For more than 50 years there has been universal agreement that the triad for endodontic success is shaping canals, cleaning in 3 dimensions, and filling root canal systems. Further, it is globally accepted that 3D disinfection is central to success and has traditionally required a well-shaped canal...
Ruddle Projects & Diagnostic Imaging What Ruddle Is Working On & Interpreting Radiographs
This show opens with Ruddle reflecting on Halloween, the arch enemy of dentistry. After, Ruddle gives us an insider’s glimpse into some of the exciting endodontic projects he is working on. Next, Ruddle focuses on imaging and diagnostics; expect to raise your game when it comes to interpreting radiographs. Stay tuned for the close of the show where the bloopers will give you a little chuckle.
Related Materials & Show Notes
Dentists are trained to thoroughly review medical and dental histories and perform comprehensive extraoral and intraoral examinations. Yet, in spite of these efforts to optimally serve patients, the dominant clinical reality is...
Clifford J. Ruddle, DDS, discusses innovations in endodontics...
This transcript is made available by The Ruddle Show in an effort to share opinions and information, and as an added service. Since all show text has been transcribed by a third party, grammatical errors and/or misspellings may occur. As such, we encourage you to listen/watch the show whenever possible and use the transcript for your own general, personal information. Any reproduction of show content (visual, audio or written) is strictly forbidden.
Welcome to The Ruddle Show. I’m Lisette, and this is my dad, Cliff Ruddle. So, this weekend is Halloween. Do you have any Halloween plans?
Well, before I celebrate Halloween --
-- I just want to let the world know that David Landwehr’s very, very pleased, because he’s a Wisconsin man, but he’s a Dodger man. So, I tip my hat to the Dodgers!
Yes, it was very exciting last night. It’s been a long time. So, okay. So, do you have Halloween plans? [laughs]
Well, it’s been thrown off just a little bit this year. We usually, as you know – maybe I should tell the whole world, but we go to this place that’s an acreage, and it has a maze and a corn patch, and it has thousands – thousands and thousands of pumpkins. There’s a tractor ride. So, we do all that, but we didn’t do it this year. So, plans are a little bit off, but we’re gonna – we’re gonna carve, though, still. We got some pumpkins, but we didn’t do the pumpkin patch.
You usually have a picture of you and all the grandkids on the Christmas card that you send out every year, at the pumpkin patch. It’s kind of like where you get the photo. So, this year --
Well, I just told them, they’re not gonna get it. [laughs]
-- it’s [laughs] – it’s still gonna be a Christmas card, but there’s probably gonna be a different featured photo [laughs].
So, a couple years ago, though, you did dress up in a costume with Mom, for Halloween. And I think we have a picture. Let’s look at that. It’s – I don’t know if you can guess what movie this is from, but they are Neo and Trinity from “The Matrix”. So do you remember anything about that, where it was taken?
It was maybe 15, 20 years ago, and it was somewhere aouth, and I don’t actually remember.
Oh, I got it. San Diego, okay. Yeah.
So, it was a – you guys were in a contest, too. It was some Dentsply event?
Okay. And I think you actually placed in the contest.
I think second or third. There was a little girl that won, was – it was fixed. [laughs]
A child. [laughs]
Oh, no. Okay [laughs].
I guess you know that in some circles of subterfuge, Neo, in different arrangements of the letters, it could actually be “One”.
Okay. Well, I have a couple little Halloween jokes for the two of you.
Oh, okay [laughs]. For you [laughs].
Whoa. We have a trap door here. She’s going down six --
She’s going down many steps into the cellar, where we have a secret laboratory. [laughs]
-- and another set.
Okay. So, what did the ghost say when he found out he had cavities? [laughs]
Oh, come on! [laughs] I don’t know [laughs].
And let me just do one more. What do you call a bear without teeth? Actually, you might know this one, Mom.
[laughs] And then, one more. Why did the vampire need mouthwash?
Oh, I don’t know.
He had bat breath [laughs].
[laughs] Oh, geez. I think the show’s gonna get canceled.
Okay. So [laughs], those are some Halloween dental jokes for you. So, we have a great show planned, and let’s get started on it. [Music playing]
SEGMENT 1: Ruddle Future Projects
So, we had hinted on some previous shows that you are working on some projects. And today, we wanted to give you a glimpse into what these projects actually are. And besides just naming the projects, we also wanted to give you an idea of the time and the work that goes into bringing these projects to fruition. Because it’s easy to say that you’re working on a file, but what does that really mean? Does it mean you’re thinking really hard about the file, or on the phone a lot?
So, we want to figure out what you’re actually doing, today. And I heard you mention several times in the last few months that you’re working on a trifecta. So, I want you to explain what you mean by that. But first, I wanted to draw attention to this really cool graphic behind us of you, looking out to the future.
And Isaac, my son, made this graphic, and he also made the Halloween one that you saw earlier. And he puts in some time to making these graphics for our show, and we really like them, and we think they’re fun. So, we just wanted to draw attention. Do you wanna say something?
Well, what he depicted is, I missed my opportunity to go out into space and to make the next whatever, because the shuttle’s ripping by me at warp speed, and it’s on its way to the Space Station. And I guess I’m waiting for the next trip.
