There has been massive growth in endodontic treatment in recent years. This increase in clinical activity can be attributable to better-trained dentists and specialists alike. Necessary for this unfolding story is the general public's growing selection for root canal treatment...
Exploration & Disassembly Exploratory Treatment & the Coronal Disassembly Decision Tree
What did Ruddle do to prepare for his day? In the Opener, Ruddle reveals his last actions before shooting this episode. Next, Ruddle and Lisette discuss another “Specific Scenario”… What is exploratory treatment and when is it indicated? Then, in a nonsurgical retreatment segment, Ruddle lectures on coronal disassembly and presents the Decision Tree. Finally, stay tuned for some tough love at the close of the show with the return of Demotivators!
Show Content & Timecodes00:09 - INTRO: Last Actions Before the Shoot - PREPARATION 04:40 - SEGMENT 1: Specific Scenario – Exploratory Treatment 21:06 - SEGMENT 2: RETX – Coronal Disassembly 48:53 - CLOSE: Demotivators
Extra content referenced within show:
Downloadable PDFs & Related Materials
Ruddle on Shape•Clean•Pack Supply List and Supplier Contact Information Listing
Ruddle on Retreatment Supply List and Supplier Contact Information Listing
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.
INTRO: Last Actions Before the Shoot – PREPARATION
Welcome to The Ruddle Show. I’m Lisette and there’s Cliff, my dad. How are you doing?
Terrific, thank you.
Well we’ll find out really how he’s doing. Okay, we wanted to start the show off today with something fun and lighthearted. But it’s going to turn out to have a little deeper meaning than maybe you would expect. So I’m going to ask you some questions about the last things you did before our shoot today, and you’re going to answer them. Okay?
The first forum.
So are you ready?
Here we go. What is last thing you ate?
Oh, I had oatmeal, a banana, and a cup of blueberries.
And what is the last thing you drank?
I had hot water with a slice of lemon.
Okay. What is the last thing on TV you were watching, or the last program on the radio you were listening to?
I don’t watch any of that on show mornings.
Okay. What is the last song you heard, or sang?
Oh, I heard a song, “Imagine” and also “Hey Jude.” Today; that was great.
Who is the last person you spoke with on the phone or texted, and what was it regarding?
My multimedia guy, and I’ll just give a little plug. We were talking about the product we’re launching, the Trifecta, and we were talking about the ultimate project for making educational assets.
What is the last conversation you were having with Mom before you left the house today?
Well, I got so inspired after hearing “Imagine,” I ran downstairs with my phone and I played it to her and we both hummed along.
Okay. What is the last email you were reading?
Oh, I got an email from this guy in Chennai, Dr. V.K. Karthikeyan.
Karthikeyan, I think.
Yeah, say it again.
Karthikeyan; yeah, that’s it.
Okay, and when did you last exercise and what did you do?
Well, I like to do my morning walk.
Okay. And what is the last thing you were reading, besides an email, before the shoot this morning? It could even be like -
Oh, it’s show notes.
Show notes? Okay. And is there anything unexpected you did or was everything pretty much like routine?
Everything moved perfectly.
Okay. So the reason I’m asking you all these questions is because what you do in the morning, your morning actions, are basically a metaphor for setting the table for the rest of your day. So you want to do it with care. You want to make sure you have everything you need. So for example, if you don’t have your knife or your spoon or your fork, it’s going to be a challenging meal. And I could actually beat this metaphor to death, but I’m not going to. But I think we all get the picture. It’s important what you do in the morning, because it’s going to affect the rest of your day.
Well, I’m very happy first, to know I’m awake. That means the day holds great promise for me. But yeah, you’re right. I always like to start the day off kind of like what I said, because I like to plan a lot of really positive things in my head and I have said for years, how you communicate is how it is. So we talk about the inner game and the outer game, we talk about audible communication versus internal communication. But those conversations that are going on between my ears, they are setting the plate for the day and they’re going to bounce around in there and reverberate. I think you mentioned that it can echo throughout your head during the entire rest of the day. So if I plant really good stuff there, that’s what I’m thinking about and that gives me a lot of juice.
Yeah. I think that’s actually true. I try always to start my day off as well as I possibly can. It seems like there’s always something, though, that kind of throws me a little bit for a loop.
And takes recovering. Okay, well we have a great show for you today and we’re excited about it, so let’s get started.
SEGMENT 1: Specific Scenario – Exploratory Treatment
Okay, today we wanted to talk about another specific scenario, exploratory treatment, and when it is indicated. Now this was an option that was presented to me by my endodontist after I had had a root canal, but was still experiencing symptoms. However, by this time, I had lost confidence in his abilities and so I chose to go to another endodontist, who when he went back into my tooth immediately found a missed canal. So does my experience represent a typical scenario where exploratory treatment would be indicated?
Sure, absolutely. I mean what’s classic about your situation is you had an initial effort done by an endodontist that had a radiographic machine, had CVCT, had a microscope, had the best that technology could offer. So when there’s as much pain as you experienced following treatment, and if there’s a loss of confidence, then of course you would go to another professional. Because it wouldn’t be that they had some technology that they other one didn’t have; it would be a way of thinking. And so critical thinking is really important. And if a CVCT shows that there’s a second canal, we’d like to think we can find that. So I think knowing where the anatomy is and having that familiarity; maybe there’s recurrent decay and maybe it’s a perf.
