Dr. Thomas Bilski

Simplifying dental therapies that are predictable and reproducible for long-term success along with meeting the patients’ goals can be challenging. Combining multi-disciplinary dental treatments can be achieved with technology and the best quality rotary instruments provided by Komet USA.

Endodontic therapy and post- and core-restorative techniques will transform a potentially terminal dentition into a full arch restoration with minimizing chair time and delivering a less costly treatment plan to a budget-minded patient. The EndoPilot (motor and built-in apex location handpiece) and the F-360 endodontic rotary file system were designed by Komet USA to complete root canal preparations efficiently and swiftly, usually within approximately 3-5 minutes per canal. The design of the rotary file and its flexibility safely negotiates and prepares the canal to the apex of the tooth with exceptional accuracy utilizing 2 to 3 rotary files. This system allows for salvaging teeth that usually were extracted and treatment planned for either complete dentures or high fee all-on-X restorations.

Saving the roots with endodontic therapy of the natural dentition with locator root form attachments and overdenture restorations can service the patient for a considerable amount of time, as well as prepare the patient for future implant dentistry in the event the natural dentition must be extracted. The EndoPilot and F-360 rotary file system is a simplified, reproducible, and predictable endodontic therapy that provides joy for the clinician by reducing intra-canal negotiation and obturation times, therefore reducing chair time. Tortuous and curved root canals are easily negotiated utilizing the pre-sterilized, single-use files, which reduces the risk of the dreaded file separation due to over-worked files. The motor automatically sets the correct torque in the range of 250-300 rpm for the ISO color-matched nickel-titanium F-360 endodontic files. Extirpating and shaping the canal conservatively minimizes over-preparing the dentin and providing an exquisite 0.04 degree tapered final seal and fill.

The following case depicts the combination of endodontic therapy utilizing Komet USA’s EndoPilot with F-360 rotary files for overdenture removable prosthetics with root form locator attachments and dental implants.

Case Report: Mandibular overdenture with endodontic therapy (Komet USA), natural dentition root form locator attachments and Lodi dental implants (Zest Dental Solutions)

Case Report: EndoPilot Technology Expedites Multidisciplinary Dental Therapies

The pre-op panoramic image shows severe periodontitis in the maxilla and mandible (

). The patient initially accepted mandibular incisors to be extracted and a removable RPD. One year later he decided to accept an overdenture with a natural dentition root form locator-supported snap-on prosthesis primarily due to the uncomfortable nature of the removable partial denture. Many adjustments were made to the intaglio side of the RPD with multiple clasp tightenings, resulting in clasp fracture and decreased retention and stability (

Moving forward with a tissue and locator root form attachment-supported overdenture begins with endodontic therapy. The intention of salvaging the natural roots is to develop the foundation for the locators to be received by the tooth just like a post and core following endodontic therapy. Proper dental dam isolation is imperative for the endodontic therapy and the restorative elements of the snap-on restoration to succeed.

Access was developed utilizing an eight-round FG high-speed diamond bur. The preparation for access is conservative, allowing for visual acuity of the canal(s) and initial coronal one-third shaping of the canal with the F-360 initiator (

The video in Figure 9 shows the preparation of the access openings for the canine and second bicuspid, working length determination with a #10 K-File and the series of two file preparation for the canals. The technique followed in this demonstration utilizes only a water-soluble peroxide gel. The F-360 files remove debris and dentin shavings very efficiently.

Throughout this procedure copious irrigation was not used, as too much irrigation can disturb the apex location handpiece and can be difficult to identify the final working length. Sodium hypochlorite irrigation was only used after the final file and working length was determined. The irrigation solution was allowed to remain in the canals for approximately ten minutes.

