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From: Rafaël Michiels
To: ROOTS
Sent: Wednesday, July 08, 2009 5:40 PM
Subject: [roots] Easy cases.
Here are 2 cases I did yesterday. Technically they are easy, but I wanted
to show them, because they show that a good cleaning is more important
than the obturation technique.
Both cases were done with cold lateral condensation.
Case 1
2.4 with apical periodontitis.
Instrumentation, until a protaper F2, apical preparation with handfiles
until size 0.40
Cleaning with NaOCl 3%, EDTA 17% final rinse, both activated with Irrisafe.
Alot of cone pumping after the preparation.
Temporary restoration in glass ionomer.
Case 2
3.4 with apical periodontitis. Suspected a lateral canal. Cleaning and
shaping was similar to the case above. The temporary restoration was done
in glass ionomer.
Further build up needs to be done, because the composite restoration
is well.... lost. Referring dentist is going to remove it completely and
place a post and crown - Rafaël
Rafael, Just out of curiosity....how do these specific cases that you
finished yesterday, demonstrated on an immediate post-treatment radiograph,
show that good cleaning is more important than obturation? - Terry
Hi Terry, I was not referring to the clinical outcome of the cases, rather
I wanted to make a point about the technical side of cleaning, shaping and
obturating.
We all like lateral canals to be filled, but some say that we need to use a
warm technique to fill these canals. I wanted to show that even with cold
lateral condensation, you can actually obturate this kind of anatomy.
It all comes down to your cleaning and shaping protocol, more than the kind
of obturation technique you use.
In short, the propagators of warm techniques want endodontists to fill as
much accessory anatomy as possible and they are absolutely right on this,
except for the fact that it would not be possible with a cold technique,
because it is.
There are some cases which I would not think of doing with a cold technique,
but in pretty round canals; I do not see, why I would not.
As for the clinical outcome, both have the same outcome.
I hoped I answered your question with this - Rafaël
Hi Rafael, Here are the questions:
1. Do you really think you fill as many lateral canals and obliterate/entomb
as much space with a cold technique?
2. Doesn't a space radiographically filled on a radiograph imply that something
was removed from that space?....something like a lotta debris and crap? :):):)
3. Do you think it's much of a theoretical stretch to presume that very small
residual disinfecting irrigants pumped through lateral systems/tertiary anatomy
during the last phase of hydraulically active obturation might just provide some
additional debridement efficacy compared to those passive techniques that leave
unobturated gross gaps?
There seems to be a high degree of simple clarity to idea that three-dimensional
meticulously controlled cleaning, shaping, and compaction of a deforming,
dimensioinally-stable, nonresorbable material should be regarded as the gold-standard
endodontic technique.
For some reason Schilder's principles have become symbol of endodontic excellence
although many of the principles have become rephrased, repackaged and emulated by
those who seek a more convenient, easier-to-perform display of "Fool's Gold". :):):)
This is how I see it - Terry
1. Do you really think you fill as many lateral canals and obliterate/entomb as much space with a cold technique?
If you cleaned them and removed the debris and opened them, you can fill them with a cold technique too.
But with the cold technique you fill them with sealer. Blasphemy from the 'leakage' point of view. Since sealer
shrinks. However, if you fill the lateral canals with guttapercha like in the warm vertical technique, you cannot
control the shrinkage of the guttapercha either. As for the amount of filled accessory anatomy, maybe it is more
maybe it is less. I really do not know, do you?
Entombment is a different story. I do not think you entomb more bacteria with a warm technique than with a cold
technique. You fill the whole canal and you entomb the micro-organisms in the parts you don't fill like tubuli etc.
So then comes sealer penetration into play. There is no significant difference between warm and cold techniques in
sealer penetration into the tubuli. A colleague of mine, Nikolaas Dewilde, has done research on this subject and
his study will appear somewhere later this year. Warm vertical condensation even tended to have less penetration,
but it could have had something to do with the fact that the sealer in this technique gets mixed a bit more with
the guttapercha, I mean it is not as separate as in a cold technique.
Penetration of sealer in tubules, filling of lateral canals, it is all about pressure. You have pressure in both
warm and cold techniques.
In short, I do fill alot of accessory anatomy with a cold technique, is it the same amount? That is yet to be proven.
