Gary writes:

Of course, it's possible to do these cases without cone fits. Some you'll
overfill and some you'll underfill' and some you'll get lucky. What we're really talking about
here is what kind of consistency do you want in your practice? How often do you want to hit a
home run? Cone fit radiographs are an extra step that increases your slugging average.To me,
excellence is about consistency. Out of a thousand cases, how many demonstrate this level
of care?

Since they all will probably be successful regardless, some clinicians can't see the importance
of it. - Gary .

From: Glenn van As
Newsgroups: roots
To: ROOTS
Sent: Thursday, October 04, 2001 9:14 PM
Subject: [roots] Re: Nasty little curve

Gary and Richard:  First of all Richard outstanding case.......gosh that was a touch curve, I
just marvel at your technique and results!!

Gary:  when you mention that you liked the cone fit film......what kind of things are you looking
for and what kind of things make you worry when you evaluate the cone fit films.  I know that
many of the endodontists are wincing at my remarks but I just wanted to know what you evaluate
when you look a good and not so good cone fit film.

Thanks again .......Glenn

From: Dr.Carr
To: ROOTS
Sent: Friday, October 05, 2001 9:12 AM
Subject: [roots] Re: Nasty little curve

Glenn,

Because the cone almost always has to be cut back so the apical diameter approximates the final
apical patency file size, the cone fit is nearly always problematical, especially around abrupt
apical curvatures like the beautiful one Richard showed. Establishing an adequate "capture zone"
around cases like that really tests a clinician's skill and commitment and the cone fit verifies
the result. If the shape is not there, a file may easily go to place but the cone may not--it
tells you so much more than a file film, Combined with your own tactile sense of the location of
resistance, a cone fit film guarantees a well done case. Because measuring the exact length can
be difficult because of reference point variability, a cone fit is confirmation that the measured
length is correct. In Richard's case, there's a million things that can go wrong with a case like
this if the cone fit is not done.

Of course, it's possible to do these cases without cone fits. Some you'll overfill and some
you'll underfill' and some you'll get lucky. What we're really talking about here is what kind of
consistency do you want in your practice? How often do you want to hit a home run? Cone fit
radiographs are an extra step that increases your slugging average.To me, excellence is about
consistency. Out of a thousand cases, how many demonstrate this level of care?

Since they all will probably be successful regardless, some clinicians can't see the importance
of it. - Gary .

Bill Watson wrote:

You mention something again, Gary, that I have a question about and it involves the cone fit and
the capture zone.  Since, as I understand it, you have ~0.2T in the apical 2 mm.  I am assuming
that you do this with hand files which means that if you are #20 at 0 mm at 2 mm you are at a
#60.  How do you transition the 0.2T apically with the lesser degree taper?  I believe you
mentioned that you use GT files in the past.  There seems to be a gap between the custom
hand-created taper and the GT file taper.  For example, if you use the .10T GT file it isn't a
#60 size till 4mm back.  Exactly how are you blending those areas?

Another observation and question:  I have been preparing some teeth this morning with some
different files and have noted how really fine some of the apical thirds of the roots are of the
extracted teeth.  I'm not sure, radiographically, that I would be able to determine just how fine
these root shapes are.  So now the question:  How do you modify your capture zone preparation to
account for such variability in root morphology?   How do decide to reduce the degree of taper or
if keeping the degree of taper the same, how do you determine what the size of the apical
preparation should be?

Another observation and question:  I believe (perhaps mistakenly) that you mostly use GT GP and
cut it back to fit the appropriate apical size.  Now if you are using a .10T GT GP master cone in
your typical capture zone preparation, there is a large discrepancy in the canal preparation and
your cone size.  This is one of the reasons [among others] that you feel you must get to within
3mm of the GP on your downpack.  Backing up just one step, here is the question:  Since that
large discrepancy exists between the prep and the cone do you find that you get a crumple zone in
the GP when you place it?  If not, the you must place the cone very gently without much apical
pressure.

Summary of questions:

1-Exactly, step by step, how are you blending the transition zone of the custom hand-created
capture zone and your GT file (or any other greater tapered file that you use) file.  If you had
a visual to demonstrate this that would be wonderful.

2-Keeping in mind the wide variability of root morphology, how do you determine the apical
preparation and taper preparation?

3-Keeping in mind the large discrepancy between the canal preparation and the GT GP, how do you
deal with the 'crumple' zone problem of fitting the master cone?

