Minimally Invasive Endodontics - A Revie · Microscope. : Minimally Invasive Endodontics, Access...

Journal of Dental & Oro-facial Research Vol. 15 Issue 02 Aug. 2019 JDOR

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Minimally Invasive Endodontics - A Review

*Arbiya Anjum S.1, Swaroop Hegde2 and Sylvia Mathew3

*Corresponding Author E-mail: [email protected]

Contributors:

1 Post Graduate Student, 2Professor

and Head, 3Professor, Department

of Conservative Dentistry and

Endodontics, Faculty of Dental

Sciences, M.S. Ramaiah University

of Applied Sciences, Bangalore -

560054

Abstract

This review compares the various methods of Minimally Invasive Treatment

approaches with Traditional approaches in Endodontics. The MEDLINE, PubMed

databases, bibliographies of all relevant articles and textbooks were searched. As

Devan once quoted “Our goal should be perpetual preservation of what remains

rather than meticulous restoration of what is missing” which is achieved by the shift

of endodontics from extension for prevention to the minimal invasion with the

systematic respect of original tissue. Preserving the integrity of tooth by following

means mentioned in this article one can achieve minimal invasion with maximum

appropriateness. Minimally invasive approach requires in-depth knowledge of Root

Canal Anatomy, Diagnosis and Decision Making, Preservation of Structural

Integrity of Tooth, Alternate Access Designs, Image Guided Endodontic Access,

Dynamically Guided Endodontic Access, Microguided Endodontic Access, Modern

Bur Designs, Cleaning and Shaping, 3D Irrigation and Disinfection, Root

Strengthening and Magnification aids like Loupes and Surgical Operative

Microscope.

Keywords: Minimally Invasive Endodontics, Access Designs, Image Guided

Endodontic Access, Dynamically Guided Endodontic Access, Microguided

Endodontic Access, Loupes and Surgical Operative Microscope

1. INTRODUCTION

With the extensive research, it is seen that it is

virtually impossible to render root canal systems

of teeth bacteria-free. The objective of root canal

treatment is eliminating microorganisms and

pathologic debris from the root canal system and

preventing reinfection1. Dr. Herbert Schielder in

1974, gave the mechanical objectives of cleaning

and shaping which would promote the success of

root canal therapy.

In the quest of eliminating the microorganisms

from the canal system one should also make sure

that there is no extensive loss of tooth structure in

the process. During the endodontic procedures

diagnosis to Treatment Planning involves

minimal invasive approach which includes

correct diagnosis and decision making, minimal

but decisively crafted access openings depending

on anatomical challenges, during access opening

minimal removal of dentin, cleaning and shaping

of the root canal to retain as much sound dentin

as possible, retention of tooth structure,

performing a crown lengthening procedure to

establish sound tooth margins for core/crown

restorations rather than planning a tooth

extraction and implant or bridge placement. The

article here by lists out a few of the approaches of

Minimally Invasive Endodontics (MIE) which

changes the future of dental practice.

2. DIAGNOSIS AND TREATMENT

PLANNING

Usually cases of mature teeth diagnosed with

irreversible pulpitis or apical periodontitis, often

root canal treatment is the treatment of choice to

save the tooth, which lead to loss of dental hard

tissue and subsequently weakening the tooth,

making them more prone to fracture2. With

advancement in research new insights in pulp

biology have developed overtime, a clinical

research on vital pulp therapy now provides

options for enveloping new biologically driven

treatment protocols3.Minimally invasive

endodontics treatment modalities include two

major rewards: firstly, preservation and

maintaining physiological and defensive

functions; secondly, lesser removal of hard tissue


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which preserves structural integrity of tooth.

Thorough knowledge of pulp biology and insight

into why traditional treatment methods leads to

shift in thinking about endodontic treatment.

