Dental Tribune International The World’s Largest News and Educational Network in Dentistry www.dental-tribune.com

I content _ roots page 6 page 12 page 18 I editorial 03 Dear Reader | Dr Sekar Mahalaxmi I CE article I research 26 Diclofenac, dexamethasone or laser phototherapy? Part II | Jan Tunér I special 06 Restoration of endodontic teeth: 30 Daktari for Maasai– An engineering perspective | Dr Gregori M. Kurtzman I industry report 14 Pressing endodontic issues | Dr Antonis Chaniotis I case report 18 S-shaped root–risks of a master challenge in endodontology | Dr Friedrich Müller I trends 20 PIPS and retreatment | Dr Reid Pullen I feature Mobile Dental Care in the Serengeti | Prof. Martin Jörgens I industry news 38 Planmeca and the University of Turku found Nordic Institute of Dental Education | Planmeca I events 40 International Events I about the publisher 41 42 | submission guidelines | imprint 24 “Continuous Education is a top priority for us, first proof is our new Training Centers” | Interview with Alexandre Mulhauser, FKG Dentaire Middle East & Africa Director Cover image courtesy: Ocskay Bence/shutterstock.com page 20 page 24 page 30 04 I roots 3_ 2014

I CE article _ restoration Restoration of endodontic teeth: An engineering perspective Author_ Dr Gregori M. Kurtzman, USA _ce credit roots shown to significantly reduce the incidence of frac- ture in the endodontically treated tooth.1, 2 This article qualifies for CE credit. To take the CE quiz, log on to www.dtstudyclub.com. Click on ‘CE articles’ and search for this edition of the magazine. If you are not registered with the site, you will be asked to do so before taking the quiz. You may also access the quiz by using the QR code. _Introduction Identifying the canals and negotiating them to be able to instrument and obturate the tooth is nec- essary to clinical success. But restoration of the en- dodontically treated tooth is critical to long-term success. It does not matter if we can complete the endodontic portion of treatment if the tooth can- not be restored. With this in mind, we need to look at the restoration phase from an engineering per- spective. What is needed to reinforce the remaining tooth so that it can manage the repetitive loading that occurs during mastication? This article will dis- cuss the importance of ferrule in adhesive dentistry as well as when to use posts and what materials are best. _Ferrule: How important is it today? Fig. 1 Important to this concept is the margin design of the crown preparation, which may include a chamfer or a shoulder preparation. Because a chamfer margin has a bevelled area that is not parallel to the vertical axis of the tooth, it does not properly contribute to ferrule height. Therefore, when a chamfer is utilized it would require an additional 1mm of height between the edge of the margin and the top aspect of the coro- nal portion of remaining tooth structure. Thus, use of a chamfer may not be the best margin design when restoring endodontically treated teeth or those teeth with significant portions of missing tooth structure. With today’s movement toward scanning and milling for fixed prosthetics, whether done in the practi- tioner’s office or at the laboratory, it should be noted that it is difficult to scan the internal aspect of a shoulder preparation and it has been uniformly rec- ommended that a rounded shoulder be used. The rounded shoulder preparation provides the maxi- mum vertical wall at the margin, with the internal as- pect being slightly rounded versus at a 90-degree an- gle. This ensures better replication of the margins when scanned and milled. Some studies suggest that while ferrule is certainly desirable, it should not be provided at the expense of the remaining tooth/root structure.3 Alternatively, it has also been shown that the difference be- tween an effective, long-term restoration and restorative fail- ure can be as small as 1mm of additional tooth structure that, when encased by a ferrule, pro- vides greater protection. When such a long-lasting, functional restora- tion cannot be predictably created, osseous crown lengthening should be considered to increase what tooth structure is available to achieve a fer- rule, but this is also dependent on the periodontal status of the tooth, and Ferrule was an important con- cept in dentistry but has been de-emphasized with the bond- ing evolution. Yet this concept is as important today as it was prior to dental bonding. But what is a ferrule? A ferrule is a band that encircles the external dimension of residual tooth struc- ture, not unlike the metal bands that exist around a barrel to hold the slats together. Sufficient vertical height of tooth structure that will be grasped by the future crown is neces- sary to allow for a ferrule effect of the future prosthetic crown; it has been Fig. 1_Strain analysis of a posterior tooth demonstrating concentration of strain on loading at the cervical. (Image/Dr Gene McCoy) 06 I roots 3_ 2014

I CE article _ restoration Fig. 5_Comparison of load distribution of fiber posts compared to a cast post and prefabricated metal post. Fig. 5 _Detecting failure at the coronal seal It is not unusual to have a patient present for a rou- tine recall appointment and the clinician or hygienist note recurrent decay at a crown margin with the pa- tient unaware of the issue. This becomes more com- plicated with teeth that have previously undergone endodontic treatment, as there is no pulp present that could warn the patient an issue is present until often extensive decay occurs or the crown dislodges from the remaining tooth. Freeman, et al, in their published study, stated, “Fatigue loading of three different post and core designs with the presence of a full cast crown leads to preliminary failure of leakage between the restoration and tooth that is clinically undetectable.”8 Fig. 6_Tooth restored with a fiber post demonstrating coronal horizontal fracture supracrestally typically seen with teeth restored with fiber posts when overloaded. Fig. 6 08 I roots 3_ 2014 The literature supports that coronal leakage may be a major factor in failure of endodontic treatment.9–11 As previously discussed, when loaded during mastication, margins with inadequate ferrule may demonstrate mi- cro opening on the tension side, leading to leakage over time. This initially may be observed as recurrent decay, but as it deepens and exposure of the obturation ma- terial results, failure of the endodontics may result due to apical migration of oral bacteria. This is minimized when a bonded core or post/core is present, but given sufficient time when a ferrule of sufficient height is not present the endodontics or the restoration will fail. _Do all posts function the same? Teeth function differently, depending on the ma- terial that the post is fabricated from, with loads distributed within the root relative to the modulus of elasticity of the post compared to the dentin of the root (Fig. 5). When a tooth restored with a fiber post does fail due to overload, the mode of failure is coronal, pro- tecting remaining root and tooth structure.12 This mode of failure with fiber-post-restored teeth typi- cally allows the tooth to be restored, as vertical root fracture is a rare occurrence. Bitter reported, “Com- pared to metal posts, FRC posts revealed reduced fracture resistance in vitro, along with a usually re- storable failure mode”13 (Fig. 6). Whereas, with metal posts either prefabricated or cast, failure was at a higher value for cast post and core 91 per cent of the specimens had fractured roots, none of the specimens with a fiber post demonstrated root fracture; the post and core usually fractured at the tooth composite core interface.14 As stress concentrates at the apical tip of the metal post due to its higher modulus of elas-

