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Original Article Int Dent Res 2011;1:1-6

International Dental Research © 2011 1

Removal of Debris and Smear Layer in Curved Root Canals Using Self-Adjusting File with Different Operation Times – A Scanning Electron Microscope Study Senem YİĞİT ÖZER1, Özkan ADIGÜZEL1, Sadullah KAYA1 1 Assistant Professor, Dicle University, Faculty of Dentistry, Department of Operative Dentistry and Endodontics, Diyarbakır, TURKEY Key Words Apical third of root canal, curved root canal, debridement, self-adjusting file, smear layer Correspondence: Senem YİĞİT ÖZER Dicle University, Faculty of Dentistry, Department of Operative Dentistry and Endodontics, 21280, Diyarbakir, TURKEY. e-mail: [email protected]

Abstract Aim: Debridement during root canal treatment is mandatory and it is provided by means of chemomechanical instrumentation and irrigation methods. This article analysis the debridement capacity of a novel system, SAF and its special irrigation device when used with different operation times in curved root canals. Methodology: 30 mesiobuccal root canals of maxillary molars were instrumented using SAF. Teeth were divided into three groups. In Group 1, 10 new SAF files were used for operation for 4 minutes. In Group 2, the 4-min previously used SAF files were operated in the same manner. In Group 3, the 8-min previously used SAF files were operated. During SAF operation 2.6 % NaOCl and 17 % EDTA were used alternately in all groups. Debris and smear layer removal were evaluated for the apical thirds under scanning electron microscope. Results: Non-used, 4-min preused, and 8-min preused SAF efficiently removed debris and smear layer in the apical thirds. There were no significant difference among the groups in terms of debridement. Conclusions: When SAF is operated in curved root canals with continous flow of irrigation it results in debris and smear-free canal walls in the critical apical thirds within 12 minutes. (Int Dent Res 2011;1:1-6)

Introduction

Root canal instrumentation produces smear layer. This amorphous structure is composed of dentin particles, necrotic debris, and odontoblastic processes that occlude the orifices of dentinal tubules (1). Smear layer is reported to prevent the penetration of irrigation solutions, medications, and filling materials into dentinal tubules and many researchers believe that it is detrimental (2). The literature reports generally show that regardless of the instrumentation and irrigation techniques, the effectiveness of irrigating solutions remains limited

in the apical one third of a prepared canal. This is particularly true for curved root canals (3). Therefore, the improvement of irrigating protocols is essential during root canal treatment in order to achieve better cleaning efficiency especially in the very complex apical area.

Rotary nickel-titanium files are successful to clean and shape the straight and narrow canals,and completion of the file sequence may result in a clean canal with no tissue debris and with removal of all or most of the inner layer of the heavily contaminated dentin (4). Recently micro–computed tomographic studies by Peters et al (5) have extended the

Using Self-Adjusting File in Curved Root Canals Yiğit Özer et al.

2 IDR — Volume 1, Number 1, 2011

understanding of the limitations of rotary file systems reporting that inadequate preparation often occurs in curved root canals. In upper molars treated with a conventional rotary system, 49% of the canal walls were reported to be untouched, even in the larger palatal canals (6). To overcome this handicap, these common nickel-titanium file designs are being modified for a higher percent of the root canal surface to be prepared by the shaping procedure (7).

Self-Adjusting file (SAF) is a novel system among the nickel-titanium files operating in a different manner. It adapts itself longitudinally to a curved canal, as most rotary nickel-titanium files do, but differently adapts itself to the cross-section of the canal (7). It is a hollow file designed as a compressible, thin-walled, pointed cylinder, composed of a thin derivate of nickel-titanium lattice with high torsional and fatigue resistance. The lattice surface is slightly abrasive and it allows removing dentin with a back-and-forth grinding motion (8). This reciprocating file system is used with a specially designed irrigation device providing continuous flow of the irrigant.

During the operating procedure, SAF is inserted into the canal while vibrating and is lightly pushed in until it reaches the predetermined working length. It is then operated with in-and-out manual motion and with continuous irrigation using two cycles of 2 minutes each for a total of 4 minutes per canal. This procedure is reported to remove a uniform dentin layer 60- to 75-mm thick from the canal circumference (8).

Every available rotary file systems are reported to generate a smear layer leaving debris in the root canal (9) however a recent study by Metzger et al. (10), who used the SAF system with a 4-min application of 3% NaOCl and 17% EDTA reported clean and mostly smear layer–free dentinal surface in all parts of the root canal. However the evaluative tests showed the efficacy of the SAF file declined with time. A file that was preused for 30 minutes was found to be 40% less effective than a new file (8). Nevertheless, when used for 12 minutes, according to the manufacturer’s instructions, the SAF efficacy was not reported to substantially reduce. However the ability to remove dentin is claimed to decrease if the file was reused (8).

Thus the aim of this present study was to evaluate the debridement capacity of SAF when used in curved root canals in an operation time as advised by the manufacturer. The null hypothesis is when SAF is used within 12 minutes it removes smear layer and debris efficiently in the apical thirds of curved root canals.

Materials and Methods Selection of Teeth

The study sample consisted of 30 maxillary molars with fully formed apices that had been extracted for periodontal and/or prosthetic reasons. The teeth were stored in 10% buffered formalin until they were used. The mesiobuccal (MB) root canals of maxillary molars were instrumented using SAF. Curvature of the MB canals was measured according to the protocoldescribed previously by Estrela et al. (11). The 30 canals showed curvatures ranging from 32 to 45°. This sample was equally divided into 3 groups of 10 teeth for instrumentation with SAF. The working length of each canal was determined by subtracting 1mm from the observed length of protrusion of the number 10 file through the apical foramen.

Root Canal Instrumentation and Irrigation with the SAF

After endodontic accesss cavity, the root canal was negotiated using a size 10 K-file. The working lengths were set 1 mm shorter than the apical foramen. A glide path was established by manual instrumentation up to a size 20 K-file. The 10 SAF files were operated using an in-and-out vibrating handpiece as described by Metzger et al. (6) with 5000 vibrations/min and a 0.4-mm amplitude, with the irrigation device (VATEA; ReDent-Nova) that provided flow of the irrigation solution at a flow rate of 5 mL/min until it reached the predetermined working length for 4 minutes. The irrigation solution flowed into the file and freely escaped into the root canal through the lattice wall to backflow coronally without positive pressure. Because a flow rate of 5 mL/min was chosen, 15 mL of NaOCl (2.6%) and 5 mL of EDTA (17%) were used. NaOCl was used as the initial irrigant during the first 3 min of the operation, followed by 1 min of irrigation with EDTA. A final flush with 5 mL NaOCl was used to remove the EDTA, and distilled water was used in the last step. The canals were dried using paper points.

In Group 1, 10 new SAF files were used for operation for 4 minutes. In Group 2, the 4-min previously used SAF files were operated in the same manner. In Group 3, the 8-min previously used SAF files were operated.

SEM Evaluation Two longitudinal grooves were prepared on the

buccal and lingual surfaces of each root using a diamond disc, avoiding penetration into the canal. The roots were then split into 2 halves with a chisel and coded. The coded specimens were mounted on metallic stubs, gold sputtered, and examined

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Yiğit Özer et al. Using Self-Adjusting File in Curved Root Canals


(16). EDTA is a chelating agent used to remove the smear layer (17). This dual combination of irrigants has been shown to be effective in debriding and disinfecting root canals as well as other irrigants (18-21). Studies have shown an increased efficacy of canal debridement with increased apical size preparations and increased taper of instruments (14,22). As reported recently by Peters et al (5) the resulting apical size is usually at least equivalent to a #40 file when SAF is used during preparation in 5-minutes. Several studies confirmed that larger apical preparation reduces the bacterial count (23,24) and enhances the effectiveness of irrigation (25). Probably apical preparation performed using SAF and vibrating motion of the file’s delicate mesh within the fluid that is continuously replaced had synergist effect for debridement and resulted with clean root canals almost free of smear layer on the critical apical region.

In addition, the role of chlorine should not be overlooked. It is known that chlorine is responsible for the dissolution of organic tissue and the antimicrobial effect of NaOCl (26). However, chlorine is consumed rapidly during the first phase of tissue dissolution, probably within 2 min (26,27). Therefore regular replenishment and large volumes of NaOCl are required for successful debridement. During SAF operation with continous irrigation, one should consider that NaOCl is refreshed every second making it possible for sufficient free chlorine to be present in the root canal to dissolve the organic component of dentine debris. It could be possible that NaOCl contains enough free chlorine to dissolve the organic component of the dentine debris and despite the increased operation time with the used files NaOCl had enough flushing effect on debridement especially at the apical portions of the curved root canals. NaOCl entering the file through a free-rotating hub is continuously replaced during the procedure, thus providing a fresh and totally active irrigation solution. Because positive pressure is absent throughout the root canal system, the solution can easily escape through openings in the lattice of the file (8). The success in removing the smear layer in the apical third, may be due to the vibrating motion of the file’s delicate mesh within the fluid that is continuously replaced.

Conclusions

When SAF is operated in curved root canals

with continous flow of irrigation it results in debris and smear-free canal walls in the critical apical thirds within 12 minutes. Thus our null hypothesis is accepted.

References

1. McComb D, Smith DC. A preliminary scanning

electron microscopic study of root canals after endodontic procedures. J Endod 1975;1:238–42.

2. Karagöz-Küçükay I, Bayirli G. An apical leakage study in the presence and absence of the smear layer. Int Endod J 1994;27;87-93.

3. Sedgley CM, Nagel AC, Hall D, et al. Influence of irrigant needle depth in removing bioluminescent bacteria inoculated into instrumented root canals using real-time imaging in vitro. Int Endod J 2005;38:97–104.

4. Wu M-K, van der Sluis LWM, Wesselink PR. The capacity of two hand instrumentation techniques to remove the inner layer of dentin in oval canals. Int Endod J 2003; 36:218–24.

