Root Canal on Maxillary 1st & 2nd Molars – Dental Minute with Steven T. Cutbirth, DDS

Root Canal on Maxillary 1st & 2nd Molars – Dental Minute with Steven T. Cutbirth, DDS

This is an ongoing full mouth reconstruction case in this first part, I’m performing endodontics it’s on the maxillary first and second molars. Why are we saving these teeth?

It’s a very good philosophical situation because you can see. We’ve got advanced periodontal disease. Interestingly, only between these teeth and then the fer cation of the first molar.

Now what happens if we extract these teeth, there’s not enough vertical bone between the alveolar crest and the sinus to place an implant without a sinus lift and bone grafting. That’s a that’s a big procedure: the teeth are not mobile because they’re tri-rooted teeth, they have three roots.

So, it’s stable, like a stool we’ve got some calculus built up here, and so the patient does not want a removable appliance, which is the only other option. If you extract them – and you don’t want to do a maxillary, sinus lift and bone grafting, so it was decided because these teeth were hypersensitive you’ll, see in the photograph here in a minute that there’s lots of gum, recession and then the bone loss here in the Interproximal area that we would perform endodontics on the teeth and save the teeth as long as we could, we’d also perform periodontal surgery, which I’ll show in a forthcoming video. The reason again we’re doing the endodontics and saving these teeth is.

The patient did not want to go through a maxillary sinus lift in bone grafting, and she did not want a removable partial denture. The teeth are stable, they’re not mobile.

I’ve had success in the pat in the past if you can get rid of the pocket here in the inner proximal in this interproximal area and keep it nice and clean and have regular cleanings.

I have saved teeth like this for many years and the other reason is if this periodontal disease did advance, it’s not affecting anything, but these two teeth, so we really don’t have anything to lose, but the patient spending a little money if we were to lose Those teeth later on in my mind, these teeth really have a good long-term prognosis with endodontics periodontal surgery to remove the calculus and do a little bit of grafting right here and crowns on the teeth because they also had large mercury amalgam filling. So, this video is on endodontics on these two teeth you can see.

We’ve got large mercury, amalgam fillings this first molar had fractured. We’ve got a big crack on the mesial of the second molar. This is one of the reasons I don’t like large composites are mercury.

Amalgam fillings because they don’t support the cusp of the teeth. You can see the big cracks on the bicuspid here, we’re going to crown that tooth in a forthcoming video when we’re veneering the maxillary anterior teeth, so we’re going to perform endodontics on these teeth and place crowns on the teeth in this video I’ll just be performing The endodontics see here the teeth: we’ve got lots of gum recession, you can see.

The patient was a big grinder and bruxer at night did not have a night guard. I’M a big fan of night guards. Most of my patients receive a night guard when they’ve stopped growing with girls.

That’s about 16 and boys in their low 20s, painless and profound local anesthesia. Now remember, if you’re doing something significant like endodontics on a tooth or a full crown prep on a younger or really someone, that’s not 70 or 80 years old.

If you don’t give the or extracting a tooth, if you don’t give the patient an intra-ligamental injection, that tooth is probably not going to be profoundly numb to watch that video in the library of

So, this is an intra-ligamental following an infiltration, then this rubber dam technique to me is magnificent: it’s not it’s not the one you learned in dental school.

This takes about 15 seconds to place because you’re not, you, don’t, have a strip between every tooth. The problem with the conventional rubber dam technique is its such a pain to place, and you’ve got to deal with those strips interproximal strips between the teeth that most dentists don’t use rubber dams.

I use a rubber dam on almost everything because it’s so quick, it’s so easy, and it’s 99 as effective as the conventional technique. You learned in dental school, see, I just pop, pop. It’s to watch that link, so see, there are no strips in between the teeth.

So, here are the teeth: you’ve got an assistant, helping you it’s going to capture all the pieces, it’s going to keep the patient’s tongue and lips and cheeks out of the way the water is going to be contained here and the assistant’s aspirating. So, it’s 99 as effective as the conventional rubber dam technique.

