end preparation. One interesting observation can be made
without the aid of any disclosing solution. The author terms this the ‘‘Bow-Tie’’ effect,
and it is readily evident on the wet, resected surface of the root (Fig. 15). These faint lines
are not fractures, but represent the transitional line angles of the root dentin/tubules.
Because the dentinal tubules refract light differently, depending on their orientation to
the light source, they will present a different appearance when viewed with incident
Box 1
Water prism fluid effect
Movie 9 shows the prism effect of a clear fluid in the crypt of tooth #24. With the
proper fluid level, it is possible to view the resected surface without the micromirror.
Without altering the position of the DOM, the fluid is removed to reveal how much
of the light and view was being ‘‘bent’’ by the prism effect of the fluid.
390 Niemczyk
Box 2
Ferric sulfate hemostasis technique
Movie 10. Placement of a pellet moistened with ferric sulfate into this grossly
bleeding crypt. Note the immediate blackening of the occult blood and pellet.
The end of the video shows a curette creating a fresh bleeding surface, and slough-
ing of the necrotized tissue.
light. This appearance is the apical manifestation of what the author has termed ‘‘radial
dentin’’ seen in the coronal chambers of dystrophically obliterated teeth.35 This ‘‘radial
dentin’’ tracks back to the obliterated pulp space, serving as a map to the narrowed
canal. The radial dentin, apically, will point to the central location of the canal space
and isthmus. This indication is especially important if the dye used did not disclose
any canal/isthmus but the radial dentin suggests that it is present; the conclusion
must then be drawn that the resection level did not cut through, and thereby expose,
the canal/isthmus enough to capture the dye. The clinical decision is then made to either
root end prepare according to the radial dentin outlines, or resect slightly more of the
root end to reveal the suspected space(s).
One last observation ‘‘trick’’ involves the principle of a prism and its ability to bend
light. This ‘‘water prism’’is especially useful in the mandibular anterior apices, where
space in the crypt is often cramped and bleeding slightly. After resection, the crypt
is rinsed with sterile saline until it runs clear but, rather than suction the site dry, the
saline is allowed to remain in the crypt. The level of the fluid can be adjusted through
judicious suctioning with a microcannula, until the whole root end surface can be
observed. Not only will this facilitate the accurate positioning of the USREP (UltraSonic
Root End Preparation) tip without a micromirror, but the fluid itself offers a weak hemo-
static tamponade effect (Movie 9; for movie description, see Box 1).
HEMOSTASIS
Before the USREP, the absolute hemostasis of the crypt needs to be achieved.
Although the best hemostasis is achieved preoperatively with the anesthetic, a pro-
longed surgery or systemic conditions may tax the effectiveness of the Lidocaine
1:50,000. Most agents effect hemostasis by either by direct heme-agglutination or
by triggering the natural clotting cascade of the patient. Of the two, the natural effect
is preferable because it lasts for a relatively longer period of time. These agents, and
their mode of action, are as follows.
Heme-Agglutination
Solutions
Ferric sulfate or ferric subsulfate is the generic name for this agent. Depending on the
concentration of the chemical, it is also known by the trade names: Astringedent (Ul-
tradent Products Inc, UT, USA) Viscostat, Stasis (Cut-Trol Ichthys Enterprises, Mobile,
AL, USA), and Monsel’s.
Box 3
Hemodette hemostasis technique
Movie 11. Placement of a blue Hemodette pellet and hemostasis after 3 minutes.
Box 4
ActCel hemostasis technique
Movie 12. Placement of the material at the mesiobuccal (MB) apex of tooth #19.
Demonstrates the material turning to a jelly, and the excess is removed. After hemo-
stasis is achieved, the crypt is rinsed and the REF is placed.
The most efficient delivery is via small microbrushes dipped into a dappen dish con-
taining the solution, and then the moist tips are discretely applied to any small bleeding
points. The agglutinated proteins coagulate and form a physical plug almost immedi-
ately, and hemostasis is preserved so long as this plug remains undisturbed. Although
extremely effective, all remnants of the ferric sulfate must be removed, and a fresh
bleeding surface reestablished (Movie 10; for movie description, see Box 2). Other-
wise, significant and adverse effects on the osseous and soft tissue healing of the
site can be expected.36,37 The necrotizing effects, along with the difficulty in control-
ling the distribution and complete elimination of this agent, strongly preclude its selec-
tion in areas of neurovascular concern, namely, mandibular nerve, mental foramen,
maxillary sinus, and floor of the nose.
Gels
Hemodette (20% buffered aluminum chloride gel, DUX Dental, Oxnard, CA, USA) is
a water-soluble agent with agglutination properties similar to ferric sulfate, but without
the deleterious side effects. This agent is packaged as 2 impregnated cotton pellets
with an excess of gel in a sterile container resembling a prophy cup. Delivery is with
the cotton pellet or, using a microbrush, painting the crypt with the free gel. In addition
to the heme-agglutination effect, the gel itself forms a sort of passive barrier to any
minor bleeder. The blue color makes it readily identifiable in the site, and it is easily
rinsed from the crypt with saline at the conclusion of the procedure (Movie 11; for
movie description, see Box 3).
There are other gauze-based products such as ActCel (ActSys, Westlake Village,
CA, USA), HemCon (HemCon Medical Technologies, Portland, OR, USA), and Blood-
Stop (LifeSciencePlus, Palo Alto, CA, USA) that, when moistened with saline or blood
from the site, break down into a gel matrix, exerting the same combination of mild tam-
ponade and heme-agglutination as the Hemodette, and that are just as easily
removed. (Movie 12; for movie description, see Box 4).
Physiologic Clotting Agents

