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Names: Jain, Priyanka, 1976- editor.
Title: Current therapy in endodontics / [edited by] Dr. Priyanka Jain.
Description: Ames, Iowa : John Wiley & Sons, Inc., 2017. | Includes bibliographical references and index.
Identifiers: LCCN 2016024814 (print) | LCCN 2016026084 (ebook) | ISBN 9781119067559 (cloth) | ISBN 9781119067733 (pdf) | ISBN 9781119067740 (epub)
Subjects: | MESH: Root Canal Therapy–methods
Classification: LCC RK351 (print) | LCC RK351 (ebook) | NLM WU 230 | DDC 617.6/342059–dc23
LC record available at https://lccn.loc.gov/2016024814

Cover
Dedication
List of figures
List of tables
Contributors
Foreword
Preface
Acknowledgements
Chapter 1: Diagnosis
1. Chief complaint
2. Medical history
3. Relevant dental history
4. Extraoral examination
5. Intraoral examination
6. Interpreting Radiographs
7. Tips for an accurate diagnosis
8. Diagnostic terms
9. Classification of cracks in teeth
10. Conclusion
11. References
12. Questions
Chapter 2: Imaging technologies
1. Digital radiography
2. Cone‐beam technology
3. The future
4. References
5. Questions
Chapter 3: Rotary instruments
1. Cleaning and shaping
2. Physical and chemical properties of nickel–titanium alloys
3. Preparation techniques
4. Design features of rotary instruments
5. The Nickel–Titanium era
6. Advances in Nickel–Titanium Metallurgy (Thermomechanical Treatment of Nickel–Titanium Instruments)
7. Rotation versus reciprocation
8. Glide‐path rotary instruments
9. Disinfectants and lubricants
10. Irrigant delivery systems
11. Pressure‐alteration devices
12. Conclusion
13. References
14. Questions
Chapter 4: Determination of working length
1. Anatomic considerations in determining the working length
2. Limitations of traditional working length assessment
3. Radiographic methods
4. Nonradiographic methods
5. Determining working length in teeth with open apices
6. Short note on reference points
7. Conclusion
8. References
9. Questions
Chapter 5: Root canal filling
1. Conventional sealers
2. Modern sealers
3. Methacrylate resin–based sealers
4. Modern root canal filling core materials
5. Obturation with gutta‐percha
6. Adhesive obturation
7. Carrier‐based adhesive obturation
8. Conclusion
9. References
10. Questions
Chapter 6: Treatment planning of pulpless teeth
1. Treatment options
2. Ferrule
3. Esthetic considerations in deeply discolored pulpless teeth
4. Posts
5. Conclusion
6. References
7. Questions
Chapter 7: Dental traumatic injuries
1. General considerations
2. Classification of traumatic injuries
3. Management of injuries to the periodontal tissues
4. Management of injuries to the hard dental tissues and pulp
5. Avulsed Mature Permanent Teeth (Closed Apex)
6. Root Resorption
7. Future
8. References
9. Questions
Chapter 8: Visualization in endodontics
1. Visualization devices in endodontics
2. Operating microscope
3. Resources to locate root canals
4. Conclusion
5. References
6. Questions
Chapter 9: Endodontic microsurgery
1. Advances in endodontic microsurgery and improved armamentarium
2. Dental Operating microscope
3. Indications and contraindications for endodontic surgery
4. Presurgical preparations
5. Mucogingival flap designs and soft tissue management
6. Incisions
7. Flap reflection and elevation
8. Ostectomy
9. Curettage
10. Biopsy and microscopic histopathological examination
11. Root‐end resection
12. Root‐end preparation
13. Hemostatic agents and hemostasis
14. Root‐End Filling Materials and Placement of Root‐End Filling Materials
15. Flap closure and suturing techniques
16. Postoperative Management and Instructions
17. Outcomes
18. Guided tissue regeneration in endodontic surgery
19. Extraction–Replantation
20. Root amputations and hemisection techniques in endodontics
21. Surgical repair of resorptive lesions or perforations
22. Management of Complications
23. Conclusions
24. Disclaimer
25. References
26. Questions
Chapter 10: Lasers
1. History of lasers in endodontics
2. The modern concept of laser in endodontics
3. Clinical applications of lasers
4. Evidence‐based current and future research
5. Conclusions and future studies
6. References
7. Questions
Chapter 11: Dental pulp regeneration
1. History: early attempts to regenerate dental pulp
2. Clinical dental pulp regeneration
3. Dental pulp tissue engineering
4. Conclusions
5. References
6. Questions
Chapter 12: Teledentistry
1. Historical background and origins
2. Forms of teledentistry
3. Scope of teledentistry
4. Technological requirements
5. Modes of transferring information
6. Teledentistry in endodontics
7. Concerns in the use of teledentistry
8. Future prospects
9. References
10. Questions
Quiz answers
1. Answers
Index
End User License Agreement

List of Tables

Chapter 1: Diagnosis
1. Table 1.1 Interpreting the dental radiograph
2. Table 1.2 Pulpal classifications