Possibly avoiding full pulpectomies (complete

removal of the pulp to the apical constriction),

wherever possible .biological response of

immune system could be enhanced by even a

partially retained pulp thus improving the

treatment outcome ,prevents further infection of

the apical area3, and studies have proven that

results of vital pulp treatments are comparable to

conventional root canal treatment5. As stated in

Seltzer & Bender 1963, Garfunkel et al. 1973,

Dummer et al. 1980 Conventional treatment

approaches was thought to have a poor

relationship between the histological state of the

pulp in mature teeth and clinical signs and

symptoms; the recent histological study showed

that there is a good correlation between clinical

symptoms of pulpitis and the histological state of

a diseased pulp6.Irreversible pulpitis cases have

shown the morphological changes indicating the

inflammation or necrosis of coronal pulp while

the radicular pulp being viable. This paves way of

preserving radicular pulp thus preventing need

for a pulpectomy.

This minimally invasive treatment approach

called ‘Endolight’3 helps

1. To preserve immunological functions and

retain the structural integrity of tooth

2. To simplify treatment procedures and to avoid

treatment complications related with varying root

canal anatomy

3. To reduce cost and inconvenience of patients

and society

4. This procedure showed little pain8

The newer proposal for new clinical pulp

diagnosis and related treatment modalities

Initial Pulpitis

Sharp but not lengthy response to the cold test,

not sensitive to percussion with no spontaneous

pain.

Treatment: Indirect Pulp therapy5,9

Mild Pulpitis

Sharp and lengthy reaction to cold, hot and sweet

stimuli that last up to 20s and then subsides,

maybe percussion sensitive. On histology, it

shows limited local inflammation confined to the

coronal pulp.

Treatment: Indirect Pulp therapy5,9

Moderate Pulpitis

Clear symptoms, strong, sharp and prolong

reaction to cold, lasting for minutes, maybe

percussion sensitive and spontaneous dull pain.

On histology, it shows extensive local

inflammation confined to the crown pulp.

Treatment: Coronal pulpotomy10-

partly/completely

Severe Pulpitis

Severe, clear, spontaneous pain reaction to hot

and cold stimuli, regularly, sharp to dull

throbbing pain, very sensitive to touch and

percussion patients’ experiences pain which gets

worse when lying down).

Treatment: pulpectomy11 or tooth extraction.

This treatment strategies are evaluated and

revised in order to maintain the pulp vitality with

minimally invasive approach.

3. STRUCTURAL INTEGRITY OF

TOOTH

Remaining structural integrity of the tooth is

important factor that determines prognosis as it

relates to the post endodontic survival rate of

tooth. Maintenance of strength and stiffness that

resists structural deformation becomes the goal of

all restorative procedures, mainly in endodontics.

A study compared the impact of endodontic

versus restorative procedures on tooth strength2.

They found that endodontic access openings by

themselves have only 5% impact on tooth

stiffness in comparison to any restorative

preparation that removes the tooth’s marginal

ridges which reduces the cuspal stiffness by 63%.

Marginal ridges are a key factor in retaining tooth

strength. Widely held clinical perception is that

endodontically treated teeth are more brittle and

hence more vulnerable to fracture.


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Endodontic treatment major etiologic factor for

tooth fracture, Brittleness of teeth due to loss of

moisture12, insignificant difference in the

moisture content between endodontically treated

teeth and teeth with vital pulp13.

More Emphasis is given on the importance of

conserving the bulk of dentine to maintain the

structural integrity of post-endodontically

restored teeth. The question arises here is why

endodontically treated teeth fail and how to

prevent it?

When endodontically treated teeth fail under

function, that outcome is determined primarily by

2 aetiologies

Those causes stated most simply are:

1) Degree of stress experienced by the tooth

under load

2) Inherent biomechanical properties of the

remaining structure responsible for

resisting fracture.

Attempts made to prevent the fracture rates

are by Preservation of:

a) Peri Cervical Dentin

b) 3D ferrule

c) 3D Soffit

a) Peri Cervical Dentin (PCD)

The dentin surrounding the alveolar crest often

regarded as the “Irreplaceable Critical Most

Zone”. 14 Compromising PCD is not acceptable as

no man-made material can replace the original

tissues.