These products are, by and large, either bovine or porcine derived connective tissue
matrices that initiate the patient’s own clotting cascade at the site. The advantage of
this type of hemostasis is that it is usually longer lasting and more predictable in effect.
Although Avitene (Avitene microfibrillar collagen hemostat, Davol Inc, Warwick, RI,
USA) is the most effective and well known of this category, it is difficult to place and
expensive (Movie 13; for movie description, see Box 5). A reasonable substitute would
Box 5
Avitene hemostasis technique
Movie 13. Placement of the microfibrillar type, and the exceptional hemostasis after
2 minutes in situ.
392 Niemczyk
Box 6
Colla Plug hemostasis technique
Movie 14. Placement of a small Colla Plug disc shows adequate hemostasis after 2
minutes.
be either CollaPlug or CollaTape (Zimmer Dental, Carlsbad, CA, USA). The tape
dressing can be easily cut to fit the osteotomy, and the plug can be sliced into small
discs and placed over the bleeding sites. Gentle tamponade will accelerate the effect,
although once the material is removed, the clotting effect will deteriorate within a few
minutes (Movie 14; for movie description, see Box 6).
ROOT END PREPARATION
Since their introduction by Carr in the early 1990s, the use of the USREP tip has refined
the technique and practice of this phase of the surgery. USREP tips have evolved from
smooth stainless steel tips of limited configurations to a myriad of multiple bends and
angles, with coatings of diamond or zirconium nitride (Fig. 16). The safety, efficiency,
and directions for use have been well investigated in the literature, and are considered
the standard for root end preparations.38–42 There are several manufacturers of these
Fig. 16. USREP tips. (A, left to right) A stainless steel tip, a diamond-coated tip, and a zirco-
nium nitride (ZN)-coated tip. (B) the assorted tip configurations for the ZN (ProUltraSurgical
tips, Dentsply-Tulsa Dental, Tulsa, OK, USA). (C) The tip diameter of the smaller #1 universal
tip, and the larger #2 universal tip. (D) The different tip angles of the #3 and #4 posterior
surgical tips. These different angles can accommodate different surgical presentation angles
of the root end without having to affect awkward handpiece positions.
Box 7
USREP tip guide
Movie 15. A reference notch is made on the cortical plate of tooth #14 MB root with
the side of the US tip. This notch, made parallel to the long axis of the root at the
resection site, serves as a visual reference during root end preparation to maintain
the proper angle of the USREP tip.
specialized tips, and most are interchangeable with regard to the attachment to
a generating unit.
TECHNIQUE
Although the universal tips are designed for anterior teeth, and tri-angled tips for
posterior locations, there is no rule as to where a particular tip can or cannot be
used; the determining factor is access with the selected tip attached, and visibility
during its use. In single canal roots, the tip is placed into the center of the gutta per-
cha, if present, or the center of the canal space. The tip is energized, with enough
coolant delivered through the tip to cool and flush the preparation site. The tip is al-
lowed to passively seek its way down the canal, and this will happen readily if gutta
percha is in the canal. Any high-pitched squeal from the tip indicates either binding in
a small, uninstrumented canal, or that the tip is traversing off-angle. Visual inspection
with a micromirror is prudent at this point to ensure that the preparation is remaining
centered in the canal. A groove in the buccal cortical plate, placed with the side of the
USREP tip, and parallel to the long axis of the root, will also aid in the correct angu-
lation of the preparation, especially at higher magnifications (Movie 15; for movie
description, see Box 7). The preparation is complete when the full depth of the tip
is reached, usually 3 mm. In a root with multiple canals and an isthmus joining
them (ie, the MB root of the maxillary first molar), the 2 canals (MB1 and MB2) are
prepared separately to establish the correct angulation of the preparation, then the
isthmus connecting them is prepped at the same angle (Movie 16; for movie descrip-
tion, see Box 8). This action can be performed either directly or after tracing a small
groove in the isthmus with the USREP tip dry. This latter procedure creates a trough
that will be easier to replicate once the tip is activated with coolant streaming into the
site, but caution should be exercised not to overheat the tip or the root end by pro-
longed dry cutting. These coated tips are most efficient when they are new; for
that reason, it is the author’s opinion that they should be considered a single-use
item.
The identification and preparation of the isthmus is crucial to the sealing, and subse-
quent successful healing, of the root end. Although some have designated 5 or 6 types
of isthmuses, they are actually permutations, based on the level of resection in a partic-
ular root, of 2 basic types: partial and complete. First identified as a prominent surgical
Box 8
USREP technique
Movie 16 shows the preparation, using a new USREP tip, of the MB root of tooth #3.
The MB1 and MB2 canals are prepared first, then the isthmus is prepared maintain-
ing the identical angle between the 2 main canals. The preparation is viewed at
completion in the micromirror.
394 Niemczyk
Fig. 17. In the MB root of a maxillary first molar with 2 canals, the table demonstrates an
isthmus at the ideal resection length (3–4 mm) 100% of the time. (Data from Weller RN,
Niemczyk SP, Kim S. Incidence and position of the canal isthmus. Part 1. Mesiobuccal root
of the maxillary first molar. J Endod 1995;21:380–3.)
consideration in the MB root of a maxillary first molar (Fig. 17),43 it has evolved to
include any root that has the potential to contain 2 or more canals,44,45 and should
be considered present until judged otherwise.
ROOT END FILLING
Although every restorative material has been used, at one time or another, as a REF,
selection of today’s REF is predicated on whether it is contained within a root end
preparation (REP) or not. For situations whereby a REP can be created, the material
of choice is Mineral Trioxide Aggregate (MTA) (ProRoot MTA, Dentsply-Tulsa Dental,
Tulsa, OK, USA). This compound is easy to mix, not cumbersome to place, and
extremely biocompatible.46–53 MTA is manufactured in white and gray formulations
virtually identical in composition. The only caveat is that the material must be placed
Box 9
MAPS root end filling technique
