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Issue 19

ProTaper NEXT™
5th GenerationTechnology
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Dynamics

Dynamics
pages
Contents
ProTaper Next™ - 5th Generation Technology
4-9
page
GuttaCore™ Clinical Study
10
pages SDR® and Ceram•X® Mono - Clinical Success with
12-13 Simple Restorations

page
Indications for SDR® Now Extended
13
pages
Dyract® - Differentiated for 20 Years
14-15
pages
Air Polishing
16-19

Dynamics 3
Dynamics

The Shaping
Movement
5th Generation Technology
by Dr. Clifford J. Ruddle, DDS | Prof. Pierre Machtou, DDS |
Dr. John D. West, DDS

Since the beginning of modern day The purpose of this article is to identify
endodontics, there have been numerous and compare how each new generation of
concepts, strategies, and techniques for endodontic NiTi shaping files served to
preparing canals. Over the decades, a Fig. 1b. A advance canal preparation methods.
staggering array of files has emerged for pretreatment Importantly, this paper will identify a new
radiograph
negotiating and shaping canals. In spite file system and describe a clinical
reveals an
of the design of the file, the number of endodontically technique that combines the most proven
instruments required, and the surprising failing anterior design features from the past with the
multitude of techniques advocated, bridge abutment latest innovations presently developed.
endodontic treatment has been typically with a draining
approached with optimism for probable Fig. 1b fistula. NiTi Shaping Movement
success. In 1988, Walia proposed Nitinol, a NiTi
alloy for shaping canals, as it is 2-3 times
The clinical endodontic breakthrough was more flexible, in the same file sizes,
2
progressing from utilising a long series of compared to stainless steel. A game-
stainless steel (SS) hand files and several changing outcome of files manufactured
Fig. 1c. This
rotary Gates Glidden drills to integrating from NiTi was that curved canals could be
post-op
nickel titanium (NiTi) files for shaping retreatment mechanically prepared utilising a
canals. Regardless of the methods image continuous rotary motion. By the mid-
utilised, the mechanical objectives for emphasises that 1990s, the first commercially available
canal preparation were brilliantly outlined shaping canals NiTi rotary files had come to market.3 The
almost 40 years ago by Dr. Herbert promotes 3D following is a mechanical classification of
Schilder.1 When properly performed, cleaning and each generation of file systems. Rather
these mechanical objectives promote the filling root canal than identify the myriad of available cross-
biological objectives for shaping canals,
Fig. 1c systems. sections, files will be characterised as
3-D disinfection, and filling root canal having either a passive vs. an active
systems (Figure 1). cutting action.

First Generation
To appreciate the evolution of NiTi
Fig. 1a. A µCT mechanical instruments, it is useful to
image of a know that, in general, first generation NiTi
maxillary central files have passive cutting radial lands and
incisor tooth Fig. 1d. A 25- fixed tapers of 4% and 6% over the length
demonstrates a year radiographic of their active blades (Figure 2).4 This
root canal system recall image generation of technology required
with multiple demonstrates numerous files to achieve the preparation
Fig. 1a portals of exit. Fig. 1d osseous healing. objectives.

4 Dynamics
Dynamics
By the mid to late 1990s, GT files Fourth Generation
(Dentsply Tulsa Dental Specialties) Another advancement in canal preparation
became available that provided a fixed procedures utilises reciprocation, which
taper on a single file of 6%, 8%, 10%, and may be defined as any repetitive up-and-
5
12%. The single most important design down or back-and-forth motion. This
feature of first generation NiTi rotary file technology was first introduced in the late
was passive radial lands, which 1950s by the French dentist, Blanc.
encouraged a file to stay centered in Currently, the M4 (SybronEndo), Endo
canal curvatures during work. Express (Essential Dental Systems), and
Fig. 4 Endo-Eze (Ultradent) are examples of
Fig. 4. The ProTaper Shaping files cut systems that use a movement where the
dominantly in their coronal and middle clockwise (CW) and counterclockwise
one-thirds, whereas the Finishing files (CCW) degrees of rotation are absolutely
cut primarily in their apical one-thirds. equal. As compared to full rotation, a
Fig. 2. These 2 reciprocating file that utilises an equal
SEM images During this period, manufacturers began bidirectional movement requires more
reveal the cross- to focus on other methods to increase the inward pressure to progress, will not cut as
sectional and resistance to file separation. Some efficiently as a same-size rotary file, and is
lateral views of a manufacturers electropolished their files more limited in augering debris out of the
passively cutting to remove surface irregularities caused canal.
Fig. 2 radial-landed file.
from the traditional grinding process.
However, it has been clinically observed From these earlier experiences,
Second Generation and scientifically reported that innovation in reciprocation technology led
The second generation of NiTi rotary files electropolishing dulls the sharp cutting to a 4th generation of instruments for
came to market in 2001.6 The critical edges. As such, the perceived shaping canals. This generation of
distinction of this generation of advantages of electropolishing were instruments and related technology has
instruments is they have active cutting offset by the more undesirable inward largely fulfilled the long hoped-for single-
edges and require fewer instruments to pressure required to advance a file to file technique. ReDent-Nova (Henry
fully prepare a canal (Figure 3). To length. Excessive inward pressure, Schein) introduced the Self Adjusting File
discourage taper lock and the resultant especially when utilising fixed tapered (SAF). This file has a compressible open
screw effect associated with both passive files, invites taper lock, the screw effect, tube design that is purported to exert
and active fixed tapered NiTi cutting and excessive torque on a rotary file uniform pressure on the dentinal walls,
instruments, EndoSequence (Brassler during work.9 To offset deficiencies in regardless of the cross-sectional
USA) and BioRaCe (FKG Dentaire) general, or inefficiencies resulting from configuration of the canal. The SAF is
provide file lines with alternating contact electropolishing, more cross-sectional mechanically driven by a handpiece that
points.7 Although this feature is intended designs have become available and produces both a short 0.4mm vertical
to mitigate taper lock, these file lines still increased, yet more dangerous, rotational amplitude stroke and vibrating movement
have a fixed tapered design over their speeds are advocated. with constant irrigation.11 Another
active portions. The clinical breakthrough emerging single-file technique is termed
occurred when ProTaper (Dentsply Tulsa One Shape (Micro Mega), to be
Dental Specialties) came to market Third Generation mentioned further in 5th generation
utilising multiple increasing or decreasing Improvements in NiTi metallurgy became designs.
percentage tapers on a single file. This the hallmark of what may be identified as
revolutionary, progressively tapered the 3rd generation of mechanical shaping By far the most popular single-file concept
design limits each file’s cutting action to a files. In 2007, manufacturers began to is termed WaveOne (Dentsply Tulsa
specific region of the canal and affords a focus on utilising heating and cooling Dental Specialties and Maillefer) and
shorter sequence of files to safely methods to reduce cyclic fatigue and Reciproc (VDW). WaveOne represents a
produce deep Schilderian shapes (Figure improve safety when rotary NiTi convergence of the best design features
8
4). instruments work in more curved canals.10 from the 2nd and 3rd generation of files,
The desired phase-transition point coupled with a reciprocating motor that
between martensite and austenite can be drives any given file in unequal
identified to produce a more clinically bidirectional angles. The CCW engaging
optimal metal than NiTi, itself. This 3rd angle is 5 times the CW disengaging
generation of NiTi instruments angle and is designed to be less than the
Fig. 3. These 2 significantly reduces cyclic fatigue and, elastic limit of the file. Strategically, after 3
SEM images hence, broken files. Examples of brand CCW and CW cutting cycles, the file will
reveal the cross- lines that offer heat treatment technology have rotated 360º, or one circle (Figure
sectional and are Twisted File (SybronEndo), Hyflex 5). This novel reciprocating movement
lateral views of
(Coltene Whaledent) and GT, Vortex, and allows a file to more readily progress,
an active file with
sharp cutting WaveOne (Dentsply Tulsa Dental efficiently cut, and effectively auger debris
Fig. 3 Specialties). out of the canal.12
edges.
Continued over page >>>