I CE article _ restoration Fig. 8_Comparative modulus of elasticity of different post materials. GPa Comparative Modulus of Elasticity 200 100 Fig. 8 Fiber Dentin Titanium Steel Cast metal ment of fibers in the fiber post and the modulus of elasticity of a post that is less than or equal to that of the dentin may redistribute the stress into the tooth and away from the chamfered shoulder to increase the likelihood of failure of the post core/ root interface instead of root fractures. When fail- ure does occur due to overloading, failure typically is in the coronal portion, frequently demonstrat- ing fracture of the core at the tooth interface and leaving the possibility of re-restoring the tooth and not catastrophic loss.22 _Decision making for restoration of endo dontically treated teeth Restoration of endodontically treated teeth needs to take an engineering view of how best to recon- struct the remaining tooth for the best long-term sur- vival. With this in mind, the practitioner needs to cat- egorize the tooth based on how much native tooth structure is present following endodontic treatment and how much existing restorative material is cur- rently present in the tooth. The flexural properties of fiber posts were higher Minimal tooth missing or previously restored: than the metal post and similar to dentin.23 Whereas, pre-fabricated, stainless-steel post ex- hibited a significantly higher fracture resistance at failure when compared with the fiber posts. The mode of failure of the carbon fiber post was more favorable to the remaining tooth structure when compared with the pre-fabricated stainless steel post and the ceramic post.24 Ceramic posts were introduced prior to fiber posts as a more esthetic alternative to prefabricated metal posts, and, although not widely used today, they are still available. Modulus of elasticity of ceramic posts is 170–213GPa, which is approximately 15 times that of dentin. As these ceramic posts are too rigid and transmit more stress to the root canal than the fiber posts, which lead to irreversible root damage via ver- tical root fracture seen with metal posts, their use is not recommended in restoring endodontically treated teeth today.25 Posterior teeth gain strength when the marginal ridge area and proximal surface is natural tooth struc- ture and has not been restored. Teeth that have un- dergone endodontic treatment when either occlusal decay was present in the pits and fissures leading to pulpal involvement or a small- to moderate-sized previously placed amalgam or composite restoration is present require conservative restoration (Fig. 9). These teeth can be restored with removal of the existing restorative material and cleaning the pulp chamber of obturation material including 2 to 3mm of the canal. Placement of a conventional composite bonded within the tooth provides a good long-term restorative solution to these teeth, and a crown is not needed typically. The access or existing restoration should leave most of the cuspal width present. When the preparation following removal of decay and ex- isting restorative materials invades the width of the cusp leaving half of this tooth structure missing, more extensive restoration is indicated. 10 I roots 3_ 2014

I CE article _ restoration of 2.0mm of ferrule, which is more critical in maxil- lary anterior teeth due to the direction of loading dur- ing mastication. Additionally, how we restore the re- maining tooth plays a role in potential issues in the long term. Metal posts are being used less frequently due to vertical root fractures that can occur when the tooth is overloaded, and the direction has increas- ingly moved to the use of fiber posts, which mimic the roots modulus of elasticity. When teeth restored with a fiber post are overloaded, fracture typically occurs in the coronal (supragingival) portion, leaving suffi- cient tooth remaining to re-restore the tooth. Teeth rarely fail when they are over-engineered, but many fail due to under-engineering._ _References 1. Barkhodar RA, Radke R, Abbasi J: Effect of metal collars on resistance of endodontically treated teeth to root fracture. J Prosthet Dent 61:676, 1989. 2. Galen WW, Muella K.: Restoration of the Endodontically Treated Tooth. In Cohen, S. Burns, RC., editors: Pathways of the Pulp, 10th Edition. 3. Stankiewicz NR, Wilson PR. The ferrule effect: a literature re- view. Int Endod J, 35:575–581, 2002. 4. Galen WW, Mueller KI: Restoration of the Endodontically Treated Tooth. In Cohen, S. Burns, RC, editors: Pathways of the Pulp, 8th Edition. St. Louis: Mosby, Inc. 2002, page 771. 5. Ichim I, Kuzmanovic DV, Love RM.: A finite element analysis of ferrule design on restoration resistance and distribution of stress within a root. Int Endod J. 2006 Jun;39(6):443–452. 6. Nicholls JI. An engineering approach to the rebuilding of en- dodontically treated teeth, J Clin Dent, 1:41–44, 1995. 7. Libman WJ, Nicholls JI: Load fatigue of teeth restored with cast posts and cores and complete crowns. Int J Prosthodontics 8:155–161, 1995. 8. Freeman MA, Nicholls JI, Kydd WL, Harrington GW: Leakage associated with load fatigue-induced preliminary failure of full crowns placed over three different post and core systems. J Endod 24:26–32, 1998. _about the author roots Dr Gregori M. Kurtzman is in private general practice in Silver Spring, Md., and a former assistant clinical professor at University of Maryland. He has lectured internationally on the topics of restorative dentistry, endodontics and implant surgery and prosthetics, removable and fixed prosthetics, and periodontics and has over 350 published articles. He has earned fellowship in the AGD, AAIP, ACD, ICOI, Pierre Fauchard, ADI, mastership in the AGD and ICOI and diplomat status in the ICOI and American Dental Implant Association (ADIA). Kurtzman has been honored to be included in the “Top Leaders in Continuing Education” by Dentistry Today annually since 2006 and was featured on their June 2012 cover. He can be reached at dr_kurtzman@maryland-implants.com 12 I roots 3_ 2014 9. Ricucci D, Siqueira JF Jr.: Recurrent apical periodontitis and late endodontic treatment failure related to coronal leakage: a case report. J Endod. 2011 Aug;37(8):1171–5. doi: 10.1016/ j.joen.2011.05.025. 10. De Moor R1, Hommez G.: [The importance of apical and coronal leakage in the success or failure of endodontic treat- ment]. Rev Belge Med Dent (1984). 2000;55(4):334–344. 11. Sritharan A.: Discuss that the coronal seal is more important than the apical seal for endodontic success. Aust Endod J. 2002 Dec;28(3):112–115. 12. Jimenez MP, et al. Fracture resistance of endodontically treated teeth with fiber composite posts. IADR abstract no. 323, March, 2002. 13. Bitter K Kielbassa AM: Post-endodontic restorations with adhesively luted fiber-reinforced composite post systems: a review. Am J Dent. 2007 Dec;20(6):353–360. 14. Martinez-Insua A, et al. Comparison of the fracture resistances of pulpless teeth restored with a cast post and core or fiber post with a composite core. J Prosthet Dent 80(5), 1998. 15. Al-Ansari A.: Which type of post and core system should you use? Evid Based Dent. 2007;8(2):42. 16. Plotino G, Grande NM, Bedini R, Pameijer CH, Somma F.: Flex- ural properties of endodontic posts and human root dentin. Dent Mater. 2007 Sep;23(9):1129–35. Epub 2006 Nov 20. 17. Stewardson DA1, Shortall AC, Marquis PM, Lumley PJ.: The flexural properties of endodontic post materials. Dent Mater. 2010 Aug;26(8):730-6. doi: 10.1016/j.dental.2010.03.017. Epub 2010 Apr 21. 18. Pierrisnard L, Bohin F, Renault P, Barquins M.: Corono-radi - cular reconstruction of pulpless teeth: a mechanical study using finite element analysis. J Prosthet Dent. 2002 Oct; 88(4):442–448. 19. King PA, Setchell DJ. An in vitro evaluation of a prototype Carbon fiber reinforced prefabricated post developed for the restoration of pulpless teeth. J Oral Rehabil 1990;17: 599–609. 20. Purton DG, Chandler NP. Rigidity and retention of root canal posts. Br Dent J 1998;184:294–296. 21. Cormier CJ, Burns DR, Moon P. In vitro comparison of the fracture resistance and failure mode of fiber, ceramic and conventional post system at various stages of restoration. J Prosthodont 2001;10:26–36. 22. Martínez-Insua A, da Silva L, Rilo B, Santana U. Comparison of the fracture strength of pulpless teeth restored with a cast post and core or carbon fiber post with a composite core. J Prosthet Dent 1998;80:527–532. 23. Chieruzzi M, Pagano S, Pennacchi M, Lombardo G, D'Errico P, Kenny JM.: Compressive and flexural behaviour of fibre rein- forced endodontic posts. J Dent. 2012 Nov;40(11):968–78. doi: 10.1016/j.jdent.2012.08.003. Epub 2012 Aug 21. 24. Padmanabhan P. A comparative evaluation of the fracture resistance of three different pre-fabricated posts in endo - dontically treated teeth: An in vitro study. J conserve Dent 2010;13:124–128. 25. Maccari PC, Conceição EN, Nunes MF. Fracture resistance of endodontically treated teeth restored with three different prefabricated esthetic posts. J Esthet Restor Dent 2003; 15;25–31.