Movie 17. Placement of MTA using a MAPS syringe. MTA is overfilled, the excess
compacted with the back of a Molt curette, and the surface of the MTA dried and
wiped to contour with a microbrush. Micromirror view shows 2 canals in this buccal
root of tooth #12.
Box 10
MTA air-dry technique
Movie 18. The soft excess MTA is dried with an indirect airstream from the Stropko
Irrigator tip. Once dried, the MTA is condensed with a ball burnisher and the excess
is removed with a microbrush. The crypt is flushed with saline, and examined with
a micromirror.
in a dry prep; excessive bleeding or moisture will wash the material away before
setting. The most effective method to dry the REP is with a microtip attached to
a Stropko Irrigator (J Bar B Co, Carefree, AZ, USA) syringe attachment. This device
replaces the disposable tip of the triplex syringe, and the luer-lock end permits any
size luer-lock needle tip or cannula to be readily attached. With the air pressure
reduced to 3 to 5 psi, this device can direct a concentrated stream of air or water to
the REP, either rinsing or drying it.
Placement of the MTA can be accomplished with a variety of instruments, from an
inexpensive wipe-on block (Lee Endo Bloc, San Francisco, CA, USA) to a more
sophisticated and costly syringe system (MAPS Roydent, Johnson City, TN, USA).
(Movie 17; for movie description, see Box 9). Once the MTA is placed, a gentle steam
of air from the Stropko is directed across the top of the REF to desiccate, and thereby
firm or ‘‘skin’’ the exposed surface of the material, After 20 to 30 seconds, the surface
of the REF is firm enough to carve and any excess can be gently wiped away with a mi-
crobrush (Movie 18; for movie description, see Box 10). The crypt may even be rinsed
gently, provided the irrigant stream is not directed at the REF.
In instances whereby the depth of a post precludes a normal REP, then a bonded
restoration such as Geristore (DenMat, Santa Maria, CA, USA) may be placed to
seal the root end. The technique of using bonded restorations on unprepared root
ends was introduced by Rud and colleagues,54–57 and has enjoyed a great measure
of success. However, as with the MTA, it is technique sensitive with respect to mois-
ture, and the osteotomy is often enlarged to create a ‘‘high and dry’’ exposure of the
Fig. 18. Preoperative radiograph of tooth #4 reveals a post placed nearly to the root apex,
and a failing retrograde in place (arrow). A bonded restoration (Geristore) replaces the
amalgam and is the REF of choice when a REP of conventional depth cannot be achieved.
The postoperative radiograph reveals the faint radio-opacity of the REF, and the conven-
tional surgery and REF on tooth #5.
396 Niemczyk
Box 11
Geristore root end filling technique
Movie 19. Placement of Geristore in the apex of tooth #4. Note the close proximity
of the post to the restoration.
root end. After saucering the root end, it is isolated, etched, and primed. The Geristore
is a dual-cure material, so an orange filter should be placed between the DOM light
source and the surgical site to prevent premature curing of the material. The REF is
either troweled or syringed onto the root end, the filter removed, and the material
cured with the appropriate light source, then contoured to the root outline (Fig. 18)
(Movie 19; for movie description, see Box 11).
SUTURING/CLOSURE
After the site has been cleansed of all debris, the underside of the flap(s) is gently
rinsed with sterile saline and coapted back to the original positions. A moistened
gauze is placed over the coapted tissue, and gentle pressure is applied for approxi-
mately 5 minutes. This procedure effectively expresses any occult blood under the
flap, and initiates a preliminary attachment of the tissues. The flap is secured with
either interrupted or sling sutures; the choice of type and size is dictated by the flap
design and retention requirements. Postoperative instructions should include diet
and hygiene restrictions, pain medication guidelines and, most importantly, chilling
of the overlying facial surface with ice (preferably in a zip-lock bag wrapped with
a moist washcloth). The application of cold controls the amount of swelling from the
rebound vasodilatation phase, and therefore reduces the postoperative potential for
discomfort from swelling. Chilling should continue for the first 24 hours postoperatively
(10–15 minutes on, 5 minutes off) except while sleeping. Suture removal, in uncompli-
cated cases, is normally 1 to 3 days after the operation.
SUMMARY
Today, endodontic surgeons are able to render a level of service with confidence and
great precision that 20 years ago would have seemed unattainable by any standard.
The development of a sophisticated armamentarium, groundbreaking techniques, and
the willingness to embrace them is the future of the specialty. The next 20 years should
eclipse anything previously dreamt of, if the last 20 are any barometer of things to come.
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Endodontic and
Implant Algorithms
W.R. Bowles, DDS, MS, PhDa,*, Melissa Drum, DDS, MS
b
,
P.D. Eleazer, DDS, MSc
KEYWORDS
Endodontic Implant Esthetic Restoration
Dental professionals often face challenges when formulating a treatment plan for patients
presenting with a compromised tooth, and have a duty to provide appropriate care for
these patients to maintain dental health and esthetics. A common dilemma involves
the decision between tooth retention using endodontic treatment with crown restoration,
and extraction and an implant-borne restoration. Endodontic and implant restorations
are performed daily by dentists and specialists. For endodontic treatment, estimates
for the year 2000 were 30 million endodontic procedures annually (American Diabetes
Association), while the number of patients receiving endosseous implants were esti-
mated annually at 300,000 to 400,000 in 1996 and 910,000 in 2000 (Millennium Research
Group). This may be a conservative estimate, according to the authors, because there
has been an average growth rate increase of more than 40% annually for the 10-year
period from 1997 to 2007 at the University of Minnesota (Fig. 1). In the year 2008, for
the first time, the authors had seen a drop in the number of patients receiving implants,
and this may have been because of the economic downturn or the generational changes
that were occurring (in that the authors are now seeing less completely edentulous
patients, while their partially edentulous patient population continues to increase).
OUTCOMES
In deciding on an appropriate treatment plan, the outcomes of treatment play a key