Is it perfect? Well, probably not perfect, there may be a little water dribble through or something like that, but it’s very, very effective. So, the first thing we do is measure the length of the teeth. So, we’ve got a close approximation on a peripheral radiograph of the length of the roots. Then I’m using a 330 carbide bur to access the pulp chamber.

Like I said both these teeth were hyporamic extremely sensitive to cold. So, if we’re going to save them, we had to do endodontics. Remember that pulp exposure or abscessed teeth is one of many reasons to do. Endodontics on a tooth. Hypersensitivity is another reason if a patient can’t drink hot or cold, or you know, have any exposure on that tooth.

That’s a good reason to do. Endodontics, if you have a tooth, that’s in the aesthetic zone and there’s a lot of ginger recession such that you have to prep down on the root. That’s another reason to perform endodontics on the tooth.

A crown does not make a tooth less sensitive. It makes it more sensitive if anything, especially if you have to prepare onto the root of the tooth because the tooth’s in the aesthetic zone now in this case, with these teeth, they’re not in the aesthetic zone.

So, I’m going to do a super gingival preparation and keep the preparation in enamel. That’s always a preference if you can, but if you have to prep onto the root of the tooth, you better think about endodontics because the patient will forgive you and understand.

If you tell them ahead of time, this tooth is going to need endodontics if you place the crown and have to go back later and charge them more and make a hole in their brand-new crown. They’re not going to appreciate that. So remember.

If you tell somebody something ahead of time, it’s a reason, if you tell them after the fact, it’s an excuse, you can see the big cracks on the bicuspid, we’re going to crown those teeth at a later appointment.

Now. This is a large, of course, football diamond, and I’m using that to open the access opening because you want direct access to each of those canals. Dr Alex Flory taught the endodontics course at my teaching center in Dallas, the center for aesthetic restorative dentistry.

For many years – and that was one of the points Alex always made – was you want direct access to the canals, you don’t want to have to bend a drill or a file this way to get into a canal?

You want to go straight into it, so I’m opening that up with this coarse football diamond. So i have direct access to the canals set. The stage for success with your access opening, be sure. You’ve got plenty of space to access the canals. Now i’m reducing the occlusion, i’m doing all this before I actually start the endo.

How much am I reducing the occlusion, about two millimeters? I like about two millimeters of space, for the crown some people say a millimeter well, millimeters is really testing the technician and there’s just so many things that could be a problem if you’re only reducing the occlusion a millimeter.

If you reduce it to the tooth, doesn’t know the difference, the technician’s got plenty of room, so this is an occlusal reduction bur. Now back to the access opening, you can see the bleeding. These are vital.

Pulps we’ve accessed the pulp chamber and now i’m just removing the pulp chamber, then I’m going to come back. This is just connecting the canals in the coronal part of the pulp chain chamber. Now this is a 30 gauge needle, and I’m just re-anesthetizing the nerve. You sit and s 4 plane or lidocaine. 100.

Let’s just be sure, everything is totally numb now this is the number six round burr on a slow speed, hand piece, and you go into the coronal part of the canal and then pull up just to clean that out real well, so you’ve got good access To the canal set the stage first now those are the instruments that I use for endodontics. This is a scout file.

This is the Brazilian real world endo system, and it’s a fabulous system, but that scalp file is worth its weight in gold because it will access anything and it. It’s very flexible.

I’ve never separated a scout file, and you can go down to the tip of the canal and access it so that things are open, and then you can follow it with hand files, so we’re we’ve measured, got lubrication, which is sodium hypochlorite with water.

Now I mix the sodium hydrochloride three parts: water to one part, sodium hypochlorite three to one water is three sodium hypochlorite is one there’s a reason that a lot of endodontists use straight sodium, pipe chloride, that’s great.

Unless you have a sodium hydrochloride accident, which means that sodium hypochlorite gets into the inferior alveolar nerve canal, I’ve had a few patients present in my office that have had relatives. Have that happen. I had somebody talk to me about that.

The other day that it happened to their daughter when she’d gone to an endodontist. It’s not you know, certainly it’s not on purpose, but it can happen.

