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Scan perfectly with CEREC Primescan and gain time for what is really important: your patients

Initial situation of tooth #37. (Image: Dr Bernhild-Elke Stamnitz, Germany)

Dr Bernhild-Elke Stamnitz

Wed. 24. July 2019

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At a practice in which digital technologies have been prioritised right from the start, new devices are a real pleasure rather than a duty. That’s why Dr Bernhild-Elke Stamnitz, from Langen in Germany, was delighted to be one of the first dentists to be able to use CEREC Prime scan, the new intraoral scanner from Dentsply Sirona, for her daily work. As a CEREC coach, she is very familiar with digital impressioning, but she is convinced from her first experiences with the device that CEREC Primescan represents a great advance in quality.

“I simply love new technologies,” explains Dr Bernhild-Elke Stamnitz. She has her own fully digital practice, which she has been running in Langen since 2004. During her studies in Heidelberg in Germany, she had her first encounters with CAD/CAM technologies in dentistry. “At the time, it was a long way from being perfect, but in my opinion, the idea behind it was groundbreaking,” she says. “Whereas in the early days of digital impressioning, we still asked ourselves which indications it could really be used for; today we ask ourselves: where can’t it be used?”

For Dr Stamnitz, the advantages are obvious. “First of all, it’s simply faster,” she explains. “One only has to consider the various steps of the process: lay out trays of various sizes and try them for size. Afterwards, all of them have to be prepared for use. Then the material for the impressioning has to be selected, and the first time it might not work perfectly so you have to repeat some steps. All of that can be omitted if you use digital impressioning.” She also sees digital impressioning as providing a path to greater sustainability because nothing has to be thrown away afterwards, and the need to store materials is reduced. Most importantly for Dr Stamnitz, the focus is centred more on the patient. “Digital technologies are also a great communication tool. During digital impressioning, the patient experiences what’s going on, can see the situation in his or her mouth on the screen and is far better able to understand where and why the treatment is necessary.”

Fig. 1: Initial situation of tooth #37.

Fig. 2: Scan of lower jaw, with prepared tooth #37.

Fig. 3: The preparation margin is automatically delineated by the software, but if desired, it can be adjusted manually.

Fig. 4: The user interface for designing the restoration, which can be operated via the touch screen.

Fig. 5: The user interface for the beginning of the restoration of the crown.

Fig. 6: Final situation of tooth #37.

“Very good” to “simply better”

Once she recognised it as correct and appropriate for her practice, Dr Stamnitz could no longer imagine doing her daily work without digital impressioning. In her opinion, the technology in this area has developed enormously in recent years. On the one hand, this is thanks to the software updates. The calculation of the 3D models, the quality of the initial suggestions and the accuracy of fit have improved constantly. On the other hand, the CEREC Primescan intraoral scanner, which has now entered the marketplace, speeds up and simplifies the process noticeably and produces results that have hardly been possible until now. “Impressioning was already really good before, but now it is simply better.”

In her opinion, this can be demonstrated by several points. With CEREC Primescan, scans can be done in situations where the patient shows signs of periodontally damaged teeth, which are characterised by long crowns and exposed areas of roots. If subgingival preparations need to be made, the scanner can also reach those positions. “Until now, that has been an issue that many people have raised as an argument against digital impressioning,” says the CAD/CAM expert. “Places that are difficult to reach can easily be captured with Primescan without having to make too much effort with the scanner. That really is a great advantage.” Another important improvement is the representation of the margins of the prosthesis. This is very important for the further processing of the scan, because on the one hand, it simplifies the further process of design and fabrication when manufacturing the restoration in the practice, and on the other hand, the scan reliably delivers all the information that the technician requires. He or she can work on the model and can set the occlusion and articulation with ease. Dr Stamnitz mostly works chairside (“I make up to three teeth directly beside the chair”), but she also hands over larger jobs to her dental technician in the in-practice laboratory. “Overall, it is a very useful concept for the practice,” says Dr Stamnitz. “Digital impressioning makes sense, from both a clinical and an economical perspective,” she explains. “But the additional advantage for the patients, who really appreciate the ‘digital experience’, and talk about it to others, is just as important.”