But I want to make a clear distinction to you and the audience. A perf doesn’t really hurt post-treatment. It’s a problem where you could lose your tooth. Leaving caries behind isn’t going to cause severe pain. So dentists that do endodontics know that that usually comes from vital, highly inflamed tissue. So when you have that level of pain, I think diagnostically, the second clinician is coming in there thinking there’s probably a missed canal to cause that level of pain.
Okay, well how do you present this option of exploratory treatment to the patient? Because from my experience, having undergone several hours of treatment and then still having symptoms – and incidentally, even worse symptoms than I had prior to treatment – I have to say it was pretty discouraging.
Well I think I’ll take the personal part of it out now, and just when a patient came to me – and I saw a lot of people – I said for years and years that about 900 out of every 1000 patients that were new patients to me had already had endodontics. So that means to me I had to start really getting good at trying to figure out what was going on. Because you don’t want to come galloping in on your white horse and save the world when, in fact, you don’t to anything and you just contribute to the patient’s anxiety, chaos, time, expense, and all that. So I think I’d like to assess on a scale of 0-10, how would you rate it. So I want to ask any patient; 0 you don’t even know you have teeth in your mouth, and 10 you can’t even imagine it and you probably think you’re going to die or want to die. So you want them to quantify it; where is it on a scale of 0-10? And remember, pain is subjective. We don’t compare patient to patient; we just compare that patient to their patient.
The next thing is, if I know now the level of the pain, I can say well, is it appropriate to wait and watch? Maybe not in your case, because you had too much pain to wait and watch. But if it’s more of a 1 or a 2 and you get the patient’s confidence, they might say well I don’t mind waiting a little bit if something more will manifest itself, that now becomes diagnostic. So wait and watch. And then of course the next thing I would say is offer to go back in and see if we can discover something that was missed; and if identified, we could treat it and push the case towards success, we could flap it and do surgery, or we could extract the tooth. So I gave every patient those four choices, and look right at them candidly and just say, what would be most appropriate for you?
Now, I obviously wouldn’t let a patient tell me, well let’s go in and do surgery if I knew there was a missed canal. So I would want to slant the conversation so they can make a good choice that’s probably in their best interest.
Well, I just want to add that I did feel some urgency to do something besides just wait and see. Because I had my crown lined up that I was getting the crown put on, so I didn’t want to do all of that if there was still a problem.
But you were not on a 1 or a 2; you were in a lot of pain. So you can’t give a patient an option of wait and watch when they didn’t sleep last night.
Okay. So the first endodontist who worked on my tooth; he did express during treatment the suspicion of another canal that he could not find. So as such, I really had no reason to believe that he would be successful on a second attempt. The second endodontist I went to, Dr. Terry Pannkuk, who we’ve had on our show, went into my tooth and immediately found the missed canal. And he could also see where the other endodontist had been searching – which was not by that canal – but he could see where he’d been searching, because there was a minute perforation.
Is that like being a little bit pregnant?
So I think that if you’re going to be doing exploratory treatment, you should obviously exercise some caution, but have some experience and maybe know what you’re looking for and how you’re going to look for it.
Sure. If we’re going into these teeth and we’re like the second or third – because I saw a lot of cases that were previously treated by endodontists in California or wherever and so people start flying into Santa Barbara to have re-treatment. Well, you have to really communicate well with the patient, so you can’t try to be a hero; elevate a hero to make a villain. So really all you do is have a great familiarity with the anatomy; you have to have a good idea of how to manage perforations and repair them; and you should have some idea about caries control in fractures. We need to – fractures don’t cause pain like that, though. So for you, it sounded like you had a pulp, a residual pulp, highly inflamed, and it just needed to be removed. But those are pretty much what, if you’re going to go back in, you should candidly talk to patients about what you’re thinking about. I mean just treat a patient like family and explain to them you don’t know exactly, but this is what you’re going to be looking for, because this is what your experience tells you you might find.
All right. So say the patient agrees; let’s do exploratory treatment and you begin disassembly. To what extent do you disassemble? Like I imagine you need to see maybe the pulpal floor, so you need to get into the pulp chamber, obviously. But should you also be removing the gutta percha out of the filled canal?
She has an honorary DDS, but anyway. Absolutely. Her point is, when you make an access back into a previously treated tooth, to the extent you can, you want to see axial walls. You want to see those axial walls all the way from just sub-orifice – I’m sorry – below the casting, where it is occlusally; and then there’s usually walls that you can see. And you’re looking for cracks. Are they fading out as they get towards the pulpal floor? You definitely want to get to the pulpal floor, because an overt crack will go maybe across the floor; so down an axial wall, across the floor, and maybe up another axial wall. And so you want to really open up that chamber for great visibility.