So, I don’t like straight sodium hypochlorite, just in case any of it got into the sinus or into the inferior alveolar canal. Hopefully, that will never happen, but I want to eliminate the big mistakes.

So, let’s go with three parts: water, one part sodium hypochlorite, and I’ve used that for 40 years successfully, so we’re back to the scout file.

Now what I like to do is have two hands: pieces with one hand piece. I keep the scalp file in the hand piece and with the other one I change the drills and I keep going back and forth to the scalp file just to be sure the canal is patent, so I’ve measured each of these canals pre-operatively on the application.

On my computer to know the approximate length of each of the canals, so I’m going back and forth with the two hand pieces with the scalp file, and then I’m going to use these drills now. Normally, I use the medium drills. This is 25, 30, 35 and 40 And I would say 90 of the endo i do.

I use these canals. There’s also a single file technique, the ej02, which is very good. The only problem I’ve got with the ej02 is, if you, if you open the coronal part of the canal and use the ej02 you’re going to fill the canal with a size, 30 gutta-percha cones.

Well, unless you add accessory cones to the coronal part of the canal, you’re going to have voids in the fill which is not the end of the world, but part of it’s just personal fragrance, it just looks better if you’ve got that filled up with gutta-percha and Cedar and there aren’t any voids in it, so the ej02 is a good technique. I’ve used it many times, but I’ve, at least for now.

I’ve gone back to the drill, the several drills tech technique, just because the canal is completely filled with the gutter, perchicone and the sealer okay. So, we’re going back and forth here.

This is called a crown down technique, which is a really good idea. What that means, is you open up the coronal part of the canal? First, the reason you do that is because it accepts the water soap, sodium, hypochlorite, lubricant, and it pulls it in that open part if you’ve got just a little bitty thin thread, size canal, it’s harder for that lubrication to get down into the canal.

So, you open the coronal part first now, whenever you’re using these drills, it’s very important. You don’t put any pressure on the drill, just barely any pressure because you don’t want to notch the inside of the canal.

If you do, every drill will stick in that notch, and you’ll have a hard time getting to the apical part of the canal, so start with. In this case, I’ll start with a size, 40 and gently go down into that lubricated canal and open it, just get that going. Then I’m going to come back with a hand.

File very quickly see this is a probably a 40, and I’m just opening up the coronal part. So, I can have that lubricant pool in that little depression. So just opening it up, I’m putting no pressure on it.

Then I’m lubricating again – and this is just a regular, syringe and needle I’m just put you’re not putting pressure with the sodium hypochlorite water solution. You’re just squirting it into the coronal part of the tooth and letting it pool right there.

And then your drills and scalp file and hand files will take it down into the canal, with the objective being this dissolves the little parts of the nerve down in the canal. Okay, so you can see I’ve accessed all six of the canals, we’re just pulling it.

So, I’m not putting that into i’m not putting that syringe tip that needle tip into the canals I’m just pulling it up here in the top and letting everything float to the top.

Now I’m going back and forth with the scalp file, just to be sure the canal remains patent, so I’ll use a drill, and then I’ll come back with the scalp file. You want to have two hand pieces, so you don’t have to keep going back and forth.

I’ve not done very much with the drills at this point. I’ve just opened up the coronal part. Let’s talk about file separation or drill separation, if you’ve cleaned out the canal well with the hand, files and irrigated well from time to time, everybody is going to separate a file.

It’s just going to happen. Well, if you’ve cleaned it out really well, with that number 10 headstrong file and irrigated it real well, and you separate a file, it’s not the end of the world.

It’s going to that file is going to be like an old silver point and chances are 99. The tooth is going to be fine, you’ve just filled it with a silver point, and you don’t have to remove it.

Now, I’m not encouraging you to be sloppy with your endo technique, but especially when you get into the larger files, the larger drills. You want to be sure you don’t put any pressure on them because they’re the ones that normally would separate I’ve, never separated a scalp file, and I can’t even remember separating a smaller file, but I have separated a few number 40s. So, those are the ones you want to be really careful with.

