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Advancements in Root Canal Therapy:
New Technology to Improve Patient
OutcomesThomas V. McClammy, DMD, MS; Enrico DiVito, DDS
SUPPORTED BY AN UNRESTRICTED GRANT FROM SONENDO • Published by Dental Learning Systems, LLC © 2018
eBookCE Continuing Dental Education
FEBRUARY 2018 V5 N97
P E E R - R E V I E W E D2 C D E C R E D I T S
W W W . C D E W O R L D . C O M
E N D O D O N T I C S T E C H N O LO G Y
FEBRUARY 2018
Thomas V. McClammy, DMD, MS
Private Practice
Scottsdale, Arizona
Enrico DiVito, DDS
Private Practice
Scottsdale, Arizona
eBookCE Continuing Dental Education
About the Authors
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CDEWORLD.COMVOLUME 5 • NUMBER 97 3
A clinician’s endodontic success rate can be difficult to
determine, either in the long or short term. Complications
of root canal anatomy can make success difficult to gauge.
The main opportunity that clinicians can take advantage of regarding
root canal system anatomy relates to microanatomy. This article will
provide an overview of root canal system anatomy and historical
root canal therapy. It will then introduce multisonic technology,
which can dramatically improve endodontic outcomes for patients.
This technology enables clinicians to be more conservative in their
treatment and achieve greater case success.1,2
ENDODONTIC SUCCESS AND THE ROOT CANAL SYSTEMSome dentists are familiar with the 1917 study of the root canal system
that was brought to the United States in 1925 by Walter Hess.3 The
study set the benchmark for the modern understanding of dental
anatomy, but it also created limitations, because of the concept of a
single “root canal.” A better concept for this anatomy is root canal
“systems,” a term introduced by Dr. Herbert Schilder in 1974.4 Today,
a cursory Google search will provide incredibly detailed displays of
digitized micro computed tomography (CT) of root canal system
anatomy. These images demonstrate the complexity of root canal
systems, which can be compared to a fingerprint because of their
person-specific nature. Figure 1 provides a representation of a lower
premolar micro CT that makes it clear how difficult the endodontic
clinician’s task of cleaning and shaping such an intricate system can
be. This complexity also illustrates why clinicians may be falling
short of fully debriding and disinfecting these anatomical systems
regardless of what instruments and irrigation protocols are utilized.
Irrigation methods have changed over time, transitioning from
passive irrigation to active irrigation. Gutta-percha cone activation
gave way to the EndoActivator® (Dentsply Sirona, dentsplysirona.
com) by Dr. Clifford Ruddle, which opened the door for moving
irrigants more effectively throughout the root canal system. Next
came ultrasonic activation technologies, including PiezoFlow®
(Dentsply Sirona), EndoVac® (Kerr Dental, kerrdental.com), and, more
T h o m a s V . M c C l a m m y , D M D , M S ; E n r i c o D i V i t o , D D S
ABSTRACT
Success rates for endodontic procedures can be quantifiably and qualitatively improved with the use of new multisonic technology, which provides a far more conservative and thorough methodology than common root canal procedures. Using multisonic technology, the clinician can achieve the five mechanical objectives initially proposed by Dr. Herbert Schilder. The system allows the clinician to transition from a sense of “cleaning and shaping” to “preparing” the root canal system. Overall, advantages can be found in reduced clinical fatigue and decreased discomfort for the patient. The authors conclude that multisonic technology enables the clinician to provide a higher level of care that better accounts for the complexity of the root canal system.
LEARNING OBJECTIVES
• Describe the principles underlying root canal therapy and mechanical objectives.
• Discuss the endodontic procedure protocol for a new technology.
• Explain the advantages of using the new technology.
Advancements in Root Canal Therapy: New Technology to Improve Patient Outcomes
P E E R - R E V I E W E D
2 C D E C R E D I T S
4 FEBRUARY 2018CDEWORLD.COM
recently, EndoVac Pure™ (Kerr Dental), which have
collectively helped clinicians to realize the value of
active over passive irrigation. In the 1970s and early
1980s, dental school education for root canals did not
consider the system view. This limited perspective
later shifted, as exemplified by Schilder’s article,
“Cleaning and Shaping the Root Canal.”4 In a key
quote from this article, Schilder states, “Initially,
root canals were manipulated primarily to allow
placement of intracanal medicaments, with little
attempt to remove completely the organic contents
of the root canal system. In spite of elaborate
modifications over the years, many methods of
preparing root canals mechanically still fail to
cleanse root canal systems effectively.”