To your point, sometimes if you don’t find another canal, a missed canal, or maybe even an advertly positioned orifice, you might start thinking well, I don’t see a fracture, I don’t see a missed canal. But the patient is genuinely having symptomology for this tooth. I would then take out some gutta percha. And sometimes when you’re taking out gutta percha, you’re plunging with a hot instrument, you can smell putrescence through your mask; well, that’s starting to tell me that this thing is leaking and it’s probably got a number of micro-organisms in here. So permission to take out gutta percha, not only to see if it’s putrescent, but sometimes, as you know, when you take out some gutta percha coronally, you can now with your microscope you can look down into at least the coronal 1/3 of that root, and sometimes you’ll see a fracture sub-orifice level. Well then you want to look and see if there’s external pockets, maybe you can pick it up with probing. So fractures and pockets and the shape of the lesion on CVCT and radiographs are all very diagnostic.
Yeah, I want to point out that I did have pain and throbbing pretty much continually after my initial appointment. When Dr. Pannkuk found the other canal and cleaned it out, I had absolutely zero pain that night. I even could chew kind of in that general area and it was fine. So I mean, I guess it was making a big difference.
Well, we have an old expression as you’ve probably heard me say. What a big issue about a little tissue.
Okay. Well, let me get your opinion now on another situation. So say you have a patient that comes in for a recall and has no signs or symptoms, but you’re not really seeing the level of healing that you would expect and maybe even have suspicions that not all is well. What then?
Okay, that’s a great question, because it’s not unusual for new patients to be referred in. And maybe a dentist wants to put a new crown on the tooth; or maybe there’s no future plans for restorative, but there is a – I’ll call it a lucency, a radiolucency. Let’s make a clear distinction between radiolucencies and active infection. So a lesion of endodontic origin is pathological and it’s secondary to something inside the tooth leaking. Whereas if somebody did a root canal six months ago and a lesion – I’m making this up – the lesion is this big, and I see them four months later. Well this isn’t going to be healed, but it’s going to be a radiolucency. So that’s where we can get back to that let’s wait and watch if there’s no planned treatment. So if there’s planned treatment, then we have to have candid discussions; I might even want to try to get previous films from another era just to compare so I can get a little better idea of how this radiolucency is behaving. But radiolucencies should be getting smaller with time, and that would just be a signal it’s healing; versus if they’re status quo and time is going by, or they’re expanding. If they’re expanding, they’re status quo. At some point if it’s status quo, if there’s nothing planned, I don’t mind continuing to watch. But if there’s something planned, that’s the time to intervene.
Okay, let’s move on to another situation now. So this situation would generally involve maybe a younger patient who has maybe caries or a recent restoration and is having symptoms. So could it also be classified as exploratory treatment if you’re going into the pulp chamber to check the condition of the pulp to see if maybe this tooth is a candidate for a vital pulp therapy?
Oh, very good. You know, in my graduate residency program, my mentor, Dr. Al Krakow, and a pediatrician, pedodontist ,I should say, Harold Burke. And we got wonderful training in vital pulp therapy as residents. And so in other words, let’s be clear. We’ve got to know what the symptoms are. So if you say you tap on the tooth and it hurts, that’s disease that’s left the tooth; it’s out in the bone. No pulpotomies, no pulp gaps, no pulpectomy. You’re going to need a pulpectomy. But if you can tap the tooth and it doesn’t hurt, if you put cold on it and it’s had caries or a recent restorative and it hurts quite bad but it’s transient – goes right away as soon as they swallow – that’s an inflamed pulp. But the signal is maybe the inflammation is confined dominantly to the pulp chamber.
So there’s levels of vital pulp therapy. Sometimes we'll go in and clean out the caries, see red, and do a pulp cap if they didn’t have symptoms to heed, they didn’t have percussion, they didn’t have swelling or palpation. If they didn’t have that, we’ll do a pulp – if you go in to do a pulp cap and you can’t control the bleeding, we were trained to go a little deeper. So maybe do a pulpotomy and amputate at the orifice. And if you can reasonably control bleeding in like a minute or two, oftentimes leaving the patient’s own residual pulp is way better than any rubber pulp Cliff can put in the tooth. And then if we’re talking about younger patients, maybe we’re trying to get root formation and stimulate – first for example do a root sheath so they can develop dentin and grow and mature with the tooth.
So there’s different levels to do, but that would be all diagnostic. It would be exploratory and there would be a good reason then to have good talks with the parents. They’re usually – these kids are usually accompanied by a parent – and let them know; because you could go in and promise something and it might eventuate into something further.
Yeah. I think that from the patient’s perspective, exploratory treatment sounds a bit scary because of the unknown. And from my experience, there was really no way I was going to let that first endodontist back into my tooth; mostly because I had lost confidence. And I think the reason that I lost confidence was not only was there a clear lack of communication, but I was also beginning to question his abilities. But I want to return to the communication, because not only did I feel like I wasn’t being told everything, but I felt that the way he was talking to me that maybe he didn’t even have a lot of confidence that he could find the problem. Like the way you’re talking to me; if you would have spoken to me now as my endodontist, it seems that you seem very knowledgeable and you seem like I can look for this, this and this. I was not getting that from him. I was just kind of getting like head scratching. And so I think communication is very important; not only what you communicate but how you communicate.
You know, how you communicate is how it is. And a lot of the confidence that’s lost with patients is just because you’re not setting out a very clear, boom-boom-boom treatment plan or strategy. Patients are pretty forgiving if they know what’s next and what’s coming. No surprises. So we always say treatment plan for no surprises.