3. Table 1.3 Periradicular classifications
Chapter 2: Imaging technologies
1. Table 2.1 Radiation doses for common imaging modalities in dentistry and medicine, compared to background radiation
Chapter 3: Rotary instruments
1. Table 3.1 Available motors for root canal preparation using NiTi instruments
2. Table 3.2 Categories of Ni Ti instruments
3. Table 3.3 Hero shapers preparation sequence
4. Table 3.4 Available RaCe instruments
5. Table 3.5 ProFile preparation sequence
6. Table 3.6 GT series X sequence
7. Table 3.7 Twisted file preparation sequence
8. Table 3.8 Files and systems for rotation and reciprocation
9. Table 3.9 Characteristics of rotary systems
10. Table 3.10 Characteristics of few currently used intracanal irrigants
Chapter 4: Determination of working length
1. Table 4.1 Generations of apex locators
2. Table 4.2 Characteristics of different generations of apex locators
Chapter 5: Root canal filling
1. Table 5.1 Classification of root canal sealers
2. Table 5.2 Techniques for obturating root canal systems
Chapter 6: Treatment planning of pulpless teeth
1. Table 6.1 Restorative treatment plans for anterior and posterior teeth
2. Table 6.2 Dental cements
Chapter 7: Dental traumatic injuries
1. Table 7.1 Different types of storage media
2. Table 7.2 Classification of root resorption
Chapter 10: Lasers
1. Table 10.1 Effect of temperature on tissues
2. Table 10.2 Comparison between modern lasers and old lasers
Chapter 11: Dental pulp regeneration
1. Table 11.1 Clinical protocols and success rates of pulp regeneration outcome studies

List of Illustrations

Chapter 1: Diagnosis
1. Figure 1.1 Extraoral examination includes a visual assessment of facial asymmetry.
2. Figure 1.2 The presence of a sinus tract must be noted in the examination report.
3. Figure 1.3 A gutta‐percha point is placed through the opening of the sinus tract until resistance is felt. A radiograph is obtained to identify the path of the sinus tract.
4. Figure 1.4 Percussion testing is best performed by tapping a tooth using the back end of a mirror handle. The tapping force should be consistent when testing multiple teeth.
5. Figure 1.5 The Tooth Slooth is used to test for biting sensitivity in a given tooth.
6. Figure 1.6 The Vitality Scanner 2006 from Kerr is a common electrical pulp testing device used in endodontic diagnosis.
7. Figure 1.7 Endo Ice has an effective working temperature to make it an ideal refrigerant for thermal testing.
8. Figure 1.8 Placing the pellet on the cervical third of the tooth ensures an accurate patient response.
9. Figure 1.9 Even though endodontic treatment on tooth #14 is incomplete, the pulpal diagnosis would still be previously treated.
10. Figure 1.10 After the restoration is removed, inspection of the underlying tooth surfaces reveal an incomplete fracture of the mesiobuccal cusp, extending mesiodistally and buccolingually along a buccal groove.
11. Figure 1.11 A crack is seen advancing in the mesiodistal direction. A, With the restoration in place. B, With the restoration removed.
12. Figure 1.12 A coronal and axial slice from a conebeam volume reveals a crack that has extended apically and formed two separate segments. This is known as a split tooth.
13. Figure 1.13 This is a more obvious example of a vertical root fracture. In most cases, identifying a vertical root fracture can be challenging without the aid of advanced imaging modalities.
Chapter 2: Imaging technologies
1. Figure 2.1 A digital image is viewable instantly on a large computer monitor. With available image enhancement tools, patients can more easily visualize important findings, such as caries or a periapical radiolucency.
2. Figure 2.2 The Dexis Platinum Sensor features a beveled corner design to enhance patient comfort. The attached wire connects to a computer via USB to yield high‐resolution images instantly.
3. Figure 2.3 ScanX from Air Techniques is an example of a photo‐stimulable phosphor system. A, The scanning units come in various sizes to handle larger tasks. B, The imaging plates come in various sizes similar to a wet film.
4. Figure 2.4 A, Periapical lucency is seen associated with the right maxillary central incisor. B, A cone‐beam computed tomography scan of the area depicts a well‐defined circular low‐density area palatal to the root of the tooth. An overread from an oral and maxillofacial radiologist confirms a diagnosis of nasopalatine duct cyst.
5. Figure 2.5 A and B, The Veraviewepocs 3De (J. Morita Manufacturing Corp., Kyoto, Japan) cone‐beam computed tomography machine has a footprint similar to that of a panoramic machine.
6. Figure 2.6 One Volume Viewer (J. Morita Manufacturing Corp., Kyoto, Japan) is a versatile viewing program designed to give the clinician maximum functionality in an easy and intuitive interface.
