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CLINICAL MEETING: Clinical challenges and current trends in access cavity design and working length determination

The 2018 ESE Clinical Meeting will provide participants with an update on current concepts of access cavity design and preparation as well as how to assess working length during root canal treatment. The key aims are:

- To describe the most recent progress in term of technology and clinical approaches to both access cavity design/preparation and working length determination;

- To discuss gaps in knowledge and deficiencies in the available technology for access cavity preparation and working length determination;

- To consider the establishment of multi-centred clinical studies to evaluate the impact of access cavity design and methods of determining working length;

- To consider whether the proposed topics are worthy of an ESE Position statement;

- To develop discussion and eventually consensus on the proposed topics to inform the new ESE quality guidelines.

Overview – Part 1

The morning session had two presentations focused on the principles of access cavity design and recent innovations. This has always been a clinically relevant topic, which has recently become more controversial because minimally invasive concepts have been suggested in order to save tooth structure, and thus potentially increase the long-term prognosis of the root filled tooth. Moreover, the clinical approach is also evolving due to new digital endodontic techniques, mainly focused in providing a better access and easier localization of canals in complex cases, i.e. calcified pulp chambers and canals. After the two presentations, a debate was held, with the two speakers answering questions from the audience and discussing related topics arising from the audience.

Gabriel Krastl - Basic principles of access cavity design. Locating canals. Management of calcified canal systems. The use of CBCT for guided access cavities.

The presentation focused on access to the endodontic system and reviewed the current strategies for the treatment of teeth with calcified canal systems. An adequately prepared access cavity is crucial for all steps which follow during the endodontic therapy: for locating the root canals, for effective instrumentation, for irrigation, and root filling. Furthermore, an ideal endodontic access cavity should be a balance between the demands for an adequate endodontic treatment and an optimized structural strength of the tooth. In teeth with severe calcifications of the endodontic system and apical pathosis, the access to obliterated root canals is challenging and it is prone to technical failures, including alterations of root canal geometry, and loss of hard substance, which may result in a considerable weakening of the tooth or in root perforation. Even with the use of a dental microscope, the preparation of an adequate access cavity may lead to excessive substance loss that impairs stability and thereby reduces the long-term prognosis of the tooth.

To overcome these complications, guided endodontics, a novel approach for the preparation of apically extended access cavities was introduced. For this purpose, preoperative surface scans and cone-beam computed tomography scans are matched. After planning the position of the drill for root canal location, a virtual template is designed, and the data is exported as an STL file and sent to a 3D printer for template fabrication. The template is positioned on the teeth. A specific drill is used to penetrate through the obliterated part of the root canal so as to obtain minimally invasive access to the root canal. After miniaturization of the instruments, the technique was made accessible even for teeth with narrow roots such as mandibular incisors.

A recent study demonstrated that the (micro)guided endodontic access leads to a faster and more predictable location of calcified root canals with significantly less substance loss compared to the traditional endodontic access using the OPM. Furthermore, in contrast to the traditional access, the success of the guided approach is not influenced by the experience of the operator. Even though clinical studies are missing, several case reports demonstrate the successful clinical implementation of this technique particularly for anterior teeth, but also in the posterior region.

Apart from static guidance, dynamic navigation may be a new approach for the negotiation of calcified root canals. A stereo vision computer triangulation setup can be used to guide the bur during preparation of the access cavity. While the initial data is available on the accuracy of the method in the field of Implantology, future research has to demonstrate whether its implementation in Endodontics is feasible.

Antonis Chianotis - A rational approach to access cavity designs

Traditional access cavity designs are geometrically predesigned shapes dictated by the underlying anatomy and guided by the endodontic disease. Access cavity designs remained unchanged for many decades because of the inherent advantages they offered. Convenience form, extension for prevention and complete unroofing of the pulp chamber usually resulted in great visibility, ease and safety during all stages of root canal treatment procedures.

