Every orthograde endodontic procedure requires restoration of the coronal (access) cavity. The specific type of treatment used in individual cases greatly depends on the amount and config- uration of the residual coronal tooth structure...
Special Guest Presentation Dr. Marco Martignoni on Modern Restoration Techniques
This show opens with a fun discussion on the pros and cons of chewing gum. Next, Dr. Marco Martignoni from Italy gives a special presentation on the modern-day restoration of endodontically treated teeth. Then, Ruddle and Lisette follow up with some commentary of their own to close out Dr. Martignoni’s lecture. Finally, stay tuned for a well-documented and informative Ruddle nonsurgical retreatment case report on the removal of a fiber post.
Show Content & Timecodes00:09 - INTRO: Gum Chewing - Pros and Cons 08:02 - SEGMENT 1: Guest Presentation by Marco Martignoni 30:39 - SEGMENT 2: Post-Presentation Discussion 44:06 - CLOSE: Case Report - Fiber Post Removal
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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: Chewing Gum – Pros and Cons
Welcome to The Ruddle Show. I’m Lisette and this is my dad, Cliff Ruddle. How are you doing today?
More than good again.
Well, I’m going to embarrass you a little bit and say that I just love what you’re wearing today. Lori picked this out and maybe you can’t see all the details like through the camera, but he has a maroon coat with blue that brings out the navy-blue shirt and then there’s maroon in the shirt and tie. It’s just – I feel pretty dumpy here.
And we didn’t even get to my underwear yet!
Okay, well we’re going to start off today talking about chewing gum. And I actually had the impression that chewing gum is kind of a bad thing. Generally, you can’t chew gum in school. People who chew gum tend to make loud smacking noises a lot. If you swallow gum, apparently it might stay in your stomach forever, and then it also rots your teeth unless I guess if you’re chewing sugar-free gum, but then you can’t blow bubbles with sugar-free gum, and that’s kind of the whole fun part. And then I won’t even go into the horror of trying to scrape gum off your shoe after you step on it. So, that’s my views on chewing gum. What about you? Do you chew gum?
Well, you provoke quite a lot of memories. My idea about gum is well, I remember traveling a lot over the years. I’ve been to Singapore several times, and on the entry card that you sign before your plane lands, it’s death to drug dealers, and gum is strictly forbidden. Let me clarify. You can take a pack of gum and go to Singapore and chew it. Patrick Singh would want me to say that for you. But it’s how you discard that gum.
If it comes out of your mouth and finds the sidewalk or if it goes into the bushes or it goes under the table, that’s a $1,000 fine for the first offense. And if you try to import gum like more than just a handful of packs, that’s $100,000 fine and probably jail time. So, chewing gum coming into Singapore, I’m always thinking about maybe just leave it on the plane.
Yeah, well I guess Singapore then shares some of my views.
But I mean from a dental standpoint, probably what you want me to say is if we use sugared gum, a gum that has sugar, then of course this feeds the naturally occurring bacteria in our mouth and it can lead to caries, tooth decay, so you know, I don’t know if that’s a big deal.
Maybe jaw problems too?
Sometimes they – we see that in the practice, where people come in and we find out they have a habit of it, habit meaning they’re chewing all the time like all day long. They’re nervous or trying to quite smoking, and they’ll say my TMJ hurts.
Okay, well apparently there are some benefits to chewing gum. It can boost memory and reduce stress, right?
Well yeah, in fact, apparently if you start reading about this, I mean this person has me dive into the archives of the gum chewing literature.
There’s a lot written about it.
And apparently when you chew, you stimulate blood flow and more blood flow to your brain means better cognitive abilities, you can focus better, you can be more alert, you can have better memory. I mean I’m chewing gum right now so I can remember my script.
Well, what else? I guess it can reduce stress.
Yeah. Well, that’s because if you can reduce Xylitol, I’m sorry, Cortisol.
If you can reduce Cortisol, that reduces stress. A lot of kids around finals time – I used to – when I was practicing a lot you could almost tell when a quarter or a semester was up, because there was more emergencies from the University of California Santa Barbara, as an example, and kids would come in and they were stressed out over an exam. But they found out that college kids that chewed gum for two weeks, they can approach their workload, their studies, with more zeal and more gusto and they have better memory and they learn better. So, maybe put a learner on a two-week regime of gum chewing.