I industry report _ innovative filling systems Pressing endodontic issues Author_ Dr Antonis Chaniotis, Greece Fig. 1 Fig. 2 Fig. 1_Clinical situation. Fig. 2_Periapical lesion in highly curved root. _Sealing the root canal system with a durable and bacteria-tight material guarantees a successful endodontic treatment in the long run. Easier said than done, if you consider the complex nature of the given dental anatomy. The following case report demon- strates that a reliable obturation of the root canal system sometimes just needs a little unusual pres- sure, i.e. negative pressure. Fig. 3_Confluent canals. Fig. 4_Instrumentation with the HyFlex CM rotary files. After having shaped and cleaned the canal, the endo specialist seeks to obturate the prepared space effectively. For this purpose, a number of innovative fast flowing filling materials are already available on the market. However, multiple canals, hidden acces- sory canals or lateral branches make it difficult to create a permanent seal against bacteria and fluids that can just re-enter the root canal system. Irregu- larities like culs-de-sac or isthmi are not easy to spot, let alone to be filled properly. A new, simple technique using standard instruments can help practitioners to get the job done in no time. All you need is free-flow filling material and a new, special endodontic aspi- rating tip to create a bit of negative pressure, as my latest endodontic case shows. Fig. 3 Fig. 4 14 I roots 3_ 2014

I industry report _ innovative filling systems Fig. 8 Fig. 9 Fig. 10 Fig. 11 Fig. 12 Fig. 8_Fixing both tips in the orifices by sealing material. Fig. 9_Attaching the Surgitip-endo and GuttaFlow 2 FAST capsule. Fig. 10_Visualisation of the technique in a plastic training block. Fig. 11_Classic backfill after removal of temporary seal. Fig. 12_Seating of pre-fitted master cones. Fig. 13_Position of the master cones. use of the Surgitip-endo and the tight seal material GuttaFlow 2 (Fig. 7). This filling material combines cold free-flow gutta-percha and a sealer creating an easy to handle, fast flowing filling material, which has been proven as a reliable barrier against bacteria and liquids re-entering the root canal. Its working time takes approximately ten to fifteen minutes. Before the actual procedure starts, it is necessary to fix both the Surgitip-endo front part as well as the CanalTip of the GuttaFlow capsules at the entrance of both canals. Both the front part of Surgitip-endo and a Fig. 13 16 I roots 3_ 2014 canal tip are firmly fixed in the different orifices by a sealing material that is polymerised for approxi- mately 10 seconds (Fig. 8). The seal at the canal en- trance works as a temporary cap to enable the estab- lishment of negative pressure underneath it with the aid of the aspirating tip. With this special trick a negative pressure zone can be created, which allows literally to pull the gutta-percha filling material into smaller lateral canals and ramifications that were hardly detectable in the anamnesis before. Now a GuttaFlow 2 FAST capsule was attached to the CanalTip as well as the Surgitip-endo to its front part (Fig. 9). While the air was sucked off with the Surgitip-endo above the filling, the gutta-percha material was released into the canal system simulta- neously and quickly spread into the prepared root canal system. In general, the innovative design of the suction tip ensures unrestricted high suction per- formance at all angles, therefore the gutta-percha was evenly distributed and filled the confluent canals within seconds. Complete control of the material ex- trusion was consequently achieved (Fig. 10). After the injected GuttaFlow 2 had reached the Surgitip-endo, the temporary sealing material could be removed. The rest of the GuttaFlow 2 capsule was used for a classic backfill and the pre-fitted master cones were very slowly seated in place (Figs. 11–13). The tooth was re- stored with a fiber post, a composite built up and a PFM crown. In the final radiographic image of the

