November 2018 Vol. 32 - endodonzia.it · Dr. CASTELLUCCI ARNALDO Private practice in Florence...

EDITORIAL

◆ EDITORIAL

ORIGINAL ARTICLES

◆ COMPARISON OF SHAPING ABILITY OF PROTAPER NEXT AND 2SHAPE NICKEL—TITANIUM FILES IN SIMULATED SEVERE CURVED CANALS

◆ CANAL TRANSPORTATION CAUSED BY ONE SINGLE-FILE AND TWO MULTIPLE-FILE ROTARY SYSTEMS: A COMPARATIVE STUDY USING CONE-BEAM COMPUTED TOMOGRAPHY

◆ SURVIVAL STUDY ON TEETH AFTER SUCCESSFUL ENDODONTIC SURGICAL RETREATMENT: INFLUENCE OF CROWN HEIGHT, ROOT LENGTH, CROWN-TO-ROOT RATIO AND TOOTH TYPE

CASE REPORTS

◆ LUDWIG’S ANGINA: A CASE REPORT WITH A 5-YEAR FOLLOW-UP

◆ HOME MANAGEMENT OF CROWN FRACTURES OF TWO CENTRAL INCISORS COMPLICATED BY EXPOSURE OF THE PULP

CLINICAL ARTICLE

◆ APICAL PREPARATION SIZE AFTER REPETITIVE PECKING TO THE WORKING LENGTH USING DIFFERENT ENDODONTIC FILE SYSTEMS

WINNER OF GIORGIO LAVAGNOLI AWARD - 35° NATIONAL CONGRESS, BOLOGNA 2017

◆ TOOTH AUTOTRANSPLANTATION. WHAT’S THE LIMIT OF OUR POSSIBILITIES IN CONSERVATIVE TREATMENTS?

ISSN 1121 – 4171

2 | November 2018 | Vol. 32 |

Available online at www.sciencedirect.com

ScienceDirect

L’ESSENZA DEGLI STRUMENTI NITI ORA HA UN NUOVO NOME

INTELLIGENTE

CONSERVATIVO

EFFICIENTE

veloce59%�+ rispetto a una

sequenza di strumenti

100% +fl essibile e precurvabile

One Curve è lo strumento unico progettato per tutte le fasi di sagomatura canalare che nella sua semplicità racchiude l’essenza dei trattamenti canalari di successo.

Un unico strumento iper-fl essibile e pre-curvabile che garantisce un perfetto controllo del trattamento e si adatta ad anatomie canalari semplici e complesse.

Il protocollo One Curve è sicuro, veloce e semplifi cato: l’ accesso facilitato al canale e l’ adattamento a qualunque anatomia rendono più sicuro il trattamento, consentendo di dedicare maggior tempo all’ irrigazione del canale. 2,4 X

più resistente alla frattura (stress ciclico)

DISTRIBUTORE ESCLUSIVO PER L’ITALIA DENTALICA S.p.A. – Via Rimini, 22 – 20142 Milano T 02.895981 – F 02.89504249 – [email protected] – www.dentalica.com

■ Semplicità

■ Sicurezza

■ Efficacia

Trattamento termicoesclusivo MICRO-MEGA®

Maggiore flessibilità

Maggioreresistenza alla

frattura

Sagomatura con 2Shape : TS1 e TS2. Dr. Jean-Philippe Mallet, Francia

Caso clinico

Novità

Organo Uf� ciale della SIE – Società Italiana di Endodonzia

EDITOR IN CHIEF

Prof. RENGO SANDROProfessor and Chair of Endodontics, Federico II University of NaplesItaly, Former President of SIE

ASSOCIATE EDITORS

Prof. DOTT. PLOTINO GIANLUCAPrivate Practice, Grande Plotino Torsello - Studio di Odontoiatria, Rome - Italy

Prof. PRATI CARLOFull Professor of Endodontics and Operative Dentistry, Dean Master in Clinical EndodontologyHead Endodontic Clinical Section Dental School - University of Bologna, Bologna, Italy

ASSISTANT EDITORS

Prof. BERUTTI ELIOProfessor and Chair of EndodonticsUniversity of TurinDental SchoolFormer President of SIE

Prof. CERUTTI ANTONIOProfessor and Chair of RestorativeDentistryUniversity of BresciaDental SchoolActive member of SIE

Prof. COTTI ELISABETTAProfessor and Chair of EndodonticsUniversity of CagliariDental SchoolActive member of SIE

Prof. DI LENARDA ROBERTOProfessor and Chair of EndodonticsDean of Dental SchoolUniversity of TriesteDental School

Prof. GAGLIANI MASSIMOProfessor and Chair of EndodonticsUniversity of MilanDental School

Prof. PIATTELLI ADRIANOProfessor and Chair of Oral PathologyUniversity of ChietiDental School

EDITORIAL COMMITTEE

Prof. AMATO MASSIMOAssociate ProfessorUniversity of SalernoDepartment of Medicine and SurgeryActive member of SIE

Dr. BADINO MARIOPrivate practice in Milan SIE Of� cer

Dr. CARDINALI FILIPPOPrivate practice in AnconaActive member of SIE

Dr. CASTRO DAVIDE FABIOPrivate practice in Varese SIE Of� cer

Dr. CORAINI CRISTIANPrivate practice in Milan Active member of SIE

Prof. FORTUNATO LEONZIOAssociate Professor of Odontostomato-logical Illnesses, University of Magna Graecia, CZ Italy Active Member of SIE

Dr. FABIANI CRISTIANOPrivate practice in Rome Active member of SIE

Dr. FORNARA ROBERTOPrivate practice in MagentaCerti� ed Member of ESESIE Of� cer

Prof. MANGANI FRANCESCOProfessor and Chair of Restorative DentistryUniversity of Rome Tor Vergata Dental SchoolActive member of SIE

Dr. PISACANE CLAUDIOPrivate practice in Rome Active member of SIE

Prof. RE DINOProfessor and Chair of Prosthodontics University of Milan Dental SchoolActive member of SIE

Dr. TASCHIERI SILVIOPrivate practice in MilanActive member of SIE

Dr. TOSCO EUGENIOPrivate practice in FermoActive member of SIE

EDITORIAL BOARD

Dr. BARBONI MARIA GIOVANNAPrivate practice in Bologna Active member of SIE

Dr. BATE ANNA LOUISEPrivate practice in Cuneo Active member of SIE

Dr. BERTANI PIOPrivate practice in Parma Elected President of SIE

Prof. CANTATORE GIUSEPPEProfessor of Endodontics University of Verona Dental School Former President of SIE

Dr. CASTELLUCCI ARNALDOPrivate practice in FlorenceFormer President of SIE Former President of ESE

Prof. CAVALLERI GIACOMOProfessor and Chair of Endodontics University of Verona Dental School Former President of SIE

Dr. COLLA MARCOPrivate practice in Bolzano Active member of SIE

Prof. GALLOTTINI LIVIOProfessor and Chair of Endodontics II University of Rome La Sapienza Dental SchoolActive member of SIE

Prof. GEROSA ROBERTOProfessor and Chair of Endodontics University of Verona Dental School Active member of SIE

Dr. GIARDINO LUCIANOPrivate practice in Crotone Member of SIE

Dr. GORNI FABIOPrivate practice in MilanFormer President of SIE

Dr. GRECO KATIA Lecturer in Endodontology University of Catanzaro Scienti� c Board Coordinator SIE

Prof. KAITSAS VASSILIOSProfessor of Endodontics University of Thesalonikki (Greece) Active member of SIE

Dr. LENDINI MARIOPrivate practice in Turin Scienti� c Secretary of SIE

Prof. MALAGNINO VITO ANTONIOProfessor and Chair of Endodontics University of Chieti Dental School Former President of SIE

Dr. MALENTACCA AUGUSTOPrivate practice in RomeFormer President of SIE

Dr. MANFRINI FRANCESCAPrivate practice in RivaActive member of SIE

Dr. MARCOLI PIERO ALESSANDROPrivate pratice in Brescia

Dr. MARTIGNONI MARCOPrivate practice in Rome President of SIE

Prof. PECORA GABRIELEFormer Professor of Microscopic Endodontics Post-graduate courses University of Pennsylvania (USA)Active member of SIE

Dr. PONGIONE GIANCARLOPrivate practice in Naples Active member of SIE

Prof. RICCITIELLO FRANCESCOProfessor of Restorative Dentistry University of Naples Dental SchoolVice-President of SIE

Dr. SBERNA MARIA TERESAPrivate practice in Milan SIE Of� cer

Dr. SCAGNOLI LUIGIPrivate practice in Rome Active member of SIE

Prof. TESTORI TIZIANOPrivate practice in Como Former Editor of Giornale Italiano di Endodonzia

INTERNATIONAL EDITORIAL BOARD

ANG LESLIEClinical assistant professor of Endodontics Division of Graduate Dental Studies National University of Singapore

BOVEDA CARLOSProfessor Post-graduate Courses University of Caracas (Venezuela)

CANCELLIER PETERClinical instructor at the University of Southern California (USA) School of Dentistry GraduateEndodontic Program President of the California State Association of Endodontists

CHO YONGBUMInternational lecturer and researcher Private practice in Seoul (Korea)

DEBELIAN GILBERTOAdjunct associate professor Department of EndodonticsUniversity of North Carolina, Chapel HillUniversity of Pennsylvania, Philadelphia (USA)

FIGUEIREDO JOSE ANTONIOClinical lecturer in Endodontology Eastman Dental Institute, London (UK)

GLASSMAN GARYInternational lecturer and researcher Private Practice in Ontario (Canada) Editor in Chief of Dental Health

GLICKMAN N. GERARDProfessor and Chairman of Endodontics School of Dentistry University of Washington (USA)

HIMEL T. VANProfessor of Endodontics School of Dentistry University of Tennessee (USA)

HUTTER W. JEFFREYProfessor and Chairman of Endodontics Goldman School of Dental Medicine Boston University (USA)

JEERAPHAT JANTARATProfessor of Endodontics Mehidol University of Bangkok (Thailand) Dental School

KARTAL NEVINProfessor of Endodontics Marmara University Istanbul (Turkey) School of Dentistry

KHAYAT BERTRANDInternational lecturer and researcher Private practice in Paris (France)

MOUNCE RICHARDInternational lecturer and researcher Private practice in Portland (Oregon)

NERVO GARYInternational lecturer and researcher Private practice in Melbourne (Australia)

PUENTE CARLOS GARCIAProfessor of Endodontics University of Buenos Aires (Argentina) School of Dentistry

ROIG MIGUELProfessor and Head Department of Restorative Dentistry and Endodontics Universitat Internacional de Catalunya, Barcelona, (Spain)

RUDDLE J. CLIFFORDAssistant Professor Dept. of Graduate Endodontics Loma Linda University (USA)

TROPE MARTINProfessor and Chairman of Endodontics School of DentistryUniversity of North Carolina (USA)

VERA JORGEProfessor of Endodontics University of Tlaxcala (Mexico)

EDITORIAL BOARD

Dr. PLOTINO GIANLUCA

Organo Uffi ciale della SIE – Società Italiana di Endodonzia

Editorial/Editoriale

51 EditorialS. Rengo

Original Articles/Articoli Originali

52 Comparison of shaping ability of ProTaper Next and 2Shape nickel—titanium les in simulated severe curved canalsAnalisi sperimentale della preparazione endodontica in canali artri ciali con curvature complesse: ProTaper Next Vs. 2ShapeS. Staffoli, T. Özyürek, A. Hadad, A. Lvovsky, M. Solomonov, H. Azizi, J.B. Itzhak, M. Bossù, N.M. Grande, G. Plotino and A. Polimeni

57 Canal transportation caused by one single- le and two multiple- le rotary systems: a comparative study using cone-beam computed tomographyTrasporto canalare causato da un sistema rotante mono-strumento e due sequenze di strumenti rotanti: studio comparativo con tomogra a computerizzata a fascio conicoE.A. Saberi, N.F. Mollashahi and F. Farahi

63 Surv ival study on teeth after successful endodontic surgical retreatment: influence of crown height, root length, crown-to-root ratio and tooth typeStudio di sopravvivenza su denti guariti a seguito di endodonzia chirurgica: in uenza dell’altezza coronale, della lunghezza radicolare, del rapporto corona-radice e del tipo di denteD. Angerame, M. De Biasi, M. Lenhardt, L. Bevilacqua and V. Franco

Case Reports/Casi Clinici

70 Ludwig’s angina: A case report with a 5-year follow-upAngina di Ludwig: un caso clinico con 5 anni di follow-upD. Re Cecconi and R. Fornara

TABLE OF CONTENTSSIE BOARD 2018

Editor in ChiefSandro Rengo

Associate EditorsGianluca PlotinoCarlo Prati

Assistant EditorsElio BeruttiAntonio CeruttiElisabetta CottiRoberto Di LenardaMassimo GaglianiAdriano PiattelliEditorial CommitteeMassimo AmatoMario BadinoFilippo CardinaliDavide Fabio CastroCristian CorainiCristiano FabianiRoberto FornaraLeonzio FortunatoFrancesco ManganiClaudio PisacaneDino ReSilvio TaschieriEugenio Tosco

SIE - BOARD OF DIRECTORS

Past PresidentPio BertaniPresidentFrancesco RiccitielloPresident ElectVittorio FrancoVice PresidentMaria Teresa SbernaSecretaryRoberto FornaraTreasurerFilippo CardinaliCultural CoordinatorMauro RigoloneComunication’s CoordinatorItalo Di GiuseppeAdvisersKatia GrecoAlberto RieppiSIE - Società Italiana di EndodonziaLegal Head Of� ce:Via San Pietro snc 98050 Lipari - Isola di Panarea (ME)Headquarters: Via Pietro Custodi, 3 20136 MilanoContacts:Tel. 02.8376799 Fax. 02.89424876Email: [email protected]@endodonzia.itPEC: [email protected]: www.endodonzia.itwww.journals.elsevier.com/giornale-italiano-di-endodonzia/

2 | November 2018 | Vol. 32 |

>

76 Home management of crown fractures of two central incisors complicated by exposure of the pulpGestione domiciliare delle fratture della corona di due incisivi centrali complicata dall’esposizione della polpaL. Boschini

Clinical Articles/Articoli Clinici

80 Apical preparation size after repetitive pecking to the working length using different endodontic le systemsDimensione di preparazione apicale dopo ripetuti movimenti di preparazione alla lunghezza di lavoro utilizzando diversi sistemi endodonticiT.I. Nathani, A.I. Nathani, A.M. Banode, M.I. Khakiani, J.G.O. Fernandez, F.D. Terol and F.A. Sans

WINNER OF GIORGIO LAVAGNOLI AWARD - 35° NATIONAL CONGRESS, BOLOGNA 2017

86 Tooth autotransplantation. What’s the limit of our possibilities in conservative treatments?Autotrapianto autologo. Qual’è il limite delle nostre possibilità conservative?S. Milani and P. Generali

TABLE OF CONTENTSEDITORIAL OFFICE

Gaia GarlaschèE-mail: [email protected]: www.journals.elsevier.com/ giornale-italiano-di-endodonzia/

Managing DirectorPio Bertani

Editorial DirectorRoberto Fornara

PUBLISHING

Publishing Support ManagerPonni Brinda [email protected]

Giornale Italiano di Endo-donzia was founded in 1987 and is the offi cial journal of the Italian Society of Endodontics (SIE). It is a peer-reviewed journal publishing original articles on clinical research and/or clinical methodology, case reports related to Endodontics. The Journal evaluates also contributes in restorative dentistr y, dental t r auma to logy, expe r imen ta l pathophysiology, pharmacology and microbiology dealing with Endodontics. Giornale Italiano di Endodonzia is indexed in Scopus and Embase and pub l i shed online only on ScienceDirect. SIE members can access the journal through the website: www.journals.elsevier.com/giornale-italiano-di-endodonzia/

Copyright © 2018 Società Italiana di Endodonzia. Production and hosting by Elsevier B.V. All rights reserved.

REGISTRATION Court of Milan n ° 89, 3 March 2009

Giornale Italiano di Endodonzia - full text available on ScienceDirect©

Volume 32 | n. 2 | November 2018

Amsterdam • Boston • Jena • London • New York • Oxford • Paris • Philadelphia • San Diego • St. Louis

per il glide path meccanico con RECIPROC® -

se e quando necessario

Scopri nuove opportunità in endo con R-PILOT™

Gestione del glide path in modalità reciprocante più sicura e veloce*

Maggior rispetto dell’anatomia canalare* per un trattamento endodontico predicibile

* Confrontato con altri strumenti in acciaio della linea VDW dentsplysirona.com

[email protected]

dentsplysirona.italia

Il potere sonico di EDDY® e il movimento di oscillazione tridimensionale della punta si sono dimostrati efficaci nell’attivazione degli irriganti quanto i sistemi ad ultrasuoni e migliori rispetto all’irrigazione manuale per la rimozione di detriti e dello smear layer.* La punta EDDY® in poliammide è più sicura e flessibile rispetto alle punte in metallo, senza rischi di danneggiamento della dentina.

Prova i benefici clinicamente testati di EDDY® nella tua pratica quotidiana.

* Source: Neuhaus, Klaus W, Liebi, Melanie, et. al. Antibacterial Efficacy of a New Sonic Irrigation Device for Root Canal Disinfection. Journal of Endodontics 2016, 42 (12): 1799-1803.

Tre benefici in un’unica soluzione

Sistema innovativo per l’Irrigazione

Sonica

Sicuro Clinicamente testato

Efficace

www.dentsplysirona.com

EDITORIAL/EDITORIALE

Uno dei megatrend della nostra disciplina e la valutazione deifattori critici coinvolti nel successo del trattamento canalaree lo sviluppo di nuove tecniche per ridurre il tasso di fall-imento. Nonostante l’alto tasso di successo del trattamentoendodontico, i fallimenti si verificano in un gran numero dicasi e il piu delle volte possono essere attribuiti alla persis-tenza di batteri nei canali e all’apice, a una detersioneinadeguata o a scarsa qualita dell’otturazione. L’opzionedi trattamento di prima linea dopo il fallimento del tratta-mento iniziale e un ritrattamento non chirurgico. L’Endodon-zia chirurgica e l’autotrapianto devono essere a loro voltaconsiderati prima dell’estrazione e della sostituzione con unimpianto singolo.

In questo numero del GIE un articolo e focalizzato suifattori coinvolti nella sopravvivenza dei denti dopo un trat-tamento endodontico chirurgico. Il successo dell’Endodonziachirurgica e migliorato nel corso degli anni e questo inter-essante studio fornira nuove informazioni utili per la praticaclinica quotidiana.

L’attuale evidenza dalla letteratura sull’autotrapianto didenti mostra percentuali di successo e sopravvivenza favor-evoli e bassi tassi di complicanze, indicando che si tratta diun’opzione di trattamento affidabile. L’obiettivo finaledell’Endodonzia e quello di mantenere i denti naturali delpaziente. A questo proposito, l’auto-trapianto di denti eun’alternativa terapeutica che endodontisti, parodontologied ortodontisti non dovrebbero dimenticare.

One of the megatrend of our discipline is the evaluation ofcritical factors involved in the success of root canal treat-ment and the development of new techniques to reduce thefailure rate. Despite the high success rate of Endodontictreatment, failures do occur in a large number of casesand most of the times could be attributed to persistenceof bacteria in the canals and apex, inappropriate mechanicaldebridement and poor obturation quality. The first-line treat-ment option after failure of initial root canal treatment isnonsurgical retreatment. Surgical Endodontics and auto-transplantation should be considered before extractionand replacement by a single-tooth implant.

In this issue of GIE an original article is focused on thefactors involved in the survival of teeth after a successfulEndodontic surgical retreatment. Surgical Endodontic successhas improved over the years and this interesting study willprovide new information useful for daily clinical practice.

Current evidence from the literature on autotransplanta-tion of teeth shows favourable survival and success rates andlow complication rates, indicating it is a reliable treatmentoption. The ultimate goal of Endodontic treatment is toretain the natural dentition. In this regards tooth auto-transplantation is an alternative treatment option that Endo-dontists, periodologists and orthodontists should not forget.

Sandro RengoEditor-in-Chief

Giornale Italiano di EndodonziaE-mail address: [email protected]

Giornale Italiano di Endodonzia (2018) 32, 51

Peer review under responsibility of Societa Italiana di Endodonzia.


ScienceDirect

journa l homepage: www.e l sev ier.com/locate/g ie

https://doi.org/10.1016/j.gien.2018.10.0011121-4171/� 2018 Societa Italiana di Endodonzia. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-NDlicense (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Il sistema Mtwo: immutato negli anni ma sempre in evoluzione nell’utilizzo clinicoMASTER CLINICIANS SESSIONVenerdì 9 novembre, ore 15.10

Milano, 8 - 10 Novembre 2018San Raffaele Congress Center

Prof. Vinio Malagnino

III SIE INTERNATIONAL CONGRESS 2018

ENDODONTICS:CLINICAL SOLUTIONS

VI PRESENTIAMO F22ALIGNER

I risultati si vedono.

F22 Aligner no.Ideato dal Prof. Giuseppe Siciliani e dal Team dell’Università degli Studi di Ferrara

Semplice, geniale e assolutamente sicuro.Perfetto per qualsiasi canale radicolare.

Il nuovo TriAuto ZX2 semplifica il trattamento canalare con la massima sicurezza – perfetto per tutti i tuoi pazienti.Il manipolo con localizzatore apicale integrato è veramente sorprendente per la sua leggerezza: Senza cavo ed ergonomico si adatta perfettamente alla mano e garantisce massima libertà di movimento Il trattamento è sicuro e facile grazie alle nuove funzioni di sicurezza, quali l’ Optimum Glide Path (OGP) e l‘Optimum Torque Reverse (OTR). L’OPG semplifica la realizzazione del glide path. L’OTR protegge dalla rottura del file e dalle microfratture invertendo automaticamente la direzione di rotazione

quando viene superato il livello di torque. In questo modo, TriAuto ZX2 preserva la sostanza del dente naturale e rende il trattamento

ancora più efficiente. Per ulteriori informazioni, vedere www.jmoritaitalia.com.

Thinking ahead. Focused on life.

TriAuto X2 - UNICO

- COMPATTO- INNOVATIVO

210x280_Markteinfuehrung_TriAuto_ZX_II_OTR_RZ_AD_IT4.indd 1 06.04.2018 11:18:46

ORIGINAL ARTICLE/ARTICOLO ORIGINALE

Comparison of shaping ability of ProTaper Nextand 2Shape nickel—titanium files in simulatedsevere curved canals

Analisi sperimentale della preparazione endodontica in canali artrificialicon curvature complesse: ProTaper Next Vs. 2Shape

Simone Staffoli a,*, Taha Ozyurek b, Avi Hadad c, Alex Lvovsky c,Michael Solomonov c, Hadas Azizi c, Joe Ben Itzhak c, Maurizo Bossu a,Nicola M. Grande d, Gianluca Plotino e, Antonella Polimeni a

aDepartment of Oral & Maxillofacial Science, Sapienza University of Rome, ItalybDepartment of Endodontics, Faculty of Dentistry, Istanbul Medeniyet University, Samsun, TurkeycDepartment of Endodontics, Israel Defense Forces Medical Corps, Tel Hashomer, IsraeldDepartment of Endodontics, Catholic University of Sacred Heart, Rome, Italye Private Practice, Grande Plotino & Torsello — Studio di Odontoiatria, Rome, Italy

Received 10 May 2018; accepted 10 May 2018Available online 13 July 2018

Giornale Italiano di Endodonzia (2018) 32, 52—56

KEYWORDSCentering ability;Centering ratio;Heat treatment;2Shape;ProTaper Next.

Abstract

Aim: To evaluate the centering ability of ProTaper Next (PTN) and 2Shape (TS) nickel—titanium(NiTi) instruments in terms of maintaining the original root canal configuration in a simulatedtooth with severe curvature.Methodology: Twenty standardized simulated curved root canals were prepared to an apical sizeof 0.25 mm using PTN and TS (n = 10 canal/group) nickel-titanium files. A gig was constructed toenable reproducible image acquisition using a photographic camera. Pre- and post-instrumentedimages were recorded and superimposed using a computer software. The ability of the instru-ments to remain centered in the canal was determined by calculating a centering ratio at threeindependent points of the simulated canal: coronal, middle and apical third of the curvature,


* Corresponding author.E-mail: [email protected] (S. Staffoli).


ScienceDirect

journa l homepage: www.el sev ier.com/locate/g ie


Introduction

The purpose of instrumentation is mechanical debridement,the creation of space for the delivery of irrigation andoptimized canal geometries for adequate obturation,1 whilemaintaining the original canal anatomy.2 In the curved canal,large stainless-steel files (SS) are less flexible and tend tostraighten and transport the canal with creating of apical zipsand ledges.3 In danger zone areas, such straightening maylead to strip perforations.4

Nickel-titanium (NiTi) instruments have been reported tohave a decreased tendency for canal transportation andbetter centering ability than)SS)5 due to their greater elas-ticity.6 Manufacturers strive to improve NiTi instruments bychanging their design and enhancing the structural alloy in anattempt to improve their mechanical performance.4,7,8

ProTaper Next (PTN; Dentsply Sirona, Ballaigues, Switzer-land) is made of M-wire heat-treated alloy with an asym-metric square cross-section. The PTN system is consist of X1(17/.04), X2 (25/.06), X3 (30/.07), X4 (40/.06), and X5 (50/.06) files. 2Shape (TS; MicroMega, Besancon, France) is madeof T-wire heat-treated alloy with an asymmetric triangularcross-section. The 2S system is composed of TS1 (25/.04), TS2(25/.06), F35 (36/.06), and F40 (40/.04) files.

To our knowledge, no research investigated the centeringability of TS instruments. Thus the purpose of the presentstudy was to evaluate the centering ability of PTN and TSinstruments in terms of maintaining the original root canalconfiguration in a simulated tooth with severe curvature. Thenull hypothesis was that there would be no significant dif-ference between the PTN and TS in terms of shaping abilities.

Materials and methods

In order to standardize the root canal curvature, 20 artificialmolar tooth models (MM tooth; Micro-Mega) that havingseverely MB and ML canals (>608)9 were selected. The work-ing length (WL) of the ML and MB canals were 23.5 mm and23 mm respectively. An apical foramen size of 0.1 mm wasconfirmed by a #10 K-file (Dentsply Sirona). Each simulatedcanal was colored with blue ink injected using a 27-G closed-end tip and side-vented needle (Ultradent Products, Inc.,South Jordan, UT). The canals were randomly assigned to twogroups (n = 10) according to the system that was used forcanal instrumentation.

In Group 1, MB and ML canals were prepared using One G(Micro-Mega), 2Shape TS1 (25/.04) and TS2 (25/.06) files at300 rpm and 1.2 Ncm torque values using VDW Gold (VDW,Munich, Germany) endodontic motor.

In Group 2, MB and ML canals were prepared using PathFile1 and 2 (Dentsply Sirona), ProTaper X1 (17/.04) and X2 (25/.06) files at 300 rpm and 2 Ncm torque values using VDW Goldendodontic motor.

A single operator with experience in rotary systemsperformed all instrumentation procedures according tothe manufacturer’s instructions. Each new instrumentwas used to prepare only two canals. Between each pre-paration step, apical patency was confirmed by using a #10K-file until the tip of the file could be seen protrudingthrough the apical foramen. The canal was irrigated with1.0 mL sterile water using a 27-gauge needle after each fileand as a final rinse. Each tooth was embedded in a puttybase without obscuring the canals. A gig was constructed to

PAROLE CHIAVENichelTitanio;Capacita di centratura;Trattamento termico;2Shape;Protaper Next.

using a computer software. Statistical analysis was performed using one-way analysis of variance(ANOVA) followed by independent sample t-test at 5% significance level.Results: No significant difference was found between the two systems (p > 0.05). At the apicalthird, the mean centering ratio was significantly higher than the centering ratio of the coronaland the middle thirds in both TS and PTN (p < 0.05).Conclusions: There were no significant differences in the centering ability of the ProTaper Nextand 2Shape systems in simulated severe curved canals. Both systems exhibited some degree oftransportation, especially in the apical third.� 2018 Societa Italiana di Endodonzia. Production and hosting by Elsevier B.V. This is an openaccess article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Riassunto

OBIETTIVI: L’obiettivo e confrontare la centratura di preparazione tra Protaper Next e 2Shape incanali artificiali con curvature complesse.MATERIALI E METODI: 20 molari inferiori artificiali con canali colorati sono stati divisi random perI due tipi di strumenti testate.Le immagini prima e dopo la strumentazione sono state rilevate mediante un software (AdobePhotoshop 7.0.1; Adobe Systems, Inc., Mountain View, California, USA). La capacita di centraturadegli strumenti e stata calcolata misurando i canali in tre differenti porzioni: Coronale, Media edApicale.ANOVA test e stato successivamente eseguito per determinare I valori ottenuti.RISULTATI: Non sono risultate differenze significativamente tra la capacita di centratura di prepa-razione tra I due strumenti testati.CONCLUSIONI: No differenze significative tra I due strumenti testati, entrambi hanno evidenziato uncerto trasporto della centratura della pereparazione sopratutto nel terzo apicale.� 2018 Societa Italiana di Endodonzia. Production and hosting by Elsevier B.V. Cet article est publieen Open Access sous licence CC BY-NC-ND (http://creativecommons.org/licenses/by-nc-nd/4.0/)

Comparison of shaping ability of ProTaper Next and 2Shape nickel—titanium files 53

enable reproducible image acquisition using a photo-graphic camera (EOS 70D; Canon, Tokyo, Japan). Threereference points were marked around the tooth position toallow for exact superimposition of the images. Pre- andpost-instrumented images were recorded. Then, theimages were superimposed using a computer software(Adobe Photoshop 7.0.1; Adobe Systems, Inc., MountainView, CA, USA). The ability of the instruments to remaincentered in the canal was determined by calculating acentering ratio at three independent points (coronal, mid-dle, and apical) of the simulated canal.

The calculation of the centering ratio was used the fol-lowing formula: (X1—X2)/Y (X1 — the maximum extent ofcanal movement in one direction, X2- the movement in theopposite direction, Y — the wideness of the final canalpreparation). The calculation was made using a computersoftware (ImageJ; NIH, Bethesda, MD).

Statistical analysis was performed using SPSS 22.0 (IBM-SPSS Inc., Chicago, IL, USA) using one-way analysis of var-iance (ANOVA) followed by independent sample t-test at 5%significance level.