However, recently, the traditional access cavity designs have been questioned, modified and regarded as legacy concepts. The reason for this is linked to the development of minimal invasive dentistry concepts in Endodontology. These concepts recognise that an artificial material is of less biological value than the original tissue and they suggest that minimum access cavity designs and limited canal instrumentation sizes in order to preserve dentine. The ultimate objective is an increase on the mechanical stability and fracture resistance of the tooth.

Although technological advancements have enabled dentine conservation procedures, problems do exist and can complicate treatment to unacceptable levels. Moreover, the evidence for an increase in fracture resistance remains limited and controversial. More research is needed to clarify the benefits and possible risks of minimal access cavity designs and the effect they may have on the outcome of root canal treatment.

Overview – Part 2

The afternoon session had two presentations focused on the determination of working length during root canal treatment. The apical limit of root canal treatment has always been a challenge in clinical endodontics due to the limitations of 2D periapical radiographs, the variability of the apical constriction, the problems related to apex locators and the changes of canal length related to different access cavity design and shaping procedures. The two speakers provided an update of the most current research and trends on the topic, aiming to provide useful clinical hints to solve most of the common practical issues related to this procedure. After the two presentations, a debate occurred, with the two speakers answering questions from participants and discussing related topics arising from the audience.

Ashraf ElAyouti - The anatomy of the root apex. Where is the canal terminus? The use of electronic apex locators. Tips and tricks to determine the end-point of canal preparation and filling

A meta-analysis of outcome studies has so far showed a clear consensus and concordance of evidence regarding the end-point of root canal treatment. The scientific consensus is that long root canal fillings do not result in a better outcomes, in fact short fillings have a better outcome than long fillings. Micro-CT analysis and extensive serial measurements of canal cross-sections have revealed the existence of the apical constriction (the smallest canal cross sectional area) in each canal. In contrast, the apical constriction was barely detected when longitudinal sections of the root canal were used, and in addition, canal topography varied greatly according to the position of the longitudinal section. This may explain why the apical constriction remained undetected in many studies using longitudinal sections of root canals. The apical position of the constriction is very close to the foramen; within <¼ mm in most of the root canals examined. At the apical constriction, root canals were rounder, smaller in size and had non-divergent dentinal walls. At the major foramen, root canals were larger in size, oval in shape and the dentinal walls diverged towards the foramen. Moreover, at the foramen, root canals ended oblique to root surface so that a thin dentinal wall was present in most canals. Therefore, in order to keep the area of the wound at the periapical tissues as small as possible and to avoid over-fillings and apical laceration, it is recommended to shape root canals to the apical extent of the constriction and only disinfect to the foramen. Modern apex locators operating on the basis of relative impedance measurements have been shown to be accurate. Using micro-CT images to superimpose the location of the constriction and foramen to the display of apex locators revealed that nearly all apex locators were accurate within +/- ¼ mm. In the process of working length determination, the main source of measurement error was the operator and the procedure itself. Mainly, due to adjusting and reading the length of measuring files as well as adaptation and movement of rubber stoppers. The repeatability and reproducibility of the operators were a further source of measurement error.

Vittorio Franco - The limits of endodontic procedure. Management of the apex and the apical third.

The presentation focused on the management of the apical third of the root canal and in particular of the foramina. Endodontic treatments are currently based on changes in the shape and contents of what is known as the endodontic space: it is difficult to distinguish the point, or, better, the so-called passage between ‘‘in’’ and ‘’out’’. The first part of the presentation is the description of the landmarks and the difficulties when identifying them clinically. Limitations of periapical radiographs and electronic apex locators were briefly described: a systematic review on the use of CBCT for the establishment of working length confirms the possibility of using this device to identify the position of the foramen and its distance from a coronal reference point.

In the second part, several points to consider were presented on the shaping procedure and its relationship with working length: the action of the files on tissues and the modifications of the WL after the pre-flaring were the main points discussed as well as the role of apical enlargement.

The third part was a brief description of the principles of root filling and its relationship with the surrounding tissues.