Okay, well I guess you mentioned Xylitol like when you said Xylitol instead of Cortisol, the Xylitol in gum is beneficial, like has benefits as well.
It’s an artificial sweetener. It’s a sugar alcohol, and basically, it’s kind of interesting, it stimulates the immune system, and it causes improvement in digestion and lipid and bone metabolism.
And I think –
Just Xylitol does.
Doesn’t it also reduce the bacteria in your mouth?
It reduces bacteria in your mouth.
By quite a bit?
So there are some things that I didn’t really know going into this segment that are benefits. I’m going to try to be chewing several packs a day now.
Okay, well, I also read that the Xylitol can prevent ear infections maybe in children.
And you had mentioned that smokers can chew gum to stop – help stop smoking.
And apparently, it can help your gut heal faster after surgery.
So, there are some benefits.
Do you chew gum? I actually prefer breath mints, which I chew.
The time I like to chew gum is when I’m at 36,000 feet and I hear the captain’s voice saying, “It is now time to return to your seats, you need to buckle up, and we’ll be landing,” let’s just say for fun, in Singapore, and so I usually ask Phyllis if she has any Dentyne. It’s with artificial sweetener Xylitol. And it helps open up my ears. Sometimes when we change altitude, that’s the connection from 36,000 feet to the ground. But when we change altitude, sometimes when I’m going through customs and I can barely hear the custom officer. But I found if I chew gum, it opens up my ears.
Yeah, that is actually a good point. That would be maybe the one time that I would maybe ask someone if I could have a piece of gum.
Yeah, carry some gum if you’re flying.
Okay, well anything else you want to add about that?
Yeah. If you’re a young kid out there or an old kid, you want to get the bubble gum with the baseball cards.
Do they still put the gum in the baseball card packs?
I don’t know, but when I was growing up they did, and boy, we would buy not to get the gum, but to get the cards.
And of course, it was bubble gum so we could blow bubbles in the dugout and we could blow bubbles and be cool. So, you know, it was a good thing.
Well, I was in the collectibles business just a little bit, and sometimes we opened up these chewing gum packs, or not, I’m sorry, baseball card packs that were maybe a couple decades old, and it was – the gum would just be stuck to the card.
Uh-oh, lose its value.
Yeah, loses its value when the gum stuck. So, if you have old baseball card packs and you think you’re saving them cause they’re going to be very valuable, I would make sure there’s no chewing gum in there.
Okay, good tip.
All right, well we have a great show for you today, and we have a guest presentation, so let’s get going on that.
SEGMENT 1: Guest Presentation by Marco Martignoni
So, today we have a guest presentation which you will see momentarily by Professor Marco Martignoni from Italy. So besides maintaining a private practice in Rome focused on endodontics and restorative dentistry, he is also on staff at the University of Siena. He has lectured extensively around the world, published a lot on endodontics and restorative procedures utilizing the dental operating microscope. He has been past President of the Italian Endodontic Society, and also the founder of the Italian Academy of Microscopic Dentistry. So, you have known Professor Martignoni for a very long time now. So, why don’t you share a little bit about your history with him?
Oh, he’s a fabulous guy! Look at him. Anyway, my kind of guy. I have known him since about 1992. He came over with a group of Italians and he took the week-long course, not the two-day course, but the week-long course. So, that’s when I first saw a kid that I thought, you know what, at the end of that week I told Phyllis, “He’s special. He's going to do something very special in our profession.” Well then, you know, he came back and took another week-long course, and then I was traveling, so I would hook up with him in Italy. Then he invited me over when he was President of the Italian – what is it called, Endodontic Society.
And so, anyway, there’s been many, many interactions suffice it to say. I met his dad. His dad was the dentist of the Pope, and his dad was using a microscope in 1960 to do all procedures and ran a very, very special office, and he was a professor at the university. And then, of course, well I don’t want to get too long. I have known him for a lot of years. He’s a fabulous clinician. He’s got a great family. His wife is a primo ballerina, and so the world is going to learn a little bit for The Ruddle Show about Marco. Marco has got hands of Leonardo da Vinci, he’s got the mind of Moses, and he probably is like right up there with one of my top guys. So, you’re going to really enjoy his little presentation. I say “little” cause it’s – you can – you want to hear him all day, but this will be a nice glimpse.