Schilder, whose thinking was forward-looking,
provided five mechanical objectives. These five
objectives were reduced to four by Ruddle: continuous
tapering preparation, original anatomy maintained,
position of foramen maintained, and foramen kept as
small as practical.5 With new, disruptive root canal
treatment technology currently on the market, the
objective of a continuous tapering preparation is,
in the opinion of these authors, perhaps no longer
necessary. Throughout the history of endodontics,
there have been many times when a new technology
challenged the status quo, was dismissed or disliked,
but then became the norm. Microscope technology
that emerged in the early 1990s and cone-beam
computed tomography (CBCT)/three-dimensional
(3D) imaging are examples of disruptive technologies
that were met with skepticism but have now become
commonplace.
ADVANCED ROOT CANAL TECHNOLOGYThe new technology introduced in this article is
based on advanced multisonic technology. Several
current systems take advantage of ultrasonics
and/or piezoelectric ultrasonic technology to
deliver endodontic therapy. Some of these include
MiniEndo™ (Kerr Dental), Varios® (NSK, nskdental.
us), and Newtron® (Satelec, A-dec Inc, a-dec.com).
The cases documented in this article feature the
GentleWave® System (Sonendo®, sonendo.com),
which employs a proprietary multisonic cleansing
technology to deliver therapeutic irrigants into
the root canal system, including lateral canals and
tubules of complex root canal systems, while leaving
the dentin largely intact.1,6-11 In the case shown in
Figure 2 (preoperative radiograph) and Figure 3
(postoperative), the clinician was initially under
1 2 3
4 5 6
Fig 1. Mandibular premolar. Courtesy of Dr. Bernardo Camargo, Rio de Janeiro, Brazil. Fig 2 and Fig 3. Preoperative (Fig 2) and postoperative (Fig 3) radiographic images. Fig 4 through Fig 6. Preoperative (Fig 4), cone fit (Fig 5), and postoperative (Fig 6) radiographic images.
5CDEWORLD.COMVOLUME 5 • NUMBER 97
the misconception that simple
“cleaning and shaping” could be
used for the root canal system
in the conventional manner.
The clinician evaluated the root
canal system digitally in 2D and
3D before starting the case. The
case was accessed, prepared,
and cleaned and disinfected.
Special attention to the digital
imagery of the mesiobuccal root
complex allowed the clinician
to appreciate that the MB1 and
MB2 merged before exiting
from a common foramen. The
2D postoperative radiograph
(Figure 3) illustrates that all of
the mechanical objectives were
realized.
Figure 4 shows another
preoperative radiographic image.
The clinician was especially
interested in observing what
would happen in the apical one-
third of the distal canal. Figure 5
shows the cone-fit radiograph, and
Figure 6 shows the postoperative
2D image. The introduction of
multisonic technology allowed
the clinician to preserve more
dentin while keeping the access
more conservative.
Figure 7 shows another
tooth that was diagnosed with a
necrotic pulp; Figure 8 shows a
preoperative CBCT slice from
the volumetric scan of the tooth.
The clinician observed that
there was more than one canal in the mesiobuccal
system and that a periapical lesion was present.
Lesions were visible radiographically on every
root, adjacent to numerous portals of exit in
the apical one-third. In this case, the clinician
aimed to be more conservative
and was able to better maintain
the original anatomy. In the
mesiobuccal root, the canals
crisscrossed, and considering
the delicate anatomy in
the apical one-third, it was
imperative to keep the foramen
as small as practical. A much
larger palatal canal was also
observed. The clinician
provided a coronal seal buildup
before the rubber dam was
removed from the tooth. Figure
9 shows the postoperative 2D
radiograph.
Figure 10 is from a case
on the upper arch, tooth No.
3. On the distal buccal area,
superimposed over the palatal
and distobuccal root, there was
a large periapical lesion. Figure
11 shows the preoperative
CBCT slice. The tooth had
preoperative draining via a
sinus tract through the buccal
plate that the clinician was able
to appreciate before initiating
the procedure. These images
clarify the amount of bone
destruction periapically, in
the axial view. Recognition
of the preoperative indicators
enabled the clinician to
consider how to best proceed
with treatment. Figure 12
shows the postoperative 2D
radiograph, which reveals a
delicate buccal system and
significant anatomy in the palatal canal. There
was some extrusion of sealer palatally and at
other portals of exit. Figure 13 shows a 3-week
postoperative recall 2D radiograph of the case.
7
Fig 7 through Fig 9. Preoperative radiographic image (Fig 7), preoperative CBCT (Fig 8), and postoperative radiographic image (Fig 9).
