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Troubleshooting calcified canals: clinical case review / News / Obturation system positions pack and flow side-by-side / An endodontic absurdity

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ENDO TRIBUNE
The World’s Endodontic Newspaper · U.S. Edition

February 2010

www.endo-tribune.com

Vol. 5, No. 2

Troubleshooting calcified
canals: clinical case review
By Richard E.  Mounce, DDS

Dr. George
Huang

The patient pictured in figure 1
was referred because the first clinician
could not locate the canal(s).
The patient had pain when chewing on #13 and mild spontaneous pain
leading to a diagnosis of a non-vital
pulp before referral. The referring doctor accessed the tooth without canal
location. The patient was subsequently referred. This clinical case review
will discuss the clinical findings, management and potential complications
treating this case from a treatment
planning perspective and discuss the
clinical technique and materials used.
Upon referral the patient was asymptomatic and there was no swelling. The
tooth was mildly percussion sensitive,
and within normal limits to palpation,
mobility and probings. Radiographic
assessment of #13 showed open crown
margins and calcified canals.

Risk factors in endodontic
management of #13

#13 is at moderate risk of cervical perforation if the access were to veer off
a coronal to apical straight line. Every
effort must be made to continue dentin
removal in line with the true canal
until the canals are located.
Excessive removal of dentin at the
cervical region of the tooth could, in
addition to perforation risk, make the
coronal tooth structure susceptible to
coronal and, ultimately, vertical root
fracture.
The anticipated master apical taper
and master apical diameter of the case
should be determined before starting.
In this clinical case, the anticipated
master apical taper was .08 and the
anticipated master apical diameter was
#40 or possibly a #50 ISO tip size.
The porcelain was at risk of fracture
during access if the coronal opening
needed expansion significantly beyond
its current size.
In order to gain the greatest visual and tactile command over access,
the use of enhanced visualization and
magnification is essential. The surgical
operating microscope (SOM) (Global
Surgical, St. Louis, Mo.) is optimal and
in this case a suitable substitute would
be the 4.8x Class IV HiRes Plus loupes
with a light source (Orascoptic, Middleton, Wis.).  
While a comprehensive discussion
of the use of the SOM or loupes is
beyond the scope of this paper, it is
noteworthy that once the temporary
filling is removed, the texture and
color of the dentin should be evaluated
to determine if the clinician is in line

Broke a
tooth?
Grow
another!

Fig. 1: The case (#13) before access at the general practitioner’s.

To all those who have made
deals with the tooth fairy in the
past: You probably sold your
teeth below their fair value.
Herbert Schilder Professor
in Endodontics and Director
of the Postdoctoral Program in
Endodontics at Boston University Henry M. Goldman School
of Dental Medicine (GSDM) Dr.
George Huang said those baby
teeth and extracted third molars
we are throwing away hold valuable dental stem cells.
“Our team found for the first
time that we can reprogram
dental stem cells into human
embryonic-like cells called
induced pluripotent stem (iPS)
cells, which may be an unlimited
source of cells for tissue regeneration,” Huang said.
So far, scientists have had
luck creating iPS cells from various cells in mice easily, but this
hasn’t been as easy in humans,
until more recently. All three
types of human dental stem cells
the GSDM team tested are easier
to reprogram than fibroblasts,
which previously seemed to be
g ET page 2B

Fig. 2: The case after access at the referring doctors’.
AD

with the canal or off track.
The depth of dentin removal in the
access is critical. If the clinician has
progressed 7 to 8 mm in access and
the canal is not located, it is a virtual
certainty that the access is misdirected
and perforation risk is extreme.
Once the canal is located, the clinician faces the risk of canal blockage
if canal enlargement  is mismanaged.
The use of large orifice openers (.12,
.10 or .08) or Gates Glidden drills (as
g ET page 3B