In the last part before the conclusions. irrigation protocols were described focusing on the apical part of the root canal. The most popular activation systems were briefly described and pros and cons in term od apical debridement and disinfection were evaluated.

Conclusions: all the stages of a root canal treatment have to address the working length issue. The shaping WL could be different, depending on the kind of treatment, e.g. pulpotomy, pulpectomy and revascularization have a totally different approach to the management of the apical foramina. Since all endodontic procedures can cause a microsurgical wound and an inflammation of the involved tissue, in this perspective establishing and using the correct working length could contribute to a better outcome.

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9:00
rightIntroduction and overview: access cavities: what is minimally invasive? what are the advantages and what are the risks?

Abstract

Access cavity design is currently widely debated in endodontics, in order to minimize loss of tooth structure, and reduce the risk of fracture, which is one of the main cause of long-term endodontic failures. On the other hand, a minimally invasive approach should not enhance the risk of inadequate instrumentation and irrigation of the root canal system. A correct balance between these needs should be found while planning endodontic access.

Aims

Promote the debate concerning access cavity design, the current different strategies, the definition of minimally invasive , and provide clinical hints on how to perform assess cavity with the aid of 3d technology.

Objectives

Introducing the discussion about the advantages and disadvantages of minimally invasive access cavity design and the new clinical approaches to the access cavity design.

rightGianluca Gambarini
 Gianluca Gambarini

Full-time Professor; Head of the Endodontic Department, University of Rome, La Sapienza, Dental School; Director of Master of Endodontics in Sapienza. International lecturer and researcher, He is author of more than 400 scientific articles, He has lectured all over the world (more than 500 presentations) as a main speaker in the most important international congresses and many Universities worldwide. During his academic career he gained many awards and recognition, and was responsible of many scientific projects with national and international grants. He has focused his interests on endodontic materials and clinical endodontics. He is also actively cooperating as a consultant to develop new technologies, operative procedures and materials for root canal treatment. He is currently the Chairman of Clinical Practice Committee of ESE. He still maintains a private practice limited to Endodontics in Rome,Italy.

9:30
rightBasic principles of access cavity design. Locating canals. Management of calcified canal systems. The use of CBCT for guided access cavities
Guided Endodontics

Abstract

The endodontic access to calcified root canals is a challenging task and it is prone to technical failures including alterations of the root canal geometry, and loss of hard substance, which may result in a considerable weakening of the tooth or in root perforation. To overcome these complications, guided endodontics, a novel guided approach for the preparation of apically extended access cavities was introduced. After miniaturization of the instruments, the technique was made accessible even for teeth with narrow roots such as mandibular incisors. A recent study demonstrated that the (micro)guided endodontic access leads to a faster and more predictable location of calcified root canals with significantly less substance loss compared to the traditional endodontic access using the OPM. Furthermore, in contrast to the traditional access, the success of the guided approach is not influenced by the experience of the operator. Even though clinical studies are missing, recent case reports demonstrate the successful clinical implementation of this technique particularly for anterior teeth, while the access to posterior teeth remains challenging.

Aims

The aim of this presentation will be to review the current strategies to the treatment of teeth with calcified canal systems

Objectives

To discuss the clinical problems associated with pulp canal calcification and to discuss the possibilities and limits of guided procedures in endodontology.

rightGabriel Krastl
 Gabriel Krastl

Dr. Gabriel Krastl received his degree in dentistry from the University of Tübingen, Germany in 1998 and has been a staff member and research associate until 2005. From 2005 to 2014 he was a senior research associate at the Clinic of Periodontology, Endodontology and Cariology in Basel, Switzerland. 2006 he co-founded the interdisciplinary Center of Dental Traumatology at the Basel University. Since 2014 Gabriel Krastl is Professor and chair of the Department of Conservative Dentistry and Periodontology at the University Hospital of Würzburg, Germany and directs the Center of Dental Traumatology which he founded in 2015. He published more than 100 papers mostly in the field of endodontology and dental traumatology and serves as a reviewer in several scientific journals.

