I can't do molar endo - please help

[groker2009]

I have a difficult time with molar endos.

1) I have a hard time instrumenting narrow canals, which is the case for mb/db canals on maxillary molars and mb/ml canals on mandibular molars. ( at least based on my experience; don't know if I'm doing anything wrong ) I find the canals too stiff to instrument to anything over a size 20.

2) For the canals of all molar teeth, I can't easily get gutta percha all the way down to the apex. Even with the narrow cones, they always seem to be several mm away from the apex.

I never have either problems when treating any other teeth. I'm getting these issues only when dealing with molars. Also, I don't use rotary or thermoplastic condensation. I only have hand instruments and gutta percha at my disposal.

I would gladly appreciate some tips and pointers.

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[aphistis]

I have a difficult time with molar endos.

1) I have a hard time instrumenting narrow canals, which is the case for mb/db canals on maxillary molars and mb/ml canals on mandibular molars. ( at least based on my experience; don't know if I'm doing anything wrong ) I find the canals too stiff to instrument to anything over a size 20.

2) For the canals of all molar teeth, I can't easily get gutta percha all the way down to the apex. Even with the narrow cones, they always seem to be several mm away from the apex.

I never have either problems when treating any other teeth. I'm getting these issues only when dealing with molars. Also, I don't use rotary or thermoplastic condensation. I only have hand instruments and gutta percha at my disposal.

I would gladly appreciate some tips and pointers.

What's your technique? Walk us through a typical molar endo the way you do them.

Are you caught up on CE? A few good endo courses and some benchtop practice to refresh your technique can do wonders.

I don't know what your circumstances are, but I'd seriously consider purchasing a rotary system if you want to do molar endo in your practice. Apex locators too, if you don't have any.

 

[CanuckDDS]

What's your technique? Walk us through a typical molar endo the way you do them.

Are you caught up on CE? A few good endo courses and some benchtop practice to refresh your technique can do wonders.

I don't know what your circumstances are, but I'd seriously consider purchasing a rotary system if you want to do molar endo in your practice. Apex locators too, if you don't have any.

agreed. Rotary, when used correctly, is a very effective method of opening up canals. I did a ton of endo in private practice. Some CE is a very good idea, they will teach you how to get down that stubborn canal and other methods to obturate. Although you have to go in with a critical mind, b/c a lot of CE courses/instructors push their way as being the best thing since anesthetic but they have other interests in the products that they are pushing. Namely $$$$.

Also I found loupes really helped.

 

[groker2009]

What's your technique? Walk us through a typical molar endo the way you do them.

My steps are pretty standard for someone using hand files and gutta percha.

I first locate all the canals. Then I try obtain straight-line access for each of them. I use RC Prep for every hand file. I first use a size 10. I then instrument with a size 15. With size 15 files in the canals, I take xrays to verify length.

Then I instrument with a size 20 and recapitulate with 15. For some reasons, whenever I am only doing molar endo, I always find it physically hard to instrument with a size 20 and up. ( my fingers literally hurt when I try flaring the canals with sizes 30 and 35 + ) Size 25 is the last file I use to the full length of the canal.

I use size 30 up to one mm short of the apex. I recapitulate with size 25. Then I use size 35 up to two mm short of the apex. Again I recapitulate with 25. Generally for molar canals, I find the canals too narrow for a size 40 and up.

In between the above steps, I rinse the canals with water on and off depending on how much irrigation I feel I need. And somewhere in between these steps, I also irrigate with NaOCl.

With most molar canals being stiff and narrow ( or maybe it's my technique that's making it this way? ), I prefer to try using master cones of size 25 ( occasionally a 20 ), and then I would use a lot of cement and use lateral condensation to obtain a good radiographic fill.

But the problem is how a gutta percha size 25 or even a size 20 wouldn't go down to the full length of the canal. The cones would usually be around 4-5 mm short of reaching the apex.

What should I try doing?

 

[aegdboy]

Sounds to me like you are using the wrong tapered gutta percha. If you use files with a certain taper than the gutta percha needs to match it.

Think about it, if the canal is instrumented to a 25 and you are using a 25 gutta percha but the gutta percha has a wider taper, then it won't reach the apex.

 

[aegdboy]

See here is an example if you move to rotary. You can use a .04 or .06

http://www.brasselerusa.com/products/dEndodonDsply.cfm?id=297

I was trained on the brasseler and like them. I never really had an issue or file seperations with their rotary.

 

[HupHolland]

are you using plenty of NaOCl between each file? are you keeping the canal flushed w/ irrigant during instrumentation?

it's possible that you have dentin debris building up at the apex.

Hup

 

[groker2009]

are you using plenty of NaOCl between each file? are you keeping the canal flushed w/ irrigant during instrumentation?

