In addition to the pleasure you can get from a free demonstration of the phases and procedures of such a retreatment, I think I can use this case to make some considerations.

I have always thought of myself as a good endodontist, ever since my degree. At the beginning I used to work with the naked eye, occasionally using, with low satisfaction, 3.5x goggles with no coaxial light that slightly improved my view of the endodontic field.

However, the fact that I often found the MB2 canal in the upper sixth was the best proof for my belief that magnification was not necessary and that I was a bit of a “chosen one” of endodontics, one of the few who can find the fourth canal with my eyes closed.

And, as a matter of fact, comparing how I worked back at the time and how I work now, I was basically working with my eyes closed!?

After thousands of canals and having started to always use goggles with coaxial light first and the microscope after, I’ve understood a few things.

First of all, as a new graduate I was indeed better than the majority of dentists who don’t have any idea of how you can decently perform a devitalization, if only for my theoretical knowledge and the fact that I was always using the dam, the mechanical equipment and thermafils. But, anyways, I sucked.

Secondly, whoever says that it’s not necessary to use goggles first (“I don’t want to risk and become dependant on them”?) and then the microscope (“after all, I can do everything with my goggles!”) simply does not have the experience and the means to make these statements. And I say so because I did it too!

The third point I want to make here, is that if you know what you could or should look for and you have the tools/instruments to see what you are doing, then things are not that difficult anymore.

Endodontics surely require a certain manual dexterity, great precision and a lot of patience.

And it also requires having all the instruments that technology makes available to us. Nickel-titanium rotary instruments, apex locator, irrigating solutions, a device for warm condensation, etc.

I would add the microscope and a cone beam for the more complex cases.

But the key to becoming a great endodontist is KNOWING HOW TO IMAGINE

Yes, that’s it. You need to be able to visualize the exact strategy you are going to use to manage the case even before you open the teeth. Exactly as a pilot can visualize and run the racetrack, before the start line, with his eyes closed.

You must predict all the obstacles you are going to face.

You need to be ready to look for exceptions, because teeth are not all the same!

In the past, I gave for granted that all incisors had one canal, except for some sporadic lower incisors where I could find, almost by chance, two canals. The lower premolars had only one canal, and that famous Weine’s class IV of the lower first premolar, occurring in the 25% of cases, was a useless bogeyman.

Lower molars had 3 canals, except for some first molars with two distal canals.

The upper first molar had almost always the fourth canal and that was my strong suit, the one that made me a great endodontist.

However, with time, I have learnt that the extra canals are there. And there are a lot of them. Even so, only few people know that they can be there, and even fewer people know how to find them.

You don’t believe it, do you? Just have a look at this very interesting page from Dr. Mario Venturi’s website: http://www.endodonziamauroventuri.it/Anatomia%20sistema%20canalare.htm. And that’s it, if I see an x-ray of a lower incisor now, I check straightaway if it’s likely to have two canals, which is a very frequent thing.

If an upper first molar in the preoperative x-ray has somehow unusual roots, it could have three canals.

If a lower first premolar has a canal that disappears at a certain point, it’s likely to be a case of Weine’s class IV.

50% of the lower first molars have a middle mesial canal. And sometimes that happens for lower second molars too.

The upper second molar can have two canals. Or also just one. And often it’s the preoperative x-ray that tells you what the case is.

The lower second molar can have a C-shaped canal.

Moreover, the lower first molar can have an independent radix entomolaris at distolingual level.

And I have learnt that many of these anatomies can be predicted if you understand how to read x-rays that, even if two-dimensional, become a three-dimensional image for me, an expert endodontist. This happens exactly because I have learnt to visualize what kind of three-dimensional shape can have impressed on the x-ray I’m examining.

Sure, you need experience.

However, no one has ever told me how to visualize particular anatomies and I am sure that, having a good teacher that shows you how to do it, it’s possible to learn faster than I did.

In the retreatments then, if you see decent treatments that failed, you need to learn to suppose what might have happened. And here you are, a first molar like the one in the video you’ll see in a while. You have a decent treatment, but there is a lingual fistula. Therefore, in this case, I start the retreatment already knowing that there will probably be a middle mesial canal. I don’t simply retrace the canals thinking that, just by disinfecting a bit better and placing the dam, the granuloma will disappear, because this will hardly ever happen!

Needless to say, in order to be able to anticipate what you will find, you need experience. But sometimes CBCT can help you. I’m not one of those who think chat it’s better to do a CBCT in all the endodontic cases in order to get as much informations as possible. At first it can be useful doing a CBCT when you intuit the presence of some exception from initial x-ray: in these cases

I’ll give you an example.