I case report _ s-shaped roots S-shaped root– risks of a master challenge in endodontology Author_ Dr Friedrich Müller, Germany Fig. 1_Diagnostic radiograph of tooth 45 an tooth 44. Fig. 2_Radiograph with masterpoint in tooth 45 and hedstrom file in tooth 44. Fig. 1 Fig. 2 _An 81-year-old female patient came with typ- ical pulpitic pain in the right side lower mandible. The sensitivity testing showed a prolonged positive result in tooth 45 and no result in tooth 44. The per- cussion testing showed contrary results; no result in tooth 45 and a slight positive result in tooth 44. A ra- diograph showed an apical lesion of endodontic origin in tooth 44 and no diagnostic findings in tooth 45. Although the endodontic lesion in tooth 44 must have been present for several months due to its di- mension, the cause of her acute pain was tooth 45. Furthermore, the radiograph showed an s-shaped root morphology in tooth 44 that made endodontic treatment not just difficult, but a real master chal- lenge. The pulp chamber of both teeth were opened after anaesthesia and the diagnosis of irreversible pulpitis in tooth 45 and infected necrosis in tooth 44 was con- firmed by intracoronal inspection. While prolonged intracanal bleeding could be observed in tooth 45, there was upwelling pus in tooth 44. Fig. 3_Radiograph with masterpoint in tooth 44. Fig. 4_Radiograph of canal obturation in tooth 45 and tooth 44. 18 I roots 3_ 2014 Fig. 3 Fig. 4

I trends _ laser therapy PIPS and retreatment Author_ Dr Reid Pullen, USA methods? Is the root canal undefiled and/or under condensed? Is there periodontal involvement? If the supporting periodontum appears healthy and the root does not appear to be fractured, than typically the root canal failure is originating from inside the canal system. With all of these factors in play it is not surprising that the retreatment success in endodontics is lower than primary root canal success by 10 to 20 per cent. While retreatment success can vary from 70 to 90 per cent, non-surgical root canal treatment success hovers around 90 per cent. This article will review the Photon Induced Photoacoustic Streaming (PIPS) (Lightwalker Laser from Fotona) literature and discuss a retreat- ment case where the PIPS irrigation technique was in- stituted in hopes of increasing the success rate. _PIPS introduction _Retreatment can be a difficult and time-con- suming endeavour. The first order of business is to figure out why the primary root canal treatment is failing. Sometimes the answer will be evident after the patient interview, clinical exam and radiographic analysis, but other times the root canal failure is a mystery. Some of the questions I recommend think- ing about are: Was a rubber dam used? Is there a root fracture? Is there a missed canal? Did the practitioner use sodium hypochlorite and use proper irrigation PIPS is a technique that uses Erbium:YAG laser energy to agitate the irrigation solution inside a root canal system and cause a violent shockwave effect that can lyse bacteria cells and remove biofilm. By placing the tapered PIPS tip into the access and irri- gation solution, subablative laser is used to push a tsunami of irrigation solution into the main root canal, the lateral, secondary and accessory canals, isthmuses and the deep complex apical anatomy of the treated tooth. PIPS creates an irrigant shockwave of bacterial destruction. Fig. 1 Fig. 1_Pre-op #18. Fig. 2_Intact gutta-percha cone removal. Fig. 2 20 I roots 3_ 2014

I trends _ laser therapy Fig. 5 _Conclusion PIPS is a ER:YAG laser-enhanced irrigation tech- nique where laser energy is used to violently agitate canal irrigant. Studies have shown that it is more ef- fective in killing bacteria, removing biofilm, removing canal debris and increasing canal space than standard needle irrigation, sonic irrigation and passive ultra- sonic irrigation. In my experience of “PIPSing” over 2,000 cases, I see an increase in the obturation of lateral canals and deep complex apical anatomy. PIPS also aids in removing pulp stones, retreatment canal debris and separated files that have been loosened by ultrasonics. Photon induced photoacoustic streaming gives the clinician confidence that they are doing everything in their power to clean the entire root canal system._ _References Fig. 5_PIPS in action. (Photos: Provided by treatment time for 6 per cent NaOCl to soak inside the canal system. 1. Peters OA, Bardsley S, Fong J, Pandher G, Divito E. Disinfection of Root Canals with Photon-initiated Photoacoustic Streaming. Technology4Medicine) The technique was as follows: Carefully drill into the gutta-percha with the retreatment rotary file and after a 5- to 10-mm bite stop rotation. Let it cool for a few seconds and then with one hand pull up on the rotary hand piece head while the other hand is pro- tecting the maxillary teeth from any blunt trauma in case the hand piece head pulls out of the canal with high velocity. J Endod 2011;37:1008–1012. 2. Jaramillo DE, Aprecio RM, Angelov N, Divito E, McClammy T. Efficacy of photon induced photoacoustic streaming (PIPS) on root canals infected with Enterococcus faecalis: A pilot study. Endo dontic Practice 07/2012. 3. Ordinola-Zapata R, Bramante CM, Aprecio RM, Handysides D, Jaramillo DE. Biofilm removal by 6% sodium hypochlorite acti- vated by different irrigation technique. International Endodontic Journal; 10/2013. 4. Lloyd A, Uhles JP, Clement DJ, Garcia-Godoy F. Elimination of In some cases if a single cone has been used and/or if the sealer did not set or was inadequately placed, the entire cone will come out in one piece. Intracanal Tissue and Debris through a Novel Laser-activated System Assessed Using High-resolution Micro-computed Tomography: A Pilot Study. J Endod 2014;40:584–587. In this case, two of the three cones were extracted fully intact while using the rotary technique men- tioned above. The third cone was removed intact with a #35 Hedström file (Figs. 2 & 3). The canals were then “PIPSed” for 30 seconds with 6 per cent NaOCl as the irrigation solution and then patency and working length were established using hand files and an elec- tronic apex locator (EAL). The canals were then re- shaped with a reciprocating WaveOne Primary file (DENTYPLY Tulsa) and a final PIPS protocol was fol- lowed using 6 per cent NaOCl, distilled water, 17 per cent EDTA and then distilled water (Fig. 5). Because it appeared that a single cone technique was used and that the resin sealer did not fully set, or was not ade- quately placed into the canal, the case was completed in one visit. The canals were obturated with Bioce- ramic Gutta Percha coated cones and Bioceramic Sealer (Brasseler USA). A modified warm vertical con- densation technique was used to help condense and pack the gutta-percha and sealer. The canals were backfilled with warm gutta-percha (Fig. 4). _about the author roots Dr Reid Pullen, DDS, FAGD, graduated from USC dental school in 1999 and served three years in the US Army as a dentist in Landstuhl, Germany. While in the Army, he completed a one-year advanced educa- tion in general dentistry residency. After the military, Pullen practiced as a general dentist for two years in southern California, prior to attending the en- dodontic residency at the Long Beach Veterans Hospital in 2004. He graduated from the endodon- tic residency in 2006 and has maintained a private practice limited to endodontics in Brea, Calif., since 2007. Pullen obtained his endodontic board certifi- cation in 2012. 22 I roots 3_ 2014