Results

The mean centering ratio for TS and PTN were 0.42 and 0.43,respectively. No significant difference was found betweenthe different systems (p > 0.05) as shown in Fig. 1. At theapical third, themean centering ratio was significantly higherthan the centering ratio of the coronal and the middle thirdsin both TS and PTN (p < 0.05) (Fig. 2). There was no differ-ence between the coronal third and the middle third with thedifferent systems.

Discussion

In the past, files and reamers were manufactured from eithercarbon-steel or SS. The relatively high modulus of elasticityof these materials made it difficult for the larger file sizes tonegotiate curved canals.10 NiTi rotary files are manufacturedfrom a NiTi alloy that is significantly more elastic than SS11

and was developed by William Buehler in 1962.11 In 1988,Walia et al. introduced NiTi for the manufacturing of endo-dontic instruments.12

Since the introduction of this alloy, a number of differentfiles have been developed from NiTi. Many studies demon-strate that NiTi instruments remain better centered in thecanal compared to SS. Esposito and Cunningham13 comparedNiTi hand and engine-driven files to SS hand files in curvedcanals. They found that for instruments larger than ISO size30, both hand and rotary NiTi files were significantly moreeffective than SS in maintaining the original path of thecanal. Glossen et al. reported similar findings with instru-ments larger than size 45.14

However, transportation of the canal can still occur withNiTi instruments in the apical, middle, and coronal thirds.Over the years, many NiTi instruments have been developedto improve root canal preparation. Hand and rotary instru-ments are available in various designs that differ in tip andtaper design, rake angles, helical angles, pitch and differenttypes of alloys.15

Numerous studies compared the ability of several newrotary NiTi systems to maintain original canal shape andtherefore remain better centered.7,16—18 The present studyfocused on two relatively new rotary NiTi systems withasymmetrical cross-section and with a different type of heattreated NiTi alloy. PTN is a M-wire alloy and TS is a T-wire

Figure 1 Total mean centering ratio of 2Shape and ProTaper Next.

54 S. Staffoli et al.

alloy. Both M-wire and T-wire are nitinol after a proprietarythermomechanical processing procedure that increased theflexibility and the fatigue resistance.

In the present study, both PTN and TS exhibit some degreeof deflection of the original canal axis. There were no sig-nificant differences between the tested file systems. Bothsystems showed significantly more deflection at the apicalthird of the simulated canal.

It would be of clinical interest to investigate the perfor-mances and centering abilities of these systems in severelycurved canals in human teeth.

Conclusion

Based on the parameters examined in this study andwithin itslimitations, it can be concluded that there were no significantdifferences in the centering ability of the PTN and 2Shapesystems in simulated severe curved canals. Both systemsexhibited some degree of transportation, especially in theapical third.

Clinical relevance

The respect of the original anatomy is one on the goals ofmodern endodontics.

Investigation may help the clinical expectation of theinstruments tested and help clinicians.

Conflict of interest

The authors deny any conflicts of interest related to thisstudy.

Acknowledgement

Thanks to the companies that provided the materials to makethis research possible.

References

1. Peters OA. Current challenges and concepts in the preparation ofroot canal systems: a review. J Endod 2004;30:559—67.

2. Schilder H. Cleaning and shaping the root canal. Dent Clin NorthAm 1974;18:269—96.

3. Weine FS, Kelly RF, Lio PJ. The effect of preparation procedureson original canal shape and on apical foramen shape. J Endod1975;1:255—62.

4. Walton RE, Torabinejad M. Principles and practice of endodon-tics. Elsevier Health Sciences; 2014: 210.

5. McSpadden JT. Rationales for rotary nickel-titanium instru-ments. Chattanooga, TN: NT Co; 1994.

Figure 2 Mean centering ratio of 2Shape and ProTaper Next at the coronal, middle and apical third of the c.

Comparison of shaping ability of ProTaper Next and 2Shape nickel—titanium files 55

6. Miura F, Mogi M, Ohura Y, Hamanaka H. The super-elastic prop-erty of the Japanese NiTi alloy wire for use in orthodontics. Am JOrthod Dentofacial Orthop 1986;90:1—10.

7. Hulsmann M, Peters OA, Dummer PM. Mechanical preparation ofroot canals: shaping goals, techniques and means. Endod Top2005;10:30—76.

8. Koch K, Brave D. Real world endo: design features of rotary filesand how they affect clinical performance. Oral Health2002;92:39—49.

9. Marending M, Biel P, Attin T, Zehnder M. Comparison of twocontemporary rotary systems in a pre-clinical student coursesetting. Int Endo J 2016;49:591—8.

10. Ponti TM, McDonald NJ, Kuttler S, Strassler HE, Dumsha TC.Canal-centering ability of two rotary file systems. J Endod2002;28:283—6.

11. Buehler WJ, Gilfrich JV, Wiley RC. Effect of low-temperaturephase changes on the mechanical properties of alloys nearcomposition TiNi. J Appl Phys 1963;34:1475—7.

12. Walia H, Brantley WA, Gerstein H. An initial investigation of thebending and torsional properties of Nitinol root canal files. JEndod 1988;14:346—51.

13. Esposito PT, Cunningham CJ. A comparison of canal preparationwith nickel-titanium and stainless steel instruments. J Endod1995;21:173—6.

14. Glosson CR, Haller RH, Dove SB, Carlos E. A comparison of rootcanal preparations using Ni-Ti hand, Ni-Ti engine-driven, and K-Flex endodontic instruments. J Endod 1995;21:146—51.

15. Lim YJ, Park SJ, Kim HC, Min KS. Comparison of the centeringability of Wave� One and Reciproc nickel-titanium instruments insimulated curved canals. Restor Dent Endod 2013;38:21—5.

16. Al-Sudani D, Al-Shahrani S. A comparison of the canal centeringability of ProFile, K3, and RaCe Nickel Titanium rotary systems. JEndod 2006;32:1198—201.

17. Paleker F, Van Der Vyver PJ. Comparison of canal transportationand centering ability of k-files, proglider file, and g-files: amicro-computed tomography study of curved root canals. JEndod 2016;42:1105—9.

18. Jain A, Asrani H, Singhal AC, Bhatia TK, Sharma V, Jaiswal P.Comparative evaluation of canal transportation, centering abil-ity, and remaining dentin thickness between WaveOne andProTaper rotary by using cone beam computed tomography:an in vitro study. J Conserv Dent 2016;9:440—4.

56 S. Staffoli et al.

[11_TD$DIFF]ORIGINAL ARTICLE/ARTICOLO ORIGINALE

Canal transportation caused by one single-fileand two multiple-file rotary systems:A comparative study using cone-beam computedtomography

Trasporto canalare causato da un sistema rotante mono-strumentoe due sequenze di strumenti rotanti: studio comparativo con tomografiacomputerizzata a fascio conico

Eshagh Ali Saberi, Narges Farhad Mollashahi, Forugh Farahi *[14_TD$DIFF]

[15_TD$DIFF]Department of Endodontics, Dental School, Zahedan University of Medical Science [16_TD$DIFF], Zahedan, Iran

Received 14 May 2017; accepted 6 April 2018Available online 6 June 2018


KEYWORDSCanal [22_TD$DIFF]transportation;Nickel—titanium;Rotary files;CBCT.

Abstract

Aim: This ex-vivo study aimed to compare canal transportation in mesio-buccal canal ofmandibular first molars prepared with Mtwo and Revo-S multi-file and Neoniti single-filenickel [18_TD$DIFF]—titanium (Ni—Ti) rotary systems using cone-beam computed tomography (CBCT).Methodology: CBCTscans were obtained from 60 extractedmandibular first molars and the teethwere randomly divided into three groups. Mesio-buccal canal of mesial root was prepared withRevo-S, Neoniti or Mtwo rotary systems according to the instructions of the manufacturers. Post-operative CBCT scans were also obtained. A single operator performed canal preparations whileanother operator blinded to the group allocation of teeth did the measurements. Data wereanalyzed using SPSS 20. The mean and standard deviation (SD) of the amount of canaltransportation were calculated and compared between the groups using the Friedman test([19_TD$DIFF]P � 0.05).


* Corresponding author[17_TD$DIFF].E-mail: [email protected] (E.A. Saberi), [email protected] (N.F. Mollashahi), [email protected] (F. Farahi).


ScienceDirect



Introduction

The main objective of endodontic treatment is to eliminateor minimize microorganisms in the root canal system whilemaintaining the original shape and path of root canals.1

Variations in the anatomy and morphology of the root canalsystem, presence of isthmus, communications within theroot canal system and with the periodontal ligament via theaccessory canals, canal curvature and oval shape rootcanals, complicate an efficient disinfection of the root canalsystem.2 According to Schilder, root canal must have aconical shape from the coronal to the apical region.3 More-over, the original shape of the apical foramen must bepreserved and no significant change should be made in theoriginal curvature of the root canal path during cleaning andshaping.4

Although most root canals have a curvature, endodonticinstruments are often manufactured in a straight form. Thus,they tend to straighten up the canal path when in function.This results in occurrence of procedural errors such as ledgeformation, transportation, zipping and perforation of canal,which adversely affect the quality of cleaning and shapingand obturation and compromise the success of treatment.5,6

Nickel—titanium (NiTi) instruments were introduced inthe 1990s to enhance and accelerate the process of rootcanal preparation especially in curved canals since they aremore flexible than stainless-steel instruments.7 [23_TD$DIFF] Evidenceshows that NiTi rotary instruments enable the clinician toadequately and predictably prepare the root canal anddecrease the risk of procedural errors.8

The Mtwo rotary system (VDW, Munich, Germany) wasintroduced worldwide in 2005. It has a S-shaped cross-sectionand two cutting blades, enabling efficient cutting of dentin.Moreover, the length of pitch from the tip to the shaft hasincreased in this system. This design has two advantagesnamely decreased screwing into the canal and decreasedextrusion of debris through the apex.9[24_TD$DIFF] The manufacturer ofthis system suggests the single-length preparation techniqueinstead of crown-down technique.10 A previous study showedthat preparation of curved canals with Mtwo maintains thecentral path of canal.9

Revo-S (Micro-Mega, Besancon Cedex, France) is a NiTirotary instrument with asymmetrical cross-section. Thisdesign should enhance the flexibility of the file and reducethe stress applied to it, making it a suitable instrument forcanal negotiation.11

PAROLE CHIAVETrasporto canalare;Nichel-titanio;Strumenti rotanti CBCT.

Results: No significant difference was noted in canal transportation among the groups in themiddle and apical third ([20_TD$DIFF]P > 0.05). The rotary single-file instrument caused significantly greatercanal transportation in the coronal third.Conclusion: No significant difference exists among different rotary systems in the amount ofcanal transportation caused in the middle and apical third of the mesio-buccal canal inmandibular first molars. Although all rotary files caused some degrees of canal transportation,the rotary single-file instrument caused significantly greater canal transportation than themultiple-file sequences in the coronal third.� 2018 Societa Italiana di Endodonzia. Production and hosting by Elsevier B.V. This is an openaccess article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Riassunto

Obiettivi: Questo studio ex-vivo ha lo scopo di confrontare il trasporto canalare nel canalemesio-buccale di primi molari mandibolari preparati con i sistemi rotanti in nichel-titanio (Ni-Ti)Mtwo e Revo-S ed il sistema mono-strumento Neoniti, utilizzando la tomografia computerizzata araggio conico (CBCT).Materiali e metodi: Le scansioni CBCTsono state ottenute in 60 primi molari mandibolari estrattie i denti sono stati suddivisi in tre gruppi. Il canale mesio-buccale della radice mesiale e statopreparato con sistemi rotanti Mtwo, Revo-S o Neoniti seguendo le istruzioni del produttore. Sonostate quindi ottenute scansioni CBCT post-strumentazione. Un singolo operatore ha eseguito lepreparazioni dei canali mentre un altro operatore ha effettuato le misurazioni. I dati sono statianalizzati utilizzando SPSS 20. La media e la deviazione standard (SD) della quantita di trasportocanalare sono stati calcolati e confrontati tra i gruppi usando il test Friedman (P [21_TD$DIFF]� 0.05).Risultati: Nessuna differenza significativa e stata osservata tra i gruppi nel trasporto dei canalinel terzo medio e apicale (P > 0.05), ma la tecnica mono-strumento ha causato un trasporto piusignificativo del canale nel terzo coronale.Conclusioni: Nessuna differenza significativa e stata riscontrata tra i diversi sistemi rotanti nellaquantita di trasporto canalare nel terzo medio e apicale nel canale mesio-buccale di primi molarimandibolari. Anche se tutti i file rotanti hanno causato un certo grado di trasporto del canale, latecnica mono-strumento rotante ha causato un trasporto del canale nel terzo coronale signi-ficativamente maggiore rispetto alle sequenze di file multipli.� 2018 Societa Italiana di Endodonzia. Production and hosting by Elsevier B.V. Cet article estpublie en Open Access sous licence CC BY-NC-ND (http://creativecommons.org/licenses/by-nc-nd/4.0/)

58 E.A. Saberi et al.

In a study on canal transportation and centering ability, nosignificant difference was noted between Revo-S and Mtworotary systems.8 [25_TD$DIFF] Another study compared preparation ofseverely curved canals with six rotary instruments includingRevo-S and Mtwo and found no significant difference in canaltransportation caused by rotary files; however, canal trans-portation was greater by use of the hand files compared torotary files.12

Single-file systems were recently introduced on the mar-ket, mainly used in reciprocatingmovement.13 These systemsare efficient and require less time for bio-mechanical pre-paration of root canals.14 Recently, a new single-file rotarysystem, known as Neoniti (Neolix SAS, Chatres-La-Foret,France), was introduced to the market. It operates with fullrotation movement and has been recommended for efficientroot canal preparation. This system is manufactured byelectric discharge machining technology, which confersunique properties to the file such as greater flexibility, sharpcutting edges, changing profile and variable built-in abrasiveproperties.15,16

Moazzami et al.1 [26_TD$DIFF] compared the amount of canal trans-portation caused by the use of Neoniti and Reciproc files usingcone-beam computed tomography (CBCT) and concludedthat canal transportation was lower when Neoniti instru-ments were used; they attributed this finding to the non-homothetic rectangular cross-section and rounded tip of thisfile.

CBCT is among the recent techniques suggested for assess-ment of the quality and efficacy of root canal preparationtechniques. CBCT has advantages such as low patient radia-tion dose and a small field of view, which enhances theresolution and diagnostic value.16,17 CBCT scans are moreaccurate than the conventional radiographs and do notrequire destruction of samples. They have high reproduci-bility and can provide numerous images of a single canal.18

No previous study has compared canal transportationcaused by Mtwo and Revo-S multi-file and Neoniti single-filesystems. Thus, this study aimed to compare canal transpor-tation in the mesio-buccal canal of mandibular first molarsprepared withMtwo and Revo-S multi-file and Neoniti single-file NiTi rotary systems evaluated using CBCT.


This ex vivo study was conducted on 45 mandibular firstmolars extracted for periodontal or orthodontic reasons inthe Oral and Maxillofacial Surgery Department of ZahedanUniversity of Medical Sciences, School of Dentistry. The studyprotocol was approved in the ethics committee of this uni-versity (IR.ZAUMS.REC.1395.101). The teeth had closedapices and the mean root curvature was [28_TD$DIFF]20—408 accordingto the Schneider’s method.4 [27_TD$DIFF] Root curvature had [29_TD$DIFF]5—9 mmdistance from the apex and the mean length of root was[30_TD$DIFF]19—22 mm.

Tissue remnants and calcified debris were removed by ascaler. The teeth were immersed in 0.1% thymol solution for24 ours at 9 8C for disinfection. They were rinsed underrunning water to eliminate thymol residues and stored insaline at 4 8C. Initial radiographs of the mesial root wereobtained and degree of root curvature was measured. Mesialcanals each had a separate apical foramen and had no signs of

calcification or internal resorption. S- or C-shaped canalswere excluded. All teeth were inspected under a stereomi-croscope at [31_TD$DIFF]12� magnification to ensure absence of crazelines, cracks or fracture. The teeth with such defects wereexcluded and replaced with sound teeth. Access cavity wasprepared by a diamond bur and high-speed hand-piece underwater and air spray. To determine the working length of themesio-buccal canal, a size 10 K-file (Mani, Tochigi, Japan) wasintroduced into the canal until its tip was visible at the apex.One millimeter was subtracted of this length to determinethe working length.

Silicon impression material (Oranwash, Zhermack spa,Rovigo, Italy) was used to cover the cementum surface tosimulate the periodontal ligament. Apical foramen wassealed with red wax to prevent intrusion of silicon materialinto the apical foramen. The teeth were then mounted inblocks measuring 5 [32_TD$DIFF]� 5 cm filled with putty to the level of thecemento-enamel junction in a parallel fashion to standardizepre- and post-operative radiographs. A small piece of ortho-dontic wire was placed at the corner of silicon blocks as areference to mark the direction of scanning. The teeth wererandomly divided into three groups of 15. Mtwo was used ingroup 1, Revo-S was used in group 2 and Neoniti was used ingroup 3.

Root canal preparation

[33_TD$DIFF]All canals were instrumented to the working length using ahand-piece (X-Smart; Dentsply-Maillefer, Baillagues, Swit-zerland) with the torque recommended by the manufacturerfor each system along with irrigation with 2.5% sodiumhypochlorite with 30 gage needle between instruments;17% EDTA and 5.25% sodium hypochlorite were used for finalrinse and elimination of smear layer.

Group 1. Mtwo rotary system (VDW GmbH, Germany) wasused for root canal preparation in this group. First, a #10 K filewas used to obtain a glide path to the working length. Then,10/0.04, 15/0.05, 20/0.06 and 25/0.06 files were used at280 rpm and 1.2 N/cm torque for instrumentation of thecoronal, middle and apical thirds of the root canal to theworking length. Frequent recapitulation was done using a #10K-file. Root canals were rinsed with 2.5% sodium hypochloriteafter using each instrument. Glyde (Dentsply-Maillefer,Konstanz, Germany) was used as the lubricant.

Group 2. Revo-S (Micro Mega, Besancon, France) NiTi filewas used for root canal preparation, which was started withSC1 (25/0.06) at 300 rpm with 2 N/cm torque according tothe manufacturer’s instructions followed by SC2 (25/0.04)and SU (25/0.06) to the working length for final preparation.Recapitulation was repeatedly done using #10 K-file andrinsing with 2.5% sodium hypochlorite was performed afterusing each instrument. Glyde was used as the lubricant.

Group 3. Mesiobuccal canal in this group was preparedusing Neolix (25/0.08) (Neoniti A1, France) at 300 rpm and1.5 N/cm torque according to the manufacturer’s instruc-tions to the working length. Recapitulation was repeatedlydone using #10 K-file and rinsing with 2.5% sodium hypochlor-ite was performed after using each instrument. Glyde wasused as the lubricant.

Three-dimensional CBCT scans were obtained (Vatec,Korea) with high resolution, 50 [34_TD$DIFF]� 50 mm, 89 kVp, 5.4 mA,

Canal transportation caused by one single-file and two multiple-file rotary systems 59

0.8 voxel size and 17 [35_TD$DIFF]s time before root canal preparation.CBCT scans were obtained again with the same exposuresettings after root canal preparation. Thickness of root canalwall before and after instrumentation was measured at 3, 6and 9 mm distances from the apex. Canal transportation wascalculated using the following formula:CT = ([36_TD$DIFF]A1 � A2) � (B1 � B2).

A1 is the shortest distance from the external root surfaceto the un-instrumented canal border; [37_TD$DIFF]A2 is the minimumdistance from the external root surface to the border ofinstrumented canal, [38_TD$DIFF]B1 is the minimum distance from theinternal root surface to the un-instrumented canal borderand [39_TD$DIFF]B2 is the minimum distance from the internal root sur-face to the instrumented canal border. In this formula, CT = 0indicates no transportation while negative values indicatetransportation toward [40_TD$DIFF]the distal (furcation site) and positivevalues indicate transportation toward [40_TD$DIFF]the mesial.

It should be noted that canal preparation was done by asingle operator while measurements were made by anotheroperator blinded to the group allocation of teeth. Data wereanalyzed using SPSS version 20. The mean and standarddeviation (SD) of root canal transportation were calculatedand compared using non-parametric Kruskal [41_TD$DIFF]—Wallis test(since data were not normally distributed). [42_TD$DIFF]P � 0.05 wasconsidered statistically significant.

Results

Table 1 and Fig. 1 shows the mean and SD of canal transporta-tion in mesio-distal direction in the three systems. No sig-nificant difference was noted in canal transportation amongthe three systems at the middle and apical third ([20_TD$DIFF]P > 0.05);but this difference in the coronal third was statisticallysignificant and Neoniti removed significantly more amountof dentin from the internal wall of the curvature in thecoronal third and caused significantly greater canal trans-portation toward [43_TD$DIFF]the furcation (P = 0.008).

Discussion

One major goal of root canal preparation is to createa conical shape from the apical to the coronal while

maintaining the original canal path.2 Mandibular molarsthat commonly require endodontic treatment usually pre-sent a curved mesial root.19 The greatest curvature isusually seen in the mesio-buccal canal.19 Thus, this canalis more susceptible to transportation during instrumenta-tion compared to other canals. If transportation occurs,it would be impossible to regain the original canal shapeand risk of ledge formation, perforation and zippingincreases.8,20

CBCT is an efficient modality for assessment and mea-surement of dentin thickness, canal curvature, canal trans-portation and centering ability.2 This experimental studyassessed canal transportation in the mesio-buccal canal ofextracted human mandibular first molars using CBCT andshowed that the three types of NiTi rotary systems, irre-spective of the number of files used (single-file or multi-filesystems) were significantly different in terms of canal trans-portation.

The results of this study showed that Neoniti file causedsignificant transportation in the cervical third of canaltoward the furcation. No significant difference was notedamong the rotary instruments in the middle and apicalthirds.

Evidence shows that dimensions of instrument, metallur-gical properties, design of instrument and its applicationmode can all affect the amount of canal transportationduring instrumentation.21 [40_TD$DIFF] Neoniti system has a single filewith 8% taper and triangular-shaped cross-section. Greatertapering of this instrument compared toMtwo and Revo-S canexplain greater removal of dentin [44_TD$DIFF]from the cervical third andgreater transportation compared to other multi-file systemsin the cervical third of the canal.1

Moazzami et al.1 [45_TD$DIFF] showed that Neoniti file caused signifi-cantly greater transportation in bucco-lingual compared tomesio-distal direction in the apical 5 mm of the canal. Revo-Shas constant taper and a cross-section with three asymme-trical blades. This design decreases mechanical stress on theinstrument and enhances canal preparation by snake-likemovement. A previous study assessed the effect of asymme-try on three-helix cross-section and concluded that thismodified performance decreases axial stress.20 Another studycompared the amount of canal transportation and centeringability of Revo-S and ProTaper and concluded that althoughno significant difference existed between the two systems,Revo-S had a superior performance than ProTaper.22 [46_TD$DIFF] In thepresent study, Mtwo caused the least amount of canal trans-portation;Mtwo has two cutting blades with a small S-shapedcross-section. This design aims to increase the flexibility ofthe instrument and to achieve higher cutting ability com-pared to triangular cross-section.8 In the present study, theleast amount of transportation caused by Mtwo was in themiddle region, which can be attributed to the relatively lownumber of blades per each unit of length. Yang et al. reportedresults similar and concluded that Mtwo well preserves theoriginal canal path.23 [47_TD$DIFF] [48_TD$DIFF]Schafer et al. showed that Mtwo pre-served the original canal curvature significantly better thanother instruments.24

Apical transportation more than 0.3 mm results in loss ofseal in the apical region and compromises the prognosis oftreatment.25 In the present study, the amount of transporta-tion ranged from 0.04 to 0.09 mm, which would not affectapical seal.

Table 1 Comparison of themean canal transportation in thecoronal, middle and apical thirds of root canals in the threegroups ([2_TD$DIFF]n = 15).

Region System Mean Standarddeviation

[3_TD$DIFF]P value

Apical third Neoniti A1 .0933 0.11238 0.102[4_TD$DIFF]Revo-S �.0400 0.10403Mtwo .0800 0.10862

[5_TD$DIFF]Middle third Neoniti A1 [6_TD$DIFF]�.0600 0.10593 0.443[7_TD$DIFF]Revo-S �.0200 0.08255Mtwo .0133 0.10024

Coronal third Neoniti A1 [8_TD$DIFF]�.1733 0.09824 0.041Revo-S .0267 0.11112[9_TD$DIFF]Mtwo .0800 0.12509

[10_TD$DIFF]P value: Kruskal—Wallis test.


Conclusion

No significant difference was noted in terms of the amount ofcanal transportation among different rotary systems in theapical and middle third. Although all rotary systems causedsome degrees of canal transportation, Neoniti caused sig-nificantly greater canal transportation in the coronal third.


The authors deny any conflict of interest.

Acknowledgements

The authors would like to thank the Research Deputy ofZahedan University of Medical Sciences for funding this study.Also, we appreciate the cooperation of Marzneshinan ImagingCenter for taking the CBCT scans.

References

1. Moazzami F, Khojastepour L, Nabavizadeh M, Habashi MS. Cone-beam computed tomography assessment of root canal transpor-tation by Neoniti and Reciproc single-file systems. Iran Endod J2016;11(2):96.

2. Elsherief SM, Zayet MK, Hamouda IM. Cone-beam computedtomography analysis of curved root canals after mechanicalpreparation with three nickel—titanium rotary instruments. JBiomed Res 2013;27(4):326—35.

3. Schilder H. Filling root canals in three dimensions. J Endod2006;32(4):281—90.

4. Schneider SW. A comparison of canal preparations in straight andcurved root canals. Oral Surg Oral Med Oral Pathol1971;32(2):271—5.

5. You S-Y, Kim H-C, Bae K-S, Baek S-H, Kum K-Y, Lee W. Shapingability of reciprocating motion in curved root canals: a

comparative study with micro-computed tomography. J Endod2011;37(9):1296—300.

6. Karabucak B, Gatan AJ, Hsiao C, Iqbal MK. A comparison of apicaltransportation and length control between EndoSequence andGuidance rotary instruments. J Endod 2010;36(1):123—5.

7. Walia H, Brantley WA, Gerstein H. An initial investigation of thebending and torsional properties of Nitinol root canal files. JEndod 1988;14(7):346—51.

8. Vallaeys K, Chevalier V, Arbab-Chirani R. Comparative analysisof canal transportation and centring ability of three Ni—Tirotary endodontic systems: Protaper1, MTwo1 and Revo-STM,assessed by micro-computed tomography. Odontology2016;104(1):83—8.

9. Aminsobhani M, Ghorbanzadeh A, Dehghan S, Niasar AN, Khar-azifard MJ. A comparison of canal preparations by Mtwo andRaCe rotary files using full sequence versus one rotary filetechniques; a cone-beam computed tomography analysis. SaudiEndod J 2014;4(2):70.

10. Plotino G, Grande NM, Sorci E, Malagnino V, Somma F. A compar-ison of cyclic fatigue between used and new Mtwo Ni—Ti rotaryinstruments. Int Endod J 2006;39(9):716—23.

11. Versiani MA, Leoni GB, Steier L, De-Deus G, Tassani S, PecoraJD, et al. Micro-computed tomography study of oval-shapedcanals prepared with the Self-adjusting File, Reciproc,WaveOne, and Protaper Universal systems. J Endod2013;39(8):1060—6.

12. Celik D, Tasdemir T, Er K. Comparative study of 6 rotary nickel—titanium systems and hand instrumentation for root canal pre-paration in severely curved root canals of extracted teeth.J Endod 2013;39(2):278—82.

13. Grande NM, Ahmed HMA, Cohen S, Bukiet F, Plotino G. Currentassessment of reciprocation in endodontic preparation: a com-prehensive review–—Part I: Historic perspectives and currentapplications. J Endod 2015;41(11):1778—83.

14. Gupta R, Dhingra A, Aggarwal N, Yadav V. A new approach tosingle file endodontics: Neoniti rotary file system. Int J Adv CaseRep 2015;2(16):1030—2.

15. Gergi R, Arbab-Chirani R, Osta N, Naaman A. Micro-computedtomographic evaluation of canal transportation instrumentedby different kinematics rotary nickel—titanium instruments. JEndod 2014;40(8):1223—7.

[1_TD$DIFF]Figure 1 Comparison of canal transportation in the coronal, middle and apical thirds of root canals in the three groups (n = 15). In the1/3 of coronal, the mean Revo-s was rounded up to 0.03.

Canal transportation caused by one single-file and two multiple-file rotary systems 61

16. Ludlow JB, Davies-Ludlow L, Brooks S, HowertonW. Dosimetry of3 CBCT devices for oral andmaxillofacial radiology: CB Mercuray,NewTom 3G and i-CAT. Dentomaxillofac Radiol 2014.

17. Hatcher DC. Operational principles for cone-beam computedtomography. JADA 2010;141:3S—6S.

18. sadat Madani Z, Goudarzipour D, Haddadi A, Saeidi A, Bijani A. ACBCTassessment of apical transportation in root canals preparedwith hand K-Flexofile and K3 rotary instruments. Iran Endod J2014;10(1):44—8.

19. Cunningham CJ, Senia ES. A three-dimensional study of canalcurvatures in the mesial roots of mandibular molars. J Endod1992;18(6):294—300.

20. Diemer F, Michetti J, Mallet J-P, Piquet R. Effect of asymmetry onthe behavior of prototype rotary triple helix root canal instru-ments. J Endod 2013;39(6):829—32.

21. Zhao D, Shen Y, Peng B, Haapasalo M. Root canal preparationof mandibular molars with 3 nickel—titanium rotary instruments:

a micro-computed tomographic study. J Endod 2014;40(11):1860—4.

22. Hashem AAR, Ghoneim AG, Lutfy RA, Foda MY, Omar GAF. Geo-metric analysis of root canals prepared by four rotary NiTishaping systems. J Endod 2012;38(7):996—1000.

23. Yang G, Yuan G, Yun X, Zhou X, Liu B, Wu H. Effects of Twonickel—titanium instrument systems, Mtwo versus ProTaper uni-versal, on root canal geometry assessed by micro-computedtomography. J Endod 2011;37(10):1412—6.

24. Schafer E, Erler M, Dammaschke T. Comparative study on theshaping ability and cleaning efficiency of rotary Mtwo instru-ments. Part 2. Cleaning effectiveness and shaping ability inseverely curved root canals of extracted teeth. Int Endod J2006;39(3):203—12.