Okay, well that’s a lot of good information. Do you have any closing comments?
Well we have just touched the surface. In exploratory treatment, it’s done quite frequently, especially in the cases of failures. We usually – and to close off my part – we don’t do exploratory treatment on non-endodontically involved teeth. Well they might be endodontically involved, but there’s no previous treatment. Non-endodontically treated teeth. And so we normally with good diagnostics, films, clinical exams, stuff like that, we can identify the pulp or tooth. So this is usually when we don’t know what’s going on. It’s already had treatment and so we have to decide what’s next. Throw it in the waste basket, open it up, flap it, do surgery, extract it, do an implant or bridge.
Okay, I imagine also probably the person, the clinician doing the exploratory treatment is probably more often the referral than the original dentist. Unless you just really trust your endodontist to go back in. Like I would probably actually let Terry Pannkuk go back into my tooth. So I guess it really depends.
The thing about your master clinicians; there’s that old expression in life. There’s never time to do it right, but there’s always time to do it over. Terry Pannkuk; there’s not a chance in Hell Terry Pannkuk would probably ever go back into your tooth, because master clinicians are depending. We all make mistakes; we can all have a bad day. But at some point – he was in your tooth more than once – so at some point, there’s familiarity. And he knows that tooth, he documents, he’s got photographs; he doesn’t have to really go back, because he knows he was very thorough.
And to this day my tooth is doing great.
Very good job out there buddy! Keep doing that exploratory work.
All right, well thank you. That was a great segment.
SEGMENT 2: RETX – Coronal Disassembly
Well, as dentists doing endodontics, oftentimes people come in with endodontic problems and pathology and disease, and we’re called upon to do endodontic procedures. And of course this makes us immediately decide; are we going to access through the existing coronal restoration. If that restoration is esthetically pleasing, if it has marginal integrity, if there’s a good biological adaptation of the tissue to margins, if they’re sub-g, if occlusion is good; if all that’s good, we recognize that we often then access through the existing restoration. If there’s deficiencies in the restoration, it’s easy to section and buccal the lingual, and then we can use like a crown splitter and pop one of the segments off, use ultrasonics to remove the other segment. So I have done that many, many times in my life; it’s a quick way to disassemble.
However, what’s not talked about very often around the world is how do you disassemble restorations with the intention of preserving them; with the idea after endodontic treatment they could be either provisionalized for several weeks or months, or maybe definitively resubmitted. So today we’re going to look at that decision tree. But I’m going to focus primarily, though, on how to remove dentistry.
Now a lot of you might go, come on Cliff. We’re going to have a whole presentation today on taking crowns and bridges off? I’ll tell you; if you haven’t been doing it, you need to have this in your bag of tricks, because you can save a lot of emotional distress for the patient. A lot of times, these people come in and they’ve paid quite a bit of money for existing dentistry; and oftentimes when you tell them you’re going to have to drill a hole through an existing crown that they’ve just paid for, the stakes can be quite high. And then oftentimes for the clinician, we need to get the crown off or the bridge off so we can have better access, more interocclusal space. Sometimes we can evaluate the tooth more definitively for fractures and things like that. So there’s a lot of advantages, if you have in your bag of tricks, a few simple ideas to take dentistry off and disassemble it. Let’s take a look.
So the first thing we should talk about when you’re looking at a splint or a bridge or a single unit crown is what is the preparation type? A lot of times the preparation is prepared and we have to think about the length of the preparation. We need to think about the width, because we’re talking about surface area. And when you have big surface areas, you have more retention. There can be retentive grooves, axial grooves. Also, we have to think about what else on that crown could have made it more retentive to hold the dentistry on? So begin to think about the surface area that you might have to overcome.
Another thing is, is it a ¾ crown; is it a 7/8 crown; is it an onlay, is it an MOD, is it a full veneer? So those are all things that are going to influence. And of course the materials. There’s porcelain, there’s all porcelain, there’s porcelain fused to metal, there’s all gold, there’s new ceramics that are really, really hard and you go through a few burrs even trying to get through the restoration. So these are more and more factors that we have to think about on these abutments; how they’re prepared.
I want to also talk about the cementing agents. When I started my practice back in the ‘70s, we were using polycarboxylate cements, we were using zinc phosphate cements. And then as time went on, we got into adhesion dentistry, and now we have very formal restorations. I think you’ll remember Gordon Christensen’s presentation a few shows ago, where he talked about the hot button for restorative dentistry is different kinds of glass ionomers. So anyway, those are going to influence removal. And so finally, of course, you want to know what are the devices that could be employed to take things apart?
So with that said, we’ll get into this pretty quickly. This won’t be a definitive thing. I wrote a chapter in a book that we never published back in 2020, so it was interesting having my daughter, Lori, send that chapter back home to me from the office so I could review what I said 21 years ago. And you know what? It hasn’t really changed. It’s the same tools. In fact, if you Google stuff, it’s the same instruments. There’s a lot more of what I would call the “me-too” products that have come to market, but I’m going to show you the basic ones that really tend to work; and they work really well if you understand their limitations and their strengths.