Yeah. I guess you’re looking – you’re watching it go, like you missed your shuttle [laughs].
But I got inspired by it, and it probably did prompt me to be thinking about the trifecta, with my team. The trifecta is none other than the things that we’ve been doing for maybe, say, 50, 60 years. The trifecta is: we all agree that we make some kind of a shape. That’s the preparation. We don’t agree on the dimensions, the taper, the D0 diameter, the triple diameter. We also focus really a lot on disinfection. That’s our purpose to exist, is to take out diseased tissue. So, that would be the second leg. We prepare, we clean and disinfect, in three dimensions, and then, filling root canal systems. So everybody in the world is doing some version of that.
It’s kind of odd to me that some people challenge the trifecta. And then you look at them post – an x-ray. Well, they have an access cavity, they’ve made a preparation, they’ve done some kind of irrigation, and they show wide lengths on an x-ray. So, I guess they’re doing it, too. So, we don’t necessarily all agree on the components. But the trifecta for us is supposed to be harmony. Lots of companies make this. Let’s just say, shaping files. Other companies make disinfection, Sonendo, as an example. But Sonendo doesn’t offer any obturation solution. They don’t offer any access solution. They don’t offer any preparation solution.
So, they’re a one-horse pony, and it’s disinfection. Fine! Give ‘em a round of applause [clapping hands]. Other companies make great files. Somebody else might make something else, but we wanted to make three things that went together as a system. Each one is significant, and it is part of a greater whole.
Okay. And who’s – who all is working on this project?
Well, our longtime team that was focused last season was Pierre Machtou, Professor Machtou, and Dr. John West. They’re – we’ve been a team for – since ’95. So typically, without getting into detail, when we launch something, we’re already working on what’s next. So, the whole market’s excited about ProTaper Gold. We’ve been working on this trifecta for a couple years now. So, it’ll be a – probably another year.
Okay. So, you probably remember Dr. West and Professor Machtou from the ProTaper story that we showed last season. And at the end of that show, there was like a hint at something to come for the future. It looked like it said “ProTaper Ultimate”, but maybe that’s not for sure the name yet? But why don’t you tell us about what you’re working on, as far as ProTaper goes.
Well, when you do projects, they get names, sometimes Omaha. Sometimes it’s called Caravelle. Sometimes it’s called Calamus. You never know, years before the launch, what these names are, if they’re gonna be fluid. But right now, the working title in emails and with keeping 50 people on the same page, I mentioned 3 people, but there’s engineers, there’s marketing people, there’s regulatory people, there’s injection molding people, there’s – it’s a big team. And so, we all have to have consensus on what we’re talking about. So, there’s a buzzword called “Ultimate”.
So, what can you tell us about the new file, without revealing too much?
Yeah. I’ll probably get killed. The new file’s really exciting, because everybody makes files, and all the world needs is another system to go along with the previous hundred-plus systems out there! But we wanted to do something about not just making another file. That’s been done before. We’ve done it before. And I said that would be the most boring thing Ruddle would participate in, unless we could attack the disinfection and take that to the next level, and then have a breakthrough obturation method and have a package, where if you do these steps, you have everything you need, and it fits in the palm of your hand.
And everything’s inexpensive. We’re not doing $70,000 things, $100,000 things. We’re doing affordable things that the masses can use. Even many, many endodontists are [laughs] gonna use this for its simplicity.
So, you’re doing upgrades, not just making a new file?
We’re changing the geometries. ProTaper’s been working with a convex triangular cross-section for – from the beginning. So, the cross-section’s completely different. We have way more chip space. That means we can haul debris more efficiently. We have more efficiency, more safety. We’ve massively improved flexibility because of metallurgy. And everybody’s heard of M wire, gold wire, blue wire. Well, we have a breakthrough in metallurgy, and not the same metallurgy on every file.
Okay. And there’s also something that’s gonna be a super shaper? Can you say anything about that? Or --
Well, we wanted to simplify. Dentists aren’t looking for more files. Now, you’re gonna see, this system has quite a few files, because we’ll have a greater range to address virtually every anatomical situation with this range. In other words, you might break out a 5012, 3 times a year. But when you need it because of internal resorption or reversed apical architecture, you still need to get some kind of resistance form, to pack up into and to hold your irrigation before that. So, we have a big range, but we’ve really simplified what most dentists will do. We’ve reduced the number of files.
And you just said “shaper”. We have one – we used to have two shapers. Now, we’ll have one shaper.
Okay. And it’s kind of neat that you’re doing these upgrades to an existing file system that’s already very successful. It kinda reminds me of the iPhone. Even though it’s already very successful, there’s constant updates that are being done to keep it just as relevant as it possibly can be and just the latest and the greatest. So, that’s great. But you’re also working on some – an EndoActivator Two, right?
Yeah. Well, Bob Sharp, my partner in the EndoActivator One, or what we’ll call the market version, that has over 90,000 international users. It costs in the United States $550, and every disposable tip is less than $2 per patient. We have 19 peer-reviewed papers. Why would we do anything? Especially when you’re as old as I am. Well, because we know if we’re gonna get to regenerative endodontics, we have to have cleaner root canal systems, and not everybody’s gonna buy a laser or GentleWave.