25. Wu M-K, Fan B, Wesselink PR. Leakage along apical root fillings incurved root canals. Part I: Effects of apical transportation on sealof root fillings. J Endod 2000;26(4):210—6.


ORIGINAL ARTICLE/ARTICOLO ORIGINALE

Survival study on teeth after successfulendodontic surgical retreatment: influence ofcrown height, root length, crown-to [1_TD$DIFF]-root ratioand tooth type

Studio di sopravvivenza su denti guariti a seguito di endodonzia chirurgica:influenza dell’altezza coronale, della lunghezza radicolare, del rapportocorona-radice e del tipo di dente

Daniele Angerame a,*, Matteo De Biasi a, Massimiliano Lenhardt a,Lorenzo Bevilacqua a, Vittorio Franco b

aDental Clinic, University Clinical Department of Medical, Surgical and Health Sciences, University of Trieste,Trieste, Italyb Private Practice, Rome, Italy

Received 29 July 2018; accepted 11 September 2018Available online 9 October 2018


KEYWORDSCrown-to-root ratio;Late failure;Retrospective study;Survival analysis;Surgical endodonticretreatment.

Abstract

Aim: To assess the influence of the crown height, root length, crown-to-root ratio, and toothtype on the survival of teeth subjected to surgical endodontic retreatment and classified asperiapically healed.Methodology: A single operator performed endodontic microsurgery interventions between 2008and 2018 on teeth with refractory apical periodontitis. The present analysis selected the teethclassified as ‘‘complete periapical healing’’ according to the scale suggested by Molven. Thepostoperative periapical radiographs and those taken at the last recall visit were analysed by two


* Corresponding author.E-mail: [email protected] (D. Angerame).


ScienceDirect



Introduction

When conducted in full respect of the principles of contem-porary root-end surgery techniques with magnification tools,microinstruments, ultrasonic tips, and specific filling materi-als, surgical endodontic retreatment (SER) is a reliable andsuccessful approach in cases root-filled teeth with chronicapical periodontitis, according to randomized controlledtrials and meta-analyses.1—4 Indeed, SER can have higher

success rates than orthograde retreatment after 1 year, butthe healing rates of the two approaches tend to be similarafter 3 years.5—7 A possible explanation for this phenomenonis the occurrence of late failures in 5—25% of SER cases,8 thecauses of which are only partially understood and predict-able. A copious series of clinical studies has investigated theoutcome of SER in the middle- and long-term9—17; nonethe-less, their huge methodological differences in techniques,instruments, materials, selection criteria, and follow-up

PAROLE CHIAVEAnalisi di sopravvivenza;Fallimento tardivo;Rapporto corona-radice;Ritrattamentoendodontico chirurgico;Studio retrospettivo.

independent calibrated examiners, who measured crown height and root length in a blindmanner. The crown-to-root ratio was calculated as the ratio of the two variables. The level ofinter- and intra-operator agreement was tested with Bland—Altman plots with 95% limits ofagreement. An independent statistician conducted a survival analysis using Kaplan—Meier plotsand a log-rank test (a = 0.05) to assess the significance of the differences among the subgroupsdefined by the following criteria: (a) crown height <median vs. >median; (b) root length<median vs. >median; (c) crown-to-root ratio <1 vs. >1; (d) crown-to-root ratio <medianvs. >median; (e) single-rooted teeth vs. multi-rooted teeth.Results: At the end of the analysis, 42 patients were evaluated, each one contributing to thestudy with a single tooth. The mean follow-up period was 4.2 � 2.4 years. Survival estimateswere significantly improved for the teeth with roots longer than 8 mm, in comparison with thatwith shorter roots ( p < 0.05). There were no statistically significant differences among theremaining considered subgroups.Conclusions: Under the conditions of this retrospective study, teeth with longer residual rootsafter apical surgery exhibited better chances of survival when compared to teeth with rootsshorter than 8 mm. The other considered variables did not seem to affect the survival of apicallyresected teeth.� 2018 Societa Italiana di Endodonzia. Production and hosting by Elsevier B.V. This is an openaccess article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Riassunto

Obiettivi: Valutare l’influenza dell’altezza coronale, della lunghezza radicolare, del rapportocorona-radice e del tipo di dente sulla sopravvivenza di denti sottoposti ad apicectomia eclassificati come guariti a livello periapicale.Materiali e metodi: Un singolo operatore ha svolto interventi di endodonzia microchirurgica dal2008 al 2018 su denti con paradentite periapicale refrattaria. La presente analisi ha selezionato identi classificati come «guarigione radicolare completa» secondo la scala di Molven. Le radio-grafie periapicali postoperatorie e quelle scattate all’ultima visita di controllo sono stateanalizzate da due operatori indipendenti e calibrati che hanno misurato in cieco altezza coronalee lunghezza radicolare. Il rapporto corona-radice e stato calcolato dal rapporto delle duevariabili. Il livello di concordanza inter- e intra-operatore e stato testato con i diagrammi diBland-Altman con limiti di concordanza al 95%. Uno statistico indipendente ha svolto un’analisi disopravvivenza usando le curve di Kaplan-Meier e test Log-Rank (a = 0.05) per verificare lasignificativita delle differenze tra i sottogruppi definiti dai seguenti criteri: altezza corona-le<mediana vs. >mediana; lunghezza radicolare<mediana vs. >mediana; rapporto corona-radice<1 vs. >1; rapporto corona-radice<mediana vs. >mediana; denti monoradicolati vs.pluriradicolati.Risultati: Al termine dell’analisi il campione era costituito da 42 pazienti, seguiti per 4,2�2,4anni, ciascuno dei quali ha contribuito allo studio con un dente. Le stime di sopravvivenza sonorisultate significativamente migliori per i denti con radici piu lunghe di 8 mm nel confronto conquelle di lunghezza inferiore (p < 0.05). Non sono emerse ulteriori differenze statisticamentesignificative dal confronto tra gli altri sottogruppi considerati.Conclusioni: Nelle condizioni del presente studio retrospettivo, elementi dentari con radiciresidue lunghe a seguito di chirurgia apicale hanno mostrato migliori probabilita di sopravvi-venza, paragonati a elementi con radici piu corte di 8 mm. Le altre variabili testate non hannoinfluenzato la sopravvivenza dei denti sottoposti a resezione apicale.� 2018 Societa Italiana di Endodonzia. Production and hosting by Elsevier B.V. Cet article estpublie en Open Access sous licence CC BY-NC-ND (http://creativecommons.org/licenses/by-nc-nd/4.0/)

64 D. Angerame et al.

periods constitute an obstacle to synthesize and comparetheir data in a meta-analysis.17

During the surgical intervention, apical resection is anessential phase to remove the majority of the secondaryendodontic structures18 and the infected content, wherethis is arduous or impossible in an orthogradeway.19 However,root resection, by definition, inevitably shortens the root andmay alter the biomechanical behaviour and stress distribu-tion of the treated tooth.20—22 It is noteworthy that, evenafter complete periapical recovery, apically resected teethcontinue to be exposed to occlusal loading, whose impactmight be harmful, especially when the tooth is not prosthe-tically splinted to other abutment teeth. Although it has beensuggested that the apical loss of 3 mm of root length hasminimal influence in the biomechanical parameters of teethsupported by a normal periodontium,21 teeth undergoing SERare frequently affected by various degrees of periodontalbone loss in the clinical settings. A recent finite elementanalysis showed that the periodontal bone loss progressivelydeteriorates the biomechanical response of apically resectedteeth, in comparison with a tooth with intact periodontalsupport.20

The crown-to-root ratio (CRR) is a parameter that wasinvented for the evaluation of teeth eligible as abutments tosupport prosthetic bridges and crowns; the condition in whichCRR is equal to 1:1.5 is considered optimal, while a 1:1 ratio isthe is the minimum that can be accepted.23 It is still unknownwhether the same criteria could be valid for the teeth thathave been subjected to apical resection,24 since CRR wasoriginally conceived for the assessment of the periodontalsupport loss at the coronal third of the root and not atthe apical level. Furthermore, other biomechanical factorsmay — hypothetically — play a relevant role in the determi-nation of the tooth prognosis after successful SER, crownheight (CH) or root length (RL) in the first place, actingindependently of CRR.

All of this considered, the aim of the present study was toassess how CH, RL, CRR, and the tooth type affect the survivalof teeth subjected to apicectomy and classified as periapi-cally healed.

Materials and methodology

The present retrospective study was conducted in full accor-dance with the last version of the Declaration of Helsinki (9thJuly 2018). Clinical data were collected from patients of theDental Clinic of the Ospedale Maggiore, University of Trieste,Trieste, Italy. Dental records and periapical radiographs weresearched exclusively from the charts of the patients that hadgiven their approval for the handling and analysis of theirdata for epidemiological and scientific purposes by signing adedicated form. Dental records of patients who underwentSER for the treatment of teeth with refractory periapicalpathosis between 2008 and January 2018 were obtained.Ethical clearance was obtained by tacit approval of the LocalEthic Committee after communication of the study protocol.

Only the cases classified as ‘‘complete periapical healing’’according to the scale proposed by Molven25 were included inthe present analysis. Teeth used as an abutment for pros-thetic bridges, splinted to the surrounding teeth, or originally

affected by a lesion of combined endodontic-periodontalorigin were excluded.

Surgical procedures

A single experienced endodontist performed all the surgicalinterventions, according to the modern principles of micro-surgical endodontics. All surgical procedures were carried outusing an operating microscope (M525, Leica Microsystems CMSGmbH, Mannheim, Germany). In brief, the flap was reflectedafter local anaesthesia with lidocaine and 1:50,000 epinephr-ine and an osteotomy performed with rotary burs. Inflamma-tory soft tissues were manually removed with a surgicalcurette and the root was sectioned 3 mm from its tip witha tapered fissure bur kept perpendicular to the root long-itudinal axis under copious water irrigation. After havingreached haemostasis applying ferric sulphate (Astal, Ogna,Muggio, Italy), methylene blue was used to stain the resectedsurface to exclude the presence of visible fractures and locatethe canals by using surgical micromirrors (Obtura Spartan,Fenton, MO, USA). A 3-mm deep root-end cavity was preparedwith ultrasonic tips (KiS, Obtura Spartan), dried with sterilepaper points (Inline, BM Dentale, Turin, Italy), and filled withSuperEBA cement (Bosworth, Skokie, IL, USA). The flap wassutured with 5-0 monofilament sutures, and a postoperativeperiapical radiograph was taken.

Following the routine follow-up schedule of our clinicalpractice, the patients were contacted by telephone every6 months for 2 years and, after the 2 first years, annually. Onevery follow-up visit, the treated teeth were checked clini-cally and radiographically.

Radiographic examination and analysis

The periapical radiographs taken at the recall visits, as wellas the immediate postoperative ones, were subjectedto image analysis with dedicated software (DBSWIN, DurrDental, Bietigheim-Bissingen, Germany). Two independent,trained, and calibrated operators measured in a blindmannerthe CH, defined as the distance between the alveolar ridgeand the top of the cusp, and RL, defined as the distancebetween the alveolar ridge and the resected apex. For eachcase, CRR was arithmetically calculated. The measurementswere made on the postoperative (t0) and on the last available(t1) radiographs. The level of intra- and interobserver agree-ment was tested with the Bland-Altman plots with 95% limitsof agreement (GraphPad Prism 7, GraphPad Software, LaJolla, CA, USA).

Statistical analysis

A statistician, who was kept blind from the study design andpurpose, handled and analysed the collected data, conduct-ing the whole analysis using statistical software (StatisticalPackage for Social Sciences v.15, SPSS Inc., Chicago, IL, USA).Continuous data were tested for the normality of the dis-tribution and equality of variances by means of a Shapiro—Wilk and a Levene test, respectively. Differences in thevariables of interest (CH, RL, CRR) between the two con-sidered timepoints (t0 � t1) were assessed by means of apaired sample t-test. A survival analysis was performed by

Survival study on teeth after successful endodontic surgical retreatment 65

using Kaplan—Meier plots and a log-rank test to assess thesignificance of the differences among the subgroups definedby the following criteria: (a) CH lower or greater than themedian value; (b) RL lower or greater than the median value;(c) CRR lower or greater than 1; (d) CRR lower or greater thanthe median value; (e) single-rooted teeth vs. multi-rootedteeth. All types of unrecoverable SER-related late failureswere considered as ‘‘event’’ for the analysis, including atooth fracture, acute periradicular abscess, formation of

class III periodontal furcation defects, grade 3 tooth mobility,etc. The level of significance was set at 0.05.

Results

A minimal and not significant ( p > 0.05) variation of thevariables of interest was observed between the measure-ments made on the postoperative and on the last availableradiographs: CH, 7.84 � 2.51 mm at t0 and 7.73 � 2.48 mmat t1; RL, 10.22 � 1.95 mm at t0 and 10.61 � 1.91 mm at t1;CRR, 1.48 � 0.49 at t0 and 1.52 � 0.60 at t1. The completedistribution of CH, RL, and CRR values relative to the sampleof patients selected for the present study is shown in the boxand whiskers plot in Fig. 1. The level of inter- and intra-observer agreement was found to be fully satisfactory, asdemonstrated by the Bland—Altman plots reported in Fig. 2.

Three teeth were excluded from the present studybecause they were not available for the evaluation, as theyhad been previously extracted by other dentists for prosthe-tic purposes. At the end of the analysis, the sample wasconstituted by 42 patients, each one contributing to thestudy with a single tooth, who were followed-up on averagefor 4.2 � 2.4 years. In the sample, the mean age was 45 � 12years and 26 patients were female. The treated tooth typesof the included patients were as follows: 20 incisors (19maxillary), 7 canines (5 maxillary), 9 premolars (6 maxillary),6 molars (5 maxillary).

Data distribution and survival rates are shown in Table 1.The outcome of the survival analysis is represented by meansof Kaplan—Meier curves in Fig. 3. In the comparison betweenthe teeth with the longest roots (longer than the medianvalue, 8 mm) and those with the shortest roots, the formersubgroup showed improved survival ( p < 0.05). No statisti-cally significant difference emerged among the remainingconsidered subgroups.

Discussion

The present study seems to preliminarily demonstrate thatthe clinical relevance of CRR in teeth successfully subjected

Figure 1 Box and whisker plot reporting the distribution ofthe variables of interest of the present study measured on thepostoperative periapical radiographs, namely crown height (CH),root length (RL), and crown-to-root-ratio (CRR). The first twoare reported in mm referring to the primary y-axis, CRR valuesare reported on the secondary y-axis.

Figure 2 Bland—Altman plots reporting the mean of the two measurements as the abscissa value, and the difference between thetwo values as the ordinate value. Eight plots are presented for the analysis of both inter- and intra-observer level of agreement. CH,crown height; RL, root length; SD, standard deviation.


Table 1 Data distribution and univariate log-rank analysis of the treated teeth included in the present study.

Variables No. of teeth No. of teeth with late failure No. of survived teeth p value

Crown height>median value 21 1 (4.8) 20 (95.2) 0.459<median value 21 2 (9.5) 19 (90.5)

Root length>median value 21 0 (0.0) 21 (100.0) 0.028<median value 21 3 (14.3) 18 (85.7)

Crown-to-root ratio>median value 21 1 (4.8) 20 (95.2) 0.415<median value 21 2 (9.5) 19 (90.5)

Crown-to-root ratio>1 35 3 (8.6) 32 (91.4) 0.381<1 7 0 (0.0) 7 (100.0)

Tooth typeSingle-rooted 34 2 (5.9) 32 (94.1) 0.377Multi-rooted 8 1 (12.5) 7 (87.5)

Percentages of teeth are in parentheses. A significant difference is indicated by the log-rank test (a = 0.05): comparison of the survival ratewithin each factor.

Figure 3 Kaplan—Meier cumulative survival curves of teeth subjected to surgical endodontic retreatment in relation to the divisionin subgroups. CH, crown height; RL, root length; CRR, crow-to-root ratio.


to SER might be limited, despite the hypotheses of otherAuthors, who reported that CRR changes significantly afterapical resections of 3.58 � 1.43 mm and could play a signifi-cant role in the long-term prognosis of root-end resectedteeth.24 Conversely, the clinical relevance of the residual RLdeserves to be further investigated, since in the presentstudy longer roots were associated with higher survival,apparently regardless of CRR. A possible explanation for thisfinding is that the biomechanical behaviour of an apicallyresected tooth is affected only in small part by the apical lossof 3 mm of root length, while a more relevant influence isattributed to the loss of marginal periodontal bone.20 In turn,this is ascribable to the little impact that the loss of a smallportion of the external root surface has, compared to theattachment loss at the coronal level, where the root surfaceis much greater for geometrical reasons, being the rootapproximately cone-shaped. It is noteworthy that the major-ity (>75%) of the analysed teeth exhibited undesirable CRRratios (>1). Given the high survival rates observed in thissubgroup (32/35 cases, 91.4%), this finding might be preli-minarily indicative that the 1:1 threshold value of CRRsuggested in prosthetic dentistry may be excessively ‘‘pessi-mistic’’ when applied to teeth subjected to SER.

In the clinical setting, the assessment of treatment out-come is generally based on the subjective symptoms reportedby the patient, the findings of the clinical examination, andthe radiographic signs. From its introduction several yearsago, the Molven’s scale has been widely used for the radio-graphic evaluation of SER outcome in a multitude of clinicalstudies.1,3,4,6,9,11,26,27 The global acceptance of Molven’sscale can be attributed to its intrinsic simplicity of inter-pretation and completeness in the contemplation of thepossible healing patterns of a periapical defect. For themedium- and long-term follow-up of apically resected teeth,onemay argue that cone-beam computed tomography shouldbe preferred over traditional two-dimensional periapicalradiography because it is known that the latter has inherentlimitations such as superimposition and distortion of anato-mical structures that may interfere with a correct diagno-sis.28,29 However, the objective of the present study was toevaluate teeth whose periapical healing process had alreadybeen documented; this kind of assessment is undoubtedlymore straightforward than the search for a periapical lesionfor diagnostic purposes, which, differently from a surgicaldefect, can be limited to the cancellous bone and not easilydetectable.30 Although the accuracy of cone beam computertomography is considered excellent,29 the Authors stronglybelieve that this three-dimensional imaging technique shouldbe used for the cases where it is diagnostically advantageousand not for routine follow-up controls, in order to minimizethe radiation dose for the patient.31 Furthermore, the verypositive outcome of the Bland—Altman analysis demonstratesthat the use of periapical radiographs was a reliable analy-tical approach for the purpose of the present investigation.

In comparison with other previously published reportswith similar research objective,13,14 the present study ana-lysed a relatively small-sized sample. However, the smallnumber of selected cases was due to the restrictive inclusioncriteria that were chosen for the present study. Specifically,the exclusion of teeth adhesively or prosthetically connectedto other teeth caused a relevant decrease of the number ofthe eligible patients but guaranteed protection against the

bias that could derive from the biomechanical impact oftooth splinting. Moreover, the present study was designedto minimise the impact and number of confounding factors,as it intentionally involved the analysis of cases treated by asingle operator and following the same unvaried surgicalprotocol. Such decision inevitably reduced the sample sizebut provided a sample that is likely to be homogeneous and,thus, capable of furnishingmore reliable data. Notwithstand-ing, some results of the present study must be interpretedwith caution because some subgroups were composed of fewelements, as was the case of CCR <1 and multi-rooted teethsubgroups. For better understanding of the influence of thesefactors, a study on a larger scale appears advisable. If a morenumerous sample becomes available, the possible effectother clinical variables could be tested, considering theimpact of occlusal load distribution, para-functional activ-ities, and periodontal health in the first place.

As to teeth with more than one root, further tomographicinvestigations could hypothetically take into considerationthe effect that the root surface area may have on toothsurvival. Indeed, it may be speculated that root character-istics other than the length may contribute to improvethe prognosis of root-end resected teeth, for example rootshape, transversal diameters, curvature, etc. For instance, itis conceivable that a thin root may be at risk when strongocclusal forces are exerted on the apically resected tooth,especially in case of loss of other teeth, bruxism, or clenching.

Conclusions

Under the conditions of the present study, teeth with longerresidual roots after apical surgery exhibited better chancesof survival when compared to teeth with roots shorter than8 mm. The other considered variables did not seem to affectthe survival of apically resected teeth. Further studies areneeded to confirm these findings on a larger sample ofpatients.

Clinical relevance

The present retrospective study preliminarily suggests that,after successful root end surgery, the residual root lengthmight play a more relevant role than the crown-to-root ratioin determining the long-term survival of the apically resectedteeth.


The authors declare that there are no conflicts of interest.

Acknowledgements

The study was self-funded.

References

1. Setzer FC, Shah SB, Kohli MR, Karabucak B, Kim S. Outcome ofendodontic surgery: a meta-analysis of the literature — part 1:comparison of traditional root-end surgery and endodonticmicrosurgery. J Endod 2010;36:1757—65.


2. Kohli MR, Berenji H, Setzer FC, Lee SM, Karabucak B. Outcome ofendodontic surgery: a meta-analysis of the literature — part 3:comparison of endodontic microsurgical techniques with 2 dif-ferent root-end filling materials. J Endod 2018;44:923—31.

3. Setzer FC, Kohli MR, Shah SB, Karabucak B, Kim S. Outcome ofendodontic surgery: a meta-analysis of the literature — part 2:comparison of endodontic microsurgical techniques with andwithout the use of higher magnification. J Endod 2012;38:1—10.

4. Kang M, Jung HI, Song M, Kim SY, Kim HC, Kim E. Outcome ofnonsurgical retreatment and endodontic microsurgery: a meta-analysis. Clin Oral Investig 2015;19:569—82.

5. Danin J, Stromberg T, Forsgren H, Linder LE, Ramskold LO.Clinical management of nonhealing periradicular pathosis. Sur-gery versus endodontic retreatment. Oral Surg Oral Med OralPathol Oral Radiol Endod 1996;82:213—7.

6. Del Fabbro M, Taschieri S, Testori T, Francetti L, Weinstein RL.Surgical versus non-surgical endodontic re-treatment for peri-radicular lesions. Cochrane Database Syst Rev 2007;CD005511.

7. Kvist T, Reit C. Results of endodontic retreatment: a randomizedclinical study comparing surgical and nonsurgical procedures.JEndod 1999;25:814—7.

8. Torabinejad M, Corr R, Handysides R, Shabahang S. Outcomes ofnonsurgical retreatment and endodontic surgery: a systematicreview. J Endod 2009;35:930—7.

9. Caliskan MK, Tekin U, Kaval ME, Solmaz MC. The outcome ofapical microsurgery using MTA as the root-end filling material:2- to 6-year follow-up study. Int Endod J 2016;49:245—54.

10. Jesslen P, Zetterqvist L, Heimdahl A. Long-term results of amal-gam versus glass ionomer cement as apical sealant after api-cectomy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod1995;79:101—3.

11. Kim E, Song JS, Jung IY, Lee SJ, Kim S. Prospective clinical studyevaluating endodontic microsurgery outcomes for cases withlesions of endodontic origin compared with cases with lesionsof combined periodontal-endodontic origin. J Endod 2008;34:546—51.

12. Maddalone M, Gagliani M. Periapical endodontic surgery: a3-year follow-up study. Int Endod J 2003;36:193—8.

13. Rubinstein RA, Kim S. Long-term follow-up of cases consideredhealed one year after apical microsurgery. J Endod 2002;28:378—83.

14. Song M, Chung W, Lee SJ, Kim E. Long-term outcome of the casesclassified as successes based on short-term follow-up in endo-dontic microsurgery. J Endod 2012;38:1192—6.

15. SongM, NamT, Shin SJ, Kim E. Comparison of clinical outcomes ofendodontic microsurgery: 1 year versus long-term follow-up. JEndod 2014;40:490—4.

16. Testori T, Capelli M, Milani S, Weinstein RL. Success and failure inperiradicular surgery: a longitudinal retrospective analysis. OralSurg Oral Med Oral Pathol Oral Radiol Endod 1999;87:493—8.

17. von Arx T, Jensen SS, Hanni S, Friedman S. Five-year longitudinalassessment of the prognosis of apical microsurgery. J Endod2012;38:570—9.

18. Kim S, Kratchman S. Modern endodontic surgery concepts andpractice: a review. J Endod 2006;32:601—23.

19. De Deus QD. Frequency, location, and direction of the lateral,secondary, and accessory canals. J Endod 1975;1:361—6.

20. Jang Y, Hong HT, Chun HJ, Roh BD. Influence of apical rootresection on the biomechanical response of a single-rootedtooth — part 2: apical root resection combined with periodontalbone loss. J Endod 2015;41:412—6.

21. Jang Y, Hong HT, Roh BD, Chun HJ. Influence of apical rootresection on the biomechanical response of a single-rootedtooth: a 3-dimensional finite element analysis. J Endod2014;40:1489—93.

22. Sauveur G, Boccara E, Colon P, Sobel M, Boucher Y. A photo-elastimetric analysis of stress induced by root-end resection.JEndod 1998;24:740—3.

23. Grossmann Y, Sadan A. The prosthodontic concept of crown-to-root ratio: a review of the literature. J Prosthet Dent 2005;93:559—62.

24. von Arx T, Jensen SS, Bornstein MM. Changes of root length androot-to-crown ratio after apical surgery: an analysis by usingcone-beam computed tomography. J Endod 2015;41:1424—9.

25. Molven O, Halse A, Grung B. Observer strategy and the radio-graphic classification of healing after endodontic surgery. IntJ Oral Maxillofac Surg 1987;16:432—9.

26. Chong BS, Pitt Ford TR, Hudson MB. A prospective clinical studyof Mineral Trioxide Aggregate and IRM when used as root-endfilling materials in endodontic surgery. Int Endod J 2003;36:520—6.

27. Lindeboom JA, Frenken JW, Kroon FH, van den Akker HP. Acomparative prospective randomized clinical study of MTA andIRM as root-end filling materials in single-rooted teeth in endo-dontic surgery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod2005;100:495—500.

28. LeQuire AK, Cunningham CJ, Pelleu Jr GB. Radiographic inter-pretation of experimentally produced osseous lesions of thehuman mandible. J Endod 1977;3:274—6.

29. Leonardi Dutra K, Haas L, Porporatti AL, Flores-Mir C, Santos JN,Mezzomo LA, et al. Diagnostic accuracy of cone-beam computedtomography and conventional radiography on apical periodonti-tis: a systematic review and meta-analysis. J Endod 2016;42:356—64.

30. Bender IB, Seltzer S. Roentgenographic and direct observation ofexperimental lesions in bone: II. 1961. J Endod 2003;29:707—12.discussion 701.

31. Aanenson JW, Till JE, Grogan HA. Understanding and commu-nicating radiation dose and risk from cone beam computedtomography in dentistry. J Prosthet Dent 2018.


CASE REPORT/CASO CLINICO

Ludwig [42_TD$DIFF]’s angina: a case report with a 5-yearfollow-up

Angina di Ludwig: un caso clinico con 5 anni di follow-up

Dario Re Cecconi a,*, Roberto Fornara b,c

aUniversity of Milan, Department of Biomedical Sciences, Surgery and Dentistry, Unit of Oral Medicine, Oral Pathologyand Gerodontology, ItalybPrivate Practice in Magenta, ItalycNational Secretary of Italian Endodontic Society (SIE), Italy

Received 13 April 2018; accepted 27 June 2018Available online 2 October 2018


KEYWORDSLudwig[42_TD$DIFF]’s angina;Endodontic therapy;Endodontic infection;CBCT;Management infection.

Abstract

Aim: Ludwig’s angina is a rare aggressive infection, often of dental origin, characterized by arapid spread of cellulitis in the submandibular and sublingual spaces. Ludwig [42_TD$DIFF]’s angina ispotentially fatal, if it obstructs the airways and if it is not treated with appropriate antibiotictherapy.Summary: The case report describes the diagnosis and the management of a Ludwig [42_TD$DIFF]’s anginacaused by an endodontic infection in a 16 years-old female patient. The infection has beencaused by a decay of the second lower right molar. After hospitalization and systemic antibiotictherapy, in accordance with the patient and the parents endodontic and restorative treatmentsof the tooth were performed. After 3 and 5 years, the radiological examination revealed noperiapical lesions around right lower second molar and the presence of lamina dura.Key learning points: This aggressive infection may often be undervalued and this may causedangerous consequences to the patient [43_TD$DIFF]’s life. The infection can be prevented by periodic dentalcare and interventions, which can avoid odontogenic infections. In the case of Ludwig’s angina,early diagnosis is fundamental to save the patient’s life. After the initial antibiotic therapy andonce the life of the patient is no longer at risk, an appropriate endodontic therapy can beconsidered a valid therapy for this disease.


* Corresponding author at: Via G. Cler, 42, 20013 Magenta, Milano, Italy.E-mail: [email protected] (D. Re Cecconi).


ScienceDirect



Introduction

Ludwig [42_TD$DIFF]’s angina is a rare aggressive infection, often of dentalorigin, characterised by a rapid spread of cellulitis in thesubmandibular and sublingual spaces.1,2 [42_TD$DIFF]

The first case was described by Karl Friedrich Wilhelm vonLudwig in 1836.3 The most common victim of Ludwig’s anginais a male, aged between 20 and 40.4 [42_TD$DIFF] The origin of Ludwig[42_TD$DIFF]’sangina is odontogenic in 90% of cases.5 It is usually theconsequence of tooth extraction or infection.2 The originis generally the second and third inferior molar (70—80%).6 Infact, the roots of these teeth penetrate the mylohyoid ridge,such that any abscess or dental infection has direct access tothe submaxillary space. The propagation of the cellulitisdepends on the anatomy of the neck.7 Once infection devel-ops, it spreads contiguously to the sublingual space. Infectioncan also spread contiguously to involve the pharyngomaxil-lary and retropharyngeal spaces.8 Other causes of infectionhave also been reported, such as pharyngeal infection ortonsillitis, infections due to foreign bodies, or infections thatare secondary to squamous cell carcinoma, located at thebase of the tongue and at the floor of mouth.8 Other pre-disposing conditions include poor dental hygiene, dentalcaries, intravenous drug abuse, malnutrition, diabetes mel-litus, AIDS, immunosuppression, and systemic lupus erythe-matosus. In children, Ludwig’s angina can occur without anypredisposing condition.8 [42_TD$DIFF]

At an initial examination, the general health of thepatient is often already clearly compromised but, never-theless, the local condition is not severe. Bilateral supra-hyoid swelling is observed, with a hard, cardboard-like

consistency. It is non-fluctuating and painful on palpation.The mouth hangs somewhat open and the tongue is in contactwith the palate, with clear oedema of the floor of the mouth.There is difficulty in swallowing and breathing, which are themost salient presenting clinical features of the illness, andthis is due to cellulitis, aided by the awkwardness resultingfrom the position of the tongue.7,9 It can also highlighterythema and redness of the skin area in front of the neck.

