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Q U I N T E S S E N C E I N T E R N AT I O N A L

ENDODONTICS

Sebastian Brklein

Minimally invasive endodontics


Sebastian Brklein, Dr med dent1/Edgar Schfer, Prof Dr med dent 2
Minimally invasive endodontics (MIE) aims to preserve the
maximum of tooth structure during root canal therapy. In the
last 15 years there has been rapid progress and development
in endodontics, making treatment procedures safer, more
accurate, and more ecient. Meanwhile, reproducible results
can be achieved even in dicult root canal morphologies with
severe or double curvatures. In addition to various material

improvements, the implementation of the surgical microscope


(SM) in endodontics is an important innovation, making it possible to optimize each step in the treatment protocol in terms
of substance preservation. (Originally published in Quintessenz
2014;65:565570; Quintessence Int 2015;46:119124; doi:
10.3290/j.qi.a33047)

Key words: endodontics, minimally invasive endodontics (MIE), preservation of tooth structure, surgical microscope

Successful root canal treatment depends on many factors. Up to now, most individual steps during root canal
treatment are carried out without a direct view into the
entire root canal system, especially in curved canal systems. Manual tactility in conjunction with a diagnostic
radiograph mainly represents the sole basis of the
treatment. This raises the question of whether
improved visibility leads to better preservation of tooth
structure or if it is more likely associated with greater
substance weakening.

LIMITS OF THE HUMAN EYE


The better the spatial resolution or visual acuity of eyes,
the smaller the distance between two separate points
or lines that can still be perceived as separate. The reso-

Central Interdisciplinary Ambulance, School of Dentistry, University of Mnster,


Germany. Email: sebastian.buerklein@ukmuenster.de

Head, Central Interdisciplinary Ambulance, School of Dentistry, University of


Mnster, Germany.

Correspondence: Dr Sebastian Brklein, Albert-Schweitzer-Campus 1/


W30, D-48149 Mnster, Germany.

VOLUME 46 NUMBER 2 FEBRUARY 2015

lution of the human eye is about 0.2 mm. However,


numerous treatment steps in endodontics require
accuracy well below the resolution the human eye can
differentiate without an optical aid. With a surgical
microscope the resolution can be increased to up to 6
m (Fig 1). Thus, magnification is an almost indisputable condition for implementing minimally invasive
procedures.

MINIMALLY INVASIVE ENDODONTICS


In each step of root canal treatment including diagnosis, the decision-making process, the design of endodontic access cavity, instrumentation of the root
canals, or even apical surgery (Fig 2) or surgical crownlengthening, minimally invasive strategies will probably supersede more invasive methods. Nevertheless,
knowledge of the exact anatomical structures and their
variations is decisive for the individual treatment steps.
As part of the root canal treatment, the aspects listed
below offer the option to implement a minimally invasive therapy.

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4
Fig 1

8 16

32

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Access cavity
The design of the access cavity is crucial to maintain
healthy tooth structure (Figs 3 and 4). A diagnostic radiograph to display the anatomy of the tooth and morphology of the root canals is a prerequisite to prepare minimally invasive access cavities as it provides a first orientation concerning the localization of the pulp chamber
and the root canals. However, before access cavity preparation, insufficient coronal restorations and caries
lesions should be removed and a pre-endodontic restoration performed to minimize the risk of recontamination
of the endodontic system during treatment procedures.
The preparation of the access cavity can be divided
into three steps:1
Primary access cavity: Cleaning the whole pulp chamber including complete removal of hard tissues that
may impede the straight line access to the root canals
represents the first step. The differentiation of tertiary
dentin (normally colored differently compared to
regular dentin) is only achievable with good illumination and after drying the cavity. Magnification aids
(eg, surgical microscope or magnifying glasses) facilitate the procedure. Fine diamond-coated or nondiamond-coated ultrasonic tips allow a careful dissection along the recognizable boundaries. This gentle
and fine preparation can usually be performed without the water cooling that hinders clear visibility.

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Possibilities of an operating microscope: gradual enlargement of a millimeter scale (output size 2 mm, scale 0.01 mm).

Secondary access cavity: The number of root canal


orifices in a particular tooth can never be known
prior to the commencement of the treatment.
Hence, canal orifices should be identified with the
utmost care. With the exception of single-rooted
teeth, canal orifices are never localized in the center
of the pulp chamber but always at the junction of
the dark horizontal floor and the lighter vertical walls
of the pulp chamber. Consequently, a clear identification of the floor-wall junction is one of the important aspects of the accessing phase of root canal
treatment. Useful methods to find the orifices are
staining with erythrosine or methylene blue, transillumination of the tooth with a polymerization or cold
light lamp, and gentle probing with a sharp probe.
Micro-instruments facilitate this procedure and guarantee optimal preservation of healthy tooth structure (eg, pilot instruments, orifice opener, microdebrider, or engine driven files). In particular, forced
use of Peeso reamers and Gates Glidden drills is
often associated with excessive material removal in
the coronal portion of the root canal (Fig 5).
The chemomechanical preparation of the root canal
system is the next step and should usually start with
the creation of a glide path that can be prepared
either with hand instruments or with engine driven
rotary path files.

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Fig 2 Fractured instrument seen during


apical surgery to remove the fragment.

Fig 3 Minimally invasive endodontics: design of the access cavity. Instrumentation:


mesial, size 40, taper .06; distal, size 70, taper .02.

Figs 4a to 4c Minimally invasive access cavity of a maxillary


molar to obtain the circumferential stabilization of the restoration
with views into the canal orifices: (a) palatal; (b) mesiobuccal 1 and
2; (c) distobuccal.