Dynamics 5
Dynamics

<<<<Continued from previous page


ProTaper Next exactly the same way and the sequence
There are 5 ProTaper Next (PTN) files always follows the ISO color progression
(Dentsply Tulsa Dental Specialties) and is always the same regardless of the
available, in different lengths, for shaping length, diameter, or curvature of a canal.
canals, namely X1, X2, X3, X4, and X5
(Figure 7). In sequence, these files have ProTaper Next Shaping Technique
yellow, red, blue, double black, and The ProTaper Next shaping technique is
double yellow identification rings on their extraordinarily safe, efficient, and
Fig. 5 handles, corresponding to sizes 17/04, simplistic when attention is focused on the
Fig. 5. A WaveOne reciprocating file 25/06, 30/07, 40/06, and 50/06, access preparation and glide path
utilises unequal CCW/CW angles to respectively. The tapers just listed are management (GPM). As is required for
improve efficiency, inward progression, NOT fixed over the active portion of any any shaping technique, straightline
and augering debris out of the canal.
given PTN file. Appreciate the PTN X1 access to each orifice is emphasised.
and X2 files have both an increasing and Attention is directed to flaring, flattening,
Fifth Generation decreasing percentage tapered design on and finishing the internal axial walls. For
The 5th generation of shaping files has a single file; whereas the PTN X3, X4, radicular access, the original ProTaper
been designed such that the centre of and X5 files have a fixed taper from D1- system offers the auxiliary Shaping file,
mass and/or the centre of rotation are D3, then a decreasing percentage termed SX. The SX file is used in a
offset (Figure 6). In rotation, files that tapered design over the rest of their active brushing manner on the outstroke, to pre-
have an offset design produce a portions. flare the orifice, eliminate triangles of
mechanical wave of motion that travels dentin, relocate the coronal most aspect
along the active length of the file. Like the of a canal away from external root
progressively percentage tapered design concavities, or produce more shape, as
of any given ProTaper file, this offset desired.
design serves to further minimise the
engagement between the file and Perhaps the greatest challenge
dentin.13 In addition, an offset design performing endodontic treatment is to
enhances augering debris out of a canal find, follow, and predictably secure any
Fig. 7
and improves flexibility along the active given canal to its terminus. Negotiating
portion of a PTN file. The advantages of Fig. 7. This image depicts the 5 and securing canals with small-sized
an offset design will be discussed later in ProTaper Next files. Most canals in manual files requires a mechanical
posterior teeth can be optimally shaped
this article. using 2 or 3 instruments. strategy, skillful touch, patience, and
desire. A small-sized hand file is initially
PTN files are the convergence of 3 used to scout, expand, and refine the
significant design features, including internal walls of the canal. Once the canal
progressive percentage tapers on a single can be manually reproduced, a dedicated
file, M-wire technology, and the 5th mechanical glide path file may be used to
generation of continuous improvement, expand the working width in preparation
the offset design. As a single example, the for shaping procedures.15 To clarify, a
PTN X1 file has a centered mass and axis canal is secured when it is empty and has
Fig. 6
of rotation from D1-D3, whereas from D4- a confirmed, smooth, and reproducible
Fig. 6. A cross-section of a ProTaper D16, the X1 file has an offset mass of glide path.
Next file. Note an offset mass desirably
rotation. Starting at 4%, the X1 file has 10
reduces file engagement, provides
greater space debris, and improves increasing percentage tapers from D1- With an estimated working length and in
flexibility. D11; whereas, from D12-D16, there are the presence of a viscous chelator, insert
decreasing percentage tapers to enhance a #10 file into the orifice and determine if
Commercial examples of file brands that flexibility and conserve radicular dentin the file will easily move toward the
offer variations of this technology are during shaping procedures. terminus of the canal. In shorter, wider,
Revo-S, One Shape (Micro Mega) and and straighter canals, a #10 file can
ProTaper Next (Dentsply Tulsa Dental The PTN files are used at 300 rpm and a usually be readily carried to the desired
Specialties/Dentsply Maillefer). Today, the torque of 2.0-5.2 Ncm, based on the working length. Once a #10 file is
safest, most efficient, and simplest file method of use. However, the authors confirmed loose at length, the glide path
systems utilise the most proven design prefer a torque of 5.2 Ncm, as this level of may be further enlarged with either a #15
features from the past, coupled with the torque has been validated as profoundly hand file or dedicated mechanical glide
most recent technological advancements safe if clinicians perform meticulous glide path files, such as PathFiles (Dentsply
currently available. The following is a brief path management procedures and utilise Tulsa Dental Specialties). The glide path
technical description of the ProTaper Next a deliberate outward brushing motion just described confirms sufficient existing
rotary file system. when progressively shaping canals.14 In space is available to initiate mechanical
the PTN technique, all files are used in shaping procedures with the PTN X1 file.

6 Dynamics
Dynamics

In other instances, certain endodontically any given PTN file to passively move on the length, width, and curvature of any
involved teeth have roots that harbour inward, follow the glide path, and given canal (Figure 8d).
longer, narrower, and more curved canals progress toward the working length. The
(Figure 8a). In these situations, a #10 file X1 file is carried through the access and
will oftentimes not initially go to length. passively inserted into a pre-flared orifice
Generally, there is no need to select and and secured canal. Before resistance,
use size #06 and/or #08 hand files in an immediately begin to deliberately brush
effort to immediately reach the terminus on the outstroke (Figure 8c). Brushing
of the canal. Simply and gently work the creates lateral space and enables this file
size #10 hand file, within any region of the to progress a few millimeters inward. A
Fig. 8d
canal, until it is completely loose. PTN brushing action serves to improve contact
files can be utilised to shape any region between the file and dentin, especially in Fig. 8d. This video grab image reveals
of a canal that has a smooth and canals that exhibit irregular cross-sections a PTN X2 file at length in the MB
system.
reproducible glide path. Regardless of the or eccentricities off their rounder parts.
glide path and shaping sequence, the Once the PTN X2 file has reached the
endgame is to negotiate the entire length working length, it is removed. The shape
of the canal, establish working length, and may be confirmed as finished when the
confirm apical patency (Figure 8b). The apical flutes of this file are visibly loaded
canal is secured and a glide path is with dentin. Alternatively, the size of the
verified when a #10 file is loose at length foramen may be gauged with a size 25/02
and can reproducibly slip, slide, and glide NiTi hand file. When the size #25 hand file
over the apical one-third of the canal. is snug at length, the shape is finished. If
Fig. 8c
the size 25/02 hand file is loose at length,
Fig. 8c. This video grab image shows a it simply means the foramen is larger than
mechanical wave of motion traveling
0.25mm. In this instance, the foramen may
along the active portion of a PTN X1
Shaping file. be gauged with a size 30/02 NiTi hand file.

