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Apex Locators in the diagnosis of perforations

 Secrets of Paper Points

Source: "Roots" Molar Del Sud (Ace Dentura)" wrote: Has anyone put forward studies on paper points in canals?......viz a viz....length determination? Of course when you drop an ink droplet on a blotting paper it never spreads...... of course a wet point on a paper point ,never travels upwards or does it?Dry the canal to length 3 or 4 times ,the stick a new a paper point thru the apex for an accurate measurement of working length.....I don't think so....you've got BP,hydrostatic pressure,inflammation,shape of the apical foramen ,be it oval or absolutely round........comes back to where do you finish the prep. Of course I made this all up...and I'm only playing devil's advocate..... then again I use pp's for corroboration not determination....... Sunday afternoon could be interesting. Molar Del Sud
From: gary Sent: Thursday, May 03, 2001 6:13 AM Subject: Paper point verification of WL Who said anything about "sticking it through the apex"? Of course paper points wick. The point is that if you do this carefully, you can achieve, in most cases, an added degree of accuracy over any other method: radiographic, electronic, touch and feel, etc. Also. the smaller you keep the foramen and the earlier in the procedure you do this, the more accurate the determination is, No? - Gary
From: Jerry Avillion Sent: Friday, May 04, 2001 12:29 AM Subject: Paper point verification of WL Do you ever check length with the paper points at the second appointment? How would that differ from what you described? Jerry Avillion
"Mark Dreyer, DMD, PA" wrote: > When you dry the canals, doesn't the tip of the paper point have some > moisture on it when it goes out the end? Yes there is moisture most typically. You're saying that I should routinely measure to that point in order to confirm my WL? Haven't been doing that routinely-I'll start though. Thanks! Mark Dreyer, DMD, PA
From: Gary B. Carr Sent: Wednesday, May 02, 2001 3:18 PM Subject: post op pain Mark, The paper point measurement is, without question, THE most accurate way to determine length. Ideally, you want this length determined after your electronic length has enabled you to take a 15 or 20 to the terminus but BEFORE you do a lot of apical instrumentation. . Then use the paper point test to refine the electronic length BEFORE you do a lot of apical instrumentation. This insures that you do not enlarge the apical 2mm unnecessarily.Remember, the electronic length is almost ALWAYS long. So if you are using that as your patency length, you will be off when you create your capture zone. Being super accurate with this length is the secret to controlling the puffs, overextentions, etc and keeps your apical sizes small and disciplined. . It's great to see you reasoning through all this and growing and improving with each passing day! - Gary
From: Fred Barnett Sent: Wednesday, May 02, 2001 9:18 PM Subject: paper point measurement Very interesting. Being a periapex respecter, formerly known as the pulp lover, ;>) I have a couple of questions concerning the paper point measurement: 1. does a certain degree of wicking occur? And does that effect your measurement? 2. how often does the point come out dry but in reality it is just outside the constriction? 3. how often does periapical exudate/tissue fluid enter the apical canal and thus invalidate your paper point measurement? 4. if there is a discrepancy, do you trust the apex locator or paper point measurement? I have NO experience with this, and my questions are sincere. Fred
From: gary Sent: Thursday, May 03, 2001 3:38 PM Subject:secrets of paper points Fred, These are excellent questions and show you are thinking through these issues carefully. I'll try to answer clearly. If you accept that the electronic measurement is almost always slightly long, it behooves us to get as accurate a measurement as soon as possible in the procedure. Using paper points to check your length at the end of the procedure is too late! If the electronic measurement is slightly long and you use that length to create your capture zone or resistance form at the apex, many times you are not going to end up with the minimal apical size you desire and your apical shapes will not have the form you need to prevent large puffs or over extrusions. If you use the paper point determination EARLY in the procedure, you refine your electronic length BEFORE apical shaping ,your apical shapes will consistently remain defined and disciplined and you will minimize the puffs and overfills. Following Dave Rosenberg's suggestions, I now do the following: 1. Determine electronic length after the coronal shaping is done. 2. Once a 15 or 20 file is at the electronic length without any coronal interference but before any apical shaping, use a paper point to