If I see a lower premolar that, in the x-rays, looks like it’s been well treated, but it has a big granuloma, I need to expect a vertical fracture or a second canal. The first times I looked for a second canal, I was always looking towards the vestibule aspect. Only after perforating a couple of premolars, I found out that the second canal, in the lower premolar, is always lingual. At the beginning you think it’s impossible, because looking at the teeth from occlusal it looks like you’re perforating it while you extend lingually. However, with CBCT and a vestibular perforation, you quickly understand how lower premolars with two canals are done and, at the end of the treatment, you will see that, opening the pulp chamber in the right way, these canals are well centred in the tooth, even though it seemed impossible before. And you understand it even better if you imagine you’re opening a tooth like this.

Do you understand, then, why you cannot find this canal if you don’t know it exists and if you don’t know that, when present, it’s in that position? We will definitely talk about the lower premolars in other posts.

For now, I felt it was important to give you some piece of advice.

If you assume that you don’t treat many teeth and therefore you cannot be that unlucky and find a premolar with three canals, you will never find it. But you will experience a lot of failures.

Actually, you will never experience any failures and you will remain convinced of this because your patients will have gone to some other dentist.

Only coming as little comfort to you and bad luck to you patient: whoever will come after you, won’t probably be any better than you. Unfortunately, nowadays, dentists still don’t know how to practice endodontics, although the instruments we have make it much easier for us than it was for Schilder and the fathers of modern endodontics.

My endodontics professor at the university asked to be paid for each canal and said that was the only way to get motivated to find them. I don’t know if that’s true. I find canals as a passion and because endodontics is fun if you know how to do stuff other people can’t do.

And, ironically, I reckon that canal treatments can fail now even more than when I just graduated. That’s because, back at the time, I didn’t do follow-up x-rays. And probably also because I didn’t notice some initial failures when my patients went to a different dentist.

As usual, I wrote too much. I’ll leave you to the video I promised I would post.

It’s a 3.6 with three distal and three mesial canals. The tooth had a fistula at lingual level on the mesial root. The disto-lingual and middle-distal canals were confluent, and I transformed them into one canal with a big apex and a favourable access that convinced me to obturate them with Biodentine. I obturated the other canals with Thermafil.

I hope I can transmit the emotion I feel when completing a case like this. Endodontics is beautiful if you know how to perform it. Enjoy the video and until next time!

Stefano

L'articolo A canals leads to another: if you know what to search and you see it, you can do it sembra essere il primo su Mastering Dentistry.

I was assigned 3 monocanals.

I remember that because of the thousands of protocols and all the documents for rx that were requested added to the inexperience, we needed at least two appointments for each tooth.And, during the second, I still remember that we were quite scared of the ROOT CANAL OBTURATION WITH THE OBTURA SYRINGE! A highly technological device that you had to request, after filling out forms and ensuring that you would have repaid with your poor student pockets the delicate 30 gauge needles if you accidentally lost or broke them. The department had a single syringe back then, which you received packed in a box with all the pieces laid out with manic care due to its high economic value!

When it was time to perform, after having gone to a great deal of trouble to document the case, you would start managing the delicate root canal treatment starting with the downpack with Touch’n Heat and pluggers with the Schilder technique, and eventually completing the backpacking with the Obtura syringe .

While hesitantly doing the maneuvers, without even realizing what you were doing, as you worked without goggles, you could already feel the anxiety for the moment of the final x-ray. After filling out another dozen forms to access the x-ray and the holder you would go to the printer … look at the x-ray hoping the liquids were not exhausted … you would go to the diaphanoscope … and … A SHITTY CLOSURE FULL OF GAPS !?

Three crappy closures out of three! 100%! Clear round!

I must confess that after this experience I kind of started to hate endodontics.

The following year, in the prosthesis department, the syringe Obtura and Touch’n’heat were unavailable, so, after learning the previous year that the cold condensation technique sucks, the next year you had to put it into practice while managing prosthetic cases. When they say “practice what you preach”…? With the conceit of who has already used the best technique on the planet, I reluctantly approached this primordial and primitive technique… though the x-ray were much more beautiful! Even if I knew that closure was probably going to be less successful than the one performed with heat the previous year, I restarted feeling passionate about endodontics.

In the meantime, while attending some endodontic courses I discovered this technique I could not figure out: THERMAFIL. I was wondering how to be sure to compact the gutta percha with that simple gesture … Where were all those measurements of the apex, the cone, the choice of the plugger, etc.? Too easy to work properly.

However, shortly before graduating, I had the chance to work for free in a center where they treated immigrants without residence permit and poor people. I bought a detector, rotating tools, endo motor, endodontic holder and then I decided to use Thermafil because the stove was easier to carry than the Obtura syringe and System-B or the Touch’n Heat, it cost less and it could fit into my padded endodontic killer-style briefcase…

Without clear criteria on how to select the Thermafil diameters and how to handle the work lenght, because the University had elegantly skipped this technique, I guessed the first thermafil 25 (definitely under-sized as I had a gauging of 25… ) and stunned by its simplicity I looked at the x-ray skeptical… sure of having restarted the series of negative results begun in the endodontics department. I was amazed by my first root canal treatment with small puffs. And it was a premolar, not a monocanal! No kidding!