7. Figure 2.7 A, A panoramic scout image is used to define the region of interest for 3D imaging: Axial plane (red box), sagittal plane (blue box), and coronal plane (green box). B, An isotropic (symmetrical) voxel provides a highly accurate image that is free of distortion.
8. Figure 2.8 A comparison of a periapical (PA) radiograph (A) and a proximal slice from a cone‐beam computed tomography scan of the same area (B) highlights the advantages of 3D imaging in endodontic diagnosis. The proximal slice shows a transported and perforated root canal treatment that is not evident in the PA radiograph.
9. Figure 2.9 A, Right maxillary central incisor exhibits an apparent resorptive lesion at midroot level. B, An axial slice from a cone‐beam computed tomography scan provides the necessary information on the type of resorption (internal or external) and the prognosis of the tooth.
10. Figure 2.10 A, Posteroanterior radiograph of the mandibular right second molar depicts a normal presentation of bone. B, A sagittal slice of a cone‐beam computed tomography scan of the same area depicts a well‐defined low‐density finding in the periapical region of the tooth.
11. Figure 2.11 A, A panoramic radiograph fails to show a radiopaque finding apical to the area of the maxillary right bicuspids. Sagittal (B) and coronal (C) slices from a cone‐beam computed tomography scan of the same area depict the high‐density mass clearly. An overread provided by an oral and maxillofacial radiologist identified the high‐density mass as idiopathic osteosclerosis.
12. Figure 2.12 A, Scatter artifact is seen as light and dark lines extending radially from metallic sources. B and C, Beam hardening artifacts from cone‐beam computed tomography imaging can resemble bone loss or root fracture.
Chapter 3: Rotary instruments
1. Figure 3.1 Motion for rotary instruments. A, Brushing technique. File is moved laterally so as to avoid threading. This motion is most effective with stiffer instruments with a positive rake angle, like ProTaper. B, Up‐and‐down motion. In this a rotary file is moved in an up‐and‐down motion with a very light touch so as to dissipate the forces until desired working length is reached or resistance is met. C, Taking file in the canal till it meets resistance. Gentle apical pressure is used till the file meets resistance and then withdrawn. The instrument is inserted again with a similar motion, e.g., RaCe files.
2. Figure 3.2 Creating a glide path.
3. Figure 3.3 Examples of motors. A, First‐generation motor without torque control. B, Newest‐generation motor with built‐in apex locator and torque control.
4. Figure 3.4 Crown‐down approach. Arrows indicate corresponding cutting area.
5. Figure 3.5 Recommended steps for hybrid technique.
6. Figure 3.6 Rake angles.
7. Figure 3.7 Variable helical angle.
8. Figure 3.8 Pitch refers to the number of flutes per unit length.
9. Figure 3.9 Cross‐section of different rotary instruments. A, K‐File RaCe. B, ProFile, GT, LightSpeed. C, Hero 642. D, K3. E, ProTaper, Flexmaster. F, ProTaper F3.
10. Figure 3.10 LightSpeed LSX. A, Safe‐failure design. B, Absence of flute. C, Front view.
11. Figure 3.11 Hero Shapers rotary files.
12. Figure 3.12 Cross section of a Quantec file.
13. Figure 3.13 Quantec Files. Top, LX noncutting (gold handles). Bottom, SC safe cutting (silver handles).
14. Figure 3.14 K3 file design.
15. Figure 3.15 RaCe design characteristics.
16. Figure 3.16 Safety memo disc (SMD) showing how petals are used.
17. Figure 3.17 Mtwo file characteristics.
18. Figure 3.18 Mtwo preparation sequence. All the files in sequence 1 and sequence 2 are to working length.
19. Figure 3.19 Differences between ProTaper shaping files and finishing files.
20. Figure 3.20 ProTaper instrument sequence.
21. Figure 3.21 R‐Phase diagram. Force and temperature‐dependent transitions for austenite to martensite, including the intermediary R‐phase. The proportion of alloy that is in R‐phase depends on heat treatment of the raw wire.
22. Figure 3.22 GT Series X File design. At the tip and shank ends, the land widths are half the size of the lands in the middle region of the flutes, allowing rapid and efficient cutting.
23. Figure 3.23 GT Series X instrument system.
24. Figure 3.24 ProFile
25. Figure 3.25 Vortex Blue.
26. Figure 3.26 ProTaper Next. A, Cross section. B, Swaggering effect. Three unique elements are used in the design of this ProTaper NEXT file: a rectangular cross section, an asymmetric rotary motion, and M‐wire NiTi alloy.
27. Figure 3.27 ProTaper Universal (PTU) versus PTN.
28. Figure 3.28 Twisted File (TF) rotary system.
29. Figure 3.29 Adaptive motion. A, File motion when minimal or no load is applied. B, File motion when it engages dentin and load is applied.
30. Figure 3.30 TF Adaptive File system uses a color‐coded identification system for efficiency and ease of use. Just like a traffic light, start with green and stop with red.