refine and adjust the electronic length. This may take 4-7 points before you know exactly where that length is. The microscope makes this so much easier. I inspect the point and measure the point under the scope. .25mm looks large at 12X. 3. Now I have modified my electronic measurement with the more accurate paper point measurement and when I'm doing my apical capture zone prep, I'm never working long. This prevents me from ripping the apicies open and allows for constantly producing minimal apical diameters because my knowledge of the actual location of the foramen (or cavo-surface margin) has been verified. This may seem like overly compulsive to many but ,in truth, it is the secret to consistent accuracy. Measurement accuracy is the key to producing world class endo. Especially now, where these newer instruments allow anyone and everyone to attain close to ideal shapes. If the ideal shape is created .5mm long, your consistency drops dramatically and your apicies get opened up. Hope this clarifies, - Gary
From: Julian Webber Sent: Friday, May 04, 2001 12:54 AM Subject: paper point measurement Fred, The patency length is "00" on the AL and i never go more than a 10 to this point. I prep first wave to 1mm short of this point and take a paper point measurement and confirm again with AL I then go no more than 20 with rotary to this terminus length, guage terminal dia and do paper point again to finish and establish continuity of taper behind terminal dia. All cones are fitted .5mm short of this point I go for the paper point every time and although one shouldnt I have especially with sedation cases taken no X Rays and used the technique to perfection ( Hang me ) If the point is dry as far as I am concerned I am not through and therefore cannot be accurate When doing a pp measure put it in grab it and remove as immediately as poss to prevent wicking . Do it 2,3 x to be consistent This technique is the best way to avoid squirting stuff through the end which a lot of folks seem happy with but personally I think it looks a bit untidy Good apical control in this fashion sorts out the men from the boys Julian
From: gary Sent: Thursday, May 03, 2001 6:06 AM Fred, This is so much more enjoyable than debating whether you can do great endo in 30 min or not! I'll try to answer, but this is Dave Rosenberg's terminology so I'll ask him to chime in also because he understands it and can demonstrate it so much better than I. . The "apical capture zone" is an area at the apical 1-2mm that has an exaggerated taper.This dramatically increases the resistance form of the prep and insures against inadvertent extrusion of GP. For example, if the apical diameter is .25 mm, an apical capture zone would be.30mm a quarter of a mm back and a .35 mm a half a mm back.and .40mm at 3/4mm back and a .45mm at one mm back. This produces an exaggerated taper in the apical 1mm.. This is actually a 2.0 taper than cannot be produced by any single rotary that I know of. For me, this is a far better way of producing apical shape than Steve B method of taking the GT's long. This method also allows for precise apical control around curvatures and recurvatures where the rotaries simply straighten everything out, especially if you are taking them long. Hope this helps. Gary
"Molar Del Sud (Ace Dentura)" wrote: How do you get a pp to do this...... Photos by Molar Del Sud
You can't ice the varmint in shape.....I actually like early too.....after 2 or 3 determinations with the Root ZX.....using differnet sized files.....nominally 10,15, and 20 Who said anything about "sticking it through the apex"? Of course paper points wick. The point is that if you do this carefully, you can achieve, in most cases, an added degree of accuracy over any other method: radiographic, electronic, touch and feel, etc. Also. the smaller you keep the foramen and the earlier in the procedure you do this, the more accurate the determination is, No? Molar Del Sud is
From: gary Sent: Thursday, May 03, 2001 6:34 AM Subject:Paper point verification of WL Ace, Actually, this is precisely the kind of case where the pp measurement can help dramatically.The radiograph is of almost no help in determining the length. You can preshape paper points to go around curves--we do it every day. I even use the Buch. file bender to bend the points! Gary
From: DANNY office Sent: Thursday, May 03, 2001 7:30 PM Subject:Paper point verification of WL Watching this paper point appoication very carefully. Beginning to wonder about using an instrument to bend pp, ect.especially from someone who escaped from school since my experience was they wanted me out as soon as possible. How about a complete explanation about the theory of the pp. I have gotten bits and pieces of how it is used. Thanks, Danny
From: Jerry Avillion Sent: Friday, May 04, 2001 1:32 AM Subject: Paper point verification of WL What brand of paper points do you use? Any significant difference between one brand and another? Jerry Avillion
