From: Rafaël Michiels
To: ROOTS
Sent: Tuesday, June 23, 2009 11:11 PM
Subject: [roots] The advantage of a warm technique. (and full sequence of treatment)

Here is my last case of the day.

On may 5th, the patient came in the office for a RCT of tooth 3.6 (#19). The referring dentist had done an expulp
and a temporary restoration. In the first visit, I made a new temporary restoration in glass ionomer (Ketac Fil).
I tried to get patency in the canals, but had problems in the distal. I could not get to length. The distal was
very wide. So I expected two POE's or even more. I placed calciumhydroxide, a cotton pellet and sealed the cavity
with glass ionomer. As anaesthetic Articaïne with adrenaline was used (septanest special). Rinsing was done with
NaOCl 3% and a final rinse before the calciumhydroxide with EDTA 17%.

In the second visit today, I could get patency in all canals, but the distal was pretty though.
In the apical part I continuously felt irregularities and alot of files 0.06 and 0.08 were needed to get down.
In the end, I prepared the canals until a protaper F1 and finished apically with a size 0.25 K-file.
Normally I end up with a bigger MAF, but in this case this was not necessary, I believe, since I had to start
active filing from a 0.15 onwards. Length was 26mm in all canals. Rinsing with NaOCl 3% and EDTA 17%.
Anaesthetic was mepivacaine in the second visit (scandonest)

Then I dried the canals and filled them with the Elements obturation unit. First an apical plug of 4mm then
backfill with light body guttapercha in little layers. As sealer I used AH+. Afterwards I sealed the cavity with
glass ionomer. In the distal you can see the apical delta, being filled. Maybe it is even a missed canal or a
big lateral. Anyway it is filled. :) This would not be possible with a cold technique, which I mostly use.
Critique and comments welcome as always (I'll start myself: The distal edge of the temporary filling should
have been better.) - Rafaël






for my critique, i felt this Gutta Percha irregularities around distal apex is caused by material extrusion
overlapping the apex on x ray; as vertical condensation tech. had been used. anyhow nice work - Ahmed Jamleh

I think it is only sealer which has been extruded. This is indeed difficult to control. But practice makes perfect.
So I'll practice some more ;-). - Rafaël

Hi Rafael! Thanks for sharing your case and sequence.

Regarding that, what is your rational for choosing your MAF? What size is your irrigation needle?
The distal box is quite tricky when we work so near the bone level. Have you considered crown lengthening
before final restoration? - Ricardo

Hello Ricardo, The rationale for choosing this size of MAF was the following. Getting a 0.06 to length, was not
possible passively. So I needed to file already with this small size. Consequently I needed to file with all
the ones I used. With a size 0.25 I got white dentine debris. Meaning I was creating an apical box with this
size already. So, I believed this size was sufficient to stop. As for the irrigation needle The size is
comparable to a size 40, if you know that the taper in this case is 7. This means that I can put the needle
at approximately 2mm ( a little more) from the apex. Not sufficient, that is when the Irrisafe comes into
place and in some cases I do cone pumping (not in this one, though, maybe should have done this.)

I am not a fan of such small MAF, but in this case I thought it was sufficient. Though it is subjective.
- Rafaël

Hi Rafael, Thanks for the answer. You were very clear about the procedure. My question was what is your
guide-lines/rational in general for MAF determination? And regarding that I’m not sure yet if I get it.
(maybe my answer was not that evident)

Is it dependent on the size of your negotiation files? - Ricardo

No - Rafaël

Pre or post coronal flare? Is the first rotary
that cuts dentine form there first flutes? (is this Dr. Buchanan, isn’t it?:-)  or
Minimum box size that  guarantee a good apical stop to pack?

Yes. In this case the 25 was the file that actively cuts dentine from the apical part.
So this was indeed the rationale for this - Rafaël

With a F1 and an ISO40 needle, I wouldn’t get it so deep (3mm). Although mathematically possible it will
engage easily, and shit happens. What I try do is enlarge a bit more, and use a narrow tip 30G side-vented.
1mm short of WL and loose - Ricardo

Thanks for the tip - Rafaël

Rafael you endo is excellent but your rxs are very bad...just joking. Very nice filing and looks like the distal
has some apical colateral canal - Carlos Murgel CD, Dr.