Okay. So we took that bridge off, and now we have access to – we’ll go back just for a second. When you’re thinking about tunneling in here with your access cavity and you’re trying to hit that little pulp chamber, and then you notice there’s something peculiar, because if you look right in here, that’s a trifurcation. This is a 3-rooted, maxillary bicuspid anterior abutment. So there’s a lot of considerations. Would you loosen the bridge; would you have one of the anterior abutments come loose; would you worry about your access into those small, buccal roots? If you never had a 3-root bicuspid in your hand and really evaluated it – and I’ve had many in my hands over the decades – it’s humbling. They have really thin little roots and they have a lot of splay and divergence, so angles become really important to get into these canals. And so sometimes just getting the bridge off is very helpful.
So in this case, we did take the bridge off and that gave us access. And there we are going into the DB. Here we’re going over into the MB. Files are crossing each other, got all that can be done, predictable endodontics. And then what we can do is go ahead and provisionalize – so I put the core in and then I send it back to the referral. And the referral will make the call whether they want to use this and let it go a little further, or if it can be definitely re-submitted. In this case, it was definitively resubmitted, and everybody’s really, really happy. So we’ll talk about exactly what I just did on now some cases. So I just showed a case where we took a bridge off so we could make a complicated anatomical tooth a little bit easier.
What are Ruddle’s favorite removal devices? Well, you have grasping instruments, and those are like pliers, okay, with two arms that can come together. And there’s different kinds of pliers – I’ll show you my favorites. We have a family of percussive instruments and we’ll look at those. There’s more than one, but I have my favorite. And then we have isometric instruments; instruments that are a little bit invasive, because you to make a small 2mm diameter hole in the occlusal surface as an example. But once you’ve done that, which is way smaller than a traditional access cavity, you now have the absolute control to use instruments that are safe, they’re efficient, and they’re pretty effective.
So let’s take a look at grasping instruments. I like the K.Y. pliers. They’re really strong; they have two handles that you can obviously squeeze. And they’re stout, they’re light, they’re very, very fine steel. And then they have the option to have little packings – they call them packings – but those little packings can be taken off, and I’ll show you the advantage of taking them off. Because you can have this waffle grid and these arms; that waffle grid pattern can get a resin provisionalized crown, and you can gently rock it off to get access, clean up the abutment, and off you go. So K.Y. pliers aren’t to remove a definitively cemented restorative; they’re made to remove provisionals. But provisionals can sometimes be tricky to get off. So if you just have this plier, you’re going to be a lot better off.
Now let’s look at the example where we would actually use the packings. So when you have a gold crown – this is like a full veneer gold crown – when you have something like that and you begin to look at the pulp chamber. You look at the MB swinging out that way, DB is coming off like this, you have quite a bit of curvature here in the root. All of a sudden, you’re thinking, you know, it would just be easier to get it off; and maybe I even have a poor marginal adaptation that we can better evaluate internally. So when you take things off, you see more. You can evaluate better; you can look for recurrent decay and see fractures and their propagation and maybe their whole extent. You can look for missed canals. There’s a lot of things to do when you take crowns off that give you more permission to be more definitive because you’re not really blowing the dentistry.
So here we go. We’ll come back to the K.Y. pliers. They have emery powder. This emery powder is – you dip the pads into the emery powder – this will give you anti slippage. It’ll give you like a bulldog grip on a smooth, gold casting. Try to get below the height of contour. Little micro-movements back and forth, real gentle, back and forth, buccal to lingual. And again, you can take off a lot of provisional dentistry, provisionalized dentistry, with the K.Y. pliers and the packing, the yellow packers, with the emery powder. File that away, because you don’t want to be slipping off of teeth, maybe flying against the opposing arch, chipping a tooth, startle patients, make them lose their security. Maybe they have doubt now about what you’re doing. Have the right tools. What else?
With grasping instruments, I’ll come back and I’ll show an example of the Wynman crown placer and remover; that’s a grasping instrument. There’s different pliers you might think you have. Some people just like hemostats, but I really like the K.Y. So let’s look at percussive instruments.
Now percussive instruments are going to send a load, a physical load, into the restorative. So we really have to be careful with percussive instruments, especially in the instance when we are using removal devices against porcelain fused to metal, or maybe all ceramic. That even sounds like heresy to talk about trying to remove an all ceramic. We’ll take a look.
The Crown-A-Matic, the Peerless Crown-A-Matic is perhaps the industry’s favorite; it’s been around forever. It’s a wonderful device. It’s fairly inexpensive, and you have a power control. You notice these rings here. You have a ring, a ring and a ring. If you grab this neural part right in here, and you grab with your other hand this part, you can collapse and push this back into the handle. This is the low power force; you just push it a little bit. And if you push it in further you get to the medium power, and finally you can get to the high power. Remember, with percussive instruments, it’s not the big power that’s the most potent. The most potent is small, repeated episodes of putting a load on a crown. Small, repeated loads are better than one big, massive load. That’s where you can have maybe fractures of either the restorative or even the coronal tooth structure, and God forbid, maybe the radicular root itself.
