Common Sense approach to Molar Root Canals

Part 3 - Shaping the apical one-third

Instructors:

Dr. Marvin Berlin, DDS

Dr. Marvin Berlin, DDS

Dr. Berlin has a very unique combination of providing comprehensive dentistry, mixed with a business first philosophy. He enjoys teaching his management and marketing techniques of a multi-doctor/multi-location practice and how it can be applied to practices of all sizes.

Dr. Marvin Berlin continues shaping the apical one-third and prepares for obturation.

Let's do mesiolingual. Again, I'm getting a little resistance there. I'm going to go and set this into 21. A lot of times that mesiobuccal and mesiolingual are exactly the same. Sometimes they're not. But let's just see if we're living right. Mesiolingual. Yup. Right on 21 again. Fantastic. We're going to go to our distal buccal. Same situation. I'll try to get out of your way here. It's going to be a little bit longer on the distal. You can hear that beep that's perfect right there. You take that stopper out and we're going to re-measure this. This is going to be a little bit longer. And typically they are longer on the distal so that wouldn't surprise us at all. Here's our length. It looks like it's about 23. And 23 that's mesiobuccal, I mean distal buccal. Let's try our distolingual and see where that I'm going to put it at 23 as well cause they're usually the same. Perfect. And make that stopper right up there. I know I'm blocking the view guys. Here we go. And we'll measure that. So the distal lingual is also 23. So we have 21 on both of our mesial canals, 23 on our distal canals. So here we go. You're uniform. All right. Now that we know accurate length, I'm going to take my first file going back with just a 10 and we're going to take it to 21. And usually I add about half a millimeter so I'm actually going to be 21.5. I want to go just out that apex. Just to make sure any bacteria that kind of snuck its way out we're going to get rid of them. A little bit of Glyde. And again anytime we put anything metal, Victoria starts with the Glyde. Perfect. Twenty-one. I usually do a turn or two just to make sure I can feel that apex and I can. Same thing on the mesiolingual 21. I can almost feel right where it pooches out cause I got it about 21.5. Right there I can feel it going out. Endo is all about feel guys. Okay we'll bump that to 23. We go to our distal canals. Perfect. A little more resistance there. I can feel a little curve at the end. Again we saw that even on our x-ray. A lot of times a little counterclockwise rotation will just kind of follow you right in there. You can even see what it's doing to the tip of that. I don't know if you can see this or not but it's putting a little curves. So that's kind of what the tip of that root looks like. And I can almost feel that so that was the mesial. But that's okay. If it was easy, everybody would be a dentist. Same thing the distolingual is about the same. I feel a little twist right at the very bottom. Perfect. We might even get some hemorrhaging here. I bet we do cause I could just feel it pop through. See a little bleeding in there. That would be what I would expect. Okay. Let's use some sodium hypochlorite. Again I follow every instrument with sodium hypochlorite. I'm vibrating. I'm not going to length here I'm just going about 18 or 19. I'm just getting rid of debris here. We're just cleaning up these canals. If this was a washing machine this was hot water with soap and agitation getting rid of it all. Very good. Okay. Our last file was a 10. We're going to go to a 15. We're doing the exact same thing. We started at 21. Okay. Our 15 file. Victoria, thank you ma'am. Take that up to 21. Make sure that fills good. I want to get patency. Patency you know means we're kind of stopping right at the apex. Twenty one. Perfect. Take it to 23. We'll do our distal canals. I'm feeling a little resistance here. Not bad. I can feel a little curve on the end but that's good. Okay. Let's irrigate that again with sodium hypochlorite. We're getting a little drainage on that distal. You know our decay was on the distal. A lot of bacteria in that distal canal. So definitely what I would expect there. Again if you notice I got real big access here easy to get there. I don't want to hinder myself the ability to get to where I need to get to. There's a lot file system out there as far as rotary in nickel titanium. And I've tried most of them. I beta-tested a lot of them and going back and forth and seeing what works best in our hands, in our practice hands it's Pro Tapers. The Tulsa's Pro Tapers are the best and then I finished them off