role. The definition of success for dental implant studies is often implant survival,
whereas root canal studies measure the healing of existing disease and the
This work was supported in part by a research grant from the American Association of
Endodontists Foundation.
a
Department of Restorative Sciences, University of Minnesota School of Dentistry, 515
Delaware Street SE, Minneapolis, MN 55455, USA
b
Department of Endodontics, The Ohio State University School of Dentistry, 305 West 12th
Avenue, PO Box 182357, Columbus, OH 43218, USA
c
Department of Endodontics and Pulp Biology, University of Alabama at Birmingham, 4256
Sharpsburg Drive, Birmingham, AL 35213, USA
E-mail address: bowle001@umn.edu
Dent Clin N Am 54 (2010) 401–413

402 Bowles et al
900
800
Implants
700
Patients
600
500
400
300
200
100
0
1996 1998 2000 2002 2004 2006 2008
Year
Fig. 1. Number of patients receiving implant treatment at the University of Minnesota and
the total number of implants placed from 1997 to 2008.
occurrence of new disease.1 The use of lenient success criteria in implant studies may
translate to higher success rates, whereas stringent criteria used in root canal studies
may lead to lower success rates.2–4 To establish accurate comparisons, it is critical
that the same outcome measures be used to assess endodontic and implant restora-
tions. Because of these differences in the meanings of success, it is probable that
survival rates will permit less biased, albeit less informative comparisons.1,5–7 Often
the stringent criteria in past endodontic studies have labeled some cases as failures
when they were healing.8
Other factors can also affect outcomes, such as the restorative impact with
endodontics. It has been shown that unrestored endodontically treated teeth were
significantly more likely (4 times) to undergo extraction.9 This restorative impact has
been demonstrated by many investigators.10–15 Examples of how restorations on
endodontically treated and severely damaged teeth fail are shown in Box 1. Sug-
gested restoration guidelines are shown in the flow chart shown in Fig. 2. Before using
the flow chart, preliminary steps need to be done, which are shown in Box 2.
When evaluating the quality of the root canal treatment, common misconceptions
surround what can or cannot be addressed with retreatments, endodontic surgery,
Box 1
How restorations on endodontically treated and severely damaged teeth fail
1. Stress breaks anatomic crown at the neck of the tooth

