Advancements in Root Canal Therapy:

New Technology to Improve Patient

OutcomesThomas V. McClammy, DMD, MS; Enrico DiVito, DDS

SUPPORTED BY AN UNRESTRICTED GRANT FROM SONENDO • Published by Dental Learning Systems, LLC © 2018

eBookCE Continuing Dental Education

FEBRUARY 2018 V5 N97

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W W W . C D E W O R L D . C O M

E N D O D O N T I C S T E C H N O LO G Y

FEBRUARY 2018

Thomas V. McClammy, DMD, MS

Private Practice

Scottsdale, Arizona

Enrico DiVito, DDS

Private Practice

Scottsdale, Arizona

eBookCE Continuing Dental Education

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CDEWORLD.COMVOLUME 5 • NUMBER 97 3

A clinician’s endodontic success rate can be difficult to

determine, either in the long or short term. Complications

of root canal anatomy can make success difficult to gauge.

The main opportunity that clinicians can take advantage of regarding

root canal system anatomy relates to microanatomy. This article will

provide an overview of root canal system anatomy and historical

root canal therapy. It will then introduce multisonic technology,

which can dramatically improve endodontic outcomes for patients.

This technology enables clinicians to be more conservative in their

treatment and achieve greater case success.1,2

ENDODONTIC SUCCESS AND THE ROOT CANAL SYSTEMSome dentists are familiar with the 1917 study of the root canal system

that was brought to the United States in 1925 by Walter Hess.3 The

study set the benchmark for the modern understanding of dental

anatomy, but it also created limitations, because of the concept of a

single “root canal.” A better concept for this anatomy is root canal

“systems,” a term introduced by Dr. Herbert Schilder in 1974.4 Today,

a cursory Google search will provide incredibly detailed displays of

digitized micro computed tomography (CT) of root canal system

anatomy. These images demonstrate the complexity of root canal

systems, which can be compared to a fingerprint because of their

person-specific nature. Figure 1 provides a representation of a lower

premolar micro CT that makes it clear how difficult the endodontic

clinician’s task of cleaning and shaping such an intricate system can

be. This complexity also illustrates why clinicians may be falling

short of fully debriding and disinfecting these anatomical systems

regardless of what instruments and irrigation protocols are utilized.

Irrigation methods have changed over time, transitioning from

passive irrigation to active irrigation. Gutta-percha cone activation

gave way to the EndoActivator® (Dentsply Sirona, dentsplysirona.

com) by Dr. Clifford Ruddle, which opened the door for moving

irrigants more effectively throughout the root canal system. Next

came ultrasonic activation technologies, including PiezoFlow®

(Dentsply Sirona), EndoVac® (Kerr Dental, kerrdental.com), and, more

T h o m a s V . M c C l a m m y , D M D , M S ; E n r i c o D i V i t o , D D S

ABSTRACT

Success rates for endodontic procedures can be quantifiably and qualitatively improved with the use of new multisonic technology, which provides a far more conservative and thorough methodology than common root canal procedures. Using multisonic technology, the clinician can achieve the five mechanical objectives initially proposed by Dr. Herbert Schilder. The system allows the clinician to transition from a sense of “cleaning and shaping” to “preparing” the root canal system. Overall, advantages can be found in reduced clinical fatigue and decreased discomfort for the patient. The authors conclude that multisonic technology enables the clinician to provide a higher level of care that better accounts for the complexity of the root canal system.

LEARNING OBJECTIVES

• Describe the principles underlying root canal therapy and mechanical objectives.

• Discuss the endodontic procedure protocol for a new technology.

• Explain the advantages of using the new technology.

Advancements in Root Canal Therapy: New Technology to Improve Patient Outcomes

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2 C D E C R E D I T S

4 FEBRUARY 2018CDEWORLD.COM

recently, EndoVac Pure™ (Kerr Dental), which have

collectively helped clinicians to realize the value of

active over passive irrigation. In the 1970s and early

1980s, dental school education for root canals did not

consider the system view. This limited perspective

later shifted, as exemplified by Schilder’s article,

“Cleaning and Shaping the Root Canal.”4 In a key

quote from this article, Schilder states, “Initially,

root canals were manipulated primarily to allow

placement of intracanal medicaments, with little

attempt to remove completely the organic contents

of the root canal system. In spite of elaborate

modifications over the years, many methods of

preparing root canals mechanically still fail to

cleanse root canal systems effectively.”