These two teeth will receive root form locators once the complete overdenture is fabricated. The same endodontic treatment and locator root form attachments were done on the other side, utilizing the canine and second bicuspid as well. The first bicuspids will be extracted at the time of the clinical crown reduction of the canines and the second bicuspids (coronectomy) with intra-oral cold cure pickup of the root form locators and overdenture housings. The four endodontic therapies for the mandibular canines and second bicuspids were completed in one appointment, with a total elapsed time of 43 minutes (

). The pre-op and post-op radiographs show the completed root canals worked up to 35-.04 tapered files (

After the EndoPilot and F-360 endodontic technique has been completed, the restorative workflow begins with analog poly-vinyl impressions along with digital impressions and bite registration. The two impression techniques help the dental laboratory confirm that all needed details have been captured. Once verification of the impressions and bite registration have been accepted, then the virtual setup can be evaluated. The overdenture can be processed with a cast metal reinforcement bar to ensure more stability (

The final overdenture prosthesis is completed and available for the coronectomy appointment along with cementation of root form locators, dental implant placement, extraction of the first bicuspids and cold cure intra-oral pickup of the locator attachments and overdenture housings. The intaglio surface of the overdenture in the locator attachment wells was prepared with a 4mm straight nose cone slow speed lab bur (Komet USA). This intaglio denture well preparation creates space for acrylic and a passive seat of the overdenture, assuring appropriate bonding of the housings during pick up (

The video in Figure 20 shows the initial reduction preparation of the natural dentition (coronectomy) utilizing a carbide 700XXL FG high-speed bur. The preparation for the clinical crown reduction eliminates the tooth to the level of 1 mm above the crest of the gingival tissue and refined with an eight-round FG high-speed diamond bur.

The locator root forms were cemented into the endodontically-treated teeth, extractions were completed atraumatically with the assistance of the 700XXL carbide bur to improve purchase point and elevation of the first bicuspids, and Lodi dental implants were placed all in one appointment. The surgical sites were managed and sutured with 4-0 PTFE sutures (

The overdenture was seated, and cold cure pickup of attachments was completed, finished, and polished with a straight slow-speed handpiece. The dental implants will be loaded 12 weeks following placement to allow for osseointegration (

Following intra-oral pickup of attachments, the occlusion was verified and minimal occlusal adjustments were provided. Minimal occlusal adjustments are normal with digital denture sequencing due to the increasing accuracy of the virtual denture fabrication technology (

The patient was seen two weeks post-op surgery for evaluation of restorative cementation and intra-oral attachment pickup. The patient was doing well, without pain or soft tissue irritation due to the root form locator support providing retention and stability (

Self-esteem issues were evident with this patient. He felt uncomfortable when he was asked to smile pre-op (

). Once he had experienced the increased retention and stability of his Snap-on overdenture, his “Hollywood smile” was displayed (

Time is of the essence when it comes to delivering dental therapies to dental patients. The Komet USA EndoPilot motor and apex location handpiece and the development of the F-360 rotary files have increased the speed of completion for endodontic treatment significantly with accuracy, predictability, and reproducibility. The Komet USA high speed and slow speed burs help expedite procedural tasks as well as reducing chair time for the doctor and staff when completing restorative procedures. Dental practices and their patients certainly benefit from these technologies and products. Endodontics becomes more enjoyable and offers opportunities to expand the growth of the dental practice.

Articles

Read this case study, sponsored by KOMET USA, to learn about technology designed to make multidisciplinary care more efficient.

The following case began with an endodontic treatment plan, but we quickly determined the tooth was fractured and non-restorable.

After the patient was presented with the dental treatment options, we decided to extract tooth No. 12 and to move forward with dental implant placement followed by restoration with a cement-retained, implant-supported crown.

Two kits from Komet USA figure prominently in this case, facilitating a successful and predictable end result. The first is the custom-designed 

Everyday Dentistry Crown Down kit (LD0586) 

Developed in conjunction with ceramics engineers and bur specialists, the kit is a “reverse-engineering” endeavor to create the ideal system for crown preparations. The second kit featured in this case-the MaxilloPrep bone-spreading kit -addresses challenges faced when dealing with insufficient space for implant placement.

How to complete a restoration with a cement-retained, implant-supported crown [VIDEO]

As modern-day dentists, we are faced with a complex set of treatment decisions, compelling us to continually weigh the available therapeutic choices as we push toward optimal patient care combined with efficient and profitable clinical practices. 

Endodontic treatment is one area of dentistry in which the options are plentiful and varied, often leading us to ponder how best to provide conservative, predictable root canal treatment that offers long-term solutions.

To achieve this goal, we must begin with confidence in our instrument system and technique. The right mix yields a therapy based on the ideal combination of safety, simplicity and sophistication.