From: Fred Barnett Sent: Thursday, May 03, 2001 7:03 PM Gary, Yes, this is way more enjoyable...since I can't do a great endo in 30min ;-( My next question is regarding cone fit. As your apical capture zone appears to be a 0.20 mm/mm taper, what type/size/taper of gp do you use for your cone fit, and where does the "tug-back" occur? - Fred
From: gary Sent: Thursday, May 03, 2001 4:48 PM If you look at the masterful apical shapes of Dave's cases, you can see this would never be accomplished so routinely without hand inst of this area. - Gary
From: Fred Barnett Sent: Thursday, May 03, 2001 6:13 PM Gary, Thanks for your well thought out reply. These nuances are certainly what allows one to achieve consistent high-quality results. It also clearly illustrates that endodontic treatment is so much more than just bringing rotaries to a predetermined length and then obturating the canal. Can you define "capture zone" for me, please? Jim Roane talks of a "control zone", and its morphology depends upon the apical canal diameter and curvature. Thanks again! - Fred
From: "Mark Dreyer" Sent: Thursday, May 03, 2001 9:30 PM Subject: Paper Points R Us The paper points I have correspond to the autofit gutta percha in taper. Thus, if I'm using them early in the instrumentation phase, as Gary and others recommend, they won't go to length because I haven't instrumented any taper into my apical prep at that point. Obviously I need to use a different brand paper point. What works best for this? Fine paper points? Any specific brand better than another? Mark Dreyer, DMD, PA
From: Jerry Avillion Sent: Friday, May 04, 2001 12:34 AM What's the relationship between 'masterful apical shapes' and success rate? I think we all pretty much agree on what 'looks' nice on the x-ray, but can we accurately say that the ones that look the nicest heal the bestest? :) I'm giving a lecture on Tuesday and I KNOW they are going to ask me why I am so hell bent on maintaining patency and getting my little 'puff'. I think I know why, but I'd like some of you other guys to give me some of your reasons. Jerry Avillion
From: Jerry Avillion Sent: Friday, May 04, 2001 3:18 AM How far away from the foramen does an instrument need to be before you can be sure that no apical shaping has taken place? Is it normally possible to get a 15 or 20 file to electronic length with only coronal flaring? <> But wouldnt the healing rate go up as you opened the size of the apex? Jerry Avillion Hope this clarifies, Gary
From: Fred Barnett Sent: Friday, May 04, 2001 1:24 AM Jerry, I'll be at your lecture just to bust your stones ;-> Wide apical enlargement removes more bacteria, substrate, etc. (Orstavik et al, Dalton et al, Shuping et al, Rollison et al). Kerekes and Tronstad showed a higher success rate with the standardized technic, which means wider apical MAF's, than the traditional step-back (size #25 at WL). Just WOW them with your bone magnet cases! Good luck!! Fred
From: Fred Barnett Sent: Friday, May 04, 2001 1:28 AM Actually, I forgot to mention, that when the root filling looks good; no voids, good apical level, etc., there is a very good association with PA healing. Molven's thesis was on this, I believe. Also, there are a number of other cross-sectional epidemiological studies that also show this to be true, as well as Sjogren's thesis. Fred
From: Sirendo@aol.com Sent: Thursday, May 03, 2001 6:43 PM Gary, I think this can only be done by hand files and since not rotaries helps to separate the men from the boys. This is what I gained from Dave in talking with him. Right? Regards Bob
From: gary Sent: Friday, May 04, 2001 9:31 AM Fred, To illustrate the importance of early paper point determination of the real cavo-surface margin, I post this case where the electronic length was wrong by over 1.5 mm! If I had accepted that as the definitive length, I would have been instrumenting the MB long the whole time. Working long around a 90 degree bend like this, you can open up the apical diameter big time,yes? That leads to suprises when you do the downpack that none of us like.When I was making these mistakes learning warm technique, I always thought I was pushing too hard or heating too much when I overfilled these. It wasn't until I had overfilled many that I realized it was the innaccuracy of my measurement that was causing the problem, not errors in the actual the warm vertical technique..... I'm a slow learner--maybe someone can avoid these surprises by understanding the crucial importance of accuracy early in the game...... Gary Preop and working wire AT the correct electronic length:
Photos by Gary

Downpack after adjusting the length 1.75mm shorter than the electronic length based on a paper point refinement: Shape was produced 1.75mm short of electronic length.