So, we’re now going to be at a level that they are, and we’re gonna be less than $1,000. So, it has to do with tip movement. Right now, we’re linear motion. We’re going to change the motion. New tip designs, think of animals that live in the ocean [laughs].
Think of – think of a shark, and think of a shark’s fin, and think about displacing fluids and getting forward thrust. So, anyway, it’s really exciting. We’re gonna massively increase the frequency, almost double. So between the tips, the frequency, and different tip movement, it’s gonna be pretty exciting.
Okay. That sounds cool. What about in the obturation department?
Well, Kevin Wilkinson is an engineer, and people have heard me speak of Dr. Nathan Lee. He’s a practicing dentist, but he’s actually a manufacturer and a thought thinker. And those two guys and – with our team, giving some coaching from the clinical side, Nathan has the clinical side, there’s a possibility with the new carrier-based obturator – like, everybody loves single cone, okay? They take a gutta-percha point, stick it in a sea of BC sealer, and their work [clapping hands together] is done.
What if we could give them a single cone that was warm gutta-percha? And they’re thinking, “Oh, we’ve heard of this! CBO, THERMAFIL.” No. This is completely different. Auto-Lock, Scuppers, come on! We’re going to get hydraulics, variable viscosity, tapered – look [claps hands]! Okay. It’s all good. I can’t say anymore, or I’ll get killed!
What about a new sealer? I though you said – can you say – that’s secret?
Okay. And what about paper points? Can you say anything about that, or is that secret, too?
I’ll just say this about paper points. Everybody that uses a microscope has noticed a cellulose fiber in their oculars. So, you’re – let’s just say you’re all through shaping, and you’re drawing your canal, and you’re gonna get ready to put your sealer in, and you look through your oculars, and you go, “God, there’s a hair down there.” Well, it’s a cellulose fiber off of a paper point. In fact, Professor Machtou showed many, many times in – and even recently, foreign body reactions that we as endodontists and general dentists, doing endodontics, we don’t even know, because, I mean, you can’t see a fiber radiographically. If it gets pushed through the foramen, you wonder why something keeps festering. So, the new paper point won’t have cellulose fibers, and it’ll have a tamponade effect that’s about 400 percent more than a paper point.
Okay. Well, this sounds like – you’re giving us some ideas. I understand you can’t say everything, because it’s still a work in progress.
Well, you know, we’re copied on everything we do. I think I did a rant recently.
And what we’re going to probably have a moniker is, “to replace all knock-offs”.
Because everybody that’s trying to knock off the number-one file, we just thought, “Well, what if we had a moniker, ‘The File that Replaces All Knockoffs’?”
Oh, I’m just having fun.
[laughs] So, you’re working with John and Pierre, and then, a big group of 50-plus people from Dentsply, related to Dentsply, at least, somehow.
Yeah. All over the world.
So, what – what’s the structure of your working on this project? Like, what – how do you do it?
Well, there’s a big team, because there’s the – in a trifecta, you have a team for the preparation itself. And that would be engineers and the clinicians. Then, you have a separate team for 3D disinfection. These people read the literature, they – there’s a lot of scientific endeavor here. There’s university studies that are being done behind the scenes. They’ll probably never get published, but it helps navigate the future, so we know we’re going in the right tack. Then, there’s an obturation team. So, every other Tuesday, about 40 or 50 people get on a Zoom meeting, and we talk this stuff through. We have regulatory people there, marketing people, ethicists, engineers, clinical people, and people, I don’t even know what they’re doing, but they all do something.
So, then we have little, smaller break-out meetings, besides the every other Tuesdays. We use the in-between Tuesdays to have a shaping conference or a disinfection conference. And then the people that are putting this together, the manufacturing people, are all over the world. So you’re – they’re on the phones. So it’s fun, and with COVID, we used to go physically, and now, we have to call in all of our changes, and the files get mailed to us, and then, we do endless trials. I mean, you fill out paperwork that is like a small phonebook, and that’s just on one project. But through all that, you navigate a very tough road through regulatory, and you get to market.
And so, like how many iterations do you test, about, like when you’re working on this? Is it just one or two?
[laughs] Well, maybe we’re just slow. But on the files, we made it to about 41 iterations, before we froze. And we just froze the files last – two weeks ago. So that was after – since January of 2019, when we started this next endeavor. We were thinking a lot behind the scenes, since ProTaper Gold launched in 2014. But then, Corporate has to be ready. Then when COVID smites, that means all the dentists can’t work in the world, except for triage and emergencies. So all of a sudden, Corporate’s revenue goes down, because there’s no sales. So all companies are starting to climb back up as dentistry reopens.
Well, what about the future of The Ruddle Show? All that sounds very interesting, what you’re working on, clinically. But I’m wondering about The Ruddle Show. Like I’m wondering if I’m gonna have a job, next year. [laughs]
You know, before I go there, people need to know that we spend hours and hours and hours, and I’ve picked some people to replace me, okay? Because I told Corporate, I’m not gonna always be here. So, that doesn’t mean anything grim or – like dying or anything. It just means that, at some point, I won’t jump on a plane, or I won’t write an article, or I won’t do a show. No, I think we’ll do shows for a long time. I’ll get that.