Okay, well we’re going to watch the presentation now which is on the restoration of endodontically treated teeth, and this is currently a very hot topic, considering that the design, the quality, and the timeliness of the restoration is really crucial to endodontic success. So, without further ado, let’s watch.
Hello, everyone. Hello, Cliff, and hello to all The Ruddle Show. It’s for me, a great pleasure to be here. Well, the focus today is going to be on the restoration of endodontically treated teeth. We know important it is to get rid of all the bacteria that are inside and to do a good root canal thoroughly. And we know how important it is to create the good conditions for obtaining good cleaning, so the shape, the cleaning, in order to simplify the obturation. Well at the end, will come the restoration.
So, the whole treatment includes cleaning and shaping, free the obturation as much as possible, and the restoration, what we like to call “root to crown,” which is a process that includes not only the endo, the post-endo, and the final restoration. So, whenever we see a case, we will have to decide ahead of time what kind of restoration will go on that tooth in order to adjust not only the shaping in order to create the right amount of space inside canals, but also the obturation. And we’ll design the obturation in accordance to the post and the restoration that we will decide to apply.
It is not always a post. It is not always a crown. According to the case, we will decide a specific shaping and obturation technique in order to enhance and simplify the restoration. Of course, in the severely destroyed cases such as this case, it will be a full crown restoration. But not always, not at all times.
You may ask yourself is post-endo restoration so important? It is important. Well, according to the best evidence that we can find in literature, according to science, if we look for success rate on the long-term, a satisfactory restoration plays an important role. It's difficult to say how important that is, but for sure, we all have to agree that if we combine the best endo treatment that we can do, and we combine it to the best restorative treatment that we can do, we will see very, very limited amount of lesions.
That is as it was shown in this beautiful article where it was noted – it was clear that when you combine good endo to good resto for the majority of cases, more than 91 percent of cases, there was no lesion in the bone on the long-term. Where if you combine bad endo treatment, as you can see in the X-ray, to that restorative treatment, as you can judge on the X-ray, the chances of having a lesion are very, very big. So, of those cases, the ones that were running okay were only 18 percent of cases, not even 20 percent of those cases were doing good.
So, whenever we see a case, we not only have to think of shaping, we not only have to think obturation, we have to think the overall gain. And the overall gain includes cleaning, shaping, obturation and the restoration, and obviously, that has to do with the endo, the post-endo part, and the final restoration. So, our part of the game, if we do endo only, will be designing and describing and figuring out the right amount of space for the restorative part.
But on the other hand, if we do also the restorative, we will have to think ahead, and think ahead anyway, and figure in our head what we have to achieve. And the goal will always be maintaining tooth structure as much as possible, but we have to adjust because the final part of the game is the restoration. So, we have to think endo, post-endo and final restorative every time. And again, there is so many evidences that support the fact that if we want good tendency to heal in our cases, or lesion endodontic origin or apical periodontitis, you can call it the way you like, but they will have better odds if we do good restorative according to good endo.
So, regardless of the size and position of the lesion, we will always have to think the end of the game, and the end of the game is not only the obturation. Cases will start healing right after the cleaning procedures, but they will finally heal completely on the long-term after we restore the cases. And as you can see in this case, there’s nice healing on the long-term, and even in this case on a very long follow-up after 20 years, you can see that the patient is not a good patient. It has calculus, he has lost the tendency to get his teeth clean, but still the tooth is there nicely positioned, no lesion, the crown is there.
So, regardless of the size and position of the lesion, if we combine good endo and good restorative, we will see good tendency to heal over time. Regardless of the lesion, whether it’s small or big or near or far like in this case, we’ll still see good tendency to heal. On the right side, you see the old-fashioned; on the left side on the first pre-molar, you see the modern way. There’s no metal in there. Still a root canal. Therapy trying to maintain tooth structure, then there is composite and a fiber post and then there is a lithium silicate crown on top in order to protect from the load of chewing. Still same results.
So, then you may ask yourself, because we always ask – we always want to ask ourselves, “should I place a post?” Is a post always necessary? Well, the objective is not placing a post, regardless of the material of the post, whether it’s gold, whether it’s zirconia, whether it’s titanium or glass fiber or carbon. The objective is to restore. And the post will have to support the severely destroyed. There’s plenty of literature that tells that the post will support the severely destroyed cases.