8
9
6 FEBRUARY 2018CDEWORLD.COM
The draining sinus tract had healed by that point
in time.
Figure 14 and Figure 15 show the
preoperative digital images for another case
with a necrotic pulp. In the preoperative 3D
CBCT volume, the clinician observed that
the mesiobuccal system, distobuccal system,
and palatal system all communicated. On
evaluating the mesiobuccal system, the
clinician observed anastomoses between
the canals. The clinician sought to employ
a conservative approach to treating the case.
Figure 16 and Figure 17 show the postoperative
scans wherein it can be seen that the clinician
practiced “directed dentin conservation” (a
term attributed to Dr. David Clark and Dr.
John Khademi and perpetuated by Dr. Eric
Herbranson).12 The only mechanical objective
not illustrated by this case is the continuous
tapering preparation. Overall, the original root
canal system anatomy was maintained and
the foramen was kept as small as practical.
Figure 18 shows an inverted postoperative
radiograph that better illustrates both of these
principles.
Figure 19 and Figure 20 illustrate a premolar
in which the condition of the pulp was initially
misdiagnosed and the patient was referred for
restorative work. She returned within a few
months, explaining that her tooth hurt. The
clinician found that the pulp of tooth No. 12
was necrotic and the tooth had multiple portals
of exit and multiple lesions of endodontic
origin adjacent to these portals of exit. Figure
21 shows the postoperative 2D radiograph
Fig 10 through Fig 13. Preoperative radiographic image (Fig 10), preoperative CBCT (Fig 11), postoperative radiographic image (Fig 12), and 3-week recall radiographic image (Fig 13).
10 11
12 13
CDEWORLD.COMVOLUME 5 • NUMBER 97 7
of the tooth after multisonic technology was
used to clean and debride the microanatomy.
ADVANTAGES OF THE TECHNOLOGYIn the authors’ experience, the multisonic procedure
does not take appreciable additional time and, in
most cases, can be completed in a single-visit
appointment. Clinician, staff, and patient fatigue
are noticeably decreased because the process
requires less time in shaping/preparation of the root
canal system. In lieu of shaping of the root canal
system, the clinician’s objective is solely to create
a pathway to allow the multisonic technology to
deliver degassed irrigants to the entire root canal
system. The potential for instrument fatigue is
reduced because the clinician does not attempt to
enlarge the systems significantly beyond the natural
anatomy. Instrument stress is lessened, resulting in
fewer separated instruments and reduced anxiety
for both clinician and staff. There is decreased
schedule disruption and reduced loss of valuable
tooth structure.
Employment of this technique alleviates the
need for multiple instrument passage and repeated
16 17 18
14 15
Fig 14 through Fig 18. Preoperative radiographic image (Fig 14), preoperative CBCT (Fig 15), postoperative scans (Fig 16 and Fig 17), and inverted postoperative image (Fig 18). Fig 19 through Fig 21. Preoperative (Fig 19 and Fig 20) and postoperative (Fig 21) images.
19 20 21
8 FEBRUARY 2018CDEWORLD.COM
recapitulations. As a result, this procedure
dramatically lessens the production of the smear
layer,11 leading to cleaner systems and more
thorough debridement.
The technology involves a less-invasive technique
with smaller, more conservative shapes.1 Less
patient time is required because it is predominantly
a single-visit procedure. The authors have found that
only rarely will a case require placement of calcium
hydroxide or an intra-appointment medicament.
Postoperatively, the procedure results in less
pain, less sensitivity, no swelling, and little to no
discomfort; over-the-counter non-narcotic anti-
inflammatory medications are all that are necessary
postoperatively for most patients.
CONCLUSIONSuccess rates for endodontic procedures can be
quantifiably and qualitatively improved with the use
of new technology. Multisonic treatment advances
root canal therapy and supports improvements to
endodontic outcomes for patients. It accomplishes
this through a far more conservative and thorough
method than traditional root canal procedures.
Using this modality, the clinician can achieve the
five mechanical objectives determined initially by
Schilder. This allows the clinician to transition from
a sense of “cleaning and shaping” to “preparing” the
root canal system. Overall, success can be measured
by the reduction of clinical fatigue, a decrease in
discomfort for the patient and improved healing
rates, enabling the clinician to provide a higher level
of care that better addresses the complexity of the
root canal system.
REFERENCES1. Sigurdsson A, Garland RW, Le KT, Woo SM.
12-month healing rates after endodontic therapy using
the novel GentleWave System: a prospective multicenter
clinical study. J Endod. 2016;42(7):1040-1048.