5. Peters OA, Boessler C, Paque´ F. Root canal preparation with a novel nickel-titanium instrument evaluated with micro-computed tomography: canal surface preparation over time J Endod 2010;36:1068–72.

6. Peters OA, Peters CI, Schönenberger K, et al. ProTaper rotary root canal preparation: effects of root canal anatomy on final shape analyzed by micro CT. Int Endod J 2003;36:86–92.

7. Metzger Z, Teperovich E, Zary R, et al. Respecting the root canal: a new concept of a Self Adjusting File (SAF). J Endod 2010;36:679–90.

8. Hof R, Perevalov V, Eltanani M, Zary R, Metzger Z. The Self Adjusting File (SAF), Part 2: mechanical analysis. J Endod 2010;36:691-96.

9. Torabinejad M, Handisides R, Khamedi AA, et al. Clinical implications of smear layer in endodontics: a review. Oral Surg Oral Med Oral Path Oral Radiol Endod 2002;94: 658–66.

10. Metzger Z, Teperovich E, Cohen R, et al. The Self Adjusting File (SAF). Part 3: Removal of debris and smear layer. A scanning electron microscope study. J Endod 2010;36;697-702.

11. Estrela C, Bueno MR, Sousa-Neto MD, Pécora JD. Method for determination of root curvature radius using cone-beam computed tomography images. Braz Dent J 2008;2:114-8.

12. Hülsmann M, Ruümmelin C, Schäfers F. Root canal cleanliness after preparation with different endodontic handpieces and hand instruments: a comparative SEM investigation. J Endod 1997;23:301–6.

13. Bystrom A, Sundqvist G. Bacteriologic evaluation of the efficacy of mechanical root canal instrumentation in endodontic therapy. Scand J Dent Res 1981;89:321– 8.

14. Usman N, Baumgartner JC, Marshall JG. Influence of instrument size on root canal debridement. J Endod 2004;30:110 –2.

15. Walters MJ, Baumgartner JC, Marshall JG. Efficacy of irrigation with rotary instrumentation. J Endod 2002;28:837–9.

16. Hand RE, Smith ML, Harrison JW. Analysis of the effect of dilution on the necrotic tissue dissolution property of sodium hypochlorite. J Endod 1978;4:60–4.

Using Self-Adjusting File in Curved Root Canals Yiğit Özer et al.


17. Baumgartner JC, Mader C. A scanning electron microscopic evaluation of four root canal irrigation regimens. J Endod 1987;13:147–52.

18. Bystrom A, Sundqvist G. The antibacterial action of sodium hypochlorite and EDTA in 60 cases of endodontic therapy. Int Endod J 1985;1:35– 40.

19. Baumgartner JC, Mader C. A scanning electron microscopic evaluation of four root canal irrigation regimens. J Endod 1987;13:147–52.

20. Johal S, Baumgartner JC, Marshall JG. Comparison of the antimicrobial effect of 1.3% NaOCl/MTAD with 5.25% NaOCl/15% EDTA for root canal irrigation. J Endod 2007; 33:48 –51.

21. Kho P, Baumgartner JC. A comparison of the antimicrobial efficacy of NaOCI/Biopure MTAD versus NaOCI/EDTA against Enterococcus faecalis. J Endod 2006;32:652–5.

22. Wu MK, Wesselink PR. Efficacy of three techniques in cleaning the apical portion ofcurved root canals. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;79:492– 6.

23. Card SJ, Sigurdsson A, Orstavik D, Trope M. The effectiveness of increased apical enlargement in reducing intracanal bacteria. J Endod 2002; 28:779–83.

24. Rollison S, Barnett F, Stevens RH. Efficacy of bacterial removal from instrumented root canals in vitro related to instrumentation technique and size. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;94:366–71.

25. Chow TW. Mechanical effectiveness of root canal irrigation. J Endod 1983;9:475–9.

26. Moorer WR, Wesselink PR. Factors promoting the tissue dissolving capability of sodium hypochlorite. Int Endod J 1982;15:187-96.

27. Van der Sluis WM, Gambarini G, 2, Wu MK, Wesselink PR. The influence of volume, type of irrigant and flushing method on removing artificially placed dentine debris from the apical root canal during passive ultrasonic irrigation. Int Endod J 2006;39:472-76.



The Gingival Crevicular Fluid Levels of IL-1β, IL-6 and TNF-α in Late Adult Rats Filiz ACUN KAYA1, Seher GÜNDÜZ ARSLAN2, Can Ayhan KAYA3, Hüseyin ARSLAN4, Orhan HAMAMCI5 1 Associate Professor, Dicle University, Faculty of Dentistry, Deparment of Periodontology, Diyarbakır, Turkey. 2 Associate Professor, Dicle University, Faculty of Dentistry, Deparment of Orthodontics, Diyarbakır, Turkey. 3 Dr, PhD, Meat and Fish Corporation, Department of Veterinary Diyarbakır,Turkey 4Associate Professor, Dicle University, Faculty of Medicine, Deparment of Orthopedics and Traumatology, Diyarbakır, Turkey. 5 Professor, Dicle University Faculty of Dentistry, Deparment of Orthodontics, Diyarbakır, Turkey. Key Words Orthodontic tooth movement, gingival crevicular fluid, IL-1β, IL-6,TNF-α,late adult rat. Correspondence: Filiz ACUN KAYA, Associate Professor, Dicle University, Faculty of Dentistry, Department of Periodontology, 21280 Diyarbakır, Turkey e-mail: [email protected]

Abstract Aim: To evaluate the levels of interleukin1β (IL-1β), interleukin 6 (IL-6) and tumor necrosis factor alpha (TNF-α) in the samples of gingival crevicular fluid (GCF) taken from the late adult rats during the orthodontic tooth movement and to evaluate the responses to orthodontic treatment . Methodology: In experiment 19 adult (120 days) Spraque-Dawley rats were used. Approximately 15 g force applying open coil spring was applied actively between the upper incisors of the rats. Before and after the activation on the 3rd and 7th and 10th days GCF samples were taken from the vestibular surfaces of appliance fixed teeth using periopaper®. Then the samples were biochemically analyzed. For the statistical analysis of working days of each cytokines repetitive variance analysis technique was used. Results: The levels of IL-1β, IL-6 and TNF-α were the highest in the 3rd day and started to decrease on the 7th and 10th days. Conclusions: The cytokine levels of orthodontic force applied teeth in late adult rats are compatible with the levels of studies in young rats. (Int Dent Res 2011;1:7-12)

Introduction

Although a tremendous increase in the demand for adult orthodontic therapy was seen in the past decades, our knowledge on the efficiency of adult tooth movement through the alveolar bone in adults is indeed possible by means of treatments modalities based on experiences in adolescent. However, certain treatments seem to be more time-consuming in adult than juvenile patients. This Goz to the conclusion that, in adults, the biological possibilities

for tooth movement are decreased to about one-third of those found in children (1).

Orthodontic tooth movement is based on forceinduced periodontal ligament (PDL) and alveolar bone remodeling. Mechanical stimuli exerted on a tooth cause an inflammatory response in the periodontal tissues. Inflammatory mediators are released that trigger the biological processes associated with alveolar bone resorption and apposition (2-4).

It was suggested that the presence of neuroimmune interactions may be of importance in

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reactive, and its metabolism slows (25, 26). Another possible cause might be the use of inappropriate stimuli, because the biological requirements for inducing optimal tissue responses in young and adult invidiuals may different (27).Concerning the age effect on bone activity, there is evidence that bone formative activity of osteoblasts and bone-resorptive activity of osteoblast decrease with age (28, 29), but also, in adults, these cell may recover a higly activated state under orthodontic stimuli (30). This ractivation in adults, however, may take more than in jüveniles.

The few experimental studies on age effects on orthodontic tooth movement have been performed in rats. Some of them indicate that tooth movement occurs at higer rates and over agreater distance in young than in adult rats (31—33) while others (26, 34) found similiar osteoblastic and osteoclastic activity during orthodontic tooth movement in young and adults rats (30, 34). By thinking the results of these studies;in our study no experimental groups in which young rats took place were performed. We thought that this study plan was much more suitable for the ethics of animal studies.Because of this reason, our findings were compared with the results of the studies performed in young rats.

The testing site in this study was the gingival sulcus, because its access in the oral cavity is easy and it has a continuity with the PDL. In rats GCF studies micropipettes were used (35). But we used paper strips that are used frequently in human studies.The reason of choosing this method was that it was more practical and to understand whether this technique can be used in rats.

The maxillary incisive teeths of all patients were monitored because these teeth are accessible. It has been shown that levels of biochemical markers in the GCF might depend on different collection sites (36, 37). For this reason, the incisives were used as both test and control teeth. The control data, collected at the baselines, were obtained before any force was applied. The continuous eruption of the mandibular incisors was bloced, and the incisors werw shortened and abrased to some degree during the experiment.

Iwasaki et al (38) reported that IL-1β levels fluctuated with a 28-day cycle when a continuous orthodontic force was applied. In the early stages of orthodontic force application it has been shown that many PDL cells stain positively for IL-1β.10 Also, Lynch et al (15) reported that in the early stages of tooth movement (12 and 24 hours) many PDL cell types stained positively for IL-1β. Lowney et al (12) demonstrated that TNF-α plays a pivotal part in the assessment of orthodontic tooth movement.

Tzannetou et al (18) used low and high forces to the maxillary molars to expand the palate. Low forces were produced by separator placement and

higher forces by a palatal expansion device. They observed high levels of IL-1β levels with both the force levels. Also, Lee et al (39) demonstrated that the mean concentrations of IL-1β increase in the first 24 hours after continuous and interrupted forces. All these studies examined GCF in short time periods as compared with this study. They found that especially in the first 24 hours, cytokine levels increased and then equilibrium is reached, which is higher than the baseline levels.

King et al (40) described an early phase of bone resorption (3–5 days), its reversal (5–7 days), and a late phase (7–14 days) of bone deposition. A similar bone cycle has also been reported in humans (41, 42) but in humans this timing seems to be longer than in rats. In our study the aim was to evaluate the early ctokine levels and because of this the working period was limited to 10 days.