Moreover, the post will support the small teeth. So, today there’s probably not much need for a post in an intact big tooth with a big chamber like a molar. But there is still room for a post on a small tooth, like a premolar or a smaller tooth, like an incisor. In molars, regular composite or better substitutes for dentine, will work extremely good instead of placing a post, because you have the chamber to support all the coronal structure. And this is the case when we have to carefully design ahead the restoration.
Because if we decide not to cover the tooth, which there’s nothing bad, but you remove a lot of structure, if you decide not to cover the tooth, we will have to work conservative. We have to work minimally invasive, trying to save the tooth structure, trying to maintain the cusps, the marginal ridges, and develop enough space inside the tooth so that we can do the full treatment, and the full treatment is not only the shaping, it’s not only the cleaning, it’s including the obturation and the restoration itself.
So, cases that are perfectly intact, they will need tooth conservation. They will need minimal invasiveness. They will need in the future more and more conservative instruments in order to develop enough space to do the whole treatment, and the full treatment still is the whole endo treatment, but also the restoration, because there should be no need to drill the tooth after we remove the dentine to do the shaping.
So, the fiber post plays the role of supporting the coronal structure nowadays. We’ve done a lot of research on fiber post ands the fiber post itself finds the perfect adaptation within a dual cure rigid material in order to offer similar flexibility to that of the natural tooth, the one you see on the left of the screen. So, the fiber, when compared to metal and when compared to carbon or another rigid material, performs much better in terms of load absorption. So, if we decide to place a post, the fiber post may be a good choice at this moment.
Well, in the University of Siena where I work along with Professor Simone Grandini, my good friend, and the Director of the Department, we do a lot of research, and we have done research on load, on restorative. We did research on how quick we have to restore teeth, and in what kind of adhesive protocols, and if we can simplify the adhesive protocols in approaching our cases.
Well, what we could clearly demonstrate, scientifically demonstrate, is that first of all, you don’t need to drill the canal. After you have the space, all you have to do is create the conditions to have the perfect adhesion, the perfect bonding, of the composite. The post itself never bonds. The post bonds to the composite. The composite bonds to the adhesive, which stays attached to the dentine as much as possible.
Another thing we demonstrated is that if you lose tooth structure, if you loose tooth structure mesial on a distil, in single-rooted teeth, you have an increased resistance to failure, which is more than double. And you can see the graphic in the lower part of the screen, all the way to the right. If you loose the marginal ridges and you place a post, the amount of resistance to failure, it’s more than double than if you compare the same tooth without a fiber post inside.
And this tells us a lot of things. It tells us that we do not need to drill the canal after we create the shape, so we better create the shape at the time of the development of the axis cavity eventually to extend it inside the canal so that we do not want to over drill the canal because it’s not needed. And once we are over our preparation and obturation, we establish the base of the post. We know the length, we know the diameters. All we need to do is do the adhesive protocol and then inject the dual cure inside the remaining part of the empty canal and place a fiber post.
The procedure is extremely simple if you carefully plan it ahead. All you need to do is to follow the steps for the adhesion and then adjust the final restoration. In this case, the final restoration is a full crown, and you develop in this case is a chair-side provisional crown made out of PMMA, extremely fast, extremely simple and extremely satisfying for the patient.
So, to summarize, the restoration is extremely important for the good health of the teeth that we treat from the endodontic point of view. If we want to place a full crown on every of the teeth that we treat, there’s nothing bad about it, but it could be a little bit of an overtreatment. It definitely is an overtreatment if you have an intact tooth and the patient does not have power functions or bad habits like biting ice. And therefore, we should or we better adjust the protocols and adjust the materials such as post or no post in accordance to specific rules.
For instance, in molars we normally do not place posts anymore. Probably it’s not needed in none of the cases. We instead like to place a post in pre-molars because the post offers us a number of advantages, and ever we should forget that pre-molars or upper pre-molars are the most likely to receive a transverse load during chewing, and they are most likely to show a fracture in the long-term if they receive an endodontic treatment, so these are the cases that will be – that will receive an advantage of being protected with a crown or a full crown, and in that case, a fiber post in the center of the tooth will offer an advantage of load transfer.
So, in every case, in every tooth of the mouth, the post may be used or may be not used, depending on the coronal structure and depending on the treatment. Now the summary of the philosophy of the root to crown has been published by two friends of mine and myself, Professor Alan Atlas from Penn, Simone Grandini from Siena and myself. I’m proud to be in this group, and if you are interested in having a better idea of what are the influences from habits and para functions and what are the major directions in the restoration of endodontically treated teeth, I invite you to read this article, this recent article.