with their new M1 nickel titanium file called Vortex. To me that combination of Pro Tapers and finishing over Vortex seems to be the absolute best. The beauty of it is I see that it follows the canal shape more often than not. There's hardly any separation as we follow the sequence that we've done today. They'll follow right to the canals and to the apex. And then when you finished it off and you operate with the Thermafil that are made by the same company as the Vortex, they follow right on that. When I finished to a size #30 0.04 taper Vortex and I fill with size #30 Thermafil, I know that Vortex was right blank my Thermafil is going to be right blank. So I rarely have instances where the post-op radiograph looks long or short. They're typically right on the money. Okay. We're going to go to our first rotary. We'll start 21 and we're going to start with our purple which is our size 10. Measure that to a 21. Very light pressure. I'm just letting this follow, just kind of follow in the canal. It will almost stop where it needs to. Once I get it to length them I'm going to rotate about four or five times and then I'm taking it out. It's done its job. There's no reason to just let it sit there and build up stress. All righty. Same thing. About right now why don't we reheat that bleach. We have our warmer. Okay. What Victoria is doing during the procedure she handles the sodium hypochlorite. She keeps that warm. We keep it on the warmer. So we always want to use hot bleach. It's the best way to kill bugs and that's what root canal is all about. Let's take this now to our, all we need is a 15. Same thing. We got 21 on the mesial. Always going through Glyde. Kind of repetitive but it always flows right in where we want it. On the mesiolingual same thing. Right in where we want it. It's filling a lot better. Each rotary file kind of set up the next rotary file. About 23 on the distal. It's kind of falling right into place. I like that. Very good. Okay. Let's clean it out then we'll go back and put our hand file. We'll check our pace to make sure we still could get access. What can happen sometimes is you can pack in debris on that apex. So you want to always make sure that we can take a hand file. I usually use a 15 and just make I can always get back to my original working length. Fortunately with these rotary files, they pulled the debris out and so we're not pushing anything down there. But you still want to make sure again21 on the mesiobuccal, 21 on mesiolingual. That's I can feel my stop that's really good. And 23 on the distal and 23 on the distal lingual. Perfect. Yup. We're fine. Okay. We're doing great. GW, you're perfect buddy. Right. Our next file is going to be a 20. Perfect. You know these are nickel titanium which is my favorite metal in the whole world. Because as we know this is kind of cool. Nickel titanium is the only metal that if you bend it, let me see if I can get it for you. You know how this work. You can bend that file. I'm going to show you this. This is pretty neat. It will turn on the bend which is kind of cool and it will keep its shape. It actually flexes. It really doesn't bend. It just kind of flexes for us but it keeps that shape and so we like that. So on canals that are curve like GW were, this follow that flows right to where we need it to go. Okay. Twenty-one on the mesiobuccal, 21 on the mesiolingual. Getting a little resistance. Not bad but just a little. Always clean with little sponge here. I'm just cleaning that every time we come out. Okay. Our distal lengths were 23. Again this is just going to fall right to about 23 maybe 22.5. Nice. It's doing great. sodium hypochlorite one more time. Every time I use the rotary file I follow with my ultrasonic. We're just cleaning out debris here. Very good. I'm really close to finishing this. So what we're doing I feel like we got good patency. We've cleaned that canal out. Now we're ready to arbitrate here just a minute. I'm going to switch over to Tulsa's M1 Vortex file. This is with the little red line we got the three, which is 0.06 taper. And this rotary file is in direct size to what I'm going to fill those mesial canals which is going to be a Thermofil 25 and so I'll set this to 21. I know if this goes to length then my fills is going to be pretty accurate. We switched our rpm. These are 500 rpm. I already got that programmed so we're good there. Let's just turn a little bit better. This is a new nickel titanium. They're M1 version. A little bit different flute configuration that feels good right at 21. I can feel apex. I set a good stop. Mesiolingual the same way. This feels good. Clean