The experimental tooth movement leads to significantly increased recruitment of cells that belong to the mononuclear phagocytic system, and it was suggested that the presence of neuroimmune interactions may be of importance in the initial inflammatory response and regenerative processes of the PDLs that are incident to orthodontic tooth movement (43). The macrophage has the ability to produce cytokines, such as IL-1β and IL-6, the levels of which are known to increase during orthodontic tooth movement (44). IL-1β may act synergistically with TNF-α (45) and be a powerful inducer of IL-6 (46, 47). IL-1β, IL-6 and TNF-α were suggested to stimulate bone resorption and bone-cell replication (48, 49)

In our experiment, the maximal level was detected on day 3 after the application of orthodontic force. The decreased number of IL-1β, IL-6 and TNF-α on days 7 and 10.The spring did not require reactivation during the experiment. This fact may explain the reason that IL-1β, IL-6 and TNF-α levels were decreased at 7 and 10 days.

Conclusions

The results of this study support the hypothesis

that proinflammatory cytokines play a potent role in bone resorption after the application of orthodontic force. The changes in the cytokine levels supports the results of the studies which state that the young and adult rats have similar osteoblastic and osteoclastic activity during orthodontic movement. Also, in our study it was shown that the periopaper® can be used to obtain GCF in rats.

Acun Kaya et al. Levels of IL-1β,IL-6 and TNF-α in Late Adult Rats


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Comparing MTA and Ketac Molar Easymix for Furcation Perforation Repair using a Volumetric Method Sadullah KAYA1, Selengül GANİDAĞLI AYAZ2, Mehmet Sinan DOĞAN3, Haluk AYDIN4

1 Dicle University, Faculty of Dentistry, Department of Operative Dentistry and Endodontics, Diyarbakir, Turkey 2 Dicle University, Faculty of Dentistry, Department of Operative Dentistry and Endodontics, Diyarbakir, Turkey 3 Dicle University, Faculty of Dentistry, Department of Pediatric Dentistry, Diyarbakir, Turkey 4 Dicle University, Science and Arts Faculty, Department of Chemistry, Diyarbakir, Turkey Key Words MTA, Ketac Molar Easymix, volume measurement method, methylene blue. Correspondence: Sadullah KAYA Dicle University, Faculty of Dentistry, Department of Operative Dentistry and Endodontics, 21280, Diyarbakir, TURKEY. e-mail: [email protected]

Abstract Aim: We compared the ability of mineral trioxide aggregate (MTA) and Ketac Molar Easymix (KM) to repair furcal perforations in extracted human molars, based on the volume of methylene blue dye penetration. Methodology: In total, 44 human mandibular molars were divided randomly into two (n = 20 each) experimental groups, with two teeth used as positive controls and two teeth without perforations used as negative controls. Group 1 was repaired with MTA and group 2 with Ketac Molar Easymix. The volumetric determination of dye penetration was based on the molecular characteristics of methylene blue. The standard area of a methylene blue particle is known and the surface area can be calculated. We converted the dye penetration area into a volume and performed quantitative analyses. Results: Volume measurement using the dye penetration method showed that KM resulted in more microleakage than MTA (p < 0.05). Conclusions: Mineral trioxide aggregate resulted in significantly less dye leakage than Ketac Molar Easymix using a volumetric measurement method. (Int Dent Res 2011;1:13-17)

Introduction

Perforations of teeth are procedural accidents that can have adverse effects on the success of endodontic treatment. The etiology of dental perforations includes deep caries, resorption, or iatrogenic factors. Regardless of the cause, a perforation allows microorganisms to invade the supporting structures, triggering inflammation and a loss of attachment, which may ultimately compromise the prognosis of the tooth (1, 2). In a literature review, Alhadainy (3) stated the ideal features of a perforation repair material: it should be biocompatible, non-toxic, radiopaque, non-resorbable, and bacteriostatic, and have excellent

sealing qualities. Additionally, the repair material should be esthetically pleasing. Mineral trioxide aggregate (MTA) is used for furcation repair, resorption treatment, pulpotomy procedures, and capping pulps with reversible pulpitis (4-6). However, one major disadvantages of using MTA is its long setting time (7).

Glass ionomer cements are popular in restorative dentistry because of their esthetic properties. Clinical studies have provided evidence of the effectiveness of Ketac Molar as a restorative (8). The adhesion of Ketac Molar Easymix (KM) to dental tissue relies primarily on a chemical interaction and to a lesser extent on micromechanical interlocking (9). Several leakage models have been used to assess the ability of

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penetration, fluid filtration, and bacterial leakage models (14); there are advantages and disadvantages to each. In this study, we used a volume measurement method. Comparing the volume measurement method with fluid filtration and dye extraction methods, the former technique has the advantages of a shorter time requirement, greater accuracy, changes that are not simply dependent on spectrophotometric readings, and the ability to calculate small volume using devices that are standard equipment in most laboratories. Additionally, the volumetric measurement method gives quantitative results. The materials used are important and may affect the study results. MTA (17), amalgam (23), calcium hydroxide (24), and glass ionomer cements (17, 25) are among the materials that have been tested for repairing furcation perforations. The quality of the repairs demonstrates the difficulty in repairing furcal perforations. Many factors can affect the repair, including the technique used, the material chosen, the physician’s ability, the clinical conditions, and the biocompatibility of the repair material (17, 26). Our found a significant (p < 0.05) difference between the MTA and KM groups.

Any material or technique may have particular features that must be considered with its clinical use. MTA is a fine powder, composed primarily of tricalcium silicate, tricalcium oxide, tricalcium aluminate, and silicate oxide, that forms a colloidal gel on hydration that solidifies in approximately 3 h (27). Consequently, when used as a root repair material, although there is some moisture on the external surface of the periradicular tissues, to assure proper setting, the internal aspect of the root must also be moistened using a cotton pellet.

Conclusions

Within the limitations of this study, MTA resulted in significantly less dye leakage than Ketac Molar Easymix using a volumetric measurement method. The volumetric method may be a good alternative for evaluating leakage because it includes most of the advantages of leakage studies and gives quantitative results.

References

1. American Association of Endodontists Glossary of Endodontic Terms. 2003; 7th ed; 2003.

2. Ruddle CJ. Nonsurgical Endodontic Retreatment. In Cohen S, Burns RC (eds). Pathways of the pulp, 8th ed. St Louis: Mosby Inc., 2002:917.

3. Alhadainy HA. Root perforations. A review of literature. Oral Surg Oral Med Oral Pathol 1994;78:368–74.

4. Tuna D, Olmez A. Clinical long-term evaluation of MTA as a direct pulp capping material in primary teeth. Int Endod J 2008;41:273–8.

5. Torabinejad M, Chivian N. Clinical applications of mineral trioxide aggregate. J Endod 1999;25:197–205.

6. Sarı S, Sönmez D. Internal resorption treated with mineral trioxide aggregate in a primary molar tooth: 18 month follow-up. J Endod 2006;32:69–71.

7. Islam I, Chng HK, Yap AU. Comparison of the physical and mechanical properties of MTA and Portland cement. J Endod 2006;32:193–7.

8. Taifour D, Frencken JE, Beiruti N, van't Hof MA, Truin GJ. Effectiveness of glass-ionomer (ART) and amalgam restorations in the deciduous dentition: Results after 3 years. Caries Res 2002; 36: 437-44.

9. Glasspoole EA, Erickson RL, Davidson CL. Effect of surface treatments on the bond strength of glass ionomers to enamel. Dent Mater 2002;8:454–62.

10. Camps J, Pashley D. Reliability of the dye penetration studies. J Endod 2003;29:592-4.

11. Barthel CR, Moshonov J, Shuping G, Orstavik D. Bacterial leakage versus dye leakage in obturated root canals. Int Endod J 1999;32:370-5.

12. Oliver CM, Abbott PV. Entrapped air and its effect on dye penetration of voids. Endod Dent Traumatol 1991;7:135-8.

13. Hashem AAR, Hassanien EE. ProRoot MTA, MTA-Angelus and IRM used to repair large furcation perforations: sealability study. J Endod 2008;34:59-61.

14. Hamad HA, Tordik PA, McClanahan SB. Furcation perforation repair comparing gray and white MTA: a dye extraction study. J Endod 2006;32:337–40.

15. Aydın H, Baysal G. Adsorption of acid dyes in aqueous solutions by shells of bittim (Pistacia khinju stocks), besalination. 2006;196:248-59.

16. Pathomvanich S, Edmunds DH. The sealing ability of Thermafil obtutarors assessedby four different microleakage techniques. Int Endod J 1996;29:327-34.

17. Daoudi MF, Saunders WP. In Vitro Evaluation of Furcal Perforation Repair Using Mineral Trioxide Aggregate or Resin Modified Glass Ionomer Cement with and without the Use of the Operating Microscope. J Endod. 2002;28:512-5.

18. Bryan EB, Woollard G, Mitchell WC. Nonsurgical repair of furcal perforations: a literature review. Gen Dent 1999;47:274–8.

Kaya et al. Furcation perforation and volume measurement method


19. Nakata TT, Bae KS, Baumgartner JC. Perforation repair comparing mineral trioxide aggregate and amalgam using an anaerobic bacterial leakage model. J Endod 1998;24:184–6.

20. Hardy I, Liewehr FR, Joyce AP, Agee K, Pashley DH. Sealing ability of One-Up Bond and MTA with and without a secondary seal as furcation perforation repair materials. J Endod 2004;30:658–61.

21. Hashem AA, Hassanien EE, ProRoot MTA. MTA-Angelus and IRM used to repair large furcation perforations: sealability study. J Endod 2008;34:59–61.

22. Pace R ,Giuliani V, Pagavino G. Mineral Trioxide Aggregate as Repair Material for Furcal Perforation: Case Series. J Endod 2008;34:1130–3.