The diagnosis in patients with Ludwig’s angina is based onclinical findings. Panoramic radiography can help to discoverthe origin of the dental infection, while a cervico-thoracic CTscan can help to determine its extent, especially when thereis abscess formation.10,6 [42_TD$DIFF]

Microbiological investigations are useful to assess themost effective antibiotic therapy. A common cause of Lud-wig[42_TD$DIFF]’s angina is a mixture of aerobic and anaerobic bacteria,including, predominately, normal oral flora.3

The management of Ludwig’s angina involves antibiotics andmaintenance of a secure airway to prevent asphyxia, and surgicaldrainage ifnecessary.2,11,12[42_TD$DIFF] IntravenouspenicillinG,clindamycin,andmetronidazoleare theantibiotics recommended forusepriorto obtaining culture and antibiogram results. Some authors alsorecommend the use of gentamicin.13,14,6 Other studies are basedon the fact that infections caused by aerobic Gram-negativeorganisms are uncommon in deep neck abscesses. Thus, theuse of gentamicin is not recommended as a first choice in theinitial treatment by some authors.7,15

Ludwig’s angina is potentially fatal, if it obstructs theairways2,16 [42_TD$DIFF] and if it is not treated with appropriate antibiotictherapy.7 Its mortality rate can reach up to 50%.8 The odon-togenic infections that may cause Ludwig’s angina can largelybe prevented by timely interventions and periodic dentalcare.17 [42_TD$DIFF]

PAROLE CHIAVEAngina di Ludwig;Terapia endodontica;Infezione endodontica;CBCT;Gestione dell’infezione.

� 2018 Societa Italiana di Endodonzia. Production and hosting by Elsevier B.V. This is an openaccess article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Riassunto

Obiettivi: L’angina di Ludwig e un’infezione aggressiva, spesso di origine odontogena, caratte-rizzata da una raccolta cellulitica a rapida evoluzione che coinvolge gli spazi sotto-mandibolare esotto-linguale. Essa puo ostruire le vie respiratorie ed essere potenzialmente fatale se nontempestivamente trattata con cure antibiotiche appropriate.Riassunto: In questo articolo viene descritto un caso di diagnosi e trattamento di un’angina diLudwig causata da un’infezione odontogena in una ragazza di 16 anni. L’infezione e stata causatada una carie a carico del secondo molare inferiore di destra. Dopo il ricovero ospedaliero ed unaterapia antibiotica sistemica parenterale, con il consenso dei genitori abbiamo e stata eseguitauna terapia endodontica e la successiva ricostruzione con materiali adesivi dell’elementodentario in questione. Dopo 3 e 5 anni gli esami radiografici mostrano assenza di lesioniperiapicali e la presenza della lamina dura.[44_TD$DIFF]Punti chiave di apprendimento: Questa infezione aggressiva e spesso sottovalutata e cio puocausare conseguenze gravi per la vita del paziente. Tali infezioni possono essere prevenute concontrolli periodici del cavo orale. In caso di angina di Ludwig una diagnosi tempestiva efondamentale per salvare la vita del paziente. Dopo l’iniziale terapia antibiotica ed aver messoin sicurezza la salute generale del paziente, la terapia endodontica puo essere considerata unavalida alternativa per questa patologia.� 2018 Societa Italiana di Endodonzia. Production and hosting by Elsevier B.V. This is an openaccess article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Ludwig’s angina: A case report with a 5-year follow-up 71

Case report

A 16-year-old female was referred to the author’s practicewith pain, swelling and difficult swallowing for 1 day. Thepatient reported that another dentist had performed a pul-potomy and administered a medication with non-specifiedmaterials. The patient was taking 1 g amoxicillin per day.

A clinical examination revealed extra-oral bilateral swel-ling, especially on the right side of the face (Fig. 1). The skinof the perioral tissue and of the neck was red and hot. Thetemperature of the patient was about 38 8C. The patient haddifficulties in opening her mouth. The lateral cervical lymphnodes were positive on palpation. During the visit, there wasan increase in breathing frequency (26 breaths per minute)and subsequent increasing difficulty in breathing. Given thesevere clinical situation, the patient was referred to theemergency department of Oral and Maxillofacial Surgerywhere she stayed for 7 days and treated with intravenousantibiotic therapy. During the hospitalization, an orthopan-tomography and CT scans with and without contrast liquidwere performed to visualize the size of the lesion and itsrelationship with the surrounding anatomical structures(Figs. 2 and 3).

After the acute phase, initially the extraction of the rightlower second molar was suggested because the poor endo-dontic therapy caused the severe clinical situation. A moreaccurate clinical examination revealed that the tooth had atemporary restoration, the clinical and radiography analysisshowed a good residual structure and that extraction was notnecessary.

The patient and her parents were advised of the technicaldifficulties and potential risks of endodontic treatment, ofpotential new swelling and of the uncertainty recovery. Theparents gave written consent for the proposed treatment.

The treatment plan included cleaning of the canal space,endodontic obturation with gutta-percha and direct recon-struction with composite. A preoperative periapical radio-graphic examination (Soredx, Digora, MI, Italy) (Fig. 4A)showed an abnormal previous access to the endodonticspace.

From the initial pre-operative radiograph (Fig. 4A) in notevident a big periapical lesion but we remember that thepatient had an abscess that required hospitalization for 7days (Fig. 1).

At the first session, after a mouth rinse with 0.2% chlor-hexidine gluconate (Curasept, Curaden Healthcare, Saronno,VA, Italy) the tooth was anaesthetised with inferior alveolarnerve block and buccal infiltration of 2% articaine containing1:100,000 epinephrine (Ubistesin 3M ESPE, Neuss, Germany).The tooth was isolated with a rubber dam (Nictone Manufac-turera Dental Continental, Zapopan, Jalisco, Mexico). The

occlusal access cavity was modified with diamond bur D6CIntensiv (Intensiv, Lugan, Switzerland).

The tooth had three canals: two mesial and one distal.Root canals were cleaned and then the electronic workinglength was taken with an apex locator (Morita Denta Port ZX,Dietzenbach, Germany). The canals were instrumented usinga crown-down technique with ProTaper Universal files (Dents-ply Sirona Endodontics, Ballaigues, Switzerland) up to a sizeF3 (Fig. 4B) and abundant irrigation with 5.25% sodiumhypochlorite at 50 8C (Niclor Ogna, Muggio, MB, Italy) wasperformed. Calcium hydroxide was placed as interappoint-ment dressing (Stomidros Funo, BO, Italy) and the accesscavity was temporarily sealed with Cavit G (3M ESPE, Neuss,Germany).

After 7 days, the root canals were irrigated with EDTA(17%, Ogna, Muggio) and 5.25% sodium hypochlorite. The rootcanals were dried with calibrated absorbent paper points andthe canal was obturated with gutta percha and Pulp CanalSealer (SybornEndo, Amersfoort, Netherland) using the warmvertical compaction with heated pluggers and condensers(Hu-Friedy, MI, Italy). At the next clinical session, the coronalaccess was adhesively restored with a fibre post (D.T. LightPost, Dentsply, Rome, Italy) resin cement and composite (AllBond 2, Bisco, Schaumburg, IL, USA; Clearfil SA Cement,Kuraray, Hattersheim am Main, Germany; Filtek, 3M ESPE,Neuss, Germany) and an immediate postoperative radiographwas taken (Fig. 4C). All the treatment was performed undermagnification (4.3�; Zeiss, Oberkochen, Germany).

After the therapy, the patient moved to another city. After3 years, the patient came back to the author’s practice with aCBCT (Fig. 5A and B) and she gave her consent to take aperiapical radiograph (Fig. 5C). The radiological examinationrevealed no periapical lesions around tooth 47, the presenceof lamina dura (Fig. 6A—C) and showed the confluence of themesial canals (Fig. 7).

After 5 years, another periapical control radiograph wastaken, revealing a normal periapical status (Fig. 8).

Figure 1 Three-dimensional reconstruction of the patient’s face obtained by 3D reprocessing of the CT. Note the strong swelling ofthe right side.

Figure 2 Orthopantomography showing an abnormal access tothe endodontic space.

72 D. Re Cecconi, R. Fornara

Figure 3 (A—D) Cervico-thoracic CT scan with and with-out contrast fluid showing the extension of cellulitis, the occlusion ofesophagus and the deviation of trachea.

Figure 4 (A) Pre-operative periapical radiograph showing a good residual structure and small periapical lesions; (B) working lengthwith gutta-percha points; (C) final periapical radiograph showing a good compaction of endodontic obturation.

Figure 5 (A and B) Axial CBCTcross-sections showing good endodontic obturation and healing of the bone. (C) Periapical radiograph 3years after the therapy showing absence of periapical lesions.

Figure 6 Axial CBCT cross-sections showing of the mesial root (A) and the distal root (B) the absence of periapical lesions aroundtooth 47 and the presence of lamina dura. (C) Sagittal cross-sections confirm the presence of lamina dura[41_TD$DIFF], the absence of materialextrusion of root canal obturation and the proximity of the apical root to the mandibular canal.


Discussion

Ludwig [42_TD$DIFF]’s angina usually presents in patients with poor dentalhygiene, which accounts for approximately 75—95% ofcases.3 The clinical presentation consists of malaise, dys-phagia, bilateral cervical swelling, neck tenderness, dys-phonia, elevation and swelling of the tongue, pain in thefloor of the mouth, sore throat, restricted neck movementand stridor, suggestive of impending airway obstruction.3,8

The anatomy of the neck is crucial to the understanding ofthe pathophysiology of Ludwig’s angina. Odontogenic infec-tions are the most common cause of Ludwig [42_TD$DIFF]’s angina espe-cially, when the second and third lowermolars are involved.7 [42_TD$DIFF]Infection in the submandibular space may extend to thelateral pharyngeal and retropharyngeal spaces becausethese lie below the level of the deep superficial cervicalfascia. Infections in the retropharyngeal space can traveldownward to the mediastinum and cause acute mediastini-tis, empyema, or pericarditis.7,8

A mixture of aerobic and anaerobic bacteria can cause theinfection. Anaerobic bacteria are responsible for the gasformation in the soft tissues.18 Dentists should be consciousof the signs of infections, especially those that extend intothe deep planes. These signs can include fever, swelling ofthe floor of the mouth, swelling below the inferior border ofthe mandible, asymmetric bulging of the pharyngeal walls,and trismus or pain out of proportion to the amount ofswelling.3,7 [45_TD$DIFF] A cervicothoracic CT scan, with or without con-trast fluid, can help to determine the extent of the infection,especially when there is abscess formation.3 Antimicrobialtherapy for odontogenic infections has been described inmany other references and is not the focus of this article.

Although many authors recognise the importance of sur-gical drainage,8 in this case it was not considered necessaryby the maxillofacial surgeons, who focused on the antibiotictherapy and on the evaluation of the vital signs of thepatient.

In the literature, there is no previous case of Ludwig[42_TD$DIFF]’sangina with an endodontic origin that has been treated withendodontic therapy, with follow-up.

Conclusions

Ludwig [42_TD$DIFF]’s angina is a rare and not very well known disease thatcan rapidly progress and can be potentially fatal. This aggres-sive infection may often be undervalued and this may causedangerous consequences to the patient [46_TD$DIFF]’s life. The infectioncan be prevented by timely interventions and periodic dentalcare, which can avoid odontogenic infections. In the case ofLudwig’s angina, early diagnosis is fundamental to save thepatient’s life. After the initial antibiotic therapy and once thelife of the patient is no longer at risk, appropriate endodontictherapy can be considered a valid therapy for this disease.


The authors decline any conflicts of interest.

Acknowledgements

The authors are grateful to Dott. Stefano Ferrari for thesupport given during the treatment of the patient.

References

1. Fursta IM, Ersil P, Caminiti M. A rare complication of toothabscess Ludwig[42_TD$DIFF]’s angina and mediastinitis. J Can Dent Assoc2001;67(6):324—7.

2. Chueng K, Clinkard DJ, Enepekides D, Peerbaye Y, Lin VY. Anunusual presentation of Ludwig[42_TD$DIFF]’s angina complicated by cervicalnecrotizing fasciitis: a case report and review of the literature.Case Rep Otolaryngol 2012;2012:931350.

3. Marcus BJ, Kaplan J, Collins KA. A case of Ludwig angina: a casereport and review of the literature. Am J Forensic Med Pathol2008;29(3):255—9.

4. Bross-Soriano D, Arrieta-Gomez JR, Prado-Calleros H, Schimel-mitz-Idi J, Jorba-Basave S. Management of Ludwig[42_TD$DIFF]’s angina withsmall neck incisions: 18 years experience. Otolaryngol HeadNeck Surg 2004;130(6):712—7.

5. MorelandLW,Corey J,McKenzie R. Ludwig[42_TD$DIFF]’s angina. Report of a caseand review of the literature. Arch Intern Med 1988;148(2):461—6.

Figure 8 A periapical radiograph 5 years after the therapyshowing absence of periapical lesions.

Figure 7 Three-dimensional reconstruction obtained from theCBCT of the right lower second molar showing the root canalfilling. Note the absence of gaps in the three-dimensional fillingand the confluence of the mesial canals.

74 D. Re Cecconi, R. Fornara

6. Jimenez Y, Bagan JV, Murillo J, Poveda R. Odontogenic infec-tions. Complications. Systemic manifestations. Med Oral PatolOral Cir Bucal 2004;9(Suppl. 143—147):139—43.

7. Saifeldeen K. Ludwig[42_TD$DIFF]’s angina. Emerg Med J 2004;21(2):242—3.8. Candamourty R, Venkatachalam S, Babu MR, Kumar GS. Ludwig[42_TD$DIFF]’s

angina — an emergency: a case report with literature review. JNat Sci Biol Med 2012;3(2):206—8.

9. Scully C, Langdon J, Evans J. Marathon of eponyms: 12 Ludwigangina. Oral Dis 2010;16(5):496—7.

10. Har-El G, Aroesty JH, Shaha A, Lucente FE. Changing trends indeep neck abscess. A retrospective study of 110 patients. OralSurg Oral Med Oral Pathol 1994;77(5):446—50.

11. Boscolo-Rizzo P, Da Mosto MC. Submandibular space infection:a potentially lethal infection. Int J Infect Dis 2009;13(3):327—33.

12. DeAngelis AF, Barrowman RA, Harrod R, Nastri AL. Review arti-cle: maxillofacial emergencies: oral pain and odontogenic infec-tions. Emerg Med Australas 2014;26(4):336—42.

13. Dugan MJ, Lazow SK, Berger JR. Thoracic empyema resultingfrom direct extension of Ludwig[42_TD$DIFF]’s angina: a case report. J OralMaxillofac Surg 1998;56(8):968—71.

14. Hart BT. Tracheotomy for Ludwig[42_TD$DIFF][40_TD$DIFF]’s angina. Oral Surg Oral MedOral Pathol 1994;78(4):414—5.

15. Parhiscar A, Har-El G. Deep neck abscess: a retrospective reviewof 210 cases. Ann Otol Rhinol Laryngol 2001;110(11):1051—4.

16. Diaz Manzano JA, Cegarra Navarro MF, Medina Banegas A, LopezMeseguer E. Diagnostic and treatment of necrotizing cervicalfascitis. Clinical course after a Ludwig angina. An Otorrinolar-ingol Ibero Am 2006;33(3):317—22.

17. Allareddy V, Rampa S, Nalliah RP, Allareddy V. Longitudinaldischarge trends and outcomes after hospitalization for mouthcellulitis and Ludwig angina. Oral Surg Oral Med Oral Pathol OralRadiol 2014;118(5):524—31.

18. Whitesides L, Cotto-Cumba C, Myers RA. Cervical necrotizingfasciitis of odontogenic origin: a case report and review of 12cases. J Oral Maxillofac Surg 2000;58(2):144—51.


CASE REPORT/CASO CLINICO

Home management of crown fractures of twocentral incisors complicated by exposureof the pulp

Gestione domiciliare delle fratture della corona di due incisivi centralicomplicata dall’esposizione della polpa

Luca Boschini [1_TD$DIFF]

Private Clinic, Viale Enrico Panzacchi 21, 47922 Rimini, RN, Italy

Received 27 July 2018; accepted 10 September 2018Available online 2 October 2018


KEYWORDSCapping materials;Complicated crownfracture;Dental injuries;Pulp capping;Pulp exposure;Pulp vitality.

Abstract

Aim: As dental trauma is an unpredictable event, [16_TD$DIFF]the [17_TD$DIFF]patient is [18_TD$DIFF]sometimes [19_TD$DIFF]unable to [20_TD$DIFF]receivedental care [21_TD$DIFF] immediately in case of tooth fracture complicated by exposure [22_TD$DIFF]to the pulp. It isconceivable that a long wait may favor bacterial contamination that can lead to[4_TD$DIFF] necrosis [23_TD$DIFF] of thepulp. The [24_TD$DIFF]aim [25_TD$DIFF]of [26_TD$DIFF]this [27_TD$DIFF]paper [28_TD$DIFF]is to [29_TD$DIFF]present a [30_TD$DIFF]clinical [31_TD$DIFF]case [32_TD$DIFF]in which the pulp [33_TD$DIFF]has [34_TD$DIFF]been [35_TD$DIFF]protected[36_TD$DIFF]domiciliary [37_TD$DIFF]to [38_TD$DIFF]reduce post-traumatic hypersensitivity and the risk of pulpal necrosis.[39_TD$DIFF]Materials and methods: In [40_TD$DIFF]the presented clinical case[41_TD$DIFF], [42_TD$DIFF]the nail [43_TD$DIFF]polish was used as an emergencymaterial for [44_TD$DIFF]the [45_TD$DIFF]direct capping[46_TD$DIFF] of the pulp of two fractured[5_TD$DIFF] incisors. In thisway[6_TD$DIFF] itwas possible to protectthe pulp and seal the dentinal tubules for 5 days,[47_TD$DIFF] such it is the time[7_TD$DIFF] between[8_TD$DIFF] trauma[9_TD$DIFF] and[8_TD$DIFF] therapy[10_TD$DIFF].[48_TD$DIFF]Results: The [49_TD$DIFF]application [37_TD$DIFF]of the [50_TD$DIFF]nail [51_TD$DIFF]polish [52_TD$DIFF]led [53_TD$DIFF]to [54_TD$DIFF]a [55_TD$DIFF]reduction in [56_TD$DIFF]hypersensitivity; [57_TD$DIFF]at [58_TD$DIFF]2-year [59_TD$DIFF]follow-up [60_TD$DIFF]both[27_TD$DIFF]teeth [61_TD$DIFF]were [62_TD$DIFF]still [63_TD$DIFF]vital.[64_TD$DIFF]Conclusions: Basedon this experience, [65_TD$DIFF]it [66_TD$D IFF]is suggested thepossibility to[67_TD$DIFF] recommend theuse of nail [43_TD$DIFF]polishas a protective material for the pulp and [68_TD$DIFF]for [69_TD$DIFF]reducing symptoms in case of complicated anduncomplicated fractures, if the dentist [70_TD$DIFF]is consulted by telephone and the patient [71_TD$DIFF]is not in [72_TD$DIFF]conditionto reach it quickly.� 2018 Societa Italiana di Endodonzia. Production and hosting by Elsevier B.V. This is an open accessarticle under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).


E-mail: [email protected].


ScienceDirect



Introduction

Traumatology is an important branch of pediatric dentistry andoften involves tooth pulp. The peculiarity of a trauma is that itmay happen in any circumstance, even in a moment in which itis not possible to immediately reach the care of a doctor. Theearly management of the dental emergency is able to improvethe prognosis, so generally it is essential to manage the patientas soon as possible. This is particularly true in the case ofavulsive traumas, but this can also be extended to thosetraumas involving the pulp, in order to maintain its vitalityand to reduce the high sensitivity following the trauma. Somestudies about the factors influencing themaintenance of pulpalvitality observed that the subluxation associated with compli-cated or uncomplicated coronal fractures influences pulp vital-ity resulting in an increased risk of pulp necrosis, because vitalpulp with a regular and functional blood circulation wouldappear to be more resistant to invasion of bacteria.1,2 Alsothe root formation stage and the depth of the fracture sig-nificantly influence the pulp vitality; the immature elementsshow less probability of developing pulpal necrosis than theelements with fully formed roots and deep fractures evolvemore easily towards necrosis. In the teeth with complicatedfracture the time interval between the trauma and the therapyseems also to influence the maintenance of pulpal vitality,1,3,4

but some author found no significant differences between thetime elapsed before treatment and the appearance of pulpalnecrosis.5,6 The quality of the marginal seal is also important7

and it underlines the importance of protecting the pulp frombacterial contamination. All these factors suggest the need fora rapid emergency treatment.

Report

This case report describes the personal experience of the 9years old son of the author.

The child slipped on the edge of a water slide, bumpinginto the upper central incisors and fracturing them. The

teeth fractures were both complicated by pulp exposure.The fragments have been recovered. The child has experi-enced a high dentinal sensitivity after the trauma.

The trauma occurred during the Easter holidays and alldentists were unavailable.

It was impossible to provide a professional treatmentbefore 5 days, thus it was mandatory to find a material toperform an emergency pulp capping and a nail polish wasused for this purpose.

Nail polish was carefully applied after drying the toothwith a paper towel; there was a micro-bleeding of the pulpimmediately after applying the first coat of nail polish on oneof the two teeth. After waiting aminute a second layer of nailpolish was applied. Following application, all the pulp anddentin were protected up to the cavity edge in enamel.Sensitivity was immediately diminished after applying nailpolish. The pulp has always remained protected and no longerexposed until the therapeutic session was performed (Fig. 1).The fractured fragments were stored in saliva, changed dailyafter rinsing the fragments under running water.

After 5 days from the trauma, the therapeutic treatmentwas performed. The vitality was tested before anesthesia andwas positive. Nail polish was removed from the teeth with anexcavator. Immediately after the removal of the nail polish

PAROLE CHIAVEMateriale perincappucciamento;Frattura complicatadella corona;Trauma dentale;Incappucciamentopulpare;Esposizione pulpare;Vitalita pulpare.

Riassunto

[73_TD$DIFF]Scopo: Poiche [74_TD$DIFF]il [75_TD$DIFF]trauma [76_TD$DIFF]dentale e un [77_TD$DIFF]evento imprevedibile, a volte [78_TD$DIFF] il paziente non e [79_TD$DIFF]in [80_TD$DIFF]grado [81_TD$DIFF]di[82_TD$DIFF]ricevere [83_TD$DIFF]immediatamente [84_TD$DIFF]una [85_TD$DIFF]cura odontoiatrica in caso di frattura del dente complicatadall’esposizione della polpa. E immaginabile che una lunga attesa possa favorire la contamina-zione batterica che puo portare alla necrosi della polpa. Lo scopo del presente articolo e quello dipresentare un caso clinico nel quale la polpa e stata protetta domiciliarmente per ridurre la[86_TD$DIFF]ipersensibilita post-traumatica e allontanare il rischio della necrosi pulpare.Materiali e metodi: Nel caso clinico presentato, lo smalto per unghie e stato usato comemateriale di emergenza per l’incappucciamento diretto della polpa di due incisivi fratturati.In questo modo e stato possibile proteggere la polpa e sigillare i tubuli dentinali per 5 giorni, talee il tempo trascorso tra il trauma e la terapia.Risultati: L’applicazione dello smalto ha determinato una riduzione della [87_TD$DIFF]ipersensibilita;[13_TD$DIFF] a 2 anni[88_TD$DIFF]di [89_TD$DIFF]follow-up entrambi i denti[90_TD$DIFF] erano ancora vitali.Conclusioni: Sulla base di questa esperienza viene suggerita la possibilita di consigliare l’usodello smalto per unghie come materiale protettivo per la polpa e per ridurre i sintomi in caso difratture complicate e non complicate, qualora il dentista sia consultato telefonicamente e ilpaziente non sia nella condizione di poterlo raggiungere rapidamente.� 2018 Societa Italiana di Endodonzia. Production and hosting by Elsevier B.V. This is an openaccess article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Figure 1 Teeth after application of the nail polish over thefractured surfaces.

Management of crown fractures 77

there was a slight bleeding of the pulp that stopped sponta-neously in a few seconds. With a margin trimmer the enamelprisms not supported by dentin were removed, both on thecavity edge and on the fractured fragment. Then, in accor-dance with the guidelines of the IADT (International Associa-tion for Dental Traumatology),8 a direct pulp capping wasperformed using calcium hydroxide and protected with a verythin layer of glass-ionomer cement. On the side of thefragments a small removal of dentinal tissue was performedin order to compensate for the increase in volume due to thecapping. The reattachment of the fragments was carried outwith the commonmethods of adhesion (Fig. 2): etching of thecavities and fragments, application of a layer of bondingagent and application of flowable composite on the frag-ments, which, once repositioned, squeezed out the excess ofcomposite material. This excess of composite was removedwith a micro-brush before curing. After the polymerization, apolishing with a silicone rubber was performed.

The vitality test was repeated quarterly for up to two yearand was always positive. The radiograph done two years afterthe trauma showed the reattached fragments in position andno periapical lesion accordingly to the positive vitality test(Fig. 3). The root apexes are still open accordingly to the ageof the child.

Discussion

The unpredictability of a trauma can cause delay in theappropriate therapy even when it would be important tointervene in a short time. The motivation is that the morerapid the intervention, the lower the bacterial invasion; alsothe improvement of the symptoms and the patient’s comfortis greater if the time interval between trauma and treatmentis smaller.

Some interventions should be managed at the site of thetrauma even by rescuers who are not operators in the dentalsector, perhaps under the directives of their dentist. This isespecially true in the case of traumas such as dental avul-sions,9 but also the early protection of an exposed pulp canhelp to maintain the vitality of the tooth and reduce the highsensitivity following the trauma. Traumatology is usuallyconsidered a dental emergency, therefore it is desirable thatthe therapy could be performed within a few hours from thetrauma (cut off point 3 h) in the acute phase compared tointervention in the subacute phase (within 24 h) or delayed(over 24 h).10

In the case described in the present report, the vitalitywas still present at a distance of two years from the trauma,even though 5 days passed before performing the therapy.Most of the factors were favorable because the teeth had notundergone a subluxation and because the apexes were stillopen; also the area of exposure of the pulp was not parti-cularly extensive. Without the emergency protection of thepulp, the risk of necrosis would have increased and thepatient’s discomfort would have been greater.

In an emergency situation, a nail polish could be easilyfound and may provide an early pulp protection and atemporary seal for the dentinal tubules, while waiting forthe patient to go to the dentist for the appropriate treat-ment.

Conclusion

It is reasonable to provide protection to the pulp exposed by atrauma in the shortest possible time in order to maintain thevitality and reduce the sensitivity. In an emergency condi-tion, it is possible that the pulp capping and the restorationperformed by the dentist should be post-poned and alter-native materials available at home or on holiday may repre-sent a resource for protecting the pulp. In this case report,nail polish was used as emergency material and it allowed tomaintain the vitality of the tooth and reduce symptoms evenif 5 days passed after the trauma to perform the appropriatedental intervention. Therefore, even considering the limita-tions of a case report, the nail polish can be recommended asa material to perform an emergency home pulp capping whenthe patient is not able to reach the dentist quickly.

Figure 2 Teeth after fragments reattachment.

Figure 3 Radiographic follow up of the fractured.

78 L. Boschini

Clinical relevance

An emergency material for home capping is useful for pro-tecting the pulp and reducing the symptoms. Nail polish canbe suggested to this purpose.


The author declare that he has no conflict of interest [91_TD$DIFF].

Acknowledgements

The author thanks Dr. Gianluca Plotino for the assistance tothe present paper[92_TD$DIFF].

References

1. Viduskalne I, Care R. Analysis of the crown fractures and factorsaffecting pulp survival due to dental trauma. Stomatol BalticDent Maxillofac J 2010;12:109—15.

2. Robertson A, Andreasen FM, Andreasen JO. Long-term prognosisof crown-fractured permanent incisors. The effect of stage ofroot development and associated luxation injury. Int J PaediatrDent 2000;10:191—9.

3. Hallett GEM, Porteus JR. Fractured incisors treated by vitalpulpotomy. Br Dent J 1963;115(7):279—86.

4. Gelbier S, Winter GB. Traumatised incisors treated by vitalpulpotomy: a retrospective study. Br Dent J 1988;164:319—23.

5. Wang G, Wang C, Qin M. Pulp prognosis following conservativepulp treatment in teeth with complicated crown fractures — arestrospective study. Dent Traumatol 2017;33(4):255—60.

6. Fuks AB, Bielak S, Chosak A. Clinical and radiographic assessmentof direct pulp capping and pulpotomy in young permanent teeth.Pediatr Dent 1982;4:240—4.

7. Maguire A, Murray II, Al-Majed I. Retrospective study of treat-ment provided in the primary and secondary care services forchildren attending a dental hospital following complicatedcrown fractures in the permanent dentition. Int J Paediatr Dent2000;10:182—90.

8. Andersson L, Andreasen JO, Day P, et al. Guidelines for theManagement of Traumatic Dental Injuries: 1. Fractures andluxations of permanent teeth. Pediatr Dent 2016;38(6):358—68.

9. Andersson L, Andreasen JO, Day P, et al. Guidelines for theManagement of Traumatic Dental Injuries: 2. Avulsion of perma-nent teeth. Pediatr Dent 2016;38(6):369—76.

10. Andreasen JO, Andreasen FM, Skeie A, et al. Effect of treatmentdelay upon pulp and periodontal healing of traumatic dentalinjuries — a review article. Dent Traumatol 2002;18:116—28.