[2] =>

News

Endo Tribune | February 2010

Ultradent takes C.E. to the tropics

ENDO TRIBUNE

The World’s Endodontic Newspaper · U.S. Edition

Publisher & Chairman
Torsten R. Oemus
t.oemus@dental-tribune.com
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Managing Editor/Designer
Implant & Endo Tribunes
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Managing Editor/Designer
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Marketing Manager
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a.wlodarczyk@dental-tribune.com

Ultradent just completed three days of entertainment and education in Kona, Hawaii, with Dr. Dan Fischer. The
presentation addressed tooth preparation for adhesively-retained, direct-bonded composite restorations, new
endodontic technology and opportunities to integrate new business concepts to help both the office and patient
in a downturned economy, and more. Attendees earned 12 C.E. credit hours while enjoying the sun and sand
of Hawaii. Even the local wildlife benefitted from Ultradent’s visit: Above, on a break from the day’s schedule,
a quick periodontal cleaning courtesy of Scout, Fischer’s granddaughter, set this dolphin back on course for a
great oral health check-up! For information on other Ultradent C.E. courses, visit www.ultradent.com/seminars.

f ET page 1B

the best way to make human iPS
cells.
In a related study, Huang regenerated two major human tooth components — dental pulp and dentin
— for the first time in a mouse
experimental model. The mouse
was used to supply nutrition for
human tissue regeneration. Using
tissue engineering, researchers
saw empty root canal space fill with
pulp-like tissue with ample blood
supplies. Dentin-like tissue regrew
on the dentinal wall.
“The finding will revolutionize
endodontic and dental clinical practice by helping to preserve teeth,”
Huang said.
The studies, iPS cells reprogrammed from mesenchymal-like

stem/progenitor cells of dental tissue origin and Stem/progenitor
cell–mediated de novo regeneration
of dental pulp with newly deposited continuous layer of dentin in
an in vivo model, appear in “Stem

(Source: Boston University Henry
M. Goldman School of Dental
Medicine)

C.E. Manager
Julia Wehkamp
j.wehkamp@dental-tribune.com

Dental Tribune America, LLC
213 West 35th Street, Suite #801
New York, NY 10001
Tel.: (212) 244-7181
Fax: (212) 244-7185

Published by Dental Tribune America
© 2010 Dental Tribune America, LLC
All rights reserved.
Dental Tribune America makes every effort
to report clinical information and manufacturer’s product news accurately, but cannot
assume responsibility for the validity of product claims, or for typographical errors. The
publishers also do not assume responsibility
for product names or claims, or statements
made by advertisers. Opinions expressed by
authors are their own and may not reflect
those of Dental Tribune America.

Editorial Advisory Board

Corrections

Endo Tribune strives to
maintain the utmost accuracy in its news and clinical reports. If you find
a factual error or content that requires clarification, please report the
details to Managing Editor
Sierra Rendon at s.rendon@
dental-tribune.com.

Cells and Development” and “Tissue
Engineering.” ET

Marketing & Sales Assistant
Lorrie Young
l.young@dental-tribune.com

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Frederic Barnett, DMD (Editor in Chief)
Roman Borczyk, DDS
L. Stephen Buchanan, DDS, FICD, FACD
Gary B. Carr, DDS
Prof. Dr. Arnaldo Castellucci
Joseph S. Dovgan, DDS, MS, PC
Unni Endal, DDS
Fernando Goldberg, DDS, PhD
Vladimir Gorokhovsky, PhD
Fabio G.M. Gorni, DDS
James L. Gutmann, DDS, PhD (honoris
causa), Cert Endo, FACD, FICD, FADI
William “Ben” Johnson, DDS
Kenneth Koch, DMD
Sergio Kuttler, DDS
John T. McSpadden, DDS
Richard E. Mounce, DDS, PC
John Nusstein, DDS, MS
Ove A. Peters, PD Dr. med dent., MS, FICD
David B. Rosenberg, DDS
Dr. Clifford J. Ruddle, DDS, FACD, FICD
William P. Saunders, Phd, BDS, FDS, RCS Edin
Kenneth S. Serota, DDS, MMSc
Asgeir Sigurdsson, DDS
Yoshitsugu Terauchi, DDS
John D. West, DDS, MSD