Other articles have been published by the group, by Siena Groups. And other articles are coming up in order to clarify what is really needed and what is not needed at all. But one thing that’s definitely not needed is to drill the canal more than we have done already in the treatment and the other thing that is really needed is to proceed to an adhesive protocol that needs to be simplified in accordance to all the materials that we are going to use.
So, thanking all of you, thanking Cliff and all the staff of The Ruddle Show. I hope to be soon live on The Ruddle Show. I was planning before, but then all the situation, world situation, influenza, the results, and therefore, I wish you very good endo and I’ll talk to you soon. Bye-bye.
SEGMENT 2: Post-Presentation Discussion
Well that was an excellent presentation. He is a very clear speaker. One thing that stood out to me right at the beginning was Professor Martignoni talking about the root to crown concept, essentially, the idea that full treatment consists of shaping, disinfection, obturation and the restoration, which made me think that he was suggesting that the endodontist would be performing the restorative work, and then that made me think of the episode we shot last season about whose job it was to do the restoration.
And so, just to remind everyone, in that episode, we discussed some current controversy between the AGD and the AAE with the President of the AGD taking issue with an article that was published in the AAE newsletter that seemed to be suggesting that the endodontist should become more involved in the restorative process. And so, I’m not going to go into all the details of that controversy there. You can check out that episode. But with that in mind, my first question to you after watching Professor Martignoni’s presentation, was is it common for endodontists in Europe to also do the restorative work? So, maybe you can give us some perspective on this.
Do you have a couple hours? Well, I’ll just go by my experience. When I first started traveling to foreign countries, and that was many, many years ago, when I went to Italy and you talked to people at night around dinner, I found out, to my surprise, that all dentists were physicians first. They were MDs, doctors, physicians, and then they specialized in dentistry. So, it was quite normal for dentists to do everything, and there wasn’t really specialties. I want to make a very clear point. Europe didn’t really have specialties. Schools at that time, they were cranking out post-grad students, residents and future endodontists. So, it was very normal for you to do the endodontics and do the restorative.
That’s all changed over the last 25 years, and they now have many specialty programs for endodontists. And they come out and they pretty much localize their practice too and specialize in and limit to endodontics. However, in Marco’s case, if the AGD is listening, they have a large practice in Rome. Marco has many private patients that come in and he does crowns, bridges, restores implants and all those kinds of things. And then he does get referrals. And when he gets referrals, he tends to send those back to the referring dentist just like here in the states. So, a lot of it’s just, you know, how it evolved in the various parts of the world, the profession.
Okay. Well, he does say that whether or not the endodontist is going to be doing the restorative work, he or she should still have the restorative needs in mind at the beginning of treatment. And you know, you’ve always told me my whole life growing up, start with the end in mind. And even when we had John West on our show, talking about his recently published article, he emphasized over and over again the importance of really visualizing a successful outcome. But very specifically visualizing it. And so, clearly, foresight is important.
Marco did a really great job on that, too, because he talked about when he sees the patient present, and let’s just say they have proximal caries, maybe even mesial-distal. As a restorative dentist, his whole life – his dad, as I already said, wrote books and everything. He’s known all over the world. Well maybe he’ll use the caries as the access into the pulp chamber. So, rather than make a traditional access to the top of the tooth, he might use the caries because he realizes he’s got to clean that out. He’s thinking with the end in mind.
Yeah, and you can still – like that’s a very novel idea, the side access, I thought.
Yeah, the proximal, yeah.
Well, he does emphasize that good endodontics combined with a good restoration is successful with no lesions about 91 percent of the time I think he said.
So, and then I guess if you have bad endodontics and a bad restoration, I guess it’s still successful about 18 percent of the time?
That surprised you, didn’t it?
I actually have a little cognitive dissonance around that idea, because why would it be successful like why would you still have a one in five chance of being successful with like bad endodontics and a bad restoration? I mean I’m thinking maybe it has to do with how well the canals were disinfected and maybe enough bacteria was removed for it to be successful.
I have said my whole life, lousy endodontics probably works for five years. So, lots of things we can get away with until finally, many things line up in alignment and then there’s like can be a phoenix abscess, a flare up of a very tough thing for the patient, swelling and everything. So, I guess what I’m trying to say is even when I see bad endo – maybe I’ll tell a quick story.