CEREC Primescan—A practical test

A case history demonstrates how CEREC Primescan proves its worth in everyday practice. A patient came to the practice with an inadequate crown, with secondary caries, in position #37. After excavation, a new CEREC crown was to be mounted. In order to do so, the new acquisition centre, CEREC Primescan AC, with its significantly larger, tiltable touch screen, was first disinfected. Thanks to the seamless surfaces, it is possible to do so quickly, thoroughly and simply, at any time. Before beginning with the scans, the patient data was retrieved in CEREC Primescan AC, and a new case was created. Overall, the scanner was used three times during treatment: after preparation of the lower dental arch with tooth #37, for the scan of the opposing dental arch and for the scan of the buccal bite on both sides.

All of that could be delegated to an assistant, but the experienced CEREC user prefers to do it by herself: “I am interested in this technology, and—I’ll be completely honest— scanning is so much fun.”

After removal of the inadequate crown and the final preparation, it was time to use the CEREC Primescan. Dr Stamnitz describes it as follows: “As a long-time user of a CEREC Omnicam, I realised immediately that CEREC Primescan felt different in my hand. The scanner is even better balanced. The actual scanning is quick and easy—partially due to the fact that I don’t have to consider specific scanning angles or scan procedures. It all went intuitively and fluidly. The full dental arch scan was completed in less than a minute, which certainly cannot be taken for granted. What made it really special was that the patient was immediately able to see the results on the monitor with me. The scan was converted into a 3D image immediately. Compared with previous scanners, I noticed immediately that it is also able to scan other materials, such as gold crowns. Therefore, no information on the adjacent teeth or antagonists was lost. I consider that to be real progress.”

After the scan, the software automatically delineates the preparation margin. If so desired, the margin can be adjusted manually. “I find that to be a great advantage,” says the digital expert, “because that way I can decide for myself every time whether I want to accept the suggestion—which, by the way, I generally do with a clear conscience.” It is operated via the touch screen (which replaces the trackball), a tool that many users, including Dr Stamnitz, wished for. Finally, the CEREC Software 5 made an initial suggestion. “I also always look at this very carefully,” she says. “The software can do a lot. I am often surprised at how good the suggestions are. Mostly, as in this case, I am very satisfied after just a few minor adjustments.”

The software learns together with the user

The reason for the significantly improved initial suggestions with the CEREC Software 5 is the use of artificial intelligence. With immediate effect, the new generation of software learns, together with the user, so that it is able to create even better initial suggestions for future versions. Not only are the initial suggestions for the crown improved by artificial intelligence, but the entire workflow is supported by the software in many areas. In this way, the indications for the restoration are automatically recognised, and the preparation margin is delineated. The axis for the model is also set fully automatically.

Dr Stamnitz is fascinated by working directly on the screen: “The workflow is very simple, and thanks to the operation via the touch screen, I can maintain my concentration. I can keep my eyes on the screen constantly.” During the design and preparations for making the crown the patient was there, and she could watch her dentist at work. “In cases like this, the treatment experience is always something very special for my patients,” Dr Stamnitz remarks. “They are included at all times, they are able to ask questions and they can experience, live, how the crown is made.” This one was milled from a Celtra Duo block (Dentsply Sirona), a zirconia-reinforced lithium silicate with excellent aesthetic properties and a high degree of stability. The crown was ready after just 11 minutes. Even during fitting, it was evident that it was a perfect fit. The crown was individualised and glazed with colour and glazing material. Then it was cemented into the patient’s mouth with a high-strength, dual-curing composite cement adhesive (Calibra Ceram, Dentsply Sirona). In this case, the overall time required for the treatment was about 90 minutes. This proved to be particularly advantageous to the patient, who was pressed for time.

Better quality in less time

The accuracy of the scan and the speed of the data acquisition and processing obviously have an effect on the end result—to an experienced user, this becomes apparent immediately. The structure of the crown, especially on the edges, is highly dependent on the quality of the impression, and this is where it pays to use CEREC Prime scan. Dr Stamnitz: “Thanks to the new CEREC Software 5, the ground or milled restorations are worked even more finely and in more detail—and all of this in an even shorter process, from scan to insertion. I spend the time I save on the entire process on my patients. We gain the time to build up a good relationship with them. We are not simply treating a tooth. We are dealing with a patient every time. That’s exactly who should be the centre of focus, because there is more to the lovely smile we help patients to achieve than just attractive, healthy teeth.