Yes to both. And I'm often able to insert files of sizes 10 - 25 into the full lengths of canals.

 

[groker2009]

Sounds to me like you are using the wrong tapered gutta percha. If you use files with a certain taper than the gutta percha needs to match it.

Think about it, if the canal is instrumented to a 25 and you are using a 25 gutta percha but the gutta percha has a wider taper, then it won't reach the apex.

The same problem happens to me wherever I go. I'm pretty sure it's not from using gutta percha of the wrong taper.

Honestly I'm suspecting that the problem lies somewhere in my technique of hand instrumenting. Any suggestions on what I can try?

 

[aegdboy]

The same problem happens to me wherever I go. I'm pretty sure it's not from using gutta percha of the wrong taper.

Honestly I'm suspecting that the problem lies somewhere in my technique of hand instrumenting. Any suggestions on what I can try?

Yeah. Stop using HI and go rotary!


What I always do is HI to at least a 25 to the apex then do the rest crown down with rotary.

I put in the master cone and on avg about 1-2 accessory cones.

Comes out great every time.

Also, are you just using gutta percha handed to you without looking at the taper of the instruments and gutta percha? Just make sure you are using two like systems.

How often are you stepping back? Maybe that is your issue. Or you are stepping back and not measuring properly therefore not getting a good canal taper. Just do rotary and it solves that problem

I would go to dentaltown.com and post vs here. A lot more practing dentist there.

 

[groker2009]

Yeah. Stop using HI and go rotary!


What I always do is HI to at least a 25 to the apex then do the rest crown down with rotary.

I put in the master cone and on avg about 1-2 accessory cones.

Comes out great every time.

Also, are you just using gutta percha handed to you without looking at the taper of the instruments and gutta percha? Just make sure you are using two like systems.

How often are you stepping back? Maybe that is your issue. Or you are stepping back and not measuring properly therefore not getting a good canal taper. Just do rotary and it solves that problem

I would go to dentaltown.com and post vs here. A lot more practing dentist there.

So apparently you're able to seat gutta percha to the full length in molars? Can you post your exact hand-filing techniques here? ( this is in reference to molars, by the way. Not single rooted teeth where canals are wide open )

I know J. Morita rotary + Dentsply Thermafil can lead to 30 min molar endos with no hand fatigue. But most insurance-based offices do not have the resources for $10-$15 for each rotary file and an extra $50 for each thermaplastic fill, not including the rotary/auto obturation equipment to be thousands in dollars. In my location, most clinics are impressed if you're fast in molar endo using hand instruments, and they'll think you're really good. ( they're like 'duh.' What dentist can't do good endo with rotary and thermafil? )

 

[aegdboy]

I just did molar endo, #19, on my cousin. 4 canals. Gutta percha on all 4 canals .5mm from apex.

All 4 canals (but standard 2 root) were very small. I opened the coronal 1/3 with an orifice opener to get unobstructed access. I then used a 10 file (15 would not fit in any canal) with an apex locator. After working length determined on all 4 canals with apex locator I instrumented to the apex up to 25 with HI. to instrument I did 1/4 turn clockwise, push down slightly, 1/4 counterclockwise, irrigate. like I said, I started with a 10 then 15, then 20, then 25

used rotary. Started with a 50 going crown down. Made it to the apex with 30 on three of them and 25 on the other.

I placed the corresponding gutta percha points in. Took a radiograph. two were perfect. One required 1mm cut back the other 1/2mm cut back. I placed cement on a 20 file and coated the canal. I placed cement on the gutta percha but not the apical 1mm. put in the canal, condensed, added 1-2 extra points, removed with a heated instrument.

Cotton pellet, IRM and made sure out of occlusion.

 

[teeth63a]

The one thing that I didn't read you did was opening up the coronal orifice more. This could be critical as you're trying to get bigger files down. I use a gates glidden #3 to open up the orifice big.

aegdboy touched on the taper issue. If your GP taper is bigger than the file, you'll never get it down.

 

[aphistis]

I just did molar endo, #19, on my cousin. 4 canals. Gutta percha on all 4 canals .5mm from apex.

All 4 canals (but standard 2 root) were very small. I opened the coronal 1/3 with an orifice opener to get unobstructed access. I then used a 10 file (15 would not fit in any canal) with an apex locator. After working length determined on all 4 canals with apex locator I instrumented to the apex up to 25 with HI. to instrument I did 1/4 turn clockwise, push down slightly, 1/4 counterclockwise, irrigate. like I said, I started with a 10 then 15, then 20, then 25

used rotary. Started with a 50 going crown down. Made it to the apex with 30 on three of them and 25 on the other.

I placed the corresponding gutta percha points in. Took a radiograph. two were perfect. One required 1mm cut back the other 1/2mm cut back. I placed cement on a 20 file and coated the canal. I placed cement on the gutta percha but not the apical 1mm. put in the canal, condensed, added 1-2 extra points, removed with a heated instrument.