So what else do you want to know? You need to know that when you push this lever, once you have this loaded and deployed at whatever power level you like, you have these insert tips. And you can choose the one that’s most appropriate to engage the restorative you’re trying to remove. This is really good on bridges where you have solder joints and you can come in from the lingual; and you can place this through the contact under the solder joint, and then if you push this, this tip travels 0.5. So it’s a very short, crisp load. It’s not a long 1mm; it’s a blip. You can’t even see it. And when you deploy this, I usually put the tip on, screw it on, push it in to say the second one as an example.
And I’ll say to the patient, I’m going to fire this off and I’m going to do it pretty close to your ear. Because that’ll pretty much simulate what we’re going to do when we get into your mouth, but I wanted to do it so you won’t be surprised; so you’re not afraid, okay? Treatment plan for no surprises. So what I’ll do is I’ll do it, and they’ll kind of jump; and then you go okay. Well that’s what it’s going to sound like in your mouth. Should we do it one more time for practice? And they’ll say no, they’re good. So then go into the mouth, and now they’re not that concerned because they’ve heard the noise first. You have done a little rehearsal.
All right. So when you come into a bridge – an example, and it’s a porcelain fused to metal bridge – you would never put this little angled foot in from the buccal, because you’ll definitely be putting loads right in here on the porcelain and you’ll for sure blow it off. So what I want you to do is come from the lingual, because it’s all gold, okay? So now you can put this tip through the lingual, under the contact, and here’s the trick. If you’re – try to anticipate the path of removal; which should have been the same as the path of insertion. If you try to pull off axes, that’s not good; so try to pull on axes, number one. Number two: pull up, pull up; and almost like you’re going to lift the patient up. Because that means you have a really snug contact between the tip and the gold. And then when you fire it, you don’t have sloppiness where you can get false vibration and more damage. So pull on the line of removal, on the anticipated line of removal, as you fire the power right. This can be done 2-3 times here, come back and do 2 or 3 times, back and forth. Don’t just keep pounding away on the anterior abutment; remember there’s two ends to the bridge and you’ve got to walk them up together.
So I’ve taken a lot of dentistry off, provisionalized and definitively cemented with this device. So again, pretty inexpensive. So now you’ve got your grasping pliers, you’ve got a little percussive instrument. There’s many percussive instruments, and I won’t talk about the whole family. I would just throw up right now; there is the KaVo CORONAflex. That is probably – we’re going to have another presentation on that because it’s so important. It’s pretty pricey, but if you want to get everything off – I said everything off – you could pretty much do it with KaVo’s CORONAflex. That’s a percussive instrument. This is something you should – every dentist should have one of these in their office.
All right. Well, come to the back, come just anterior to the posterior abutment, go in from the lingual, and bam-bam-bam. And then you can come in with the trident. This is a trident. I don’t really think it’s that important in terms of grasping and removing stuff, but dentists like it to fill it up with cement, both abutments, and placement. And then they like it when something is kind of loose and we’ve already broken the seals down here; then it’s a good way to reach in and just grab it. It’s got these big, rubber footings. They distort and deform to take on the contours in this case of the pontic; so you get a good grip and you don’t have things going down the hatch. If you’re international, going down the hatch would be much like going down the oral pharyngeal airway. Okay.
So what’s next? We have some things going; let’s go to the isometrics. Isometrics are probably absolutely my most favorite. When you start to talk about stuff that’s definitively cemented, you can bang and percuss, but all of us are a little shy of that. Because what’s missing so far in this presentation is communication with the patient. I mean if it was just about Cliff, saw the damn thing in half, throw it in the waste basket, and the dentist can always make a new bridge. That could be the attitude, right? Don’t fool around. But remember, there’s people here. So you’ve got to explain to them the risk and the benefits, and what could happen. And you’ve got to get their permission. And if they start to understand you really care and you try and you’ll know when to stop, but you can’t promise you wouldn’t blow off a little porcelain. But often, if you can get the bridge off and it can go off to the lab, and the laboratory technician can rebuild the porcelain, and everybody’s happy because you just saved them maybe $2000.
So let’s look at a good example of something like a porcelain fused to metal crown, previous treatment, it’s failing, there’s a big lesion of endodontic origin apically. You might say well Cliff; just plow right through that thing. But if you do this once or twice, you’re probably thinking just make the access like I always do. But if you do it 3, 4, 5, 10 – if you do 20, 30 in a row – you know what? You build proficiency; you get pretty good at it. And you start to recognize how to be more successful. So don’t let your inexperience threaten your possibility.
So on a PFM, if you’re using the Metalift System; it has a bunch of burrs in here, but we’re going to get a diamond and we’re going to make about a 2mm window through the porcelain, the glass. Okay, so you can use your own burrs, but the kit has all this in it. Then you can use like a little carbide round burr and tunnel on through, and make a pilot-hole to substructure. That could be an amalgam, it could be a composite, it could be a buildup of some sort; zinc phosphate, for example. And now we use a very precision drill from the kit, and that drill is about 1mm. I’m going to put this on pause.