Management of crown fractures 79

CLINICAL ARTICLE/ARTICOLO CLINICO

Apical preparation size after repetitive peckingto the working length using different endodonticfile systems

Dimensione di preparazione apicale dopo ripetuti movimenti di preparazionealla lunghezza di lavoro utilizzando diversi sistemi endodontici

Tousif Iqbal Nathani a [3_TD$DIFF],*, Aatif Iqbal Nathani b, Ankur Mahesh Banode b,Moez Ismail Khakiani c, Juan Gonzalo Olivieri Fernandez a,Fernando Duran-Sindreu Terol a, Francesc Abella Sans a

aDepartment of Restorative Dentistry and Endodontics, Universitat Internacional de Catalunya, Barcelona, SpainbDepartment of Conservative Dentistry and Endodontics, Swargiya Dadasaheb Kalmegh Dental College and Hospital,Nagpur, IndiacA/64, Yuwan Apts, 413/414 Mount Mary Rd, Bandra W., 400050 Mumbai, India

Received 11 June 2018; accepted 10 September 2018Available online 29 September 2018


KEYWORDSApical preparation size;Nickel [8_TD$DIFF]—titanium;Reciprocating files;Rotary files;Self-Adjusting [9_TD$DIFF]File.

Abstract

Aim: The purpose of this study was to determine and evaluate the apical preparation sizeresulting from different pecking times to the working length (WL) with five different file systems.Materials andmethods: Fifty standard simulated endodontic J-shaped blocks were instrumentedusing ProTaper NEXT (PTN), WaveOne (WO), WaveOne Gold (WOG), OneShape (OS) and the Self-Adjusting File (SAF) (n = 10) with different pecking times (1, 2 and 4) to the WL. For the SAFgroup, instrumentation was done till WL according to the time, i.e. [5_TD$DIFF]1, 3 and 4 min. On completionof each stage, silicone impressionmaterial was used to take canal impressions for comparison andevaluation of the apical size preparation, using a stereomicroscope. Two-way analysis of variancewas applied to determine differences between groups and pecking times.


* Corresponding author.E-mail: [email protected] (T.I. Nathani).


ScienceDirect



Introduction

Preservation of the integrity and location of apical canalanatomy is crucial during root canal preparation.1 [4_TD$DIFF] However,this is not always possible, because files have a tendency tostraighten themselves inside the root canal.2 As a result,over-preparation toward the outer curve in apical areas canoccur. However, a root canal does not have a single curve andit changes in different planes of the root canal curvature.3

Thus, the root canal preparation from curved root canalsresults in asymmetric dentin removal, which can lead tocanal transportation (CT). CT increases the risk of iatrogenicdamage, and prevents canals from being adequately cleaned,with the potential outcome of persistent apical lesions.2

Nickel—titanium (NiTi) instruments are widely used inendodontics4 and their increased flexibility permits a safemechanical preparation of curved canals. This has reducedthe risk of possible iatrogenic errors comparedwith stainlessinstruments.4 Nevertheless, it can still lead to an insufficientpreparation of the apical area.5,6 Apical size is necessary tobe identified after canal preparation for a hermetic sealobturation.7 NiTi instruments tend to straighten in thecanal, which may cause apical transportation causing unin-tended apical preparation size.8,9 Although manufacturersrecommend a single peck to the working length, clinicians

especially unexperienced, might tend to peck more times tothe working length, even for retreatment or removal ofintracanal medicament.

The ProTaper Next (Dentsply Sirona Endodontics, Ballai-gues, Switzerland) is a multiple file system manufacturedusing m-wire with a quadrangular cross-section and an offsetmass of rotation that (according to the manufacturer)reduces the file engagement during root canal preparation.

The recently introduced single-file instruments have con-siderably reduced root canal preparation time comparedwith multiple file systems, while maintaining the root canalanatomy.10,11 The WaveOne and WaveOne Gold nickel-tita-nium (NiTi) file systems (Dentsply Sirona Endodontics, Ballai-gues, Switzerland) are reciprocating single-file systemsdesigned to shape the root canal completely. WaveOne ismade from m-wire and WaveOne Gold from what is commer-cially known as gold-wire technology. In addition, the stresson the instrument is relieved through unequal bi-directionalreciprocating motion, thereby increasing the resistance tocyclic fatigue in comparison with continuous rotary sys-tems.12

The One Shape file system (Micro-Mega, Besancon Cedex,France) is also a NiTi single-file system used in continuousrotation. It has a triangular cutting edge in the apical partand a cross-section that progressively changes from 3 to 2

PAROLE CHIAVEDimensione dipreparazione apicale;Nichel-titanio;Strumenti reciprocanti;Strumenti rotanti;Self-adjusting file.

Results: After four pecking times, a significant increase was observed in the apical diameter offour test groups compared to SAF ([6_TD$DIFF]P < 0.05), which was not associated with increased apicalpreparation at all times.Conclusion: A greater apical enlargement occurs with increasing pecking times; however, SAFinstrumentation exhibits the minimum changes in the apical preparation after 1, 3 and 4 min [7_TD$DIFF].WO, WOG and OS are able to prepare the apical size similar to their tip at a single peck to the WL.� 2018 Societa Italiana di Endodonzia. Production and hosting by Elsevier B.V. This is an openaccess article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Riassunto

Obiettivi: Lo scopo di questo studio e stato di determinare e valutare la dimensione dellapreparazione apicale risultante da diversi tempi di movimento alla lunghezza di lavoro con cinquediversi file system.Materiali e metodi: Cinquanta blocchetti di resina endodontici standard con canali simulati aforma di J sono stati strumentati utilizzando ProTaper NEXT (PTN), WaveOne (WO), WaveOneGold (WOG), OneShape (OS) e Self-Adjusting File (SAF) (n = 10) con numero di movimentiall’apice diversi (uno, due e quattro). Per il gruppo SAF, la strumentazione e stata eseguitafino alla lunghezza di lavoro in base al tempo, cioe 1 minuto, 3 minuti e 4 minuti. Alcompletamento di ogni fase, e stato utilizzato materiale per impronte in silicone per prenderel’impronta del canale per il confronto e la valutazione della preparazione della dimensioneapicale, utilizzando uno stereomicroscopio. L’analisi della varianza a due vie e stata applicataper determinare le differenze statistiche tra i gruppi e i tempi di preparazione apicale.Risultati: Dopo quattro movimenti all’apice, e stato osservato un aumento significativo neldiametro apicale nei quattro gruppi testati rispetto al SAF ( p < 0,05), che non e stato associatoad un aumento della preparazione apicale in ogni momento.Conclusioni: Si e rilevato un maggiore allargamento apicale con l’aumentare del numero dimovimenti eseguiti all’apice; tuttavia, la strumentazione SAF mostra dei cambiamenti miniminella preparazione apicale dopo 1, 3 e 4 minuti. WO, WOG e OS sono in grado di preparare ladimensione apicale simile alla loro punta effettuando un singolo movimento alla lunghezza dilavoro.� 2018 Societa Italiana di Endodonzia. Production and hosting by Elsevier B.V. Cet article estpublie en Open Access sous licence CC BY-NC-ND (http://creativecommons.org/licenses/by-nc-nd/4.0/)

Apical preparation size after repetitive pecking to the WL 81

cutting edges between the apical and coronal parts. This issupposed to give the file an optimal cutting action causingless micro-cracks compared with conventional rotary sys-tems.13

The Self-Adjusting File system (SAF) (ReDent-Nova, Ra’a-nana, Israel) is a single-file system that has a hollow lattice-like cylindrical structure with no metal core that scrubs thedentinal wall by vibrations. The hollow design allows the fileto three dimensionally adapt to the root canal system14

permitting continuous irrigation while simultaneously shap-ing the canal.14,15

A study by Jeon et al.7 found no differences between tworeciprocating files (WO and Reciproc) in apical enlargementafter different pecking motions. However, to date, no studyhas evaluated the effect of different pecking times with 3different motion systems. Thus, the purpose of this study wasto evaluate and compare differences between differentsystems regarding apical enlargement after one, two andfour pecking times to the working length (WL) and after 1 and3 min with the SAF system. The null hypothesis tested wasthat there are no differences between systems regarding thesize of the final apical preparation after different peckingtimes.


Fifty standard simulated endodontic training blocks (ReDent-Nova, Ra’nana, Israel) with a J-shaped canal were used.These were divided into 5 groups according to the instru-ments used for canal preparation (n = 10):

Group 1: ProTaper Next X2 (Dentsply Sirona Endodontics,Ballaigues, Switzerland).Group 2: WaveOne Primary (Dentsply Sirona Endodontics,Ballaigues, Switzerland).Group 3: WaveOne Gold Primary (Dentsply Sirona Endo-dontics, Ballaigues, Switzerland).Group 4: OneShape1[11_TD$DIFF][10_TD$DIFF] (Micro Mega, Besancon, France).Group 5: Self Adjusting File 1.5 mm (ReDentNova,Ra’nana, Israel).

A #10 K-file (Dentsply Sirona Endodontics, Ballaigues,Switzerland) was introduced in the canals in the acrylic blockuntil it was visible at the apical foramen. The WL wasdetermined by subtracting 0.5 mm from this measurement.A rubber stop for each file was fixed with cyanoacrylateadhesive (Loctite; Henkel, Dusseldorf, Germany) at the WLto accurately maintain it for every file. Hand instrumentationwith K-files upto ISO #20 was performed in each block. Rotarypreparation was performed according to the manufacturers’instructions for each system using an endodontic torquecontrol motor (X-Smart Plus; Dentsply Sirona Endodontics,Ballaigues, Switzerland) for ProTaper Next, WaveOne,WaveOne Gold and OneShape file systems while the Endosta-tion System (ReDentNova, Ra’nana, Israel) for the SAF.

For OneShape (25/0.06) and ProTaper NEXT, X1 (17/0.04)& X2 (25/0.06) were used in continuous rotation to the WL.WaveOne primary (25/0.08) and WaveOne Gold (25/0.07)were used in reciprocation with a pecking (in-and-out)motion until the WL. For the SAF group, the 1.5 mm diameterfile was used in a light pecking-motion up to the WL for [12_TD$DIFF]1, 3and 4 min. A single operator with previous experience in allsystems performed the canal preparation.

Patency was confirmedwith a #10 K-file after each peckingmovement until the WL was reached, followed by copiousirrigation with saline. Following the methodology from Jeonet al[13_TD$DIFF].,16 a resin block and light body silicon impression(Aquasil, Dentsply Sirona Endodontics) material were usedto make an impression of the prepared canal for evaluation.Impressions were made after the first, second and fourthrepetitive pecking times to the WL. The apical 3 mm of theimpression replicas were zoomed and focused to evaluatepreparation size at the D0 level under a stereomicroscope(Zeiss Stero Discovery V8, Carl Zeiss, Oberkochen, Ger-many.). A gutta-percha guage (Dentsply Sirona Endodontics,Ballaigues, Switzerland) was used before measuring anyimpression to calibrate the stereomicroscope and to haveaccurate measurements. In addition, ten simulated canalblocks were used as a control group and canal impressionswere made without instrumentation to evaluate homogene-ity and measurement accuracy. As there was a 0.5 mm unin-strumented canal from the working length, each impressionwas evaluated using this tapering end under the steriomicro-scope for distortion immediately after removal of the mate-rial from the canal. If found, impressions were repeated untilaccuracy was achieved (Fig. 1).

The Shapiro—Wilk test was used to determine result dis-tribution (P = 0.0011). As no normal distribution wasobserved, the non-parametric tests, Mann[15_TD$DIFF]—Whitney U-testor the Kruskal—Wallis test, were used to evaluate differencesamong groups for the apical diameter of the canal prepara-tion, with the number of peckings and the different systemsbeing considered as two sources of variation. Significance wasset at P < [16_TD$DIFF]0.05. Statistical analysis was performed using

Figure 1 Impression after instrumentation verified by thetapering shape at the apex showing differences between unin-strumented and instrumented area.

82 T.I. Nathani et al.

Statgraphics Centurion XV software 15.2.06 (SPSS Inc., Chi-cago, IL).

Results

No instrument separation of any file occurred during thestudy. The apical diameter of the simulated canals was of150 [17_TD$DIFF]mm (D0), which was confirmed by the impression replicas.Table 1 shows the median apical preparation size of the filesystems used after the different number of pecking times tothe WL.

[18_TD$DIFF]The apical preparation with all the systems evaluatedshowed a statistically significant increase after every peckingmovement to the WL (P < 0.05) (Table 1).

After one peck to the WL, no significant differences wereobserved in the apical preparation size between WO, WOGand OS (P > 0.05). Instrumentation with ProTaper Nextresulted in a higher apical preparation, compared withWO, WOG and OS (P < 0.05).

After the second peck to theWL, no significant differenceswere observed in the apical preparation size between WO,WOG and OS (P > 0.05), and ProTaper Next instrumentationstill resulted in an increased apical preparation (P < 0.05).

After the fourth peck to the WL, no significant differenceswere observed in the apical preparation size between PTNext, WOG and OS (P > 0.05), but instrumentation with WOresulted in a smaller apical preparation compared with theother systems (P < 0.05).

When comparing with the SAF, after [19_TD$DIFF]1 min of canal shapingto the WL, SAF resulted in an increased apical preparationsize compared with the other systems after the first peck tothe WL (P < 0.05), but in the second peck a significantdifference was observed only with PT Next (P [20_TD$DIFF]< 0.05) andnot with other file systems (P > 0.05) [21_TD$DIFF](Table 1).

After 3 min, canal shaping with SAF produced an apicalenlargement significantly higher as compared with all theother groups at the first, second and fourth peck to the WL(P < 0.05). (Table 1)

Canal preparation with SAF after 4 min [22_TD$DIFF]resulted in anapical diameter preparation of 352.3 (�2.6 mm), similar toan ISO #35 as claimed by the manufacturer [23_TD$DIFF](Table 1).

Discussion

The main goals of root canal preparation are to clean andshape the root canal system with minimal procedural errorswhile maintaining the original canal configuration.16,17 [14_TD$DIFF] Thealternating motion could be beneficial in the shaping of root

canals by reducing the screwing effect.18 This effect is oftenassociated with the continuous rotary motion and may resultin over instrumentation beyond the apical constriction,which sometimes causes apical transportation.18 Althoughseveral studies have compared the efficacy and preparationsizes of reciprocating and rotary file systems,7,17 to theauthor’s knowledge no study has assessed and comparedthe apical preparation sizes after using different types ofinstruments by increasing the number of pecking times to theWL.

The purpose of this study was to evaluate the apicalpreparation size of five different file systems according tothe number of pecking times (motions) to the WL. Four of thefile systems evaluated, have an identical tip diameter of #25(Wave One, WaveOne Gold, One Shape and ProTaper Next)but with differences in file design and movement. BothProTaper NEXT and OneShape showed similar values aftertwo and four pecking motions to the working length. How-ever, instrumentation with PTN resulted in a larger apicalpreparation size. These differences may be due to the dif-ferent cross sections of the systems themselves. Where twoinstruments reached the WL for the final preparation, sig-nificant differences were found after the first peck to theWL.

Capar et al.11[24_TD$DIFF] compared 6 different systems, includingcontinuous and reciprocating motion and concluded that allthe systems produced straightening of canal curvature, butbetter results were observed with Reciproc R25 (VDW) filesystem. However, Jeon et al.7 found no differences in apicalsize preparation between Waveone and Reciproc (P < 0.05).Thus, only WO was used for study comparison or for thesingle-file reciprocating system group. WaveOne Gold wasincluded in the study due to its different cross section, alloyand that WaveOne being discontinued by the manufacturer.Similar results were obtained in our study after canal pre-paration with WO, which corroborates both our results andthis methodology for comparison.

The results of different studies comparing the canaltransportation with rotary and reciprocating files11,19[25_TD$DIFF] con-clude that there are no significant differences betweensystems and that the canal transportation was within thesafety limit. Stern et al.20 reported that use of PU instrumentshowed similar dentin removal with rotation or reciprocatingmotions. Significantly higher difference was found betweenWaveOne andWaveOne Gold in the 4th peck and interestinglyWaveOne Gold had similar results to ProTaper Next in thissection. It is important to note that ProTaper Next andWaveOne Gold have similar cross section but different taperand kinematics. It is not clear how the increase of apicalpreparation occurs from the file tip diameter, although with

Table 1 Mean size (mm) and standard deviation (SD) of the apical diameter after different pecking times of the different systems.

[1_TD$DIFF]System Number of pecking times or minutes to the WL

[2_TD$DIFF]Single or 1 min SAFMean � SD (mm)

Double or 1 min SAFMean � SD (mm)

Double or 3 min SAFMean � SD (mm)

Four or 3 min SAFMean � SD (mm)

4 min SAFMean � SD (mm)

WaveOne 251 � 3.53 271.05 � 3.53 271.05 � 3.53 285.95 � 2.33 —Waveone Gold 250.04 � 5.64 270.04 � 4.93b 270.04 � 4.93b 299.23 � 9.01 —OneShape 251.1 � 0.42 273.3 � 9.05 273.3 � 9.05 305.8 � 5.23 —Pro Taper NEXT 258.85 � 2.05 277 � 3.67 277 � 3.67 303.45 � 3.04 —SAF 268.85 � 3.74 268.85 � 3.74 314.95 � 1.20 314.95 � 1.20 352.3 � 1.83


regards to these studies it can be said that different crosssections of the file systems may be responsible rather thandifferent kinematics.11 [26_TD$DIFF] However when comparing the single-file instruments (continuous rotation vs. reciprocation) in thepresent study (WO, WOG and OS), no differences were foundin the apical size preparation after one or two peckingmotions to the working length (P > [25_TD$DIFF]0.05). Nevertheless,canal instrumentation with OS resulted in a larger apicalpreparation after the fourth peck. Thus, it can be concludedthat an alternating motion may be safer for apical sizediameter when performing more than two pecking motions.

The SAF is also a single-file shaping system such as the WO,WOG and OS but the cross section, design and action arecompletely different. SAF adapts to the natural anatomy ofthe canal and shapes it by vertical scrubbing with simulta-neous irrigation. Siqueira et al [27_TD$DIFF].,21 comparing different filesystems, including reciprocating, rotary and SAF, found nodifferences in root canal shaping ability. However, this studyis difficult to understand since the authors compared differ-ent systems with a final apical preparation of #25 (Reciprocand Twisted files) with #35 (SAF 1.5 mm). As in our study,Siqueira et al.21 used the smallest file tip in the system(1.5 mm of diameter) and according to the manufacturer,the final preparation size after 4 min of preparation would bean ISO #35. According to the findings of the present study theSAF was able to enlarge the apical diameter to an ISO 35 after4 min [29_TD$DIFF]of pecking time.

In the present study all the four files, except the SAF, havean ISO #25 available in their systems. The SAF does not have a# 25 file size. The smallest file of the SAF system has a tipdiameter of 1.5 mm which produces an apical preparationsize of ISO #35 after 4 min[30_TD$DIFF], according to the manufacturer.This fact limited the comparison between SAF and the othersystems evaluated which is one of the limitations of thisstudy. Thus, for a better comparison the apical preparationsof the other systems were compared with [31_TD$DIFF]1 and 3 min of SAFpreparation.

When preparing canals with WO and Reciproc (VDW) theapical preparation size increases with the increase in thenumber of peckings to the WL [32_TD$DIFF].7 [28_TD$DIFF] This is in agreement with theresults in our study, where the four systems evaluated pro-duced a statistical increase in the apical diameter ( [33_TD$DIFF]P > 0.05)under the same conditions after every pecking motion to theWL, except the SAF, which resulted in a similar apical pre-paration after different pecking motions to the WL. This maybe due to the hollow lattice structure of the SAF, whichprevents excessive cutting even after continuous peckingmotions.

The use of simulated resin blocks allows standardization ofdegree, location and radius of root canal curvature in threedimensions.1 Thus, a direct comparison of the final canalpreparation can be obtained with different instruments.Furthermore, it also permits comparison with other studies.However, it should be noted that there is a difference inmicro-hardness between dentin (35—40 kg/mm2

[34_TD$DIFF]) and resin[35_TD$DIFF](20—22 kg/mm).1 This is a limitation of the study as theresults are not reproducible in clinical setting, rather justgive an indication about the effect on the apical preparationsize.

Although the impressions of the simulated resin blockcanals were taken with utmost care, they were repeatedimmediately if verified by the stereomicroscope to be dis-

torted; retrieval of impression material from the canal mayhave produced errors affecting the results, which is anotherlimitation of this study.

Canal transportation and deviation may readily occurduring the shaping procedure, especially in curved canals,because of the file’s tendency to revert to its original shapealong with the reaction torque to the canal wall.22 Thismechanical phenomenon may occur particularly during repe-titive pecking motions. Although apical enlargement hasbeen proven to mechanically remove up to more than 90%of bacterial cells from the root canal,23 in order to obtain apredictable apical preparation size, clinicians must avoidrepetitive pecking motions and rather select a bigger instru-ment size for this purpose.

Conclusion

With the limitations of this study it can be concluded thatWO, WOG and OS were able to prepare the apical size similarto their tip at a single peck and significant difference wasfound with ProTaper Next. SAF, even after 4 min of peckingtime, produced the desirable size. Nevertheless, more num-ber of pecking times may result in a larger diameter of theapical area than the file itself. Therefore, the clinician mustbe careful in choosing the appropriate system to prepare thecanals and must confirm the apical gauge before obturatingthe canal space.

Clinical relevance

More number of pecking times may result in a larger diameterof apical area than the file itself. Clinicians must be careful inchoosing appropriate system to prepare the canals and mustconfirm the apical gauge before obturating.


The authors deny any conflicts of interest [36_TD$DIFF].

Acknowledgements

The authors deny any financial affiliations related to thisstudy or its sponsors[37_TD$DIFF].

References

1. Hulsmann M, Peters OA, Dummer PMH. Mechanical preparationof root canals: shaping goals, techniques and means. EndodTop [Internet] 2005;10(1):30—76. http://dx.doi.org/http://dx.doi.org/10.1111/j.1601-1546.2005.00152.x.

2. Peters OA, Ficd MS. Current challenges and concepts inthe preparation of root canal systems: a review. J Endod2004;30(8):559—67.

3. CunninghamCJ. A three-dimensional study of canal curvatures inthe mesial roots of mandibular molars. J Endod 1992;18(6):294—300.

4. Pettiette MT, Olutayo Delano E, Trope M. Evaluation of successrate of endodontic treatment performed by students with stain-less-steel k-files and nickel-titanium hand files. J Endod2001;27(2):124—7.

84 T.I. Nathani et al.

5. Van der Vyver Peet JSMJ. Clinical guidelines for the use ofProTaper Next instruments (Part I). Dent Trib 2014;12—6.

6. Markvart M, Darvann TA, Larsen P, Dalstra M, Kreiborg S, BjørndalL. Micro-CTanalyses of apical enlargement and molar root canalcomplexity. Int Endod J 2012;45(3):273—81.

7. Jeon HJ, Paranjpe A, Ha JH, Kim E, Lee W, Kim HC. Apicalenlargement according to different pecking times at workinglength using reciprocating files. J Endod 2014;40(2):281—4.

8. Wildey WL, Senia ES. Another look at root canal obturation. DentToday 2002;21(3):68—73.

9. Wu MK, Fan B, Wesselink PR. Leakage along apical root fillings incurved root canals. Part I: effects of apical transportation on sealof root fillings. J Endod 2000;26(4):210—6.

10. Burklein S, Hinschitza K, Dammaschke T, Schafer E. Shapingability and cleaning effectiveness of two single-file systems inseverely curved root canals of extracted teeth: Reciproc andWaveOne versus Mtwo and ProTaper. Int Endod J 2012;45(5):449—61.

11. Capar ID, Ertas H, Ok E, Arslan H, Ertas ET. Comparative study ofdifferent novel nickel-titanium rotary systems for root canalpreparation in severely curved root canals. J Endod 2014;40(6):852—6.

12. Topcuoglu HS, Duzgun S, Aktı A, Topcuoglu G. Laboratory com-parison of cyclic fatigue resistance of WaveOne Gold, Reciprocand WaveOne files in canals with a double curvature. Int Endod J2017;50(7):713—7.

13. Liu R, Hou BX,Wesselink PR,WuMK, Shemesh H. The incidence ofroot microcracks caused by 3 different single-file systems versusthe protaper system. J Endod 2013;39(8):1054—6.

14. Metzger Z, Teperovich E, Cohen R, Zary R, Paque F, Hulsmann M.The self-adjusting file (SAF). Part 3: Removal of Debris and SmearLayer — A Scanning Electron Microscope Study. J Endod2010;36(4):697—702.

15. Metzger Z, Teperovich E, Zary R, Cohen R, Hof R. The self-adjusting file (SAF). Part 1: respecting the root canal anatomy— a new concept of endodontic files and its implementation. JEndod 2010;36(4):679—90.

16. Sonntag D, Delschen S, Stachniss V. Root-canal shaping withmanual and rotary Ni-Ti files performed by students. Int EndodJ 2003;36(11):715—23.

17. Yun HH, Kim SK. A comparison of the shaping abilities of 4 nickel-titanium rotary instruments in simulated root canals. Oral SurgOral Med Oral Pathol Oral Radiol Endod 2003;95(2):228—33.

18. You SY, Kim HC, Bae KS, Baek SH, Kum KY, LeeW. Shaping ability ofreciprocating motion in curved root canals: a comparative studywithmicro-computed tomography. J Endod2011;37(9):1296—300.

19. Junaid A, Freire LG, Da Silveira Bueno CE, Mello I, Cunha RS.Influence of single-file endodontics on apical transportation incurved root canals: an ex vivo micro-computed tomographicstudy. J Endod 2014;40(5):717—20.

20. Stern S, Patel S, Foschi F, Sherriff M, Mannocci F. Changes incentring and shaping ability using three nickel-titanium instru-mentation techniques analysed by micro-computed tomography(mCT). Int Endod J 2012;45(6):514—23.

21. Siqueira JF, Alves FRF, Versiani MA, Rocas IN, Almeida BM, NevesMAS, et al. Correlative bacteriologic and micro-computed tomo-graphic analysis of mandibular molar mesial canals prepared byself-adjusting file, reciproc, and twisted file systems. J Endod2013;39(8):1044—50.

22. Peters OA, Peters CI, Schonenberger K, Barbakow F. ProTaperrotary root canal preparation: effects of canal anatomy on finalshape analysed by micro CT. Int Endod J 2003;36(2):86—92.

23. Siqueira JF, Lima KC, Magalhaes FAC, Lopes HP, De Uzeda M.Mechanical reduction of the bacterial population in the rootcanal by three instrumentation techniques. J Endod 1999;25(5):332—5.


WINNER OF GIORGIO LAVAGNOLI AWARD - 358 NATIONAL CONGRESS, BOLOGNA 2017

CASE SERIES/SERIE DI CASI

Tooth autotransplantation. What’s the limit ofour possibilities in conservative treatments?

Autotrapianto autologo. Qual’e il limite delle nostre possibilita conservative?

Stefano Milani *, Paolo Generali

Private Practice, Piacenza, Italy

Received 28 February 2018; accepted 27 May 2018Available online 25 June 2018


KEYWORDSAutotransplantation;Transplantation;Root canal treatment;Implantology;Periodontology.

Abstract

Aim: When an extraction is necessary, it is possible to choose a donor tooth and transplant it intothe site of the previous extraction. Aim of the present article is to present a series of cases oftooth autotransplantation to demonstrate how it is possible to preserve natural teeth and avoidor delay implant therapy.Summary: In the 3 cases presented the donor site was initially selected and the compatibility ofthe roots was evaluated. Then the compromised tooth was atraumatically extracted and thedonor tooth was replanted in the receiving site; after 2 weeks the sutures were removed and 2 or3 months later root canal therapy was performed. The results show medium/long-term successwith controls from 4 to 12 years without any primary or secondary complication.Key learning points: Tooth autotransplantation allowed to completely restore the originalfunctional and morphological condition of patient. Even if implantology is the most commontherapy for replacing missing teeth, tooth autotransplantation should be considered as theelective treatment if a donor tooth is available.� 2018 Societa Italiana di Endodonzia. Production and hosting by Elsevier B.V. This is an openaccess article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).


* Corresponding author at: via Martini, 13, 29121 Piacenza (PC), Italy. Tel./fax: +39 0523755250.E-mail: [email protected] (S. Milani).


ScienceDirect



Introduction

The prognosis of a natural tooth, even if compromised due toperiodontal or endodontic disease,may be longer than the oneof an implant substitute.1 On the other hand, sometimes toothextraction is mandatory. In these cases, one of the treatmentoptions is dental autotransplantation, which consists inextracting and repositioning a tooth into a different site inthe mouth of the same patient. A successfully transplantedtooth offers several advantages compared to a dental implant,given the preservation of the periodontal ligament: the pro-prioceptive function ismaintained, thealveolar bonevolume ispreserved, orthodontics can be included in the treatment planand dento-facial development is not impaired. Moreover, pulpregenerationandcontinued rootdevelopmentcanbeexpectedwhen a donor tooth with incomplete root formation is chosenand infection of the necrotic pulp tissue is prevented.2

Tooth transplantation has been carried out for centuries.The earliest reports of tooth transplantation involve slaves inancient Egypt who were forced to give their teeth to theirpharaohs. In the late 18th and early 19th century transplantsof teeth between people were relatively common at specia-list dental practices in London. Surprisingly tooth allotrans-plants have been found to last 6 years on average. InScandinavia during the 1950s and 1960s autotransplantationof teeth began to be carried out under increasingly controlledconditions. High success and survival rates have beenreported for autotransplantation if a proper case selectionand surgical technique are performed. A prospective study byMejare et al.3 reported a cumulative survival rate of 81.4%over a 4-year follow-up, while other studies have reportedsurvival rates ranging from 71% to 95% up to 10 years offollow-up.4,5 Favourable prognostic factors include: youngpatients (15—25 years old), donor tooth with an open apexand root (or roots) length ranging from 2/3 to completedevelopment, possibility for an atraumatic extraction andrepositioning of the donor tooth (root morphology, position,

size of the crown), suitable recipient site conditions (absenceof inflammation, good bone volume and quality), employ-ment of an adequate protocol (atraumatic technique, mini-mal extraoral time, type of stabilisation, adequate follow-up, timing of the eventual endodontic treatment).6,7 Accord-ingly, the most common indications of autotransplantationare: non-restorable molars and anterior teeth, missing ante-rior teeth due to agenesis or avulsion, impacted or ectopicanterior teeth which cannot be orthodontically extruded.