Continue with the PTN X1 file through the If the size #30 hand file is snug at length,
body of the canal. After every few the shape is done. However, if the size #30
Fig. 8a
millimeters of file progression, remove this hand file is short of the working length,
mechanical shaping file to inspect and proceed to the PTN X3 file, following the
Fig. 8a. This radiographic image
clean its flutes. Before reinserting the X1 exact method just described for the PTN
reveals an endodontically involved
posterior bridge abutment. Note the file, it is critical to irrigate and flush out X1 and X2 files.
orientation of the prosthesis to the gross debris, recapitulate with a #10 file
underlying roots. to break up residual debris and move it The vast majority of canals will be optimally
into solution, then re-irrigate to liberate shaped after using either the PTN X2 or X3
this debris. In one or more passes, files (Figure 8e). The PTN X4 and X5 files
continue with the X1 file until the full are primarily used to prepare and finish
working length is reached. To promote the larger diameter canals. When the apical
mechanical objectives, always irrigate, foramen is determined to be larger than a
recapitulate, and then re-irrigate after PTN 50/06 X5 file, recognise other shaping
removing any mechanical shaping file. methods may be utilised to finish these
larger, typically less curved, and more
Fig. 8b Select the PTN X2 file and let it begin to straightforward canals. What is important
Fig. 8b. A working image reveals run inward. Before resistance, laterally is to appreciate that meticulously secured
coronal disassembly, isolation, and #10 brush against the dentinal walls, which, in canals promote shaping, 3-D cleaning, and
files traversing through canals that turn will enable the X2 file to passively filling root canals systems (Figure 8f).
exhibit curvatures and recurvatures.
and progressively advance inward. The
X2 file will easily follow the path of the X1
When any given canal is secured, the file, progressively shape, and
access cavity is voluminously flushed with incrementally advance toward length. If
a 6% solution of NaOCl. Shaping can this file bogs down and ceases to move
commence, starting with the PTN X1 file. inward, remove the file and clean and
It should be emphasised that PTN files inspect its flutes. Again, irrigate,
are never utilised with an inward pumping recapitulate, and re-irrigate to promote the
or pecking motion; rather, PTN files are mechanical objectives for shaping canals.
Fig. 8e
utilised with an outward brushing motion. Continue with the X2 file until the working
length is reached; appreciate it may Fig. 8e. This video grab image shows a
Importantly, this method of use will enable require one or more passes, depending PTN X3 file at length in the D system.
Continued over page >>>

Dynamics 7
Dynamics
<<<<Continued from previous page
between martensite and austenite. It should rotation will generate a mechanical wave
be appreciated that the best transition point of motion analogous to the oscillation
is dependent on the cross-section of the file. noted along a sinusoidal wave (Figure
Research has shown that M-wire, a 10). As a result of this design, any given
metallurgically improved version of NiTi, PTN file can cut a bigger envelope of
reduces cyclic fatigue by 400% when motion compared to a similarly-sized file
comparing files of the same D0 diameter, with a symmetrical mass and axis of
cross-section, and taper.17 This 3rd rotation (Figure 6). The clinical
Fig. 8f
generational advancement is a strategic advantage of this is a smaller-sized and
Fig. 8f. This radiographic image improvement to the overall clinical safety more flexible PTN file can cut the same-
demonstrates the bridge provisionalised, and performance of the PTN rotary file size preparation as a larger and stiffer file
flowing shapes, and the importance of system. with a centered mass and axis of rotation
treating root canal systems. (Figure 9).
The third design feature of PTN is related to
Discussion its offset cross-sectional design. There are
From a clinical standpoint, the PTN rotary 3 major advantages when a continuously
system is a convergence of the most rotating file is designed so its mass of
proven and successful generational rotation is offset.13
designs from the past, coupled with the
most recent advances in critical path 1. An offset design generates a traveling
technology. This brief discussion will mechanical wave of motion along the
describe how design influences active portion of a file. This swaggering Fig. 10
performance. effect serves to minimise the Fig. 10. Similar to a sinusoidal wave, a
engagement between the file and dentin rotating PTN file produces a mechanical
The most successful generational design of compared to the action of a fixed tapered wave of motion, or swaggering effect,
the past is the mechanical concept of file with a centered mass of rotation along its active portion.
utilising a progressively percentage tapered (Figure 9). Reduced engagement limits
design on a single file. The patent protected undesirable taper lock, the screw effect,
ProTaper Universal NiTi rotary file system and the torque on any given file. Conclusion
utilises both an increasing or decreasing Each new generation of shaping files has
percentage tapered design on a single file. had something to offer, has been
This design feature serves to minimise the described in different ways, and has been
contact between a file and dentin, which intended to improve on previous
decreases dangerous taper lock and the generations. PTN has emerged as a 5th
screw effect, while increasing efficiency.8 generation system designed to bring the
Compared to a similarly-sized fixed tapered most proven performance features from
file, a decreasing percentage tapered file the past together with the most recent
design, strategically improves flexibility, Fig. 9 technological advancements. This system
limits shaping in the body of the canal, and Fig. 9. A PTN file has a progressively should simplify rotary shaping procedures
conserves coronal two-thirds dentin. Taking tapered and offset design. These by eliminating the number of files typically
advantage of this mechanical design, PTN features minimise engagement, used to shape canals and the so-called
maximise debris removal, and improve
also utilises progressive tapers on a single hybrid techniques. Clinically, the PTN
flexibility. By contrast, the bottom image
file. This design has contributed to the shows a fixed tapered file with a shapes fulfill the 3 sacred tenets for
ProTaper system becoming the #1 selling centered mass and axis of rotation. shaping canals, which are safety,
file in the world, the #1 file choice of efficiency, and simplicity. Scientifically,
endodontists, and the #1 system taught in 2. A file with an offset design affords more evidence-based research will be needed to
international dental schools to cross-sectional space for enhanced validate the potential benefits of this
undergraduate students.16 cutting, loading, and augering debris out system.
of a canal compared to a file with a
Another critical design feature that is centered mass and axis of rotation Acknowledgment
intended to benefit certain brand lines of (Figure 9). Many instruments break as a The authors would like to recognise Dr.
mechanical shaping files is metallurgy. result of excessive intrablade debris Michael J. Scianamblo for his work in the
Although NiTi files have been shown to be packed between the cutting flutes over field of critical path technology, which led
2-3 times more flexible than same-sized SS the active portion of a file. Importantly, an to the development of ProTaper Next.
files, additional metallurgical benefits have offset file design decreases the
been identified using heat treatment. R&D probability for laterally compacting debris Disclosure
has focused on heating and cooling and blocking root canal system anatomy Drs. Ruddle, Machtou, and West have a
traditional NiTi, either pre- or post- (Figure 6). financial interest in products they design
machining. Heat treatment serves to create and develop, which includes the ProTaper
a more optimal phase transition point 3. A shaping file with an offset mass of Universal system.