I haven’t separated the file in a long time because I’ve gotten the hang of this technique, and I’ve gotten used to it, and I know I don’t want to put any pressure on it. So, when you’re starting with the technique, just remember, keep it patent, and before you do any drilling to the apex, be sure you clean the canal out and irrigate it well with either a number 10 either headstone, headstrong or k-type file.

I personally like headstrong files because they cut better, always bend the file before you place it in the canal, then I’m just moving it up and down and cleaning it out now we’re measuring with our apex locator and that’s perfect with this system you’d like to be At about half a millimeter from the apex, so 0.5 is the perfect number.

This is 0 4, i’m doing another canal and just up and down be sure to connect the file is curved always before you place it in a canal and be sure there’s lots of lubrication now.

For some reason, you can’t get a good read on your apex locator. It just keeps going up and down 0.2 1.5. One point: you’ve probably got too much lubrication, too much moisture in the canal.

So take your air water, syringe and just dry. It out a little bit then put the file back in and measure, and you should get a good reading. This is the second canal, 0.5. Now we’re going on.

Third one always curve it always lubrication. 0.4. That’s plenty good! Remember!

If you don’t get a good reading on that apex locator, it’s probably because there’s too much fluid in the canal, okay, so these are my reeds now what about the mb2 canal? What about the mb2 canal? Always in endo circles people talk about the mb2 canal. That means there’s a mesial canal and then mb2 is a little canal that connects to the mesial canal. Well, I always try to get the mb2 canal.

If it’s gettable, but many times, you can’t find it, or you know you can’t get down in there. Well, I’ve been doing endo for 40 years, and I’ve been to my knowledge. I’ve only had one endodontic procedure. That’s failed in that time. It’s because it was a fracture all the way through the floor of the two.

So don’t stay up nights unable to sleep because you couldn’t get a mb2 canal because it joins to the mesial canal. Like that, then all the rest of the canal is cleaned out and filled, and so I’ve never had a problem with it that I’m aware of you’re probably not either.

I’M not saying don’t get it if you can, but don’t think this procedure has been a failure. If you can’t access the mb2 canal, still just cleaning and filing so the objective of this procedure, is you want to open up the coronal part of the canal first, so it can hold the lubricant, and then you’re going to take the lubricant down into the Canal with the hand, files and the drills, so you start with about a with a 40 and then once you’ve accessed that, and you’ve opened up the coronal part of the canal, so it’ll hold the lubricant. Then you and you’ve gotten the scout file to go to the apex of the canal.

Then you come back with the hedgeroom number 10 hand, file and curve it and clean that canal out and irrigate. It is really well, then, continue with the crown down procedure. That means you’ve used the 40 Next you’re going to use the 35 in between each drill pick up the other hand piece with the scalp file.

That’s measured on their take the scout file to the measured length, so you’re sure that canal is remaining patent, and then you irrigate it out. Then you come back with your 40, then 35, then 30 scout files in between each time and then 25.

But as soon as you get to the apex or to the measured working length, then that’s the end of the five of the drills. So say you started with a 40, and you can’t get to the apex with the 40 or 35, but you can get to the working length with the 30.

Then that’s as far as you have to go. You don’t have to go with the 25 drill, and you’ve cleaned it out with your hand, file, and you’ve continued to check the patency with the scout file, and so some people fill with gutta-percha cone, one size smaller than the last drill size, meaning if the last drill size was a 30; they fill with the 25 gutter perchicone i like to place the gutta-percha cone in the canal, that’s the same size as the last drill. So if the last drill was at 30, I’m going to place a gutta-percha cone in the canal for a trial radiograph, that’s a 30 If, for some reason it’s a little short then go with the 25 because remember the thing that seals the canal is not the gutta-percha cone, it’s the sealer.

Dr flooring made this very clear to us in his endo seminars that the gutta-percha cone is just to press. The sealer out into all parts of the canal and to fill the bulk with the canal, but the thing that seals it is the sealer opening the coronal part filing irrigating.