31. Figure 3.31 K3XF File.
32. Figure 3.32 Hyflex CM. A, Hyflex CM NiTi File. B, After heat treatment (autoclaving).
33. Figure 3.33 Cross sections of Hyflex NiTi files.
34. Figure 3.34 Typhoon Infinite Flex NiTi files.
35. Figure 3.35 WaveOne file cross section. This image depicts two different cross sections on a single WaveOne file. The more distal cross section improves safety and inward movement.
36. Figure 3.36 WaveOne Rotary Files and their sequence of use.
37. Figure 3.37 A, Self‐adjusting file design. B, VATEA irrigation device attached with silicon tube on the shaft of the file. The SAF instrument is activated with a transline vibrating handpiece adapted with a RDT3 head.
38. Figure 3.38 TRUshape 3D Conforming File.
39. Figure 3.39 Different types of needles used for irrigation in endodontics.
40. Figure 3.40 sNaviTip FX.
41. Figure 3.41 Vibringe Irrigator.
42. Figure 3.42 A, EndoActivator. B, Sonic Motion.
43. Figure 3.43 EndoVac.
Chapter 4: Determination of working length
1. 4.1 Anatomy of the apical root.
2. 4.2 Diagrammatic representation of an endodontic instrument, the root canal system, and the electrical features [43]. The resistance is 6.5 kΩ when a file touches the periodontal ligament space at the apical foramen.
3. 4.3 A, Third‐generation apex locator. B, Fourth‐generation apex locator.
4. 4.4 Clinical use of an apex locator.
5. 4.5 A, Fifth‐generation apex locator. B, Sixth‐generator apex locator.
6. 4.6 Troubleshooting the apex locator.
7. 4.7 Determining working length in an open apex [91].
Chapter 5: Root canal filling
1. Figure 5.1 The monoblock concept.
2. Figure 5.2 Epiphany root canal primer and sealant.
3. Figure 5.3 Scanning electron microscope images of Resilon Epiphany System.
4. Figure 5.4 a, Downpak Obturation System (now marketed as Rootbuddy) (Nikinc Dental, Eindhoven, Netherlands). b, Touch 'N Heat System (SybronEndo, Orange, CA, USA). c, Endotec II (Medidenta International Inc.).
5. Figure 5.5 Obtura III (Obtura Spartan).
6. Figure 5.6 Calamus Obturation System (Dentsply) with two hand pieces for downpacking and backpacking.
7. Figure 5.7 a, Elements Free Obturation System. b, Downpack with the Downpack Unit. c, Buchanan hand pluggers with one end stainless steel and the other end nickel titanium. d, Backfill unit.
8. Figure 5.8 Case treated using Elements Obturation Unit.
9. Figure 5.9 Gutta flow system including capsules, ISO‐sized canal tips, and dispenser.
10. Figure 5.10 a, GuttaFlow powder. b, GuttaFlow sealer. c, Mixed Gutta Flow powder and sealer.
11. Figure 5.11 Thermafil obturation.
12. Figure 5.12 GuttaCore obturator structure.
13. Figure 5.13 ActiV GP.
14. Figure 5.14 Relative leakage behavior of endodontic obturation techniques. (From Von Fraunofer JA. Dental materials at a glance. Oxford: Wiley‐Blackwell; 2009).
Chapter 6: Treatment planning of pulpless teeth
1. Figure 6.1 Force vectors on anterior and posterior teeth. Anterior teeth undergo off‐axis loading, and posterior teeth undergo axial and some off‐axis loading.
2. Figure 6.2 Fracture resistance.
3. Figure 6.3 Crown‐to‐root ratio changes after crown lengthening and orthodontic extrusion. The ratio is more favorable with orthodontic extrusion.
4. Figure 6.4 Left, Preoperative tooth #9 showing severe discoloration. Right, After internal bleaching.
5. Figure 6.5 Masking ability is a function of ceramic thickness (a), ceramic type (b), and cement opacity (c).
6. Figure 6.6 Technique for manufacturing a direct fiber‐reinforced composite post and composite core. a, Initial preparation. b, Measuring the required length of the final post. c, Using the initial drill to clear the endodontic filing material. d, Based on the size of the canal, the final drill is used. e, The fiber‐reinforced composite post is tried in, making sure it is completely seating. f, The excess length of post is sectioned. g and h, Dual‐polymerizing resin cement is applied both into the canal (g) and onto the post (h). i, Incremental buildup and final preparation of composite.
Chapter 7: Dental traumatic injuries
1. Figure 7.1 Dental trauma involving soft and hard tissues; the trauma was due to fall on the ground during school games.
2. Figure 7.2 Extrusion. A, Extrusion of the upper left central incisor of a 9‐year‐old boy. B, A radiograph showing an open apex and chipped crown of upper right central tooth. C, Two years after trauma with apical closure and pulp canal calcification. Apical maturation and resorption of upper left lateral incisor.
