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Endo tips    Better Endo    Endo abstracts    Endo discussions

 Very Unusual Apex
The opinions within this web page are not ours.Authors have been credited
for the individual posts where they are. - photographs courtesy: Terry Pannkuk,Bartek Cerkaski
From: Terry Pannkuk
Sent: Friday, July 07, 2006 4:06 AM
Subject: [roots] Very Unusual Apex

I'íve treated several teeth on this guy.  One was a 
nonsurgical Ag-retro removal bicuspid case
(Ií'll post the recall if anyone is interested).  
I treated the adjacent first molar (#14) in 1999.

The patient presented with a necrotic pulp and LEO.  
I two-stepped it with CH and performed the final
apical prep today.  I used a CKT-?D tip.  This has 
interesting demonstration anatomy that was easy to
photograph.  Basically it started off with a buccal 
and lingual canal separated by a very long pulp stone
that I completely troughed out.  I wanted to see if 
the system branched and I wanted clear access to the
apex which I knew was going to be highly irregular in 
outline form requiring MTA.  I used the side-cutting
action of the CKT-?D to clear away all the clumps of 
biofilm harboring in the bays and crypts existing at
the at the apical terminus.  It would be improper 
terminology to call it a Portal of Exit because
I know the shape of a portal when I see one. If I was 
on the AAE glossary committee instead of the
clinical practice committee I could make a better 
contribution by adding a more appropriate term
apical vagina, or AV which is clearly distinguishable 
from a simple POE which causes much less concern,
trouble, and expensive complicated treatment to prevent 
a flare-up.  Basically, I just went in fearlessly
with the ultrasonic and smoothed everything out.

I bonded a core on top of the MTA that I placed to the 
coronal third.  - Terry

Nice work and terminology dr. Pankuk. I second that. - Ananya. Hello Terry, I treated similar ones two years ago, and I remember that it was the first time I met such morphology. It looked like the buccals were fused while palatal remained normal. I like your terminology it really looked like AV ;-) I removed pulp tissue with Gates burs supplied with ultrasonics. I had a problem to determine the end-point of preparation as EAL was crazy and MAF cone on Rx looked like it does not follow the curvature distally in second molar. It is a bit too short in first molar, too, but since it was vital case I decided to leave it like it is. Unfortunately I donít have recall Rx as patient did not show up, but If he does I wiil certainly post it. I treated also upper premolar in the same patient, and it was classic. Second premolar anatomy at radiograph you posted looks pretty similar to molars. How often do you meet this particular morphology in upper molars? - Bartek Cerkaski, Poland

Hi Bartek, I only see these forms rarely. I donít think you can adequately obturate these cases with any gutta percha technique (especially squirting and PacMac) because the AV is irregular and the gp/sealer (especially resin) will shrink away resulting in a very poor seal. MTA is definitely the way to go and because of the high viscosity you better ultrasonically prepare the apex to take out the bays and fins that would harbor pathogens since you donít get much hydraulics and flow. If a lateral canal exists you are going to miss it so this is always somewhat of a compromise. Many of these types of cases require that you balance compromises and pick the technique the permits you to compromise the least. This is the Art of clinical judgment. There is no literature evidence base that tells the clinician what choice to make and this is the essence of clinical performance art where the skilled clinicians artfully pick the best of the scientifically based choices. When I posted the old case that demonstrated a cone fit into just one of 4 apical branches that were obturated with gp and sealer, I received an email arguing, Why should I care if there is gutta percha or sealer in those branches? I really enjoyed writing the person this response: Whether ZOE, AH+, Epiphany, Sargenti Paste, Squirt, or Homogenate, the volume of uncontrolled Non-cone is the space likely to contain voids and the potential space available for future pathogens. Whether it develops from the initial lack of meticulous obturation, the inability to obliterate complex anatomy, shrinkage of a non-ideal material, or resorption of a non-ideal material; the reality remains that it exists. An intellectually dishonest person or a weak clinician consumed with self denial will make speculative assumptions that anachoresis doesnít occur. They will also maintain that a non- patent portal of exit is blocked with sterile debris, or that their compromised cleaning and shaping technique is virtually as good as someone elseís technique because the myriad of compromised nuanced techniques used in reported studies allow them to excuse their failures via the intuitively illogical outcome literature base. In other words, not worrying about the material and its density is careless and foolish; whether we like it or not we own our own failures. Every patient that presents their endodontic problem to you for treatment tests your integrity and challenges your soul. Few in our profession are capable of rising to the occasion whether you are talking about apical density or ethical propensity. This is the essence of everything I learned in my residency from Herb Schilder. It has served me extremely well. His life work was not just his technique but more importantly the method of logical understanding that he taught his students. - Terry Aloha Terry - I dig the cases you've been posting. Got a question about your Apical Vagina protocol. I had to type that because, in my mind, it sounds pretty funny and makes me crack up. Would you use this same 'clean and shape and fill' protocol for a tooth that has had a previous failed apico with or without a retrofill that you are trying to retreat non-surgically? - Jason Pretty much, the goal is to create a convenience form you can clean and seal. I donít think it matters much what it used to be. It only matters what you change it to. I donít really have too many mysterious failures I need to blame on biofilm. If you accomplish the objectives of treatment you get predictable success. If the AV or POE is large fill it with MTA instead of gp. A larger diameter of gp and sealer is more likely to shrink and develop interstitial areas of concern compromising the seal and harboring pathogens. - Terry Aloha again Jason, I was a bit embarrassed that I came up with that term, not thinking about what I was really saying to a discriminating group of highly educated clinicians. The more I think about it, the more I realize how inappropriate the terminology was. Never would this term be an acceptable addition to my personal endodontic Lexicon. Everyone knows that portals of exit should not be described as existing only at the apex hence apical is an inappropriate term. Iím thinking of referring to these entities more appropriately as PRP (Periradicular Poon) or TT (Tang Termini). Either of these terms display more descriptive outside-the-box thinking (figuratively of course).What do you think? - Terry
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