So, I want people to know that we spend weekends, Sundays, Saturdays, weeknights. We’re really into this. I mean, this – we eat, breathe, and sleep this. The show is now replacing – it’s the most joyful thing I do, because I have a chance to talk to the market, you know? Every week. And you and I used to write articles, right?
And by the time we submitted it, that’d take us maybe three months to write an article and keep polishing. Like we had it roughed out in a month, three or four weeks. But then, we’d polish, polish, get cases, references, and then, we’d submit it. And when would it get published?
Like three or four months later.
Yeah. Well by then, what you’re talking about isn’t even relevant. So, the show allows me to get more relevant and say something to the market pretty much in time with when it actually happened. Like Andreasen died, we did a tribute, we shot the show. They’ll see it in two or three weeks, but it’s within the period of reasonableness for a man as great as him. So for you and me on The Ruddle Show, we have a chance to even be more on time. I have some ideas, where we can do stuff that pretty much happened right now, and we’ll be talking about it and releasing the show, more or less, just in time.
Okay. I was joking before when I asked if I was gonna still have a job. But [laughs] --
Well, when you retire, I’m retiring.
-- we – we do have three seasons planned next year. So, that’s going to keep us busy. And I know that we try to, you know, get better. I think we’re improving. But also, our set has really advanced a lot. We have these new mics. So our lighting and our sound has gotten better, and we’re planning to have some more guests. What kind of guests do you wanna have in the future?
Well, I want to have some guests – titans of industry. I want to have some financial, businesspeople on that have really been successful, massively [with emphasis] successful, financially. And some of these people are dentists. And my impressions are, most young dentists don’t start planning until they’re well into their careers. So, I want to have financial people on, titans of industry. Obviously, we’re going to have international clinicians as guests. We’re going to have the best of the best. We’re going to have the top five people in the world on CBCT, on regeneration, on technology. So, yeah. It keeps – it never sleeps.
We also want to have more residents, maybe, included on our show, like hear what they’re working on for their thesis, and, you know, just find out what the younger generation is doing as well. Because that’s the future!
You want me to reveal to the audience what you told me, about residents?
I don’t – what did I tell you? That they’re the future? [laughs]
Well, you definitely said that. And because we did so many years of Ruddle with the residents, and we came into contact with so many young residents, for decades, and now, this show is going to start featuring some ongoing cadence of residents. And her idea is, she wants to get residents on the show from different schools across the United States and North America, that’s Canada. There’s about 51 or 2. And we’re going to have them on, and they’re gonna spend five minutes each, I think you told me, and they’re gonna tell us what their research is. And then, we’re going to have you, the audience, probably weigh in and vote who wins!
And then she said I have to give a cash benefit to the winner! And she said, and the second and the third prize! So residents, stay tuned! You’re going to be on the show, and you’re gonna tell the world about your new benchtop something that sterilizes and checks for bio loads! Oh!
[laughs] We haven’t really worked out a formal structure. We’ve kind of just been brainstorming about it. But it would be kind of fun to have some kinda little contest thing in the future.
Yeah. There’s a lot of international dentists I want to get on, because I’m blessed. I’ve traveled, I think I said we went 5 million miles, 2 years ago, just lecture related. So, I’ve gotten to see these people. I want everybody, like say here in the States, to see like a Castellucci or to see an Elio Berutti or, you know, whoever they are. I want – I want to bring some of these people, they’re bigger than life, and put ‘em on the show, so everybody can benefit from their knowledge.
And with our more recent discovery, maybe some of you were familiar a while ago, but our – we recently discovered Zoom, and that actually, you know, makes it so we can interview people internationally, just very quickly, without them having to come here. So, we’re excited about that.
And we also – we have an opportunity to have some study clubs and some – this sounds difficult to understand, but I know Gary Glassman’s already doing this in Canada, but we’ll probably have some kind of a hands-on, virtual component to the program in the days or months ahead.
Yeah. I heard you say something about maybe have some study clubs under the umbrella of The Ruddle Show, where they report in every now and then to let everybody know what they’re doing and what they’re working on. So, yeah. That’s all – sounds exciting.
Yeah. It’ll be fun.
So, exciting times ahead. So, keep watching The Ruddle Show, because we’re gonna – it’s gonna – going to keep trying to inspire [laughs] you all the time.
Well, I think we can tell ‘em, we have 5 platforms, and on those 5 platforms, we have tens of thousands of people that watch every single week. So, we’re happy to do it free, and as long as you keep coming, we’ll keep doing it. But at some point, if you don’t tell your friends about this, we’ll probably move on to something else. Maybe we’ll catch the shuttle.
[laughs] Okay. Thank you. [Music playing]
SEGMENT 2: Imaging & Diagnostics
Today, we’re going to talk a little bit about imaging and interpretation. And of course, that equals diagnostics. So, we’ve talked a little bit about this area and we’ve skirted around it, a little bit. But we’ll talk about it a little bit more. I’ll show about six, seven, eight slides and maybe just three cases, but the three cases will be completely oriented to how do you see it, how are you looking at it, and what are you thinking? So, we all have x-rays in our office, and pretty much – a lot of us have digital x-rays now. We can get images on the screen. But this is our lifeblood in endodontics, just to visualize and be able to understand and appreciate what we’re trying to understand and do.