The extraction of a natural tooth leads not only to masti-catory deficiency, but also to a lower stimulation of thecerebral cortex because of the loss of proprioceptive functionof periodontal ligament,8—10 for these reasons tooth autotrans-plantation may be evaluated as a possibile alternative toimplant therapy. Dental autotransplantation is effectively aplanned avulsion and replantation in the least traumatic way.Local anaesthesia is administered and prophylactic antibioticcover is also recommended. Preparation of the recipient siteincludes extraction of root remnants and debridement andthen the donor tooth is atraumatically extracted. A loose fit ofthe transplanted tooth in its new socket is generally recom-mended. In some cases, when the donor tooth fitting is satis-factory, no further preparation of the new socket is requiredand the donor tooth is directly placed into a fresh extractionsocket; if this is not the case, an atraumatic preparation of thenew socket with the use of surgical burs is performed.

The transplanted tooth is then tried in the recipientsocket and relative adjustments are done, if needed. Inthe meantime, the tooth is kept in the donor socket or insaline solution. The transplanted tooth should be put slightlybelow the occlusal plane. When proper fit and position areachieved, the transplanted tooth is fixed with silk suturescrossing the occlusal surface. Post-operative care consists inoral hygiene and dietary instructions; a recall is usually setafter 7—14 days, for the removal of the sutures.3,6 A series ofcases was presented with hopeless teeth that were extractedand substituted with an autogenous third molar.

PAROLE CHIAVETrapianto;Autotrapianto;Terapia canalare;Implantologia;Parodontologia.

Riassunto

Obiettivi: Quando l’estrazione di un elemento naturale diviene una scelta obbligata e possibileselezionare, se disponibile, un elemento donatore e trapiantarlo nell’alveolo del dente daestrarre. Lo scopo dello studio e quindi di mostrare una serie di casi di autotrapianto e come siapossibile sfruttare gli elementi naturali gia presenti per ripristinare la funzione ed evitare oritardare la terapia implantare.Riassunto: Nei 3 casi di autrotrapianto descritti, e stato inizialmente selezionato un sitodontatore ed e stata valutata la compatibilita con l’anatomia radicolare del dente da estrarre.Se le condizioni per l’autotrapianto erano soddisfatte si e proceduto con l’estrazione atraumaticadell’elemento compromesso e il reimpianto del donatore; dopo 2 settimane sono state rimosse lesuture e a 2/3 mesi e stata effettuata la terapia canalare. Si e osservato un completo successodella terapia nel medio-lungo termine, con controlli dai 4 ai 12 anni senza alcuna complicazione oeffetto avverso.Key learning points: Le tecniche di autotrapianto permettono di ripristinare con successo lecondizioni di salute iniziali del paziente. Nonostante l’implantologia sia la terapia piu diffusa perla sostituzione di un dente da estrarre, l’autotrapianto andrebbe valutato come scelta elettivanei casi in cui si abbia la disponibilita di un dente donatore.� 2018 Societa Italiana di Endodonzia. Production and hosting by Elsevier B.V. This is an openaccess article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Tooth autotransplantation 87

Report

Case 1 (Figs. 1 and 2)

Left upper second molar from a 19 years old woman wascompromised because of severe decay and extraction wasmandatory. Patient did not have the economical possibilitiesto replace it with an implant and asked for a possible alter-native therapy to maintain masticatory function.

There was a presence of the left upper third molar thatmay be used as donor; anatomy of the roots was compatiblewith the receiving site, even if the donor tooth showed longerroots. After local anesthesia with 2% mepivacaine with1:100.000 adrenaline, the left upper second molar wasatraumatically extracted. Initially with a 15c surgical bladethe periotomy was realised and then tooth was extractedafter separating the roots to avoid unnecessary trauma to thealveolar bone. Then the donor left upper third molar wasextracted after periotomy as described before and trans-planted in the adjacent site. Because of the slight differencesin roots anatomy it was necessary to remove the intraradi-cular bone sectum of the receiving site to allow toothpositioning, and a plastic of donor tooth crown was per-formed to maintain it not in occlusion. Antibiotics (Amox-icillin/clavulanic acid per os 1 g 2 times a day for 5 days) wereprescribed, along with rinses with 0.2%chlorexidine. Toothwas maintained stable with sutures and, after the removal attwo weeks, tooth showed a good stability and a positiveadaptation of soft tissue was observed. At two months theroot canal treatment was performed and controls showedpositive results both radiographically and in terms of func-

tion. Patients did not show any adverse event neither ininitial phase nor in mid-term 4 year control.

Case 2 (Figs. 3 and 4)

The left lower second molar of a 35 years old woman wascompromised because of a vertical root fracture and a largeperiapical lesion was present. After explanations andinformed consent, the treatment was scheduled. The rightlower third molar was preferred as a donor to the left lowerthird molar because of amore compatible anatomy and for aneasier stabilisation. After local anaesthesia at both the donorand the recipient sites with 2% mepivacaine and 1:100.000adrenaline, the left lower second molar was extracted andthe alveolus debrided. Then, the donor tooth was atrauma-tically extracted, quickly repositioned in the recipient siteand stabilised with sutures at about 1.5—2 mm of infraocclu-sion. Antibiotics (Amoxicillin/clavulanic acid per os 1 g, 2times a day for 5 days) and painkillers (ibuprofen 600 mg, 2times a day for 5 days) were prescribed, along with rinseswith 0.2% chlorexidine. Sutures were removed after 2 weeksand endodontic treatment was performed after 3 months.The periapical lesion healed and the tooth is still in fullfunctional after 12 years.

Case 3 (Fig. 5)

A right lower first molar tooth from a 16 years old womanwithheavily structural damage was extracted after explanation,informed consent and the mandibular block with 3% mepi-vacaine. The receiving site was debrided, the right lower

Figure 1 Case 1. Pre-operative situation with the upper left second molar that needed to be extracted and the third molar that maybe used as donor. After autotransplantation with the third milar repositioned in the receiving site. Radiographs after root canaltreatment and 4 years mid-term control showed new periodontal ligament formation on the entire surface of the roots.

88 S. Milani, P. Generali

third molar was atraumatically extracted, positioned in thealveolus and stabilised with sutures. Antibiotics (Amoxicillin/clavulanic acid per os 1 g, 2 times a day for 5 days) andpainkillers (ibuprofen 600 mg, 2 times a day for 5 days) were

prescribed, along with rinses with 0.2% chlorexidine. Sutureswere removed after 2 weeks and the endodontic treatmentwas performed after 2 months. Tooth is still in full functionafter 11 years.

Discussion

Autotransplantation gives to the clinicians the possibilityto successfully recreate all the pre-existent anatomicaland functional conditions without any complication. Inthe radiographic controls presented in the present article,the presence of a new formed periodontal ligament isclearly visible on the entire surfaces of the roots, even ifliterature reported some cases of failure for ankylosis orroot resorption in less than the 10% of cases11 [1_TD$DIFF]. Andreasen in19906 had a survival rate superior to 95% over 370 cases,with a follow-up period up to 13 years. In a recent meta-analysis, the survival rate at 5 years was approximately 98%for teeth with incomplete root formation12 and 90% forteeth with complete root formation.13,14

The ideal recipient site should be free of inflammation.Unfortunately, a hopeless tooth scheduled for extractionoften presents periapical lesions, but if other prognosticcriteria were met, (age, general health, shape of third molarroot, keratinised tissue, easy extraction), autotransplanta-tion may be evaluated. The cases presented in this articledemonstrated a good prognosis of the one-step approachdespite the presence of periapical pathosis, as suggestedby Shim.15 On the contrary, Nimcenko16 suggested extractionof the diseased tooth two weeks before the transplant.

Figure 2 Case 1. Clinical images of the autotransplantationprocedure. From up to down, the pre-operative situation, thesuture at the time of the surgery and the control at 2 weeks aftersuture removal.

Figure 3 Case 2. Pre-operative orthopantomography showing the periapical lesion of the lower left second molar and periapicalradiographs after autotransplantation of the lower right third molar in the position of the lower left second molar. The 2-years controlradiograph (lower left): showing incomplete healing of the periapical lesion. The 12 years radiographic control (lower right) showed acomplete healing of periapical lesion but the coronal restoration needs to be replaced.


Conclusion

The substitution of an extracted tooth with autotrans-plantation allows the clinicians to entirely recreate theorganic complexity of the natural tooth. In the cases

presented, therapeutic phases may be summarised asfollows:1) pre-operatory evaluation of compatibility between root

anatomies;2) atraumatic extraction of the compromised tooth;

Figure 4 Case 2. Clinical images of the autotransplantation procedure showing the pre-operative situation, the extracted fracturedtooth, the transplanted tooth in position stabilised with sutures and the healing after 2 weeks.

Figure 5 Case 3. Pre-operative radiograph showing periapical lesion and structural damage of the right lower first molar, periapicalradiograph 3 months after tooth transplantation, 2-years (lower left) and 11 years (lower right) controls.

90 S. Milani, P. Generali

3) [2_TD$DIFF]atraumatic extraction of the donor tooth;4) osteoplastic, if necessary, of receiving site;5) donor tooth insertion in the new site and stabilisation with

sutures;6) sutures removal after 2 weeks;7) root canal treatment after 2 or 3 months.8) follow-ups.

Clinical relevance

Even if implantology is the most common therapy to replaceextracted teeth, it is not able to adapt to the craniofacial andocclusal modification occurring during patients’ growth. Forthese reasons autotransplantation may be a valid treatmentalternatives, especially in young patients.


The authors declare no conflict of interest.

References

1. Giannobile WV, Lang NP. Are dental implants a panacea or shouldwe better strive to save teeth? J Dent Res 2016;95(1):5—6.

2. Tsukiboshi M. Autotransplantation of teeth: requirements forpredictable success. Dent Traumatol 2002;18:157—80.

3. Mejare B, Wannfors K, Jansson L. A prospective study on trans-plantation of third molars with complete root formation. OralSurg Oral Med Oral Pathol Oral Radiol Endod 2004;97(2):231—8.

4. Sugai T, Yoshizawa M, Kobayashi T, Ono K, Takagi R, Kitamura N,et al. Clinical study on prognostic factors for autotransplantationof teeth with complete root formation. Int J Oral Maxillofac Surg2010;39(12):1193—203.

5. Andreasen JO, Paulsen HU, Yu Z, Bayer T. A long-term study of370 autotransplanted premolars. Part II. Tooth survival and pulp

healing subsequent to transplantation. Eur J Orthod 1990;12(1):14—24.

6. Andreasen JO, Paulsen HU, Yu Z, Ahlquist R, Bayer T, Schwartz O.A long-term study of 370 autotransplanted premolars. Part I.Surgical procedures and standardized techniques for monitoringhealing. Eur J Orthod 1990;12(1):3—13.

7. Rohof ECM, Kerdijk W, Jansma J, Livas C, Ren Y. Autotransplan-tation of teeth with incomplete root formation: a systematicreview and meta-analysis. Clin Oral Investig 2018;22:1613—24.

8. Trulsson M, Francis ST, Bowtell R, McGlone F. Brain activations inresponse to vibrotactile tooth stimulation: a psychophysical andfMRI study. J Neurophysiol 2010;104(4):2257—65.

9. Ono Y, Yamamoto T, Kubo KY, Onozuka M. Occlusion and brainfunction: mastication as a prevention of cognitive dysfunction. JOral Rehabil 2010;37(8):624—40.

10. WeijenbergRA, ScherderEJ, LobbezooF.Mastication for themind— the relationship between mastication and cognition in ageingand dementia. Neurosci Biobehav Rev 2011;35(3):483—97.

11. ChungW-C, Tu Y-K, Lin Y-H, Lu HK. Outcomes of autotransplantedteeth with complete root formation: a systematic review andmeta-analysis. J Clin Periodontol 2014;41:412—23.

12. Atala-Acevedo C, Abarca J, Martınez-Zapata MJ, Dıaz J, Olate S,Zaror C. Success rate of autotransplantation of teeth with anopen apex: systematic review and meta-analysis. J Oral Max-illofac Surg 2017;75:35—50.

13. Czochrowska EM, Stenvik A, Bjercke B, Zachrisson BU. Outcome oftooth transplantation: survival and success rates 17—41 yearsposttreatment. Am J Orthod Dentofac Orthop 2002;121(2):110—9.

14. Machado LA, do Nascimento RR, Ferreira DM, Mattos CT, VilellaOV. Long-term prognosis of tooth autotransplantation: a sys-tematic review and meta-analysis. Int J Oral Maxillofac Surg2016;45(5):610—7.

15. Shim JS, Park JH, Shin JH. Autotransplantation for the manage-ment of teeth with severe alveolar bone resorption: a casereport. Dentistry 2017;7:441. http://dx.doi.org/http://dx.doi.org/10.4172/2161-1122.1000441.

16. Nimcenko T, Omerca G, Bramanti E, Cervino G, Laino L, Cicciu M.Autogenous wisdom tooth transplantation: a case series with 6—9 months follow-up. Dent Res J 2014;11(November (6)):705—10.


92

LETTERA DEL PRESIDENTE

Carissimi,

Si avvicina il nostro Congres-so Internazionale di Milano.

L’internazionalizzazione è da sempre uno degli obiettivi della SIE e che il Consiglio Direttivo ha fortemente spinto negli ultimi anni, infatti sem-pre più numerosi sono i nostri Soci conosciuti ed apprezzati all’estero.

- Il Corso Pre-Congresso sarà tenuto da Arnaldo Castellucci ed Augusto Malentacca e intitolato “Problem solving within the scope and challenges of endodontic procedures”;

- Un programma innovativo e di sempre altissimo livello, vedrà susseguirsi Relatori Italiani e Stranieri nella Sala Auditorium: Pio Bertani, Giuseppe Cantatore, Filippo Cardinali, Antonios Chaniotis, Vittorio Franco, Massimo Giovarruscio, Salvato-re Sauro, Francesco Mannocci, Walid Nehme, Mohammad Hossein Nekoofar, Francesco Riccitiello, Katia Greco, Patrick Sequeira-Byron, Stephane Simon;

- Avremo una Sala apposita che fungerà da rimando all’in-terno della quale verranno proiettate tutte le conferenze della Sala principale, per far si che tutti i numerosissimi partecipanti iscritti possano godersi nel totale comfort il Congresso;

- La Sessione Premi SIE intitolati a Garberoglio, Riitano e La-vagnoli hanno riscosso un successo incredibile all’estero e non abbiamo mai avuto così tante submission come quest’anno.

- La Sessione Poster vedrà come di consueto l’affissione del manifesto per tutta la durata del Congresso, ma l’innovazione di quest’anno è che i selezionati dalla commissione esami-natrice potranno esporre il loro lavoro nella sala parallela, davanti ad una platea di persone interessate oltre che ai va-lutatori.

- Avremo 5 Master Clinician Session Live con dimostrazioni clinche in diretta tenute da Relatori di chiara fama Nazionale e Internazionale;

- Quest’anno introdurremo una nuova modalità di partecipa-zione per tutti i congressisti a cui abbiamo dato il nome di Teatro Clinico: realizzeremo tre teatri, ed abbiamo scelto tre argomenti di sicuro interesse che saranno completamente svi-scerati da bravissimi Soci Attivi SIE;

- verranno organizzate le Tavole Cliniche Sponsorizzate che anno dopo anno diventano un momento importante per gli sponsor, che hanno così la possibilità di mostrare le ultime uscite sul mercato e farle provare direttamente ai congressisti;

- Posso anticiparVi che già fin dai primi mesi dell’anno l’inte-resse per il Congresso da parte delle Aziende Sponsor era così elevato che abbiamo già definito la maggior parte delle postazioni;

- Il Congresso sarà accreditato ECM, come tutti i nostri eventi e avremo, per agevolare sia italiani che stranieri, la traduzione simultanea...

...tutto questo per raccontare una volta di più la passione che tutti noi della SIE ci mettiamo per accrescere ogni anno l’ag-giornamento scientifico in campo endodontico e invogliarVi ancor di più a partecipare ad un evento che già di Suo non ha bisogno di presentazioni, perchè di sicuro imperdibile!

Concludere il mio mandato con il Congresso Internazionale di Milano e passare il testimone al Presidente eletto - Vittorio Franco, è il miglior viatico per un futuro radioso della SIE. Ab-biamo fatto tanto anche se con non poche difficoltà: un grazie all’esperienza del Past President - Pio Bertani e dell’entusiasmo del mio Vice Presidente - Maria Teresa Sberna, alla quale devo grande riconoscenza per la sua capacità nella realiz-zazione del Congresso al San Raffaele. Il lavoro che questo consiglio ha concretizzato è stato un rigoroso controllo delle spese e questo grazie ad un attento lavoro della Segreteria e del Tesoriere - Filippo Cardinali, che ringrazio per il lavoro svolto.

La risoluzione di piccoli problemi fiscali ma soprattutto l’aver aumentato il numero degli sponsor, portando a 5 i Main Spon-sor per questo Congresso, è motivo di grande soddisfazione. Aver vissuto quasi in simbiosi questi due anni con il Segretario - Roberto Fornara, al quale chiedo pubblicamente scusa, per le mie telefonate ad ore improbabili della mattina, ma con il quale abbiamo lavorato sempre nell’interesse della Società e dei Soci. Un grazie al Coordinatore della Comunicazione - Italo Di Giuseppe ed al Coordinatore culturale - Mauro Rigo-lone per il loro lavoro, ma permettetemi di ringraziare Katia Greco e Alberto Rieppi i nostri Revisori dei Conti, sempre presenti ai nostri consigli anche senza diritto di voto.

Un grandissimo bacio va a Gaia preziosissima collaboratrice, lei rappresenta la vera anima della Società e non potevamo fare migliore scelta.

Devo ora ringraziare tutti Voi che avete voluto darmi l’onore di essere il vostro Presidente per questo biennio, incarico che ho portato avanti mettendo il mio massimo impegno per l’amore e per l’interesse che tutti noi nutriamo per la nostra splendida disciplina: L’ENDODONZIA.

Il Presidente SIE Francesco Riccitiello

93

COORDINATORE CULTURALE

Dott. Mauro RigoloneVia Giovine Italia,1813100 Vercelli (VC)Tel. 0161-503450Fax 0161-503450e-mail: [email protected]

COORDINATORE DELLE SEZIONI REGIONALI

Dott. Cristian CorainiPiazza Repubblica, 3220124 Milano (MI)Tel. 02-781924Cell 327-0444922e-mail: [email protected]

SEGRETARI REGIONALI 2017/2018

STRUTTURA SOCIETARIA

SAE Abruzzo dott. Lucio DanieleViale Corrado IV, 667100 L’Aquila (AQ)tel. 0862-25469fax 0862-422309cell. [email protected]

SEL Liguria dott. Luca IvaldiVia Leopardi,1815011 Acqui Terme (AL)cell. [email protected]

SES Sardegna dott.ssa Claudia DettoriVia Tolmino, 709122 Cagliari (CA)tel. 070-743758fax [email protected]

SEB Basilicatadott. Eduardo VeralliVia XX Settembre,1985100 Potenza (PO)tel. 0971-22170 cell. 338-7028109 [email protected]

SLE Lombardia dott. Stefano GaffuriVia Napoleone, 5025039 Travagliato (BS)tel. 030-6864844fax 030-6866189cell. [email protected]

SSE Sicilia dott. Alfio PappalardoVia Canfora, 5095128 Catania (CT)tel. e fax [email protected]

SEC Campania dott.ssa Paola CarratùVia Belvedere, 22280127 Napoli (NA)tel. 081-642373cell. [email protected]

SME Marche dott. Stefano VecchiVia Cappannini, 39/d60030 Serra dè Conti (AN) tel. e fax 0731-878355cell. [email protected]

STE Triveneto dott. Alberto MazzoccoVia Cà di Cozzi, 41/a37124 Verona (VR)tel. e fax 045-8344430cell. [email protected]

SERE Emilia Romagna dott. Luca VenutiVia Carlo Jussi, 7940068 San Lazzaro di Savena (BO)tel. 051-321489cell. [email protected]

SPE Piemonte e Valle d’Aosta dott. Davide Fabio Castro Via Oioli, 6B 28013 Gattico (NO) tel. 0331-735276 cell. 338-7075126 [email protected]

SER Laziodott.ssa Alessandra D’AgostinoVia Bellini, 5 03043 Cassino (FR)tel. 0776-312378 cell. [email protected]

SEP Puglia dott. Giuseppe SqueoVia G. Murat, 9870123 Bari (BA)tel. 080-9189351cell. [email protected]

94

SOCI ONORARI

Borsotti Prof. GianfrancoBresciano Dott. BartoloCavalleri Prof. GiacomoMantero Prof. FrancoPecora Prof. GabrielePerrini Dott. NicolaVignoletti Dott. Gianfranco

SOCI ATTIVI

Agresti Dott. DanieleAltamura Dott. CarloAmato Prof. MassimoAmbu Dott. EmanueleAmoroso D’Aragona Dott.ssa EvaAscione Dott.ssa Maria RosariaAutieri Dott. GiorgioBadino Dott. MarioBarattolo Dott. RanieroBarboni Dott.ssa Maria GiovannaBecciani Dott. RiccardoBeccio Dott. RobertoBertani Dott. PioBerutti Prof. ElioBianco Dott. AlessandroBonaccorso Dott. Antonino MariaBonacossa Dott. LorenzoBonelli Bassano Dott. MarcoBorrelli Dott. MarinoBoschi Dott. MaurizioBottacchiari Dott. Renato StefanoBotticelli Dott. ClaudioBrenna Dott. FrancoBuda Dott. MassimoCabiddu Dott. MauroCalapaj Dott. MassimoCalderoli Dott. StefanoCampo Dott.ssa SimonettaCanonica Dott. MassimoCantatore Prof. GiuseppeCapelli Dott. MatteoCardinali Dott. FilippoCardosi Carrara Dott. FabrizioCarmignani Dott. EnricoCarratù Dott.ssa PaolaCarrieri Dott. GiuseppeCascone Dott. AndreaCassai Dott. EnricoCastellucci Dott. ArnaldoCastro Dott. Davide FabioCavalli Dott. GiovanniCecchinato Dott. LuigiCerutti Prof. AntonioCiunci Dott. Renato PasqualeColla Dott. MarcoConconi Dott. MarcelloCoraini Dott. CristianCortellazzi Dott. GianlucaCotti Prof.ssa ElisabettaCozzani Dott.ssa MarinaD’Agostino Dott.ssa AlessandraDaniele Dott. LucioDel Mastro Dott. GiulioDettori Dott.ssa Claudia

Di Ferrante Dott. GiancarloDi Giuseppe Dott. ItaloDonati Dott. PaoloDorigato Dott.ssa AlessandraFabbri Dott. MassimilianoFabiani Dott. CristianoFaitelli Dott.ssa EmanuelaFassi Dott. AngeloFavatà Dott. MassimoFermani Dott. GiorgioFerrari Dott. PaoloFerrini Dott. FrancescoFoce Dott. EdoardoForestali Dott. MarcoFornara Dott. RobertoFortunato Prof. LeonzioFranchi Dott.ssa IreneFranco Dott. VittorioFuschino Dott. CiroGaffuri Dott. StefanoGagliani Prof. MassimoGallo Dott. RobertoGallottini Prof. LivioGambarini Prof. GianlucaGenerali Dott. PaoloGesi Dott. AndreaGiacomelli Dott.ssa GraziaGiovarruscio Dott. MassimoGnesutta Dott. CarloGnoli Dott.ssa RitaGorni Dott. FabioGreco Dott.ssa KatiaGullà Dott. RenatoHazini Dott. Abdol HamidIacono Dott. FrancescoIandolo Dott. AlfredoIvaldi Dott. LucaKaitsas Prof. VassiliosKaitsas Dott. RobertoLamorgese Dott. VincenzoLendini Dott. MarioMaggiore Dott. FrancescoMalagnino Prof. Vito AntonioMalagnino Dott. Giovanni PietroMalentacca Dott. AugustoMalvano Dott. MarianoMancini Dott. ManueleMancini Dott. MarioMancini Dott. RobertoManfrini Dott.ssa FrancescaMangani Prof. FrancescoMartignoni Dott. MarcoMazzocco Dott. AlbertoMigliau Dott. GuidoMonza Dott. DanieleMori Dott. MassimoMultari Dott. GiuseppeMura Dott. GiovanniNatalini Dott. DanieleNegro Dott. Alfonso RobertoOlivi Dott. GiovanniOngaro Dott. FrancoOrsi Dott.ssa Maria VeronicaPadovan Dott. PieroPalazzi Dott. FlavioPalmeri Dott. MarioPansecchi Dott. DavidePapaleoni Dott. Matteo

Pappalardo Dott. AlfioParente Dott. BrunoPasqualini Dott. DamianoPiferi Dott. MarcoPilotti Dott. EmilioPirani Dott.ssa ChiaraPisacane Dott. ClaudioPolesel Prof. AndreaPollastro Dott. GiuseppePongione Dott. GiancarloPontoriero Dott.ssa Denise Portulano Dott. FrancescoPracella Dott. PasqualePreti Dott. RiccardoPulella Dott. CarmeloPuttini Dott.ssa MonicaRaffaelli Dott. RenzoRaia Dott. RobertoRapisarda Prof. ErnestoRe Prof. DinoRengo Prof. SandroRiccitiello Prof. FrancescoRicucci Dott. DomenicoRieppi Dott. AlbertoRigolone Dott. MauroRizzoli Dott. SergioRoggero Dott. EmilioRusso Dott. ErnestoSantarcangelo Dott. Filippo SergioSbardella Dott.ssa Maria ElviraSberna Dott.ssa Maria TeresaScagnoli Dott. LuigiSchianchi Dott. GiovanniSchirosa Dott. Pier LuigiSerra Dott. StefanoSimeone Prof. MicheleSmorto Dott.ssa NataliaSonaglia Dott. AngeloSqueo Dott. GiuseppeStorti Dott.ssa PaolaStrafella Dott. RobertoStuffer Dott. FranzTaglioretti Dott. VitoTaschieri Dott. SilvioTavernise Dott. SalvatoreTiberi Dott. ClaudioTocchio Dott. CarloTonini Dott. RiccardoTosco Dott. EugenioTripi Dott.ssa Valeria RomanaUberti Dott.ssa ManuelaUccioli Dott. UmbertoVecchi Dott. StefanoVenturi Dott. GiuseppeVenturi Dott. MauroVenuti Dott. LucaVeralli Dott. EduardoVittoria Dott. GiorgioVolpi Dott. Luca FedeleZaccheo Dott. FrancescoZerbinati Dott. MassimoZilocchi Dott. FrancoZuffetti Dott. PierFrancesco

SOCI AGGREGATI

Bugea Dott. CalogeroCuppini Dott.ssa ElisaD’Alessandro Dott. AlfonsoGiovinazzo Dott. LucaMessina Dott. GiovanniMilani Dott. StefanoPaone Dott. PasqualeReggio Dott.ssa LuciaZaccheo Dott. Fabrizio

SOCI SCOMPARSIRicordiamo con affetto e gratitudine i Soci scomparsi:

Attanasio Dott. SalvatoreSocio AttivoCastagnola Prof. LuigiSocio OnorarioDe Fazio Prof. PietroSocio AttivoDolci Prof. GiovanniSocio OnorarioDuillo Dott. SergioSocio OnorarioGarberoglio Dott. RiccardoSocio OnorarioLavagnoli Dott. GiorgioSocio OnorarioPecchioni Prof. AugustoSocio OnorarioRiitano Dott. FrancescoSocio OnorarioSpina Dott. VincenzoSocio OnorarioZerosi Prof. CarloSocio Onorario

CONSIGLIO DIRETTIVO SIE BIENNIO 2017-2018

Past PresidentBertani Dott. Pio

PresidenteRiccitiello Prof. Francesco

Presidente ElettoFranco Dott. Vittorio

Vice Presidente Sberna Dott.ssa Maria Teresa

SegretarioFornara Dott. Roberto

TesoriereCardinali Dott. Filippo

Coordinatore CulturaleRigolone Dott. Mauro

Coordinatore della Comunicazione Di Giuseppe Dott. Italo

Revisori dei ContiGreco Dott.ssa KatiaRieppi Dott. Alberto

STRUTTURA SOCIETARIA

95

SOCIO AGGREGATO

Per avere lo status di Socio Ag-gregato si dovrà presentare la documentazione descritta nel sito www.endodonzia.it che sarà va-lutata dalla Commissione Accet-tazione Soci. La documentazione che verrà presentata dovrà mo-strare con rigore, attraverso casi clinici, l’interessamento del candi-dato alla disciplina endodontica. Un meccanismo a punti è stato in-trodotto per valutare l’ammissibili-tà del candidato allo “status” di Socio Aggregato: i punti saranno attribuiti in base al tipo di docu-mentazione presentata. Possono accedere alla qualifica di Socio Aggregato tutti i Soci Ordinari della SIE, in regola con le quote associative degli ultimi TRE anni, che completino e forniscano la documentazione alla Segreteria Nazionale (Via Pietro Custodi 3, 20136 Milano) entro i termini che verranno indicati all’indirizzo web: www.endodonzia.itLa domanda dovrà essere firmata da un Socio Attivo il quale do-vrà aver esaminato e approvato la documentazione. Quest’ultimo è responsabile della correttezza clinica e formale della documen-tazione presentata.

DOCUMENTAZIONE PER DIVENTARE SOCIO AGGREGATOQualsiasi Socio Ordinario, con i requisiti necessari, può pre-sentare la documentazione per ottenere la qualifica di Socio Ag-gregato. Un meccanismo a punti è stato introdotto per valutare il candidato: un minimo di 80 pun-ti è richiesto per divenire Socio Aggregato.

La documentazione clinica per ottenere la qualifica di Socio Ag-gregato dovrà presentare alme-no sei casi, di cui non più di tre senza lesione visibile nella radio-grafia preoperatoria e non più di uno di Endodonzia Chirurgica Retrograda.Nella domanda non potranno es-sere presentati casi la cui somma superi i 120 punti per la qualifica di Socio Aggregato. L’aspirante Socio Aggregato po-trà presentare la documentazione clinica in più volte, con un mini-mo di 40 punti per presentazio-ne, in un arco massimo di cinque anni. Il mancato rinnovo della quota associativa, anche per un solo anno, annulla l’iter di presen-tazione dei casi.