Sam Seltzer used to show a case that he did back in the ‘50s, and he did it from start to finish. He is the first guy in and the last guy out. And then he sent it off to the – in the school that got restored. And there was no lesions and everything was fine. Years later, the patient had massive caries under the crown and they had an apical lesion. He didn’t want to redo the root canal. He said, “Go back to the general dentist and have a new crown.” Lousy endo. Got to a brand-new crown, good restorative. And he shows now more recall with the lesion re-healing.
That is completely crazy, because the bacteria came in coronally, leaked all the way through from stem to stern of the endodontics, and caused an apical lesion. Didn’t redo the endo, just put a new crown on, it was sealed well and the lesion was demonstrating – healed radiographically over time. So bad endo/great restorative, he had a little crack at it, but it’s when it’s bad endo and bad restorative that all the things collide and we have catastrophic failures, or can.
Well, it sounds like I guess if the patient’s immune – maybe it’s the patient’s immune system that’s just so excellent that they can –
Or that they’re a great brusher, you know. Floss every night, get in there and do all that stuff. Even with a wide-open crown that you can drive a tractor through, you could probably keep your flora down a little bit, and if you have a good immune system, maybe you’re good, maybe.
Okay, well two really main points of Professor Martignoni’s presentation were one, that he talked about using a fiber post instead of a more traditional metal one, and then also the idea that a post may not always be necessary. So, why don’t you give us a little bit of your opinion on this fiber post replacing the traditional metal post?
Oh, I just love it. You know why I love it? Because I came through an era where every tooth that got root canals got a post, then finally we got everybody off of that and we could use the pulp chambers as a retentive for our core, and we started to back off from posts, but the worst thing was when we did do a post there was – usually they were stock posts and they came with correspondingly sized drills and we took an optimally prepared canal that was like appropriate for the root that held the canal, and we would make that canal bigger.
So, I really like it because in this way of practicing, we don’t alter the shape of the canal, we use a post that’s passive, it fits loose, and it sits on top of the gutta-percha, should go in at least 10 millimeters and maybe about two-thirds of the length of the overall length of tooth. Well then if you put that in with a composite, all of a sudden, the composite takes up the space around the post and you have wall to wall – okay, the composite, dual-cured composite, bonds to the post and bonds to the dentin.
So, you have like a monoblock. So, there’s no stresses building up, the post can flex about the Brinell hardness of dentin. So, it – they move a little bit unlike the metal posts. So, no drills, it’s passive, it bonds, post to dentin, and we have like a monoblock, and all this is done without changing the canal.
Maybe with the fiber post, there’s also les of a chance for a tooth to crack maybe because you were saying the flexibility is good.
He said the teeth that have mesial, this is what I heard, you go back and watch it the second time, I watched it three times and I want to watch it this afternoon, because I love watching Marco lecture. But what he said is, “If a tooth has proximal, mesial, and distal caries, a fiber post enforces the tooth, it makes it more resistant to fracture by double” (paraphrased).
Well, so if I’m understanding correctly, this movement away from the more traditional metal post, whether it be active or non-active, to this fiber post held by the adhesives, that kind of seems to be that trend we always talk about on our show from mechanical solutions to more biomedical solutions.
Well, there you go.
Because this adhesive which can be a dual-cured composite could also have like anti-microbiologic component.
And Gordon Christensen talked a little bit about how these fluorides have these great time-release, and when they’re approximating the dentinal wall, you can get diffusion of fluoride ions in the tubules and resist caries. So, absolutely, Gordon, if you watch Gordon’s lecture which is not about endodontics, but it was about the materials and the hot buttons and what’s new in their world, and then you look at Marco Martignoni’s, you begin to see a new way forward in restoration of the endodontically treated tooth or what is affectionately called R2C, root to crown.
Okay, now you briefly mentioned this. I want to hear more of your opinion on it, the idea that not every tooth needs a post.
Yes, we – I just mentioned it briefly, but what I know, and I think most of you know are learning to know, and certainly restorative dentists are knowing, that in many intact molars maybe the only access is to do the endodontics. In today’s age with adhesion dentistry, they do not necessarily need to have any kind of a post, period. If you did do endodontics, and you have that pulp chamber, pulp chambers have enormous retention for our core build-ups.