Schilder, whose thinking was forward-looking,

provided five mechanical objectives. These five

objectives were reduced to four by Ruddle: continuous

tapering preparation, original anatomy maintained,

position of foramen maintained, and foramen kept as

small as practical.5 With new, disruptive root canal

treatment technology currently on the market, the

objective of a continuous tapering preparation is,

in the opinion of these authors, perhaps no longer

necessary. Throughout the history of endodontics,

there have been many times when a new technology

challenged the status quo, was dismissed or disliked,

but then became the norm. Microscope technology

that emerged in the early 1990s and cone-beam

computed tomography (CBCT)/three-dimensional

(3D) imaging are examples of disruptive technologies

that were met with skepticism but have now become

commonplace.

ADVANCED ROOT CANAL TECHNOLOGYThe new technology introduced in this article is

based on advanced multisonic technology. Several

current systems take advantage of ultrasonics

and/or piezoelectric ultrasonic technology to

deliver endodontic therapy. Some of these include

MiniEndo™ (Kerr Dental), Varios® (NSK, nskdental.

us), and Newtron® (Satelec, A-dec Inc, a-dec.com).

The cases documented in this article feature the

GentleWave® System (Sonendo®, sonendo.com),

which employs a proprietary multisonic cleansing

technology to deliver therapeutic irrigants into

the root canal system, including lateral canals and

tubules of complex root canal systems, while leaving

the dentin largely intact.1,6-11 In the case shown in

Figure 2 (preoperative radiograph) and Figure 3

(postoperative), the clinician was initially under

1 2 3

4 5 6

Fig 1. Mandibular premolar. Courtesy of Dr. Bernardo Camargo, Rio de Janeiro, Brazil. Fig 2 and Fig 3. Preoperative (Fig 2) and postoperative (Fig 3) radiographic images. Fig 4 through Fig 6. Preoperative (Fig 4), cone fit (Fig 5), and postoperative (Fig 6) radiographic images.

5CDEWORLD.COMVOLUME 5 • NUMBER 97

the misconception that simple

“cleaning and shaping” could be

used for the root canal system

in the conventional manner.

The clinician evaluated the root

canal system digitally in 2D and

3D before starting the case. The

case was accessed, prepared,

and cleaned and disinfected.

Special attention to the digital

imagery of the mesiobuccal root

complex allowed the clinician

to appreciate that the MB1 and

MB2 merged before exiting

from a common foramen. The

2D postoperative radiograph

(Figure 3) illustrates that all of

the mechanical objectives were

realized.

Figure 4 shows another

preoperative radiographic image.

The clinician was especially

interested in observing what

would happen in the apical one-

third of the distal canal. Figure 5

shows the cone-fit radiograph, and

Figure 6 shows the postoperative

2D image. The introduction of

multisonic technology allowed

the clinician to preserve more

dentin while keeping the access

more conservative.

Figure 7 shows another

tooth that was diagnosed with a

necrotic pulp; Figure 8 shows a

preoperative CBCT slice from

the volumetric scan of the tooth.

The clinician observed that

there was more than one canal in the mesiobuccal

system and that a periapical lesion was present.

Lesions were visible radiographically on every

root, adjacent to numerous portals of exit in

the apical one-third. In this case, the clinician

aimed to be more conservative

and was able to better maintain

the original anatomy. In the

mesiobuccal root, the canals

crisscrossed, and considering

the delicate anatomy in

the apical one-third, it was

imperative to keep the foramen

as small as practical. A much

larger palatal canal was also

observed. The clinician

provided a coronal seal buildup

before the rubber dam was

removed from the tooth. Figure

9 shows the postoperative 2D

radiograph.

Figure 10 is from a case

on the upper arch, tooth No.

3. On the distal buccal area,

superimposed over the palatal

and distobuccal root, there was

a large periapical lesion. Figure

11 shows the preoperative

CBCT slice. The tooth had

preoperative draining via a

sinus tract through the buccal

plate that the clinician was able

to appreciate before initiating

the procedure. These images

clarify the amount of bone

destruction periapically, in

the axial view. Recognition

of the preoperative indicators

enabled the clinician to

consider how to best proceed

with treatment. Figure 12

shows the postoperative 2D

radiograph, which reveals a

delicate buccal system and

significant anatomy in the palatal canal. There

was some extrusion of sealer palatally and at

other portals of exit. Figure 13 shows a 3-week

postoperative recall 2D radiograph of the case.

7

Fig 7 through Fig 9. Preoperative radiographic image (Fig 7), preoperative CBCT (Fig 8), and postoperative radiographic image (Fig 9).

8

9

6 FEBRUARY 2018CDEWORLD.COM

The draining sinus tract had healed by that point

in time.