So when you have a nice patient in the chair, and you have a reasonably good assistant – well, actually, this would be Phyllis. She’s actually not even an assistant. But sometimes she helps me on shoots. She’s a computer programmer. Okay. So, diagnostics. Here we go. This case, if you look at it carefully, everybody’s going, “Oh, yeah. Look at the LEO!” Look at the LEO, the lesion of endodontic origin. How many of you saw this one? How many of you saw that?
See, I practiced for decades, before CBCT. And as you look at these x-rays, and you have really good aiming devices, and those assistants get trained up on cadavers, then on each other, then on patients of record, they can take really good x-rays. And I want to stress three angles, the mesial horizontal view, the straight-on view, and then, the distal view. And those three angles together give you a better glimpse of the three-dimensionality of the tooth itself. So, let’s take a look at this case, then. And it’s pretty calcified, isn’t it? So, when you’re planning that access cavity, up into the root structure, you don’t really see evidence of discernible canals.
And of course, if you get all the views, you get to see that this is a broad root, faciolingual, probably has two systems. So when we pack the case, you can see, out with the lateral canal, to the lateral root lesion, I saw these oftentimes. I would talk about ‘em, and people would say, “I don’t even see it!” If you look at enough films, and you start looking at contrasts and densities, you start to see early lesions. You can see, we have a little bifidity, right up in the apical third. They cross over. We’ve left some restorative effort here for the general dentist to do. But that’s going to serve as a good posterior anchor for the removable partial denture.
Not that remarkable, but what I saw was calcification, and I saw a LEO that a lot of times people will just think it’s a shadow on the bone. And of course, in retrospect, you even see ‘em easier, don’t you? That’s kind of a joke, but it reinforces what you saw in your preoperative film. Make the connection. I’ve shown this to you before, but it’s going to come back, because I’m talking about – let’s just get ‘em all in here. You have a tooth, you know, it gets a restorative. The pulp starts to pull down. You get away from the irritant. It starts to, you know, narrow and constrict and mineralize. It’s receded, and lesions form.
Now if you take a 2D picture of this, if you take a 2D x-ray, I don’t think any of us are gonna see that. And if you let another one come in, the lesion’s expanded, more time has intervened, and the lesion has grown. You might begin to see this, because Seltzer told us, years ago, notice this thick, heavy cortical plate, and when the lesions start to impinge on the cortical plate, everybody says, “There’s the incipient lesion!” There’s the early LEO, lesions of endodontic origin. Well, it turns out that by the time we really see them radiographically, overtly, there’s a lot of destruction.
And I’ve mentioned this several times over my life, but when you go in to go surgery, you – and you see a preoperative lesion on an x-ray, or a CBCT, when you go in surgically, the lesion is always massively bigger than it appeared on the preoperative film. That’s because there’s a lot of destruction of this loose marrowbone, before you see more overt signs radiographically. So probably CBCT would’ve shown you this. You might’ve seen it a lot earlier. So, it’s hard to know, what was the greatest invention in the last 25 years? Was it the microscope, or was it CBCT?
If I had to choose between the two of them, it would be very, very difficult. But I think I’d take the x-ray, with the – I’m sorry, I’d take the microscope. Because the microscope is going to allow me not only to see things, but I can continue to work, and I can work at a higher level, because everything’s bigger and more magnified and illuminated. Okay? But the CBCT would be – it’d be a tough call, if you had to make a choice. So you can see, there is need to have more than just 2D imaging. And of course, many of you now are starting to get into CBCT, because of the implant and then, just treatment plan for no surprises.
Many endodontists have ‘em. Still less than five percent of North American dentists have the CBCT. So, it’s important to have it! And if you’re doing a lot of endodontics – in other words, this isn’t a one-horse pony. You can use this for treatment planning, for implants, you can do all kinds of things with your imaging. You can look here, and you can – if you didn’t see these, you would look at this, and you would say, “Well, I might have a little thickened periodontal ligament, right here. Maybe!” You might say, “He’s using his imagination!”
But when you come over and look at this view, you go, “Well, wait a minute! There might be something going on in this zone.” But you look right here, and you see, well, there’s a facial portal of exit! That’s a POE, coming right at us, in the primary beam! Probably would not see it, radiographically. It would look more like that, even with more angles. And of course, when you get this view, it’s pretty exciting, because you can see the lamina dura. The cortical plate has been lost, and you can see, debris would be coming out, break-down products. And that would cause bone destruction, osteolytic activity, and there’s your LEO.
So, CBCT is here – is here to stay. There’s a guy in Bermuda named Fay, and he shared these images with me, but I thought it was a marvelous way to open your eyes and see what you can’t normally see, with just our two-dimensional radiography. Well, I’ll show one on Cliff Ruddle! They said I should go ahead and say it was me. So, this is Cliff Ruddle. So, this tooth was treated by a very, very fabulous clinician, 40-plus years ago! So, I had that tooth in my mouth for 40 years. And then, I developed some swelling on the facial, and I had Terry Pannkuk open it up, because we both thought it was fractured, but I wanted to have that last opinion, the opinion after the access! That’s another view, you know? You can get the view internally through those axial walls.