From that moment on, I knew I became a great endodontist!In fact, I understood only a few years later that my level was still extremely pitiful, but that experience made me passionate about endodontics.

I owe everything to Thermafil and I will never deny it.

But in the following years, I began hearing some endodontists saying that Thermafil was good only for a few cases or even not good at all. And that a cool endodontist had to use the Continuous Wave of Condensation technique by Buchanan. Actually I’m not sure that Buchanan developed this technique because it sounds more like one of the martial arts techniques that Kenshiro used in the Hokuto school in the 1980s…. Are Japanese always on the go with technology…

However, the four judgments, which are also the 4 GREAT LIES we refer to on the title of the post, were:

1- “Hm, but if you have to retreat the Thermafil you’re fucked up … ”

2 – “Hm, what if the carrier is denuded touching the canal?”

3 – “Hm, the problem is that with Thermafil you struggle to put the post, and anyway you can’t put them during the same session of the canal closure.”

4 – ” Hm, but with Thermafil you can’t close difficult anatomies like bifurcations, IV Weine classes, confluent canals … you have no apical control!”

When you’ve just graduated the judgments of the masters of endodontics are dogmas, especially if preceded by the exclamation “hm!”  As a self-styled top level endodontist, if I only used Thermafil I was bound to be labeled as a geek and incomplete endodontist. And I did not want to be neither geek nor incomplete, so I bought the Obturation Unit by Sybron Endo. I used it 3 times.I made 3 shitty closures without any control, (and my hand had become more sensitive anyway…).

And to avoid leaving endodontics to Federico, who in the meantime had his hands full while denying the dogmas of the master surgeons, who often start with an even longer exclamation, such as “Hhhhhhmmmm”, I sold the magnificent Obturation Unit.

But since then I have been working more and more… you know, I don’t like days off… and I worked 6 days a week…

In one year I was doing 400 canals… then 600… then 800…

And you know what… after figuring out how to do it with Thermafil, I could put posts… and the carrier did not come out and the posts didn’t break off… at the beginning I cooled the gutta with the crio spray, then I realized that it’s enough to condense it with a plugger before cutting the carrier with a Dentsply Post Space Bur… even if I know this is not possible, so the carrier will grow again or all the posts will come off in a few months… See a post space completely clean like this is definitely a deception…

And when I bought the microscope I started to find loads of absurd anatomies… And I could only close them with the Thermafil… although I actually thought I could do it because it was impossible. Look at this first inferior premolar I have retreated about a month ago… a furcation 5 mm from the bottom of the tooth… practically a IV Weine class… What do you think I have closed it with?

I had denuded without even realizing a few thousands of Thermafil… and even if my treatments hardly fail, they will probably be back in the next few years, because we know that if Thermafil is denuded, the treatment fails because of obscene act in endodontic place…I have retreated hundreds of Thermafil… but certainly even if the result was “puff” I actually created a canal parallel to the previous one, which was impossible to retreat.See how difficult it is to retreat the  Thermafil and overcome the carrier wall…

Surely I was just lucky or incompetent. Or maybe not? Or maybe the truth is that you always have to play it cool and support the most complicated techniques to still feel a proper endodontist? Anyway the endodontic specialist in the past was undoubtedly a badass.  But when in a few years rotating instruments, apex locators and fast canalar obturation techniques enter the market and the endodontics is available to anyone, what do you speak about during once-crowded and now declining courses? “Guys, the closure is a piece of cake, put a stick in the canal and it’s done!”?

No, you have to create anxiety and sense of inferiority and inadequacy in the learners … You have to make it clear that simplifying is not good. And so for years when I go to some course or public a case on fb I hear the usual spiel. When you talk about Thermafil, everyone feels entitled to tell you that Thermafil is not to be used… they get naked, you can’t retreat them and the pivots are in serious trouble, etc. But come on, have you ever used Thermafil?!?!?! Or do you speak only based on hearsay? Only if you work and see what you’re doing you can make these kinds of statements. Otherwise you’d rather shut up.