Figure 14 and Figure 15 show the

preoperative digital images for another case

with a necrotic pulp. In the preoperative 3D

CBCT volume, the clinician observed that

the mesiobuccal system, distobuccal system,

and palatal system all communicated. On

evaluating the mesiobuccal system, the

clinician observed anastomoses between

the canals. The clinician sought to employ

a conservative approach to treating the case.

Figure 16 and Figure 17 show the postoperative

scans wherein it can be seen that the clinician

practiced “directed dentin conservation” (a

term attributed to Dr. David Clark and Dr.

John Khademi and perpetuated by Dr. Eric

Herbranson).12 The only mechanical objective

not illustrated by this case is the continuous

tapering preparation. Overall, the original root

canal system anatomy was maintained and

the foramen was kept as small as practical.

Figure 18 shows an inverted postoperative

radiograph that better illustrates both of these

principles.

Figure 19 and Figure 20 illustrate a premolar

in which the condition of the pulp was initially

misdiagnosed and the patient was referred for

restorative work. She returned within a few

months, explaining that her tooth hurt. The

clinician found that the pulp of tooth No. 12

was necrotic and the tooth had multiple portals

of exit and multiple lesions of endodontic

origin adjacent to these portals of exit. Figure

21 shows the postoperative 2D radiograph

Fig 10 through Fig 13. Preoperative radiographic image (Fig 10), preoperative CBCT (Fig 11), postoperative radiographic image (Fig 12), and 3-week recall radiographic image (Fig 13).

10 11

12 13

CDEWORLD.COMVOLUME 5 • NUMBER 97 7

of the tooth after multisonic technology was

used to clean and debride the microanatomy.

ADVANTAGES OF THE TECHNOLOGYIn the authors’ experience, the multisonic procedure

does not take appreciable additional time and, in

most cases, can be completed in a single-visit

appointment. Clinician, staff, and patient fatigue

are noticeably decreased because the process

requires less time in shaping/preparation of the root

canal system. In lieu of shaping of the root canal

system, the clinician’s objective is solely to create

a pathway to allow the multisonic technology to

deliver degassed irrigants to the entire root canal

system. The potential for instrument fatigue is

reduced because the clinician does not attempt to

enlarge the systems significantly beyond the natural

anatomy. Instrument stress is lessened, resulting in

fewer separated instruments and reduced anxiety

for both clinician and staff. There is decreased

schedule disruption and reduced loss of valuable

tooth structure.

Employment of this technique alleviates the

need for multiple instrument passage and repeated

16 17 18

14 15

Fig 14 through Fig 18. Preoperative radiographic image (Fig 14), preoperative CBCT (Fig 15), postoperative scans (Fig 16 and Fig 17), and inverted postoperative image (Fig 18). Fig 19 through Fig 21. Preoperative (Fig 19 and Fig 20) and postoperative (Fig 21) images.

19 20 21

8 FEBRUARY 2018CDEWORLD.COM

recapitulations. As a result, this procedure

dramatically lessens the production of the smear

layer,11 leading to cleaner systems and more

thorough debridement.

The technology involves a less-invasive technique

with smaller, more conservative shapes.1 Less

patient time is required because it is predominantly

a single-visit procedure. The authors have found that

only rarely will a case require placement of calcium

hydroxide or an intra-appointment medicament.

Postoperatively, the procedure results in less

pain, less sensitivity, no swelling, and little to no

discomfort; over-the-counter non-narcotic anti-

inflammatory medications are all that are necessary

postoperatively for most patients.

CONCLUSIONSuccess rates for endodontic procedures can be

quantifiably and qualitatively improved with the use

of new technology. Multisonic treatment advances

root canal therapy and supports improvements to

endodontic outcomes for patients. It accomplishes

this through a far more conservative and thorough

method than traditional root canal procedures.

Using this modality, the clinician can achieve the

five mechanical objectives determined initially by

Schilder. This allows the clinician to transition from

a sense of “cleaning and shaping” to “preparing” the

root canal system. Overall, success can be measured

by the reduction of clinical fatigue, a decrease in

discomfort for the patient and improved healing

rates, enabling the clinician to provide a higher level

of care that better addresses the complexity of the

root canal system.

REFERENCES1. Sigurdsson A, Garland RW, Le KT, Woo SM.

12-month healing rates after endodontic therapy using

the novel GentleWave System: a prospective multicenter

clinical study. J Endod. 2016;42(7):1040-1048.

2. Sigurdsson A, Le KT, Woo SM, et al. Six-month healing

success rates after endodontic treatment using the novel

GentleWave System: the PURE prospective multi-center

clinical study. J Clin Exp Dent. 2016;8(3):e290-e298.

