Effectively treating the complex anatomies of root canal systems

Endodontic Insight

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Sonendo® discusses eliminating infections from intricate root canal systems and preventing reinfection

The tooth is one of the most individual and complex anatomical, as well as histological, structures in the body,1 so much so that radiographic examination has its limitations in imaging their imperceptible tubules and isthmi. Because of this, eliminating infections from intricate root canal systems and preventing reinfection prove to be the most crucial challenges remaining for most root canal protocols.

Relying heavily on mechanical instrumentation, standard root canal therapy employs a series of files to shape the canal space in preparation for delivery of disinfecting irrigants as well as to remove vital and necrotic tissue and microorganisms.2,3 Not surprisingly — due to the complex nature of root canal anatomy — mechanical preparation alone cannot sufficiently remove soft tissue debris or kill microorganisms,4,5 which necessitates the irrigation of the root canal system with disinfecting fluids.

Limitations of standard root canal treatment

The traditional job of the file is to bio-mechanically remove infected tissue from the canals. Filing is followed by irrigants that serve as a chemo-mechanical means to first remove infected tissue and debris left behind by files, and then, more vitally, to reach into the crevices inaccessible through mechanical instrumentation to provide disinfection throughout the root canal system. The efficacy of irrigation depends on the working mechanisms of the irrigant and the ability to bring the irrigant in contact with those elements, materials, and structures within the canal system that must be removed.6

The introduction of ultrasonic technology in 1957 offered a much more effectual method over previous irrigant delivery systems. In a histological study that assesses root canal cleanliness, conventional techniques cleaned only 29% of the canal, whereas contemporary techniques involving passive ultrasonic irrigation cleaned 80%.5 Standard root canal therapy has made only incremental advancements since.

Multisonic Ultracleaning® technology of the GentleWave® System

In 2016, after years of research and development, Sonendo® introduced us to Multisonic Ultracleaning® with the GentleWave® System, offering a minimally invasive7 procedure that reaches into the microscopic spaces7,8 that standard root canal treatments often cannot.9 The proprietary closed-loop Multisonic Ultracleaning technology found in the GentleWave System’s Molar and Anterior/Premolar Procedure Instruments represents an entirely new way of thinking about root canal therapy. Relying less on files,8 the GentleWave Procedure redefines the job that the file is hired to accomplish.

The mechanism of action used in the GentleWave Procedure consists of the constant refreshing and removal of optimized procedure fluids (i.e., sodium hypochlorite, EDTA, and distilled water) in a closed-loop system, combined with Multisonic Ultracleaning technology, where multisonic acoustic waves deliver useful cavitation throughout the root canal system to enhance cleaning and disinfection through advanced fluid dynamics, broad spectrum acoustic energy, and tissue-dissolution chemistry.10 The GentleWave Procedure delivers irrigants deep into complex anatomies, reaching lateral canals and microscopic tubules and providing an incredible level of clean — removing biofilm11 and smear layer from the crown to the apex.8 The Multisonic Ultracleaning difference has been demonstrated in numerous case studies and publications, as evidenced in the following selections.

GentleWave® Procedure case studies: discovering complex anatomies

In this grouping of recent GentleWave Procedure case reviews, clinicians were able to reach and clean the deepest, most complex portions of the root canal system7,8 not previously visualized through radiographic examination to save important tooth structure.

Clinical Case Study 1

Complex Apical Anatomy Following Minimal Endodontics by Michael W. Ford, DDS, MS

Diagnosis: Symptomatic irreversible pulpitis with symptomatic apical periodontitis.

After utilizing the GentleWave System, postoperative radiographic examination revealed multiple lateral canals within the apical third of the palatal and distobuccal canals, as well as an isthmus between the mesiobuccal canals.

Figure 1: Pre-GentleWave® Procedure
Figure 2: Post-GentleWave® Procedure
Images courtesy of Michael W. Ford, DDS, MS

Clinical Case Study 2

6-month Healing of a Mandibular First Molar with Complex Anatomy by Khang T. Le, DDS

Diagnosis: After clinical and radiographic examinations, the subject tooth was diagnosed as necrotic pulp with symptomatic apical periodontitis.