2. Sigurdsson A, Le KT, Woo SM, et al. Six-month healing
success rates after endodontic treatment using the novel
GentleWave System: the PURE prospective multi-center
clinical study. J Clin Exp Dent. 2016;8(3):e290-e298.
3. Hess W. The Anatomy of the Root-Canals of the Teeth
of the Permanent Dentition, Part 1. New York: William
Wood and Co.; 1925.
4. Schilder H. Cleaning and shaping the root canal. Dent
Clin North Am. 1974;18(2):269-296.
5. Ruddle CJ. WaveOne: helpful hints. The Ruddle
Report. http://www.endoruddle.com/blogs/show/20/
waveone-helpful-hints. Published May 9, 2012. Accessed
November 27, 2017.
6. Van der Sluis LWM, Shemesh H, Wu MK, Wesselink
PR. An evaluation of the influence of passive ultrasonic
irrigation on the seal of root canal fillings. Int Endod J.
2007;40(5):356-361.
7. Haapasalo M, Wang Z, Shen Y, et al. Tissue dissolution
by a novel multisonic ultracleaning system and sodium
hypochlorite. J Endod. 2014;40(8):1178-1181.
8. Ma J, Shen Y, Yang Y, et al. In vitro study of calcium
hydroxide removal from mandibular molar root canals.
J Endod. 2015;41(4):553-558.
9. Charara K, Friedman S, Sherman A, et al. Assessment
of apical extrusion during root canal procedure with
the novel GentleWave system in a simulated apical
environment. J Endod. 2016;42(1):135-139.
10. Macedo RG, Robinson JP, Verhaagen B, et al. A
novel methodology providing insights into removal of
biofilm-mimicking hydrogel from lateral morphological
features of the root canal during irrigation procedures.
Int Endod J. 2014;47(11):1040-1051.
11. Vandrangi P, Basrani B. Multisonic ultracleaning
in molars with the GentleWave system. Oral Health.
May 2015;72-86.
12. Clark D, Khademi J. Modern molar endodontic
access and directed dentin conservation. Dent Clin
North Am. 2010;54(2):249-273.
10. Macedo RG, Robinson JP, Verhaagen B, Walmsley AD,
Versluis M, Cooper PR, and van der Sluis LM. A novel
methodology providing new insights into the ultrasonic
removal of a biofilm-mimicking hydrogel from lateral
morphological features of the root canal. Int Endod J. 2014;
47: 1040–1051.
11. Vandrangi P, Basrani B. Multisonic ultracleaning in molars
with the GentleWave system. Oral Health. 2015;May:72-86.
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QuizCDE 2 CDE Credits
Advancements in Root Canal Therapy: New Technology to Improve Patient Outcomes
6. According to Schilder, many methods of preparing
root canals mechanically:
A. are considered effective about 40% of the time. B. are considered effective about 60% of the time. C. are considered effective about 80% of the time. D. still fail to cleanse the root canal systems effectively.
7. Schilder provided how many mechanical objectives
when preparing a root canal?
A. three B. four C. five D. six
8. This article describes a proprietary:
A. endodontic shaping system. B. multisonic cleansing technology. C. endodontic length-measuring device. D. endodontic access-opening procedure.
9. Multisonic technology allows the clinician to:
A. conserve more dentin while keeping accesses more conservative.
B. conserve more dentin while making accesses larger. C. remove more dentin while keeping accesses more
conservative. D. remove more dentin while making accesses larger.
10. Using a multisonic device decreases:
A. clinician fatigue. B. staff fatigue. C. patient fatigue. D. all of the above
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9CDEWORLD.COMVOLUME 5 • NUMBER 97
1. Whatmakesrootcanaltherapydifficulttogauge? A. the lack of a recall appointment B. the inability to access the pulp chamber C. complication of root canal anatomy D. the high percentage of retreatments based on national data
2. The limitation of the 1917 study by Hess was because of:
A. the concept of a single “root canal.” B. the concept of complex root canal anatomy. C. the concept of multiple small apices on virtually all teeth. D. the lack of applied scientific rigor to the study, leading to
inflated conclusions.
3. The term root canal “systems” was introduced in 1974 by:
A. Torbinijad. B. Gow-Gates. C. Schilder. D. Kakehashi.
4. Rootcanalsystemscanbecomparedtoafingerprintbecause: A. they have a similar classification system in the United
States. B. they have a similar classification system internationally. C. of their person-specific nature. D. of a consensus paper by endodontists in 2002.