8 Dynamics
Dynamics
References 7. Schäfer E, Vlassis M: Comparative 12. Yared G: Canal preparation using only one
1. Schilder H: Cleaning and shaping the root investigation of two rotary nickel-titanium Ni-Ti rotary instrument: preliminary
canal, Dent Clin North Am 18:2, pp. 269-296, instruments: ProTaper versus RaCe. Part 2. observations, Int Endod J 41:4, pp. 339-344,
April 1974. Cleaning effectiveness and shaping ability in 2008.
2. Walia HM, Brantley WA, Gerstein H: An initial severely curved root canals of extracted teeth, 13. Hashem AA, Ghoneim AG, Lutfy RA, Foda
investigation of the bending and torsional Int Endod J 37:4, pp. 239-248, 2004. MY, Omar GA: Geometric analysis of root
properties of Nitinol root canal files, J Endod 8. Ruddle CJ: The ProTaper endodontic system: canals prepared by four rotary NiTi shaping
14:7, pp. 346-351, 1988. geometries, features, and guidelines for use, systems, J Endod, 38:7, pp. 996-1000, 2012.
3. Thompson SA: An overview of nickel-titanium Dent Today 20:10, pp. 60-67, 2001. 14. Blum JY, Machtou P, Ruddle CJ, Micallef JP:
alloys used in dentistry, Int Endod J 33:4, pp. 9. Boessler C, Paque F, Peters OA: The effect of Analysis of mechanical preparations in
297-310, 2000. electropolishing on torque and force during extracted teeth using the ProTaper rotary
4. Bryant ST, Dummer PM, Pitoni C, Bourba M, simulated root canal preparation with instruments: value of the safety quotient, J
Moghal S: Shaping ability of .04 and .06 taper ProTaper shaping files, J Endod 35:1, pp. Endod 29:9, pp. 567-575, 2003.
ProFile rotary nickel-titanium instruments in 102-106, 2009. 15. West JD: The endodontic glidepath: secret
simulated root canals, Int Endod J 32:3, pp. 10. Gutmann JL, Gao Y: Alteration in the to rotary safety, Dent Today 29:9, pp. 86, 88,
155-164, 1999. inherent metallic and surface properties of 90-93, 2010.
5. Kramkowski TR, Bahcall J: An in vitro nickel-titanium root nickel root canal 16. Dentsply International, personal
comparison of torsional stress and cyclic instruments enhance performance, durability communication.
fatigue resistance of ProFile GT and ProFile and safety: a focused review, Int Endod J 17. Johnson E, Lloyd A, Kuttler S, Namerow K:
GT Series X rotary nickel-titanium files, J 45:2, pp. 113-128, 2012. Comparison between a novel nickel-titanium
Endod 35:3, pp. 404-407, 2009. 11. Metzger Z, Teperovich E, Zary R, Cohen R, Hof alloy and 508 nitinol on the cyclic fatigue life
6. Machtou, P, Ruddle CJ: Advancements in the R: The self-adjusting file (SAF). Part 1: respecting of ProFile 25/.04 rotary instruments, J Endod
design of endodontic instruments for root the root canal anatomy—a new concept of 34:11, pp. 1406-1409, 2008.
canal preparation, Alpha Omegan 97:4, pp. 8- endodontic files and its implementation, J Endod
15, 2004. 36:4, pp. 679-690, 2010.

Dr. Clifford J. Ruddle, DDS, FICD, FACD


Dr. Clifford J. Ruddle is Founder and Director of Advanced Endodontics, an international educational source, in
Santa Barbara, California. He is an Assistant Professor of Graduate Endodontics at Loma Linda University and
University of California, Los Angeles, is an Associate Clinical Professor at University of California, San Francisco,
and is an Adjunct Assistant Professor of Endodontics at University of the Pacific, School of Dentistry. As an inventor,
Dr. Ruddle has designed and developed several instruments and devices that are widely used internationally. He
is well known for providing superb endodontic education through his lectures, clinical articles, training manuals,
videos and DVDs. Additionally, he maintains a private practice in Santa Barbara, California.
He can be reached at (800) 753-3636 or www.endoruddle.com.

Prof. Pierre Machtou, DDS, MS, PhD, FICD


Prof. Dr. Pierre Machtou graduated in 1967 from Paris 7-Denis Diderot University. He completed his studies and
became a full professor in 1997. Prof. Machtou is the past Scientific Director and General Secretary of the French
Endodontic Society. He is a member of numerous national and international endodontic and dental associations.
In 2006, he was the recipient of the Pierre Fauchard’s Elmer S. Best Memorial Award. Prof. Machtou continues
to lecture extensively in many countries and venues worldwide. He is the sole endodontic author of two textbooks,
co-editor of another textbook, and has additionally written 9 endodontic book chapters and 70 articles in peer-
reviewed journals.

Dr. John West, DDS, MSD


As the founder and director of the Center for Endodontics, Dr. West continues to be recognised as one of the
premier educators in clinical and interdisciplinary endodontics. John West received his DDS from the University
of Washington in 1971 where he is an Affiliate Associate Professor. He then received his MSD in endodontics at
Boston University Henry M. Goldman School of Dental Medicine in 1975 where he is a clinical instructor and has
been awarded the Distinguished Alumni Award. Dr. West has presented unmatched endodontic continuing
education in North America, South America, and Europe while maintaining a private practice in Tacoma,
Washington. Dr. West’s memberships include: 2009 president and fellow of the American Academy of Esthetic
Dentistry and 2010 president of the Academy of Microscope Enhanced Dentistry, the Northwest Network for Dental
Excellence, and the International College of Dentists. He is a 2010 consultant for the ADA’s prestigious ADA Board
of Trustees where he serves as a consultant to the ADA Council on Dental Practice.

Dynamics 9
Dynamics

Time Required to Remove GuttaCore™ Thermafil® Plus and


Thermoplasticized Gutta-percha from Moderately Curved Root
Canals with ProTaper® Files
By Robert T. Beasley, DMD, Anne E. Williamson, DDS, MS, Bruce C. Justman, DDS, Fang Qian, PhD
Department of Endodontics, University of Iowa, Iowa City, Iowa

Study objective Results


To evaluate the time required to re-treat GuttaCore, Thermafil Significantly quicker time for reaching working length (T1)
Plus and traditional gutta-percha obturations in moderately and for filling material removal (T2) in GuttaCore Group.
curved canals with ProTaper Universal Retreatment and
Finishing files.

Study design
Canal preparation:
70 mesial roots of mandibular molars without previous
endodontic treatment were prepared to ISO size 30 with 0.04
taper and divided in 3 groups:
Group 1: Warm vertical obturation (n=20)
Group 2: Thermafil Plus (n=20)
Group 3: GuttaCore (n=20)
Control (n=10)

Canal obturation:
Group 1: canal coating with AH Plus® sealer followed by
Groups Mean File File
obturation using a continuous-wave technique of gutta-percha Curvature unwinding separation
compaction (mm3)

Group 2: canal coating with AH Plus sealer followed by ___


Warm 24.2± 3 (D3)
obturation with Thermafil Plus following manufacturer vertical 7.1
instructions
Thermafil 23.0± 4 (D3) 3 (D3)
Group 3: canal coating with AH Plus sealer followed by 6.2
obturation with GuttaCore following manufacturer instructions
___
GuttaCore 24.2± 2 (D3)
Retreatment: 6.2
Instrumentation in a crown-down fashion with ProTaper
Retreatment files D1, D2, D3 and ProTaper Universal F3

Conclusion
• GuttaCore obturation was significantly quicker to remove than Thermafil Plus or thermoplasticized gutta-percha (*P < .05).
• GuttaCore retreatment is respectively 22.0% and 33.3% time saving compared to thermoplasticized gutta-percha and
Thermafil Plus.
• GuttaCore retreatment did not induce file separation or significant risk of file unwinding.

Reference: J Endod. 2013 Jan;39(1):125-8

10 Dynamics
crosslinked gutta-percha core obturator

Gutta-percha Crosslinked gutta-percha core

•superior 3D fills
• ease of retreatment
• post space simplified

Distributed by

www.dentsplymea.com
Dynamics

Clinical Success with


Simple Restorations
The performance of restorations made with SDR® and Ceram·X® mono+ is compared with the performance of restorations made with
Ceram·X mono+ only in a clinical study by Professor J. W. V. Van Dijken, Biomaterial Research Group, Umea, and Associate Professor
U. Pallesen, Copenhagen. Results after 12 months

Objectives
Clinical evaluation of the bulk fill composite SDR, in Class I and Class II cavities, bonded with the single step self-etching primer
Xeno® V+ and covered with the nanoceramic resin composite Ceram·X mono+.

Design
Prospective, longitudinal, controlled, randomised clinical study; method according to ADA Guidelines for Resin Based Composites for
Posterior Restorations (2001).

