Complex molar anatomy - Courtesy ROOTS
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From: Terry Pannkuk
Sent: Tuesday, July 06, 2010 10:05 AM
Subject: [roots] Complex Molar Anatomy
This patient is a professor at UCSB and a great patient. The patient was
Asian with a very prominent zygoma and unusual root anatomy with an MB root
being bifid/almost two separate roots. The DB and MB1 were both well over
25 mm long. The MB2 was 23.5mm and the Palatal 24mm long with a complex
terminus. I took a post-treatment CBCT which was interesting. The buccal
systems were quite ribbon shaped. This type of root canal system geometry
cannot be adequately described by a taper size, apical gauge diameter, or
working length. In other words, what brand and size of rotary file that
was used is a meaningless discussion - Terry
Very very nice case Terry. Nothing to say really but bravo. I for one know
that proper radiographic documentation of such cases is not easy and you show
perfectly how CbCT can help in such cases. Furthermore you really put your
finger on the main issue that shaping in endodontics is all about adapting
the instrumentation to the tooth and not the tooth to the instrumentation.
Warm regards, - Hani
PS: I am attaching a series of photos/xrays of an extracted second upper
maxillary molar (anatomy similar to what you're showing) that I have used
in my courses to illustrate the difficulty of interpreting radiographs and
evaluating tooth anatomy and working length radiographically. I think they
would/could complement your case rather well (just to illustrate the anatomy).
Please feel free to use them. (XR1 is ortho view, XR1 deviee is what would
get by offsetting the cone, and XR1 md is mesiodistal view, a clinically
impossible angulation. The 2 others photos are rather obvious) - Hani
Nice images. Iím going up to UCSF to teach the residents on Friday and I
think I'íll add them as a very nice compliment to the concept of root anatomy
not being a tube. The common perception is that a taper size, glide path,
and gauge apical diameter can be determined by two contact points and a
conventional PA radiograph which belies the true complex internal anatomy
in 3-D. For years many in academia denied the reality of 3-D interpretation
which Schilder so elegantly described. Mantras such as itís what you take out
of the canal not what you put in .you can fill canals with bird crap and yada
yada yada .simply serve to trivialize the true clinical art which consists
of astute perception and an understanding that 3-D interpretation facilitates
the cleaning via shaping while copious flushing of the contents to evacuate
churned debris and contaminants. A focus on file design, artificially imposed
geometry, and a cookbook preparation mentality simply makes a clinican
wholly inadequate and distracted from the true goals of endodontic therapy;
i.e. to debride, eliminate space, seal the portals of exit of the root,
protect the attachment apparatus, and to definitively restore the dentition to
health and function. . Thanks for your images! - Terry
[This is a drive-by]
I can post case-after-case-after case just like these 25+ year recalls...
What is missing is the 20+ year recalls on all the over-accessed, over-prepared,
hogged out BU-style endo. Surely 40+ years of BU alumni should be able to bury
us with tens-of-thousands of 20+ year recalls.
The obturation-driven shaping protocols result in beautiful looking endo that
simply doesn't go the distance.
If the clinician takes a serious, unbiased look at the truly long-term cases,
you will see that the things listed below in blue are irrelevant at 20 years.
The word "seal" should simply be removed from the endodontic dictionary, and
using it speaks miles to the incongruities in peoples' mental models of what
they do versus what they actually do.
Preservation of the PCD trumps everything at 20+ years.
I mean...take a look...these teeth aren't even crowned...
The mantra should be:
"It's not what you take out or put in...it's what you leave behind."
- John A Khademy
Mantras such as "itís what you take out of the canal not what you put in"
you can fill canals with bird crap and yada yada yada simply serve to
trivialize the true clinical art which consists of astute perception and
an understanding that 3-D interpretation facilitates the cleaning via
shaping while copious flushing of the contents to evacuate churned debris
and contaminants. A focus on file design, artificially imposed geometry,
and a cookbook preparation mentality simply makes a clinican wholly
inadequate and distracted from the true goals of endodontic therapy;
i.e. to debride,eliminate space, seal the portals of exit of the root,
protect the attachment apparatus, and to definitively restore the
dentition to health and function !