a. Not strong enough ferrule (length and thickness)
b. Core/tooth structure interface fails, shell of tooth structure suffers from stress, tooth
structure fracture, crown fracture
Solution: Unless there is adequate length and thickness of ferrule, extract the tooth. Unless
there is enough tooth structure available for mechanical retention or bonding, use cast dowel
and core.
2. Cast dowel and core comes out from the root cement because it is not strong enough to
withstand stress, especially under lateral or para-functional stress
Solution: Use resin cement for cast dowel and core and prefabricated post.
(Courtesy of Dr Wook-Jin Seong.)
Endodontic and Implant Algorithms 403
and other treatments. Unfortunately, many of these teeth are deemed hopeless when
that is not the case.
Fig. 2 can be used as a guideline to assist in treatment planning, although it may not
fit every scenario precisely.
COSTS
In formulating patient treatment plans, costs often play an increasingly important role.
Analysis of insurance data of 2005 concluded that restored single-tooth implants cost
75% to 90% more than similarly restored endodontic-treated teeth. Using mean
United States fees, the implant restoration costs twice as much as endodontic resto-
ration.22 Examination of treatment costs at university settings have shown that
implants cost more than twice as much (230%) as similar endodontically restored
teeth (Bowles WR, Drum MM, Eleazer PE, unpublished data, 2009).23 In addition, post-
treatment complications are more common with implant restorations,7,23–25 and these
problems may increase this cost difference.
NEW STUDIES NEEDED
Patients prefer that their dentists use the best techniques and materials available.
These advances in endodontics and implant treatment make some older studies
less relevant. Because advanced materials and techniques come into use, success
rates may be affected, which suggests the need for new outcome studies. For
example, the use of intracanal medicaments in endodontics has changed over
time.26,27 Endodontic access openings are seldom left open, which allowed additional
microbial contamination.28,29 A retrospective look at endodontic surgery using newer
techniques and instruments (no root-end bevel, ultrasonic instruments) found
a twofold increase in success rate compared with older methods (91.1% vs
44.2%).30 Endodontic treatment now includes the use of dental operating micro-
scopes for better visibility, and hand instrumentation combined with nickel-titanium
rotary instrumentation. Newer materials such as sustained-release antibacterial
agents and new forms of mineral trioxide aggregate allow for potentially better treat-
ment and call for additional outcome studies.
Advances in implants also continue to occur with improvements in such areas as
shape, implant surface modifications, interface changes, and immediate placement.
Previously, with implant placement 1.0 mm of bone loss during the first year of place-
ment with an additional 0.1 mm annual loss was expected,23,31,32 but this can vary
with newer implant designs and materials. Although longevity outcomes for implant
restorations are high, one recently reported concern is that patients with dental
implant restorations have significantly lower maximum bite forces and reduced chew-
ing efficiency compared with contralateral natural teeth, or even with endodontic
restorations.33
Using matched implant and endodontic restorations in patients, the authors found
similar longevity outcomes for endodontic and implant restorations (Fig. 3).
Several factors seem to be associated with higher failure rate of endodontic treat-
ment. Smokers had an endodontic failure rate significantly (4 times) higher than
nonsmokers (Fig 4A), whereas diabetic patients had almost a threefold increase in
their failure rate (Fig 4B). Smoking and diabetes have previously been found to be
a risk indicator for apical periodontitis.34–36 In endodontic restorations, restoration
with a post was also associated with a higher failure rate as seen in Fig 5. Earlier
studies had suggested that the presence of posts do not affect the outcome of
endodontic treatment.37,38
404 Bowles et al
Carious dentin, temporary Consider crown

restorations, and unsupported lengthening C/R ratio, How much of Ferrule1
enamel should be removed vertical space for available?
and only sound tooth core guidance, (Length and thickness2)
structure remaining. para-function, etc.
More than 1.5mm long and Less than 1mm long and
1mm thick Ferrule 1mm thick Ferrule
Tooth can be restored by either Extract the tooth and