Thank you very much for your kind consideration. - bill

Jerry Avillion writes:

I must not be doing it correctly.  I have plenty of cases where I did a cone fit film and got
overfills, underfills and 'lucky'.

Obviously, you can get an approximation of length, but what else are you looking for with the
cone fit film?     When you do one that is 'wrong' (but the length is correct), what does it look
like?

Regarding consistency, I've found that the most important thing (at least for me) is to allow
enough time to do what you need to do so as to not be 'rushed'.


Bill,

To answer this comprehensively requires a full day course! Or more time than I have! I recommend
Dave Rosenberg's course where he goes over these fine nuances in very great detail in a hands on
environment. Dave will be at the TDO User group meeting in Nov at La Costa. - Gary

From: Bill Watson
To: ROOTS
Sent: Saturday, October 06, 2001 12:11 AM
Subject: [roots] Re: Nasty little curve

I thought I might get lucky.  I did realize that when I wrote it that it was very invloved and
quite specific and would probably take more time than you have.  Well I thought I would at least
try.  They were good questions though, don't you think, that get to the very finer points?

It is very difficult to find higher level endodontic hands on courses that go anything beyond the
"Here's how to use this rotary system".  I would most certainly be interested in Dave's course or
anyone else's that addresses higher level issues. Has anyone heard anything about Donal Yu's
course.  I personally believe that the difference between the master endodontist and the
endodontist du jour lies in the ability to manipulate skillfully the hand files.  That is one of
the resaons that I enjoy this forum is that it fills in the holes of personal deficiency and the
lack of formal training.  The quest for excellence is on of perserverance. - bill

Jerry Avillion writes:

<< I personally believe that the difference between the master endodontist and the endodontist du
our lies in the ability to manipulate skillfully the hand files.>>

Hand files, rotary files, high speed handpieces, low speeds handpieces, etc, etc.  Some of us
don't have the talent to be a master endodontist.  I know,  I dont.    I think we can all get
'better', but I don't think we can all get to be masters.

Besides, it's alot cheaper for my patients to be treated by an endodontist du jour instead of a
master.

Gary replies:

I'm not sure I know what a "master endodontist" is. To me, the only distinction between
endodontists is in their desire to work up to their highest potential and perhaps their common
contempt for mediocrity. I don't think "cost" has anything to do at all with this. Patients
generally get what they pay for.

From: "Bill Watson"
To: "ROOTS" 
Sent: Saturday, October 06, 2001 1:46 AM
Subject: [roots] Re: Nasty little curve

I suppose that you have defined the difference between the master [perhaps as much of an attitude
(part I) as technical skill (part II)] the du jour. I feel the desire (part I) but part II
occasionally doesn't live up to the expectations for myself. -  bill

That's part of the equation! Never being satisfied with yourself! - Gary

I love these philosophical discussions.

There was a study done that showed people who thought themselves to be incompetent were actually
more competent than those who thought they were competent.   The idea being that you don't know
what you don't know.

This is why I'm happy being an endodontist du jour instead of a master, if I was a master I
wouldn't be as good as I thought I was, whereas right now, I'm alot better. ;) - Jerry Avillion


From: "Jerry Avillion"
To: "ROOTS" 
Sent: Saturday, October 06, 2001 12:17 AM
Subject: [roots] Re: Nasty little curve

> To me, the only distinction between endodontists is in their desire to work up to their
>highest potential and perhaps their common contempt for mediocrity.

Potential and a dime won't get you a cup of coffee.  Results are what count.

The only result that matters with regard to endodontic treatment is healing. It really wouldn't
matter (to me) how well my cases 'looked' or how many redundant steps I took or how many
appointments it took,  if the cases didnt heal. And like you pointed out, most of the time, ANY
endo is going to heal, that's why I think it's important to look at the cases that don't heal and
try to figure out why, and re-treat them and try to determine what we did differently to get them
to heal (if they do).

>I don't think "cost" has anything to do at all with this. Patients generally get what they >pay
for.

Sure it does.  Some patients can't afford or don't want a higher quality care. Some practitioners
can't deliver or don't want to deliver a higher quality care.

>>Patients generally get what they pay for.

YOU know that, and *I* know that, but the patient's dont.   At least not well enough.  Heck, some
dentists can't even determine why one way of doing endo is going to be worth more than another
way.