I feature _ interview “Continuous Education is a top priority for us, first proof is our new Training Centers” Interview with Alexandre Mulhauser, FKG Dentaire Middle East & Africa Director. bution channels, selection and training of serious Distributors that share our vision of quality and the service to customers. It has been a success also thanks to the reactivity and flexibility of the structure and a fluidity of information together with fast decision processes with our CEO, Thierry Rouiller. Even with all the effort and dedication, we believed being in the core of this market and tightening the links with our customers will be the key to success. The decision was finalized in December 2012 and by June 2013 the subsidiary was created and we moved to Dubai. _Has the decision been good to choose UAE as your regional hub? Companies that open a regional headquarter in the ME-A Region usually open it either in Egypt, Jordan, Lebanon or United Arab Emirates. Due to the number of meetings we have around the region, in- stalling the ME-A office less than 45 minutes road of two major airports (Dubai and Abu Dhabi) was the best choice to manage efficiently our travels. We de- cided to create the first MEA Endo Training Center owned by an Endo manufacturer and fully equipped with microscopes. The UAE training center receives groups from Middle East, Africa but also now India and is open to all other countries. Dentists who would like to come for a training do not have time to lose in connections between airports and these two hubs and their great number of connections are very use- ful for us to organize trainings. In addition, many love to travel to Dubai for the trainings while enjoying a visit to the Emirates. In all cases the decision has proved a perfect choice. _What are the plans for the nearest future and the Training Centre? FKG Dentaire is already collaborating with inter- national speakers (Dr Gilberto Debelian, Dr Martin Trope, Dr Bertrand Khayat and others). We are cur- rently finalizing a team of highly skilled clinicians based in the ME-A Region passionate about FKG In- struments and ready to share their experiences and knowledge. Dentists are eager to test our technolo- gies and we may increase the number of trainings in the UAE Office and around the ME-A Region. Regard- ing the training center, thanks to the growing number of top products in the FKG Dentaire range, along with partnerships with other companies we plan to also Fig. 1_Alexandre Mulhauser, FKG Dentaire Middle East and Africa Director. _DTI:Can you introduce us FKG Dentaire? Alexandre Mulhauser: Founded in 1931 in the heart of the watch valley, FKG Dentaire is a Swiss company internationally renowned for its high qual- ity products for dentists, Endodontists and laborato- ries. The Swiss High Tech company is led by two vi- sionaries namely Jean Claude Rouiller (Chairman) and his son Thierry Rouiller (CEO), who have a mission to always push Endo forward for the benefit of both the dentists and patients. This has been made possible thanks to the creation of one of the most modern Endo factories as well as the close collaboration be- tween the teams of Research & Development, Sales, Marketing and a team of General Practitioners and Endodontists globally. _FKG inaugurated its Regional Office and Training Centre around 6 months ago in Dubai. What were the reasons for this set up? I joined the FKG team almost four years ago to build up a new strategy which was to develop FKG Dentaire in the Middle East and Africa Region. When I started this new challenge the FKG Dentaire name was known but the distribution network in the ME-A region was not operating properly with sales being below average compared to other regions. We are pleased to see that in a few years we were able to level up from the few countries where we were represented to over 30 countries today and we continue to in- crease monthly. This has been possible thanks to a new positioning, a complete reorganization of the distri- 24 I roots 3_ 2014

I research _ phototherapy Diclofenac, dexamethasone or laser phototherapy? Part II Author_Jan Tunér, Sweden [PICTURE: ©ROBERT KNESCHKE] 26 I roots 3_ 2014 _Introduction In part I, the author informed about studies which investigated the effects of diclofenac and LPT. In the second part, they continue their investigation into the vast literature and studies on this topic and give their conclusion. In the May 2013 edition of Photomedicine and Laser Surgery, the editorial written by Prof. Tina Karu is titled “Is it time to consider photobiomodulation as a drug equivalent?” Well, is it? Let us have a look and see what the literature has to say about two very popular drugs. Although the previously-mentioned studies indicate that LPT is as effective, or more effective as diclofenac, a potentiation of the effect of diclofenac by adding LPT is suggested in the following study: The aim of the study by Markovic11 was twofold: (1) to evaluate the postoperative analgesic efficacy, comparing long-acting and intermediate-acting local anaesthetics; and (2) to compare the use of laser irradiation and the non-steroid anti-inflam- matory drug diclofenac, which are claimed to be among the most successful aids in postoperative pain control. A twofold study of 102 patients of both sexes undergoing surgical extraction of LTM was conducted. In the first part of the study, twelve patients with bilaterally impacted lower molars were treated in a double-blind crossover fashion; local anaesthesia was achieved with 0.5 % bupiva- caine plain or 2 % lidocaine with 1: 80,000 epi- nephrine. In the second part of the study, 90 pa- tients under going lower molar surgical extraction with local anaesthesia received postoperative laser irradiation (30 patients) and a preoperative single dose of 100 mg diclofenac (30 patients), or only reg- ular postoperative recommendations (30 patients). The results of the first part of the study showed a strikingly better postoperative analgesic effect of bupivacaine than lidocaine/epinephrine (eleven out of twelve; four out of twelve, respectively, pa- tients without postoperative pain). In the second part of the study, LPT irradiation significantly re- duced postoperative pain intensity in patients pre- medicated with diclofenac, compared with the controls. Provided that basic principles of surgical practice have been achieved, the use of long-acting local anaesthetics and LPT irradiation enables the best postoperative analgesic effect and the most comfortable postoperative course after the surgi- cal extraction of lower molars. Dexamethasone is a corticosteroid, thus not an NSAID, but the issue of replacing pharmaceuticals with long-term negative effects to a treatment with no side effect is urgent here as well. A rabbit model of endophthalmitis was estab- lished by Ma12 to evaluate the anti-inflammatory ef- fect of LPT as an adjunct to treatment for Staphylo- coccus epidermidis endophthalmitis. Rabbits were randomly divided into three groups to receive in- travitreal injections into their left eye: group A re- ceived 0.5 mg vancomycin (100 mcl), group B re- ceived 0.5 mg vancomycin + 0.2 mg dexamethasone