Number of Restorations
200 (76 Class I, 124 Class II) on 84 patients.

Test Materials
Xeno V+, Ceram·X mono+ and SDR.

Control Materials
Xeno V+, Ceram·X mono+.

Method of Evaluation
Clinical examination, rating according to Van Dijken (1986).

Success Criteria
Determination of the effectiveness of the restorations was carried out by assessing the following parameters:
• Secondary caries
• Anatomic form
• Marginal adaptation
• Marginal discolouration
• Surface roughness
• Colour match

These were assessed by using the slightly modified US Public Health Service criteria. For marginal adaptation and discolouration,
the involvement of marginal excess was noted. Postoperative sensitivity was also analysed.

12 Dynamics
Dynamics
Detailed results at 12 months Class I and Class II

T=Xeno V+, SDR, CXm+


Criteria C=Xeno V+, CXm+ n Alpha Bravo Charlie Delta

T 98 95.00% 4.00% 1.00% n/a


Anatomic form C 98 98.00% 2.00% 0.00%
T 98 99.00% 0.00% 1.00% 0.00%
Marginal adapation C 98 100.00% 0.00% 0.00% 0.00%
T 98 89.70% 10.30% 0.00% n/a
Colour match
C 98 94.90% 5.10% 0.00%
T 98 96.9% 3.10% 0.00% n/a
Marginal discolouration
C 98 99.00% 1.00% 0.00%
T 98 100.00% 0.00% 0.00% n/a
Surface roughness
C 98 100.00% 0.00% 0.00%
Secondary caries T 98 100.00% 0.00%
n/a
C 98 100.00% 0.00%

Conclusion of Principal Investigator at Baseline


No significant differences were seen between the two experimental restorations for the evaluated variables in the two cavity classes.
In some of the restorations the adhesive could be detected as local small white marginal lines.

Conclusion of the Principal Investigator at 12 months


No significant differences were seen between the two experimental restorations for the evaluated variables in the two cavity classes.

Conclusion of the Sponsor at 12 months


No significant difference was seen between the two techniques (SDR-based and conventional non-based). The use of SDR, which
involves a simpler and shorter placement technique, seems to have no negative impact on restoration quality.

Both SDR-based and non-SDR based posterior Ceram·X restorations performed well with a survival rate close to 100%.

Indications for
®
SDR now
extended
The range of indications for SDR, the 4mm bulk fill composite material, have
been extended.

In addition to use as a base in cavity Class I and II direct restorations and a


liner under direct restorative materials, SDR has been approved as a fissure
sealant, for core build-ups and small Class I restorations in direct occlusal
contact without a separate enamel cap. These extended indications mean that
SDR is also ideal for use in paediatric dentistry.

SDR is the original bulk filling material with unique self-


levelling properties still unsurpassed when it comes to
simplifying the restoration of posterior teeth.

Dynamics 13
Dynamics

Dyract : Differentiated ®

for 20 Years
Dyract was first presented to the world at the FDI congress in Göteborg (Sweden) in September 1993. Since then, there has
hardly been a material that has been discussed and studied more intensively.1 The following article demonstrates that the
intended application of Dyract reflects a very modern approach in adhesive dentistry.

History
In the late 1980s, DENTSPLY DeTrey, worked on the As the paste formulation of Dyract doesn’t contain water, no acid-
development of a light-cured material that was to be presented in base reaction can take place between the acidic groups and the
a paste form, could be used without acid-etching and that would basic glass ionomer fillers. This means, unlike conventional glass
be a meaningful substitution for a glass ionomer. Gordon ionomers, Dyract can only be set through light curing. The acid-
Blackwell, an experienced development chemist with patents in base reaction sets in only after water is absorbed. Similarly to
glass ionomers, resin-based adhesives and acid-modified resins glass ionomers, when the acid-based reaction does set in,
(Engelbrecht, 1989) worked on laying the foundation for a new fluoride is released – almost as a by-product of the ionic reaction
material: Dyract. The overall aim of Dyract was to combine the (Figure 2). The initial fluoride release of Dyract is not as high as
best properties from composites such as surface hardness, traditional glass ionomers. However, long-term testing at the
physical strength, low shrinkage and resistance to wear with the University of Copenhagen demonstrates that the level of fluoride
best properties of glass ionomers such as the release of fluoride that is released by Dyract after one year is comparable to a
ions and low technique tolerance. The brand name was created conventional glass ionomer (Asmussen et al., 2002).
by Rolf Käse and was developed to reflect how the specific
composition of Dyract enables the curing of the material to take
place in two reactions (“dy”) and (“ract”).

When Dyract was first developed, it was used together with


Dyract PSA (primer, sealer, adhesive) for the pre-treatment of the Fig. 2. Acid-
cavity. Today, the etching of dentin with phosphoric acid and the base reaction
application of an adhesive is preferred as standard clinical after water
practice. The ability to achieve reliable adhesion through the uptake,
simple application of a bond and subsequent light curing has resulting
been a large contributor to the success of Dyract. Another critical fluoride
success factor for Dyract was the expansion of indications to Fig. 2 release
include the restoration of deciduous teeth – this meant that there
was finally a generally accepted alternative to the conventional
amalgam which had been the standard in paediatric dentistry
(Kramer et al., 2007). In 1997 Dyract was indicated for Caries Protective Effect
restoration placement under occlusal load in posterior teeth. To Many laboratory studies have shown that the fluoride release
date, approximately 250 million Dyract restorations have been from Dyract has an inhibitory effect on the development of
placed worldwide. carious lesions (Wiegand et al., 2007). During an in-situ study at
the University of Göttingen, two groups of subjects were required
Features of Dyract: to wear a removable appliance that simulated proximal contacts
Special Chemical Properties: between intact enamel and a restorative material; either Dyract,
By integrating acid groups into polymerisable resins (Blackwell, or the composite Spectrum® TPH3® (Figure 3). A caries
1993) and combining with basic glass ionomer fillers, Dyract protective effect was demonstrated for the Dyract group and was
behaves like a composite resin during light-curing – the resins significantly higher than that of the Spectrum TPH3 group, even
immediately form a stable network by way of a free-radical though a fluoride toothpaste solution was applied twice daily to all
polymerisation. This network also chemically binds the partially specimens (Lennon et al., 2007).
silanised fillers (Figure 1).

Fig. 3. Simulated
proximal contact
for in-situ study to
Fig. 1. Radical investigate caries
polymerisation protective effect
whilst light of restorative
curing takes materials (Lennon
Fig. 1 place Fig. 3 et al., 2007)

14 Dynamics
Dynamics

Strength Comparable to Composites and identical to the failure rate of the QuiXfil/Xeno III group
Laboratory studies at the Universities of Marburg and Erlangen (Figure 7).
have demonstrated that Dyract has a marginal quality (Figure
4) that is comparable to conventional composites
(Frankenberger, 2013). Further studies testing mechanical
properties such as flexural strength (Figure 5) and flexural
fatigue (Figure 6) also demonstrate Dyract to be comparable
to conventional restorative composites (Lohbauer, 2013).

Fig. 7

Fig. 7. Success rate, failures and annual failure rate (AFR)


after 10 years (Manhart et al., 2013)
Outlook
Fig. 4 Dyract provides proven mechanical strength comparable to
conventional composites, caries protective effect on proximal
Fig. 4.1 Evaluation of marginal quality under scanning surfaces (demonstrated in-situ) and is indicated for permanent
electron microscopy: percentage of perfect margins posterior restorations with buccovestibular dimensions of up
(Frankenberger, 2013 and 2009) to two thirds of intercuspal distance. On this basis, it can be
concluded that this filling material is ideal for the initial
treatment for carious lesions, not only by restoring the lesion
itself with a clinically proven material, but by exerting a
prophylactic effect on adjacent proximal surfaces through a
continuous release of fluoride.