23. Grossman LI. The management of accidents encountered in endodontic practice. Dent Clin North Am 1957;2:11.

24. lmura N, Mie Otani S, Hata G, Toda T, Zuolo ML. Sealing ability of composite resin placed over calcium hydroxide an calcium sulphate plugs in the repair furcation perforation in mandibular molars: a study in vitro. Int Endod J 1998;31:79-84.

25. Fuss Z, Szajkis S, Tagger M. Periodontal response to glass ionomer cement in treatment of furcation perforations in dogs. J Dent Res 1992;71:1031.

26. Nicholls E. Treatment of traumatic perforations of the pulp cavity. Oral Surg Oral Med Oral Pathol 1962;15:603–12.

27. Nicholls E. Treatment of traumatic perforations of the pulp cavity. Oral Surg Oral Med Oral Pathol 1962;15:603–12.

Review Article Int Dent Res 2011;1:18-25


A Literature Review of Self Adjusting File Özkan ADIGÜZEL Assistant Professor, Dicle University, Faculty of Dentistry, Department of Operative Dentistry and Endodontics, Diyarbakır, TURKEY Key Words Self-adjusting file, new rotary file, nickel-titanium, endodontic files Correspondence: Ozkan ADIGUZEL Dicle University, Faculty of Dentistry, Department of Operative Dentistry and Endodontics, 21280, Diyarbakir, TURKEY. e-mail: [email protected]

Abstract

A primary aim of root canal treatment is to completely clean and shape the root canal system. Various instruments are available for endodontic instruemntation. Although rotary systems do prepare many canals without major procedural errors, they do not address canal types with long-oval or flat cross sections. A newly developed self-adjusting file (SAF) was designed to address the shortcomings of traditional rotary files by adjusting itself to the canal cross section. This instrument consists of a compressible opened NiTi tube that, on placement into a root canal, will exert pressure against the canal Wall. The SAF is used in an in-and-out motion powered by a handpiece and under constant irrigation.

The aim of this review was to describe instrument design, usage parameters and features of Self Adjusting File. (Int Dent Res 2011;1:18-25)

Introduction

The cleaning and shaping of the root canal

system is an important objective of root canal treatment (1,2). Original root canal path should be maintained and the root canal wall dentin should be cut circumferentially so that prepared root canal wall outline reflects the original outline (1). The goal of instrumentation is to provide a continuously tapered preparation that maintains original root canal anatomy, keeping the foramen without any ledge and transportation from the original canal curvature (3,4).

A variety of instruments are available for the root canal instrumentation. For many years, hand files are the most commonly used for endodontic instruments (5). Traditionally, this group of instruments has been manufactured from stainless steel and comprises two basic designs, the K-type instruments (K-files and K-reamers) and the Hedstrom file (5, 6). Although almost all these instruments were designed between many years

ago, important changes have introduced in recent years with regard to their quality, efficacy, and standardization (7). Nickel-titanium instruments for manuel and rotary use have been developed during the last decade (8). It was introduced to facilitate root canal instrumentation (8).

Nickel-Titanium Rotary Instruments Since the early 1990s, several endodontic

instrument systems manufactured from nickel-titanium have been introduced into endodontic clinic practice. The specific design characteristics vary, such as tip sizing, taper, cross section, helix angle, and pitch. To date, several devices and methods have been used to perform endodontic treatment. The specific design characteristics vary, such as tip sizing, taper, helix angle, cross section (Fig. 1) (9), and pitch. New designs continually are produced (9).

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During the operating procedure, the SAF is

inserted into the root canal while vibrating and is meticulously pushed in until it reaches the measured working length. The SAF file is operated in two cycles of 2 minutes each for a total of 4 minutes per canal. It is performed with in-and-out manual motion and with continuous irrigation VATEA Irrigation Device, in this way allowing continuous fresh irrigant to be present in the canal during the procedure. This procedure is reported to remove a uniform dentin layer 60- to 75-mm thick from the root canal circumference. The SAF is removed from the canal for inspection after each cycle. Each SAF file is designed and recommended for single use (14).

During the first minute of each cycle of 2 minutes, sodium hypochlorite (3%) is used as the root canal irrigant and EDTA (17%) is used during the second minute. The flow rate of the irrigants set at 5 mL/min, resulting in a total volume of 10 mL of each irrigant used during the procedure with additional activation of the irrigant by its vibrating motion. After two cycles, an additional irrigation with EDTA (17%) is used for 0.5 minutes with the vibrational mechanism turned off followed by a final short flush with sodium hypochlorite (3%, 5 mL) to remove the remaining EDTA (14).

Mechanical Analysis of SAF

Compressibility of the SAF force applied as a

result of compression, surface roughness, abrasivity test, durability (torque test, ada cyclic fatigue test, free buckling fatigue test, functional fatigue-to-failure test), SAF degradation as a function of working time and irrigation experiments mechanical analysis tests were conducted as previously reported by Hof et al.(15). It can be summarized as follows (15):

a. The SAF file may be elastically

compressed considerably from a diameter of 1.5 mm to dimensions resembling those of an ISO # 20 K-file because of the special design of the file.

b. The SAF file creates circumferential force when initially compressed.

c. The rough surface, combined with the force and the in-and out vibrational mechanism, allows for the removal of dentin by filing.

d. The circumferential force and the ability to remove dentin decreases as the diameter of the canal enlarges.

e. If the file is reused, the ability to remove dentin declines.

f. The SAF file is mechanically durable for continuous operation for 29 minutes.

g. SAF application does not push the irrigant beyond the apical foramen.

Removal of the Smear Layer in the Apical Part of the Canal

Debridement of the root canal system is important for endodontic success (16). Irrigants must be brought into direct contact with the entire root canal wall for optimal effectiveness and it was reported that enhancement of the flushing action is essential to improve root canal cleanliness (17, 18). As with any endodontic instrument, the SAF produces a smear layer on the root canal walls (19). This layer should be removed in order to provide the penetration of intracanal disinfectant into the dentinal tubules and also the complete adaptation of obturation materials to the dentin walls (17). Although sodium hypochlorite has been recommended as the main irrigant, it can not dissolve inorganic dentin particles (17). Irrigation with NaOCl in association with a chelating agent such as ethylenediaminetetraaceticacid (EDTA) citric acid have been recommended in endodontic therapy (17). Studies have shown that debris can remain in the root canal system after instrumentation and irrigation. However, scanning electron microscopic studies show that the removal of the smear layer and debris in the apical third of the root canal using either a syringe and a needle or a chelating agent leaves much to be desired (19). It was reported that when 3% sodium hypochlorite and 17% EDTA were used as irrigants with the SAF file, the root canal wall (including its apical third) was rendered clean of debris and the smear layer (19). It might be attributed to effective continuous substitute of the chelator in the apical third and to the mechanical vibrating action of the SAF in this region (14).

Root Canal Obturation of SAF-

prepared root canals

Obturation of the root canal system has been performed using various techniques. Obturation of SAF-prepared root canals might be possible done by any of the obturation methods. Obturation using lateral compaction using chloroform-dipped customized master cones is reported. This technique has the advantage of providing visualize the shape of the SAF-treated root canals (14). Metzger et al reported that the self-adjusting files showed better

Self-Adjusting File - Review Adıgüzel


cleaning and shaping and better adaptation of the root canal filling material (20).

Clinical Use A series cases with SAF treatment have been

completed according to protocol as described by Metzger et al (14). It was reported in more than 100 clinical cases without any file seperation (14).

Conclusions The usage new concept of rotary nickel-

titanium files adds a new quality to root canal preparation. SAF operated with continous flow of irrigation results in debris and smear free in most of the root canal walls. The SAF represents a new approach in endodontic rotary file design and operation. It contributes greatly to endodontic armamentarium. Its main features are as follows (14, 15, 19):

1. The SAF file is different from any nickel-

titanium rotary file. It is claimed to adapt itself three-dimensionally to the shape of the root canal, including to adapt to its cross-section

2. One file is used during the procedure. 3. Canal straightening and canal transportation

of curved canals are largely denied because of the lack of a rigid metal core.

4. High mechanical durability overcomes the mechanical failure of nickel-titanium instruments.

5. Hollow and flexible design allows continuous irrigation with constant refreshment of the irrigant throughout the procedure.

6. SAF file generates circumferential force. 7. It tends to keep the apical part of curved

canals closer to its original location with no zipping. 8. SAF application with continuous irrigation

does not push the irrigant beyond the apical foramen.

References

1. Baugh D, Wallace J. The Role of Apical Instrumentation in Root Canal Treatment: A Review of the Literature J Endod, 2005;31(5):333-340

2. Bartha T, Kalwitzki M, Löst C, Weiger R. Extended apical enlargement with hand files versus rotary NiTi files. Part II. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006 Nov;102(5):692-7.

3. Carvalho LA,, Bonetti I, Aurelio M, Borges G. A comparison of molar root canal preparation using stainless-steel and nickel-titanium instruments. Journal of Endodontics, 1999;25(12):807-10

4. Matwychuk M, Bowles W, McClanahan S, Hodges J, Pesun I. Shaping abilities of two different engine-driven rotary nickel titanium systems or stainless steel balanced-force technique in mandibular molars. J Endod. 2007;33:868–871.

5. Walton RE, Torabinejad M. Principles and Practice of Endodontics. 2nd ed. Philadelphia, PA: Saunders; 1996.

6. Wein FS. Endodontic Therapy. 5th ed. St Louis, MO: Mosby; 1996.

7. Leif Tronstad. Clinical Endodontics, A Textbook.. 2nd ed. Thieme, New York; 2003.

8. Yoshimine Y, Ono M, Akamine A. The shaping effects of three nickel-titanium rotary instruments in simulated S-Shaped canals. J Endod 2005;31:373-5.

9. Hargreaves KM, Cohen S. Patways of the pulp. 6th ed. Mosby, 2006.

10. Wu M-K, Wesselink PR. A primary observation on the preparation and obturation in oval canals. Int Endod J 2001;34:137–41.