that out. Bump that up to 23 for the distal. Now I'll probably take those distal canals to a 30 but I'm going to leave those mesial at 25. Again taking it right to 23. That feels good. All right. Let's go. sodium hypochlorite one more time. Again, we clean it out. If you notice this, I don't know if you'll see it, I'll show you with a mirror but this is getting a lot cleaner. Very good. I'm just going to double check our patency here. I know we're good but I want to feel that it's good. Twenty-one on the mesiolingual. Twenty-one on the mesi0buccal. We'll bump that 23. Again making sure that follows right in there. Cool. I like that. Cellphone is optional. There we go. That feels good on the mesio, distolingual. Perfect. Okay. One more. The last file I'm going to use is the Vortex size #30. And the little two bars mean that it's an old Pro Taper. I've created a pretty good taper with it at [25 06]. And basically what this file is the tip right there is tip to a size #30 which I'm going to fill those distal canals. Both distal canals will be at 30. So we're going to fill the mesial to 25, the distal to 30 and we're almost done. sodium hypochlorite one more time. I'm going to just gauge the final step before I arbitrate is I'm going to take my 25 which is exactly the size of my Thermafil file and make sure I can take it to 25 on the mesiobuccal. Got a good stop there on mesiolingual, got a good stop. And then I'll take my 30 do the same thing on distal. This one is going to be a 23. Let's put a little bend in that. I don't know if you can see. I always put a little soft bend right there. It's easy to navigate the canals in a straight file. Put that at 23 and that feels good. I'm going to make sure I don't have any resistance. I can feel my apical stop right there which is my 23. It feels good. And then the same on the mesiobuccal. Right there that's 23 and that feels good. So we're good. We're ready to fill. So next step is EDTA. EDTA get rids of the smear layer, the inorganic parts. So the debris that we just created, the EDTA gets rid of that. So we'll go in and we'll aerate that in each canal. We're going let that set in here for about 30 seconds. Once I kind of irrigated out any debris leave that for just a second Victoria. In our sequence of root canal once we've removed all the pulpal tissue and I feel confident in that just with the file sequence that we've had. Once we start getting ready for arbitration. We got to get it dry. We need to remove all the inorganic material that we created. We do that with EDTA. I'm going to follow that with one more rinse of sodium hypochlorite and I know that inside of that canal is completely clean. We then are going to go dry it. You'll see me I'll use the same syringe that we irrigate it with. I'd use it in reverse and set it in the canal and actually pull the stopper up like a little vacuum cleaner and we'll get the sodium hypochlorite out of that canals. We're going to dry it with paper points and then we'll going to seal it up with Thermafil. The plastic obturators Thermafil are phenomenal. They allow you to measure your, we know something is 18 mm I can measure that 18 slide it right in and I know it's right on the money every time. You can tell how clean that is now. Sorry about that. I'm working on a mirror. It's kind of tough. But when you can see those canals they're just spotlessly clean. I know we've got rid of all the bugs. It's going to be pretty simple to fill. After the EDTA, we get rid f the EDTA. We do that back with sodium hypochlorite. So our last fill with sodium hypochlorite. I'm just going to fill that in there. Perfect. And then to get rid of that sodium hypochlorite now our goal is to get this really good and dry. So we'll switch over and Victoria will use a little, first step we use a little surgical suction tip which get rid a lot of it. Before we do our paper points, I'll go back in with our syringe here and I'll insert it and I'm just going to pull this out. Small little vacuum cleaner and this get rid of a lot of any kind of fluid. You don't want to leave any fluid in that canal. It needs to be perfectly bone dry. Otherwise you if there's something in that canal the liquid will actually cool the gutta-percha after we warm it and will make it short. So we don't want to do that. That's pretty dry. I can almost feel air coming in. So I know that I got nice and dry. We still double check it with paper points just to be on the safe side. Again, I'm just going to let that follow in. Now we got two on the distal. And perfect. I don't know if you can see there or not but you can see this paper points they're