References
1. Tetric Evo Ceram and Syntac are registered trademarks of Ivoclar
Vivadent Limited
2. Filtek Z250 and Filtek Supreme XT are registered trademarks of 3M
3. Venus Diamond is a registered trademark of Hereaus Kulzer

Fig. 5 Asmussen E, Peutzfeldt A (2002). Long-term fluoride release from a


glass ionomer cement, a compomer, and from experimental resin
Fig. 5.2,3 Flexural Strength under 4-point loading (Lohbauer, composites. Acta Odontol Scand. 2002 Mar;60(2):93-7.
2013 and 2009)
Blackwell G (1993). US patent 5,218,070: Dental/medical composition
and use.

Engelbrecht J (1989). US patent 4,872,936: Polymerizable cement


mixtures.

Frankenberger R (2013). Study report 14.1460.

Frankenberger R (2009). Study report 14.1351.

Krämer N, Frankenberger R (2007). Compomers in restorative therapy


of children: a literature review. Int J Paediatr Dent. 17:2-9.

Krejci I, Gebrauer L, Häusler T, Lutz F (1994). Kompomere –


Fig. 6 Amalgamersatz für Milchzahnkavitäten? Schweiz Monatsschr
Zahnmed 104: 724–730.
Fig. 6. Flexural fatigue limit (Lohbauer , 2013 and 2009)
Lennon ÁM, Wiegand A, Buchalla W, Attin T (2007). Approximal caries
developmentin contact with fluoride releasing and non-fluoride
10 Year Clinical Data releasing restorativematerials – an in situ study. Eur J Oral Sci
The University of Munich conducted a study to assess the 115:497-501.
suitability of Dyract for permanent restorations in the posterior
region (Hickel, 2013). Three groups were set up, comparing Lohbauer U (2013). Study report 14.1461.
Lohbauer U (2009). Study report 14.1436.
Dyract/Xeno® III with QuiXfil®/Xeno III and Tetric
Manhart J, Hickel R (2013). Report 10-year recall 4.361.
Ceram/Syntac1 to test annual failure rates. Ten years after
placement, 102 of the restorations were examined by Wiegand A, Buchalla W, Attin T (2007). Review on fluoride-releasing
independent experts. The annual failure rate in the restorative materials--fluoride release and uptake characteristics,
Dyract/Xeno III group was 1.8%, this was not statistically antibacterial activity and influence on caries formation. Dent Mater.
different from the failure rate of the Tetric Ceram/Syntac group 23:343-62.

Dynamics 15
Dynamics

Air Polishing
Salim Rayman, R.D.H., M.P.A.
Associate Professor, Dental Hygiene Program
Eugenio Maria de Hostos Community College of the City University of New York
Email: srayman@hostos.cuny.edu Telephone: 718.319.7945

Elvir Dincer, D.D.S.


Associate Professor, Dental Hygiene Program
Eugenio Maria de Hostos Community College of the City University of New York
Email: edincer@hostos.cuny.edu Telephone: 718.319.7944

Educational Objectives: Indications for use efficient, safe and effective in removing
1. Discuss the indications for use of air Coronal polishing is a cosmetic procedure extrinsic stain and plaque biofilm for tooth
polishing designed to remove extrinsic stains from surfaces.5 It is equally effective in
2. Review the science of air polishing the enamel surfaces of the teeth. This decreasing root surface roughness after
including advantages and benefits of can be accomplished by abrasion and instrumentation.6 It is also reported to
using air polishing erosion of the extrinsic stain. The most remove plaque biofilm and staining as
3. Implement appropriate air polishing common technique for stain removal is effectively as a rubber cup and does so in
technique rubber cup polishing. This technique uses less time.2 Patients exhibit extensive
4. Understand maintenance of air an abrasive polishing agent and a slowly staining on root surfaces, specifically on
polishing systems revolving polishing cup to abrade stain areas of recession and at the
from the tooth surface.3 Air powder cementoenamel junction. Removing
polishing is accomplished by erosion of those stains with a curet, has shown to
extrinsic stains by suspended abrasive have reduced root structure. However,
Introduction particles within a moving fluid. Kinetic when stain removal is for aesthetic
The concept of air polishing is based on a energy propels the air powder polishing reasons, the air-powder polisher is
technology developed by Dr. Robert Black slurry particles against the tooth surface preferable to the curet. The air-powder
in 1945. Dr. Black invented a device thus removing stain.4 (Figure 1) polisher removes less root structure than
called the Air Dent which used the curet in simulated three month recalls
compressed air, water and a highly Before for three years. The stain was also
abrasive powder to eliminate pain from removed more than three times faster
cavity preparation, making anesthesia with the air-powder polisher.5 Using the
unnecessary. While the Air Dent air-powder polisher also creates less
presented many problems, the technology discomfort for patients who have dentinal
became the first step in air polishing hypersensitivity because the sodium
devices. Air polishing was first marketed bicarbonate particles embed in the
in 1976 and from then forth it became Fig. 1 dentinal tubules, lessening dentinal
widely available.1 Air powder polishing is hypersensitivity discomfort almost
After
accomplished by the propulsion of immediately.7 In vitro, research has shown
abrasive particles through a mixture of that there is little or no disruption of
compressed air and water through a enamel, cementum, and dentin surfaces
handpiece nozzle.2 The handpiece nozzle with air-powder polishing.8 Other research
through which the slurry is propelled is points out that air-powder polishing can
activated with a foot control. The psi render cementum surfaces uniformly
produced depends on the type of air smooth, compared to traditional polishing
powder polisher being used. Air powder Fig. 1 or the use of curets.5
polishers are manufactured hand piece Fig. 1. Removal of extrinsic stains
units that attach directly to the air/water (Image courtesy of Yosi Behroozan, The air-powder polisher can remove
connector on the dental unit, as separate DDS/DENTSPLY Professional) subgingival bacteria through the Venturi
units, or in combination with an ultrasonic effect. This occurs when the air-water -
scaler. The air-powder polisher is shown to be powder spray is directed at a 90 degree