3. Figure 7.3 Palatal luxation. A, Patient under orthodontic treatment due to trauma to teeth displaced labially. B, CBCT showing labial bone fracture with displacement of upper central incisors.
4. Figure 7.4 Intrusion (upper left lateral incisor). A, Occlusal radiograph. B, Periapical radiograph. C, Tooth erupted and MTA placed in both the central incisors; secondary midroot fracture. (D) Eleven years later, implant was placed.
5. Figure 7.5 Treatment of avulsed immature teeth.
6. Figure 7.6 Treatment of avulsed mature teeth.
7. Figure 7.7 Avulsion with extraoral time less than 60 minutes. A, Upper right central incisor replanted. B, Follow‐up after 4 years.
8. Figure 7.8 A, Avulsion with extraoral time of two hours. B, Three months after replantation. C, Inflammatory root resorption noticed after two and a half years. Left central canal obliterated. D, Five and half years later, with the tooth still holding its position in the alveolar bone, with the gutta‐percha filling and free gingiva. E, Tooth removed and implant placed without bone augmentation.
9. Figure 7.9 Avulsion with extraoral time more than 60 minutes. A, Upper right central incisor kept dry for four hours. B, Mesial and distal resorption after five years. C, Nine years after trauma.
10. Figure 7.10 A, Inflammatory root resorption. B, Two years after avulsion and replantation. C, CBCT image showing that most of the root is resorbed.
11. Figure 7.11 When to perform regenerative procedures.
12. Figure 7.12 Enamel dentin fracture. A, Arrow indicates fractured crown fragment. B, Arrow indicates the displacement of the fragment. C, Soft tissue radiograph of the upper lip showing the fractured fragment.
13. Figure 7.13 A, Cervical crown root fracture as presented with the wire splint. B, After removing the fractured part and preparing for orthodontic extrusion. C, Placing a hook wire in the root canal, with orthodontic wire labially on the adjacent teeth and force erupting over two months. D, Cast post and crown placed after four months. E, CBCT image showing the cemented crown in position.
14. Figure 7.14 A, Middle root fracture of an immature tooth without displacement. B, Five years after the injury without treatment, all anterior teeth matured and the fracture line healed with hard tissue.
15. Figure 7.15 Apical third root fracture of lower anterior teeth.
16. Figure 7.16 Multiple fractures of the cervical margin of a lateral incisor.
17. Figure 7.17 A, Middle root fracture without displacement of the fractured segments. B, Four years with displacement of the apical segment endodontic therapy has been performed. C, Nine years after trauma, extracted tooth showing the two separated fragments. D, Implant placed after extraction.
18. Figure 7.18 A, Healing with bone and connective tissue. B, Healing with hard tissue and connective tissue without endodontic treatment.
19. Figure 7.19 Differential diagnosis of internal and external resorption. A, Internal resorption. Radiographically, the canal appears interrupted. B, External resorption. The canal appears irregular, and a radiolucent area appears overlying the canal.
20. Figure 7.20 Internal resorption. A, Resorption that is confined within the root canal. B, The resorption has progressed to extend beyond the root, perforating the root.
21. Figure 7.21 Internal resorption with irregular shape can present challenges on treatment.
22. Figure 7.22 Internal resorption after endodontic therapy was performed.
23. Figure 7.23 The extent of external resorption radiographically usually appears less extensive than it actually is in reality. A, Radiograph showing resorption. B, Resorption in the extracted tooth.
24. Figure 7.24 Using CBTC scan for diagnosing internal and external resorption.
25. Figure 7.25 External resorption. A, Transient resorption. B, Surface pressure (orthodontic). C, Surface pressure (impaction). D, Pathologic resorption (ankylosis). E, Pathologic resorption (inflammatory).
26. Figure 7.26 Invasive cervical root resorption. A, root resorption without penetrating the crest. B, Root resorption with penetration of crestal bone.
27. Figure 7.27 EndoSequence bioceramic root repair material to fill a resorption crater.
28. Figure 7.28 Clinical classification of invasive cervical resorption. Class 1: Small invasive resorptive lesion near the cervical area with penetration into dentin. Class 2: Well‐defined invasive resorptive lesion that has penetrated close to the coronal pulp chamber. Class 3: Deeper invasion of dentin by resorbing tissue;. Class 4: Large invasive resorptive process extending beyond the coronal third of the root.
29. Figure 7.29 Progression of root resorption.
30. Figure 7.30 Ankylosis related root resorption.
Chapter 8: Visualization in endodontics
1. Figure 8.1 Operating microscope showing the binocular, objective, and the nosepiece.
2. Figure 8.2 Vario Focus da JC‐Optik, It Allows focus between 200 and 300 mm.
3. Figure 8.3 Line of coronal fracture located during the access to pulp chamber.
4. Figure 8.4 Endodontic instrument fractured within root canal.
5. Figure 8.5 Periapical surgery with magnification, allowing the clinician to view: A, Gutta‐percha cone exhibition. B, Apical retropreparation with ultrasonic tip. C, Retrograde retrofilling image with MTA. D, Initial radiography. E, Postoperative radiography. F, Radiography of the control after eight months showing the repair process.