The use of cone beam computed tomography (CBCT)


with its superimposition-free three-dimensional pictures reconstructed with mathematical algorithms from
multiple projections provides further information concerning root anatomy, resorptions, root fractures, and
other complications like perforations or even fractured
instruments for treatment planning compared to conventional two-dimensional periapical radiographs.
However, a CBCT-based design of the access cavity
seems not to be associated with an improved preservation of sound tooth structure in teeth without special
anatomical root morphologies.2

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Fig 5 Excessive preparation


of the canal orifices with
Gates Glidden drills (superimposed with a minimally invasive approach; the arrows
display the additional
removed tooth structure
[white]).

Root canal preparation


Influence of tapered instruments
Proper chemomechanical disinfection of the canal system is crucial for the success of the entire root canal
therapy, but irrigation of the apical portion of the root
canal is challenging. To achieve sufficient irrigation
over the entire length of the root canal, a preparation
of at least size 40, taper .04 is required. According to
some clinical studies this size represents an ideal compromise between efficiency of irrigation and treatmentrelated root dentin weakening,3 particularly when irrigation is activated (eg, passive ultrasonic irrigation
(PUI).4-6 In curved canals an apical preparation size of

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Fig 6

Dentinal cracks caused by root canal preparation.

size 40, taper .06 is proposed7 to guarantee proper irrigation in the apical part.
According to these requirements, the latest micro-CT
studies of the original taper of various root canals showed
that the functional taper (over the entire canal length) in
maxillary molars is about 1.5% in the buccal root canals
and 6.2% in the palatal root canal.8 In particular, concerning the treatment of noninfected root canals (vital extirpation) this raises the question of the necessity of excessive material removal caused by the use of instruments
with greater tapers. Namely, it is known that a reduced
taper of instruments is correlated with an increased fracture resistance of root canal treated teeth,9 as remaining
structural integrity is known to have an important impact
on the long-term survival rate after adequate coronal restoration of root canal treated teeth.10,11
So far, these considerations are of clinical relevance
because each root canal treatment is associated with a
significant weakening of the tooth structure (crown and
root). The fracture resistance of a root canal treated
tooth is directly correlated with the amount of remain-

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ing sound tooth structure.12 Currently, manual root canal


preparation with ISO standardized instruments (taper
.02) appears to be associated with a lower weakening of
the tooth compared to rotary preparation.13-19 The selfadjusting file (SAF, Redent Nova) allows very substancepreserving preparations with significantly lower dentin
removal than allowed by root canal preparation using
rotary nickel-titanium instruments. In addition, when
using these instruments reduced stress induction is
described on the remaining residual dentin.19-21
The SAF is a compressible diamond-coated titanium
mesh with a roughness of 2.8 m 10%. Due to its
compressibility this hollow file adapts with circumferential pressure to the canal walls and removes in about
4 minutes 250 m of dentin from the touched canal
walls using 5,000 vibrations per minute combined with
a vertical amplitude of 0.4 mm. Continuous and simultaneous activated irrigation of the root canal system is
performed with an adjustable amount of 1 to 10 mL/
min that is directly transported inside the hollow file by
a special device.

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Influence of instrument design


The flexibility of each root canal instrument decreases
with increasing core diameter, regardless of its design
and alloy. Consequently, the straightening tendency is
more pronounced when enlarging severely curved
canals to a greater apical preparation size. Nickel-titanium (NiTi) instruments have some distinct advantages
compared to stainless steel files as they are claimed to
maintain the original canal curvature better during root
canal preparation due to their increased flexibility.
Based on recent developments in metallurgy and the
introduction of new alloys in endodontics (M-wire, CMwire), new instruments have become available (eg,
Hyflex CM, Coltne/Whaledent; Twisted Files, SybronEndo; ProTaper NEXT, Dentsply Maillefer) that possess
improved root structure preserving effects.15,22
Currently, each root canal preparation technique
seems to be associated with the induction of dentinal
damage/defects. Both rotary as well as reciprocating
mechanical root canal instrumentation may cause
micro-cracks or other dentinal damage (Fig 6).14
Although the reciprocal movement (cutting of the
instruments in counterclockwise direction, and releasing in clockwise direction) reduces the torsional and
cycling stresses on the instruments and thus the risk of
instrument separation is minimized, instruments used
in this working motion seem to induce more dentinal
micro-cracks than rotary instruments.14 However, manual instrumentation with less tapered (2%) hand instruments produces significantly less incomplete and complete micro-cracks compared to mechanical
preparation techniques.13
Obturation techniques are also associated with dentinal damage.23 Hence each endodontic procedure may
ultimately lead to a loss of tooth structure and finally
may contribute to partial or complete root fractures,
despite the primary intention of preservation. Vertical
root fractures (VRF) are one of the most serious complications during or after root canal treatment24,25 and are
associated with severe clinical problems for both the
patient and the dentist.26 Therefore, it is crucial to
establish a compromise between further simplifying
root canal preparation and obturation by using modern

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Fig 7 Radiographically adequate root canal filling with obturation of lateral canals without excessive weakening of the root.

techniques (especially with respect to thermoplastic


obturation) and the resulting weakening of tooth structure (Fig 7). The iatrogenically induced causes of fractures in root canal treated teeth (loss of tooth structure,
effects of chemical agents [irrigants and intracanal
dressings], and restorative procedures) can be influenced and minimized by the dentist, whereas non-iatrogenic causes cannot yet be influenced (ageing of
tooth structure, the anatomy of the tooth and its position in the jaw, and masticatory forces).

CONCLUSION
Minimally invasive endodontics is desirable 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. However, as yet there is
no clear evidence concerning the impact of MIE on the
success rate.

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