From: gary Sent: Friday, May 04, 2001 9:33 AM Final pics Photos by Gary   
From: Bill Watson Sent: Friday, May 04, 2001 6:48 PM Do you ever have problems with a crumple zone apically since, for example, if you are using a .10T GT GP point, you have a wide area of non-conformance btwn the GP and the canal wall unless you somehow modify the cone other than just cutting the tip to fit the constriction size. With such a large area of non-conformance btwn GP and canal wall, it becomes exceedingly important to have a superb downpack in order to fill that exaggerated gap btwn GP and canal wall. This would be unlike having a continuous .10T from the constriction coronally where there is comparatively intimate contact btwn the GP and canal wall. You obviously get world class obturations so something is working well. I am not sure if I made sense or if you could understand my thoughts. - bill
From: Fred Barnett Sent: Friday, May 04, 2001 4:12 PM Gary, Beautiful case. I, the prodigy of Scandinavian Endo Philosophy, have been defying the Gods and obturating with the SystemB and Obtura. Don't you hear the thunder already? However, I personally cannot accept the large amounts of extruded sealer/gp that I have seen posted on this site. I know, I know, if this were Survivor #3, I'd be the first one voted off the Roots Island. ;-( I asked about your cone-fit technic, as your capture zone has a taper that appeared to be .20mm/mm. If you have the time, can you kindly post your method? Which brand, size and method of achieving tug-back. What about fitting your System B pluggers--do you go to within 3mm, 5mm, ?? Thanks...the learning that is going on here is outstanding. - Fred
From: gary Sent: Friday, May 04, 2001 4:46 PM Fred, Bring on the thunder! I believe the large amount of sealer we are seeing on many of these cases does not reflect a problem with the technique itself, but as I have indicated, a problem of working long because of small errors in length determination.Obviously, if the capture zone does not have good form or if the cone fit is not done well, you get THUNDER! That's why I have requested everyone post their cone fit pics because you can tell so much from them. I'll try to post some cases this weekend where length was not adjusted early in the game and I just accepted the Working wire pic or the electronic measurement and Viola! Thunder! The reason I am so convinced of this theory is that I have wrestled with this problem of large sealer puffs and over extensions myself for a long time and didn't really improve my results until I realized the problem was where I was creating my shape. Especially around curves, if you're a little long, you've lost control of the case. The problem is you don't realize it until you see the Thunder! yes? Too late! Yes, I know you can always cut the cone back before you pack but if your shape or fit is not pretty exact, you can't really compress as much as you would like. I know from experience that the over extensions and large sealer puffs probably do not affect results--at least they do not seem to have in my cases. TDO will give me more accurate numbers on this issue later.But even if they do not affect the healing, I don't like them. Jerry has trouble with understanding this---doing it as well as you can vs well enough to heal. But we've beat that horse to death so I'll not mention it again! Gary
From: I. Blake McKinley, Jr. Sent: Friday, May 04, 2001 8:58 PM The other cause could be a cone fit to the proper length but is binding somewhere other than the apical 1-1.5 mm. When patent during cleaning and shaping, the cone fitting can be somewhat technique sensitive. Blake McKinley, Jr., DDS
From: Jerry Avillion Sent: Friday, May 04, 2001 11:51 PM When I get a larger than ideal blob of stuff out the end, I'm thinking it's sealer that I'm squirting out due to the hydraulic forces of the master cone acting like a piston. When I first got the GTs and autofit gutta percha, I would use the same size cone as file and I seemed to get bigger puffs than I wanted some of the time. Since I started using one size smaller cone, I haven't noticed this as much. I'm thinking that the sealer is better able to come coronal rather than squirt apical with the slightly less tapered cones. does that make any sense? Jerry Avillion
From: Molar Del Sud (Ace Dentura) Sent: Saturday, May 05, 2001 7:12 AM Jerry , You're getting movement through the sealer,with the thinner point, rather than pressurizing it to squirt......it's a surface area thing......plus a tighter space.I still use the 08 point with the 08 file and don't push so hard. :))
From: Jerry Avillion Sent: Saturday, May 05, 2001 12:11 AM If you fill the entire canal with sealer and then push a very well adapted cone to the perfect length, will you get alot of sealer out the end? There are some techniques that advocate using a spiral instrument to fill the canal, when I played around with these spirals, I was empirically finding bigger puffs, is that because there was too much sealer in the canal? Jerry Avillion
From: Bill Watson Sent: Saturday, May 05, 2001 1:57 AM I have found out clinically, in my experience, that there is a positive correlation (in warm vertical condensation) of sealer extrusion between the amount of sealer and the 'adaptiveness' of the GP cone in the canal. Also, if you add to the correlation a larger apical opening there is a chance of even greater sealer extrusion. I have some bad examples of this in my early learning days. Sealer extrusion was a relative rarity with lateral condensation. Where I started noticing it the most was in the cases where I had good conefit and more than adequate sealer. bill
From: Joseph Dovgan Sent: Saturday, May 05, 2001 5:01 AM Subject: Lateral Canals and puffs Hey guys, There was a paper published in JOE this month touching on a similar subject, filling lateral canals. Found out that squirting (ooops PSGP) was better then lateral condensation but thermafill obturation had the most. Unfortuantely, I would love to see the study using a more alpha phase GP instead of they beta they used during the squirting. Joey D, Don't have my JOE at home. Read it this week at work.