3. Hess W. The Anatomy of the Root-Canals of the Teeth

of the Permanent Dentition, Part 1. New York: William

Wood and Co.; 1925.

4. Schilder H. Cleaning and shaping the root canal. Dent

Clin North Am. 1974;18(2):269-296.

5. Ruddle CJ. WaveOne: helpful hints. The Ruddle

Report. http://www.endoruddle.com/blogs/show/20/

waveone-helpful-hints. Published May 9, 2012. Accessed

November 27, 2017.

6. Van der Sluis LWM, Shemesh H, Wu MK, Wesselink

PR. An evaluation of the influence of passive ultrasonic

irrigation on the seal of root canal fillings. Int Endod J.

2007;40(5):356-361.

7. Haapasalo M, Wang Z, Shen Y, et al. Tissue dissolution

by a novel multisonic ultracleaning system and sodium

hypochlorite. J Endod. 2014;40(8):1178-1181.

8. Ma J, Shen Y, Yang Y, et al. In vitro study of calcium

hydroxide removal from mandibular molar root canals.

J Endod. 2015;41(4):553-558.

9. Charara K, Friedman S, Sherman A, et al. Assessment

of apical extrusion during root canal procedure with

the novel GentleWave system in a simulated apical

environment. J Endod. 2016;42(1):135-139.

10. Macedo RG, Robinson JP, Verhaagen B, et al. A

novel methodology providing insights into removal of

biofilm-mimicking hydrogel from lateral morphological

features of the root canal during irrigation procedures.

Int Endod J. 2014;47(11):1040-1051.

11. Vandrangi P, Basrani B. Multisonic ultracleaning

in molars with the GentleWave system. Oral Health.

May 2015;72-86.

12. Clark D, Khademi J. Modern molar endodontic

access and directed dentin conservation. Dent Clin

North Am. 2010;54(2):249-273.

10. Macedo RG, Robinson JP, Verhaagen B, Walmsley AD,

Versluis M, Cooper PR, and van der Sluis LM. A novel

methodology providing new insights into the ultrasonic

removal of a biofilm-mimicking hydrogel from lateral

morphological features of the root canal. Int Endod J. 2014;

47: 1040–1051.

11. Vandrangi P, Basrani B. Multisonic ultracleaning in molars

with the GentleWave system. Oral Health. 2015;May:72-86.

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QuizCDE 2 CDE Credits

Advancements in Root Canal Therapy: New Technology to Improve Patient Outcomes

6. According to Schilder, many methods of preparing

root canals mechanically:

A. are considered effective about 40% of the time. B. are considered effective about 60% of the time. C. are considered effective about 80% of the time. D. still fail to cleanse the root canal systems effectively.

7. Schilder provided how many mechanical objectives

when preparing a root canal?

A. three B. four C. five D. six

8. This article describes a proprietary:

A. endodontic shaping system. B. multisonic cleansing technology. C. endodontic length-measuring device. D. endodontic access-opening procedure.

9. Multisonic technology allows the clinician to:

A. conserve more dentin while keeping accesses more conservative.

B. conserve more dentin while making accesses larger. C. remove more dentin while keeping accesses more

conservative. D. remove more dentin while making accesses larger.

10. Using a multisonic device decreases:

A. clinician fatigue. B. staff fatigue. C. patient fatigue. D. all of the above

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9CDEWORLD.COMVOLUME 5 • NUMBER 97

1. Whatmakesrootcanaltherapydifficulttogauge? A. the lack of a recall appointment B. the inability to access the pulp chamber C. complication of root canal anatomy D. the high percentage of retreatments based on national data

2. The limitation of the 1917 study by Hess was because of:

A. the concept of a single “root canal.” B. the concept of complex root canal anatomy. C. the concept of multiple small apices on virtually all teeth. D. the lack of applied scientific rigor to the study, leading to

inflated conclusions.

3. The term root canal “systems” was introduced in 1974 by:

A. Torbinijad. B. Gow-Gates. C. Schilder. D. Kakehashi.

4. Rootcanalsystemscanbecomparedtoafingerprintbecause: A. they have a similar classification system in the United

States. B. they have a similar classification system internationally. C. of their person-specific nature. D. of a consensus paper by endodontists in 2002.

5. More effectively moving irrigants through the endodontic

system involves:

A. passive irrigation. B. active irrigation. C. highly acidic irrigation. D. highly basic irrigation.

In all patients, the clinicians’ first priority is to obtain

an accurate pulpal diagnosis. The authors’ protocol

for incorporating multisonic technology, such as

the GentleWave® Procedure, begins with an initial

examination and consideration of the patient’s dental

history, systemic health history, and chief complaint.