Let’s be clear, when some high skilled endodontist shows me significant scientific examples I listen to them, I make my objections and we discuss… But it is much harder and longer for anyone to close with the continuous wave of condensation than with Thermafil.That’s why in the end, many make use of more exotic techniques, from the Gutta Condensor to the McSpadden in order to close with hot gutta and to escape the difficult method (the wave of condensation) or the fake one (the Thermafil). Actually, with the continuous wave of condensation or with the classic Schilder technique, the level of criticality is higher. So much so that, with this technique, I was able to successfully perform not a single closure neither as a student nor when I had an experience of thousands of treated canals. I have the utmost respect for those who know how to use it fastly and flawlessly. It’s certainly my fault, I’m probably and incapable and dummy… but in the meantime I won a Lavagnoli Prize (an agreement of the SIE-Società Italiana di Endodonzia), I have a publication on the Journal of Endodontics and managed cases where I found 6 canals in a molar. And I work with the best microscope in the world. And the cases don’t come back. In endodontics as in the rest of dentistry, you need to select the least operator-dependent effective techniques as possible. Then it can happen to have that single case out of 50-100 in which another technique would have been the best solution enabling you to save 5 minutes, that’s ok you will accept it with light heart. The 100% success will always be an utopia. And anyway, in those sporadic cases where Thermafil creates some complications, you can still be successful. I think we will be able to prepare some online courses on Thermafil. Believe me, it’s a great technique! I’ve nothing against Mr.Kenshiro and his continuous condensation Technique, but I trust more the technique invented by Ben Johnson… that even if doped, he holds a real world record and knows what speed is about.

Ben Johnson. SEOUL, DEMOCRATIC PEOPLE’S REPUBLIC OF KOREA: Ben Johnson (R) of Canada crosses the finish line to win the Olympic 100 meter final in a world record 9.79 at the Olympic stadium 24 September 1988. At (L) US Carl Lewis took the second place. Johnson was later disqualified for failing to pass a drug test. (Photo credit should read ROMEO GACAD/AFP/Getty Images)PRI101C;KOREA-BENJOHNSON

Moreover, I am a Silver Member of Style Italiano and I believe in the group’s motto: Feasable, Teachable, Repeatable. We need to teach things that work, simple and less operator-dependent. Let’s not invent complications and theories to make easy and effective things difficult. Such as Thermafil. If I wanted to learn how to use them but you do not know where to start I suggest you an interesting article by Enrico Cassai on the blog of our friends of Style Italiano about how to use them! Click here to take a look! Stay tuned!

Stefano

P.S. I apologize to Steve Buchanan and Ben Johnson, two great world- famous masters of endodontics! I took the liberty of joking a little … No intention of offending!

L'articolo THERMAFIL: THE 4 BIG LIES! sembra essere il primo su Mastering Dentistry.

"Midway in the journey of our life

I came to myself in a dark wood,

for the straight way was lost"

My working week has always ended on Saturday, not on Friday. So it is on Saturday that I run in the classic “Friday night’s last case”, which is always tricky, as we all know.

Last Saturday was no exception, and my agenda surprised with a 1.7 tooth retreatment which, starting from the pre-operative radiograph, made my jaw drop.

Can you see that mesio-buccal canal? From experience, I know that (taking for granted that he is not an incompetent doctor who cannot practice cheap football jerseys China endodontics) if the dentist who treated the patient before me manages to get in apex on two canals, but gets lost before the curve of a root, two problems may have occurred:

• He took a wrong path because of a calcified canal, or he made a mistake in locating the access to the pulp chamber
• He fractured an instrument and couldn’t penetrate further.

In this case, the patient informed me that my colleague had told him that she hadn’t managed to get to the end of a root, so at least she knew what she had not been able to do. Based on most of the pathetic treatments that have been carried out in the mouth of the patients who come here for the first time, I believe my forerunners don’t have the faintest idea of how to carry out a correct canal treatment.

So what’s the best strategy to deal with these cases?

First of all, think it over, before you rush and retreat the tooth; explain to Cheap Elite Jerseys – Wholesale NFL Jerseys Free Shipping From China your patient what Cincinnati Bengals jersey youths you’re expecting to find and what difficulties might occur. This way, if you didn’t manage to do much better than your predecessor, you could still manage to turn your failure in a “success” in the eyes of your patient.

Let me rephrase this better.

To this patient here, I said: “Alright, so this tooth might be difficult to treat in one of the roots. If you look at the x-ray, you can see this white material, which should get to the end of the tooth, as in the other two roots (and I point at the monitor). Can you see that it just gets to the half of the root? The problem is that, when a dentist stops before a big curve (and here I point at the mesio-buccal shape of the curve), he might have pierced the root or he might make us pierce it, if we follow his path; or he might Pittsburgh Steelers jerseys have fractured one of those instruments we generally use to go through the nerve canals of the tooth, failing to negotiate the canal. Now let’s see if, using a microscope, we manage to see what’s happened…Maybe we’ll get to the end of the root right away and I am just overthinking it…the problem is that the infection you have under the tooth is due exactly to that root, so if we don’t fix it, we’ll run the risk of having to remove the lesion under the tooth surgically…”

At this point, the patient has understood that the job could be tough, he senses that you know what you are doing and you have covered your ass in case of a possible failure. After all, you’re not the one who’s made a mess in your patient’s mouth and your role is just analyzing it, and possibly fix it. Canal treatments can be difficult in a vergin tooth. When you can’t carry out the treatment at your best the first time around, if you try the second time with gutta-percha or other materials, calcifications that have worsened overtime, possible fractured instruments or false paths, things cannot but get worse, and it is fair for the patient to know that we’re just trying to get right what someone else has previously screwed up, having to solve more problems than our predecessor had to.