From: benschein@prodigy.net Sent: Saturday, May 05, 2001 3:57 AM My friends: There is no doubt in my mind that anything you can do to establish correct length is commendable. But we are not charging for our Protapers or our Obtura needles, or our guttapercha material, we are charging for our time, our knowledge and skills. But our time is the most valuable asset in the office. Photos by Benschein      The more complicated the procedures we use the more time we consume and therefore the more we price ourselves above affordability of a great segment of our population. For example in this case neither the patient nor I could afford to put more than 90 minutes into the case. As it is he is paying me 3 weeks of his gross income to save his tooth.The guy is a young man (30's) who did not know he had decay. Look at 12 and 13, he will need endo in those in the future. So I used electronic measurement, paper points method and touch only. No wires, no cones fit. I felt confident I was within the mens area (not the boys area). I would have had to bring him back and eat the cost if the results were not satisfactory. I am satisfied with the result. I am not predicating 30 minutes endo, but good 90 minutes endo. Now if we get scared of surplus material into the periapex we will be working our asses off to even obtain cases good enough to heal particularly in necrotic casses with LEO'S
From: The Janians Sent: Saturday, May 05, 2001 7:34 AM Ben, Very interesting from an ethical point of view: From one point of view, you should not have done the case, since it seems you would have taken more time to do it more perfectly if the patient could have paid the proper fee. From another point of view, that if the case was not undertaken at all because there was some consideration about the fee, then the patient would have been refused treatment because he did not have enough money. He then would have gone to someone else (probably a zip 'em in and out clinic) who would probably have charged a smaller fee than Ben's, but who's results would have probably been much less refined. Looking at the case, it is an excellent result, with some itty bitty voids and a little excess sealer puff. (and that's splitting hairs) All and all, I'd say the patient made out very well. The thing I like about this posting, is that it made me think about the other side of the coin of "do the absolute very best possible treatment in all cases, at all cost" Which is a philosophy I subscribe to... Good job Ben. - Jeff
From: Fred Barnett Sent: Saturday, May 05, 2001 5:17 AM Ben, I appreciate your remarks. However, I don't quite understand your last comment. Those of us that try to instrument and confine the root filling materials to the apical constriction, are certainly NOT attempting to do a "good enough the heal case"....we are doing the optimal treatment for the human being we are treating according to all available scientific and clinical literature. That does not mean fill 3mm short...that means as close to the constriction as we can achieve. I dare say that doing it my way requires more care and control of the instruments than say the Schoeffel technic where every NiTi goes 1mm through the foramen (I heard this myself). If you take your files through the apex you will of course not block yourself out. If you stay 0.5-1mm short, you better know what your are doing NOT to block yourself out. I also have NO problem with taking a size #10 file 0.25mm past the constriction. Obturating within the confines of the root canal system which terminates at the constriction is providing a service second to none. I'm not saying that a small extrusion of sealer is harmful, but it is certainly NOT required for optimal healing. If it is, prove it. Maybe I misunderstood your statement, if so, as Yogi Berra said.."mea culpa all over again". Respectfully and sorry for the rant, Fred
From: benschein@prodigy.net Sent: Saturday, May 05, 2001 7:19 AM Fred: I hope I still have X-rays and the're not scratched of a series I did in Mexico. In which we filled molar teeth with similar size lesions in every root. One root was filled with lateral condensation a'la Howie Selden (Luks pluggers), Another one with silver cone a'la Lenny Parris (The best silver cone man ever) and or Hal Rappaport, and the third one with the Bynum (St. Louis) modification of the vertical condensation of warm guttapercha (two lateral cones to the side of the main cone) heating the all mass, and removing segments with the heat carrier and getting down to 5 mm. from the apex as the point of deepest packing. When you use the supplementary lateral cones the puffs do not occur. My associates in the project could not stand the idea of puffs. Since I was a "Philly Fanatic" before being a BU indoctrinate I did not mind. Lots,and lots, of bleach, three visits, no calcium hydroxide, just a dry cotton pellet. Cultures (worthless type ----non anaerobic). It was not a randomized sample because we never used a silver cone in a palatal root or a distal root, the silver cone was only used in mesial roots of mandibular molars or buccal roots of maxillary molars. Our criteria for healing was sorta strict. Guess what ......after 3 years they were all "good enough to heal".
From: "Philip John Lumley" Sent: Sunday, May 06, 2001 2:58 PM Clearly there would need to be an excellent coronal reference point to help in ensuring the degre of accuracy sought with the paper point masuring technique. Do you routinely flatten this off to enable easier checking. When I did Gasy's course about 4 years ago David Rosenberg was there and spoke on the apical capture zone. After it is created there is a zone of relative parallelism which varies in length depending on the taper of greater taper file taken to length. Do advocates of the apical capture zone recommend confirming continuity of taper further up the canal eg the apical 2-5mm on top of the exagerrated taper in the apical mm to over come the problem of the more parrallel shape this results in just coronal to the capture zone

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