It is round 4mm above and 4mm below to the

crestal bone. It is insisted to preserve PCD in

order to prevent fracture, preserve the ferrule and

dentinal tubule orifice proximity inside to out.

The survival rate increases with its preservation

proportionately.

Fig. 1 Pericervical Dentin

b) 3D Ferrule

Axial wall of dentin covered by axial wall of

crown. 3D refers to the components of ferrule

namely:

Fig. 2 Ferrule

It has

1. Vertical component - around 1.5 to 2.5 mm14

2. Dentin thickness (Girth) - Absolute minimum

thickness – 1-2 mm14

3. Total occlusal convergence/ Net Taper-Total

draw of 2 opposing axial walls to receive a fixed

crown which is 10° in 3mm of vertical ferrule,

20° in 4mm, possible in the traditional stainless-

steel crowns whereas the newer porcelain crowns

demands 50° or more taper owing to its deep

chamfer marginal zones.14

c) Soffit/Banking

In English literature, the underside of a ceiling, at

the corner of the ceiling and wall is referred to as

soffit but in dentistry it is the stepped access14

which is 360°. Maintain a small border amount of

the chamber roof; near the point where it curves

90° and becomes the wall.


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These 360 soffits - metal ring that stabilizes a

wooden barrel and increased moment of inertia.

In the tooth, this tiny “lip” or “cornice” could be

as small as 0.5 mm, or as large as 3.0 mm in some

cases (where extra strength is needed, or when the

anatomy allows it).

Fig. 3 Dotted line shows the typical cut made to

remove the entire pulp horn. Area between the

lines is referred to as the soffit. 14

Complete Deroofing attempts at removing the

soffit that are far more damaging to the

surrounding PCD. The primary reason to

maintain the soffit is to avoid the collateral

damage that usually occurs, namely the gouging

of the lateral wall. Thus, a more appropriate

access shape is overlaid

Partial deroofing and maintenance of a robust

amount of PCD is demonstrated below:

Fig. 4 A soffit that includes pulp horns on mesial

and distal is depicted

4. ALTERNATE ACCESS DESIGNS

Traditional access designs (TECs) aims at

straight line access into the root canals which

increases biomechanical preparation efficacy and

reduces the procedural errors.

Fig. 5 Traditional access designs (TECs)

With the emphasis on surgical operative

microscope and newer instruments, the New

vision-based mental model is Look, Groom, and

Follow

New instruments are all round-ended tapers.

The rounded ends are to increase the radii of the

gouges and nicks that can act as stress

concentration points. The flat sides help create

smoother, flatter walls and minimize the gouges

and dings that inevitably occur even with the

most careful technique. Small, cone-shaped, low-

speed bur (such as the EG2 [SS White])

Newer access designs include

a) Conservative Endodontic Access Cavity

b) Ninja Endodontic Access Cavity

c) Orifice-Directed Dentin Conservation Access

Cavity

d) Incisal Access

e) Cala Lilly Enamel Preparation

a) Conservative Endodontic Access Cavity

(CECs)

John Khademi and David Clark modified

traditional access cavities and developed the

constricted or conservative endodontic access

cavities to minimize the tooth structure removal

while maintaining the mechanical stability of the

tooth for long-term survival and function of the

endodontically treated teeth. Here, teeth are

accessed at central fossa and extended only as

necessary to detect canal orifices, thus preserves

the pericervical dentin and part of the chamber

floor.


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Fig. 6 CEC in mandibular first molar. The

occlusal view; for comparison purposes, the

outline of TEC is demarcated with a dotted line.

b) Ninja Endodontic Access Cavity (NECs)

An access with a ‘Ninja’ outline, the oblique

projection is towards the central fossa of the root

orifices in an occlusal plane. It is parallel with the

enamel cut of 90⁰ or more to the occlusal plane,

making it easier to trace the root canal orifices

from the varying visual angulations.

c) Orifice-Directed Dentin Conservation

Access Cavity / ‘Truss’ Access Cavity

Purpose of this design is to preserve the dentin ie.