Now it’s time to decide if a pre-operative X-ray is enough or we need a Cone Beam.

I myself choose to do a pre-operative CBCT when I suspect the presence of accessory root canals or to retreat external resorptions. In these cases a CBCT helps me to find what I’m looking for right away.

Still, in cases like this a CBCT is useless, because the gutta-percha present in the canals creates obstacles, and in any case seeing that the gutta-percha pushes on the root contour won’t necessarily help you sort out the situation. Besides, we might also unexpectedly find our way effortlessly, in which case we would have just X-rayed our patient for nothing.

So, let’s start the retreatment.

Palatine canal: easy peasy.

Distobuccal canal : easy peasy.

Mesiobuccal canal: there’s a wall.

Then I try to correct the opening axis of the tooth. Nothing happens.

I just check if the one I’ve found may possibly be a fourth canal and the obstruction a 90 degrees confluence with an MV canal that hadn’t been found previously. Always keep your brain active and consider every possible angle, remember. Still, nothing.

I’ll take an endodontic ultrasonic tip like the one below.

I try to enlarge the canal a bit, to understand if there’s a fractured instrument, moving distally, given the curve is in that direction. Sometimes, the canal opening has just not been corrected, forcing the files to take the wrong path. After this maneuver, I go a little deeper, I suddenly feel an empty space and I tell the patient: “ok, let’s see if we’re there yet, or if we’ve ended up deep down, as I feared.” I use the apex locator, and it rings at 12 mm rather than 20.

“Ok, as I was fearing, we are likely to have ended up off the right path, let’s just have an X-ray taken to understand where we are…”

And here’s the X-ray.

At this point, the patient isn’t worriex because what is happening is exactly what you had predicted, so he understands that the situation is difficult, but you know what you are doing.

Knowing that I proceeded mesially, I forget about that path, and through the ultrasound I create a small room in a distal direction. I try a couple of times with ultrasounds and then files, but still nothing. Ok, so this is the moment when we want to understand a bit more, because we can’t risk on turning the root into Swiss cheese.

Now I am going to perform a 3D scan of your tooth because we need to understand where we’ve ended up, whether  there is a canal or not, how the root curves and if the lesion is due to that root, because if we discovered that the canal didn’t exist at all because it’s completely calcified, and that under the root there were no infection, then closing the false path and stopping wouldn’t be a problem.”

We are providing logical explanations, and the patient understands that we have a precise strategy. Moreover, he has never seen a doctor who works with a microscope and has all these means at his disposal. He probably remembers a dentist who didn’t even have magnifying lenses and who surrendered after 10 minutes in a sweat.

Now we’ve green bay jersey cheap got the CT scan results and we can discuss them together.

Once I start working again, using the same endodonic tip that I had used previously, I make my way from where I had created the explorative room in disto-palatine direction. Ideally, I should find a pretty accessible canal without having to advance too much. 15 seconds, with an endodontic tip. I find a file…I feel it crack…Pounding heart…I use the locator…12 mm, 14 mm, 16 mm…19 mm! Ring ring ring! Awesome! Now I’m sure this is the right canal, given it is as long as the disto-buccal one, and I manage to figure out the disto-palatine curvature that I had been expecting.

Both we and the patient are greatly relieved. After this last attempt, we would have been envisaging an apicectomy, that he wanted to avoid and I would have had a hard time performing because of its unfavorable position.

I don’t even carry out the double-check X-ray to make sure that I am in the root. The patient has has been X-rayed long enough today.

I assume that the false path is so small that it can be considered just like a perfectly disenfected lateral canal, so I can rely on gutta-percha for closing it.

Instrument, irrigation and filling using Thermafil.

Voilà.

To enjoy my well-deserved satisfaction, I wait with my patient for my assistant Anna to develop the final X-ray, to have a look at it together.

The result is self-explanatory, and the patient can see for himself that he is in good hands. He’s found a professional he can rely on and he regards his expense as worth the therapy,considering the two hours spent on it, the instruments used, the skills and the competence showed.

Let’s draw our conclusions from this story.

Before rushing on a re treatment, always analyze that your predecessor did wrong and anticipate the difficulties you might have to face. Talk about it with your patient. Find a strategy and stick to it.