[3] =>

Technology 3B

ENDO Tribune | February 2010

Obturation system positions pack and flow side-by-side
By Fred Michmershuizen, Online Editor

The best equipment makes things
easy for dentists. This is true for just
about any type of system — including one for the obturation portion of
endodontic treatment. The Calamus
Dual 3D Obturation System, available from DENTSPLY Tulsa Dental
Specialties, is designed to offer the
best of both worlds in downpack and
backfill obturation techniques.
The Calamus Dual 3D positions
the handpieces on one convenient,
space-saving console.
“With the Pack and Flow positioned side-by-side, dentists can
move smoothly from one step to the
next,” says DENTSPLY Tulsa. “Use
the Pack to create an effective and

cha or successfully placing an apical
plug,” according to the company.
More information about Calamus
Dual 3D is available from DENTSP-

ADS

dense apical plug, then use the Flow
to deliver the gutta-percha backfill
at the perfect temperature and flow
rate.”
“Each ergonomically designed
handpiece features a 360-degree
activation cuff, providing ultimate
control whether delivering a smooth,
continuous expression of gutta-per-

JOR_ET_AD_0210_Layout 2 2/3/10 9:23 AM Page 1

f ET page 1B

the first instruments in the root) are
contraindicated as the canal lumen
could easily become blocked with dentin and pulp debris.
More appropriately, it is essential
the clinician spend time with small
hand K files to negotiable the canal
from orifice to apex and take the initial
canal size from a #6 to #15 before using
RNT files. In this clinical case, two
canals were located and a #6 precurved
hand K file inserted until a tangible pop
was felt at the minor constriction of the
apical foramen (MC). The electronic
apex locator was then used to take a
true working length (TWL), a length
that was confirmed when the first RNT
file was taken to the apex and after the
final RNT file was taken to the apex.
The RNT system used in this clinical case was the Twisted File* (SybronEndo, Orange, CA, USA). The cutting
flutes of TF are manufactured by twisting a piece of nickel titanium in the
Rhomohedral crystalline phase configuration. As a result of its manufacture
and triangular cross section, TF can
easily create .08 tapers in a root such as
#13. This taper is larger than the taper
commonly prepared using RNT files
that are manufactured by a grinding
process. Twisting nickel titanium in R
Phase and a triangular cross sectional
design provides a flexible and highly
efficient cutting instrument. In this
clinical case, the .08 was able to reach
the apex in approximately 4 insertions.
After the .08/25 TF reached the
apex, the .06/30/35 and .04/40 TF were
taken to the apex of the two canals in
one insertion of each TF size. The .06
and .04 tapers of the TF files easily
reached the apex of the root as they cut
dentin only on their tips.
The tooth was obturated with RealSeal* bonded obturation with the SystemB technique utilizing the Elements
Obturation Unit.* A .06/20 master cone
was utilized. 3 mm back from the tip
of a .06/20 master cone, the master
cone is approximately .38 mm. 3 mm
were trimmed from a .06/20 master
cone and tug back was achieved. RealSeal sealer was placed with the Skini
g ET page 6B

LY Tulsa Dental Specialties, which
has helped clinicians achieve beautiful, precise and 3D fills for more
than 20 years. ET

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[4] =>

Clinical Opinion

Endo Tribune | February 2010

An endodontic absurdity
By Barry Musikant, DMD

Over time, it has become increasingly clear that teaching K-files is
devoid of common sense and makes
endodontics more difficult and
fraught with procedural mishaps.
Such a statement might be met
with outrage by those who teach the
use of K-files, but I would ask them to
ask themselves (if no one else) what
has been the greatest impedus for
the introduction of rotary NiTi.
Rotary NiTi did not appear out of
the blue. It is an answer to a problem
that is created by the ineffective use
of K-files. If that were not the case,
why would there be a need for rotary
AD

Fig. 1

Fig. 2

NiTi in the first place? I don’t believe
there is too much wiggle room here.
We use K-files. They present prob-

lems that are recognized by the dentists using them, and there is a logical quest to find solutions.

