Never stick to only one system
“You have to find a way to play according to the players you have in the squad. Never stick to only one system.
by Richard Mounce, DDS
“You have to find a way to play according to the players you have in the squad. Never stick to only one system. I think that is the biggest mistake you can make. Many people think there is only one good system, but I think there are many.” — Fabio Capello
The name Fabio Capello may not be recognized by many Americans, but it is instantly recognized by global soccer fans. He is one of the most successful Italian coaches working in world soccer today. His observation about soccer “systems” is every bit as valid in endodontics.
I agree with Fabio. There are many good systems to choose from in the specialty. The system chosen should change according to the tooth’s anatomy and the clinician’s situation. Menu-driven cookbook solutions are unproductive when the tooth has not read the cookbook. For example, Crown Down methods are often ideal, but in some cases applying Step Back methods is better.
Most important, there are inviolate principles that govern endodontic treatment goals, irrespective of the materials and methods used. Within these boundaries, we can choose various methods and materials to achieve the desired goals.
Inviolate principles in endodontics include:
- the canal preparation should leave the canal in its original position
- the minor constriction should be left at its original position and size
- the taper and size of the final preparation should be proportional to the original size of the root and the size of the minor constriction (MC) of the apical foramen so as not to weaken the tooth and make it more susceptible to vertical root fracture
- the final preparation should resemble a tapering funnel with narrowing cross-sectional diameters.
Coincident to canal enlargement, irrigation should be copious and delivered with the highest and safest degree of precision to the apical third.
The obturation should be homogenous and thermally replicate all the tooth’s internal anatomy. In essence, all of the pulp should be removed through the action of files and irrigants and the space within the root filled from the orifice to the MC. After treatment, an excellent and timely coronal seal is absolutely correlated to long-term clinician success.
While several textbooks are written about how to achieve these goals, some clinician recommendations can make achieving these goals more predictable:
1) There is no substitute for the magnification and visualization of a surgical operating microscope (SOM) (Global Surgical, St. Louis, Mo.).
2) Anticipate clinical challenges before starting treatment. An early decision about referral and restorability is useful. Are you the best clinician to treat the patient given your skills, equipment, and the degree of difficulty?
3) Know the strengths and weaknesses of your instrumentation system. Whatever system you use, and especially if you are new to rotary nickel titanium, you should practice in extracted teeth extensively before you bring the files into the mouth. Become fluent in creating a glide path and achieving patency in small canal spaces with hand K files (Nos. 6 to 15) to make your RNT enlargement safe and predictable. Never use your RNT instruments as pathfinders.
These hand K files should be precurved. An excellent way to precurve them is the EndoBender pliers. An efficient adjunction to the creation of the glide path is the M4 safety handpiece attachment (both SybronEndo, Orange, Calif.).
4) If you obturate canals with cold lateral condensation, ask why. Can you replicate the tooth’s internal anatomy by pushing sealer into the ramifications of the anatomy using a single cone obturation, or with cold lateral condition? Warm techniques can move a heat-softened mass of obturation material into the narrowing cross-sectional diameters of prepared canal space and thermally replicate the internal root anatomy. Coronal seal is intimately linked with apical seal. Without coronal seal, there is no seal of the root canal system, especially with gutta percha. Gutta percha relies on a coronal seal to protect it from microleakage. RealSeal (SybronEndo) bonded obturation material resists coronal leakage. The obturation is bonded from the core material to the sealer and into the dentinal tubules. A coronal seal’s placement at the time of treatment, under a rubber dam and an SOM, is the most predictable method for eliminating microleakage. I place a flowable composite (PermaFlo, Ultradent, South Jordan, Utah) into the access cavity at the time of treatment.
In endodontic terms, the goals are the same — cleansing, shaping, and obturation of canal space in three dimensions. While methods and techniques might differ at times, i.e., the system might change as per Fabio, core principles do not.
I welcome your feedback.
Dr. Richard Mounce offers intensive, customized endodontic single-day training programs in his office for small groups of one to two doctors. For information, contact Dennis at (360) 891-9111 or e-mail RichardMounce@MounceEndo.com. Dr. Mounce lectures globally and is widely published. He is in private practice in Vancouver, Wash.