10:40
COFFEE BREAK
11:00
rightDifferences between traditional, minimally invasive and “ninja access” cavities: a critical approach. Influence of access cavity design on instrumentation of canals. How to deal with iatrogenic errors in access cavities.
Access cavity designs and their influence to endodontic treatment procedures

Abstract

By recognizing that an artifact is of less biological value than the original tissue, dentistry and endodontology recently embraced minimal invasiveness for lifetime tooth retention. Minimal invasive approaches in endodontology aim at a systematic ‘respect’ for the original tissue without jeopardizing the disinfection process. Although current technological advancements in 3dimensional imaging, disinfection, magnification, NiTi metallurgy and obturation materials rendered minimal invasive concepts feasible, clinicians have to adapt their skills to meet the challenge of working effectively through confined spaces and access cavities.

Aims

To investigate the rational behind different types of access cavity designs and the effect they might have to the disinfection procedure. Common iatrogenic problems and solutions during access cavity design are also highlighted.

Objectives

1. Develop a rational approach to minimal invasiveness in endodontics 2. Investigate the influence of different access cavities in the disinfection process and suggest solutions to possible problems 3. Investigate the most common problems and solutions during access cavity preparation

rightAntonis Chaniotis
 Antonis Chaniotis

Chaniotis Antonis graduated from the University of Athens Dental School, Greece (1998). In 2003 he completed the three-year postgraduate program in Endodontics at the University of Athens Dental School. Since 2003, he owns a limited to microscopic Endodontics private practice in Athens, Greece. For the last ten years, he served as a clinical instructor affiliated with the undergraduate and postgraduate programs at the University of Athens, Athens Dental School, Endodontic department, Greece. From 2012 to 2014 he served as Clinical fellow teacher at the University of Warwick, Warwick dentistry UK. He lectures nationally and internationally and he has published articles in International peer review Journals and textbooks. He currently serves as an active member of the Hellenic Society of Endodontology (ESE full member society), a certified member of the European Society of Endodontology (ESE) and international member of American Association of Endodontists (AAE)

12:10
Discussion
13:00
LUNCH AND NETWORKING
14:00
rightIntroduction and overview: working length determination: where is the apical limit? Can we predictably detect the canal terminus?

Abstract

Working length determination is a key point for a successful endodontic procedure, being a fundamental step to perform correctly instrumentation, irrigation and and obturation. The determination of working length has been changed during the last decades due to the introduction of different technologies; as a consequence endodontists should be knowleadgeable about the different methods of determining working length

Aims

Promote the debate concerning the determination of working length, including the most recent advances in the apex locators and 3d technologies.

Objectives

Promote the debate on how can we pratically determine working length before and during endodontic procedure.

rightGianluca Gambarini
 Gianluca Gambarini

Full-time Professor; Head of the Endodontic Department, University of Rome, La Sapienza, Dental School; Director of Master of Endodontics in Sapienza. International lecturer and researcher, He is author of more than 400 scientific articles, He has lectured all over the world (more than 500 presentations) as a main speaker in the most important international congresses and many Universities worldwide. During his academic career he gained many awards and recognition, and was responsible of many scientific projects with national and international grants. He has focused his interests on endodontic materials and clinical endodontics. He is also actively cooperating as a consultant to develop new technologies, operative procedures and materials for root canal treatment. He is currently the Chairman of Clinical Practice Committee of ESE. He still maintains a private practice limited to Endodontics in Rome,Italy.

14:20
rightThe anatomy of the root apex. Where is the canal terminus? The use of electronic apex locators. Tips and tricks to determine the end-point of canal preparation and filling

Abstract

The notion that all modern apex locators are similarly accurate has to be questioned. The diverse apical anatomy and geometry will permanently pose a challenge during working length determination and canal preparation. Which method to use in which situation will be dictated by the apical anatomy. While 3D visualization of root canal anatomy have given us an insight into the complicated anatomy of the tooth, still this is not enough to decide on the optimal method for working length determination and canal preparation. Broad analysis of micro-CT images of the teeth will provide us with enough information to decide on the optimal end point of endodontic treatment and the size, form and taper of the final canal preparation that may allow optimal disinfection and preserve the tooth. Mapping the apical anatomy and superimposing the measurements of apex locators along the canal path will help us to understand the influence of the apical anatomy on the accuracy of these devices and will aid clinicians to make the right decision when determining the extension, size and taper of root canal preparation.