What is unique in the implementation of rotary NiTi is its continuing
dependence on the very instruments
they are at least partially replacing. K-files often do their damage
at the beginning of instrumentation
with the first few files used mostly
through a No. 20.
By this time, canals may be transported, blocked or ledged (figure
1). Yet these are the instruments
recommended for glide path creation. It is important to emphasize
K-file difficulties don’t start with a
25. Depending upon the canal they
are negotiating blockage, ledging
or transportation occurs before the
canal is instrumented to a 20. Given
this situation, the continued use of
K-files to shape the canal prior to the
use of rotary NiTi is an endodontic
absurdity.
A statement as strong as that
requires rock solid logic to support
it. The rest of this article will provide
that logic.
Let’s start with the fact that K-files
have a working length of 16 mm
with approximately 30 flutes along
its working length. The compact
array of these flutes forces them
to align in a fairly horizontal orientation. Dentists generally employ
these instruments with a back-andforth watch-winding motion with the
occasional upstroke to remove the
instrument to debride the shank.
The predominant motion remains
horizontal. This is the basic stroke
we use in endodontics to negotiate to
the apices of canals.
Combining a horizontal stroke
with flutes that are also horizontally
inclined leads to a screwing in and
a screwing out of the K-file. It does
not lead to cutting the dentin along
the length of the canal. That only
occurs after the instrument engages
the canal walls and is pulled up. Or
it occurs when the K-file is screwed
in clockwise and apical pressure
applied as it is then rotated counterclockwise cleaving off the dentin
that was initially engaged in the
clockwise motion. Neither one truly
represents watch-winding that is the
motion most often employed when
using these instruments.
However, let’s consider the modification of their use as described
above. If used with a twist-and-pull
motion, dentin will only be cut on the
pull stroke with the cutting action
occurring selectively to the outer
wall in curved canals. This leads
to the transportation we wish to
avoid. If used with balanced force,
the second method described above,
the instrument will stay centered,
but please realize that it takes three
motions to produce a cutting action.
A clockwise motion must first be
employed. Then apical pressure
must be applied to the instrument
and finally the instrument is rotated
counterclockwise.
Three motions employed for one
cutting action, the height of inefficiency and one that cannot effec-

[5] =>

ENDO Tribune | February 2010
tively be employed with an engine
driven system.
With all those flutes engaging
the walls of the canals, it is quite difficult to discern what the tip of the
instrument is engaging; yet what the
tip of the instrument is engaging is
the single most important piece of
information that must be transmitted
to the dentist. If the tip of the instrument is hitting a wall and the dentist
does not know it, his only guide
is to maintain length. With enough
twist-and-pull motions the length
will be gained, but often this gain
is through distortion of the original
canal anatomy at times leading to
frank perforations.
As an aside, to bring the perspective of K-files into sharper focus,
the flute design is quite similar to
a screw. I don’t believe there are
many dentists out there who would
consider shaping canals with screws.
They engage the walls of the canal,
but serving the purpose of a screw
they don’t cut dentin away. Rather,
they cut into dentin maintaining the
engagement.
While this action is exactly what
you want in a screw, it is exactly
what you don’t want in an instrument that is shaping canals. Poor
removal of dentin, distorted shaping
of canals and inadequate tactile perception of the tip of the instrument
are all features of K-files. Despite