Leaving a truss of dentin between the two cavities

that has been prepared. Separate cavities are

made to approach the canals.15 Mandibular

molars, two separate cavities are made to

approach the mesial and the distal canals where

as in maxillary molars, the mesiobuccal and the

distobuccal cavities is approached in one cavity

and a separate cavity for the palatal canal is made.

Fig. 7 A schematic representation of the (A) TEC

access (black dotted line) and (B) DDC access (red

dotted line) cavity in a mandibular molar

Fig. 8 (A–D) A traditional access cavity (black line

dashed), (A, C, and D) conservative access cavity

(green), and (B–D) ultraconservative ‘‘ninja’’

access cavity (red). Comparison of the 3 access

cavity designs in the (C) occlusal and (D) sagittal

view, respectively. The sagittal view shown as a

conservative access cavity maintains a robust

amount of pericervical dentin. B, buccal; D, distal;

L, lingual; M, mesial

Fig. 9 (A–F) CBCT 3-dimensional reconstructions

and segmentations f lower molars prepared with

different access cavity designs in (A–C) the

sagittal view and (D–F) the axial view at the

occlusal surface. (A and D) A traditional access

cavity (purple), (B and E) conservative access

cavity (green), and (C and F) ultraconservative

‘‘ninja’’ access cavity (red) are segmented on

CBCT reconstructions.

CECs, TECs and NECs and found that TECs

presented lower fracture strength than CECs and

NECs in maxillary and mandibular premolars and

molars and no statistical significance was found

in the fracture resistance mean values of CECs

and NECs16.

CEC was associated with the risk of

compromised canal instrumentation only in the

molar distal canals, it conserved coronal dentin

and conveyed a benefit of increased fracture

resistance in mandibular molars and premolars 17.

TECs may lead to a better preservation of the

original canal anatomy during shaping compared

with CECs, particularly at the apical level18.

Instrumentation efficacy and biomechanical

responses in conservative and traditional


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preparations in maxillary molars and found no

significant difference between the two19. MB2

detection rate of CEC (53.3%) and TEC (60%)

are higher than statistically that of NEC (%31.6).

There was no significant difference between CEC

and TEC in terms of determining MB2 canals20.

No significant difference in the fracture strengths

of teeth prepared using the TEC and CEC

methods, the types of fractures were less serious

with CEC preparation21.

Fracture resistance was higher when accessed

through CEC than TEC. The dentin conservation

afforded an increased resistance to fracture in

CEC group which is doubled the fracture

resistance in TEC group22.Both traditional and

conservative access designs have their own pros

and cons as concentrating on too much

conservative designs can lead to inefficient

cleaning and shaping and also inability to get the

extra canals can in turn lead to failure of the

treatment. Therefore, one must know when to use

based on the right tooth and situation in order to

avoid failures.

d) Incisal Access

Blind Tunnelling: Gouging commonly observed

with round burs which are aggressive in nature

and cingulum access. Buccal-lingual gouging

(not easily seen in x-rays) occurs in nearly every

traditionally-accessed case. 15 Figure 10.