6. Figure 8.6 View of remaining obturation material during treatment of the root canal system.
7. Figure 8.7 A, Entrance of five canals after instrumentation. B and C, Identification of the gutta‐percha after obturation. D, Final radiograph.
Chapter 9: Endodontic microsurgery
1. Figure 9.1 Periapical radiograph of a large periapical lesion. The extent of the lesion cannot be determined on a periapical radiograph.
2. Figure 9.2 In this CBCT image of the large periapical lesions, sealer is evident. The facial–palatal width of the root canal filling is visualized. The bony margins of the lesion are intact on the palatal and nasal floor, but the facial bone is not intact and is expanded.
3. Figure 9.3 The microscope should be positioned so that the long axis of the microscope is parallel to the long axis of the tooth on which the surgical procedure is to be performed. This requires the surgeon to sit at the 12 o'clock position at the head of the dental chair, so that the long axis of the tooth points directly at the surgeon's midsection. This will ensure that the resection cuts are at 90 degrees to the long axis of the tooth. The diagram on the left demonstrates a parallel alignment where the microscope axis is parallel to the long axis of the tooth, which leads to a resection of 90 degrees to the long axis of the tooth. The diagram on the right demonstrates an angled alignment where the microscope axis does not match the long axis of the tooth, which can result in an angled resection.
4. Figure 9.4 Alignment for maxillary anterior teeth. The long axis of the tooth should be parallel to the floor. For ostectomy, curettage, and resection, the microscope can be at a 90‐degree angle to the long axis of the root. For root‐end preparation, the microscope can be angled to view the resected root end.
5. Figure 9.5 Alignment for mandibular anterior teeth. The long axis of the tooth should be parallel to the floor. For ostectomy, curettage, and resection, the microscope can be at a 90‐degree angle to the long axis of the root. For root‐end preparation, the microscope can be angled to view the resected root end.
6. Figure 9.6 Alignment for maxillary posterior teeth. The long axis of the tooth should be parallel to the floor. For ostectomy, curettage, and resection, the microscope can be at a 90‐degree angle to the long axis of the root. For root‐end preparation, the microscope can be angled to view the resected root end.
7. Figure 9.7 Alignment for mandibular posterior teeth. The long axis of the tooth should be parallel to the floor. For ostectomy, curettage, and resection, the microscope can be at a 90‐degree angle to the long axis of the root. For root‐end preparation, the microscope can be angled to view the resected root end.
8. Figure 9.8 Triangular flap design with a sulcular horizontal incision and a vertical releasing incision in the concavity between the canine and the lateral incisor.
9. Figure 9.9 Rectangular flap design with two vertical releasing incisions. Both vertical releasing incisions should be in the concavities between the bony eminences over teeth and meet the marginal gingiva at right angles at the junction of the middle and apical third of the interdental papilla. The horizontal incision is in the sulcus.
10. Figure 9.10 Supraperiosteal blood vessels deep in the reticular layer of the lamina propria of attached gingiva. The arrow indicates a vessel passing into the papillary layer to form a capillary plexus next to epithelium.
11. Figure 9.11 The vertical releasing incision starts by visually dividing the interdental papilla into coronal, middle, and apical thirds. At the junction of the middle and apical thirds the vertical releasing incision should begin at the line angle of the tooth and at a 90‐degree angle to the marginal gingiva. The vertical releasing incision forms a hockey stick shape, with the horizontal portion of the releasing incision as the blade and the vertical portion of the releasing incision forming the handle of the hockey stick. Placing the incision at the junction of the middle and apical third of the papilla allows short profusion of blood supply to the flap. This ensures a better blood supply to the rest of the papilla.
12. Figure 9.12 The submarginal incision will have a scalloped horizontal portion that will match the marginal gingival contour. It must be placed in the attached keratinized gingiva. There should be at least 3 mm of attached keratinized gingiva present for this incision.
13. Figure 9.13 Submarginal flap design demonstrating the scalloped incision in the attached keratinized gingiva corresponding to the contour of the marginal gingiva, and the crestal bone.
14. Figure 9.14 Submarginal incision. The dark blue line represents the marginal gingiva. The green line represents the mucogingival junction. The black vertical lines represent the periodontal probing depths. The yellow line represents the depth of the gingival sulcus as determined by periodontal probing. The red line represents the level of the crestal bone as determined by sounding for the crestal bone through the gingiva, which is depicted by the red vertical lines. The turquoise line represents the location of the incision line in the horizontal component of the flap.