Although several angled images and a bitewing

radiograph may no longer be necessary, it is still

advisable to take a straight-on 2D periapical radiograph.

The second step is to take a preoperative 3D CBCT

volumetric image. Following the achievement of

profound pulpal anesthesia, a rubber dam is placed,

and then the clinician can access the root canal system.

The coronal access can be more conservative because

of the benefits of the GentleWave Procedure.1,2 Next,

all canals should be located in the access cavity, aided

by the combination of the 2D periapical radiograph,

the 3D CBCT volume, and direct visual observation

through a dental operating microscope.

Canal lengths are verified as the clinician

measures each canal from a reference point in the

coronal aspect of the tooth to the apical constriction.

This can also be done within the CBCT volume, due

to the nature of its accuracy. An electronic apex

locator can also be utilized to confirm the canal

length.

The clinician can then prepare the canals to

approximately 1.0 mm short of working length.

Next, the authors generally utilize no more than

two to three variably tapered nickel-titanium rotary

files to prepare each root canal to the same length,

while maintaining much smaller diameters in the

coronal aspect of the root canal system.

Initiation of the GentleWave Procedure requires

the fabrication of an occlusal platform. Today this is

accomplished utilizing SOUNDSEAL™ (Sonendo®,

sonendo.com) and an included preformed plastic

matrix. This platform allows the GentleWave

Procedure Instrument to conform to the root canal

access cavity. The GentleWave Procedure method

of action requires an intact seal at the interface of

the Procedure Instrument and the root canal coronal

access cavity. After fabrication of the platform is

completed, the GentleWave Procedure can begin.

Currently, the procedure consists of approximately

8 minutes of continuously refreshed NaOCl,

water, and EDTA at specific computer-controlled

concentrations and intervals. During this time, the

Procedure Instrument is manually held in place by

the clinician. When the procedure is completed,

the Procedure Instrument and the SOUNDSEAL

platform are removed. Preparations for obturation of

Fig 1. The difference with the new technology is visually significant. Fig 2. The delicate distobuccal right in the apical one-third is exceptionally well maintained.

PROCEDURE PROTOCOL

FEBRUARY 201810 CDEWORLD.COM

1

2

the root canal system can then be initiated, based

on the clinician’s obturating method of choice. For

example, the clinician may choose to obturate with

warm gutta-percha in conjunction with a sealer. After

obturation has been completed, the clinician can

perform a coronal seal buildup procedure before

removing the rubber dam. Finally, a postoperative 2D

radiograph is acquired. Post-operative instructions

are provided to the patient, including detailed

information regarding the GentleWave Procedure

that has been performed.

The appreciable visual difference when using the

GentleWave Procedure is shown in Figure 1. Tooth

No. 2 is the newer shape and tooth No. 3 is the older

shape, which was still quite conservative. Tooth No.

2 showcases an example of closely maintaining the

original anatomy. The GentleWave System enables

the clinician to debride and disinfect the root canal

system, resulting in a much smaller and more

conservative shape.1,2 For example, the delicate

distobuccal root canal anatomy in the apical one-

third of Figure 2 is exceptionally well-maintained.

REFERENCES1. Sigurdsson A, Garland RW, Le KT, Woo SM. 12-month healing rates after endodontic therapy using the novel GentleWave System: a prospective multicenter clinical study. J Endod. 2016;42(7):1040-1048.

CDEWORLD.COMVOLUME 5 • NUMBER 97 11

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Being experts in saving teeth requires staying on top of the latest advances to ensure we’re giving patients

the most effective options—and improving outcomes. An endodontist with the GentleWave® System can

deliver the unprecedented cleaning and disinfection you need to do just that.

Introduce your patients to the partner who’s best for their teeth.

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SONENDO.COM/RELATIONSHIP

Before*

Post GentleWave® Procedure*

• The entire procedure from access opening to obturation can

typically be completed in just one visit1

• Cleans the deepest, most complex anatomies of the root canal

system2,3 to remove tissue, debris, biofilm and bacteria

• Helps save the structure and integrity of teeth by preserving

more dentin1

* Images courtesy Brian T. Wells, DMD 1 Sigurdsson A et al. (2016) J Endod. 42:1040-48 2 Molina B et al. (2015) J Endod. 41:1701-5 3 Vandrangi P et al. (2015) Oral Health 72-86© 2018. All rights reserved. SONENDO, the SONENDO logo, GENTLEWAVE, the GENTLEWAVE logo and SOUND SCIENCE are trademarks of Sonendo, Inc. Patented: www.sonendo.com/intellectualproperty. MM-0529 Rev 01

RELATIONSHIP GOALS.