But if you look at this CBCT image, we have a lateral LEO, from crest to apex. That is an overt fracture. I lost the tooth, and now, I have an implant, okay? So, be careful with me, because I can bite very hard, with my new implant. Oh, I can tell you, it’ll hurt! I was glad to have the implant, you know. I like the – naturally, retained root would be the ultimate dental implant, but when endodontics can’t work or doesn’t work, it’s nice to have an option. Well, this was a case that Tom McLaney [sounds like 31:24] shared with me. And if you look just here at the preop, you’re going, “I don’t see much. I don’t – well, maybe I see a little thickened PDL, right in here! Maybe just a little thickening!”
But it takes all the mystery out when you have the axial slice. You can see, actually, this is inside the bone, towards the pulp, or we could say, outside the tooth, outside in! That’s external resorption, doesn’t even appear to be communicating with the mother canal. So, that’s going to be another whole treatment challenge. And over here, you get this view, you get the sagittal slice. And you can see, yes, indeed, the pulp is not involved. But in the process of laying a flap, getting access, apically repositioned flaps, osseous recontouring, there’s gonna be some kind of a restoration in here. And you have to ask yourself, “Is that gonna influence the pulp?”
So sometimes we’ll do endodontics first. Then, we don’t have to worry. The repair can go right in, or whatever we need to do, to have a good, solid foundation. Well, imaging. It’s nice to hold samples of – human specimens in your hand. We all worked on cadavers, many years ago. And then, I continued it, for many years, after I became a dentist! Used to go to San Diego, used to work on Terry Tanaka’s heads. He had heads, okay? And we got to dissect those and work.
So, you learn a lot. When you look at this mandible, you can see the classic middle foramen. And if you do a section right through, like a frontal section, you can see, here’s our big neurovascular bundle. So this is our big NV, neurovascular bundle! And notice how the bundle has a shunt that comes up, and there’s a mouth up here, and it opens out on the external plate. That’s the mental foramen. Now, you – everybody knows this! But when you go to apply these anatomical landmarks, and their ramifications, if you don’t see them radiographically, then you’re working dangerously, because you’re working blindly.
So we were always taught in grad school, when I was a Harvard resident, they always said, “Find the mental foramen. Don’t worry about the root! Find the mental foramen, so you know where not [with emphasis] to be!” So, these are important things to see. So, let’s apply this to a case. So, this lady comes in, many years ago, and, you know, she comes in for a little work. And she’s had two root canals, by two endodontists, okay? And that’s my preop, and it’s fistulated, and you can see the sinus tract being traced. But look down here. You can see what? You see the bundle, and you see its inferior border. There’s an anterior shunt! It goes – and it continues! But what do you see? Right here, this goes up, goes up like that, and masks that mental foramen!
So I say that the root has very close proximity to a major – major nerve. We gotta talk to our patients about this, we gotta talk about the potentials for paresthesia. I really don’t make a big deal about it. I’ve done a lot of operating in the mental foramen area. Find it, to avoid it! So now you can see pretty much the surgical pretreatment set-up and what we need to be cognizant of. So we make a flap, reflect the tissue. We’ll talk about all this, flap designs, tissue reflection, osteotomies, apicoectomy-type stuff, retrograde procedures, what’s the best root-in filling material, lateral repairs, exploratory surgeries. All of this is coming in the seasons ahead.
But to get you excited, we were doing photography before anybody [with emphasis] was, basically! And it wasn’t so easy to get these photos in the old days. But here, you can see, using a Gary Carr root-in ultrasonic concept, with a diamond-coated tip, we can prep right up into that gutta-percha. We can watch that gutta-percha stream out towards that apisected root cable surface, and we know we’re on the long axis of the tooth. We’re going perfectly up the canal when you see gutta-percha streaming. Then, we add little pluggers, and we can condense the gutta-percha off the walls, and have a level platform, perhaps about at that level, right in here.
And then, we can put our reverse fill in. We got the root-in material in, the retro prep is in. You can see the xenon [sounds like 36:02] air shot. And so you’re looking at a beautiful shot in a mirror, little, tiny micromirrors, one, two millimeters in diameter, or oval, different configurations. But we can assess [with emphasis] the final product before we put the flap back down, do compression, and suturing. There’s our retro prep. The Carr preparation that was born in about the late ‘80s, it allowed us to go up the long axis of the root instead of tangential in the old days. The handpiece came in like this, so slow-speed handpiece with a little burr, and we’d come in, but we could go tangential to the canal. But we could never go up the long axis.
So, that was the Gary Carr thing that changed microsurgery. And then, of course, you can look at healing. We always like things to go in the right direction, and you can see post-op, we have a lesion. And you can see here at about five years – we’re out here about five – five- to six-year post-op, post-healing. So you can see, the bone’s very dense, intact PDL, and there’s our old pal, the mental foramen. And we’ve gotten that root beveled away from it, so that we aren’t working and operating where we could cause a traumatic injury.
Another case. The importance of the third angle! So this is our straight-on view, this is our straight view. If you angle the cone – that’s straight. If you angle the cone horizontally, and you get the distal view, you can see it throws our MB root anterior. It frees up this root, so we can really read it. So you’re taking working films as an example. Have the assistants move the cone distal, to throw the root anterior. And then finally, if you wanna free up that distal, why don’t we come from the mesial and get the mesial view. So if you get the mesial view, you can isolate the roots, and you’re going to be a better clinician, because you’ll be a better diagnostician! How about that?