1. build up only consider implant or FPD
2. prefabricated post & build up
3. cast dowel & core,
based on how much tooth structure is
available to retain core material.
Two or three walls of tooth One or two walls of tooth No or one wall of tooth
structure are present and structure are present. structure remains with
short core space is available. remaining possible high lateral stress.
Amalgam core build up Prefabricated post4 + Cast dowel & core3

or Composite core Amalgam or Composite cemented with
build up only core build up core resin cement
Is there strong tooth structure Resin cement6 can be

available for mechanical used for Cast D & C,
retention of core materials Prefabricated post, and
even after crown preparation? Crown on core build up
Yes No
Amalgam5 or Composite
Composite core build up
core build up
Box 2
Preliminary steps to be done before using flow chart
1. Complete evaluation of the whole mouth, in tandem with the particular tooth in question,
so that a clear and comprehensive treatment plan can be formulated
2. Data collection
a. Periodontal support
b. Quality of root canal treatment
c. Occlusal scheme
d. Para-function
e. Intended tooth function: single restoration or abutment of fixed partial denture,
removable partial denture, and overdenture
f. Vertical space available for the crown
(Courtesy of Dr Wook-Jin Seong.)
Endo/Implant:Survival proportions
1.0
Fraction survival
0.9
0.8
Implant
0.7
Endodontic
0.6
0.5
0 2 4 6 8 10
Time
Fig 3. Survival proportions of implant and endodontic restorations. Outcome is not
significantly different between groups (n 5 4477).
:
Fig. 2. Restorations on endodontically treated and severely damaged teeth. Footnotes

provide information for particular areas covered in this figure, and are described as follows.
1
Libman and Nicolls16 found that crown preparation designs tested with lateral cyclic stress
with ferrule of length 0.5 to 1.0 mm failed at a significantly lower number of cycles than
ferrule length of 1.5 to 2.0 mm . 2Pilo and colleagues17 found that all the fractures occurred
in the tooth structure and not in core materials. 3Creugers and colleagues18 conducted
meta-analysis and reported 81% survival rate for composite cores with screw prefabricated
post and 91% for cast dowel and cores for 6 years. 4Tjan and colleagues19 found amalgam
core retained by a post was significantly stronger than amalgam cores retained by slots or
channels. 5Kovarik and colleagues20 showed significant differences in the fatigue failure
tests, with glass ionomer core experiencing total failure of all crowns by taking 20,000
cycles, composite core experiencing 80% failure by 50,000 cycles, and amalgam core expe-
riencing 30% failure by 70,000 cycles. 6Howdle and colleagues21 found that adhesive resin
luting cement significantly decreases the microleakage around crown margins where core
restorations of amalgam or composite have been used. (Courtesy of Dr Wook-Jin Seong.)
406
A 10 B 10
8
Failure Rate (%)

8
Failure Rate (%)

6 6
4 4
2 2
0 0
Non-Smoker Smoker Non-Diabetic Pts Diabetic Pts
Fig. 4. (A) Failure rate for endodontic treatment in patients who smoke (P 5 .0013).
(B) Failure rate for endodontic treatment in patients with diabetes.
8
*
Fa i l u re Ra te ( %)
0
Restored w/o Post Restored w/Post
Fig. 5. Failure rate in endodontic restorations associated with posts (P 5 .0015).
Fig. 6. Although the implants in (A) appear osseointegrated, the esthetic results are less
than desirable (B, C). (Courtesy of Dr Deborah Johnson.)
Bone Loss (mm)