I research _ phototherapy In an effort to clarify the molecular based mech- anism of the anti-inflammatory effects of laser irra- diation, Abiko17 used a rheumatoid arthritis (RA) rat model with human rheumatoid synoviocytes (MH-7) challenged with IL-1, treated with laser or dexamethasone (DEX), monitored by gene expres- sions and analysed by the signal pathway database. RA rats were generated by the immunisation of type-II collagen, after which foot paws and knee joints became significantly swollen. The animals were laser treated and the swelling rates measured. MH-7 was challenged with IL-1␤ and gene expres- sion levels monitored, using the Affymetrix Gene Chip system, and the signal pathway database analysed using the Ingenuity Pathway Analysis (IPA) tool. LPT significantly reduced swellings in the rats' foot paws and knee joints and made it possible for them to walk on their hind legs. LPT altered many gene expressions of cytokines, chemokines, growth factors and signal transduction factors in IL-␤ in- duced MH-7. IPA revealed that LPT as well as DEX kept the MH7A at a normal state to suppress mRNA levels of IL-8, IL-1␤, CXC1, NFkB1 and FGF13, which were enhanced by IL-1␤ treatment. However, cer- tain gene expression of inflammatory factors were reduced by LPT, but were enhanced by DEX. LPT re- duced inflammatory factors through altering signal pathways by gene expression levels. Interestingly, LPT altered useful targeted gene expressions, whereas DEX randomly altered many gene expressions, in- cluding the unwanted genes for anti-inflammation. Dexomethasone is a steroid known for having a long range of serious side effects. Thus, genome-based gene expression monitored by the Gene Chip system together with a signal pathway based database pro- vide unprecedented access to elucidate the mecha- nism of the biostimulatory effects of LPT. It has been suggested that LPT acts on pulmonary inflammation. Thus, Mafra de Lima18 investigated in a work if LPT (650nm, 2.5mW, 31.2mW/cm2, 1.3J/cm2, spot size of 0.08 cm2 and irradiation time of 42 s) can attenuate oedema, neutrophil recruitment and in- flammatory mediators in acute lung inflammation. Thirty-five male Wistar rats (n = 7 per group) were distributed in the following experimental groups: control, laser, LPS, LPS+laser and dexa methasone+ LPS. Airway inflammation was measured 4 h post- LPS challenge. Pulmonary microvascular leakage was used for measuring pulmonary oedema. Broncho - alveolar lavage fluid (BALF) cellularity and myeloper - oxidase (MPO) were used for measuring neutrophil recruitment and activation. RT-PCR was performed in lung tissue to assess mRNA expression of tumour necrosis factor-alpha (TNF-alpha), interleukin-1␤ (IL-1␤), interleukin (IL-10), cytokine-induced neu- trophil chemoattractant-1 (CINC-1), macrophage in- flammatory protein-2 (MIP-2) and intercellular adhe- sion mole -cule-1 (ICAM-1). Protein levels in both BALF and lung were determined by ELISA. LPT inhib- ited pulmonary oedema and endothelial cytoskeleton damage, as well as neutrophil influx and activation. Similarly, LPT reduced the TNF-alpha and IL-1␤, in lung and BALF. LPT prevented lung ICAM-1 up-reg- ulation. The rise of CINC-1 and MIP-2 protein levels in both lung and BALF, and the lung mRNA expres- sions for IL-10, were unaffected. Data suggest that the LPT effect is due to the inhibition of ICAM-1 via the inhibition of TNF-alpha and IL-1␤. Steroids are frequently used to treat inflamma- tion. Some studies report a reduced effect of LPT in the presence of steroids, while others have found pos- itive results of LPT even in the presence of steroids. However, steroids are known to delay wound heal- ing through a reduction of leukocyte migration and a suppression of interleukins, while LPT is known to stimulate wound healing. In a study by Pessoa19, 48 rats were used, and after the execution of a wound on the dorsal region of each animal, they were di- vided into four groups (n = 12), receiving the following treat- ments: G1 (control), wounds and animals received no treat- ment; G2, wounds were treated [PICTURE: ©NIKOLAY LITOV] 28 I roots 3_ 2014

I special _ aid project Daktari for Maasai – Mobile Dental Care in the Serengeti Author_ Prof. Martin Jörgens, Germany _Even as early as the 1950s, the Serengeti had already gained worldwide attention through the numerous documentary films produced by Professor Bernhard Grzimek. The images from Serengeti darf nicht sterben (Don’t let the Serengeti die) were so powerful that he was awarded the Oscar for Best Documentary Film in 1960. Grzimek’s film reporting and personal commitment eventually led to greater sensitivity in the handling of Tanzania’s unique nat- ural resources as well as the expansion and protec- tion of Tanzania’s most important national park: the Serengeti. Many naturalists consider it the most important national park in the world, given how the migration of wildlife depends on it to ensure their survival. It is the largest active mammalian eco-system, providing living space for a total of up to six million animals. During their long migration, millions of animals con- tinuously traverse the full breadth of the Serengeti in search of food, and in the process cross the Mara River in order to reach the Maasai Mara in neigh- bouring Kenia. _Genesis of the project A safari I took in connection with an expedition to Kilimanjaro in 2010 brought me to the heart of the Serengeti and from there northward to a small Maasai village named Ololosokwan on the border with Kenia. The very proud yet quite welcoming Maasai received me warmly. My guide, Seleu Kedoki, a local ranger with andBeyond who was well ac- quainted with the region, took me to the typical gath- 30 I roots 3_ 2014