15. Figure 9.15 Submarginal incision. Note the scalloped incision in the keratinized attached gingiva that corresponds to the contour of the marginal gingiva. Also apparent is the rounded tip where the vertical releasing incision meets the horizontal scalloped incision. The beveling of the horizontal portion of the submarginal flap with a microblade provides the bevel toward the flap, which enhances repositioning and adaption of the flap into its original position and will promote better healing by primary intention.
16. Figure 9.16 Vertical releasing incision of a submarginal incision demonstrating beveling of the incision into the flap, and the rounding off of the flap where the vertical incision meets the horizontal incision to avoid a pointed edge at the corner of the flap.
17. Figure 9.17 Papilla base incision outline with split‐thickness incisions of the papillae.
18. Figure 9.18 Papilla base incision. The interdental papilla is divided into thirds (numbers 1–2, 2–3, 3–6). The initial incision (#4) is 1.5 mm in depth, and it meets the marginal gingiva at the junction of the middle and apical thirds of the papilla. This incision meets the tooth at a right angle to the marginal gingiva, arches apically, and is at a right angle to the surface of the papilla. The second incision (#5) is from the base of the first incision, and it extends to alveolar bone.
19. Figure 9.19 Papilla base incision. The image on the left demonstrates the first incision, which is perpendicular to the interdental papilla surface and 1.5 mm in depth. The second incision is depicted in the middle image, and it extends from the base of the first incision to the crest of alveolar bone, creating a split‐thickness flap in this area. The image on the right demonstrates the complete incision, with #1 representing the cul of the interdental tissue, #2 the first incision, #3 the second incision to alveolar bone, and #4 the alveolar bone.
20. Figure 9.20 Papilla base incision.
21. Figure 9.21 Papilla base incision at 3 days. Note the 7–0 suture across the incision line. Good healing is observed for this early postoperative period.
22. Figure 9.22 Sinus tract on the palate from the palatal root of the maxillary first molar that had been re‐treated and did not heal.
23. Figure 9.23 Palatal flap reflected, exposing the palatal root apex of the maxillary first molar. The vertical incision meets the marginal gingiva of the maxillary first premolar at right angles and extends to the midline of the palate, staying in the valleys between the rugae. The flap is tied to the teeth on the opposite side of the arch by a wide bracket made by broad loop of the suture rather than a small point. This provides better control of the reflected flap and prevents the suture from pulling out. Suturing the flap to the maxillary teeth on the other side of the arch reflects the flap and allows the surgeon to use indirect vision through the microscope using a mirror.
24. Figure 9.24 Palatal stent in place to adapt the flap to the palatal bone and to prevent hematoma formation between the flap and the palatal bone.
25. Figure 9.25 Angled microsurgical blades.
26. Figure 9.26 From top to bottom, #15 blade, #64 minisurgical blade (half radius), and #64 microsurgical blade (half radius).
27. Figure 9.27 Mini and microsurgical blades. They come in half‐radius or full‐radius designs. The full‐radius blade cuts in either direction. The half‐radius blade cuts only in one direction.
28. Figure 9.28 Flap elevation should begin in the vertical releasing incision in the attached keratinized gingiva, avoiding placing the elevator on the marginal gingiva. Elevation of the flap should tunnel under the tissue to free the attached gingiva and papilla. Once these tissues are lifted off of the alveolar bone, reflection proceeds in an apical direction.
29. Figure 9.29 KimTrac retractor. (B&L Biotech, Fairfax, VA, USA>). Standard retractors are often too large for endodontic microsurgery, as the operating field is very small. Retractors designed for endodontic microsurgery are available; however, the surgeon might need to customize a retractor.
30. Figure 9.30 After ostectomy and apical curettage, the apical 3 to 4 mm of the root should be “suspended in space” to facilitate root‐end resection.
31. Figure 9.31 Ultrasonic scaler used after curettage of the periapical lesion to remove the remaining small tissue tags left behind in the bony crypt.
32. Figure 9.32 The angle of the root‐end resection can affect leakage from the canal and around the root‐end filling. Leakage occurs from the canal through dentinal tubules that are cut, as illustrated in the panels on the left. Leakage can occur around the root‐end filling with a more‐severe bevel, as the root‐end filling is not deep enough on the facial surface to seal the canal.
33. Figure 9.33 Surgical handpiece with straight fissure bur resecting apical 3 mm of the root at right angles to the long axis of the root.
34. Figure 9.34 Methylene blue dye is used to stain the periodontal ligament to confirm that the entire root‐end has been resected. It can also be used to verify the existence other canals, an isthmus, or cracks.
35. Figure 9.35 Methylene blue dye will stain remaining debris around the root canal filling, indicating leakage.
36. Figure 9.36 The KiS microsurgical ultrasonic tips are coated with zirconium nitride for a more‐active cutting surface. They come in different sizes and angles to work on any roots in the mouth.