Then, a little tip. You might want to treat a case like this with goggles and coaxial light, but, trust me, it’s hard even if you have some chances to succeed. It could be done by an expert who’s been used to operating with a microscope for years. Not by an inexperienced professional who’s just started to use the goggles and doesn’t do much endodontics.

Advanced endodontics must be carried out through a microscope and a CBCT. If you don’t have this technology, but you’re interested in endodontics, make sure you buy it.

If you can’t afford it, or you don’t want to go mad working on these cases, do your patient a favor: send him to an endodontist when you start treating your first false path. Don’t try to be a hero at you patient’s expense or, even worse, scratch the tooth and place an implant tricking the patient into thinking that his tooth couldn’t be recovered due to the first (bad) treatment.

If you know what you need to look for and you see it tank to a CBCT first, and then a microscope, these are complex cases, but not impossibile ones. And, more importantly, they can be solved without resorting to an extraction.

L'articolo HOW TO FIND THE STRAIGHT WAY YOU LOST: CAN YOU CORRECT A FALSE PATH? sembra essere il primo su Mastering Dentistry.

In this post I want to show you a couple of tricks to remove a fiber post, since at the beginning of my career they were my bogeyman, as well as retreating Thermafil.

Well, let me say this…In dentistry there’s a lot of clichés…Thermafil, for example: at University they used to tell me that retreating them was a pain in the ass. But when you happen to retreat teeth with Thermafil, you immediately realize it’s something that just a person who’s never retreated any could fear. Or rather, after treating many of them, you’ll notice that you may have a hard time with a carrier in tight and curved root canals. But learning methodologies to facilitate the removal doesn’t take long.

The same goes for silver cones…When I came across one for the first time, I scheduled the procedure for one hour in my calendar and I remember removing it in 5 seconds using tweezers… ?

Ditto for fiber posts.

If you want to remove a fiber post quickly, you can try and bet on dentists’ little ability to get high adhesion values in post space. Therefore, you can remove the composite around the post until the bottom of the root canals, take universal plier, pull and…voilà! A huge number of posts come off in 5 seconds, along with the composite cement.

In case the post unravels or rips with this method, though, you’ll have to use the second method for fiber post removal, in which you wear them away with thin burs or with an ultrasonic tip, according to how deeply they are placed.

This is also the method I’ve used the most, since I have my microscope.

If you see that the post is in the coronal third of the root in the preliminary X-ray, you can wear it away with a very thin diamond bur with a head of 0.8-1 mm diameter, like this one from Komet

If the post goes deeper, then you’ll have to resort to ultrasound, using a Start X 3 kind of tip, making a perforation, like this one.

You’ve got to use this tip shifting between dry sessions and “wet” sessions in which you clean the field with water, because a fiber post (be it in quartz, glass or carbon) releases a black dust that darkens all the tooth inside, when heated. So, it is essential to wash the field with sodium hypoclorite or EDTA, and sometimes use the ultrasonic tip with water, in order to get to see what you are doing.

When you use the ultrasonic tip dry, you mustn’t use it as if you were making a metal post vibrate, but you’ve got to push hard at the center and perform circular moves, as if you were putting an umbrella in the sand on the beach, to be clear ⛱

You should feel the tip sink slowly…every so often, make sure to clean the post surface gently, letting the tip swing. Then wash everything as I told you, target the center of the post and repeat the “umbrella in the sand” movement dry.

When you think you got to the bottom of the post, you may try and “break down” the last millimeter using an endodontic retreatment tip. I use this one, with Mtwo system.

But if you can’t feel it cave in immediately, don’t push too hard or you’ll risk on damaging everything.

As I told you, since I have a microscope, I have almost never resorted to the removal method with pliers, because it almost takes me longer than wearing away the post with ultrasound. But without a specific enlargement and coaxial light, you might, at some point, find yourself not understanding where the post is, and you might risk on damaging the root or wrecking the tooth too much. Carbon fiber posts are difficult to distinguish in the middle third of the root of very dyschromic teeth, or if you try to remove them by drilling metal ceramic crowns, which darken the the field of view. Glass posts, instead, can become difficult to distinguish in non-dyschromic teeth rehabilitated with composite material. In this case too, the challenge is to figure out where the heck the post is, after 2 or 3 mm depth in the root canal.

To figure out if you are touching the post or the dentin, you can use two little tricks. The first one is to use ultrasound without water and push quite hard towards the area where you expect the post to be. Ultrasounds in this case will sink deep, produce smoke but no noise, while if they touch the dentin, they will emit the typical “creek creek” sound that you hear in a scaling session. The second trick is to dig a little, using an endodontic probe, like a DG16 …the fiber posts generally get “defibered” in this way.

Here’s an illustrative video in which I remove a carbon fiber post.