these inadequacies, the teachers
continue to advocate their usage.
The only way this can occur is a lack
of thoughtful analysis for what they
are advocating.
Now let’s look at the problem
of K-files from a different vantage
point: its comparison to K-reamers
both relieved and unrelieved.
Many readers may not know
there is really much of a difference
between the two. In fact, there are
major differences that lead to far
more rational approaches to canal
shaping.
Perhaps the single most important difference between a K-file
and a K-reamer are the number
of flutes along their respective 16
mm of working length. K-reamers
have about one half the number of
flutes. As a result, the flutes have a
more vertical orientation compared
to those on a K-file. If K-reamers are
used with the recommended watch
winding motion, the primary movement will immediately cut dentin.
There is nothing magical about this.
Any carpenter knows if you plane
a piece of wood, the cutting blade is
at right angles to the plane of motion.
In the same way, the vertically oriented flutes work productively with
the horizontal motion of the instrument and the blades cut. K-files tend
to screw in and out while K-reamers
cut when the same motion is applied.

Clinical opinion 5B
One could not ask for a more basic
difference.
In addition, K-reamers provide the
dentist with a superior tactile perception, a result of reduced engagement along length, more efficient
cutting of dentin and greater flexibility of the shaft. The dentist can
now make the all-important distinction between hitting a canal wall and
being in a tight canal. The former
will provide no immediate tugback
while the latter produces tugback
immediately. The ability to make
the distinction tells the dentist when
to remove the instrument, bend it
at the tip and negotiate around the
blockage, otherwise known as the
solid wall.
The vertical flutes along length
make the instrument an effective

cutting instrument along length
when used with a watch winding
motion, but a poor cutting instrument when used with the pull stroke
and this is exactly what we want.
Instruments that cut effectively with
a pull stroke in curved canals will
always tend to distort to the outer
wall. For years K-files have been
cutting dentin in ways that are detrimental to our final results and not
cutting dentin well where it would
be most effective.
Less engagement, more flexibility, superior cutting ability, enhanced
tactile perception, are all desirable
qualities and every one of them
is enhanced if we now modify the
K-reamer, by placing a flat along its
g ET page 6B
AD

[6] =>

Clinical

Endo Tribune | February 2010

f ET page 5B

entire length. The result is an instrument that engages far less, is significantly more flexible, cuts perceptibly
better because of the incorporation
of two columns of blades (where the
flat meets the flutes) and produces
superior better tactile perception.
Furthermore, the flat transforms
the K-reamer into an asymmetrical instrument that can differentiate
between a round and oval canal,
information that the dentist can use
in determining the degree of shaping
that a canal must attain to remove as
much debris as possible. Please note,
what might appear as a small change
in design has produced a dramatically more effective instrument without
compromising its complete safety1
(Fig 3).
I believe I have made a strong
case for the use of relieved reamers over K-files. If dentists appreciate these profound differences they
will immediately improve in their
ability to create an excellent glide
path. As important as the differences
between K-files and relieved reamers are, the incorporation of relieved
reamers has greater implications
than more effective glide path creation. Used either manually with a
tight watch-winding motion or in a
30-degree reciprocating handpiece,
relieved reamers do away with the
insecurities of rotary NiTi breakage
while shaping curved canals in an
undistorted fashion2 to dimensions
that those using rotary NiTi would
not attempt out of fear of breakage.
For those using rotary NiTi, this
is a giant step in faith and one you
might not be inclined to take. It is not
necessary for you to take that step.
Take the first step: replacing
K-files with relieved reamers and
determine for yourself if glide path
creation is more predictably and
efficiently produced. Only after you
have convinced yourself that they
are indeed much more effective,
think about the extension of their
usage for complete canal shaping.
As major motivators, they are virtually free of breakage, can be used
six to seven times before replacement, reducing the cost of these
instruments compared to rotary NiTi
by about 90 percent on a per-use
basis.
One definition of progress is the
incorporation of equally or more
effective techniques that are simpler
and safer to use while costing far
less. Relieved reamers fulfill that
definition. ET
AD

Figs. 3, 4: The completed case.