3
0
1 2 3 4 5 6 7 >8
Years after Implant Placememt
Fig. 7. Mean crestal bone loss around implants.
Outcomes for implant restorations can also be affected by several factors. Care
must be taken to preserve the esthetics with anterior implants, while obtaining
osseointegration of the implant (Fig. 6). In earlier-implant patients, crestal bone loss
occurred over the years; however, many newer implants may have decreased loss
in the crestal bone. The authors have graphically presented the bone loss around
implants over time (Fig. 7) for patients in their current study. Significant bone loss
can be observed in younger patients receiving implant treatment by the time they
reach old age.
In the authors’ current study, implant restorations were less successful with diabetic
patients, but did not seem to be affected by smoking, contrary to current literature
results.23,39,40 Implant restorations in diabetic patients had a 7.2% failure rate,
compared with a failure rate of 4.1% in nondiabetic patients (Fig. 8A). Current litera-
ture suggests a 9% implant loss rate with controlled diabetes.23,41–44 There was no
significant difference in failure rates with implant restorations in patients who smoked
compared with those who did not smoke (Fig. 8B).
For both types of treatment, gender or ethnicity has had no effect on outcome
success. Also, the location of the endodontic treatment or implant placement did
not significantly affect outcome.
To provide appropriate care, treatment must be preformed at a high-quality skill
level for complex cases. Initial radiographs before starting endodontic treatment,
A 10 B 10
8
Failure Rate (%)
8
Failure Rate (%)
6 6
4 4
2 2
0 0
Non-Diabetic Pts Diabetic Pts Non-Smoker Smoker
Fig. 8. (A) Failure rates of implant restorations in diabetic patients. (B) Failure rates of
implant restorations in patients who smoke.
408 Bowles et al
being only 2-dimensional, may not show the complexities associated with the pulp
canal system (Fig. 9).
NEW TECHNOLOGY
Newer instruments and technology may be beneficial to endodontic and implant treat-
ment modalities. Improvements in radiography have changed the algorithm of treat-
ment. Endodontic cases can now use cone beam computed tomography (CT)
scans for the evaluation of bone destruction caused by periapical lesions (Fig. 10).
Cone beam CT may also be used to improve diagnosis and treatment in implant
placement whereby esthetics may be compromised. In Fig. 11, a fracture in the tooth
led to loss of labial bone, which could not be detected clinically. By use of this advance
in radiography, the treating practitioner is better informed and able to provide proper
care for the patient while placing an immediate implant with bone graft.
Use of cone beam CT for better anatomic placement of implants and prevention
of problems such as nerve injury are also becoming more frequent. Altered sensa-
tion after mandibular implant placement can result from trauma to any of the
branches of the mandibular nerve.45 With mental nerve neuropathy cases, invasive
Fig. 9. Endodontic initial radiographs do not always show the complexities associated with
canal systems. In Fig 2A, the mandibular second premolar has 3 canals, which can be difficult
to obturate as shown in Fig 2B. In Fig 2C, a radiograph from a patient presenting with
swelling around the periradicular area of tooth #5 shows inadequate instrumentation
and obturation, to which the practitioner suggested implants for #4 and #5. Subsequent
endodontic retreatment by a different practitioner was completed with successful results,
and a recall radiograph is shown in Fig 2D. (Courtesy of Dr James Wolcott.)
Fig 10. Periradicular lesion size can be large in presenting patients. Cone beam CT 3-dimen-
sional reconstruction of periradicular lesion facial (A) and lingual (B). (C) A preoperative
radiograph. (D) A recall radiograph after conventional and surgical retreatment. (Courtesy
of Dr Joseph Petrino and Dr Mansur Ahmad.)
dental procedures (extractions, implants) were the etiologic factors in 63% of the
cases.46 The close proximity of the inferior alveolar nerve to tooth apices and
possible implants placed in these extraction sites of mandibular posterior teeth
are shown in Fig. 12.
Research is needed regarding immediate loading and compromised bone condi-
tions (trauma, infection, systemic disease).47 Also needed are improvements in bioac-
tivity of dental implants to allow recruitment of osteoblasts, periodontal biosealing,
and antimicrobial release.48 Implant stability measurement by resonance frequency
analysis may help evaluate osseointegration quickly and efficiently. 49,50
SUMMARY
Functional survival rates are high for implant and endodontic restorations; however,
areas for improvement exist for both treatment modalities. Related areas of implants
410 Bowles et al
Fig. 11. Loss of labial bone was detected from fractured root of central incisor. (Courtesy of
James E. Hinrichs, DDS, MS and Mansur Ahmad, DDS, PhD.)
include implant delivered pharmacology, faster integration, and decreased crestal