In selecting a treatment system, most clinicians aim to find reliable instruments that offer comfortable handling, perform appropriately, and, ideally, expedite treatment. The following three cases demonstrate the treatment of common endodontic problems using 

Komet USA’s new, two-file F360™ NiTi endodontic file system

The instruments in the system feature a thin-core, .04 taper, S-curve design that provides outstanding cutting efficiency while respecting natural root canal morphology. Although most cases can be completed using the .04- taper, sizes 25 and 35 files, the system also accommodates larger canals by offering additional .04-taper files in sizes 45 and 55.


	The patient presented with acute pain and reported a feeling of swelling in his face. Tooth No. 6 was sensitive to percussion, but it did not demonstrate sensitivity to air, sweets or temperature stimuli.

Following a discussion of the treatment options, the choice was made to perform endodontic therapy on the tooth to eliminate the pain. The prescription for definitive treatment was a post and core with a full-coverage IPS e.max® (Ivoclar Vivadent) CEREC® crown.


	The patient presented with temperature sensitivity and pain during mastication. The treatment plan consisted of endodontic therapy on tooth No. 13 to be followed up with post and core treatment and an IPS e.max® CEREC® crown.


	Having received treatment two weeks earlier for caries control and replacement of defective amalgam restorations, the patient presented with an inability to tolerate hot or cold temperatures. In addition, he was unable to chew any type of food. Following consultation, the patient accepted the treatment plan of endodontic therapy to be followed up with post and core and IPS e.max® CEREC® fullcrown coverage.
	 


	Typical of the types of endodontic cases seen in most dental offices, these cases each presented differently, yet they successfully responded to standard 

The two-file technique that follows access opening and coronal enlargement can be used for up to 80 percent of the root canal therapies most dentists prescribe, thus making standard endodontic treatment predictable, efficient and straightforward.

This translates into significant time savings, which in turn leads to increased profitability in the dental practice.

How to make endodontic treatment more predictable with Komet USA’s F360™ NiTi endodontic file system

While striving to accommodate dental patients with as many services as possible, general practitioners often find endodontic therapy to be one of the biggest challenges they face. 

Generally undesirable to the patient, endo therapy can be thwarted if the tooth’s condition precludes a predictable end result. In such cases, teeth are often extracted, and the patient departs the dental office with instructions to consider the treatment options, oftentimes never returning for definitive dental therapy.

By remaining flexible to patient needs while formulating a treatment plan, however, doctors and patients can work together to change those statistics in favor of predictable, successful dentistry.

The following case began with an endodontic treatment plan, but we quickly determined the tooth was fractured and non-restorable (

Two kits from Komet USA figure prominently in this case, facilitating a successful and predictable end result. The first is the custom-designed Everyday Dentistry Crown Down kit (LD0586) created to minimize fractures.

 Developed in conjunction with ceramics engineers and bur specialists, the kit is a “reverse-engineering” endeavor to create the ideal system for crown preparations. The second kit featured in this case-the MaxilloPrep bone-spreading kit (4596)-addresses challenges faced when dealing with insufficient space for implant placement.

Upon examining the quadrant, it was apparent that a considerable amount of dental treatment was indicated. In addition to tooth No. 12, we needed to treat fractured and carious tooth Nos. 13 and 14 (

). A full treatment plan was created, first calling for core build-ups and Sirona Dental Systems’ CEREC® full-porcelain crowns (cereconline.com). The treatment plan then prescribed spreading the maxillary ridge in the edentulous space of tooth No. 12, placing a 4.3 mm X 13 mm TriNex dental implant from Keystone Dental Inc. (keystonedental.com), and repairing the facial defect with Puros® bone particles from Zimmer Dental (zimmerdental.com) and autogenous platelet-rich plasma (PRP).

To begin, we used the Komet® 6807.FG.016 cavity-prep diamond to remove the existing amalgam restorative material (

). This excavating bur features a long, inverted tapered-cone design combined with coarse-grit cutting, making it ideally suited for the task.

DenMat’s GeriStore® (denmat.com) B1 composite core build-ups were completed on tooth Nos. 13 and 14 (

), and the Everyday Dentistry Crown Down Prep Technique was initiated. Note: In this technique, the operator maintains the handpiece in an occlusal-gingival direction, meaning the handpiece is held in a vertical direction and parallel to the long access of the tooth undergoing preparation for a crown or onlay.