Listen. You do not want any loads on the glass. The glass is the porcelain. If you have pressure building up on occlusal glass, you’re going to sheer it off. Let me say it another way. If porcelain flexes 1/10 of a millimeter, 1/10 of 1mm, it will crack. It will blow off; you could have a whole side sheer off. I’ve had that happen to me. I can still put the crown back on provisionally. I can send it back to the dentist, the patient has protection, they won’t fracture their tooth, they can chew better, they have occlusion. And you know what? The glass can be repaired and the dentist can decide with the patient; oh, let’s just make a new one. Those are calls that can be made in the field. But I want to come back to that communication.
So you take one of these mandrels, I’m using the smaller one; there’s a 1 and there’s a 1.5mm. But that 1mm one fits in that 2mm hole, and we’ve made a precision drill hole. And now you push down, apically directing forces, and take little, tiny, short, rotational, clockwise turns. Uh, the mandrel’s wobbling. Uh, uh, uh; and all of a sudden you’ll feel it start to engage. And then cinch it down. And once you start to feel resistance, it’s real gentle. Turn a little bit, wait, patience. Wait maybe 5 seconds, because there’s a big isometric load. You’re pushing down on the abutment, you’re pulling up on the casting, because you’ve formed threads on the gold, so you’re threaded. And so this is really a safe, progressive way to efficiently move things off. Even when you strip out, you can make another hole. You can make another hole. With experience, you’ll realize maybe don’t make a hole right in the middle of the tooth like Ruddle did. That’s what I did the first few years I started using it. Then I realized, if you move a little bit away from the central pit and get out towards those marginal ridges, mesial distal, guess what? The gold’s thicker, so you can form maybe 1 or 2 more threads, which means you have a better purchase on that casting. So even if you strip out, don’t give up.
And there’s another idea. Even if you’ve stripped out, you can go to a bigger mandrel. So you can just make a little more relief, and then use a little bigger mandrel, and that would give you another opportunity. So there’s lots of ideas with this kit; very, very sophisticated kit. The guy that made this kit was a general dentist. And he’s retired now, I think he sold his business; but this still readily available. But he had wonderful videos taking bridges and crowns off. Just little, short snippets that you can go online and see, and it was thrilling how much dentistry you can take off when you have a few ideas.
So back to the task at hand. You turn that big, neural knob, slowly, progressively. And as you push down against the tooth, you’re pulling up on the casting. And you can begin to see it lift; hence, Metalift. And this is a very fast way. This is probably 3-5 minutes; you’re going to be successful in 3-5 minutes. You’ll fail in 3-5 minutes, but you can make another hole or use a bigger hole.
Okay. So now you have access to do retreatment. So the Metalift can be used for bridges. I showed you a single unit, but here we have a 3-unit bridge. I think we have another – what I call out in the office so I don’t alert patients and make them nervous – but I’ll just say to the assistant when we’re charting; we have a PMA on the distal, or marginal adaptation. That’s a note I’ll want to flag the general dentist on to make sure they’re aware of it. The general dentist might not have even done this. This might be something that was priorly done by somebody else in another city or town.
So when you have two abutments, you’re going to drill your little hole through the metal, porcelain, then through the metal. So the smaller hole then is through the metal; there’s the porcelain and here’s the metal. When you get to substructure, you’re going to be able to take your mandrel in; you’ll put one here, one here, do a couple turns, couple turns. Turn, turn. Turn, turn. Back and forth, and chit, chit, chit; lift that bridge up together, both units; no off axes. Remember, the path of insertion should be the path of removal. So you don’t want mandrels coming in like this and pushing off axes; that’s very, very dangerous.
So you can actually do this – and here we are taking one off; it’s already broken free. You can see the margins here are exposed, you can start to see the cement; and it’s pretty thrilling to lift a bridge off like that in about 5 minutes. And you can do it very systematically if you have the Metalift and do a little practice.
We ran classes in Santa Barbara for decades, and we had many, many doctors come from around the world to take classes. And sometimes, I’d actually pay the dentists in my complex to do crowns and bridges, so when students came to take the course, they could actually take definitively cemented bridges off. And we used to use Geristore, glass ionomers; we used to set them with Durelon, all kinds of cements to see what kind of a removal load would be appropriate with the various luting agents. And it was quite amazing; I learned a lot. So get familiar with the Metalift and you’ll be pretty happy about it.
Now we have some adjunctive methods, and I’m going to talk about these two quickly in closing. But these will be another show. These are for the big boys; the big gals; the big dentists. The ones that do a lot of sophisticated retreatment. And in those instances, you’re going to want to know about the Higa. And of course I’ve already mentioned the Corona KaVo flex. But these are really great ideas.
Let’s talk about the first two; the Richwil we’ll start with. You’ve heard about this. It’s a polymer; it’s a resin. And it goes into about 146° Fahrenheit water – I want to say coffee, coffee temperature – and it will start to get pliable. You want to be able to take your finger, index finger and thumb, and push and make it indent. You don’t want it – you don’t want to bring your fingers together; that’s too soft; that’s over softening. So you want to get it pliable, but still you want to have good viscosity. So that happens in about 2 minutes at about 146°.