16 Dynamics
Dynamics

angle to the interproximal spaces so that disruption to porcelain, the luting agent or dentin are structures that are not as
a vacuum is created that extracts tissue can be removed causing a compromise in mineralised as enamel therefore more
fluids, including subgingival bacteria from the margin integrity that could quickly lead susceptible to abrasion. In addition,
the subgingival space.9 The air-powder to decay.4 patients that present with active
polisher has been used for debridement periodontal conditions with soft and
of Class V abraded areas before spongy tissue, the air-powder polisher
placement of glass ionomer cements. can be susceptible to air embolism or
When compared to cleaning the area with small blood clots. Lastly, pediatric patients
a rubber-cup polisher, the air powder with deciduous teeth or newly erupted
polished tooth had less microleakage permanent teeth are contraindicated.
around the enamel-cement interface.10
Similar results were noted when using the Patient Preparation
air-powder polisher before sealant Fig. 2. Jet Fresh It is with utmost importance that before
application. It was reported to be superior sodium free using the air-powder polisher, the clinician
to rubber-cup polishing in preparing Fig. 2
prophy powder must prepare both themselves and the
enamel for etching and sealants.11 patient. Patient preparation would include
Deeper resin penetration into enamel and Patient Assessment a thorough explanation of the procedure,
increased sealant bond strength was also Due to the various indications and review of medical history and taking of
reported in comparison with traditional contraindications for use of the air-powder blood pressure. Clinician should place a
polishing with pumice and water.12 In polisher, the patient assessment and disposable or plastic drape over patient’s
addition, clinicians prefer using the air- treatment planning are critical. Patient clothing, provide the patient with safety
powder polisher on orthodontic patients assessment includes a thorough health glasses and removal of contact lenses. In
and research has shown that it does not history evaluation to rule out patients on addition, position the patient more upright
affect the bracket adhesive system. a physician-directed sodium restricted and apply non-petroleum lubricant to the
diet and hypertension. However, the lips to protect from the abrasive spray
Types of Powder amount of sodium bicarbonate ingested which can dry the lips. When the clinician
The most common type of abrasive during air polishing is not sufficient to performs air-powder polishing, aerosols of
particle used with the air-powder polisher cause an increase in blood pressure or microorganisms that contaminate
is sodium bicarbonate, which is treated to blood levels of sodium or alkalosis.16 surfaces several feet from the operative
be free-flowing with calcium phosphate Patients that are contraindicated also site have been reported. Therefore,
and silica. Sodium bicarbonate is a food include those with end-stage renal instructing the patient to use an
grade material and each particle is disease, immunocompromised, antimicrobial preprocedural rinse, such as
approximately 74 mcm in size.13 The communicable infection, Addison’s 0.12% chlorhexidine, reduces bacterial
Mohs hardness number for sodium disease or Cushing’s disease. In addition, contamination of aerosols.18
bicarbonate is 2.5, compared to pumice, patients who have respiratory problems
which has a Mohs hardness number of 6. such as chronic obstructive pulmonary Air-powder polishing unit and operator
Sodium bicarbonate is safe for use on disease or any condition that interferes preparation
enamel, amalgam, gold, porcelain, with breathing or swallowing should avoid The clinician should be appropriately
implants (titanium), and orthodontic this treatment. These patients are protected when performing air-powder
materials. However, should be avoided on compromised by the aerosols created by polishing. The use of standard
all types of composites, glass ionomers, air-powder polishing and they are also precautions, which include wearing fluid
and luting agents (cements).13 When used vulnerable to the development of resistant protective apparel, face shield or
on implants, air polishing with sodium pneumonia.4 Contraindications for using protective safety glasses with side shield,
bicarbonate, should not be directed the air-powder polisher also include gloves and well-fitting mask with high
subgingivally, thus it is the method of patients taking potassium, anti-diuretics or filtration capabilities.19 In addition, due to
choice for decontamination of implants.14 steroid therapy which can disrupt the the high aerosols contamination the use
acid/base balance. of a high-speed evacuation system is
A sodium free powder for air powder recommended. Clinicians should always
polishing is available. (Figure 2. Jet Contraindications for use of the air- follow the manufacturer’s directions for
Fresh from DENTSPLY). It was powder polisher also extends to the hard use specific to the air-polishing unit being
developed for patients who are sodium and soft tissues therefore, the dental used.
intolerant. This powder is made of history assessment is paramount. Hard
aluminum trihydroxide, which has a Mohs tissue that is present with any composite Unit preparation includes obtaining all the
hardness number of 2.5 to 3.5 and a resins, sealants or glass ionomers should necessary equipment such as the air-
particle range in mesh size from 80 mcm be avoided due to susceptibility of surface powder polishing unit and abrasive
to 325 mcm. Aluminum trihydroxide roughness or pitting. Porcelain margins powder according to patient selection.
powder is safe for enamel, however, it is and margins of all restorations can be The unit and hand piece nozzle is
too abrasive for use on other tooth altered by extensive exposure of the air- prepared according to manufacturer’s
structures and its use should be avoided powder polisher which can lead to loss of instructions and the powder compartment
on all dental materials.15 While aluminum marginal integrity, surface roughness, filled with the appropriate product for the
trihydroxide use does not cause surface staining and pitting.1 Exposed cementum device being used (Figure 3).
Continued over page >>>

Dynamics 17
Dynamics

<<<<Continued from previous page


The unit should be turned on for at least eliminates the use of exact angulations amount of water and powder coming from
15 seconds to eliminate residual powder with cup/nozzle, use of gauze, hand the unit before activation in patients’
or moisture in the lines. Also, water lines cupping and patient positioning. Other mouth so to test the sensitivity of the
need to be flushed before use, according advantages to the Aerosol Reduction alternating cycles and to confirm the
to the recommendations of the Center for device are that it minimises the possibility powder to water ratio.20
Disease Control and Prevention.20 When of tooth abrasion since the cup is placed
filling the chamber with abrasive powder on the tooth as with traditional polishing The clinician should establish and
the unit must be turned off and filled with techniques. When using the Aerosol maintain a systemic pattern when using
powder to the top of the center tube. The Reduction device the clinician must follow the air-powder polisher. The nozzle tip
clinician can place their finger over the manufacturer’s instructions on should be an appropriate distance from
tube in the middle of the chamber to assembling and disassembling. This the tooth surface which is approximately
prevent powder from blocking the air line. aerosol reduction device contains two 3mm to 4mm. Holding the nozzle further
Next, the clinician needs to use the parts, a disposable cup that attaches to away from the tooth surface is not
control on top of the powder chamber cap the air powder polisher nozzle and a clear recommended because it minimises the
to adjust the powder flow according to tube extension which is attached to the abrasive action and increases aerosol
patient’s needs. For patients with heavy saliva ejector or HVE. production. Cupping the lip with the index
stains the control knob should be turned finger and thumb to pool water in
to H for heavy powder flow, approximately vestibule minimises aerosol and eases
12 o’ clock position. For patients with light evacuation. The nozzle tip should also be
staining, the control knob should be set at angled diagonally so that the spray is
L for reduced powder flow which is directed toward the middle third of the
approximately the 6 o’clock position tooth. The clinician will use a constant
(Figure 4). circular motion, sweeping or paint-brush
motion from interproximal to
Fig. 5 interproximal. In addition, a systematic
approach by polishing one or two teeth at
Fig. 5. Aerosol Reduction device
a time will ensure that all tooth surfaces
(Raintree Essix)
are adequately polished. Alternate cycles
Clinical Technique of full-compression powder-spray and
There is a universal air-powder polishing half-compression rinse every two or three
technique that can be used with all types teeth will increase efficiency and patient
Fig. 3 of systems, however manufacturers may comfort.20 The clinician must polish each
Fig. 3. Fill the powder chamber with an have different instructions for their tooth for approximately 1 to 2 seconds
abrasive recommended by the equipment.4 The recommended technique and should avoid loss of tooth structure by
manufacturer prevents undue aerosols from deflecting subjecting the tooth to no more than ten
back to the clinician or being directed into seconds of air polish slurry. Root surfaces
the patient soft tissues. The use of high should also be avoided or less time spent
speed evacuation or Aerosol Reduction because they abrade more rapidly than
device is the most efficient control of the enamel.
aerosol spray. While positioning of the
patient and operator are basically The DENTSPLY Cavitron Jet Plus has a
unchanged, direct vision and access Tap-On™ technology (Figure 6) which
become fundamentally important when eliminates the need for the clinician to
the polisher is active.20 Positioning the pump the pedal by automatically cycling
Fig. 4 patient slightly upright at 45 degrees with between rinse and polish. This Tap-On™
Fig. 4. Powder control knob the patient’s head toward the operator technology works by way of tapping the
and reclining to treat maxillary lingual foot pedal once which will enable an
An aerosol-reduction device that connects surfaces provide a better field of vision automatic air polishing/rinse cycle that
the saliva ejector or high speed and increase patient comfort. Placing lasts for approximately one minute and
evacuation system to the air-polisher moistened 2” x 2” gauze square over the tapping the pedal a second time disables
hand piece has been shown to be tongue or on the patient’s lip near the the automatic air polishing/rinse cycle.
effective in controlling and reducing air- work area will help reduce burning and The DENTSPLY Cavitron Jet Plus™
powder aerosols, thus decreasing the stinging experienced by some patients. device autocycles work via short, medium
potential for disease transmission.21 This The rheostat has two compressions and long settings (Figure 7) and are
device which is referred to as an Aerosol levels; full compression releases the timed cycles of one minute that
Reduction device, reduces or eliminates aerosol powder-abrasive from the tip and automatically alternate between air
the visible aerosols normally produced halfway compression produces a stream powder polishing and rinse (water only)
during air-powder polishing. Additionally, of water for rinsing and cleaning. It is without having to use the foot pedal to
the Aerosol Reduction device (Figure 5) recommended that the clinician check the alternate between the two.