In a vertical position, the Komet® 6845KR.FG.025 inlay/onlay coarse, tapered prep bur was run apically to a depth of 2 mm, creating a mesial-distal trough the width of the bur (

The bur was slightly angled to reduce the buccal and lingual occlusal inclines. This minimal handpiece re-direction created a 2 mm occlusal reduction appropriate for all-ceramic bonded or cemented crowns (

The gingival margins were prepared with the Komet® 5801.FG.023 coarse, round bur (

). Note: A round bur is the most efficient and quickest preparation bur. On a frictionless surface, two differently shaped objects such as a cylinder and a sphere are given momentum. Over a predetermined distance, the sphere traverses the frictionless surface faster than the cylinder because its shape has less inherent resistance to the surface; therefore, when attempting to create a smooth, precise gingival margin, a spherical bur such as the 5801.FG.023 coarse, round bur is the optimal choice. Also please note that burs 5801 and 6807 are not included in kit LD0586.

The Komet® S5856 FG021 coarse, round tapered bur was used to bring the occlusal and gingival reductions together without overheating the tooth during preparation.

The bur was held in a vertical position, parallel to the long access of the tooth. Very little preparation was required in the mid-body area, and interproximal preparation was completed swiftly (

The Komet® slowspeed 94010C 040 diamond-impregnated, rubber-bullet bur was held in a vertical position for smoothing and rounding axial line angles for all-porcelain, full-coverage bonded or cemented crowns.

The completed preparations on tooth Nos. 13 and 14 were ready for CEREC imaging (

 shows a facial view of the teeth immediately following the same-day preparation and cementation. Likewise, 

 depicts the occlusal post-cementation view of the CEREC crowns. The buccal defect of endentulous space No. 12, along with its V-shaped facial defect, presented the next challenges in the case.


	Once all restorative dentistry was completed, the patient rinsed with chlorhexidine oral rinse and was prepared for dental implant placement in the edentulous No. 12.


	Blood was drawn and placed in a Salvin 1310 Centrifuge. The blood samples were spun for 10 minutes, and the platelet-rich plasma (PRP) was separated and used to enhance the particulate bone material and speed healing for the patient.


	The buccal-lingual width of the edentulous space No. 12 was about 3 mm wide. The Komet® 700 XXL highspeed bur created a trough approximately 5 mm in a mesial-distal dimension and approximately 6 mm deep (

). Note: The treatment plan prescribed the MaxilloPrep kit to spread the ridge bucco-lingually to accommodate the implant without fracturing the buccal plate.


	A flat-ended, 2-mm-in-diameter parallel osteotome was tapped to a depth of 13 mm. The osteotome was allowed to rest within the site for 30 to 60 seconds, removed, and then the sequential MaxilloPrep procedure began (

). Note: At this point, osteotomes #1 through #3 were used and allowed to rest in the site for at least 60 seconds, allowing the maxillary ridge to expand. This facilitated implant placement into the site without facial bone fracture. 

 shows the final osteotomy after the final osteotome has been removed. Note: The ridge began with a buccal-lingual dimension of approximately 3 mm and was expanded to more than 7 mm in buccal-lingual width.


	The implant was placed and fully seated (

). The implant platform was positioned at the crest of the ridge and approximately 2 mm apical to the adjacent teeth.


	Particulate bone and PRP were used to plump up the facial of No. 12.


	Grafting was completed and sutured with 3-0 VICRYL sutures.


	PeriAcryl® tissue adhesive was used to glue the sutures and incisions into place.

 depicts the implant at No. 12 and the crowns at Nos. 13 and 14.

“Everyday Dentistry” refers to what many GPs manage on a daily basis. Patients require multiple dental services and often prefer to have dental services provided to them in the safe and comfortable surroundings of their general dental practice. With the new technologies and equipment available today, GPs can be both efficient and proficient in providing multi-disciplinary dentistry. Komet USA’s Everyday Dentistry Crown Down Kit and MaxilloPrep bone spreading kit can be implemented into a general dental practice interested in providing these services.

Note: Training for these procedures can be obtained through the Midwest Implant Institute (midwestimplantinstitute.com) where Dr. Bliski is the co-director. He also may be reached at his private practice in Independence, Ohio (bilskidds.com). 