Fig. 10: Blind Tunneling

The Inverse Funnel: As the access grows

internally, an inverse funnel is created. 15 Precious

peri-cervical dentin is lost each time the bur

enters the tooth

Fig. 11: Incisal Access Design

e) Cala Lilly Enamel Preparation

Traditional parallel-sided access compared with

the Cala Lilly enamel preparation. Unfavourable

C factor and poor enamel rod engagement are

typically present when removing old amalgam or

composite restorations or with traditional

endodontic access 900 degree to the occlusal

table. The enamel is cut back at 45 with the Cala

Lilly shape. 15 This modified preparation will now

allow engagement of nearly the entire occlusal

surface

Fig. 12: (a and b) Traditional parallel-sided access

(left), compared with the Cala Lilly enamel

preparation (right). Left - Unfavourable C factor

and poor enamel rod engagement are typically

present when removing old amalgam or composite

restorations or with traditional endodontic access

of 90° to the occlusal table. Right - The enamel is

cut back at 45° with the Cala Lilly shape

5. IMAGE GUIDED ENDODONTIC

ACCESS

It Utilizes image modalities available to

clinicians. Instead of “one size fits all” determine

location and size of access cavity. The objective

is to strategically remove and conserve dentin and

Smallest access cavity possible is made.

Customization of access based on the tooth.


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Fig. 13: Image Guided Endodontic Access

6. DYNAMICALLY GUIDED ACCESS

Dynamic guidance used for dental implants. In

endodontics - first introduced by Dr. Charles M.

It uses information from the patient’s CBCT

volume to plan an access cavity. Overhead

tracking cameras relate the position of the

patient’s jaw and the clinician’s bur in 3-

dimensional space. The clinician, by looking at

the software interface, gets immediate feedback

about the position of the bur as it relates to the

position of the planned access and the tooth

Fig. 14: Dynamically Guided Endodontic Access

7. MICROGUIDED ENDODONTIC

ACCESS

With the help of special software

(coDiagnostixTM, Dental Wings Inc., Montreal,

Canada), alignment with a CBCT and surface

scan allows virtual planning of an ideal access

cavity.23 Subsequently, a template can be

produced by means of a 3D printer. This template

guides a minimally invasive drill to the calcified

root canal.

Fig. 15: Micro guided Endodontic Access

8. MODERN ENDODONTIC BURS

Traditionally used round bur technique relied on

tactile feedback as the round bur drops into pulp

chamber. Round burs are aggressive in nature, the

walls are overextended and gouged in other areas.

Newer burs like ck and endoguide burs has a tip

size less than half as wide as round bur available

from SS White Burs.

Fig. 16: CK and Endoguide Burs

9. CLEANING AND SHAPING OF

CANALS

Negotiating and a complete shaping of canal

being the primary goal. A 3D cleaning and

shaping ensuring minimal mechanical shaping

and a thorough irrigation protocol. Important

things to be included during cleaning and shaping

are: Small apical terminal diameters but wide

tapers apically, while ensuring sufficient dentin

remaining in the body of the root canal.


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Studies vary on which size diameter will

accomplish maximum cleaning. Apical

overpreparation invites fracture of tooth as it

weakens tooth structure.

a. Apical Preparation Geometry: Significant

difference was not found in intracanal

bacterial reduction used with or without

apical enlargement preparation, stating it is

not necessitated to remove excessive dentin

in the apex if sufficient coronal taper is

present which allows enough

irrigation24.Root canal enlargement to sizes

larger than #25 appeared to improve the

performance of syringe irrigation25.The

minimum instrumentation size needed for

penetration of irrigants to the apical third of

the root canal is a #30 file26

b. Self-Adjusting File System: Hollow file -

compressible, thin-walled, pointed cylinder

of 1.5 mm or 2.0 mm diameter and composed

of 120-μm-thick Ni-Ti lattice. File adapts

itself to the three-dimensional canal

morphology both longitudinally and cross-

sectionally. Effectively shapes up to 92% of

the of root canal walls, while allowing for the

continuous flow of fresh NaOCl through the

hollow file by using a peristaltic irrigation

device27

Fig. 17: Self-Adjusting Files

c. Endo-Eze anatomic endodontic

technology: Introduced as a minimally

invasive endodontic preparation system.