11. Yao JH, Schwartz SA, Beeson TJ. Cyclic fatigue of three types of rotary nickel-titanium files in a dynamic model. J Endod 2006;32:55–7.

12. Peters OA, Paque F. Current developments in rotary root canal instrument technology and clinical use: a review. Quintessence Int. 2010 Jun;41(6):479-88. Review.

13. Ersev H, Yılmaz B, Çiftçioğlu E, Özkarslı ŞF. A comparison of the shaping effects of 5 nickel-titanium rotary instruments in simulated S-shaped canals. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109:e86-e93

14. 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. J Endod 2010;36:679–90.

15. Hof R, Perevalov V, Eltanani M, Zary R, Metzger Z. The self-adjusting file (Saf). Part 2: mechanical analysis. J Endod 2010;36:691–96.Sdf

16. Siqueira JF Jr, Rocas IN. Clinical implications and microbiology of bacterial persistence after treatment procedures. J Endod 2008;34:1291–301.

17. Zehnder M. Root canal irrigants. J Endod 2006;32:389–98.

18. Rödig T, Döllmann S, Konietschke F, Drebenstedt S, Hülsmann M. Effectiveness of different irrigant agitation techniques on debris and smear layer removal in curved root canals: a scanning electron microscopy study. J Endod. 2010;36(12):1983-7.

19. Metzger Z, Teperovich E, Cohen R, et al. The Self-adjusting File (SAF). Part 3: Removal of

Adıgüzel Self-Adjusting File - Review


Debris and Smear Layer—A Scanning Electron Microscope Study. J Endod 2010;36:697–702.

20. Metzger Z, Zary R, Cohen R, Teperovich E, Paqué F.The quality of root canal preparation and root canal obturation in canals treated with rotary versus self-adjusting files: a three-dimensional micro-computed tomographic study. J Endod. 2010;36(9):1569-73.



Contemporary Permanent Luting Agents Used in Dentistry: A Literature Review Ebru SÜMER1, Yalçın DEĞER2 1 Assistant, Dicle University, Faculty of Dentistry, Department of Prosthodontics, Diyarbakır, TURKEY 2 Assist. Prof., Dicle University, Faculty of Dentistry, Department of Prosthodontics, Diyarbakır, TURKEY

Key Words Dental cements, luting agents, adhesive resin cement, resin modified glass ionomer cement. Correspondence: Ebru SÜMER Dicle University, Dental Faculty, Department of Prosthodontics, 21280 Diyarbakir, Turkey e-mail: [email protected]

Abstract

Dental cements are widely used in dentistry. Base material, temporary filling material and luting agents can all have different clinical applications. Different types of cement have also been developed for various orthodontic and endodontic treatments.

In literature it is still argued that there is not ideal cement answering all purposes yet, so different materials are required for the comprehensive patient treatments and it is not always that easy to make the best choice.

The aim of this article is to provide a clinically relevant discussion of contemporary permanent luting agents, in order to enhance the dentist’s ability to make proper cementation choices and application. (Int Dent Res 2011;1:26-31)

Introduction

Dental cements are widely used in dentistry. They can all have different clinical uses in dentistry. Cements can be used as base material, temporary filling material and luting. There are also different types of cements developed to be used in orthodontic and endodontic treatments (1).

Cements used as base material protect pulp from thermal, electrical and chemical effects (1, 2). Cements are used as temporary filling material cover the cavity hermetically and protect the tooth from external effects till the next clinic seance. Luting cements are used in adapting the tooth to indirect restorations prepared out of mouth (2). Luting agents may be permanent or temporary, depending on their physical properties and the planned longevity of the restoration (3).

In literature it is still argued that there is not ideal cement answering all purposes yet, so different materials are required for the comprehensive patient treatment and it is not always that easy to make the best choice (4).

Zinc phosphate, zinc oxide eugenol and silicophosphate cements were used from the early twentieth century till 1970s when new cements were developed. At first polycarboxylate cement, next glass ionomer cements and within the last thirty years resin cements and resin modified glass ionomer cements were developed (5).

Qualities of Ideal Cement

Basic mechanical, biological, and handling requirements must be met by the cement (2, 3, 6, 7):

1. It should be well adapted to living dental tissues, it should contain no pulp irritating toxic material and it should further have anticariogenic qualities,

2. It should have very low resolution ratios within the liquids inside the mouth,

3. In order to reach the smallest details between restoration and tooth, it should possess low viscosity and film thickness,

Sümer et al. Contemporary Luting Agents


4. It should be resistant against mastication forces and pulling forces formed through the effect of gummy foods,

5. It should have sufficient light transparency, 6. It should provide sufficient heat insulation to

protect living tooth from thermal effects, 7. It should give sufficient working time and be

easy to manipulate, 8. It should be able to bond to hard dental

tissues, 9. It should have a long shelf-life. Ensuring optimal resistance and retention in

tooth preparation has primary importance but still the cement should act like a barrier against microbial leakage, it should completely fill the tooth and restoration interface and protect the bond between restoration and tooth against mechanical and chemical effects (6).

All the permanent luting cements on market have these qualities to some extent, but each type of cement displays different physical attributions with respect to their own substance (3).

Retention and Bonding

Mechanical interlocking with rough surfaces on a parallel wall preparation is the principal means of retention for luting cement, regardless of chemical composition (3). Luting mechanisms of cements are three types; chemical, mechanical and micromechanical. Retention of restoration is obtained, depending on the quality of applied cement, through combining two or three of these mechanisms (8).

Classification

Cements are mostly in the form of powder and liquid and their setting reaction is an acid-base reaction. Liquid acts like acid and powder acts like base. Aside from resin cements composed after polymerization of macromolecules, these cements that are set through acid-base reaction are classified as acid-base cements (AB Cements) (3).

The literature varies considerably on the classification and discussion of cements. Craig followed a traditional classification that grouped cements with respect to their chief ingredients (ie, zinc phosphate, zinc silicophosphate, zinc oxide-eugenol, zinc polyacrylate, glass-ionomer and resin), whereas O’Brien classified dental cements by matrix bond type (ie, phosphate, phenolate, polycarboxylate, resin and resin modified glass ionomer). Donovan simply divided cements into conventional (zinc phosphate, polycarboxylate, glass-ionomer) and contemporary (resin-modified glass-ionomers, resin) based on knowledge and experience using these materials (Table 1) (1, 3).

CONTEMPORARY PERMANENT LUTING AGENTS

Resin Modified

Glass Ionomer Cements Despite the positive aspects of glass ionomer

cements that have been used in dentistry since the seventies till present day, in order to improve some of their qualities and eliminate the disadvantages, resin modified glass ionomer cements (RMGIC) were developed in the late eighties by adding resin into glass ionomer cements (2,3).

Their contents are basically 80% glass ionomer cement and 20% resin and there may be some changes with respect to differences in brand. HEMA of which liquid is polymerized via light (Hydroxy ethyl methacrylate), methacrylate groups (EGMA, GMA and Bis-GMA etc.), tartaric acid, polyacrylic acid and water. Its powder however contains fluoro aluminosilicate glass particles. The qualities of resin modified glass ionomer cement are between conventional glass ionomer cements and composite resins which means RMGIC is a hybrid material (2).

The polymerization of methacrylate units in cement can start with light or chemically (6). In dual cure materials HEMA’s polymerization starts with light activation and slower progressing acid base reaction continues to better strengthen the material and increase the resistance. In tricure materials however there is a chemical indicator for HEMA and HEMA’s polymerization starts chemically, next a matrix strengthened via progressive acid-base reaction takes place (2, 9). Compared to dual cure cements, the advantages of cements with tricure setting mechanism are the extra chemical polymerization of resin and the occurrence of polymerization in the places where light cannot reach (2). In the set cement there are two matrixes within each other. One is ionic matrix formed through acid-base reaction and the other one is resin matrix (10).

These cements have compressive and diametral tensile strengths greater than zinc phosphate, polycarboxylate and some glass ionomers but less than resin composite. Their adhesion to enamel and dentin, and their fluoride release pattern is similar to glass ionomer cements (6). Due to the carboxyl groups in the polyalcenoic acid within them, RMGIC contain adhesive features (9). On that account there is no need for a bonding agent between the tooth and material (10).

Applying dentine polyacrylic acid conditioner prior to RMGIC application not only improves wettability of dental surface but it also enables

Contemporary Luting Agents Sümer et al.


hydrogen bond formation and strengthens the cement and ionic change (10).

Their abrasion resistance and fracture resistance are greater than GICs (Glass Ionomer Cements) and (20) they have better aesthetical features than GICs (2). Compared to GICs these cements are more resistant against water contamination during setting reaction and have low level of solubility. Another advantage of resin modified glass ionomer cements is their ease of mixing and use, because multiple bonding steps are not required. They also have adequately low film thickness (6).

In resin ionomer cements, moving the excess cement after cementation constitutes a great problem. Therefore soon after the primary setting reaction, unreacted materials below restoration margins need to be cleaned (3).

In these cements, resin addition has not significantly lowered dehydration resistance of glass ionomer content. Besides the most important disadvantage of resin ionomers is that due to poly-HEMA with hydrophilic character water absorption, plasticity and hygroscopic expansion are increased. Water absorption in the beginning lessens the stress during polymerization shrinkage but water absorption that continues creates a harmful effect. As it displays significant dimensional changes, these cements are not applicable to use in full ceramic feldspathic-type restorations and post cementation (6, 9).

Resin ionomers can be used in cementation of metal, metal-porcelain, crown and bridges, supporting amalgam, composite and glass ionomer cores as well as base material under composite fillings. They have different types developed for orthodontic applications as well (5, 6). Resin modified glass ionomer cements are available in the market as powder-liquid and automix capsule (5).

Polyacid Modified

Composite Resin Cements Resin addition to conventional glass ionomer

cements pioneered the development of a different group of luting cements. This group is somewhere between classical GICs and composite resins (3).