Editorial note: This article was published in CAD/CAM - international magazine of digital dentistry No. 02/2019.

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Broken file management is one of the most challenging parts of endodontic treatment. Regardless of whether the clinician is faced with a retreatment involving retrieval of the broken file or with a file breaking during the primary root canal preparation, the situation usually affects the success rate of treatment.

As is well known, one of the most important factors in root canal treatment is the eradication of the biofilm. The broken file is not a problem per se, but it is an obstacle to proper disinfection. In some cases, removing the broken file requires sacrificing a large amount of very precious peri-cervical dentine. Therefore, in every case, the clinician has to consider all the benefits and disadvantages of the retrieval and decide whether is it worth removing the broken file, leaving it in place or trying to bypass it.¹

The advantages of SWEEPS technology

As mentioned, one of the most important factors of endodontic treatment is root canal disinfection. Usually around the broken file, there is a great deal of accumulated hard-tissue debris, and if the broken file is located in the middle part of the root, the disinfection of the apical part of the canal may be insufficient.

The novel SWEEPS (shock wave-enhanced emission photoacoustic streaming) irrigation technique offers the clinician an easier and more predictable means of managing broken files. The basic principle of the technology is the delivery of synchronised pairs of ultra-short pulses, which create primary cavitation in the vicinity of the fibre tip, followed by secondary cavitation in the remote, difficult-to-reach apical areas. This phenomenon creates shock waves that spread in all directions at a speed of up to 10 m/s—so the impulse reaches 10 mm in depth in just 0.001 seconds.²Moreover, the available data shows that the removal of accumulated hard-tissue debris with the Er:YAG laser is very efficient³and three times more efficient than passive ultrasonic irrigation.⁴

Fig. 1: Pre-op radiograph. Periapical lesion and broken file visible.

Fig. 2: Pre-op CBCT scan. Broken file far beyond the canal curvature.

Fig. 3: Pre-op CBCT scan. Tip of the broken file located below the junction of the mesiobuccal and mesiolingual canals.

Case 1

The patient was referred to the office after failure to retrieve a broken file. After enlarging the canal and attempting to remove the file, the previous operator gave up the treatment. The tooth was symptomatic, so the patient wanted to proceed with the file retrieval and root canal treatment.

The periapical radiograph and the CBCT scan revealed that the file had broken far beyond the curvature in the mesiobuccal canal and below the junction with the mesiolingual canal. Also, a periapical lesion was visible around the apices of the mesial and distal roots (Figs. 1–3). The length of the file was approximately 5 mm. Bypassing the file through the mesiolingual canal would have been a risky procedure because it may have caused the fracture of the second instrument and the obturation may also have been very challenging. Thanks to SWEEPS technology and a bioceramic sealer, an alternative approach could be taken. After administering anaesthesia and placing a dental dam, the temporary restoration was removed (Figs. 4 & 5). The pulp chamber was rinsed with 5.25% sodium hypochlorite and the irrigant activated with ultrasonics. After cleaning the chamber of the tooth, the dental dam and clamp were rinsed with water and dried and flowable dental dam was placed to seal the tooth and enlarge the space in the pulp chamber for the laser-activated irrigation (Fig. 6). Activation was performed with the SkyPulse laser (Fotona). The AutoSWEEPS mode was chosen. The power of activation was set to 1 W. The flat SWEEPS 300/20 fibre tip was used (Fig. 7). The tip was placed slightly below the orifice of the mesiobuccal canal for the majority of the irrigation with sodium hypochlorite. After 120 seconds of activation with sodium hypochlorite, the tip was placed in the pulp chamber to activate the sodium hypochlorite in all the canals simultaneously for 30 seconds. This procedure was continued for 30 minutes. Only the distal canal was shaped with rotary files, up to size 40/.04. Both mesial canals remained the same size as they were before the file broke during the primary treatment. Finally, the canals were flushed with EDTA activated with AutoSWEEPS at a power of 0.4 W, and sodium hypochlorite was activated for three cycles with AutoSWEEPS at a power of 0.6 W and with a 30-second break for the resting phase. The irrigant flow between the mesiobuccal and mesiolingual canals was rapid, indicating that obturation could be performed.