So let’s use the three-view concept. You might not have CBCT. So, I want to introduce my old pal, M.J. Scianamblo, Michael Scianamblo, very nice guy, long-time friend, pretty much for 40 years. We were in grad school together. This was a case that humbled him. He told me it was quite humbling. This is his preoperative film. He got the three views, but he didn’t maybe get enough. Okay. What is enough? You can come up to 30 degrees mesial, up to 30 degrees from the distal. So you really throw things apart and really start to see. You won’t see the cull area, you know, these triangles. You won’t see the crest of bone. It’ll be all superimposed. But you’re going to get important diagnostic information, endodontically!
So, this is Mike’s preop film. And the root looks blunted. I think we would all say, “What happened?” Normally, roots look like this, right? You know? Some kind of a turn, or whatever. But this root looks blunted. The history was, the patient had a toothache, went to an oral maxillofacial surgeon and got surgery. So, it looks like, to me, it’s an apicoectomy. Mike treated the case, and I think, in that era, he had a very nice shape. I think, at three months, it was re-fistulated, the lesion was back, and Mike’s scratching his head! What should he do? Well, guess what? He takes a wild angle and finally when he comes really far from the distal, he throws those roots apart. We got a little – see, no separation in here. Now, we got a little separation. And now, we have more separation.
And in that angle, what do you see? Everybody here can see, I’ll trace it, almost perfectly. There it is. That’s the apicoectomy, and that is the apical one third of the root, left behind. And of course, there’s probably pulp in here! There’s probably a little pulp that’s leaking out, keeping the perpetuation of that lesion of endodontic origin. So now Mike knows he’s gotta do something different. So, now, he goes in and does the surgery, takes out the root tip. I have a photo of it. It’s five and a half millimeters. It was a pretty bit apical third. Remember a long time ago, on the different shows, we said, “Each third is about three, four, or five millimeters.” So, that was the whole apical third.
So anybody who is crazy enough to do surgery, cut off the end of the root, and not think the pulp is gonna degenerate and leak out, is somebody who is so removed from endodontics, that you wonder why they’re even a dentist! This is a surgeon! And then, to whack the root off and not even bother to get it, I would call it a clown! Maybe this is a clown. You know, maybe we’ll have to have a show and reveal the names of the clowns. How about it? So this is another case coming back to imaging interpretation, and then, our diagnosis off that interpretation. You only know what you see, and you only see what you know.
So really have those assistants get trained up, so you can get wonderful views. How many cases get referred to somebody like me, per year, and they just say, you know, “We couldn’t see it well.” And you look at their films, cone cut, blurry, part of the anatomy you’re trying to see is chopped off, okay? So you see all kinds of stuff. But if you can just get good radiographic, diagnostic images, you’re going to see! And then, you’re gonna treatment plan more effectively, and you’ll better serve your patients. And then this makes it all fun, doesn’t it? Okay.
So, in the Journal of Endodontics, it was 1994, and it was the 11th – that’s November, 11th month, Francesco Mangani, a dear friend from Rome -- listen! This guy can do endodontics like trained endodontists. He is a superb [with emphasis] clinician. Regrettably, we lost him to restorative! He’s won – he’s gone all over the world, talking about restorative and aesthetics. His books are incredible! His – he’s got artistic ideas that come from his brain, and he can execute through his hands. He’s wonderful! So he published this case of a very particular central incisor. And probably most of you know that this is a dens in dente. Okay? You can Google and study and read all about it.
But the thing I want to say is, this is not a normal tooth. And with this groove off the lingual, bacteria can get up into that groove and get into the pulp and infect it. Looks like we might even have some internal resorption. Looks like we have multiple canals. Got a big LEO, okay? So, lots going on here. If you look at the mesial-distal dimensions of the two centrals, you’ll see that there’s a disparity. One is a little bigger, maybe quite a bit bigger, to your eye. Gingiva looks fine. So here is a couple instruments in, and everything’s going fine. There they are. Beautiful camera work.
Oh, there’s another two! So these two get packed, and then, we’re going, “Wait a minute! Looks like we got something here, and we got somethin’ here.” I don’t even know what you call ‘em. This is the midline. So, this would be what, a mesial-lingual and a mesial-facial? Who knows? There’s no nomenclature for that. We just made it up. So, there’s the files that made that shape. You can see, the lesion’s already getting better on this visit, and it’s only been a few weeks. And there’s the post-op.
That’s a four-canal central incisor. You don’t expect that! We kind of come from central incisors, maxillary often have one canal. Sometimes you might see two. We know that mandibular anteriors, think about two, most of the time. There’s some one-bangers, but a lot of ‘em have two, facial and lingual. So here’s a four-canal. You won’t see it very often. There’s published papers in the JOE from time to time, where somebody reports, you know, a case report from somewhere in the world. But I was proud that Mangani and I got to publish that in November, way back in ’94, and you can see, I didn’t get a lot more recalls. I go to Rome occasionally, but you can see, the lesion, the ossification, the bone’s filling in beautifully. And so, I have photos of the restoration from the lingual, but it’s a superb gold inlay. And I just don’t see this work in the States. I just don’t see it.