SOCIO ATTIVO

Per avere lo status di Socio Attivo si dovrà presentare la documen-tazione descritta nel sito www.endodonzia.it che sarà valutata dalla Commissione Accettazio-ne Soci. La documentazione che verrà presentata dovrà mostrare con rigore, attraverso documen-tazione scientifica e casi clinici, l’interessamento del candidato alla disciplina endodontica. Un meccanismo a punti è stato introdotto per valutare l’ammissi-bilità del candidato allo “status” di Socio Attivo: i punti saranno attribuiti in base al tipo di docu-mentazione clinica e scientifica presentata. Possono accedere alla qualifica di Socio Attivo tutti i Soci Ordinari della SIE, in rego-la con le quote associative degli ultimi TRE anni, che completino

e forniscano la documentazione alla Segreteria Nazionale (Via Pietro Custodi 3, 20136 Mila-no) entro i termini che verranno indicati all’indirizzo web: www.endodonzia.itLa domanda di ammissione allo “status” di Socio Attivo rivolta al Presidente della SIE dovrà esse-re firmata da un Socio Attivo il quale dovrà aver esaminato e approvato la documentazione. Quest’ultimo è responsabile della correttezza clinica e formale del-la documentazione presentata.

DOCUMENTAZIONE PER DIVENTARE SOCIO ATTIVOQualsiasi Socio Ordinario, con i requisiti necessari, può presen-tare la documentazione per otte-nere la qualifica di Socio Attivo. Il Socio Aggregato che volesse presentare la documentazione scientifica e clinica ad integra-zione di quella clinica già ap-provata dalla CAS per lo status di socio Aggregato, potrà farlo già dall’anno successivo all’otte-nimento della sua qualifica.Un meccanismo a punti è stato introdotto per valutare il candida-to a Socio Attivo. Un minimo di 200 punti è richiesto per divenire Socio Attivo.Nella domanda non potranno es-sere presentati casi la cui somma superi i 240 punti per la qualifi-ca di Socio Aggregato. La docu-mentazione clinica per ottenere la qualifica di Socio Attivo dovrà presentare almeno sei casi, di cui non più di tre senza lesione visibi-le nella radiografia preoperatoria e non più di uno di Endodonzia Chirurgica Retrograda.La documentazione scientifica

non potrà presentare più di 2 ar-ticoli come coautore.

MODALITÀ DI DOCUMENTAZIONE DEI CASI CLINICI

Per avere i criteri e le modalità per la valutazione dei casi cli-nici idonei ad accedere alle qualifiche di Socio Aggregato e di Socio Attivo sono espressi nell’apposita sezione del Rego-lamento della Società Italiana di Endodonzia (SIE) all’indirizzo web: www.endodonzia.it

CRITERI DI VALUTAZIONE

I casi clinici verranno valutati nel loro complesso, coerentemente con gli scopi e fini della SIE, e devono essere presentati dai Candidati considerando non solo l’aspetto clinico, ma anche quello formale della documenta-zione presentata.La documentazione scientifica verrà valutata considerando la classificazione ANVUR delle Riviste Scientifiche, i documenti scientifici dovranno essere tutti di pertinenza endodontica.

ADEMPIMENTI DEL CANDIDATO

La domanda di ammissione allo “status” di Socio Aggregato/Attivo, rivolta al Presidente della SIE, dovrà pervenire, insieme alla documentazione di seguito elencata, alla Segretaria della SIE con un anticipo di 20 giorni sulle date di riunione della CAS,

COME DIVENTARE SOCIO ATTIVO / AGGREGATOScaricabile dal sito www.endodonzia.it

sufficiente per poter organizza-re il materiale dei candidati. Le date di scadenza saranno rese note sul sito. La domanda dovrà essere firmata da un Socio Attivo il quale dovrà aver esaminato e approvato la documentazione. Quest’ultimo è responsabile della correttezza clinica e formale del-la documentazione presentata.

PRESENTAZIONE DEI CASI ALLA COMMISSIONE

La presenza del Candidato è ob-bligatoria durante la riunione del-la CAS; è altresì consigliabile la presenza del Socio presentatore.

LA COMMISSIONE ACCETTAZIONE SOCI

La CAS (Commissione Accetta-zione Soci) è formata 5 Membri di indiscussa esperienza clinica, 4 Soci Attivi con almeno 5 anni di anzianità in questo ruolo elet-ti ad ogni scadenza elettorale dall’Assemblea dei Soci Attivi ed Onorari e uno dei Past President della Società incaricato dal CD ad ogni riunione. Compito del-la CAS è quello di esaminare e valutare la documentazione pre-sentata dagli aspiranti Soci Ag-gregati e Soci Attivi. Per rispetto del lavoro dei Candidati e per omogeneità di giudizio, in ogni

riunione verranno valutati non più di 5 candidati a Socio Attivo. Resta libero, invece, il numero dei candidati a Socio Aggregato valutabili in una singola riunione della CAS. Il Consiglio Direttivo (CD) incaricando la Commissio-ne Accettazione Soci (CAS) la rende responsabile dell’ applica-zione delle regole descritte nell’ articolo 2 del regolamento. Il giu-dizio della CAS è insindacabile.

MEMBRI DELLA COMMISSIONE ACCETTAZIONE SOCI 2018

Past President della SocietàDott. Mario ManciniDott. Franco OngaroDott. Andrea PoleselDott. Pier Luigi Schirosa

One Curve è lo strumento unico per la sagomatura canalare progettato per rispondere al meglio a tutte le esigenze cliniche.

L’innovativo trattamento termico del Nichel-Titanio rende lo strumento molto più fl essibile e riduce signifi cativamente il rischio di frattura, rendendo più semplice e sicura la preparazione del canale. È inoltre possibile precurvare lo strumento per permettere un accesso facilitato anche ai canali complessi e una migliore eliminazione delle interferenze.

Insieme al movimento di rotazione continua, la sezione variabile conferisce un’ottima effi cacia di taglio così come una centratura perfetta nel canale e una buona messa in sicurezza della zona apicale.

L’utilizzo di un unico strumento monouso riduce inoltre il rischio di contaminazione crociata e agevola il lavoro del personale assistente grazie all’eliminazione delle procedure di sterilizzazione.

One Curve è uno strumento affi dabile, sicuro e performante, come è tradizione degli strumenti NiTi Micro-Mega. Adatto sia agli utilizzatori più esperti, sia a chi si approccia per la prima volta allo strumento unico, One Curve garantisce un’elevata qualità della preparazione canalare, migliorando le possibilità di disinfezione e consentendo un’adeguata chiusura tridimensionale del canale.

DISTRIBUTORE ESCLUSIVO PER L’ITALIA DENTALICA S.p.A. – Via Rimini, 22 – 20142 Milano T 02.895981 – F 02.89504249 – [email protected] – www.dentalica.com

ONE CURVE, IL DNA DELL’ENDODONZIA

I coni master di gutta-percha con tecnologia Conform FitTM a conicità variabile.

La precisa corrispondenza di forme e dimensioni ottimizza il trattamento Una delle maggiori sfi de nell’otturazione cana lare è ottenere un appropriato tug back api cale. Per raggiun-gere la lunghezza di lavoro, è necessario procedere all’eliminazione dei detriti ed all’irrigazione. Tuttavia, a dispetto di queste precauzioni, l’abilità a raggiungere la lunghezza di lavoro è fortemente infl uenzata dalla sagomatura del canale e dalla compati bilità tra la gutta-percha e la strumentazione usate. In caso contra-rio si può incorrere nella falsa sensazione di un’aderenza sicura.

Aderenza apicale superiore con il tug back desideratoI coni master di guttaperca con tecnologia Conform Fit prodotti da Dentsply Sirona sono i primi ad avere una conicità variabile per adattarsi con precisione agli stru menti corrispondenti. L’avanzata formulazione micronizzata utilizza una moderna tecnica di produzione per creare una forma e un adatta mento con il 40% in più di conformità rispet to alla guttaperca tradizionale. Il conseguente adattamento apicale migliorato permette di avvertire la precisa risposta di tug back a dif-ferenza della guttaperca tradizionale, che sembra adattarsi perfettamente, ma in realtà può non corrispon-dere all’esatta misura dell’a pice.

Priva di lattice, può essere usata a temperature di lavoro inferioriStudiata per ottenere un’otturazione completa, la formula micronizzata o� re caratteristiche termiche avanzate che permettono una migliore fl uidità ed il trasferimento del calore fi no a 4 mm. Questa formula-zione migliorata continua ad assicurare l’ottimale radiopacità e la facilità di ritrattamento.Mentre la guttaperca tradizionale è realizzata in lattice di gomma naturale, quella prodotta con l’ esclusiva formulazione di Dentsply Sirona è priva di lattice per una migliore sicurezza del paziente.

Una soluzione globaleI coni master di guttaperca con tecnologia Conform Fit™ fanno parte di una soluzione globale che facilita l’operatività grazie al preciso adattamento. Forniti di una pratica linguetta identifi cativa per una facile ge-stione, i coni master sono disponibili per i sistemi WaveOne Gold®, Protaper Gold® e Protaper Next®.

Per saperne di più visita il sito www.dentsplysirona.com o contatta Simit Next al numero 0376.267811

Punte di guttaperca ProTaper Gold®Punte di guttaperca ProTaper Gold®

STRUMEN

PUNTE DI CARTA

PUNTE DI GUTTAPERCA

Parte di un sistema globale

WaveOne® Gold ProTaper Gold® ProTaper Next®

Coni master di guttaperca con tecnologia Conform Fit™

Colore Dimensione Confezione Codice #

■ Giallo Small 60 pz. A175X00000S00■ Rosso Primary 60 pz. A175X00000P00■ Verde Medium 60 pz. A175X00000M00■ Bianco Large 60 pz. A175X00000L00

Descrizione Confezione Codice #

■ Rosso X2 60 pz. B00PNGPF000X2■ Blu X3 60 pz. B00PNGPF000X3■ ■ Assortiti X2/X3 60 pz. B00PNGPF00X23■ ■ Assortiti X4/X5 60 pz. B00PNGPF00X45

Punte di guttaperca WaveOne® Gold

Descrizione Confezione Codice #

■ Giallo F1 60 pz. A241X00000100■ Rosso F2 60 pz. A241X00000200■ Blu F3 60 pz. A241X00000300■ Double Black F4 60 pz. A241X00000400■ Double Giallo F5 60 pz. A241X00000500

Assortiti 60 pz. A241X00090100

TtLe

mo

difi

che

tecn

iche

ai n

ost

ri p

rod

ott

i no

n so

no s

og

get

te a

no

tific

a. L

e fo

to d

egli

stru

men

ti n

on

sono

vin

cola

nti.

ST

8/ B

IT G

PP

0 B

RC

00

0 /

00

/20

17 –

cre

ated

12/

2017

DENTSPLY Tulsa Dental SpecialtiesDENTSPLY International, Inc.608 Rolling Hills DriveJohnson City, TN 37604, USAMade in USAwww.dentsplymaillefer.com

DENTSPLY DeTrey GmbH De-Trey-Strasse 1D-78467 Konstanz Germania

EC REP

0086

ProTaper Next®WaveOne® Gold ProTaper Gold®

EDDY® è il sistema sonico d’irrigazione canalare sicuro, efficace e clinicamente testato.

Numerosi studi clinici e più di due anni di utilizzo nella pratica quotidiana hanno dimostrato che l’attivazione sonica dell’irrigante con la punta EDDY® della VDW deterge in modo sicuro ed efficace anche i canali radicolari più curvi.

La punta EDDY® per l’attivazione sonica dell’irrigante risolve i problemi dei sistemi ultrasonici e dell’irrigazione manuale. Realizzata in poliammide, effettua un movimento oscillatorio di elevata ampiezza nel canale radicolare generato dall’aria compressa ad alta frequenza, dai 5.000 ai 6.000 Hz. Questo movimento tridimensionale innesca la cavitazione e il microstreaming dei liquidi che rendono la detersione più efficiente anche nei canali laterali, nelle ramificazioni apicali e negli istmi. La punta EDDY® in poliammide, inoltre, è più morbida della dentina e particolarmente delicata e flessibile, rispetta l’anatomia del canale ed evita il rischio di creare gradini o perforazioni. Un ulteriore vantaggio di EDDY® consiste nel notevole risparmio di tempo - richiede solo un massimo di 30 secondi per intervallo durante la preparazione - e assicura una maggiore efficienza rispetto all’irrigazione manuale con cannule.

Studi clinici dimostrano il successo del trattamento a lungo termine

Diversi studi clinici (Neuhaus et al., Urban et al.) hanno confrontato le prestazioni di EDDY® rispetto agli altri metodi di irrigazione e hanno dimostrato che produce risultati eccezionali: rimuove il biofilm batterico nei canali con anatomie complesse tanto efficacemente quanto l’irrigazione ultrasonica passiva, risultando più delicata sulle pareti canalari grazie alla morbidezza e flessibilita della poliammide. Sia l’attivazione sonica che ultrasonica rafforzano le proprietà degli irriganti di dissoluzione del tessuto. Infine, è stato dimostrato che EDDY® rimuove depositi e detriti di idrossido di calcio in modo più efficace rispetto all’irrigazione manuale.Essendo una punta monouso di dimensioni universali, EDDY® può essere facilmente ed efficacemente integrata nella pratica clinica quotidiana, grazie alla sua compatibilità con la maggior parte degli Airscaler disponibili sul mercato.

Per maggiori informazioni consultare il sito web https://www.vdw-dental.com/en/products/detail/eddy/

Movimento oscillante della punta in poliammide EDDY®

EDDY® su Airscaler sonico

Movimento oscillante della punta in poliammide EDDY®in poliammide EDDY®in poliammide EDDY

[email protected]

F22 ALIGNER: L’allineatore trasparente Invisibile, confortevole, preciso, efficace

Il sistema F22, frutto di 25 anni di esperienza e di 14 anni di ricerche della Scuola di Specializzazione in Ortognatodonzia dell’Università di Ferrara, è composto da una serie di sottili apparecchi ortodontici rimovibili (allineatori), su misura, realizzati nei moderni ed evoluti reparti produttivi di Sweden & Martina utilizzando un esclusivo materiale plastico trasparente; essi consentono lo spostamento graduale e progressivo dei denti verso la posizione ottimale, grazie ad un monitoraggio continuo, raggiungendo un’occlusione esteticamente gradevole e funzionalmente valida.

La programmazione di F22 differisce sostanzialmente da quella degli altri allineatori disponibili nel mercato. Il team di ortodontisti della Scuola di Specializzazione, guidato dal direttore, il Professor Giuseppe Siciliani, studia analiticamente ogni singolo caso e guida il medico fino alla fine del trattamento: insieme al prodotto, quindi, è offerta una consulenza gratuita estremamente qualificata anche a medici non specialisti in ortodonzia, seguendo puntualmente criteri biomeccanici estremamente precisi.

Grazie al Setup digitale e al visualizzatore 3D è possibile analizzare e visualizzare ogni singolo step di trattamento, per condividerlo con i pazienti, illustrando facilmente il piano approvato.

Rispetto agli altri allineatori disponibili, F22 Aligner ha dei plus enormi: il 20% in più di trasparenza; fitting ottimale e ritenzione perfetta (lo spazio tra allineatore e denti è inferiore a 40 micron); il 20% in più di elasticità, grazie alla quale sono trasmesse forze leggere e costanti; una superficie eccezionalmente liscia e margini arrotondati per un maggiore comfort del paziente; elevata resistenza alla rottura.

F22 Aligner è indicato per il trattamento di affollamenti, diastemi, discrepanze dell’indice di Bolton che necessitano di restauri protesici o di stripping per una completa correzione, festonature gengivali irregolari in pazienti con denti usurati o irregolari, morsi aperti o morsi profondi di lieve o moderata entità.

L’invio e lo studio dei casi avviene online, fino all’approvazione del set-up virtuale, sul quale saranno realizzati i modelli e gli allineatori trasparenti F22 per ciascuna fase del piano di trattamento del paziente.

Nuovi Case Report su www.kometacademy.itIL BLOG CHE INFORMA

Il progetto Komet Academy, coordinato dal Prof. Massimo Gagliani dell’Università di Milano, è nato con l’obiettivo di migliorare la sa-lute orale dei pazienti mediante la diffusione di contenuti clinici e tecnici di alto livello. Il blog www.kometacademy.it espone Case Report di sicuro inte-resse per i lettori, grazie anche alla presenza di chiare foto esplica-tive e, in alcuni casi, di video clinici molto curati. Tali Case Report sono il frutto della ricerca e del lavoro di odontoiatri esperti appar-tenenti al panel di Komet Academy.Per quanto riguarda l’endodonzia, nel mese di giugno sono stati pubblicati due casi clinici del Dr. Alessandro Fava, il primo sulla rimozione di un file danneggiato e sul successivo ritrattamento endodontico; il secondo riguardante un trattamento endodontico seguito da un trattamento restaurativo. Presto verranno pubblicati dei Case Report anche del Dr. Giuseppe Squeo: uno inerente pul-pite irreversibile di un primo molare inferiore curata con solo due strumenti, un secondo caso riguarderà un ritrattamento endodon-tico eseguito con nuovi e innovativi strumenti per la rimozione dei

materiali presenti all’interno dei canali. Komet, leader mondiale di strumenti rotanti ed oscillanti sonici, conferma con il suo blog l’impegno ad approfondire paradigmi specifici di condotta clinica che prevedano l’utilizzo di strumenti selezionati all’interno del proprio ampio catalogo.Il blog è facilmente consultabile anche da smartphone e tablet e tutti gli articoli possono essere facilmente individua-ti tramite comode ricerche e filtri che permettono, per esem-pio, di restringere l’ambito clinico (conservativa, protesi, chi-rurgia/implantologia, endodonzia, profilassi, parodontologia).Nel blog kometacademy.it sta riscuotendo grande interesse la se-zione dedicata agli eventi dove è possibile consultare una lista di numerosi corsi teorici e pratici programmati lungo un ampio orizzonte temporale; tramite l’integrazione con Google Maps viene fornito anche il percorso per raggiungere le location.Il blog, nato per la diffusione e la condivisione delle idee e delle informazioni, permette inoltre di commentare e condividere gli ar-ticoli sulle principali piattaforme social.

www.kometacademy.it

TriAuto ZX2Massima precisione e sicurezza per il canale radicolare

Il nuovo sistema endodontico aumenta l’efficienza e la sicurezza

In Endodonzia la necessità di lavorare su strut-ture minuscole, in spazi molto limitati ed anche le particolari situazioni anatomiche coinvolte pongono richieste straordinarie alle competen-ze del dentista, richiedendo sforzi speciali per garantire la sicurezza dei pazienti. Pioniere nel campo della Endodonzia, Morita ha sempre offer-to soluzioni di alta qualità per i dentisti per molti decenni, puntando all’efficienza, comfort e sicu-rezza. Un esempio di questo è il nuovo TriAuto ZX2, un motore endo cordless, con localizzatore apicale integrato che ora include una funzionalità innovativa per una maggiore sicurezza: la funzio-ne Ottimale Glide Path (OGP) mira a procedure ancora più precise all’interno del canale radico-lare e guida i dentisti e i pazienti al successo del trattamento, “seguendo percorsi sicuri”.L’Endodonzia ha svolto un ruolo fondamentale in più di 100 anni di storia di Morita. Già nel 1991, è stato introdotto il primo Apex Locator del mondo che ha utilizzato le misure di impedenza, il Root ZX. Il passo successivo in questo sviluppo è stato il sistema modulare DentaPort ZX che grazie alla possibilità di integrazione con il Motore Endo, ha

facilitato la preparazione del canale radicolare.Con il ZX2 TriAuto, Morita ora presenta un nuovo motore endo con localizzatore apicale integrato. Il successore del TriAuto ZX, è l’unico sistema en-dodontico sul mercato che combina entrambe le funzioni in un unico manipolo. Un display LCD mostra misure precise e forni-sce un feedback perfetto dall’interno del canale radicolare. Oltre a questo, il ZX2 TriAuto presenta due caratteristiche di sicurezza innovative - qua-li l’Optimum Torque reverse (OTR) e l’Optimum Glide Path (OGP).La funzione OTR consente di cambiare la dire-zione di rotazione del file quando viene superato il livello massimo di coppia. Combinata con la pic-colissima rotazione angolare, il rischio di rotture di file e microfessure è minimizzato. Inoltre, il sistema conserva il canale radicolare originale e assicura la rimozione affidabile dei detriti.La nuova funzione OGP semplifica la creazione del percorso canalare, rendendolo veloce e si-curo e automatico. In più, il motore può realiz-zare la pervietà apicale usando una lima #20 o più piccola. Possono essere utilizzati Niti file di

dimensioni #20 o più piccoli e file in acciaio dalla dimensione #15. La funzione OGP in combinazione con quella OTR permette allo strumento endo-dontico di essere portato alla lunghezza di lavo-ro più velocemente di quanto precedentemente possibile, senza blocco o formazione di scalini. Inoltre, TriAuto ZX2 conserva la struttura del dente naturale e rende il trattamento ancora più economico a causa di un ridotto consumo di file.Il display LCD mostra tutti i parametri importanti a colpo d’occhio, fornendo il controllo completo durante il trattamento. Un’altra caratteristica chiave del sistema en-dodontico è la piccola testina ed il basso peso (140 g.), che permettono una migliore vista del campo di trattamento. Il fatto di essere cord-less migliora significativamente la flessibilità di trattamento e ottimizza il flusso di lavoro. Il funzionamento semplice ed intuitivo e le funzio-ni automatizzate garantiscono risultati affidabili in ogni momento. La maggiore efficienza riduce anche la durata del trattamento, fornendo tempo supplementare per il risciacquo e la disinfezione del canale radicolare.

103

Anche quest’anno, dopo Giugno 2017, la SIE ha scelto la suggesti-va sede del Grand Hotel di Rimini come location per il classico ap-puntamento del Closed Meeting.All’interno del parco Federico Felli-ni, dal 15 al 17 Giugno, numerosi Soci Attivi hanno potuto partecipa-re ad un evento, che rappresenta ormai da anni un perfetto mix di aggiornamento, pianificazione dell’attività societaria e conviviali-tà; contribuendo a consolidare il senso di appartenenza alla più im-portante Società Italiana in campo endodontico. I membri del Consiglio Direttivo si sono dati appuntamento già dalla sera di Giovedì 14 per una cena informale, mentre il Closed Meeting vero e proprio ha avuto inizio Venerdì 15 con la consue-ta riunione programmatica che si protraeva per diverse ore a partire dalle 9:00. Questo ha dato la possibilità ai Soci di arrivare con calma nella stessa mattinata, per poi parteci-pare, dalle ore 15:00, all’inte-ressantissima lezione dal titolo: “Comunicazione efficace con il paziente” tenuta da Lapo Baglini, esperto di programmazione neu-ro-linguistica, invitato dal direttivo per un pomeriggio di aggiorna-mento al di fuori dei canoni tradi-zionali; il relatore, in modo sem-plice ed accattivante, ha chiarito i motivi che spingono un paziente a scegliere un professionista al posto di un altro; motivi che molto spes-so, ed anche paradossalmente se vogliamo, non hanno a che fare con le capacità clinico-operative

dello stesso. Al termine del mini corso di co-municazione con il paziente, e a conclusione della prima giornata di lavori, il dott. Jacopo Mattiussi riceveva l’applauso degli interve-nuti per il case report che gli è val-so il premio “Miglior caso clinico under 32”. Alle ore 20.00, poi, i partecipanti (tutti vestiti di bianco) si sono ritro-vati in spiaggia per un aperitivo con cena a buffet; una splendida serata a tema, con tanto di dj set, che tutti hanno molto gradito, fino a notte fonda. Il giorno successivo, sabato 16 giugno, mattinata interamente de-dicata alle riunioni delle diverse commissioni: - la CAS: con i dottori Mario Mancini, Franco Ongaro, Andrea polesel, Pier Luigi Schirosa e il Past-President Pio Bertani; - la Commissione Culturale: presie-duta dal dottor Massimo Giovar-ruscio; - la Commissione per la Ricerca: coordinata dal professor Giusep-pe Cantatore;- quella per la Comunicazione: condotta dal dottor Italo Di Giu-seppe, con il web master dottor Augusto Malentacca, la responsa-bile Social Network dott.ssa Deni-se Pontoriero e la collaborazione del dottor Massimo Calapaj; - e la consueta riunione dei Segre-tari Regionali: presieduta dal co-ordinatore culturale dottor Mauro Rigolone, insieme con il Coordina-tore delle Sezioni Regionali dottor Cristian Coraini; per effetto dell’im-minente entrata in vigore delle 4

Macro-Aree, presenti anche i 4 loro Coordinatori.Mattinata molto intensa quindi, ma pomeriggio di solo relax ed attivi-tà sportive, con il torneo di beach volley e quello di tennis, con il dot-tor Marco Colla ad aggiudicarsi il titolo sul Segretario dottor Roberto Fornara, presso il circolo Tennis Rimini. La giornata terminava con l’attesis-sima Cena di Gala presso il risto-rante Club Nautico, a pochi passi dal Grand Hotel: una piacevolis-sima serata sulla magica terrazza del locale, con vista a 360° sul ridente lido di Rimini. E infine, la Domenica mattina, tutto il tempo per una prima colazione con più calma, un tuffo in piscina e poi i saluti, con un arrivederci per tutti a Milano, in occasione del prestigioso III Congresso Interna-zionale SIE dal titolo: “Endodonti-cs: Clinical Solutions” in program-ma dall’8 al 10 Novembre 2018.

VITA SOCIETARIA

15-17 GIUGNO 2018, RIMINI

Closed Meeting 2018Grand Hotel Rimini *****L - Parco Federico Fellini 47921 Rimini (RN)

Resoconto a cura del Dott. Italo Di Giuseppe, Coordinatore della Comunicazione SIE

I SOCI SIE PRONTI PER IL BEACH PARTY

104

VITA SOCIETARIA

SOCI SIE ALLA CENA DI GALA

LA CENA DI GALA SUL MARE

IL PHOTO BOOT AL BEACH PARTY

IL PRESIDENTE PREMIA LA DOTT.SSA PONTORIERO COME VINCITRICE DEL TORNEO DI BEACH VOLLEY

105

Con il quinto incontro svoltosi il 18 settembre 2018, si è concluso a Brescia, presso l’Hotel Ambascia-tori, la terza edizione dell’Endo-dontic Course a cura della Sezio-ne Lombarda della SIE.Come nelle precedenti edizioni, anche quest’anno il successo del Corso è stato decretato, non solo dal folto numero di partecipanti ma anche dal loro grande interes-se dimostrato in ogni incontro.Numerosissimi i giovani, sia stu-denti che neo-laureati, ma anche professionisti determinati nell’ap-prendere i più moderni orienta-menti in Endodonzia.Si sono succeduti come Relatori, alcuni Soci Attivi della nostra so-cietà, sempre pronti a prodigarsi nel mettere a disposizione degli iscritti la loro esperienza clinica.Il Dr. Cavalli e il Dr. Piferi, nel pri-mo incontro, hanno affrontato la diagnosi e il piano di trattamento in Endodonzia.A seguire il Dr. Venturi ha affron-tato l’importanza dell’utilizzo della diga di gomma, con relativa eser-citazione pratica e il Dr. Gaffuri ha trattato l’argomento dell’ese-

cuzione di una corretta cavità di accesso. Il Dr. Tonini si è occupato della detersione del sistema radi-colare proponendo nuovi proto-colli operativi. Il Dr. Cecchinato nel successivo appuntamento, ha trattato la sagomatura dei canali mentre l’otturazione è stata argo-mento a cura del Dr. Gaffuri e del Dr. Venturi.Il Dr. Coraini, come nelle prece-denti edizioni ha trattato magi-stralmente l’importante tema della ricostruzione post-endodontica.Il quinto incontro ha visto come relatori il Dr. Fornara che ha spie-gato l’importanza e la chiave di lettura dell’immagine radiografica in 3D ottenuta con la CBCT e il Dr. Gaffuri ha concluso l’incontro con i Ritrattamenti ortogradi e re-trogradi.Vanno ringraziate, per la loro ap-prezzata partecipazione, gli Spon-sor Simit Next, J Morita e Komet, Sweden e Martina, Dentalica che hanno svolto per i discenti i loro workshop offrendo ai partecipan-ti la possibilità di testare strumenti e motori dedicati all’Endodonzia moderna.

VITA SOCIETARIA

SIE ENDODONTIC COURSES 2018 - SLE

Corsi di formazione teorico/pratici della SIEBRESCIA, 18 SETTEMBRE 2018

I PARTECIPANTI DELL’ENDODONTIC COURSE DI BRESCIA

I PARTECIPANTI DELL’ENDODONTIC COURSE DI BRESCIA

106

Nel contesto delle strutture Univer-sitarie del padiglione n.4 dell’O-spedale San Martino di Genova, si sono portate a termine le lezioni e le relative parti pratiche della prima edizione dell’Endodontic Course Advance SIE 2018.I numerosi corsisti (alcuni di loro provenienti anche da altre regio-ni, uno addirittura dalla Puglia!) hanno approfondito tematiche ed argomenti relativi ai ritrattamenti

endodontici, sfruttando anche l’op-portunità che i numerosi workshop hanno potuto offrire loro per mette-re in pratica ciò che si è imparato durante le relazioni. Un partico-lare ringraziamento è doveroso all’Università di Genova, specie nella figura del Prof. Stefano Bene-dicenti, per la gentile concessione delle aule per le attività didattiche teorico-pratiche.

VITA SOCIETARIA

GENOVA

Endodontic Course Advance SIE 2018Resoconto a cura del Dott. Luca Ivaldi

LA RELAZIONE DEL DOTT. ANDREA POLESEL

I PARTECIPANTI IMPEGNATI NELLA PARTE PRATICA CON IL DOTT. POLESELLA PROVA ORALE FINALE

I PARTECIPANTI IMPEGNATI NELLA PARTE PRATICA CON I RELATORI DEL CORSO

107

INSTRUCTION AUTHOR

CONTENT OF AUTHOR GUIDELINES: 1. General 2. Ethical Guidelines3. Manuscript Submission Procedure4. Manuscript Types Accepted 5. Manuscript Format and Structure 6. After Acceptance7. Open Access8. Creative Commons Attribu-tion-NonCommercial-NoDerivs (CC BY-NC-ND)9. Author Rights

The journal to which you are sub-mitting your manuscript employs a plagiarism detection system. By sub-mitting your manuscript to this journal you accept that your manuscript may be screened for plagiarism against previously published works.

1. GENERAL

Giornale Italiano di Endodonzia publishes original scientific articles, reviews, clinical articles and case reports in the field of Endodontolo-gy. Scientific contributions dealing with health, injuries to and diseases of the pulp and periradicular region, and their relationship with systemic well-being and health. Original scientific articles are published in the areas of biomedical science, applied materials science, bioengineering, epidemiology and social science re-levant to endodontic disease and its management, and to the restoration of root-treated teeth. In addition, re-view articles, reports of clinical ca-ses, book reviews, summaries and abstracts of scientific meetings and news items are accepted.

