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Apical trifurcation - Courtesy ROOTS

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From: Terry Pannkuk
To: ROOTS
Sent: Wednesday, September 20, 2006 8:52 AM
Subject: [roots] Apical trifurcaton

Here’s an interesting retreatment case I finished today.  Those clinicians who claim that filling short and
that shaping doesn’t facilitate better endodontics should be buried with the rest of the dinosaurs that have
retarded clinical endodontics for the past 40 years.

Here’s a case and point:  Poor access, weak shape, filled short, failed.  What else is new?

Initial coronal flaring to a greater degree than the previous treatment; I found two branching distal canals;
after a few recapitulations I felt another branch and flared more, found a third branch in the apical third.

It’s indefensible and inarguable that the world if relatively round not flat.  I had to say relatively round
because I’m sure someone selling products to accommodate a flat world would insist that it isn’t a perfect
sphere.

Any contrary opinions?  Should I read more outcome literature?  Sjogren?  This of course isn’t evidence-based.
Mega-analyses of the outcome literature by Kish would have clearly shown that this case would have been more
successfully treated with silver points. - Terry




Terry, Very nicely done. One thing that caught my eye was the nearness to the furca in one of the x-rays views.
Now the other view shows it not to be close at all, but then I got to wondering that, in fact, the prepartion
may be close to the furcation and the second view may be giving us a false sense of comfort. I'm always trying
to lean to the outer wall when creating my coronal flare. In fact, the coronal flare is for the express purpose
of straightening the coronal curve which is always straightened at the expense of the outer wall - Barry

The straight-angle radiograph is the money shot. It is impossible to read the depth of a concavity from any view
and we basically are guessing how deep a concavity is unless you have a CT with occlusal slices.  I don't know how
close it is to a perf but I would be willing to bet from experience that it isn't close.  You can see the subtle
but obvious double distal root outline to the mesial on the image below. I doubt it’s near a perf. I don't go over
a #4 Gates and the flaring is primarily with hand files shaping the apical third after very slight enlargement.
These cases always look wide when viewed from an angle because of the wide buccolingual dimension housing three
canals - Terry



Very nice going Terry ........................just a few questions which I hope you will answer despite of them
being basic but plz take them as coming from someone low down on the ladder.

1: Are you able to put 3 different GP points in all the 3 branchings? Or is it  one master cone and the
trifidity is filled by movement of the thermoplasticised GP into the branches.

2:Did you find the trifidity while looking down the scope or was it by poking around with pre bent
instruments ?  -  Sachin

Hi Sachin, Those are very good questions! ..simple questions are always accepted ..repeated questions that are
asked for the devious purpose of making me state the same thing over and over again for target practice are
the only ones that make me a bit cranky

In this case I was unable to place three cones and just placed two.  I judged that the last branch toward the
apex would have required a very narrow taper cone fit along side another narrow taper cone predisposing both
cones to buckling and apical void formation upon compaction.  It seemed wiser in this case to fit a blunt cone
in the larger middle branch and allow the compaction to deform and the gp into the last short buccal branch
which would result in better apical deformation and approach the ideal of a core of gp with a microfilm of
sealer.  The puff is usually in the branch that wasn’t cone fit, and you can predictably see the one puff in
the branch I didn’t cone fit with the other two not puffing.  The goal is not to get a giant puff, but rather
to have apical control during the deformation of gp.  Slow gradual development of the compaction during the
multiple waves allows most of sealer to escape coronally rather than pistoning a blob out the end.  The more
space that is initially filled with a gone, the less sealer that is going to be expelled.  This is desirable
in that you want to achieve a microfilm not a macroblob of sealer. This is one of the reasons I view squirting
as a very crude and nonclinically elegant way of accomplishing the apical obturation ideals.