Polyacid modified composite resins were defined at the end of 1990s as a composite of (compomer) composite resin (comp) and glass ionomer (omer) (3). Physical qualities of compomers are closer to composite resins (11).

The material which at first is polymerized through light then meets water absorption in mouth and similar to chemical GICs, they set at the end of acid-base reaction (10). However since in compomers no salt matrix and hydrogel are formed (in glass ionomer cements with the effect of water

that emerges when acid-base reaction starts salt matrix containing the salts of polycarboxylic acid is formed and the surface of glass particles turns into silica hydrogel) they cannot act like fluoride reservoir hence their fluoride release is restricted (2). Without etching process, only with their unique bonding agents, they bond to the hard tissue of tooth and release fluoride to the adjacent dental tissues (10).

Their compressive and flexural resistance is greater than RMGICs but lower than composite resins. Without applying bonding agent, adhesion of compomers to tooth is limited (3). Bonding agent within sets of compomers are mostly one-phase bonding systems that combine primer and adhesive mostly in one single bottle (2).

Resin Cements

Resin cements are one type of composite consisting of resin matrix and filler inorganic particles (9). The bonding between resin matrix and fillers are created via inter phase agent. This inter phase agent consists of long chain molecule silanes of which organic silica component. That means resin cements consist of three phases that are structurally different; organic phase, inorganic phase and inter phase (10). With the lower filling structure and viscosity in their context, they differ from restorative composites (9).

In a good number of resin cements, there are glass or silica particles varying between the ratios of 20%-80% (3). Silica particles strengthen mechanical qualities of mixture, they permeate and diffuse the light (10). These fillers make it possible that cement is more resistant against compressive and tensile forces and perform low solubility (6).

With respect to filler size, composite resin cements are classified into two groups as with micro filler (about 0.04 µm) and hybrid composites (about 0.7-1.7 µm) (21). In-vitro researches analyzed the effect of filling particles inside resin cement on the physical attributions of cement. It has been detected that compared to resin cements containing hybrid type filler, resin cements with micro fillers have greater resistance against wear (22).

Biological compatibility and physical qualities of resin cements do not only depend on the quality and quantity of varying polymer and inorganic materials inside, but they are also closely related to the curing mechanism of resin (12).

Resin cements can be activated chemically or via visible light or by both chemical and light (dual cure). They have a variety of types in different colors and opacities (6). Amongst them the most ideal one is, with respect to polymerization conditions, light + chemical curing system (18). Resin cements that are chemically polymerized have been produced in double paste system or in the form of powder-liquid. Polymerization starts



chemically by mixing two components. In paste system, in one of the paste there is benzoyl peroxide initiating polymerization and in the other one there is tertiary amine speeding up polymerization. Resin cements that are polymerized with light have been produced in single paste system. In these cements, as light absorber, there is camphorquinone and as accelerator there is aliphatic amine. Dual cured resin cements have been produced as two paste or in powder-liquid form. In their structure there is both a polymerization starter (camphorquinone) and chemical activator components (peroxytamine) (10).

Due to their chemical structures they provide adhesion with tooth tissues. The bonding of resin to enamel is achieved through micromechanical interlocking of resin to hydroxyapatite crystals and acidic enamel prisms. Bonding to dentin is however more complex; it is achieved through penetration of hydrophilic monomers to partially demineralized apatite structure of etched dentin. Hence adhesion is created via micromechanical interlocking of resin to hybrid layer or resin diffusion zone (6, 9).

Bonding to dentin requires multiple phases. Since total etching systems frequently cause postoperative sensitivity, less invasive self etching systems have been developed. Through the application of self etching systems, the number procedures to follow decreases (13, 22).

Polymerization shrinkage of resin cements may bring about invasive stresses in the tooth and restoration interface. If thin cement layer cannot stand high stresses, there may be a break in bonding. By applying dentin bonding agents a hermetic cover is created between resin and tooth structure, postoperative sensitivity is prevented and adhesion is strengthened (13).

Resin cements chemically bond to etched, silane-treated porcelain. One part of resin cements is bonded to the surface of prepared tooth and one part is bonded to etched and silane-treated porcelain so the stress on tooth is diffused. Based on a good number of laboratory and clinical researches, it can be suggested that resin cements are the best choice for the cementation of full ceramic restorations (3, 9). Furthermore resin cements can form a better bonding with metal alloys sanded via micromechanical retention (6).

Certain resin cements contain ytterbium trifluoride and can make some amount of fluoride releasing. Some, on the other hand contain fluorosilicate fillers. Still resin cements lack any fluoride releases with significant level (6). Film thickness may be relatively greater than the other cements. Pulpal biocompatibility however may be particularly problematic in deep penetrations. Resin cements necessitate more sensitive techniques than

conventional cements and they have higher costs (3).

In situations where there is no optimal retention and resistance in preparation, resin cements are more useful than conventional cements (6). Particularly in cementation of full ceramic crown restorations or metal-fused restorations prepared for conic cut or short clinic crown long tooth surfaces, resin-based luting cements are preferred more and these cements are advantageous in the other undesired geometric configurations as well (14).

The ability of luting multiple structures together, high resistance, less solubility inside mouth, and color options make resin cements an alternative cement in luting aesthetical restorations (6,19). They can be used in cementation of composite inlays and onlays, full ceramic inlays and onlays, veneers, crowns, bridges and fiber-forced restorations. Resin cements that are polymerized chemically are recommended for the cementation of resin bonded bridges (Maryland type) (6) and ceramic crowns inhibiting light penetration (10). Resin cements that are polymerized via light are used in luting ceramic or composite laminates that allows full penetration of visible light, with thickness less than 1,5-2 mm and having translucent structure (10).

Dual cured resin cements are used in restorations where restoration is translucent only enough to allow the penetration of little light but with a thickness (more than 1,5-2 mm) that does not allow polymerization with light only (10).

Adhesive Resin Cements

Today many of the resins that are termed as adhesive are not actually with adhesive attributions. Only adhesive resins with monomers containing 4-META and MDP have adhesive quality (9).

In the early 1980s, conventional Bis-GMA resin cement was modified by adding a phosphate ester to the monomer component, introducing to dentistry a unique group of resin luting agents that have a degree of chemical bonding as well as a micromechanical bonding to tooth structure and base metal alloys. The first product marketed, Panavia, contained the bifunctional adhesive monomer MDP (10-methacryloyloxydecyl dihydrogen phosphate) and was a powder-liquid system (3). Bond strength to etched base metal greatly exceeded that to tooth and Panavia quickly became the luting agent of choice for resin retained fixed partial dentures (3).

In 1994, Panavia was modified to include a dentin/enamel primer containing hydroxethyl methacrylate (HEMA), N-methacryloyl 5-aminosalicylic acid and MDP, intended to improve bond strength to dentin. Under a new name, Panavia 21, it was marketed as a two-paste system

Contemporary Luting Agents Sümer et al.


that offered three shades: tooth colored (TC, translucent), white (EX, semitranslucent), and opaque (OP). Panavia 21’s polymerization required exclusion of oxygen, and a covering gel was provided. The current product, Panavia F is a two-paste system that is dual-cured, self-etching and self-adhesive, plus fluoride-releasing (3).

Before the introduction of Panavia, Bis-GMA composite was modified by decreasing filler and adding %3 2-hydroxy-3b-napthoxypropyl methacrylate in methyl methacrylate with 4-methacryloyloxyethyl trimellitate anhydride (4-META) and tri-n-butyl borane and marketed as C&B Metabond (3). C&B Metabond has physical characteristics similar to other resin cements, but also has an extremely high tensile strength, which is useful for providing retention in restorative situations where less than optimal conditions exist.

It is a powder/liquid auto-curing system and may be used for resin bonded prostheses (23).

Panavia and C&B Metabond represent several available unique adhesive resin luting agents of various compositions that can help provide adequate retention for crowns and prostheses where less than ideal retention exists (3). The strong cohesion forces in the specific net structure of adhesive resin allow a better stress distribution on the surface of restored tooth (10).

These materials are usually expensive and demand sensitive technique, difficult to clean up when set, and they have no long shelf lives (6, 17).

Table 1. Varieties of contemporary permanent luting agents

Cement Type Product Company (Location)

Resin Modified Glass

Ionomer Luting Cement

Vitremer Luting Cement 3M Dental Products, USA

Fuji Plus GC Dental Industrial Corp, USA

Fuji II LC GC Dental Industrial Corp, USA

Fuji Ortho LC GC Dental Industrial Corp, USA

Photac Fil 3M ESPE, USA

Photac Bond 3M ESPE, USA

Pro Tec Cem Ivoclar, Vivadent, Liechtenstein

Polyacid Modified

Composite Resin Cement Dyract CEM plus Dentsply, USA

Resin Cement

Variolink II Ivoclar, Vivadent, Liechtenstein

Ultra-Bond Plus Resin Cement Den-Mat, Santa Maria

Duo-Link Bisco, USA

C&B Cement Bisco, USA

Adhesive Resin Cement

RelyX Unicem 3M ESPE, USA

RelyX U100 3M ESPE, USA

RelyX ARC 3M ESPE, USA

Panavia F 2.0 Kuraray, Japan

Panavia 21 Kuraray, Japan

C&B Metabond Parkell, USA

Clearfil SA Cement Kuraray, Japan



Conclusion

Restorative dentistry has been going through continuous changes as an outcome of clinical applications and development of new materials. Modern dentistry have a wide variety of application products differing from each other in content and physical attributions (5, 8). Therefore it may pose difficulty for dentists to make a choice amongst so many alternative products (15).

Presently there is a rapid development in aesthetical restorative materials and adhesive systems enabling these materials to bond on tooth (18).

Modern dentistry services which can no longer be provided through conventional water based luting cements have become diversified due to the advantages of adhesive techniques (10).