Please read the instructions below carefully for details on the submis-sion of manuscripts, the journal’s re-quirements and standards as well as information concerning the procedure after a manuscript has been accepted for publication in Giornale Italiano di Endodonzia. Authors are encouraged to visit GIE web site gi-endodonzia.com for further information on the pre-paration and submission of articles and figures.

2. ETHICAL GUIDELINES

Giornale Italiano di Endodonzia adheres to the below ethical guideli-

nes for publication and research.

2.1. Authorship and Acknowledge-mentsAuthors submitting a paper do so on the understanding that the manuscript has been read and approved by all authors and that all authors agree to the submission of the manuscript to the Giornale Italiano di Endodonzia.

Giornale Italiano di Endodonzia adheres to the definition of authorship set up by The International Committee of Medical Journal Editors (ICMJE). According to the ICMJE, authorship criteria should be based on 1) sub-stantial contributions to conception and design of, or acquisiation of data or analysis and interpretation of data, 2) drafting the article or revising it critically for important intellectual con-tent and 3) final approval of the ver-sion to be published. Authors should meet conditions 1, 2 and 3.

It is a requirement that all authors have been accredited as appropriate upon submission of the manuscript. Contributors who do not qualify as authors should be mentioned under Acknowledgements.Acknowledgements: Under acknowledgements please specify contributors to the article other than the authors accredited. Please also include specifications of the sour-ce of funding for the study and any potential conflict of interests if appro-priate.

2.2. Ethical ApprovalsExperimentation involving human subjects will only be published if such research has been conducted in full accordance with ethical principles, including the World Medical Associa-tion Declaration of Helsinki (version 2008) and the additional require-ments, if any, of the country where the research has been carried out. Manuscripts must be accompanied by a statement that the experiments were undertaken with the understanding and written consent of each subject and according to the above mentio-ned principles. A statement regarding the fact that the study has been inde-pendently reviewed and approved by an ethical board should also be included. Editors reserve the right to reject papers if there are doubts as to whether appropriate procedures have been used.

When experimental animals are used the methods section must clearly indi-cate that adequate measures were taken to minimize pain or discomfort.

Experiments should be carried out in accordance with the Guidelines laid down by the National Institute of He-alth (NIH) in the USA regarding the care and use of animals for experi-mental procedures or with the Euro-pean Communities Council Directive of 24 November 1986 (86/609/EEC) and in accordance with local laws and regulations.

All studies using human or animal subjects should include an explicit sta-tement in the Material and Methods section identifying the review and ethics committee approval for each study, if applicable. Editors reserve the right to reject papers if there is doubt as to whether appropriate pro-cedures have been used.

2.3 Clinical TrialsClinical trials should be reported using the guidelines available at www.consort-statement.org. A CONSORT checklist and flow dia-gram (as a Figure) should also be included in the submission material.

The Giornale Italiano di Endodonzia encourages authors submitting manu-scripts reporting from a clinical trial to register the trials in any of the fol-lowing free, public clinical trials regi-stries: www.clinicaltrials.gov, http://clinicaltrials.ifpma.org/clinicaltrials/, http://isrctn.org/. The clinical trial registration number and name of the trial register will then be published with the paper.

2.4 Systematic ReviewsSystematic reviews should be re-ported using the PRISMA guidelines available at http://prisma-statement.org/. A PRISMA checklist and flow diagram (as a Figure) should also be included in the submission material.

2.5 Conflict of Interest and Source of FundingGiornale Italiano di Endodonzia re-quires that all sources of institutional, private and corporate financial sup-port for the work within the manuscript must be fully acknowledged, and any potential conflicts of interest noted. Grant or contribution numbers may be acknowledged, and principal grant holders should be listed. Please include the information under Ack-nowledgements.

2.6 Appeal of DecisionThe decision on a paper is final and cannot be appealed.

2.7 Permissions

If all or parts of previously published illustrations are used, permission must be obtained from the copyright holder concerned. It is the author’s responsi-bility to obtain these in writing and provide copies to the Publishers.

3. MANUSCRIPT SUBMISSION PROCEDURE

Manuscripts should be submitted electronically by e-mail: [email protected]

3.1. Manuscript Files AcceptedManuscripts should be uploaded as Word (.doc) or Rich Text Format (.rft) files (not write-protected) plus sepa-rate figure files. GIF, JPEG, PICT or Bitmap files are acceptable for sub-mission, but only high-resolution TIF or EPS files are suitable for printing.

The text file must contain the abstract, main text, references, tables, and figu-re legends, but no embedded figures or Title page. The Title page should be provided as a separate file.In the main text, please reference fi-gures as for instance ‘Figure 1’, ‘Figu-re 2’ etc to match the tag name you choose for the individual figure files uploaded. Manuscripts should be formatted as described in the Author Guidelines below.

3.2. Blinded ReviewManuscript that do not conform to the general aims and scope of the journal will be returned immediately without review. All other manuscripts will be reviewed by experts in the field (generally two referees).Giornale Italiano di Endodonzia aims to forward referees´ comments and to inform the corresponding author of the result of the review process.

Manuscripts will be considered for fast-track publication under special circumstances after consultation with the Editor.

Giornale Italiano di Endodonzia uses double blinded review. The names of the reviewers will thus not be disclo-sed to the author submitting a paper and the name(s) of the author(s) will not be disclosed to the reviewers.

To allow double blinded review, ple-ase submit your main manuscript and

INSTRUCTION AUTHOR

CONTENT OF AUTHOR GUIDELINES:

1. General 2. Ethical Guidelines3. Manuscript Submission

Procedure4. Manuscript Types Accepted 5. Manuscript Format and

Structure 6. After Acceptance7. Open Access8. Creative Commons

Attribution-NonCommercial-NoDerivs (CC BY-NC-ND)

9. Author Rights

The journal to which you are sub-mitting your manuscript employs a plagiarism detection system. By sub-mitting your manuscript to this journal you accept that your manuscript may be screened for plagiarism against previously published works.

1. GENERAL

Giornale Italiano di Endodonzia publishes original scientific articles, reviews, clinical articles and case reports in the field of Endodontolo-gy. Scientific contributions dealing with health, injuries to and diseases of the pulp and periradicular region, and their relationship with systemic well-being and health. Original sci-entific articles are published in the areas of biomedical science, applied materials science, bioengineering, epidemiology and social science rel-evant to endodontic disease and its management, and to the restoration of root-treated teeth. In addition, re-view articles, reports of clinical cas-es, book reviews, summaries and ab-stracts of scientific meetings and news items are accepted.

Please read the instructions below carefully for details on the submis-sion of manuscripts, the journal’s re-quirements and standards as well as information concerning the procedure after a manuscript has been accepted for publication in Giornale Italiano di Endodonzia. Authors are encouraged to visit GIE web site gi-endodonzia.com for further information on the preparation and submission of arti-cles and figures.

2. ETHICAL GUIDELINES

Giornale Italiano di Endodonzia ad-heres to the below ethical guidelines for publication and research.

2.1. Authorship and Acknowledge-mentsAuthors submitting a paper do so on the understanding that the manuscript has been read and approved by all authors and that all authors agree to the submission of the manuscript to the Giornale Italiano di Endodonzia.

Giornale Italiano di Endodonzia ad-heres to the definition of authorship set up by The International Committee of Medical Journal Editors (ICMJE). According to the ICMJE, authorship criteria should be based on 1) sub-stantial contributions to conception and design of, or acquisiation of data or analysis and interpretation of data, 2) drafting the article or revising it crit-ically for important intellectual content and 3) final approval of the version to be published. Authors should meet conditions 1, 2 and 3.

It is a requirement that all authors have been accredited as appropriate upon submission of the manuscript. Contributors who do not qualify as authors should be mentioned under Acknowledgements.

Acknowledgements: Under acknowledgements please specify contributors to the article other than the authors accredited. Please also include specifications of the source of funding for the study and any potential conflict of interests if ap-propriate.

2.2. Ethical ApprovalsExperimentation involving human sub-jects will only be published if such research has been conducted in full accordance with ethical principles, including the World Medical Associ-ation Declaration of Helsinki (version 2008) and the additional require-ments, if any, of the country where the research has been carried out.

Manuscripts must be accompanied by a statement that the experiments were undertaken with the under-standing and written consent of each subject and according to the above mentioned principles. A statement regarding the fact that the study has been independently reviewed and approved by an ethical board should also be included. Editors reserve the right to reject papers if there are doubts as to whether appropriate pro-cedures have been used.

When experimental animals are used the methods section must clearly indi-cate that adequate measures were taken to minimize pain or discomfort.

Experiments should be carried out in accordance with the Guidelines laid down by the National Institute of Health (NIH) in the USA regarding the care and use of animals for exper-imental procedures or with the Euro-pean Communities Council Directive of 24 November 1986 (86/609/EEC) and in accordance with local laws and regulations.

All studies using human or animal subjects should include an explicit statement in the Material and Meth-ods section identifying the review and ethics committee approval for each study, if applicable. Editors reserve the right to reject papers if there is doubt as to whether appropriate pro-cedures have been used.

2.3 Clinical TrialsClinical trials should be reported us-ing the guidelines available at www.consort-statement.org. A CONSORT checklist and flow di-agram (as a Figure) should also be included in the submission material.

The Giornale Italiano di Endodonzia encourages authors submitting manu-scripts reporting from a clinical trial to register the trials in any of the fol-lowing free, public clinical trials reg-istries: www.clinicaltrials.gov, http://clinicaltrials.ifpma.org/clinicaltrials/, http://isrctn.org/. The clinical trial registration number and name of the trial register will then be published with the paper.

2.4 Systematic ReviewsSystematic reviews should be re-ported using the PRISMA guidelines available at http://prisma-statement.org/. A PRISMA checklist and flow diagram (as a Figure) should also be included in the submission material.

2.5 Conflict of Interest and Source of FundingGiornale Italiano di Endodonzia requires that all sources of institution-al, private and corporate financial support for the work within the man-uscript must be fully acknowledged, and any potential conflicts of interest noted. Grant or contribution numbers may be acknowledged, and princi-pal grant holders should be listed. Please include the information under Acknowledgements.

2.6 Appeal of DecisionThe decision on a paper is final and cannot be appealed.2.7 PermissionsIf all or parts of previously published

illustrations are used, permission must be obtained from the copyright holder concerned. It is the author’s responsi-bility to obtain these in writing and provide copies to the Publishers.

3. MANUSCRIPT SUBMISSION PROCEDURE

Manuscripts should be submitted elec-tronically by e-mail: [email protected]

3.1. Manuscript Files AcceptedManuscripts should be uploaded as Word (.doc) or Rich Text Format (.rft) files (not write-protected) plus sepa-rate figure files. GIF, JPEG, PICT or Bitmap files are acceptable for sub-mission, but only high-resolution TIF or EPS files are suitable for printing.

The text file must contain the abstract, main text, references, tables, and fig-ure legends, but no embedded figures or Title page. The Title page should be provided as a separate file.In the main text, please reference fig-ures as for instance ‘Figure 1’, ‘Figure 2’ etc to match the tag name you choose for the individual figure files uploaded. Manuscripts should be formatted as described in the Author Guidelines below.

3.2. Blinded ReviewManuscript that do not conform to the general aims and scope of the journal will be returned immediately without review. All other manuscripts will be reviewed by experts in the field (generally two referees).Giornale Italiano di Endodonzia aims to forward referees´ comments and to inform the corresponding author of the result of the review process.

Manuscripts will be considered for fast-track publication under special circumstances after consultation with the Editor.

Giornale Italiano di Endodonzia uses double blinded review. The names of the reviewers will thus not be dis-closed to the author submitting a pa-per and the name(s) of the author(s) will not be disclosed to the reviewers.

To allow double blinded review, please submit your main manuscript and title page as separate files.3.3. E-mail Confirmation of Submis-sionAfter submission you will receive an e-mail to confirm receipt of your man-

uscript. If you do not receive the con-firmation e-mail after 24 hours, please send an e-mail once again to [email protected] or contact [email protected].

3.4. Submission of Revised ManuscriptsAll the revised manuscripts will be sent to the author; to submit a revised masucript please re-contact the e-mail address of the journal: [email protected].

4. MANUSCRIPT TYPES ACCEPTED

Original Scientific Articles: must de-scribe significant and original experi-mental observations and provide suf-ficient detail so that the observations can be critically evaluated and, if necessary, repeated. Original Scien-tific Articles must conform to the high-est international standards in the field.

Review Articles: are accepted for their broad general interest; all are refereed by experts in the field who are asked to comment on issues such as timeliness, general interest and balanced treatment of controversies, as well as on scientific accuracy. Reviews should generally include a clearly defined search strategy and take a broad view of the field rather than merely summarizing the authors´ own previous work. Extensive or un-balanced citation of the authors´ own publications is discouraged.

Mini Review Articles: are accept-ed to address current evidence on well-defined clinical, research or methodological topics. All are refer-eed by experts in the field who are asked to comment on timeliness, gen-eral interest, balanced treatment of controversies, and scientific rigor. A clear research question, search strat-egy and balanced synthesis of the ev-idence is expected. Manuscripts are limited in terms of word-length and number of figures.

Clinical Articles: are suited to de-scribe significant improvements in clinical practice such as the report of a novel technique, a breakthrough in technology or practical approaches to recognised clinical challenges. They should conform to the highest scientific and clinical practice stand-ards.

Case Reports: illustrating unusual and clinically relevant observations are acceptable but they must be of suffi-ciently high quality to be considered worthy of publication in the Journal. On rare occasions, completed cases displaying non-obvious solutions to significant clinical challenges will be considered. Illustrative material must be of the highest quality and healing outcomes, if appropriate, should be demonstrated.

5. MANUSCRIPT FORMATAND STRUCTURE

5.1. Format

Language: The language of publica-tion is English. It is preferred that man-uscript is professionally edited. All services are paid for and arranged by the author, and use of one of these services does not guarantee accept-ance or preference for publication

Presentation: Authors should pay special attention to the presentation of their research findings or clinical reports so that they may be communi-cated clearly. Technical jargon should be avoided as much as possible and clearly explained where its use is unavoidable. Abbreviations should also be kept to a minimum, particu-larly those that are not standard. The background and hypotheses underly-ing the study, as well as its main con-clusions, should be clearly explained. Titles and abstracts especially should be written in language that will be readily intelligible to any scientist.

Abbreviations: Giornale Italiano di Endodonzia adheres to the conven-tions outlined in Units, Symbols and Abbreviations: A Guide for Medical and Scientific Editors and Authors. When non-standard terms appearing 3 or more times in the manuscript are to be abbreviated, they should be written out completely in the text when first used with the abbreviation in parenthesis.

5.2. StructureAll manuscripts submitted to Giornale Italiano di Endodonzia should include Title Page, Abstract, Main Text, Ref-erences and Acknowledgements, Ta-bles, Figures and Figure Legends as appropriateTitle Page: The title page should bear: (i) Title, which should be con-cise as well as descriptive; (ii) Ini-tial(s) and last (family) name of each author; (iii) Name and address of department, hospital or institution to which work should be attributed; (iv) Running title (no more than 30 letters and spaces); (v) No more than six keywords (in alphabetical order); (vi) Name, full postal address, telephone, fax number and e-mail address of au-thor responsible for correspondence.

Abstract for Original Scientific Ar-ticles should be no more than 250 words giving details of what was done using the following structure:•Aim: Give a clear statement of the main aim of the study and the main hypothesis tested, if any.•Methodology: Describe the meth-ods adopted including, as appropri-ate, the design of the study, the set-ting, entry requirements for subjects, use of materials, outcome measures and statistical tests.•Results: Give the main results of the study, including the outcome of any

statistical analysis.•Conclusions: State the primary con-clusions of the study and their impli-cations. Suggest areas for further re-search, if appropriate.

Abstract for Review Articles should be non-structured of no more than 250 words giving details of what was done including the literature search strategy.

Abstract for Mini Review Articles should be non-structured of no more than 250 words, including a clear research question, details of the liter-ature search strategy and clear con-clusions.

Abstract for Case Reports should be no more than 250 words using the following structure:•Aim: Give a clear statement of the main aim of the report and the clinical problem which is addressed.•Summary: Describe the methods adopted including, as appropriate, the design of the study, the setting, entry requirements for subjects, use of materials, outcome measures and analysis if any.•Key learning points: Provide up to 5 short, bullet-pointed statements to highlight the key messages of the report. All points must be fully justified by material presented in the report.

Abstract for Clinical Articles should be no more than 250 words using the following structure:•Aim: Give a clear statement of the main aim of the report and the clinical problem which is addressed.•Methodology: Describe the methods adopted.•Results: Give the main results of the study.•Conclusions: State the primary con-clusions of the study.

Main Text of Original Scientific Article should include Introduction, Materials and Methods, Results, Discussion and Conclusion.

Introduction: should be focused, out-lining the historical or logical origins of the study and gaps in knowledge. Exhaustive literature reviews are not appropriate. It should close with the explicit statement of the specific aims of the investigation, or hypothesis to be tested.Material and Methods: must contain sufficient detail such that, in combina-tion with the references cited, all clin-ical trials and experiments reported can be fully reproduced.

(i) Clinical Trials should be report-ed using the CONSORT guidelines available at www.consort-statement.org. A CONSORT checklist and flow diagram (as a Figure) should also be included in the submission material.(ii) Experimental Subjects: experi-mentation involving human subjects will only be published if such research has been conducted in full accord-ance with ethical principles, including

the World Medical Association Decla-ration of Helsinki (version 2008) and the additional requirements, if any, of the country where the research has been carried out. Manuscripts must be accompanied by a statement that the experiments were undertaken with the understanding and written consent of each subject and according to the above mentioned principles. A state-ment regarding the fact that the study has been independently reviewed and approved by an ethical board should also be included. Editors re-serve the right to reject papers if there are doubts as to whether appropriate procedures have been used.

When experimental animals are used the methods section must clearly indi-cate that adequate measures were taken to minimize pain or discomfort. Experiments should be carried out in accordance with the Guidelines laid down by the National Institute of Health (NIH) in the USA regarding the care and use of animals for exper-imental procedures or with the Euro-pean Communities Council Directive of 24 November 1986 (86/609/EEC) and in accordance with local laws and regulations. All studies using human or animal subjects should include an explicit statement in the Material and Meth-ods section identifying the review and ethics committee approval for each study, if applicable.Editors reserve the right to reject pa-pers if there is doubt as to whether appropriate procedures have been used.

(iii) Suppliers: Suppliers of materials should be named and their location (Company, town/city, state, country) included.

Results: should present the observa-tions with minimal reference to earlier literature or to possible interpretations. Data should not be duplicated in Ta-bles and Figures.

Discussion: may usefully start with a brief summary of the major findings, but repetition of parts of the abstract or of the results section should be avoided. The Discussion section should progress with a review of the methodology before discussing the results in light of previous work in the field. The Discussion should end with a brief conclusion and a comment on the potential clinical relevance of the findings. Statements and in-terpretation of the data should be appropriately supported by original references.

Conclusion: should contain a summa-ry of the findings.

Main Text of Review Articles should be divided into Introduction, Review and Conclusions. The Introduction section should be focused to place the subject matter in context and to justify the need for the review. The Review section should be divided

into logical sub-sections in order to improve readability and enhance un-derstanding. Search strategies must be described and the use of state-of-the-art evidence-based systematic approaches is expected. The use of tabulated and illustrative material is encouraged. The Conclusion section should reach clear conclusions and/or recommendations on the basis of the evidence presented.

Main Text of Mini Review Articles should be divided into Introduction, Review and Conclusions. The Intro-duction section should briefly intro-duce the subject matter and justify the need and timeliness of the literature review. The Review section should be divided into logical sub-sections to en-hance readability and understanding and may be supported by up to 5 tables and figures. Search strategies must be described and the use of state-of-the-art evidence-based sys-tematic approaches is expected. The Conclusions section should present clear statements/recommendations and suggestions for further work. The manuscript, including references and figure legends should not normally ex-ceed 4000 words.

Main Text of Clinical Reports and Clinical Articles should be divided into Introduction, Report, Discussion and Conclusion,. They should be well illustrated with clinical images, radio-graphs, diagrams and, where appro-priate, supporting tables and graphs. However, all illustrations must be of the highest quality

Acknowledgements: Giornale Ital-iano di Endodonzia requires that all sources of institutional, private and corporate financial support for the work within the manuscript must be fully acknowledged, and any poten-tial conflicts of interest noted. Grant or contribution numbers may be ac-knowledged, and principal grant holders should be listed. Acknowl-edgments should be brief and should not include thanks to anonymous ref-erees and editors.

5.3. ReferencesIt is the policy of the Journal to encour-age reference to the original papers rather than to literature reviews. Au-thors should therefore keep citations of reviews to the absolute minimum.

We recommend the use of a tool such as EndNote or Reference Man-ager for reference management and formatting. EndNote reference styles can be searched for here: www.end-note.com/support/enstyles.asp. Ref-erence Manager reference styles can be searched for here: www.refman.com/support/rmstyles.asp

In the text: a number in order of cita-tion is the reference inside the manu-script; example (1)Reference list: All references should be brought together at the end of the paper in numerical order and should

be in the following form.- Names and initials of up to six au-thors. When there are seven or more, list the first three and add et al.- Full title of paper followed by a full stop (.)- Title of journal abbreviated (es. Jour-nal of Endodontics : J Endod)- Year of publication followed by ;- Volume number - Issue number in parenthesis (es.: (5)) followed by :- First and last pages

Examples of correct forms of refer-ence follow:

Standard journal article(1) Somma F, Cammarota G, Plotino G, Grande NM, Pameijer CH. The ef-fectiveness of manual and mechanical instrumentation for the retreatment of three different root canal filling mate-rials. J Endod 2008;34(4):466—9.

Corporate authorBritish Endodontic Society - Guide-lines for root canal treatment. Gior-nale Italiano di Endodonzia 1979 ; 16: 192-5.

Journal supplementFrumin AM, Nussbaum J, Esposito M () Functional asplenia: demonstration of splenic activity by bone marrow scan (Abstract). Blood 1979; 54 (Suppl. 1): 26a.

Books and other monographs

Personal author(s)Gutmann J, Harrison JW Surgical Endodontics, 1st edn Boston, MA, USA: Blackwell Scientific Publica-tions, 1991.

Chapter in a bookWesselink P Conventional root-canal therapy III: root filling. In: Harty FJ, ed. Endodontics in Clinical Practice, (1990) , 3rd edn; pp. 186-223. Lon-don, UK: Butterworth.

Published proceedings paperDuPont B Bone marrow transplan-tation in severe combined immuno-deficiency with an unrelated MLC compatible donor. In: White HJ, Smith R, eds. Proceedings of the Third Annual Meeting of the International Society for Experimental Rematology; (1974), pp. 44-46. Houston, TX, USA: International Society for Exper-imental Hematology.

Agency publicationRanofsky AL Surgical Operations in Short-Stay Hospitals: United States-1975 (1978). DHEW publi-cation no. (PHS) 78-1785 (Vital and Health Statistics; Series 13; no. 34.) Hyattsville, MD, USA: National Cen-tre for Health Statistics.8

Dissertation or thesisSaunders EM In vitro and in vivo in-vestigations into root-canal obturation using thermally softened gutta-percha techniques (PhD Thesis) (1988). Dun-

dee, UK: University of Dundee.

URLsFull reference details must be given along with the URL, i.e. authorship, year, title of document/report and URL. If this information is not availa-ble, the reference should be removed and only the web address cited in the text.Smith A Select committee report into social care in the community [WWW document]. (1999) URL http://www.dhss.gov.uk/reports/report015285.html[accessed on 7 November 2003]

5.4. Tables, Figures and Figure Leg-ends

Tables: Tables should be dou-ble-spaced with no vertical rulings, with a single bold ruling beneath the column titles. Units of measurements must be included in the column title.Figures: All figures should be planned to fit within either 1 column width (8.0 cm), 1.5 column widths (13.0 cm) or 2 column widths (17.0 cm), and must be suitable for photocopy reproduction from the printed version of the manuscript. Lettering on figures should be in a clear, sans serif type-face (e.g. Helvetica); if possible, the same typeface should be used for all figures in a paper. After reduction for publication, upper-case text and num-bers should be at least 1.5-2.0 mm high (10 point Helvetica). After reduc-tion, symbols should be at least 2.0-3.0 mm high (10 point). All half-tone photographs should be submitted at final reproduction size. In general, multi-part figures should be arranged as they would appear in the final ver-sion. Reduction to the scale that will be used on the page is not necessary, but any special requirements (such as the separation distance of stereo pairs) should be clearly specified.

Unnecessary figures and parts (pan-els) of figures should be avoided: data presented in small tables or his-tograms, for instance, can generally be stated briefly in the text instead. Figures should not contain more than one panel unless the parts are logical-ly connected; each panel of a mul-tipart figure should be sized so that the whole figure can be reduced by the same amount and reproduced on the printed page at the smallest size at which essential details are visible.

Figures should be on a white back-ground, and should avoid excessive boxing, unnecessary colour, shading and/or decorative effects (e.g. 3-di-mensional skyscraper histograms) and highly pixelated computer drawings. The vertical axis of histograms should not be truncated to exaggerate small differences. The line spacing should be wide enough to remain clear on reduction to the minimum acceptable printed size.

Figures divided into parts should be labelled with a lower-case, boldface,

roman letter, a, b, and so on, in the same typesize as used elsewhere in the figure. Lettering in figures should be in lower-case type, with the first letter capitalized. Units should have a single space be-tween the number and the unit, and follow SI nomenclature or the nomen-clature common to a particular field. Thousands should be separated by a thin space (1 000). Unusual units or abbreviations should be spelled out in full or defined in the legend. Scale bars should be used rather than magnification factors, with the length of the bar defined in the legend rath-er than on the bar itself. In general, visual cues (on the figures themselves) are preferred to verbal explanations in the legend (e.g. broken line, open red triangles etc.).

Figure legends: Figure legends should begin with a brief title for the whole figure and continue with a short description of each panel and the symbols used; they should not contain any details of methods.

Permissions: If all or part of previ-ously published illustrations are to be used, permission must be obtained from the copyright holder concerned. This is the responsibilty of the authors before submission.

Preparation of Electronic Figures for Publication: Although low quality images are adequate for review pur-poses, print publication requires high quality images to prevent the final product being blurred or fuzzy. Submit EPS (lineart) or TIFF (halftone/photographs) files only. MS Power-Point and Word Graphics are unsuit-able for printed pictures. Do not use pixel-oriented programmes. Scans (TIFF only) should have a resolution of 300 dpi (halftone) or 600 to 1200 dpi (line drawings) in relation to the reproduction size (see below). EPS files should be saved with fonts em-bedded (and with a TIFF preview if possible). For scanned images, the scanning resolution (at final image size) should be as follows to ensure good repro-duction: lineart: >600 dpi; half-tones (including gel photographs): >300 dpi; figures containing both halftone and line images: >600 dpi.

6. AFTER ACCEPTANCE

Upon acceptance of a paper for publication, the manuscript will be forwarded to the Production Editor who is responsible for the production of the journal.

6.1. FiguresHard copies of all figures and tables are required when the manuscript is ready for publication. These will be requested by the Editor when re-quired. Each Figure copy should be marked on the reverse with the figure number and the corresponding au-thor’s name.

6.2 Proof CorrectionsThe corresponding author will receive an email alert containing a link to a web site. A working email address must there-fore be provided for the correspond-ing author. The proof can be down-loaded as a PDF (portable document format) file from this site. Acrobat Reader will be required in order to read this file. This software can be downloaded (free of charge) from the following Web site: www.adobe.com/products/acrobat/readstep2.html. This will enable the file to be opened, read on screen, and printed out in or-der for any corrections to be added. Further instructions will be sent with the proof. Hard copy proofs will be posted if no e-mail address is availa-ble; in your absence, please arrange for a colleague to access your e-mail to retrieve the proofs. Proofs must be returned to the Pro-duction Editor within five days of receipt, even if there are no correc-tions. Elsevier may proceed with publica-tion of the article if no response is received. As changes to proofs are costly, we ask that you only correct typesetting errors. Excessive changes made by the author in the proofs, excluding type-setting errors, will be charged sepa-rately. Other than in exceptional circum-stances, all illustrations are retained by the publisher. Please note that the author is respon-sible for all statements made in his work, including changes made by the copy editor.

7. OPEN ACCESS

Every peer-reviewed research article appearing in this journal will be pub-lished open access. This means that the article is universally and freely accessible via the internet in perpe-tuity, in an easily readable format immediately after publication. The author does not have any publication charges for open access. The Società Italiana di Endodonzia will pay to make the article open access. A CC user license manages the reuse of the article (see http://www.elsevier.com/openaccesslicenses). All articles will be published under the following license:

8. Creative Commons Attribution-NonCommer-cial-NoDerivs(CC BY-NC-ND)

For non-commercial purposes, lets others distribute and copy the article, and to include in a collective work (such as an anthology), as long as they credit the author(s) and provided

they do not alter or modify the article

9. AUTHOR RIGHTS

As an author you (or your employer or institution) have certain rights to reuse your work. For more information on author rights please see http://www.elsevier.com/copyright.

ISTRUZIONI AGLI AUTORI

Il Giornale Italiano di Endodonzia è una pubblicazione esclusivamente disponibile in formato elettronico e rappresenta l’organo ufficiale della Società Italiana di Endodonzia.

Si appoggia, per la sua diffusione ad Elsevier e gli articoli in esso pubblicati sono reperibili su Scopus.

La cadenza di pubblicazione è semestrale: Giugno/Novembre.

Per quanto attiene le norme editoriali per la pubblicazione di articoli aven-ti come tema l’Endodonzia in senso lato si pregano gli autori di riferirsi al documento in inglese reperibile sul sito www.gi-endodonzia.com.

Articoli in lingua italiana saranno pubblicabili, ma si darà preferenza a contributi in lingua inglese che po-trebbero avere una risonanza interna-zionale ben più ampia.

La Società Italiana di Endodonzia si farà carico di rivedere la forma dei contributi in lingua inglese attraverso un sistema di controllo specifico.

November 2018 Vol. 32 - endodonzia.it · Dr. CASTELLUCCI ARNALDO Private practice in Florence...

Documents

Transcript of November 2018 Vol. 32 - endodonzia.it · Dr. CASTELLUCCI ARNALDO Private practice in Florence...