In the endodontics course which we are going to post soon on www.masteringdentistry.dental we’ll deal with the removal of fiber posts more thoroughly, and we’ll also deal with the removal of other kinds of posts, revealing all the tricks that just experience and the use of a microscope can give you!

Stay tuned!

Stefano

L'articolo HOW TO REMOVE A FIBER POST?…DON’T MISS THIS POST! sembra essere il primo su Mastering Dentistry.

Let alone capable of treating it properly.

Hoping you are one of the colleagues who knows what I am talking about, let me briefly introduce the topic to everybody else.

Although the reason why this happens is still unknown, sometimes teeth develop an inflammatory reaction for which, starting from the cervical margin of the tooth, a granulation tissue substitutes dental hard tissue by osteoclasts.

It looks like all this happens because of a damage occourred at the amelocemental junction, and this happens concurrently with:

• traumas
• endodontic bleaching
• orthodontics
• surgical periodontal therapies

Although some etiologic hypotheses exist, the ones above are the main correlations found in external resorption patients’ medical history.

But what happens exactly to teeth affected by this phenomenon?

Basically, some bleeding tissue is created, clinically similar to a bone in a long-standing process, or to a nervous tissue in “younger” teeth, taking over the dentin.

I want to tell you how I discovered what an external root resorption was, clinically.

Yeah, because now I’m acting all cool, but back in 2011, a patient having this tooth shows up.

This was my reaction.

What the heck had happened to that tooth!?! Pretty alarmed, I showed the X-ray to Federico, my business associate, and he also thought it was something really bad. Who knows, like one of those absurd tumors we had only studied in radiology books, that had weaseled its way in this 4.6 tooth! What did I come up with, then? An explorative cavity and a biopsy of that tissue!

When I opened the cavity as if to perform a filling, to my great surprise, the tooth has bleeding where there was supposed to be dentin…! and it wouldn’t stop…???

With a spoon, I took a sample of that misterious tissue, that I thought had probably been implanted there by some aliens during the poor patient’s sleep; after doing this very gently, I kept digging until I could, looking for some healthy tissue, but I had a hard time understanding if I was touching the nerve or that bleeding kept coming from the tooth.

I didn’t want to resort to a devitalization, because I wouldn’t have known how to carry it out successfully, without a distal root; so I placed a composite filing.

After a week, the patient was asymptomatic and the test results were ready.

I thought the diagnosis could be something like a tooth carcinoma or a tissue of unknown origins, probably alien.

Instead the verdict was:

“fragments of sclerocalcific tissue”

I think the histologist hadn’t understood much more than I had.

After 5 years, the girl still has an asyntomatic tooth and the X-ray shows that the process stopped.

This happened because, unknowingly, I carried out a correct therapy for a problem I didn’t even know. I removed the granulation tissue as best as I could, stopping or slowing down the process of destruction of the tooth.

When this case was submitted to my attention, in 2013:

I recognized the same phenomenon I had observed in the abovementioned girl infested with the alien tissue, and I suddenly remembered that cheap nfl jerseys at Uni we had learned about external root resorptions.

So I studied the phenomenon and I was able to make a diagnosis.

That was an external resorption of class IV.

In 1999, in fact, Heithersay classified external root resorptions in four classes (Heythersay, 1999):

• class 1 presents with a little resorption in the cervical area, with a superficial dentin penetration;
• class 2 presents with a well-defined resorption, which penetrated near the pulp chamber with little or no extention to the root dentin;
• class 3 presents a resorption extended in the coronal third of the root;
• class 4 identifies invasive and extended root resorptions, which go beyond the coronal third of the root.

Perfect.

The treatment included removing the granulation tissue surgically or with an orthograde approach and filling the tooth with composite material, as if it were a cavity filling, in class 1 and 2 cases (it is often necessary to combine this procedure with a root canal treatment and a clinical crown lengthening. In class 3 or 4 external resorption the lesion is often filled with MTA, given it often communicate with the periodontium (so far I’ve used Biodentine, but we’ll discuss this in a further post).

Ooooook. Just when I was ready to start, this time well-aware of what cheap jerseys nfl I was about to do, I read that Heithersay recommended not to treat class 4 external root resorptions, because the success rate was 12,5%!!!! (Heithersay, 1999)

But could I possibly think of extracting a seemingly healthy tooth, that had a purely aesthetic function for my patient (who was, in the meantime, wearing an invisible brace)?

Of course not.

So, to get a deeper understanding of all the situation, I performed a  CBCT.

At this point, I wondered:

“Do I really have to surrender to a defect which is perfectly treatable, and also clearly visible, thanks to magnifying goggles or a microscope?”

After all, Heithersay worked before 1999, when enlargements and microscopes weren’t that common, as well as 3D teeth scans. And if you read the paper where he describes the technique he used, you’ll shudder. With such an antediluvian technique, I’m surprised he’s had such a high success rate!