Cotton pellet, IRM and made sure out of occlusion.

For curiosity's sake...time elapsed from start to finish?

 

[DrJeff]

The one thing that I didn't read you did was opening up the coronal orifice more. This could be critical as you're trying to get bigger files down. I use a gates glidden #3 to open up the orifice big.

aegdboy touched on the taper issue. If your GP taper is bigger than the file, you'll never get it down.

Exactly, making sure you have plenty of width access at the start of the canals on the pulpal floor is key no matter what your technique is. 👍

Also, along the same lines, make sure, no if's and's or but's about it that you have unimpaired straight line access to the canals. A Master/accessory cone semi-binding as you're going to insert it into the canal can also cause problems getting to full obturation length, and if you have to remove a little more coronal structure to get a better final fill, no big deal since you just add a smidge more of buildup material under that crown.

For me atleast one of the key ways I heard endo access prep design explained to me that really made it click, was at a CE course given by one of the big endo gurus, Dr. Steve Buchannen(of Pro-File fame). Basically he said that no matter what tooth you're working on, that access prep should like like an inlay prep with a REALLY WIDE taper to the walls (think atleast 30 degrees) Ever since I heard it explained that way to me 5 or so years ago, those typically tough access canals (typically MB's on molars) have been mch easier to properly instrument/obturate.

 

[aegdboy]

For curiosity's sake...time elapsed from start to finish?

I'll tell if you don't make fun of me 😀

 

[teeth63a]

I'll tell if you don't make fun of me 😀

He blocked out the entire morning in his schedule. 🙂


J/k. Kudos to you for taking on a huge case. The faster you get at these, the more money you'll make. Endo and oral surgery are two things I love to do. No overhead in lab fee and relatively fast to do. I've recently stopped refering out a lot of molar endos and surgery impactions and started doing it myself, because its money that I can make that would be walking out the door.

Where I'm at, my endodontist friend books 8 patients a day in a non par office. He charges $1000+ per endo. Do the math 🙂 (translation: I should have gone to endo school).

 

[aphistis]

I'll tell if you don't make fun of me 😀

Deal. I'm not fast at molar endo either, trust me. 😉

 

[aegdboy]

3 hours!

I could knock out a nice premolar in 30-45 min. Rotary makes life sooooo much easier but that molar I could start a whole new thread on 🙂

For instance, the caries were so deep that when I opened it up I did not see any canals! The body actually placed tertiary dentin at the level of the pulpal floor.

Once I located the canals (i knew they were there and not calcified bec of the film) it was a pain to get any file in. Opened up the coronal 1/3rd nicely and then I followed the above steps.

 

[ou_jay]

To save money on instruments, you may consider using a hybrid rotary system. Our Endo director created one we use at OU that lets us use our molar rotary instruments 4 times (usually 2-4 teeth depending on if you have to cycle through them). To my knowledge, separations are pretty rare in our clinics.

We do the following:

• Establish a radiographically confirmed path to the apex of at least #20 size.
• Do orifice movement with #6 & #5 GG drills to get straight line access to the middle of the root. I suspect you could do this step first, but it is not allowed in our student clinics.
• Then do crown down GG prep to a size #2. This takes a lot of stress of the files.
• Then we do the part of the root coronal to the curve w/ stiff, strong, low helical angle files (K3 to be specific). You keep it in the coronal part of the root by using big files with big tapers.
• Then we do the apical part of the root with flexible, high helical angle files (Endo Sequence). These files are smaller with more moderate tapers (25/.04 is the smallest we use although a larger one might go to length). These files are the weak point, but most of the stress has been taken off of them by pre-flaring the coronal part of the root with GG's and stronger files.

We obturate w/ WV condensation of regular GP cones. That is pretty cheap. A cone that matches the last file usually fits to within 1mm of the apex. We coat it w/ sealer and downpack it w/ a heat source. Then we backfill the rest of the root w/ a GP gun. Those cartridges are a little more expensive (~$3 per tooth) than GP cones but the technique is quick and there is better fill and less chance of fracture than lateral condensation.

 

[groker2009]

For instance, the caries were so deep that when I opened it up I did not see any canals! The body actually placed tertiary dentin at the level of the pulpal floor.

Once I located the canals (i knew they were there and not calcified bec of the film) it was a pain to get any file in. Opened up the coronal 1/3rd nicely and then I followed the above steps.

I don't know about anyone else here. But I'm always afraid of perforating whenever searching for molar canals. Maxillary molars and the third molars are the worst ones.

Generally we're taught to assume a molar root has more than one canal unless if proven otherwise. How would you know when to stop drilling and conclude the root has only one canal?