So, posterior teeth, like molars, in my opinion, and Marco agreed, and did you see all that research he showed? And did you notice, hey, did you notice the MCC and four X’s; that was 1242 it was founded, not so bad. Probably we can say there’s a real base of knowledge there.
Oh, for the University of Siena?
Yeah. Oh man, that made me like get almost chills down my back to think of the history and the excellence and how the Italians think. So, when he does a lot of that research, I just want the audience to know, there’s a lot of science beside it. He just shared a glimpse of the science and some of the publications, but basically, small teeth, like maxillary bicuspids, they commonly can fracture, and they should get a post. So, small-rooted teeth like bicuspids, mandibular maxillary, and smaller teeth, anteriorly, maxillary anteriors, mandibular incisors, especially, they can get a passive post, because we’re not drilling away more tooth structure. So, I really liked how he summed that up.
Okay, well I think that’s about all we have for now. Maybe you can add something in a second. I just want to say thank you very much, Professor Martignoni, for giving us that great presentation to show on The Ruddle Show.
Marco, good job, bud! Listen, I saw you go from like, you know, a young kid right out of school more or less when you first came over, and now you’re doing world-class endodontics. You can lecture on world-class endodontics at any time in any venue and anywhere in the world. But you’ve taken the restorative side, which was always one of your great strengths from your pop, and I love how you carried it forward and talk about this R2C concept. So, thanks again, we’ll have to have you back.
Okay, so I just want to say that we did talk about, you know, different combinations here, good endo, good restorative, bad endo, bad restorative. There could be bad endo, good restorative, so there’s different combinations.
So, treatment is not always 100 percent successful. So, in the presentation, it looked pretty easy to put in one of those fiber posts. I’m wondering, is it easy to take out?
Oh, so you want me to show the case where it’s bad endo and great restorative and it failed?
I got one of those. I got a whole bucket of those.
Okay, so we’re going to close out our show today. He’s going to show you a case report about removing a fiber post. So, let’s get to that.
CLOSE: Case Report – Fiber Post Removal
All right. Today we’re going to do a little work on post removal. I promised that some weeks ago. We talked about how to use the ultrasonic option, which is the dominant way we remove all metal posts, but today we’ll focus on the fiber post. All right. So, remember Marco said great endo, great restorative over many, many years, about 91 percent, no lesions. In other words, everything is fine. Then he talked about bad endo and bad restorative, and that worked only about 20 percent of the time. And that surprised us that it would even work that high of a level of percent.
But when we start to look at fiber posts, he showed us exquisitely how to place these posts and they’re placed passively. He talked about how to use dual-cured composites, and you could place them in and the composite would bond to the post and the composite would also bond to the surrounding dentin. That makes them formidably hard to get out and there needs to be some ideas. We certainly can’t use ultrasonics, and we can’t use the endo cowboy and we can’t use the OC loop or any of these kinds of ideas. We can’t use the file removal system. We have to have a specific tool to get these out.
Now I’m not going to do this today. I’m going to stay more clinically, but if you really start to drill down a little bit into fiber posts and how they’re actually fabricated, you can see heat destroys their internal bonding and it’s a very, very potent trick to help them soften up and get them out with a drill. The drills that we’re going to use are going to be from UltraDent, and they’re UniCore. There’s actually a size 0 and that would be six-tenths of a millimeter. But the ones that are most practical, that would be more like for a carrier or some gutta-percha in the straightaway portions of the canal. These all work in the straightaway portions in a canal where you’d put a straight fiber post.
So, we have an eight-tenths, that’s the size 1, so you got that one, you can read it, but you probably can’t see the red. The red one would be then about 1.0 and you would have the blue, and that would be about 1.2, and then the green would be 1.5. So, these are in millimeters and you can see their various sizes. I always like to start with the small one, because the small one has less surface area, less heat is generated, it can follow more carefully with less pressure, so we’ll start there. But then we’ll have to work our way up once we get a pilot hole down to the gutta-percha.
So, let’s look at this a little more carefully and see how we might be talking. So, here’s one that is exquisitely restored. I mean if you look at this photograph of this patient, which I have, I’m not showing it today, this is aesthetically pleasing. The only problem was they chipped their tooth. So, when they chipped off the incisal edge of the tooth, you can see there’s a ball on the head of that post, and nice post work, nice everything. The problem is the endodontics was inadequate, it’s deficient, and things that don’t look right, usually aren’t right, and so today we’re going to take it out.