Used in a special reciprocating/ oscillating

handpiece for instrumentation of the coronal

part of the root canal about 3 mm short of the

apex. 28 Apical files are hand files with

shortened cutting flutes to cut only in the

apical region of the canal and are used in a

clockwise turn and pull motion

Fig. 18: Endo-Eze Technology

10. 3D DISINFECTION

a. Endoactivator system – In a root canal

system, Endoactivator activates the intracanal

reagents thereby produces a vigorous

hydrodynamic phenomenon utilizing sonic

energy. 29 The flexible vibrating tip which is non

cutting generates an intracanal waves and fluid

activation creating bubbles that oscillate within

the canal, bubbles then expand and become

unstable, then it collapses and implodes. The

implosion creates the shockwaves which

dissipates at 25,000 to 30,000 times/sec.

Fig. 19: Endoactivator

b. Ultrasonic: Acoustic streaming creates

sufficient shear forces to dislodge debris in

instrumented canals. Files activated with

ultrasonic energy acoustic streaming was

sufficient to produce significantly cleaner canals

compared with hand filing alone. The flushing

action of irrigants is enhanced. Improves the

efficacy of irrigation solutions in removing

organic and inorganic debris from root canal


85

walls. 29 A much higher velocity and volume of

irrigants flow is created in the canal during

ultrasonic irrigation

c. Photoactivated Disinfection

Photon Induced Photoacoustic Streaming

(PIPS):

Requires any given canal which is prepared upto

size 20 files. Striped and tapered tip of PIPS is

placed still in the pulp chamber alone. Upon

activation of the tip, it creates non-thermal

photoacoustic shockwaves, that travel 3

Dimensionally, also into the complex apical

regions. It eradicates both biofilm and planktonic

contaminates, sterilizing more than 1000 μm

depth into the dentinal tubules.

Fig. 20: Photon Induced Photoacoustic Streaming

(PIPS)

d. GentleWave

It is a multisonic technology with a specific wide

spectrum wavelength with different frequencies.

The reagents flow through the closed system.

With this a 3-dimensional cleaning of canal is

achieved including the complex areas like

isthmuses, lateral canals and dentinal tubules. 30

Collaborative research has shown that this

disinfection method can 3D clean a canal, the

lateral anatomy, and related dentinal tubules.

Fig. 21: GentleWave System

11. ROOT STRENGTHENING

Advancing principle promoting minimally

invasive therapy directs the nominal use of posts

in endodontically treated teeth .Tooth structure is

more valuable than the use of a post in almost

every circumstance where adequate structure

exists for a ferrule.31 Adhesive materials are

minimally invasive.

Posts: Traditional post space preparation resulted

in excessive tooth preparation with the use of

peeso reamers which in turn leads to loss of

structural integrity the newer posts like Ribbond

and Everstick increases the flexibility and

requires minimal tooth preparation. Fibre-

reinforced resin posts are more elastic support to

core.

Fig. 22a. Traditional Post

Fig. 22b. Ribbond Post


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Fig. 22c. Everstick Post

12. MAGNIFICATION

DH Lawerence quoted “what the eye doesn’t see

the mind doesn’t know, doesn’t exist even if it

does!”. Magnification magnifies the look in

endodontics to the extent that one sees it clearer

which has made possible to look through the

difficulties of root canal treatment. RCT is no

longer a blind procedure with aids like loupes and

surgical microscopes.

Limits of human eye: The resolution of human

eye is 0.2mm. This can be enhanced upto 6

micrometre with the help of Surgical Operative

Microscope. 32

Fig. 23: Loupes

Fig. 24: Surgical Operative Microscope

Surgical microscopes are no longer a luxury but

a necessity in the field of dental practice.

13. CONCLUSION

Minimally invasive endodontics is in the interest

of the patient, and preserving tooth structure

requires optical magnification aids (surgical

microscope), ultrasonic-assisted preparation

techniques, modern file systems, and in-depth

knowledge of the tooth and root canal anatomy.

Focusing on too much of minimal technique my

lead to a higher rate of procedural errors and

benefit may be outweighed by poor clinical

outcome. Hence, the clinician should strike the

right balance between minimal preparation and

traditional endodontic preparation with their own

pros and cons, thus achieving the objectives of

endodontic treatment.

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