I found the bifurcation after my initial coronal flaring and could see it directly with the scope.  I felt the
third path during the recapitulations and flared out more coronally so I could see it directly and clean it
better; hence the critical need to coronally flare.  You can’t do this with narrow curved roots, so in those
cases you have to compromise otherwise you’ll weaken and perf the root -  Terry

Thanks Terry.....for me getting a direct look at the apical third is not a possibility as I don't have a scope
but I certainly can do some searching at the apex with prebent hand instruments which until now i have been
guilty of not doing - Sachin

Sachin,

Here is a case from Tuesday with a deep bifurcatin discovered by:
1) the expectation that there are two or more canals in any root
2) the notation that the initial canal located was too far to the palatal
3) searching with a precurved hand file

Pic2 is a perio probe.  You can see it is hubbed out at over 12mm at the point of bifurcation.
Pic3 is the downpack. Keep up the search.  :-)))) - John



Now that is nice, Terry.  Please post more tx's on here.I can't get on TDO. I learn a lot from pictures :-)Guy
Not bad terry.  You should think about doing this for a living - gary

Terry, Beautiful case!This failing case was more due to missed axnatomy and untreated systems - Fred

Fred, Thanks, but the point is that filling short and failing to adequately flare coronally causes you to miss
anatomy and inadequately debride.  I’m trying to push this argument until I receive a counterargument that
legitimately disposes of my claim that this is true.  This has never been a me against you; me against Trope;
or a me against Randy thing; but rather a JHC !, Is the endodontic world freakn’ retarded? Why can’t I get a
straight logical reason for what seems like a commonly accepted illogically held belief that contests my claim
(i.e. Schilder dogma)?.  I just keep pushing it more aggressively until I get a response that makes sense
to me. It doesn’t seem to be working.

95% of the arguments I push in people’s faces seem to be related to emotionalized resistance to the simplest of
all clinical principles taught by Schilder.  To make things even more ludicrous,  when they can’t fight the
logic they decide to say shit like Ok, that may be true but Schilder didn’t really say it first, Blayney did
in the Paleozoic era.  For Crissake what kind of immature, childish, insecure people can’t give this up already.
If they didn’t like Herb personally, fine, he died and I’m sure they’re happy; but all their personal moaning,
bitching, and distorting of science and logic won’t kill the brilliant influence he had on clinical endodontics.

I’m very curious about the Blayney article and would really like to see how much Herb may have taken from him,
if anything.  I’m not denying that there could have been some influence.  Did Blayney talk about recapitulations
and the envelope of motion file movements?  I don’t know.  Weston Price and others had very similar ideas.

To get back on point, the claim is that Schilder’s clinical strategy for developing shape and a flow to create
convenience form to the apical third is unequivocally the most important endodontic treatment concept to achieve
predictable success today.  It facilitates all other endodontic principles that allow effective irrigants to
perform, intracanal space to be eliminated, and anatomy to be addressed.

Where are the compelling arguments against this?  All I hear is intellectually irrelevant rubbish - Terry

John Valentine was asking us about what to teach his students in his new part tienm undersgarduate teaching position.
Pannkuk wrote: To get back on point, the claim is that Schilder's clinical strategy for developing shape and a flow
to create convenience form to the apical third is unequivocally the most important endodontic treatment concept
to achieve predictable success today.  It facilitates all other endodontic principles that allow effective irrigants
to perform, intracanal space to be eliminated, and anatomy to be addressed.

I think that's a good summation of what they should be taught -  Herb's 5 pronciples for canal  preparation.
If they just learned that , they're be miles ahead.

Also, Terry P - . Great description of how you handled the trifurcation with 2 GP cones.

A couple of questions for those who use LS/Simplifill :
1. How are you going  to handle a case like this  when you are trying to open em all to 60? ? Is it reasonable to
   expect to reliably get a straight ( not precurved) instrument to go where you want (on a consistent basis)
2. If it takes Terry P. 2 cones to fill  a trifidity like this with a warm technique - how do you expct to address
   anatomy like this with 2 plugs and a cold technique that doesn't flow?

Just wanna know how they handle stuff like that which occurs naturally.. Rob K

Thanks Rob, I always appreciate your words of wisdom when my mouth runs out into a busy street like a dog about
to be splattered by a car - Terry     Click here to continue...