Now what you can do is use that, unlike the manufacturer promotes. They say have the patient bite down, and then you’re going to have to have the patient open suddenly. Well what happens? You can put a lot of load on the TMJ and that can hurt the TMJ. You could pull off restoration inadvertently from the opposite arch that you weren’t even planning to do. So I never like to have patients just bite down and suddenly try to open. So I’m using this with another idea, and that would be called the Rand Crown and Bridge. They have two arms. Two crescent shaped arms; they’re hooked here in a pivot point. And then what we can do is put this over the tooth, put it underneath the height of contour; we can screw this down right against that little platform, and that’ll hold it so it doesn’t open up during an engagement up here. So we can pull up on this engagement window.
So here’s how it would work. You have a patient come in, they have a PFM, porcelain fused to metal. I don’t know if this is a post; I don’t know if it’s a silver point; they’ve had surgery here, it’s failing, and they’re failing here. This tooth is severe to percussion; you can hardly touch it. In fact, this one is more sore than the one with the overt pathology. It looks like they might have even beveled it, so when they were here doing surgery, they might have done apicoectomy on the contralateral tooth. Anyway, I want that off. And we’re going to redo everything, but I’m just showing the removal on the left central.
So here I adapt; I adapt the polymer, the softened polymer into the undercuts around the crown. Then I can bury my Richwil/Rand together and I can cinch that little screw down and really pinch hard. And then notice this. What do you think that is? We’ve already talked about that. That’s the Crown-A-Matic. So now the Crown-A-Matic can come in here – remember we had three levels of power – and you can boom, tap, tap, tap. And if you get good at this and adapt that properly, get it under the undercuts, you can pull a lot of dentistry off by using not just one idea or another idea, but sometimes you think of them as synergistically working together to make you more than you were, and closer towards all you can be.
So good luck in coronal disassembly, and start doing it, okay?
Okay, so we’re going to close our show today with another demotivator segment. And if you’re new to the show, it’s these cards and they have a little inspirational saying on them. But then, it also has some sarcasm and humor that’s added. So I think they’re pretty funny and we both think they’re pretty funny. I’m going to read one and then my dad’s going to tell you what it means to him.
So this first one is called Never Give Up. And it says: “Never stop trying to exceed your limits; we need the entertainment.”
Well, I don’t know about our international guests, but you know we have this show here in the United States called American Ninja Warriors. And then there’s another show called Wipeout. But they do these big, athletic things and the whole crowd’s cheering them on. But there’s obstacles that can just knock them off and they can drop sometimes 30, 40 feet into the water below. So it’s hysterical, but we’re all going [clapping] you can do it!
Yeah, I actually think it’s a little disturbing. Sometimes they look like they get pretty injured.
I don’t want to try and tie it to dentistry and training.
It actually reminds me a little bit of when I practice karate or when I dance. Like usually I’m trying to go just a little bit beyond, and usually there’s people shaking their heads and their body. So anyway, that’s the first one. Then the next one we have is called Teamwork. And this one says: “A few harmless flakes working together can unleash an avalanche of destruction.”
Well, in the world of endodontics, I’m thinking about micro-organisms. So you might have gone in there and decreased the load by 50%, and then you might have used the second file and the third file and you got the load down. But then you dismiss the patient and by the time you let them go, there’s enough resident micro-organisms to create a massive flare-up, because they go into lock face. And if they go into lock face, they can unleash an avalanche of pain.
This kind of makes me think of like conspiracy theories. Because it’s like maybe a few people believe it, but they’re so loud and vocal about it, that they seem to be almost like the dominant opinion. Like usually the people who are complaining or conspiracy theories or whatever; usually that small group is very loud and vocal.
Well I could just flip this around. Teamwork. A few harmless – okay, bla-bla-bla. Well what about flipping it around? You get a few people inspired to move towards a common goal, and you can move mountains.
That’s The Ruddle Show! Okay, and the last one we’re going to do is called Downsizing. And this one says: “Because we’re all in this together, but there’s always room for one less.”
So you were telling me just a couple of minutes ago what that might provoke. That was extemporaneous. You just thought it was. So say what the last year’s meant to you.
This is 2020. How many times have all of us heard in the last year, we’re all in this together? But there’s no job for you and there’s no job for you. I mean it’s just – there’s been a lot of downsizing in the last year, I think all around. But we’re all in it together.
Well downsizing for me is not a bad thing. I remember having many eras of my practice all collectively together; I can look back and see different things we did. And in the older days, we used to want to have more people around, because maybe there were vacations or illnesses or whatever. But when I really got this great team together and they were running like a Ferrari, and they were hitting on all cylinders. When somebody voluntarily had to leave with their husband to move to another state, I asked them: do you think we can do it ourselves or should we hire another person? And invariably the staff wanted to be smaller, leaner, and meaner; more efficient, more effective, and more all for one and one for all.
Okay, yeah. Downsizing can be a good thing, because everyone can take on a little more duties maybe; maybe they have time for it, and just be more efficient.
Okay, well that’s our show for today. Hope you enjoyed it. See you next time on The Ruddle Show.
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.
DISCLOSURE: Please note that Dr. Ruddle has received royalties on and/or continues to receive royalties on those products he has designed and developed. A complete listing of those products may be found at www.endoruddle.com/inventions.
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Advanced Endodontic Diagnosis
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1948 Endo Article & Finding the MB2
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