18 Dynamics
Dynamics
A single tap to the foot pedal starts each Completion of air-polishing procedure plaque. J Periodontal. 1984;55:486-488.
one minute cycle and each cycle begins At completion of the air-polishing 3. Nield-Gehrig JS. Fundamentals of Periodontal
Instrumentation and Advanced Root
with a 2 to 3 second stream of water. The procedure the clinician should rinse the
Instrumentation. 6th ed. LWW; 2008:599.
“short” autocycle is a .75 second of air- teeth thoroughly, floss all interproximal 4. Barnes, CM. An In-depth Look at Air Polishing.
powder polishing followed by a 1.25 surfaces and inspect the teeth for any Dimensions of Dental Hygiene, 2010; 8 (3): 32, 34-
seconds rinse; the “medium” autocycle is remaining stain. Thorough rinsing is 36, 40.
a 2 second air-powder polishing followed essential after air powder polishing 5. Berkstein S et al: Supraginvial root surface
removal during maintenance procedures utilising
by a 1 second rinse; the “long” autocycle because of the basic nature of the sodium
an air-powder abrasive system or hand scaling. J
is a 3 second air-powder polishing bicarbonate.20 If stain is still present, Periodontal 1987; 58:327-330
followed by a 2 second rinse. The reinstrumentation and or use of the air 6. Leknes KN, Lie T. Influence of polishing
“manual” cycle setting uses the Tap On™ powder polisher may be indicated. Any procedures on sonic scaling root surface
foot technology control to manually debris should be wiped off the patient’s roughnesss. J Periondontal 1991; 62:659-662.
7. Bester SP, de Wet FA, Nel JC, Dressen CH. The
alternate between air-powder polishing face with a moist towel and offer
effect of airborne particle abrasion on the dentin
and rinse. additional lip balm. The Aerosol Reduction smear layer and dentin; an in vitro investigation.
device should be disposed of and the Int J Pros. 1995; 8:46-50.
nozzle should be cleaned with a wire- 8. Gutmann ME. Air polishing: a comprehensive
cleaning tool to prevent clogging. Nozzle review of the literature. J Dent Hyg. 1998:73:47-
56.
tips must be autoclaved after each use
9. Barnes CM. The management of aerosols with air
and the entire unit should be disinfected polishing delivery systems. J Dent Hyg.
with an Environmental Protection Agency 1991;65:280-282.
approved disinfectant. Using a disposable 10. Cooley RL, Lubow RM, Patrissi GA: The effect of
barrier will help minimise disinfecting an air-powder abrasive on glass ionomer
microleakage. General Dentistry . 1989; 37(1):16-
time.22 At the end of the day the unit
18.
should be turned off, remove powder from 11. Garcia-Godoy F, Medlock JW: An SEM study of
chamber and discard the unused powder the effects of air-polishing on fissure surfaces.
to prevent clogging of lines. Also, keep Quintessence Int. 1988; 7:465-467.
Fig. 6 12. Brocklehurst PR, Joshi RI, Northeast SE. The
powder chamber and air lines free of
effect of air-polishing occlusal surfaces on the
Fig. 6. DENTSPLY Cavitron Jet Plus moisture, which can cause the system to
penetration of fissures by a sealant. Int J Paediatr
with Tap-On™ technology fail.22 The clinician will then remove any Dent. 1992; 2:157-162.
residual powder from the chamber with a 13. Barnes CM, Hayes EF, Leinfelder KF. Effects of
HVE and activate the unit for an airabrasive polishing system on restored
approximately fifteen seconds to clear any surfaces. General Dentistry. 1987; 35(3):186-189.
14. Barnes CM, Fleming LS, Mueninghoff LA. SEM
powder remaining in the chamber.
evaluation of the in-vitro effects of an air abrasive
system on various implant surfaces. Int J Oral
Conclusion Maxillofac Implants. 1991; 6:463-469.
Therapeutic polishing is the removal of 15. Johnson WW et al. An in-vitro investigation of the
toxins from the unexposed root surfaces, effects on an aluminum air polishing powder
delivered via the Prophy Jet on dental restorative
which results in a decrease in disease
materials. J Prosthodont. 2004; 13:1-7.
parameters. Polishing root surfaces is 16 . Snyder JA, McVay JT, Brown FH. The effects of
possible with both the rubber-cup or air- air abrasive polishing on blood pH and electrolyte
powder polisher, however the rationale for concentrations in healthy mongrel dogs. J
selecting the air-powder polisher is for its Periodontol. 1990; 61:81-86.
17. Glenwright HD, Knibbs PJ, Burdon DW.
effectiveness and efficacy.20 The clinician
Atmospheric contamination during use of an air
Fig. 7 should follow the precautions and polisher. Br Dent J. 1985; 159(9):294-297.
considerations presented when polishing 18. Worral SF, Knibbs PJ, Gelenwrikght HD. Methods
Fig. 7. Settings: Manual, Short, for therapeutic benefits with the air- of reducing bacterial contamination of the
Medium, and Long atmosphere arising from use of an air-polihser. Br
powder polisher. The clinician should be
Dent J. 1987; 163:118-119.
aware to direct the air-powder spray
19. Molinari JA. Face masks: effective personal
When air-polishing the anterior teeth the against the tooth surface, not the exposed protection. Compend Cont Educ Dent. 1996;
tip should be directed at a 60 degree angle soft tissues. Most importantly the clinician 17(9):818-821.
to the tooth, posterior teeth an angle of 80 must consider all options; aesthetic, 20. Daniel SJ, Harfst SA, Wilder RS. Mosby’s Dental
degree and for occlusal surfaces a 90 therapeutic, and patient goals, when Hygiene Concepts, Cases and Competencies.
2nd Ed. St. Louis, Mosby;2008: 615.
degree angle is recommended. If using designing a treatment plan that meets the
21. Muzzin KB, King TB, Berry CW: Assessing the
the Jet Shield, the clinician will apply the patient specific needs. clinical effectiveness of an aerosol reduction
disposable cup (attached to the nozzle) to device for the air polisher. J AM Dent Assoc. 1999;
the middle third of the tooth with light References: 130(9):1354-1359.
pressure to flare the cup. The clinician will 1. Gutmann ME. Air polishing: A comprehensive 22. Cooper MD and Wiechmann L. Essentials of
review of the literature. Journal of Dental Hygiene, Dental Hygiene Clinical Skills. New Jersey,
then pivot the nozzle inside the cup to
Vol. 72, Number 3, 1998, 47-56. Pearson;2006:115-123.
adapt to all areas of the tooth surface and 2. Weaks, LM, Lescher NB, Barnes CM, Holroyd SV.
polish for two seconds of spray for each Clinical evaluation of the Prophy-Jet as an
segment of tooth. instrument for routine removal of tooth stain and

Dynamics 19
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