The canals and chamber were dried with micro-suction and paper points (Fig. 8). A bioceramic sealer (CeraSeal, META BIOMED) was used in the piston technique. The sealer was injected in all canals and covered with flowable gutta-percha in the orifices (Fig. 9). Periapical radiographs were performed, and they revealed that the root canals had been filled correctly, showing puffs of sealer in the periapical area (Figs. 10 & 11).

Fig. 4: Treated tooth after dental dam isolation. Damaged temporary restoration.

Fig. 5: Tooth after removal of the temporary restoration.

Fig. 6: Tooth after removal of the caries and sealing of the chamber with flowable composite and dental dam.

Fig. 7: Fotona 300/20 laser tip.

Fig. 8: Pulp chamber after the irrigation protocol.

Fig. 9: Pulp chamber after obturation with the piston technique.

Fig. 10: Post-op radiograph. Puffs of the sealer visible.

Fig. 11: Mesially shifted post-op radiograph.

Case 2

The patient came to the office because of moderate pain connected with the mandibular right first molar. A periapical radiograph and CBCT scan were performed. The images revealed radiolucency around the mesial root of the molar. Also, two pieces of a broken instrument were visible, one in the middle part of the root, before the curvature, and the other slightly below the curvature (Figs. 12 & 13).

Fig. 12: Pre-op CBCT scan. Periapical lesion visible.

Fig. 13: Pre-op radiograph. Two pieces of the broken file visible.

After administering anaesthesia and placing a dental dam, the composite restoration was removed, and a temporary restoration with flowable composite and flowable dental dam for the root canal treatment was performed (Figs. 14–17). After removing the filling material from the mesiolingual and distal canals, access to the broken file was performed. The first piece of the instrument was removed with the ultrasonic tip (Fig. 18), and the tip of the second piece of the file then became visible. Unfortunately, the removed file piece broke in the middle and only the coronal part could be retrieved (Fig. 19). Because the apical part of the broken file was invisible and did not emerge from the canal during the irrigation and activation, an attempt at bypassing it was made. Analysis of the CBCT scan did not reveal a clear answer as to whether there was one apical foramen, so during the bypass procedure through the mesiolingual canal, a periapical radiograph was performed. The radiograph indicated that either there was a ledge in the apical area or there were two separate apical foramina (Fig. 20). For the irrigation protocol, the AutoSWEEPS mode was used at 1.2 W power with the flat SWEEPS 300/20 fibre tip. The tips of both mesial canals were placed below the orifice. The Less-Prep Endo protocol was performed twice in the manner described elsewhere.⁵ After the irrigation, irrigant flow between both canals was rapid.

The canals were dried with paper points and micro-suction (Fig. 21). After the irrigation protocol, there was still a lack of patency and tugback was achieved only in the mesiolingual canal. The mesiobuccal and distal canals were filled with an epoxy resin sealer and warm gutta-percha (squirting technique), and the mesiolingual canal was filled with a 30/.04 gutta-percha cone with the continuous wave of condensation technique (Fig. 22). A distally shifted periapical radiograph was performed (Fig. 23). The radiograph revealed a puff of sealer in the periapical area of the mesial root and the isthmus filled with the sealing material. A composite material was placed into the access cavity, and the patient was scheduled for the control appointment. At six months and 12 months, CBCT scans were performed (Figs. 24 & 25). The images found no signs of inflammation in the periapical area, and the tooth was asymptomatic.

Fig. 14: Treated tooth after dental dam isolation.

Fig. 15: Tooth after removal of the composite restoration.

Fig. 16: Tooth after removal of the restoration.

Fig. 17: Tooth after removal of the caries and sealing of the chamber with flowable composite and dental dam.

Fig. 18: First removed piece of the broken file.

Fig. 19: Second removed piece of the broken file.

Fig. 20: Intra-op radiograph confirming lack of bypass and of patency.

Fig. 21: Pulp chamber after the irrigation protocol.

Fig. 22: Pulp chamber after obturation.

Fig. 23: Post-op radiograph. Puff of the sealer visible.

Fig. 24: CBCT scan at the six-month follow-up.

Fig. 25: CBCT scan at the 12-month follow-up.