Aims

Presentation of 3D reconstructions and analysis of micro-CT images of the apical anatomy. Aid clinicians to reach the utmost accuracy when using endometric tools. Visualize the initial topography and extension of the root canal. Help avoid faulty working length and inappropriate canal preparation.

Objectives

Extensive analysis of micro-CT scans and visualization of 3D reconstructed images of the apical anatomy will help to understand the topography of the apical anatomy including apical landmarks as the foramen and constriction as well as the taper, outline and size of the root canal. Anatomical causes of strip perforations and overinstrumentation will be presented. Superimposing wide scale measurements of modern apex locators on the apical anatomy will demonstrate the diversity of the accuracy of these devices and the influence of the apical anatomy on the display of apex locators.

rightAshraf Elayouti
 Ashraf Elayouti

Dr Ashraf ElAyouti received Bachelor degree in dentistry and doctor of dental surgery in 1988, Alexandria University. After serving 2 years in the Marine as a dental surgeon and another 5 years at the University of Hamburg, he received his doctoral degree, Dr. med. dent., in 1998. Subsequently he worked at the department of Conservative Dentistry, Division of Endodontology, Tübingen University. Since January 2005, head of Endodontology (prov.) and senior lecturer and supervisor of doctoral and research programs in Endodontology and associate Professor. His main research interests are physical properties of dentin and 3-D Dental Imaging.

15:30
COFFEE
15:50
right2- and 3-dimensional radiographic approaches to working length determination. Clinical control of WL. How can it change, when and how should we measure working length? Clinical relevance of over- and under-instrumentation

Abstract

Endodontic treatments are currently based on changes in the shape and contents of what is known as the endodontic space: it is difficult to distinguish the point, or, better, the so called passage plan between "in" and "out".


In addiction new alloys or better, new thermo-mechanical treatments changed the behaviour of the shaping instruments in the root canals as well some new devices for the activation/ agitation of the irrigating solutions could change our habits during the cleaning phase.

Aims

To establish how to use the modern endodontic tools in order to identify the end of the root canal space

To focus on the management of various working lengths and on the impact that our choices could have on our results, in other words, how the different working lengths interact

Objectives

The objectives of this presentation are to give to the participants some information about the workings lengths with the aid of some videos and to help clinicians to develop strategies in the management of working length issues with the aim of promote a friendly discussion in the final part.

rightVittorio Franco
 Vittorio Franco

Dr Vittorio Franco graduated in Dentistry in 1990 at the University of Rome “La Sapienza”. At the present moment Vittorio Franco is the Treasurer of the European Society of Endodontology (ESE). Vittorio Franco is active member and President elect of the Italian Association of Endodontists (SIE), and active member of the Italian Association of Dental Microscopy (AIOM). He was the secretary of the ESE 2011 Congress in Rome, member of the ESE membership committee and Secretary of the SIE. He won the “Riccardo Garberoglio”prize for the research in 2006 and 2016 and the prize for the best presentation in Barcelona Roots Summit in 2010. During his career he gave Pre-congress Courses, Workshop, and Presentations during many National and International Meeting and was lecturer in many University’s courses. Dr Franco is author of scientific articles related to Endodontics published on National and International Dental journals and chapters of books related to Endodontics. He is reviewer for many national and international journals and was member of the scientific committee of the GIE (Italian Journal of Endodontology). Dr. Franco works in Rome and London with clinical practice limited to Endodontics under microscopic magnification.

17:00
Discussion
17:30
Round up, group discussion, next steps and close
18:00
SESSION ENDS
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