Apical trifurcation - Courtesy ROOTS
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From: Terry Pannkuk
Sent: Wednesday, September 20, 2006 8:52 AM
Subject: [roots] Apical trifurcaton
Hereís an interesting retreatment case I finished today. Those clinicians
who claim that filling short and that shaping doesnít facilitate better
endodontics should be buried with the rest of the dinosaurs that have
retarded clinical endodontics for the past 40 years.
Hereís 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.
Itís indefensible and inarguable that the world if relatively round not flat.
I had to say relatively round because Iím sure someone selling products to
accommodate a flat world would insist that it isnít a perfect
Any contrary opinions? Should I read more outcome literature? Sjogren?
This of course isnít 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 itís 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 wasnít cone fit, and you can predictably see the one puff in
the branch I didnít 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 canít do this with
narrow curved roots, so in those cases you have to compromise otherwise
youí'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
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. Iím 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 freakní retarded? Why canít 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 doesnít seem to be working.
95% of the arguments I push in peopleís 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'ít fight the logic they decide to say shit like Ok, that may be
true but Schilder didnít really say it first, Blayney did in the
Paleozoic era. For Crissake what kind of immature, childish,
insecure people canít give this up already. If they didnít like Herb
personally, fine, he died and Iím sure theyíre happy; but all their
personal moaning, bitching, and distorting of science and logic
won'ít kill the brilliant influence he had on clinical endodontics.
Iím very curious about the Blayney article and would really like to
see how much Herb may have taken from him, if anything. Ií'm not
denying that there could have been some influence. Did Blayney
talk about recapitulations and the envelope of motion file movements?
I don'ít know. Weston Price and others had very similar ideas.
To get back on point, the claim is that Schilderís 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
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...