The main part of a can of an endodontic procedure is the cleaning of the canal. I had a chairman of the endodontic department when I was in dental school, said and, and don’t take this literally, but he said if you clean a canal and irrigate it well, you can fill it with horse manure, and it will work now. You certainly do want to fill it and seal it.

Well, we don’t want to be sloppy, but the point is the cleaning. The cleaning and irrigating is the main point. As i understand endodontics and the other part, is I like the three to one water to sodium hypochlorite, just because you don’t have to worry about a sodium hypochlorite accident.

Many endodontists will dispute that and say no, use straight sodium hypochlorite. But if you get any out the tip of the tooth of the canal, there could be a problem see so don’t put the tip of this needle and syringe in the canal, you’re just filling it up and floating everything to the top.

So, you want to open that coronal part, so it’s good and open that will hold the lubricant, and then we’re going to crown down as we open it once we’ve hand file it to clean it out real, well and irrigate it real. Well then, we’re going to go crown down with the 40 35, 30 and 25 and the scalp file in between every drill to be sure the canal is patent.

I can’t stress how important it is to use those hand files first, that number 10 head strum. That’s curved with lots of lubricant to clean it out and irrigate it out. Just in case you separated a file, it’s not the end of the world.

You just fill it with a silver point because you’ve cleaned everything out, but if you start with a drill – and you separate a drill before you’ve cleaned it out, then it’s probably of consequence that you remove that the drill that’s separated in the canal and that’s not An easy thing to do, and you can compromise the tooth or damage the tooth if you perforated, trying to remove the separated drill from the canal, so main thing is: don’t put pressure when you’re using a drill, the technique, dr flory taught us, was go into the Canal until it has a little pressure, then pull it back up end of the canal has little pressure, pull it back up into the canal, a third time.

There’s a little pressure, pull it back up and then stop with that drill. Then you’re going to go to the next size down, say you started with the 40 in out, then you’re going to go back with your scout file, then and irrigate, and then you’re going to go with the 35 again three times to pull It back out in with a little pressure, pull it back out in with a little pressure, pull it back out, don’t put much pressure, and you shouldn’t have trouble with separated files. You want this rubber, stop, to contact the rim of the opening. You’ve got a definitive stop there.

This is the 30 going back, and I’ll go back and forth between these files. These drills, but I’ve always got the scalp file. On that second hand piece, so I can ensure the canal is patent. Okay, so here we go now.

I’M irrigating out the sodium hypochlorite water solution and any little bits of anything with a 30 gauge syringe, and this is local anesthetic in the syringe several of you’ve asked me in the comments.

What’s the significance of the local anesthetic, nothing, there’s no significance of local anesthetic. It just happens to be the liquid that fits into the syringe. The significance here is the 30 gauge needle an endodontist taught this technique at my teaching center years ago, and you’re not putting pressure in the canal with the needle tip you’re just putting it just in the opening, and now you’ve crowned down the canal.

So, it’s open at the top and thinner at the bottom. So if you just put the anesthetic in the top with a little just a little bit of pressure but don’t put the needle tip in a bind in the canal, it’ll wash all the debris and the sodium hypochlorite out of the canal, so the 30 gauge needle Is the significance of the needle with the local anesthetic?

If you could put water in the local anesthetic carpule? That would be fine. It would work just as well, you’re not trying to anesthetize the two. So, here are my canals. Now I’m placing the gutta-percha cones in this case I’ve gone with 25s in the buccal and 30s in the palatal, and you cut them off, and then we take a trial file or trial cone radiograph.

You can see they’re perfect, then we’re going to irrigate again with the three parts: water, one part sodium hypochlorite solution – and this is a 10cc syringe with just the needle that comes with it. No pressure in the canal, you’re just filling up the pulp chamber and floating everything to the top.

Then I’m following that. With this 30 gauge needle and local anesthetic and the again local anesthetic is of no consequence, it could just as easily be water. I just want to rinse out that sodium hypochlorite solution, any little bits of debris.