I special _ aid project _info roots &BEYOND is the world’s leading provider of adven- ture travel and safaris. The company has its roots in South Africa. The 2000 em- ployees of &Beyond cur- rently operate 33 lodges, mainly in premier national parks in both southern and eastern Africa as well as in Asia. In doing so, the com- pany contributes to the preservation of hundreds of rural communities and mil- lions of acres of valuable and sometimes endan- gered wilderness while also serving as number 1 part- ner to the Daktari Project for the Maasai. _The project gets under way It took nearly a year before our practice, Dental- Specialists, was able to launch the ‘Daktari for Maasai’ project. ‘Daktari for Maasai’ is Swahili and means ‘doctors for Maasai’. Furnished with the best in mobile equipment and full of enthusiasm and a spirit of adventure, we travelled to our objectives at Lake Manyara, the Ngorongoro Conservation Area and the Serengeti. We were able to win over &BEYOND as our primary sponsor. This South African group operates lodges in the regions where Daktari works on behalf of the Maasai and provides assistance to the project on a daily basis. On the one hand, this affords dental and medical aid to even the most remote parts of Tanzania. Depending on the region, up to 90 % of lodge staff are themselves Maasai in origin. Their fam- ilies and other residents from surrounding villages gratefully draw on the dental and medical aid we of- fer. To do so, they will often walk 200 kilometres– while Maasai from the neighbouring Massai Mara will cross the border with Kenia in order to receive dental treatment from us. At the same time, for a project like ‘Daktari for Maasai’ to function, it is vital that it has reliable local partners like andBeyond to draw on. Through this collaborative effort, the project receives logistical and communications support at every level, affording it the consistency, security and predictabil- ity that the local &Beyond staff provide on the ground. This also results in a high degree of confidence among all those involved. The philosophy at &BEYOND always places the preservation and development of nature and wildlife in the centre–along with provid- ing practical support and development for the peo- ple in the regions where &BEYOND operates. This can come about by building schools and clinics, or it may well take the form of appointing doctors to the clin- ics in order to ensure primary health care services. This is also what we provide through our collaboration with ‘Daktari for Maasai’, as we are in a position to offer highly specialised treatments that normally would be unavailable. At the time I headed out with my colleague at DentalSpecialists, Dr Caroline Kentsch, on our first pre-scouting trip to Tanzania, flying with CONDOR 32 I roots 3_ 2014

I special _ aid project _Keeping the project going During another project-related trip in January 2013, led by Dr Caroline Kentsch and Dr Axel Roschker, about 650 patients received treatment. Once again, two assistants accompanied three doctors on the trip. It is a welcome development that, owing to the technically advanced equipment available, we were able to provide treatments for pain that did not nec- essarily involve tooth extraction. Numerous glued synthetic bridges were produced to close gaps be- tween front teeth. A great many cavities were filled in front teeth as part of treatment for tooth decay. And serious cases of fluorosis were treated in order to pro- vide for a more aesthetically pleasing appearance. Fluorosis is a wide-spread problem among the Tanzanian population. In the north, in the greater Arusha metropolitan area, up to 90 per cent of inhab- itants suffer from serious cases of fluorosis. We also have been able to prevent tooth loss through root canal treatments. And we are able to preserve poste- rior teeth by putting in fillings. Using ultrasound equipment and mobile lasers, we are able to carry out comprehensive periodontal treatments. Korean-made digital X-ray machines by Dexcowin allow us to pro- duce razor-sharp images in just seconds on a laptop in any kind of situation. These devices are absolutely vital in performing surgical procedures and root canal filling therapies. In September 2013 the project achieved another milestone in its development when the University of Sevilla asked us to use the project as part of its train- ing programme for oral surgeons. In September we travelled together with Dr Axel Roschker and two Spanish oral surgeons, Dr Roberto Garrido and Dr Francisco Azcarate, to Lake Manyara, Ngorongoro and Serengeti/Ololosokwan. Joining us from England was Dr Andrea Chan, who previously served for six years as a dentist with the British Navy. Though she was only able to be with us for just one week, her visit came off smoothly owing to the availability of daily flights between Arusha and Ololosokwan by small plane. Our multi-national team operated non-stop in every part of the Tanzanian mainland previously served. The international nature of the group spurred the project on immensely. The interactions of the individual specialists, despite never having worked together before, came off like a charm. This accom- plished team of oral surgeons was even able to han- 34 I roots 3_ 2014

I special _ aid project too. After extensive preparations while still in Ger- many, we had significantly expanded the equipment available to us. Along with our tried-and-tested sur- gical suction pump, medeor Tanzania made available to us a new Chinese treatment unit. It turned out to be a real adventure getting this equipment, however, given the great number of administrative hurdles and impediments we had to overcome before the unit was finally delivered. DHL sent us daily assurances that the units would be arriving on schedule. But each and every time the African authorities put up another unexpected hurdle. One time the shipping documents were arbi- trarily altered by a customs official; another time the equipment was removed from the flight, ostensibly because the plane was too heavy for the flight from Dar-es-Salaam to Zanzibar. Thank God we had an- other treatment unit to use in handling our daily flow of patients. It was only with help from the folks at medeor Tanzania and &BEYOND that we were able to find a solution to our administrative nightmare. When the Chinese unit finally reached us, we were surprised at how compact and efficient it was. A highly efficient, integrated compressor makes the unit ready to use in just five seconds and it can be used for every kind of procedure, from putting in synthetic fillings to performing complex surgical operations. It makes for a very practical treatment tool that can even be checked in at the airport along with standard 23 kg luggage. The unit constitutes the basis for all future mobile treatments undertaken by Daktaris for Maasai. And we would like to take a moment here to extend thanks to our third primary partner, Condor Contribute, for their help in transporting medical and dental aid sup- plies. Without their support a dental project as ad- venturous as this would scarcely have been possible. The thanks we got from the people of Tanzania re- ceiving free treatment was indescribable and cannot be compared with any other experience in medicine. Sincerest thanks from the Daktaris for Maasai … Bon Voyage! – Na safari nzuri!_ _info roots medeor has produced medications on a non- profit basis for the past 50 years and pro- vides crisis regions with medical supplies of all types. Europe’s largest medical aid organisa- tion is our second primary sponsor and maintains a donations account of its own: 2-46-0170 Daktari for Maasai Account no.: 100 596 2285 Sort code: 300 501 10 (Stadtsparkasse Düsseldorf) IBAN: DE97 3005 0110 1005 9622 85 BIC: DUSSDEDDXXX _contact roots Prof. Martin Jörgens DentalSpecialist Kaiserwerther Markt 25 40489 Düsseldorf- Kaiserwerth Germany Tel.: +49 211 4790079 info@dentalspecialists.de 36 I roots 3_ 2014

