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Endo tips    Better Endo    Endo abstracts    Endo discussions

Apical trifurcation - Courtesy ROOTS
The opinions within this web page are not ours. Authors have been credited
for the individual posts and images where they are.

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 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 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...

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