5. More effectively moving irrigants through the endodontic
system involves:
A. passive irrigation. B. active irrigation. C. highly acidic irrigation. D. highly basic irrigation.
In all patients, the clinicians’ first priority is to obtain
an accurate pulpal diagnosis. The authors’ protocol
for incorporating multisonic technology, such as
the GentleWave® Procedure, begins with an initial
examination and consideration of the patient’s dental
history, systemic health history, and chief complaint.
Although several angled images and a bitewing
radiograph may no longer be necessary, it is still
advisable to take a straight-on 2D periapical radiograph.
The second step is to take a preoperative 3D CBCT
volumetric image. Following the achievement of
profound pulpal anesthesia, a rubber dam is placed,
and then the clinician can access the root canal system.
The coronal access can be more conservative because
of the benefits of the GentleWave Procedure.1,2 Next,
all canals should be located in the access cavity, aided
by the combination of the 2D periapical radiograph,
the 3D CBCT volume, and direct visual observation
through a dental operating microscope.
Canal lengths are verified as the clinician
measures each canal from a reference point in the
coronal aspect of the tooth to the apical constriction.
This can also be done within the CBCT volume, due
to the nature of its accuracy. An electronic apex
locator can also be utilized to confirm the canal
length.
The clinician can then prepare the canals to
approximately 1.0 mm short of working length.
Next, the authors generally utilize no more than
two to three variably tapered nickel-titanium rotary
files to prepare each root canal to the same length,
while maintaining much smaller diameters in the
coronal aspect of the root canal system.
Initiation of the GentleWave Procedure requires
the fabrication of an occlusal platform. Today this is
accomplished utilizing SOUNDSEAL™ (Sonendo®,
sonendo.com) and an included preformed plastic
matrix. This platform allows the GentleWave
Procedure Instrument to conform to the root canal
access cavity. The GentleWave Procedure method
of action requires an intact seal at the interface of
the Procedure Instrument and the root canal coronal
access cavity. After fabrication of the platform is
completed, the GentleWave Procedure can begin.
Currently, the procedure consists of approximately
8 minutes of continuously refreshed NaOCl,
water, and EDTA at specific computer-controlled
concentrations and intervals. During this time, the
Procedure Instrument is manually held in place by
the clinician. When the procedure is completed,
the Procedure Instrument and the SOUNDSEAL
platform are removed. Preparations for obturation of
Fig 1. The difference with the new technology is visually significant. Fig 2. The delicate distobuccal right in the apical one-third is exceptionally well maintained.
PROCEDURE PROTOCOL
FEBRUARY 201810 CDEWORLD.COM
1
2
the root canal system can then be initiated, based
on the clinician’s obturating method of choice. For
example, the clinician may choose to obturate with
warm gutta-percha in conjunction with a sealer. After
obturation has been completed, the clinician can
perform a coronal seal buildup procedure before
removing the rubber dam. Finally, a postoperative 2D
radiograph is acquired. Post-operative instructions
are provided to the patient, including detailed
information regarding the GentleWave Procedure
that has been performed.
The appreciable visual difference when using the
GentleWave Procedure is shown in Figure 1. Tooth
No. 2 is the newer shape and tooth No. 3 is the older
shape, which was still quite conservative. Tooth No.
2 showcases an example of closely maintaining the
original anatomy. The GentleWave System enables
the clinician to debride and disinfect the root canal
system, resulting in a much smaller and more
conservative shape.1,2 For example, the delicate
distobuccal root canal anatomy in the apical one-
third of Figure 2 is exceptionally well-maintained.
REFERENCES1. Sigurdsson A, Garland RW, Le KT, Woo SM. 12-month healing rates after endodontic therapy using the novel GentleWave System: a prospective multicenter clinical study. J Endod. 2016;42(7):1040-1048.
CDEWORLD.COMVOLUME 5 • NUMBER 97 11
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SONENDO.COM/RELATIONSHIP
Before*
Post GentleWave® Procedure*
• The entire procedure from access opening to obturation can
typically be completed in just one visit1
• Cleans the deepest, most complex anatomies of the root canal
system2,3 to remove tissue, debris, biofilm and bacteria
• Helps save the structure and integrity of teeth by preserving
more dentin1
* Images courtesy Brian T. Wells, DMD 1 Sigurdsson A et al. (2016) J Endod. 42:1040-48 2 Molina B et al. (2015) J Endod. 41:1701-5 3 Vandrangi P et al. (2015) Oral Health 72-86© 2018. All rights reserved. SONENDO, the SONENDO logo, GENTLEWAVE, the GENTLEWAVE logo and SOUND SCIENCE are trademarks of Sonendo, Inc. Patented: www.sonendo.com/intellectualproperty. MM-0529 Rev 01
RELATIONSHIP GOALS.