I industry news _ Planmeca Planmeca and the University of Turku found Nordic Institute of Dental Education Fig. 1_The objective of the new institute is to export and share Nordic expertise in digital dentistry on the basis of academic knowledge and technologies. (Photo: Planmeca) Fig. 1 38 I roots 3_ 2014 _Dental technology company Planmeca and the University of Turku have founded a joint venture company, the Nordic Institute of Dental Education. The institute will offer high-quality continuing education courses to dental professionals. The objective is to export and share Nordic expertise in digital dentistry on the basis of the academic knowledge of the University of Turku and the technologies developed by Planmeca, as well as their global dental networks. The courses will be held at the University of Turku and at Planmeca’s headquarters in Helsinki from au- tumn 2014. The course topics cover rapidly evolving dental technologies and their application in modern dentistry, including 3-D imaging, prosthodontics, endodontics, biomaterials science, orthodontics and CAD/CAM technologies. The University of Turku awards ECTS credits (a standard for higher education in Europe) and course certificates to the students. The joint venture company complements Planmeca’s broad range of training activities and collaboration with uni - versities around the world. The University of Turku is an active participant in the export of education. “We have now established a partnership with one of the world’s leading compa- nies in dental technology. Together with Planmeca we are a strong education provider globally,” stated Prof. Kalervo Väänänen, Rector of the University of Turku._ _contact roots Course registrations: www.nordicdented.com More information: Jenni Pajunen, Chief Executive Officer (CEO) Nordic Institute of Dental Education Tel. +358 20 779 5348 jenni.pajunen@nordicdented.com

I events _ meetings International Events 2014 ROOTS Summit 7–9 November 2014 Chennai, India www.rootssummit2014.com BES: 2014 Regional Meeting 14–15 November 2014 Manchester, UK www.britishendodonticsociety.org.uk ADF Meeting 25–29 November 2014 Paris, France www.adf.asso.fr ENDOBALTIC 2014 – Lithuanian Society of Endodontology Meeting 28–29 November 2014 Vilnius, Lithuania www.endodontologija.lt Greater New York Dental Meeting 28 November–3 December 2014 New York, USA www.gnydm.com Austrian Society of Endodontology Annual Meeting & PENN ENDO Global Symposium 4–6 December 2014 Vienna, Austria www.pennglobalvienna2014.at/ 2015 AEEDC – UAE International Dental Conference & Arab Dental Exhibition 17–19 February Dubai, UAE www.aeedc.com 36th International Dental Show 10–14 March 2015 Cologne, Germany www.ids-cologne.de 18th APEC Congress & 4th Jordanian Endodontic Conference 9–10 April 2015 Amman, Jordan www.apec2015.jo AAE15 – American Association of Endodontists Annual Meeting 6–9 May 2015 Seattle, USA www.aae.org CAE 51st – Canadian Academy of Endodontics Annual General Meeting 26–29 August 2015 Banff, Alberta, Canada www.caendo.ca ESE 17th Biennial Congress 16–19 September 2015 Barcelona, Spain www.e-s-e.eu 40 I roots 3_ 2014

Magda Wojtkiewicz, Managing Editor I about the publisher _ imprint roots international magazine of endodontology Published by Oemus Media AG Holbeinstraße 29 04229 Leipzig, Germany Tel.: +49 341 48474-0 Fax: +49 341 48474-290 kontakt@oemus-media.de www.oemus.com Printed by Silber Druck oHG Am Waldstrauch 1 34266 Niestetal, Germany Editorial Board Fernando Goldberg, Argentina Markus Haapasalo, Canada Ken Serota, Canada Clemens Bargholz, Germany Michael Baumann, Germany Benjamin Briseno, Germany Asgeir Sigurdsson, Iceland Adam Stabholz, Israel Heike Steffen, Germany Gary Cheung, Hong Kong Unni Endal, Norway Roman Borczyk, Poland Bartosz Cerkaski, Poland Esteban Brau, Spain José Pumarola, Spain Kishor Gulabivala, United Kingdom William P. Saunders, United Kingdom Fred Barnett, USA L. Stephan Buchanan, USA Jo Dovgan, USA Vladimir Gorokhovsky, USA James Gutmann, USA Ben Johnson, USA Kenneth Koch, USA Sergio Kuttler, USA John Nusstein, USA Ove Peters, USA Jorge Vera, Mexico Publisher Torsten R. Oemus oemus@oemus-media.de CEO Ingolf Döbbecke doebbecke@oemus-media.de Members of the Board Jürgen Isbaner isbaner@oemus-media.de Lutz V. Hiller hiller@oemus-media.de Managing Editor Magda Wojtkiewicz m.wojtkiewicz@oemus-media.de Executive Producer Gernot Meyer meyer@oemus-media.de Designer Josephine Ritter j.ritter@oemus-media.de Copy Editors Sabrina Raaff Hans Motschmann Copyright Regulations _roots international magazine of endodontology is published by Oemus Media AG and will appear in 2014 with one issue every quarter. The magazine and all articles and illustrations therein are protected by copyright. Any utilisation without the prior consent of editor and publisher is inadmissible and liable to prosecution. This applies in particular to duplicate copies, translations, microfilms, and storage and processing in electronic systems. Reproductions, including extracts, may only be made with the permission of the publisher. Given no statement to the contrary, any submissions to the editorial department are understood to be in agreement with a full or partial publishing of said submission. The editorial department reserves the right to check all submitted articles for formal errors and factual authority, and to make amendments if necessary. No responsibility shall be taken for unsolicited books and manuscripts. Articles bearing symbols other than that of the editorial department, or which are distinguished by the name of the author, represent the opinion of the afore-mentioned, and do not have to comply with the views of Oemus Media AG. Responsibility for such articles shall be borne by the author. Responsibility for advertisements and other specially labeled items shall not be borne by the editorial department. Likewise, no responsibility shall be assumed for information published about associations, companies and commercial markets. All cases of consequential liability arising from inaccurate or faulty representation are excluded. General terms and conditions apply, legal venue is Leipzig, Germany. 42 I roots 3_ 2014

Planmeca ProMax® 3D Endodontic imaging mode – a new era in precision Perfect visualisation of the finest details • Extremely high resolution with 75 µm voxel size • Noise-free images with intelligent Planmeca AINO™ filter • Artefact-free images with efficient Planmeca ARA™ algorithm Other unique features in Planmeca ProMax® 3D family units: Ultra low dose imaging CBCT imaging with an even lower patient dose than panoramic imaging. Adult female, FOV Ø200 x 170 mm Effective dose 14.7 µSv Planmeca ProMax ® 3D Mid Create your virtual patient A world first: One imaging unit, three types of 3D data. All in one software. CBCT + 3D model scan + 3D face photo Find more info and your local dealer www.planmeca.com Planmeca Oy Asentajankatu 6, 00880 Helsinki, Finland. Tel. +358 20 7795 500, fax +358 20 7795 555, sales@planmeca.com