Entombment is similar.
2. Doesn't a space radiographically filled on a radiograph imply that something was removed from that space?....
something like a lotta debris and crap? :):):)
Yes it does, and since I filled the space, even with a cold technique, that means that I must have removed a lot
of debris and crap from it. In other words, that is exactly, why I said that the cleaning and shaping is more
important than the obturation technique.
3. Do you think it's much of a theoretical stretch to presume that very small residual disinfecting irrigants
pumped through lateral systems/tertiary anatomy during the last phase of hydraulically active obturation might
just provide some additional debridement efficacy compared to those passive techniques that leave unobturated
gross gaps?
I am with you on the presumption that pushing very small residual disinfecting irrigants through lateral
systems/tertiary anatomy during the last phase of obtuarion can provide some additional debridement efficacy.
However, yet again, the whole purpose of showing these cases was to demonstrate that even with cold lateral
condensation you have an hydraulic effect. Otherwise I would not have filled the lateral canals.
There seems to be a high degree of simple clarity to idea that three-dimensional meticulously controlled cleaning,
shaping, and compaction of a deforming, dimensioinally-stable, nonresorbable material should be regarded as the
gold-standard endodontic technique.
Dimensionally stable. Sorry but guttapercha shrinks when you heated it and it cools down, we try to reduce the
shrinkage by plugging/condensing. But on a microscopic level there are hugh gaps. That is why people are trying
so much to find new materials like resilon. So wether or not you do it warm or cold, gaps are there, no matter what.
For some reason Schilder's principles have become symbol of endodontic excellence although many of the principles
have become rephrased, repackaged and emulated by those who seek a more convenient, easier-to-perform display of
"Fool's Gold". :):):)
Schilders technique is a benchmark, I am not arguing with that. But cold lateral condensation has been shown to
have a clinical success equally to that of a warm technique. It is being thaugt in many parts of the world as the
basic obturation technique, there is a reason for that: It works!
Advanced techniques are nice, and every endodontist should be able to perform them all. But there is no reason
to claim that one technique is superior over the rest. Warm vertical condensation, continuous wave of condensation,
cold lateral condensation, system A, hybrid, all are good techniques. This is how I see it. - Rafaël
The material properties of gutta percha when heated have been studied, but very few people read them.
You haven't read the studies and do not understand it. Your explanation is in error. Endodontic outcome studies
are poorly controlled/low level evidence and you cannot draw any conclusions based upon them.
If you can't demonstrate filled irregular space you haven't verified cleaning - Terry
Hi Terry, Interesting discussion. Good to know your point of view.
Regarding your description of gold-standard endodontic technique, the idea of three-dimensional meticulously controlled
cleaning caught my attention.
Can you briefly explore this idea in a practical/clinical perspective? How can we control our cleaning? - Ricardo
Simply by using more precurved hand files than rotary files, especially on cases with complex anatomy.
That would be a day long lecture on treatment nuances :):):)
But in a very gross summary: Access facilitates convenience form to the apical third of the root canal system
which then allows better flushing of irrigants and more complete exploration and thorough cleaning of deep
dentinal walls with the smooth arc of a precurved file. Rob Kaufmann wrote a very nice article on the
"Envelope of Motion". Deep shape means better apical third cleaning which is demonstrated upon the final "pack".
If the final shape doesn't represent a gutta percha cone taken straight out of the box, you've done well. :):):)
Densely packed irregular apical bulging and fins are a very nice sign of "completeness".
Those using only rotary files tend to contact only the outside walls of curves, leaving the inside wall "dirty".
Rotary files also tend to miss fins, secondary, and tertiary anatomy, especially when they exist beyond a first
curve that cannot be directly visualized even with the scope.
The idea that the microscope defines quality endodontic treatment and has become a litmus test for excellence
bothers me. The microscope is a necessary tool, but it certainly doesn't define excellence per se.
The microscope is not a philosophy; it is a hunk of metal; endodontic excellence is achieved by seeing as far
as you can with the microscope and then seeing beyond that with your "mind's eye". If all you see is what you
see with the microscope, then you are half blind. :):):)
This is another view point that led to my getting kicked off of TDO. :):):) - Terry
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