These words must be engraved on the wall next to the entrance of every
endo dept at Dental Schools ! Well said/written Terry !
I kinda wrote the chapter on "complex molar anatomy" about a decade ago.
Due to limits imposed by the publisher, we had to limit the number of
pictures and variations, but it's a start.
What is missing, because my chapter was an access chapter, is the shaping
protocols. Unfortunately, the shaping chapters and protocols are written
by people who don't find this kind of anatomy, like this patient from
yesterday. The MM was "shaped" to about a #20patent/#25 just short hand
file. 1 year recall.
No, I didn't retreat the distal. - John A Khademi
There are a lot of controversy in endodontics about what could be determined
as a success. See attached RX of a tooth which was treated back in 1989 and
not crowned for 21 years.( I posted this picture several times already ).
Though it looks crap on RX it is doing fine without any clinical or
radiological symptoms. And here in Bulgaria I can show you many like this
one I see everyday. They never been accessed properly, they never
been shaped and cleaned properly and they have been filled just with
formaline - resorcine paste without any gutta-percha at all.
So as Dr.Mike Miller wrote:
I can do clinical/radiographic beautiful stuff that fails in 2-5 years
and I have some of my so-so endo healing/healed ( not going there)
after 20 + years and I see Sh*#@T that lasts like this. It all comes
back to the patients ability to heal.
Endodontics is a dental speciality in which "success" is quite poorly
defined if at all imho.
Having in mind findings of cbCT, Prof.Wesselink group studies and taking
upon consideration my own clinical experience what matters is not access,
shaping, cleaning and etc. - it is the body's ability to heal - i.e.
human immune system abilities. That is like the role of immune system and
antiobiotics when we treat dental infection - immune system is THE ONE which
eradicates/"treats" the infection and AB ONLY help it to do this faster.
As I wrote this earlier here - what we must do is to ensure the best
possible conditions for the body's immune system to heal the lesion -
this means we should do exactly what Terry has said below in blue and
we should not fill the canals afterwards with bird crap, but with material
which is helping the immune system to achieve healing and not adding more
In accordance with that approach is also my opinion that we should combine
whenever possible the regular endo with apico when treating PA lesions
larger than 5 mm.
And yea, I also do not touch something that works, in spite of the fact it
may be looking filled short on RX ;-).
About shaping protocols - I do not think in almost all cases conicity of more
than 4 % is needed, although I now routinely work with 6 % conicity to stay
safe on irrigation side :-). There were colleagues in Bulgaria who were
telling me less than 10 % conicity was crap :-), but I see after few years
they have now became much more cautious on using conicity larger than 6 % !
Large white lines may look good on RX, but are hardly of any help to already
compromised tooth which needs endo. - Valeri
John, any competent restorative dentist is going to remove as little tooth
structure as possible in order to best restore the tooth and this includes
those of us restorative people doing a lot of endodontics. All of the
biomimetric stuff works fine if you are working on virgin teeth but people
like me practicing dentistry in the real world donít get to work on many
virgin teeth. We catch teeth with multiple attacks and injuries which are
The vast majority of the teeth that I see needing endodontic treatment have
already been blessed with multiple restorations resulting in a large amount
of tooth loss. Of course any sane competent practitioner is going to remove
the bare minimum in order to reach their restorative goals. Thatís why I think
this biomimetric hot topic is just another way to create CE cash. Good
restorative dentists doing adhesive dentistry are not using Blackís preps.
We are utilizing modern materials, techniques, and adhesive mentality.
That equals minimal preps. I donít need to take a course to know this. - Guy
John's disconnect with reality is the same as Carr's. I look at many of my
own 20 year recalls; Carr doesn't claiming it's too expensive and impractical
since he moved his practice from Chula Vista. Interestingly after I badgered
the crap out him to show some long-term recalls, his first one he posted had
a lesion. This was of course after he had insisted that
Endo failures don't occur after short-term validation of healed lesions.
Whether the scanned tooth I had sent Eric was perfed, or not, didn't
clinically mat - Terry Pannkuk