No pressure in the canal, just put the tip in the coronal part of the canal and flowed everything to the top. All right, then I rinse it with water from my air water. Syringe and then take air blower in my air water, syringe and just blow it gently just to get the bulk of the fluid out because otherwise, if you’re trying to get all that out with your paper points, they’ll soak up immediately so irrigate with the water and Then take your air syringe and just blow it generally dry, but don’t desiccate it because you don’t want to put pressure down into the canals just to get rid of most of that fluid then I’ll use two or three paper points per canal.

Hopefully, it’s nice and dry now what if you instrumented a little bit past the tip of the tooth, and you’ve got bleeding well. This was what was taught by the endodontics that taught the endo course at my teaching center dry it the best you can but go ahead and fill it just go ahead and fill it.

Put the paper point, a large enough paper point, into the canal to stop the bleeding. You might even want to put a little hemostatic agent on it and then immediately when you take out that paper point fill the canal, I think nice and dry. Now. This is the endosequence bc, sealer curve the tip and place it into a canal and put a little bit of pressure to squirt the sealer as far into the canal. As you can go, then put, it’s a single cone technique.

Put the cone firmly into that canal. Then you’re going to remove the coronal part with that heating element, then take a condenser put some pressure on the seared coronal part of that cone and normally, I’d do them one at a time, then, into the next canal and put a little bit of pressure with The sealer to squirt it into the canal place the cone sear it with the heating element. Then condense it, the third canal and don’t move the tip of the bc.

Sealer up and down, or you’ll incorporate air bubbles, just put it in the canal, squirt it with a little pressure and bring it out then put the cone in single cone technique. Remember the sealer is: what’s actually sealing the canal, sear that off now.

This is not my technique. I didn’t invent this. This is the real world endo technique taught at my teaching center in dallas by alex fleury and a couple of other endodontists, so this technique really works. Well, now we’re on to the first molar, just straight in with the gutta-percha cone: don’t move it up and down either just put it straight into the canal: you don’t want to incorporate air bubbles, condense it and the next one. You see how it’s filling from the apex up and some people like to put the sealer on the gutta-percha cone I like to put it into the canal and give it a little pressure just so you may get that little pop through the apex of the canal.

That’s perfect when you have a little just a little sealer going out the tip of the canal. What if you had? What, if you have a significant amount of sealer, go out the typical canal? Well, you don’t want a gallon, but if you have a little bit out the tip of the canal, it’s not going to hurt anything because it’s going to dissolve or be absorbed or go away. It’s not going to damage anything again, not encouraging poor endo technique, but things are going to happen now.

This is irm and you mix it dry. First spatulate it and then you take your fingers, your glove fingers, and you squeeze the parts you’ve spatulated into the powder. So, it’s pretty dry and pretty firm. If it’s moist and gooey you, it doesn’t work as well, so just press that into the hole. Now.

Why do I use irm? It’s easy! It’s quick, and it’s effective, and it’s not going to be exposed for a long time. We’re going to place a crown on the tooth, some people say well: irm will affect the set of composite the composite cement or a composite restoration.

I’ve never had an issue with that in 40 years of using it because I’m sure it’s set all the way before I place composite near it, including composite cement.

You can place a composite buildup if you want to, I’ve. Just always used this because it’s so simple, but you need to mix it. You can see. That’s pretty firm, you want to mix it densely so that it’s nice and firm and not gooey, then once it sets. I come back with this rubber wheel, sometimes, and just polish it a little bit round the edges, so you don’t have any sharp edges now.

We’re obviously going to place crowns on these teeth at a forthcoming appointment, so this is just making it comfortable for the patient. You don’t want to leave the irm for a long time. It’s not a permanent restoration, but it’s fine. For a few weeks now, I’ve performed the periodontal surgery here and that’s in a forthcoming video we’ve veneered the anterior teeth and or we’re veneering them and placing crowns on the bicuspids. That’s in forthcoming videos also.

So, this is just the endosequence. That’s the dental minute. These techniques work, and they work every time. Don’t you want to take your practice to the top tier, subscribe to for an organized library of all the gentleman videos, plus many complete comprehensive cases, and so many important articles that you can only find right here?

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