A 2001 survey indicated that many clinicians are now exclusively using newer resin-modified glass-ionomer and resin luting materials based primarily on ease of use, reasonable retention, and low to no postoperative sensitivity (3). However conventional cementation and adhesive cementation are, let alone being conflicting, complementing each other. The choice should be based on the type and design of planned restoration because none of the present products possesses all qualities of an ideal luting agent (10).

Each cement type has different physical, mechanical and biological features arising from its own chemical structure. That is why one single cement type alone is not sufficient for daily clinical applications. To achieve a clinical success, any clinician is expected to be aware of the qualities, advantages and disadvantages of each type of cement and conduct their clinical applications.

References

1. McCabe JF, Walls AWG. Applied Dental Materials.

9th edition. Oxford: Blackwell Publishing; 2008. p. 257-288.

2. Önal B.Simanlar. Restoratif Diş Hekimliğinde Maddeler ve Uygulamaları.1st edition. İzmir: Ege Üniversitesi Dişhekimliği Fakültesi Yayınları; 2004. p.1-145.

3. Hill EE. Dental cements for definitive luting: a review and practical clinical considerations. Dent Clin N Am 2007; 51:643-658.

4. Rosenstiel SF, Land MF, Crispin BJ. Dental luting agents: A review of the current literature. J Prosthet Dent 1998; 80:280-301.

5. O’Brien WJ. Dental materials and their selection. 3rd edition. Canada: Quintessence Publishing; 2002. p.132-154.

6. Diaz-Arnold AM, Vargas MA, Haselton DR. Current status of luting agents for fixed prothodontics. J Prosthet Dent 1999; 81:135-141.

7. Aydın M,Gür H.Sabit Protezlerde Simantasyon. Dişhekimliği Klinik Dergisi 1997; 10(4):239-243.

8. Pegoraro TA, Da Silva NRFA, Carvalho RM. Cements for use in esthetic dentistry. Dent Clin N Am 2007; 51:453-471.

9. Eskimez Ş, İzgi AD. Rezin Simanlar. Adeziv Köprüler ve Klinik Uygulamaları.1st edition. İstanbul: Quintessence Yayıncılık; 2008. p.149-160.

10. Zaimoğlu A, Can G. Sabit Protezler. Ankara: Ankara Üniversitesi Diş Hekimliği Fakültesi, 2004.p.239-267.

11. Guggenberger R, May R, Stefan KP. New trends in glass-ionomer chemistry. Biomaterials 1998; 19:479-483.

12. Attar N, Tam LE, McComb D. Mechanical and physical properties of contemporary dental luting agents. J Prosthet Dent 2003; 89:127-134.

13. Öztürk AN, Aykent F.Dentin Bonding Ajanlar ve Simantasyon. Cumhuriyet Üniversitesi Dişhekimliği Fakültesi Dergisi 2001;4(2):128-131.

14. Levent H, Oruç AZ. Rezin esaslı yapıştırma simanları ile yapıştırılan metal destekli kronlarda mikrosızıntının değerlendirilmesi. GÜ Dişhek Fak Derg 2004;21(1):19-22.

15. Paradella TC. Current adhesive systems in dentistry – what is being said and researched. Odontologia. Clín.-Científ., Recife 2007; 6 (4): 293-298 .

16. 16. Milutinovic-Nikolic AD, Medic VB, Vukovic ZM. Porosity of different dental luting agents. Dental Materials 2007;23:674-678.

17. Baydaş S. Kron-Köprü Protezleri. Erzurum: Özyurt Matbaacılık; 2005.p.127-133.

18. Akören AC, Üçtaşlı S. Farklı Porselen İnley Sistemleri ve Farklı Yapıştırma Simanlarının Mikrosızıntı Üzerine Etkileri. T Klin J Dental Sci 1998;4:100-105.

19. Miguel A, Macorra JC, Nevado S, Gomez J. Porosity of resin cements and resin-modified glass-ionomers. Am J Dent 2001; 14:17-21.

20. Smith DC. Development of glass-ionomer cement systems. Biomaterials 1998;19:467-478.

21. Shinkai K, Suzuki S,Katoh Y. Effect of filler size on wear resistance of resin cement. Odontology 2001;89:41-44.

22. Christensen GJ. Should resin cements be used for every cementation? Journal of ADA 2007; 138:817-819.

23. Ertuğrul HZ, Ismail YH. An in-vitro comparison of cast metal dowel retention using various luting agents and tensile loading. J Prosthet Dent 2005; 93(5):446-452.



Diagnosis and Treatment Modalities of Internal and External Cervical Root Resorptions: Review of the Literature with Case Reports Senem YİĞİT ÖZER Assistant Professor, Dicle University, Faculty of Dentistry, Department of Operative Dentistry and Endodontics, Diyarbakır, TURKEY Key Words Internal cervical root resorption, external cervical root resorption, cone beam computed tomography, CBCT, differential diagnosis, resorptive defect Correspondence: Senem YİĞİT ÖZER Dicle University, Faculty of Dentistry, Department of Operative Dentistry and Endodontics, 21280, Diyarbakir, TURKEY. e-mail: [email protected]

Abstract The clinical presentation of internal and external cervical lesions vary considerably, and detection of lesions is often made incidentally. Accurate diagnosis is the most important step of the treatment plan because these pathologies are quite different from each other concerning their treatment procedures. This paper gives a literature review of internal and external root resorptions with respect of their etiology and adresses the difference in treatment modalities. (Int Dent Res 2011;1:32-37)

Introduction

Diagnostic information directly influences

clinical decisions. Accurate data lead to better treatment-planning decisions and potentially more predictable outcomes. Cone beam computed tomography (CBCT) is an innovative technology that offers the clinician clinically relevant information that cannot be gathered from conventional radiography (1). The ability to assess an area of interest in 3 dimensions eliminates the superimposition that is inherent in conventional radiographic imaging (2). Intraoral radiography produces images that have objects superimposed upon each other. The observer has to make 3-D decisions on the basis of a 2-D film (3). CBCT technology provides the clinician with the ability to observe an area in 3 different planes (axial, sagittal, and coronal) and thus acquire 3-D information. The axial and sagittal views are of particular value, and they are not seen with conventional periapical radiography (4). The

ability to reduce or eliminate superimposition of the surrounding structures makes CBCT superior to conventional periapical radiography (5). Specific endodontic applications of CBCT are being identified as the technology becomes more prevalent. Potential endodontic applications include diagnosis of endodontic pathosis and canal morphology, assessment of pathosis of non-endodontic origin, evaluation of root fractures and trauma, analysis of external and internal root resorption and invasive cervical resorption, and presurgical planning (1).

Treatment of root resorptions (RR) can be complex and misdiagnosed. Imaging is critical to accurate diagnosis and appropriate treatment. Classically, Gartner et al (6) described the radiographic features of internal and external resorption. Off-angle radiographs have proven to be useful in differentiating these entities. The use of parallel radiographic techniques is advocated for differentiating internal from external resorption defects (6-8). A second radiograph taken at a different angle often confirms the nature of the resorptive lesion. External RRs will move in the same

Yiğit Özer Internal and External Cervical Root Resorptions


direction as the x-ray tube shift if they are lingually/palatally positioned. Conversly they will move in the opposite direction to the tube shift if they are buccally positioned. Internal RRs should remain in the same position relative to the canal in both radiographs. Radiologically, internal RRs present as a cloudy, mottled, radiopaque lesion with irregular margins as a result of the presence of metaplastic hard tissue deposits within the canal space. Differentiating internal RR from external RRs might be clinically challenging, especially if the metaplasia has occupied the entire resorptive cavity.

Diagnostic accuracy based on conventional and digital radiographic examination is limited by the fact that the images produced by these techniques only provide a 2-dimensional representation of 3-dimensional objects (8-10). In addition, the anatomic structures being imaged might be distorted (11). This might lead to misdiagnosis and incorrect treatment in the management of internal and external root resorptions.

Conventional radiography does not provide a true and full representation of the lesion. Conventional radiography is often unable to identify the true extent, location, or the portal of entry of a resorptive lesion. CBCT has been shown to help determine treatment complexity as well as aid the clinician in offering an accurate prognosis on the basis of the extent of the resorptive lesion (12). As a result, both treatment and treatment outcomes are likely to become more predictable.

Internal Root resorption Internal root resorption has been reported as

early as 1830 (13). Compared with external root resorption, internal root resorption is a relatively rare occurrence, and its etiology and pathogenesis have not been completely understood (14). Nevertheless, internal root resorption poses diagnostic concerns to the clinician because it is often confused with external cervical resorption (7, 15, 16). Incorrect diagnosis might result in inappropriate treatment in certain cases (17).

Once internal root resorption has been diagnosed, the clinician must make a decision on the prognosis of the tooth. If the tooth is deemed restorable and has a reasonable prognosis, root canal treatment is the treatment of choice. The aim of root canal treatment is to remove any remaining vital, apical tissue and the necrotic coronal portion of the pulp that might be sustaining and stimulating the resorbing cells via their blood supply, and to disinfect and obturate the root canal system (18).

Internal root resorption lesions present the endodontist with unique difficulties in the preparation and obturation of the affected tooth.

Access cavity preparation should be conservative, preserving as much tooth structure as possible, and should avoid further weakening of the already compromised tooth. In teeth with actively resorbing lesions, bleeding from the inflamed pulpal and granulation tissues might be profuse and might impair visibility during the initial stages of chemomechanical debridement. The shape of the resorption defect usually renders it inaccessible to direct mechanical instrumentation.

The primary objective of root canal treatment is to disinfect the root canal system. This is followed by obturation of the disinfected canal with an appropriate root-filling material to prevent it from reinfection. By their very nature, internal root resorption defects can be difficult to obturate adequately. To completely seal the resorptive defect, the obturation material should be flowable. Gutta-percha is the most commonly used filling material in endodontics. Gençoğlu et al (19) examined the quality of root fillings in teeth with artificially created internal resorptive cavities. They found that the Microseal (Sybron Endo, Orange, CA) and Obtura II (Spartan, Fenton, MO) thermoplastic gutta-percha techniques were significantly better in filling artificial resorptive cavities than Thermafil (Dentsply, York, PA), Soft-Core core systems (CMS Dental, Copenhagen, Denmark), and cold lateral condensation (CLC). The cold lateral compaction technique produced slightly fewer voids than Obtura II, but a larger proportion of the canal space was filled with sealer with this technique.