Case 3

The patient was referred to the office for root canal retreatment of three teeth before prosthodontic treatment. One of these teeth was the mandibular left first molar. The CBCT scan revealed two radiolucent spaces around both roots (Fig. 26). Moreover, the periapical radiograph showed a broken file in the mesiobuccal canal (Fig. 27). After administering anaesthesia and placing a dental dam, the old restorations were removed, a temporary composite build-up was performed, and the tooth was sealed with flowable dental dam (Figs. 28 & 29). The old gutta-percha cones were removed from all the canals (Fig. 30).

Fig. 24: CBCT scan at the six-month follow-up.

Fig. 25: CBCT scan at the 12-month follow-up.

Fig. 26: Pre-op CBCT scan. Two apical lesions visible.

Fig. 27: Pre-op radiograph. Broken files visible.

Fig. 28: Treated tooth after dental dam isolation.

Fig. 29: Tooth after removal of the caries and sealing of the chamber with flowable composite and dental dam.

Fig. 30: Removal of the gutta-percha.

Fig. 31: Apparent over-instrumentation of the root canal orifice, probably performed with ultrasonics during a previous attempt at broken file removal.

Fig. 32: Root canal orifice sealed with flowable composite.

Fig. 33: View of the two broken files together in the mesiobuccal canal.

Fig. 34: One of the retrieved file pieces in the lasso tool.

After the removal of the gutta-percha and cleaning of the root canals, it was apparent that a large amount of the dentine had been removed from the orifice of the mesiobuccal canal (Fig. 31). Most probably, this had occurred during an attempt at removing the broken file in the previous treatment. Fortunately, there were no visible signs of perforation in the orifice. The damaged wall was sealed with composite resin (Fig. 32). Irrigation of the mesiobuccal canal with the AutoSWEEPS mode and sodium hypochlorite and inspection under 16× magnification revealed two pieces of the broken instruments (Fig. 33), complicating treatment. The tips of both files were visible, but both were also jammed. An attempt at removal with an ultrasonic file was ineffective, so the flat SWEEPS 300/20 fibre tip was used with the AutoSWEEPS mode at a power of 1.2 W. After a few minutes of irrigation with sodium hypochlorite and EDTA, both file pieces started to move a little, indicating that both were removable. Both pieces were retrieved with a lasso loop tool (BTR Pen, CERKAMED; Fig. 34). A periapical radiograph was performed to confirm that there were no more broken file pieces (Fig. 35).

After the file retrieval, all the canals were shaped with rotary files, and the final irrigation protocol was performed with the SSP (super-short pulse) mode. After the irrigation protocol, irrigant flow between the mesiobuccal and mesiolingual canals was rapid. The canals were dried. We could clearly see that the orifices of the mesial canals were of very similar ISO size, indicating that the file retrieval had been very conservative (Fig. 36). The canals were filled with an epoxy resin sealer and gutta-percha with the continuous wave technique (Fig. 37). A distally shifted periapical radiograph was performed, and on it, we could see in the mesial root that two parts of the isthmus had been filled with the sealer (Fig. 38). The tooth was restored with a fibre post and referred to the prosthodontist for indirect restoration.

After 12 months, a CBCT scan was performed (Fig. 39). The image found no signs of inflammation in the periapical area, and the tooth was asymptomatic.

Fig. 35: Intra-op radiograph. All pieces of the broken files had been removed.

Fig. 36: Pulp chamber after the irrigation protocol.

Fig. 37: Pulp chamber after obturation.

Fig. 38: Post-op radiograph.

Figs. 39a & b: CBCT scan at the 12-month follow-up.

Fig. 39b

Conclusion

Incorporating the Er:YAG laser into challenging endodontic treatments gives clinicians new possibilities, allowing them to achieve more effective, predictable and conservative treatment in many cases. In some cases, we can loosen the file without using ultrasonic tips, allowing us to be more conservative. Moreover, thanks to the much more effective reduction of accumulated hard-tissue debris, we can clean the space around the broken file to avoid removing the file (for example, if the file broke behind the curvature) and still have successful treatments with less risk of creating perforations in the classic approach to file retrieval.

Editorial note:

This article was published in roots—international magazine of endodontics vol. 19, issue 2/2023. A complete list of references can be found here.