37. Figure 9.37 Stainless steel ultrasonic tips with varying angles.
38. Figure 9.38 Smaller “Slim Jim” tips for preparing narrow canals and isthmuses.
39. Figure 9.39 A groove can be placed in bone with the ultrasonic tip to correspond to the long axis of the root. This groove can be a reference point to follow to keep the root‐end preparation in the long axis of the root.
40. Figure 9.40 MTA cylinder formed in the Lee block and placed on an instrument to carry it to the root‐end preparation.
41. Figure 9.41 MTA that was formed in the Lee block being placed into a root‐end preparation.
42. Figure 9.42 MAP System (PD, Vevey, Switzerland) comes with syringe tips of different diameters and angles for placement of MTA.
43. Figure 9.43 MTA being placed with the MAP System into a root‐end preparation.
44. Figure 9.44 ProRoot MTA (Tulsa Dentsply, Tulsa, OK, USA) being placed into a root‐end preparation with the ProRoot MTA Manual Carrier.
45. Figure 9.45 EndoSequence Root Repair Material (Brasseler USA, Savanah, GA, USA) being placed into a root‐end preparation.
46. Figure 9.46 Bone‐grafting material placed into large periapical defect and over root structure.
47. Figure 9.47 A resorbable membrane is placed over the bony defect, which has been filled with a bone‐grafting material. The flap is replaced, held in place, and then sutured in place.
48. Figure 9.48 The occlusal view of crown shapes after vertical root amputations. The crown shape will resemble the remaining root structure after root amputation of the other root.
49. Figure 9.49 Hemisection of a mandibular molar. The arrow on the right diagram is pointing to a spur left after resection in the furcation. It is important to remove this overhang in all root resections, because it can be a site for plaque accumulation and makes it difficult for the patient to clean the area.
Chapter 10: Lasers
1. Figure 10.1 Wavelength of various types of lasers according to their emission.
2. Figure 10.2 Laser energy interactions with tissues. 1, Absorption,. 2, Transmission. 3, Reflection. 4, Scatter.
3. Figure 10.3 Laser tip used in cleaning and shaping of the root canal system. The figure shows the placement of the fiberoptic as close as possible to the working length, which creates a challenge during cleaning and shaping process.
4. Figure 10.4 Left and center, Use of conventional erbium chromium YSGG laser caused thermal damage to tooth structure (carbonization). Right, Scanning electron microscope (SEM) image of thermal damage and ledging.
5. Figure 10.5 A, Conventional laser tip used on samples with thermal damage. B, A more recent modern tapered and stripped nonthermal photoacoustic PIPS laser tip.
6. Figure 10.6 Er:YAG laser unit from Fotona.
7. Figure 10.7 A, Cross section shows the main canal cleaned. Arrow points to area that is free of bacteria. B, A magnified lateral canal that had intact pulpal tissues. Scale bar is 100 µm in both images.
8. Figure 10.8 A, Cross section at 1‐mm level shows remnant bacterial biofilms after PIPS and NaOCl use. B, Cross section at 1‐mm level shows significantly more remnants of bacterial biofilms after ultrasonic and NaOCl use. Scale bar is 100 µm in both images.
9. Figure 10.9 Scanning electron microscope analysis of root canal surface. A and B, Group I shows E. faecalis colonies attached to the root canal surface. C and D, Group II (PIPS + NaOCl) shows a clean root canal surface. E and F, Group III (PIPS + saline) shows colonies attached to the root canal surface. G to I, Group IV (irrigation with NaOCl) shows some colonies and the other image shows no colonies.
10. Figure 10.10 The amount of irrigant extrusion. There is no statistically significant difference.
11. Figure 10.11 A close‐up view of the PIPS tip and its composition, including the striped sheath that helps propagate the shock waves in the root canal system (a). The illustration shows how the PIPS is placed and how it delivers the shock waves (b).
Chapter 11: Dental pulp regeneration
1. Figure 11.1 Clinical pulp regeneration therapy. A, Preoperative radiograph shows an immature necrotic maxillary left central incisor with a periapical radiolucency. B, Postoperative radiograph. Sodium hypochlorite and ciprofloxacin were used to disinfect the canal. Bleeding was evoked and the tooth was sealed with a mineral trioxide aggregate and bonded resin. C, Seven‐month recall radiograph. The resolution of the periapical radiolucency and apical closure were observed.
2. Figure 11.2 Tissue‐engineering strategies. A, Cell‐based therapy using the delivery of stem cells into the defect site. A gel‐type scaffold can carry stem cells into the root canal space. Stem cells participate in tissue formation by differentiating into the resident cells. This strategy has been widely used in animal studies. B, Cell‐free therapy using the delivery of signaling molecules into the defect site. A gel‐type scaffold can carry signaling molecules into the root canal space. The signaling molecules can modulate cellular events of endogenous cells and enhance tissue formation. This strategy has fewer translational barriers.
Chapter 12: Teledentistry
1. Figure 12.1 Store and forward method.
2. Figure 12.2 Real‐time consultation.