Okay. My final case. So this is referred to me, little girl, went over the handlebars of a bicycle, banged her face. There was more than one tooth involved. In trauma, we always know there’s the one we look at, the tooth we look at, but oftentimes, the way the blow and the energy comes in, it dissipates out over adjacent teeth and even can drop down to mandibular teeth. We did a little thing with Andreasen tribute, last week, so this could’ve been in that little case selection I showed. But it is a case that originated from trauma. And the endodontist that did this is a very, very fine clinician.
But I think when you start looking at that apical third, on a young patient, this isn’t the shape he made. I mean, look at the diameters of these canals. They’re huge! They’re huge! This is a young girl. So, when she came in, this is what I saw. Kristi had been in the hospital, over the weekend. She had gotten an intravenous drip of antibiotics. And I’m seeing her on Monday morning, at 8:00, and she’s looking way better, although I think you can see the fullness, sub-orbitally. I think you can see the nasolabial fold, a little bit full, in there. And you can see, there’s a little asymmetry in this area here. But she’s better. She’s doing the right thing. She’s not real happy and she’s a little girl.
And after I connected with her and her mother, I realized I didn’t think I had a good chance to take this out and get a non-surgical result. This apex is probably bigger than any file made in dentistry. And the biggest files they make, what are they, 1.60s? 1.60? I think we’d have to have three or four of them together, to even begin to touch the walls! And I’m probably gonna push a lot of stuff out. And then, I got this canine in here! It’s the permanent canine. This is the deciduous canine. So let’s look at how Ruddle handled this one.
So, I make my flap, full thickness, intrasulcular. Up goes the flap, and pretty much immediately I’m looking at the canine. And you could see the facial part of that crown, sitting in here, and you know, you’re wondering, “Well, am I gonna disturb its developmental growth and its eruption cadence?” So you’re being really careful. So we know we gotta be just a little bit over here. But when the flap came up, that’s how it looked. So the idea is to get the root beveled down. You can see, we’ve got our retro prep in there. Probably this is – I would wanna be kind, but if Ruddle did the case – I didn’t. But if I did, I would probably say it’s not sealed. I don’t know that I can seal something that’s this parallel – this parallel, in that region.
Remember, we need taper! We need to pack into resistance form. So, when you have something so parallel, how do you get the hydraulics? How do you close space? Remember, A equals pi R squared! You’re trying to seal enormous areas! So the surgery was the way to seal it. And in that era, we beveled the root down in apicoectomy, apisection, and we placed a retrograde amalgam, in that era. We don’t now, but we did then. Doesn’t really matter, does it? And there’s how it looked, post-surgery.
Now, this is a girl that I didn’t even have to use Valium on. I got into relationship with her, and because she’d been to the other endodontist, because he had treated her so nice, she kinda liked dentists, and I thought, if I could get in and out of there in about one hour and have her profoundly anesthetized, she’s gonna do beautifully! And then, I have some assistants that were really fun with her, and they were telling little cutesy stories, and I mean, we had to sometimes tell her not to laugh so hard.
And then finally, you can see out in about ten years, I kinda watched her grow up, but about I would say, probably about a year after I did this, this tooth blew up. We had pulp tested all the teeth, mandibular and anterior, so we could tell the mother and treatment plan for no surprises. You know, they hate it when you make this thing about surgery, and parents hear “surgery”, and there’s great concern! And then, you do the surgery, and there’s another problem, they’re going, “Well, what happened? Is the surgery gonna fail? Or did they miss something?” So you gotta tell ‘em, right up front.
This tooth always tested a little bit hyperemic. This tooth always, when you put ice on it, it was always an exaggerated response. It was a little bit lingering. So it was prolonged, and I always thought, “This one’s gonna go.” Well, about six or a year later, I did it, and you can see, we got multiple apical portals of exit in here. It’s really fun to do hydraulics on a young patient, because you know it’s going to have to last for a long time. You can notice the difference here. We have good taper, so we’re packing into resistance form. So that’s why we can get the hydraulics to drive filling materials 3D, 3D.
And then, of course, all’s well that ends well. So, this was about six months later. She came back, the tissue response is excellent, the canine was dropping down, and you can see Kristi’s happy. And that’s the end of this little presentation. So in closing, what I’d like to say is, be a better diagnostician. You got it in you. You have an x-ray. Train up, get those ladies trained up. And together, make good decisions, interpret those films, and treatment plan for no surprises.
So, that’s our show for today. We’re gonna leave you with some bloopers and find some use to all that footage [laughs].
Maybe you’ll even see some bloopers from today!
See you next time, and don’t be a stranger.
[Video of bloopers] [Music playing]
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The content presented in this show is made available in an effort to share opinions and information. Note the opinions expressed by Dr. Cliff Ruddle are his opinions only and are based on over 40 years of endodontic practice and product development, direct personal observation, fellow colleague reports, and/or information gathered from online sources. Any opinions expressed by the hosts and/or guests reflect their opinions and are not necessarily the views of The Ruddle Show. While we have taken every precaution to ensure that the content of this material is both current and accurate, errors can occur. The Ruddle Show, Advanced Endodontics, and its hosts/guests assume no responsibility or liability for any errors or omissions. Any reproduction of show content is strictly forbidden.