Doug Kase
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THOUGHTS OF SUMMER begin to fade from our minds and visions of falling
leaves, colder temperatures, and inches of snow start to permeate our consciousness,
there is one thing we all can take comfort in: our patients need root-canal
therapy! Now the old saying that says you have to walk before you
can run certainly has validity when it comes to the SafeSider® technique
and EZ-Fill® obturation. The techniques that we teach you allow
dentists to incorporate their own nuances into the system without compromising
the fundamentals of ultimately creating the proper taper of the canal (.08
taper) and its single-point obturation using the EZ-Fill armamentarium,
which emphasizes the use of .02 stainless SafeSider endodontic instruments
and the # 2 Peeso reamer to accomplish 90 percent of our canal instrumentation
and hand NiTi SafeSiders to place the finishing touch (taper).
As a dental student at NYUCD and a resident at the
Manhattan VA hospital, I had the opportunity to perfect the use of the
Gates Glidden reamer as aid and shortcut to the core technique that we
were all taught way back in dental school. Now you may know that
Barry Musikant has taught all of us the equation that Gates Glidden reamers
= Peeso lights! However, I do vary the EZ-Fill technique to incorporate
the use of Gates Glidden reamers. Please understand that in no way
am I saying that this variation is better than the “EZ-Fill core technique”
that we have taught in the past, but this variation does help my technique.
Remember that the function of the NiTi .04 and .08 SafeSiders is to do
the final shaping of the apical canal after the apex has been negotiated
with a stainless .02 #30 or #35 SafeSider reamer and appropriately back-stepped.
The SafeSiders are not meant to be used to negotiate the apical 5 to 10
mm of the canal, but rather to shape the canal and eliminate the “back
step” cross-section it developed due to the use of the Peeso reamer and
back-stepped instrumentation. Thus the further the NiTi instruments
are seated on initial try in, the less work the instrument and dentist
have to do to achieve this final shape. If you already can accomplish
this with standard rotary instruments that you are accustomed to using,
such as the Peeso reamer, you may find that incorporating Gates Glidden
reamers in your procedure may make it easier.
“How?” you may ask.
The sequence that I have used—and remember that
it is only a variation on the theme that happens to work in my hands—is
the following.
I instrument to my measurement control to an .02
#20 instrument. Then I widen the coronal aspect of the canal with
“passive pressure,” starting with a Gates #1, then #2, then #3, and then
I use a #2 Peeso reamer. I move the instruments apically until I
meet resistance and go no further. Wait a second . . . I hear gasps
about using a #1 Gates! Won’t it break? If you use “passive
pressure” in a wet canal and do not force the instrument, it will never
separate. “Passive pressure” means to use only the weight of your
handpiece and tactilely feel for resistance because you may meet a curve
or constriction in the canal. Initially I do not attempt to move
beyond this point. Doing so can separate the Gates or ledge the canal.
Obviously, in a straight canal you will be able to sink the Gates and eventually
the #2 Peeso to the hub of the handpiece. Remember to straighten
the coronal aspect of the canal away from furcations and grooves by applying
selective pressure in the proper direction with a pecking motion of the
handpiece.
Now we have debris to deal with. Reiterate
the apex with a #15 and then a #20 SafeSider instrument to break up the
debris, and be sure to irrigate and use RC-Prep continually. Now
I instrument a #25 and #30 to the apex with very little resistance because
the rotary sequence I have used has done quite a bit of coronal instrumentation,
perhaps moving more apically than by just using a #2 Peeso initially.
Back-stepping with a #35 and a #40 is a piece of cake, and even moving
the 35 to apex is not an obstacle.
I can’t stress it enough: irrigate, irrigate, irrigate
and use lots of RC-Prep.
Now I do it again. I use the same sequence
of Gates and Peeso reamers and believe it or not with the same passive
pressure, the #1 and #2 Gates are apparently flexible enough to negotiate
a bit more of the curve in a canal and move further apically. Forcing
these instruments into a curve can cause a strip perforation, so be careful.
This further rotary instrumentation of the canal facilitates deeper penetration
of the NiTi instruments and thus puts less stress on the instrument and
dentist. In my experience, the .04 #30 NiTi becomes a debris breaker
and remover, and the .08 #25 NiTi usually can be inserted to within 1 to
2 mm of the apex and worked to measurement to create our .08 taper with
very little effort and thus prepare us to obturate the canal according
to the EZ-Fill technique.
Now here is my “Tale.”
The following case is an interesting one. This patient
presented with a buccal fistula associated with quite a bit of bone loss
in the furcation of a lower molar and what appeared on the radiograph to
look like some sort of perforation in the mesial aspect (Figure1).
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FIGURE 1: Showing a
possible perforation in the mesial aspect.
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I was not sure at the time whether it was resorptive
or iatrogenic. Access was gained and from the looks of the pulp chamber
it was virgin territory, so we were dealing with something pathologically
natural. I extirpated the tissue and was able to isolate the canals.
Measurement control was taken by apex locator and confirmed by radiograph
(Figures 2 and 3).
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FIGURES 2 AND 3: Measurement
control taken by apex locator (left) and confirmed by radiograph (right).
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The mesiolingual canal gave me a wild and inaccurate
reading on the apex locator in comparison to the mesiobuccal; thus I knew
that the mesiolingual was the canal with the perforation. I managed
to find the apical portion of the canal by hugging the mesial wall of the
canal. I widened the mesiolingual canal with my sequence of hand
and rotary instruments and was ultimately able to visualize the perforation
and canal with the endodontic microscope. I obturated all the canals
using the EZ-Fill technique and then removed the coronal gutta percha in
the ML canal to the level of the perforation. I packed a plug of
Colicote into the communication to the furca and then back-filled the coronal
portion of the canal with MTA cement (Figures 3 and 4).
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FIGURES 3 AND 4: A plug
of Colicote packed into the communication to the furca (left), and the
coronal portion of the canal back-filled with MTA cement (right).
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Two weeks later the fistula remains closed and the
patient will be recalled in three months to evaluate healing.
September-October 2003
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