just sitting in there. Notice how parallel they are. That's real critical. That's what we called straight line access. We flare those canals out so that I don't, it's really easy to get into. We don't want to create any barriers. So I like when I see that. Those curly roots we've straighten them out. I'm just going to make this pretty simple to clean up so. It looks pretty good. We got one little bleeding on the distobuccal. Let's just get that dry. A little bit of there. Let's just double check it. In fact let's just double check them all. It will take just a second. We want that just bone dry in there. Here we go. Now that looks great. You see no bleeding. Just dry cotton pellets. That's what I want. Okay. We're going to seal that with our ThermaSeal. This is ThermaSeal Plus. It's a self mixing so just pretty simple. And all we need is just a little drop into each of the orifices here and then we'll flow it in. And some squirt a little bit there and a little bit there, a little bit here. Just kind of filling just, I can't tell you how little I'm putting in. It may look like a lot but I'm barely just squeezing that in. Just kind of lubricate it. Then we're going to fill this. I don't use an expensive oven. We're going to use our Thermafil and we'll measure them to 21. We used a ¢99 BIC lighter. You can get them at your local 7/11. Shut up. It's 7/11. I put a little bend in that. Let me show you that. And I'm just kind of bending that so it's easier for me to access into that canal when I'm going to show you this camera too. Just notice I'm putting just a soft bend. I don't want to break it but jut enough so I can kind of roll it in. One of the things that I do completely different than most practices is I don't use an oven to heat up my Thermafil. In fact, when Thermafil came out in the early 90s, I was one of the few practices that started it. And the rep told me he said this is something you can use an oven to heat it up or you can use a little BIC lighter. And I've always used the BIC lighter. I mean you can buy $300 or $400 oven or you can buy an ¢99 BIC lighter. And the oven takes about 5 minutes to work and the BIC lighter take about 5 second. So you can imagine which way I'm going to go. But it's using fire for heat and it works every time. It's about 3 to 4 passes through it. And it warms it up to perfection. Obviously, you need to practice with that but it works great. You just kind of flow this. You just kind of pass it through a couple of times, get it warm and that's pretty perfect right there. And I'm just going to let it flow in that canal. Perfect. And that looks nice. What I'm going to do is after each one I'm going to go through and just go ahead and cut the little handle off to just kind of get it out of my way. Okay. So that's in there now. We'll go to the mesiobuccal. Again let's just put our soft bend just like that. And then we'll put a little more of a bend on this one cause this is my mesiobuccal and I got kind of rotated around. So actually almost a 90 degree bend. I don't know if you can see that or not. Okay. All right. Let's fill it. Maybe six or seven passes and then it kind of warm it up. More like were making smores. Dental smores. I like when it goes right to length. It's one of the things I love about Thermafil is when you measure that at 21, I know it's 21. I know I'm going to have a really good fill when you take your x-ray. Okay. Our distal canals are 23. Same situation. I don't need to put as much as bend cause I got a straight shot to it but I always put a little soft bend. Very good. Nice. Cutting that tip off and then one more. We'll do a mesiolingual last, I mean mesiobuccal last. Twenty three. Again a little soft bend there and we'll flow it in. And that my friend is a molar root canal. Again I like when it goes right to length. It feels good. Cut that off. Right to length. Can you see that? Yeah. Twenty-three which we like. It's all for one to length. I know I'm not going to be short. Those are going to be pretty accurate. The last thing we do is I'm going to take just a condenser and I'm not going to push on the carriers. I'm pushing on the gutta-percha around it. It's still warm. And so this will kind of fill in any voids and intricacies. It shouldn't take about a minute or so. I'm just packing gutta-percha in here. All I'm doing here. It's still warm. I'm leaving these files, not files, these carriers these plastic carriers raised up a little bit. If I need to adjust it, if I'm a hair short or hair long I can adjust those after we take your x-rays. So I'm not going not cut them off yet. That's it. That's your root canal.