Fig. 3

References

Fig. 5: Orascoptic Loupes, 4.8x
HiRes Class IV (Orascoptic,
Middleton, Wis.).

1. Laurent Scherman, Patrick Sultan.
Comparison of the canal wall states
between a mechanized system and
various rotary NiTi systems. Le
Chirurgien Dentiste de FranceNo.
1411 du Novembre 2009.
2. Nagendrababu Venkateshbabu,
Satish Emmanuel, Goud K.Santosh,
and Deivanayagam Kandaswamy.
Comparison of the canal centering
ability of K3, Liberator and SafeSiders by using spiral computed
tomography. Australian Endodontic Journal. Accepted for Publication, 2010.

Fig. 7: Twisted Files
(.12/25, .10/25, .08/25,
.06/25), (SybronEndo
(Orange, Calif.).

ET About the author

f ET page 3B

Barry Lee Musikant, DMD, is the
co-director of dental research and
co-founder
of
Essential Dental
Systems,
Inc (EDS).
The company’s roots
stem from
the desire
for product
improvements to the
items of focus in lectures and daily
practice. His research and business
partner is Allan S. Deutsch, DMD.
Musikant and Deutsch have combined 60-plus years of experience
as leading lecturers and practicing
endodontists in New York City. Contact them at info@edsdental.com.

Fig. 6: The surgical operating
microscope (SOM) (Global
Surgical, St. Louis, Mo.).

Fig. 8: Small Apical
Assorted (25/.08/23mm,
30/.06/23mm,
35/.06/23mm) (Sybron
Endo (Orange, Calif.).

syringe using Navi tips (Ultradent,
South Jordan, Utah).
The case could just have easily
been obturated with RealSeal One
Bonded Obturators (SybronEndo;
Orange, Calif.)* an obturator version of master cone based RealSeal
bonded obturation. RS1 has RealSeal obturators of .04 taper that are
injection molded over polysulphone
carriers in tip sizes 20-90. RealSeal
has been shown both in vitro and in
vivo studies to provide a statistically
significant barrier to microleakage
relative to gutta percha.
Per the referring doctor’s request,
a temporary was placed into the
access. A layer of flowable composite was placed on the pulpal floor to
protect the obturation in the form of
Permaflo Purple (Ultradent, South
Jordan, Utah) until the tooth could
be permanently restored.
After cone fit and obturation, a
sealer puff resulted. This sealer puff
is a sign that apical patency was
maintained throughout the entire
process. While it is not a sign of
treatment superiority, it does signify
the cleaning and shaping performed
fulfilled the goals of canal shaping
in that the apical foramen was kept
at its original size and position and
the original position of the canal
was maintained.
The clinical management of
a calcified upper first bicuspid is
detailed. Emphasis has been placed

Fig. 9: The Skini
Syringe and Navi
tips (Ultradent,
South Jordan, Utah).

Fig. 10: RealSeal One Bonded Obturators (SybronEndo, Orange, Calif.).
on preoperative treatment planning
to avoid iatrogenic events. The tooth
was shaped with Twisted Files to a
master apical taper of .08 and a #40
master apical diameter using four
files and approximately seven total
insertions per canal. I welcome your
feedback. ET

ET About the author
Dr. Richard E. Mounce is the author
of the non-fiction book “Dead
Stuck,” which
offers “one
man’s stories
of adventure,
parenting,
and marriage
told without
heaping platitudes of political correctness” by Pacific Sky Publishing. For
more information, see www.DeadStuck.com. Mounce lectures globally and is widely published. He is in
private practice in endodontics in
Vancouver, Wash.

[7] =>

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[8] =>

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[cover] => Endo Tribune U.S.

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Table of contents

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Troubleshooting calcified canals: clinical case review / News / Obturation system positions pack and flow side-by-side / An endodontic absurdity

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