After the GentleWave Procedure and post obturation, a complex root canal system was visible with two intercanal isthmi and a lateral canal.
Figure 3: Pre-GentleWave® Procedure
Figure 4: Post-GentleWave® Procedure
Images courtesy of Khang T. Le, DDS

Clinical Case Study 3

Locating Complex Apical Anatomy Post GentleWave Procedure by Brian T. Wells, DMD

Diagnosis: Pulpal necrosis of the mandibular left second molar with acute apical periodontitis.

Post obturation, a complex apical anatomy was visible between the mesial and distal canals. This anatomy was not known prior to the GentleWave Procedure, and therefore, additional shaping was not completed for preparation of these complexities.
Figure 5: Pre-GentleWave® Procedure
Figure 6: Post-GentleWave® Procedure
Images courtesy of Brian T. Wells, DMD

The GentleWave Procedure: con-clusive cleaning results in complex anatomies

In each case study, post-procedure radiographic examination discovered previously undetected complex anatomies found through the delivery of Multisonic Ultracleaning technology from the GentleWave Procedure. Bacteria that would have been left behind — and allowed to spread post-treatment — were removed, and tooth structures were maintained.12 Results were consistent and conclusive that the GentleWave System provided a more thorough, more effective cleaning that potentially helped reduce the need for retreatments over time.12

Sonendo is dedicated to Saving Teeth Through Sound Science®. That means that our technology has been rigorously tested before it has reached the marketplace, and that we continue to innovate to deliver remarkable results for endodontists, referring dentists and patients. To learn more about introducing the minimally invasive7 GentleWave Procedure to your practice, contact a Sonendo representative today.

  1. Anatomy of the Tooth. Kenhub Web site. https://www.kenhub.com/en/library/anatomy/anatomy-of-the-tooth. Published April 15, 2014. Accessed February 26, 2018.
  2. Ricucci D, Siqueira JF Jr. Anatomic and microbiologic challenges to achieving success with endodontic treatment: a case report. J Endod. 2008;34(10):1249-1254.
  3. Basrani B, Haapasalo M. Update on endodontic irrigating solutions. Endod Topics. 2012;27(1):74-102.
  4. Peters OA. Current challenges and concepts in the preparation of root canal systems: a review. J Endod. 2004;30(8):559-567
  5. Zandbiglari T, Davids H, Schäfer E. Influence of instrument taper on the resistance to fracture of endodontically treated roots. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006;101(0):126-131.
  6. Rosenfeld EF, James GA, Burch BS. Vital pulp tissue response to sodium hypochlorite. J Endod. 1978;4(5):140-146.
  7. Molina B, Glickman G, Vandrangi P, Khakpour M. Evaluation of root canal debridement of human molars using the GentleWave System. J Endod. 2015;41(10):1701-1705.
  8. Vandrangi P, Basrani B. Multisonic ultracleaning in molars with the GentleWave System Oral Health. 2015;72-86.
  9. Paqué F, Balmer M, Attin T, Peters OA. Preparation of oval-shaped root canals in mandibular molars using nickel-titanium rotary instruments: a micro-computed tomography study. J Endod. 2010;36(4):703-707.
  10. Ford MW. Complex Apical Anatomy Revealed Following Endodontic Treatment of a Maxillary Molar Using the GentleWave System: A Case Report. Dentistry. OMICS International Web site.
  11. Nair PN. Endodontic biofilm, technology, and pulpal regenerative therapy: where do we go from here? Int Endod J. 2014;47(11):1003-1011.
  12. Sigurdsson A, Garland RW, Le KT, Woo SM. 12-month healing rates after endodontic therapy using the novel GentleWave System: a prospective multicenter clinical study. J Endod. 2016;42(7):1040-1048.

This information was provided by Sonendo®.

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