As you’ll be able to see in this video, my idea totally made sense. With a microscope and a CBCT, treating such cases surgically is absolutely feasible and, let me tell you, not even that difficult.

You see?

Do you think this tooth will last less than 3 years? I can tell you “no” already, since this treatment turned 3 years old in September 2016 and the tooth is still perfectly healthy, both clinically and from the X-rays.

You don’t need to practice this technique 1000 times to be successful, and this is confirmed by the fact that this tooth was the first one for me.

Since then, I carried out four more class IV resorptions, publishing the clinical records first on the Journal of Endodontics and then on the Italian “Giornale Italiano di Endodonzia”, and I had previously won the Lavagnoli Award at the Italian Society of Endodontics, presenting these 4 cases.

In the meantime, I used the same technique in at least 5-6- class III or II cases, while I restored surgically other 3 or 4 cases (I don’t remember how many, right now).

This teaches us two lessons:

Firs: external root resorptions are not rare, but rather difficult to diagnose in their early stages, because they look like cavities.

Second: if you know what you’re doing and you use your brain, you don’t need to go through extraordinary experiences or attend dozens of courses for years, before actually practicing some new techniques.

I went from total idiot in 2011 to great expert, in just two years and after two cases!

There are still many aspects to consider about external root resorptions. I’d like to talk you you about how I’m thinking about proposing a new classification of the problem, based on therapy options, and I’d like to show you more videos about it.

But since this is not a course on this topic, but just a hint I wanted to give you, I hope you were intrigued, and I suggest that you keep following us, since you’ll see pretty exciting stuff!

Stefano

L'articolo EXTERNAL ROOT RESORPTION: THE GREAT UNKNOWN sembra essere il primo su Mastering Dentistry.

As many of you, for me mandibular first molars had 3 or 4 root canals, two mesial and one or two distal ones, while mandibular second molars typically had 3, at times just 2, and I would pay close attention to the possible presence of C-shaped canal.

Despite knowing that molars with 5 root canals exsisted, I contented myself just finding the traditional root canals.

I knew about the existence of a middle-mesial canal, but eventually I never managed to see it, not even with a microscope, maybe because for years I have been working on teeth that had to be retreated, so I wasn’t helped by possible bleedings after the instrumentation of “conventional” root canals.

Middle-mesial canal prevalence varies from 1 to 25%, I would read everywhere.

Then I ran into this paper:

Azim AA ET AL. – J Endod. 2015 Feb

Azim & Co. had found the middle mesial canal in 42 cases out of 91 molars! Moreover, 21 of those were second molars!

????????

How could they do that? They dug 2 mm deep into the isthmus between the mesio vestibular and the mesio lingual canal with a little diamond bur 1 mm wide on the head. In doing so, they managed to expand their total retrievals from 6 cases (all of them first molars) to 42 cases, 21 of which were second molars!

Incredible!

The day after, as soon as I stumbled upon a mandibular sixth, I immediately tried and insert a Mtwo in the isthmus between the two MV and ML canals and….BANG! The instrument engaged immediately!!!!

????????

Since then, on 48 first molars I’ve found the middle mesial root canal 24 times in 17 months! A 50% success percentage!!!

And I am considering here just first molars, while I manage to find the middle-medial canal even in mandibular second molars, as you can see below.

Usually, since purple Mtwo is a phenomenal instrument to retrieve and probe tight or calcified root canals all at once, I try to insert this instrument in the isthmus between the MV and ML canals several times, after shaping them. If I don’t feel any engagement, I go 2 mm deeper between MV and ML root canals with a Start-X 3 or, more often, with a small diamond bur 0,8 mm wide on the head and that’s it.

If I can’t find anything, after these two maneuvers, I just give up.

Realizing that the middle-mesial canal must be searched and it is often right there helps me solve this kind of cases, which I observe fairly frequently. Mesial canals of mandibular first molar apparently well obturated but having a lesion. My associate, who mostly deals with surgery, kept telling me that it might have been a cleansing issue, but I have never believed this. If a canal looks well filled from the X-rays but presents a lesion, it’s either vertically fractured or lacks a root canal.

In these events, I immediately inform the patient, and as soon as I have cleaned the chamber I immediately start looking for the missing root canal right away. It’s almost always there.

Below, I’ll show you how to find the middle-mesial canal.

I hope that starting tomorrow you’ll change the way you consider mandibular molars too.

In other future posts, I’ll tell you how I have dramatically increased the number of root canals found also in other teeth, in endodontics. Keep following us!

Stefano

L'articolo IN SEARCH OF THE LOST CANAL! THE MIDDLE-MESIAL CANAL sembra essere il primo su Mastering Dentistry.