Goldman et al (20) also concluded that the Obtura II system performed statistically better in obturating resorptive defects than cold lateral compaction, Thermafil, and a hybrid technique. Stamos and Stamos (21) reported 2 cases of internal root resorption in which the Obtura II system was used to successfully obturate the canals. Similar results were reported by others (22).

In situations when the root wall has been perforated, mineral trioxide aggregate (MTA) should be considered the material of choiceto seal the perforation. MTA is biocompatible (23) and has been shown to be effective in repairing furcation perforations (24) and lateral root perforations (25). The material is well-tolerated by periradicular tissues and has been shown to support almost complete regeneration of the periodontium (24). In addition, MTA has superior sealing properties when compared with other materials (26). A hybrid technique might also be used to obturate canals; the canal apical to the resorption defect is obturated with gutta-percha, and then the resorption defect and associated perforation are sealed with MTA (27, 28). When internal resorption has rendered the tooth untreatable or unrestorable, extraction is the only treatment option.

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non-surgical BCT image ent plan. described a

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Yiğit Özer

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(38). Essemoval of thesulting defe

ation. Endoed in cases the root canag treatmennt to advisee treatment versus extra

e the full extually means

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2011

severity, loced the root the tooth. Ssuggested iature of theon isolatedreplantationtreating the

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). Treatmentere performecanal obturactable guttaesorptive areshowed thateatment waswas elevated,emoved, thbturated usiokyo, Japan)(34). CBCT modality.

ct similar to ton the sagittas quite differrea. Surgical

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Resorptivperiapical rat was detec(Fig. 2A). Hand accurac

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t plan was toed on basis oation would a-percha sysea to the cat the tooth s not neces, the inflame

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35

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Internal and External Cervical Root Resorptions Yiğit Özer


Discussion

The use of CBCT can be invaluable in the decision-making process. The scanned data provide the clinician with a 3-dimensional appreciation of the tooth, the resorption lesion, and the adjacent anatomy. The true nature of the lesion might be assessed, including root perforations and whether the lesion is amendable to treatment. In the same study (39), the authors concluded that there was a significantly higher prevalence in the choice of the correct treatment option when CBCT was used compared with the use of intraoral radiographs for diagnosing resorptive lesions.

Kim et al (40) analyzed a case of multiple extracanal invasive resorptions by using CT and a rapid prototyping tooth model. The use of CT was very helpful in diagnosing the exact size and location of resorption. In the serial cross-sectional views, the size and the location of resorption were clearly determined. The 3-dimensional reconstruction and the fabrication of a rapid prototyping tooth model provided a more accurate image of the resorption area. In simulated external RR, Silveira et al (41) evaluated the diagnostic performance of a CT scan table. External RR defects of different sizes and in different locations were simulated in 59 human mandibular incisors. Cavities simulating RR defects of 0.6, 1.2, or 1.8 mm in diameter and 0.3, 0.6, or 0.9 mm in depth (small, medium, and large defects) were drilled in the cervical, middle, and apical thirds of buccal surfaces. Axial CT was used to obtain cross-sectional images of the teeth, and 177 root thirds were assessed by a blinded observer. CT showed good diagnostic performance, high sensitivity, and excellent specificity in the detection of simulated external resorptions. The greatest difficulty was found in the detection of small resorptions located in the apical third of tooth roots. CBCT scans were effective to identify the presence, type, and severity of RR (42,43).

Conclusions

Cone beam computed tomography appears to be a promising diagnostic tool for confirming the presence, appreciating the true nature, and managing the internal and external root resorptions. In addition to the 2-D slices, 3-D reconstruction enables further assessment of the area of interest which enables the right treatment modality for the real pathology.

References

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9. Estrela C, Bueno MR, Leles CR, Azevedo B, Azevedo JR. Accuracy of cone beam computed tomography and panoramic radiography for the detection of apical periodontitis. J Endod 2008;34:273–9.

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13. Bell T. The anatomy, physiology, and disease of the teeth. Philadelphia, PA: Carey and Lee Publishing; 1830. 171–2.

14. Levin L, Trope M. Root resorption. In: Hargreaves KM, Goodis HE, eds. Seltzer and Bender’s dental pulp. Chicago, IL: Quintessence Publishing Co Inc; 2002:425–48.

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16. Patel S, Kanagasingham S, Pitt Ford T. External cervical resorption: a review. J Endod 2009;35:616–25.

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Case Report Int Dent Res 2011;1:38-41


A Fibre-Reinforced Fixed Partial Denture on a Hemisectioned Tooth: A Case Report Süleyman AGÜLOĞLU1, Emrah AYNA2, Eylem ÖZDEMİR1 1 Assistant Professor, Dicle University, Faculty of Dentistry, Department of Prosthetic Dentistry, Diyarbakır, TURKEY 2 Associate Professor, Dicle University, Faculty of Dentistry, Department of Prosthetic Dentistry, Diyarbakır, TURKEY Key Words Fibre-reinforced, adhesive bridge, hemisection Correspondence: Eylem ÖZDEMİR Dicle University, Faculty of Dentistry, Department of Prosthetic Dentistry, 21280, Diyarbakir, TURKEY. e-mail: [email protected]

Abstract

In modern dentistry, fibre-reinforced fixed dental prostheses are considered a useful alternative to classical metal-ceramic restorations. This method allows a conservative approach for replacing missing teeth that overcomes some of the drawbacks of conventional prostheses. Our patient required extraction of tooth #46 because of an apical lesion of the mesial root, and underwent extraction by hemisection. After healing, using the superior properties of the combined fibre/composite, an adhesive bridge restoration was applied with support from the distal root of tooth #46 and teeth #45 and #47. (Int Dent Res 2011;1:38-41)

Introduction

For many years, the only prosthetic application used to deal with cases with a single missing tooth was a fixed partial prosthesis. However, the preparation of the two teeth required for correction of a single tooth deficiency causes unnecessary tissue loss. Subsequently, implant-supported fixed prostheses have been developed as an effective solution for this situation. Inevitably, implants cannot be used in some patients because surgical intervention is contraindicated due to systemic disease or the high cost of the operation. Adhesive bridges are a good alternative, as they are less expensive than implants, they do not require surgical intervention and the loss of material from the supporting tooth is small compared to conventional bridges. With the development of fibre-strengthened composites, alternative restorations have become very popular (1-4).

Fibre-reinforced composites have good mechanical properties and their endurance/weight ratios are high compared to metal alloys. Fibre-reinforced composites have several advantages: they are translucent, unlike metals; non-corrosive, easy to repair, have good adhesive properties and it

is easy to prepare the mouth to receive them. In dentistry, glass, polyethylene and carbon fibres are mainly used as the strengthening materials for composites. Saturated fibres are used as the substructure material for a fixed partial prosthesis, whereas ceramic-reinforced restorative composites are used as the superstructure material (1-7)

Case Report

A 31-year-old male patient visited our faculty

complaining of problems with tooth #46, and an apical lesion of the mesial root was detected. Based on the results of radiography and intraoral inspections, the distal root of the tooth was deemed usable (Fig. 1A). After endodontic therapy, the tooth was hemisectioned and the mesial root was separated (Fig. 1B and Fig. 1C). Following the healing period, a mandibular impression was obtained and tooth wax was used to plan the body-gum relationship for model preparation (Fig. 1D and Fig. 1E).

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of the waxThis impreregion andthe next svisit, a rubfirst glass Japan) watooth #46length waplacing pothese wereseconds afKerr Corp.of the reswashed anMedical) wdried with the body-gthe modeClearfil SEthe cavitiepreviously with bondbetween th

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g a piece of x tooth was oession was d the compostep in procebber dam wa

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storation regnd dried. Clewas applied

slow air flogum, silicon el was placeE Bond (Kures. In additi

cut to the ding agent ahe cavities in

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e radiographroot; (D) Thpreparation;

model prepara

silicon, a suobtained (Figthen placedsites were b

essing the mas placed in (Snowpost; the remainfor strength. Cavities wbre in teeth th 35% phosethylene fibrd) was cut t

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ow. To give tpreviously p

ed over thearay Medicaon, a polyetappropriate

and placed an teeth #45 a

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ic image of the buccal de; (E) The lination; (F) Th

b-body imprg. 1F and Figd in the toouilt on top oouth. On thethe mouth, Kuraray Me

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#45 and #4sphoric acid re cord (Conso twice the e cavity was

nd primer (Kund the cavitthe ideal shaprepared on e crest andal) was applthylene fibre

e size was was a doubleand #47 suc

the tooth #4esign of thengual design he obtained i

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einforced coestorations. cience, theseears. Furtheorcelain teepposite tootave good adnd repair, anse of fibre-xed partial ecause the o the framewnd the fratiffness.

The replloy/resin-bohe rebondedn the statistncrease to 7eferred to astudies havelaced in the

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ly, adhesive omposites w

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ade with fibered temporass in mateused for manot as hard

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n resin-bondeen suggestadheres betod aestheticas physiologi

rate of meontic is 61%.re reconsiderval rate wothis has berate (5). So-bonded FPsurvival ra

) Glass fibre; (D) The pr

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orced comparing the tooe-year periodIn summarypatient is a rethe restorat

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- Altieri JV, Longitudincomposite Prosthet D

- Mudassir, YI. Padihar

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and maxillaadhesive pposite in th and achie. , although tegion used fotion will surupport from th the suppo

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Burstone CJ,al clinical evafixed partial ent. 1994 JanY.E. Aboush, r. Long-term

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, Goldberg Aaluation of fibedentures: a p

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Agüloğlu et al. Fibre-reinforced Fixed Partial Denture


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