bone loss, whereas related areas of endodontics include better seal (coronal and
apical), improved disinfection of the pulp canal system (which suggests a role for anti-
microbials such as 3MP [macrogol mixed with propylene glycol] paste51 as intracanal
medicaments), and better anatomic diagnosis (use of clinical micro-CT for 3-dimen-
sional visualization of tooth with minimal radiation).
Endodontic treatment should be given priority in the treatment planning for peri-
odontally sound teeth with pulpal or periradicular pathology, whereas implants should
be given priority in the treatment planning for teeth that are to be extracted because of
nonrestorability or other reasons. The decision between retention and extraction of
a compromised tooth involves many factors that may influence the outcome, with
2.5
1.5
0.5
0
2nd Premolar 1st Molar MR 1st Molar DR 2nd Molar MR 2nd Molar DR
Fig. 12. Distance from mandibular tooth apices to inferior alveolar canal. Data were ob-
tained through cone beam CT scans of randomly selected patients. Tooth apices of the
mesial and distal roots of the second molar were significantly closer to the nerve (P<.001).
(Courtesy of Tyler Koivisto and Dr Walter Bowles.)
the evaluation of restorability being critical. Because outcomes are similar with both
treatments, decisions should be based on the patient’s informed decision concerning
restorability, costs associated with the procedures, esthetics, potential adverse
outcomes, and ethical factors.
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Contemporary Endodontics - DNCA

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Frederic Barnett, DMD

Frederic Barnett, DMD

Dent Clin N Am 54 (2010) xi

Dent Clin N Am 54 (2010) 191–214

ON THE RELATIVE SIZE OF THINGS

It is difficult, even for a scientist, to have an intuitive understanding of size. Specifically,

THE LIMITS OF HUMAN VISION

WHY ENHANCED VISION IS NECESSARY IN DENTISTRY

Because all clinicians must construct 3-dimensional structures in a patient’s mouth,

Magnifying loupes were developed to address the problem of proximity, decreased

THE PROBLEM OF LIGHT

EFFICIENT USE OF AN OM IN ENDODONTICS

Although the OM is now recognized as a powerful adjunct in endodontics, it has not

THE LAWS OF ERGONOMICS

An understanding of efficient workflow using an OM entails knowledge of the basics of

Class I motion: moving only the fingers (Fig. 9)

The introduction of the OM in a dental office requires significant forethought, planning,

OPERATORY DESIGN PRINCIPLES FOR USING OM

KEY ELEMENTS OF THE NEW DESIGN

THE OM AND CLINICAL PROCEDURES

1. Apotheker H. A microscope for use in dentistry. J Microsurg 1981;3(1):7–10.

Apical periodontitis (AP) is an infectious disease caused by bacteria (in association

Department of Conservative Dentistry and Endodontics, School of Dentistry, University of Cagliari,

Dent Clin N Am 54 (2010) 215–235

Fig. 1. Digital periapical radiographs (regular and color-coded) showing a lesion of

The information may be obtained by traditional radiology (intraoral periapical radio-

ADVANCED IMAGING TECHNIQUES

Cone Beam Volumetric Tomography

Ultrasound Real-time Echotomography

REQUIREMENTS FOR THE DETECTION AND MANAGEMET

Disclosure of the Anatomic Coordinates of the Lesions in 3 Spatial Dimensions

Orientation Toward a Differential Diagnosis of Lesions of Endodontic Origin

Evaluation in Follow-up of the Outcome of Treatment

Even if traditional radiology still represents the backbone of everyday endodontic

3. Surgical approach toward very extensive lesions

1. Need for predictable information concerning the presence of AP in the jaws

1. Torabinejad M, Eby WC, Naidorf IJ. Inflammatory and immunological aspects of

Achieving profound pulpal anesthesia is a corner stone in endodontic practice and

Dent Clin N Am 54 (2010) 237–247

of neutrophils and the release of inflammatory mediators (such as prostaglandins and

Intraligamentary (Periodontal Ligament) Injection

Mandibular Buccal Infiltration Injection with Articaine

A disadvantage of the intrapulpal injection is its short duration of action (approxi-

4. McLean C, Reader A, Beck M, et al. An evaluation of 4% prilocaine and 3%

44. Smith G, Walton R, Abbott B. Clinical evaluation of periodontal ligament anes-

62. Remmers T, Glickman G, Spears R, et al. The efficacy of IntraFlow intraosseous

Dent Clin N Am 54 (2010) 249–273

SETTING THE STAGE FOR CONTEMPORARY MOLAR ENDODONTIC ACCESS

(1) The failure of the endodontic monoblock1

Endodontic accesses are traditionally conservative to the occlusal/incisal tooth

A NEW MODEL FOR ENDODONTIC ACCESS

As endodontic access is deconstructed, it is crucial to understand the 5 catalyst

Fig. 1. Preoperative view of tooth #19 in a 20-year-old woman.

1. Implant success rates

Value to the Tooth Tissue Type

Undermined Enamel Versus Undermined Dentin

SACRIFICE VERSUS COMPROMISE

LOOK, GROOM, AND FOLLOW: SHAPING VERSUS MACHINING

These kinds of images, so frequently shown in dental school, textbooks, and

The endodontic-endorestorative-prosthodontic (EERP) continuum

Tertiary dentin (3 dentin)

Washing action (helps remove debris)