So, we’re going to use a UniCore drill and we’re going to use a latch type speed handpiece that can generate about 20,000 rpms, better write that down, about 20,000 rpms. We have to have enough rotational speed to get that drill working. And what is that drill that we’re going to use? It’s the UniCore number 1. So, first, let’s come in and let’s get a platform, so I’m going to use the high-speed friction grip diamond. And you’ll just come across that quite easily and you’ll make a nice platform.
Once you have this thing decapitated and it’s removed, then you can use something like methylene blue or Chinese red dye, and we can just blot a little cotton pellet if you will and come over and place a little bit of that on the top and we can see a lot of times discrepancies and the actual delineation, the demarcation, between fiber posts and circumferential dentin. And so you can see that. Now you can use a number 2 round burr high speed, you can use ultrasonics, you can use a number of different tools to make a little divot in that platform and right about the center of that fiber post, and this is going to give your drill a place to home in on. It’s going to sit in there, so it doesn’t skate around and start dancing.
So, you can see that drill was off-center, it was off-center. You can see that we’re using the eight-tenths of a millimeter yellow drill, you’re at about 20,000 rpms, it does take some inward pressure, and as this thing goes down, it starts to destroy the physical properties of the fiber post itself, and that softens it up and makes the drill allowed to progress and advance ports in an apical direction. Notice we’ve kind of – maybe I should just pause this for a second.
We’ve drifted a little bit. We’ve drifted just a little bit, but we’re still inside the circumferential dentin of the original post, but the drill has drifted a little bit. I want you to watch how the second drill and the third drill move back and center up and were perfectly aligned with the long axis and the post. So, I want you to know that it’s normal that you might drift a little bit, but you shouldn’t be drifting out into solid circumferential dentin. You should just be drifting to the edge of the post itself.
All right, so you can see we have some post material in here. You can see we’re down there very deep. Here comes the number 2. This would be 1 millimeter, and it will fall quite readily, the second one, and it will drift back into the body of that post and center up. So, self-adjusting as you go from drill to drill to drill, small to big, small to big. And you can have your assistant give you a little cleanout and we have a special canula we can put way down into that canal and blow a little blast of air, and we can clear everything out. We can see it. And here comes the blue one. The blue one was 1.2 millimeters. That’s a little bit bigger than a GG4, but we have to get the post out.
So, this isn’t about minimally invasive endodontics; this is about removing what is there so we can redo the endodontics. Now we can look down there pretty good, and if we rack focus, which means everything is a big blur ball, you can see we have drilled right up, right to the junction, the interface, between the bottom of the post and the coronal aspect of that gutta-percha.
But notice the lesion is around the side of the root, and notice when the pre-maxillary plates formed during tooth development, maturation of the facial structures, there is a midline radial lucency. It’s normal to see that. So, not all of this is a lesion of endodontic origin. Some of it is approximating the root, but some of it is the midline fissure, the midline fissure, which is the fusion of the maxillary plates.
All right. So, now that you can see that we got the post out and we got clean dentin circumferentially, the job is to get out gutta-percha. We’ve talked about that or will continue to talk about that in future segments, but we got to get the gutta-percha out. And then apical to the gutta-percha, we have a root up in here I can see, and we need to negotiate the rest of the canal. So, that’s the assignment, and sometimes that can be a block, there could be a plug of fibrotic tissue left behind, but we need to expect that apical to the gutta-percha, there might have been a block, and we need to negotiate the full length of the canal.
All right. So, that’s what we did. We did a little bit of shaping. Listen, it wasn’t so much shaping as it was cleaning. You can use things like the EndoActivator and activate your agitation, your solutions, once you got the shape. So, once you got the shape and you can fit the cone, remember that? When can you fit the cone? When you got the shape. How do you know you got the shape? When the last file to length comes out and it’s apical extent is loaded with dentinal debris. And since nobody’s really worked up in there, we should be able to see fresh, clean, white dentin on the blades of the last file to length.
Well, the cone fit looks good to me, we have apical tug-back, the cone is loose along the body. We’re going to get on that with heat and pressure, and we’re going to carry a wave of gutta-percha, thermal softened gutta-percha, into those narrowing cross-sectional geometries and out with the anatomy, 2,000 pounds per square inch, and that’s the downpack. This was all explained by me earlier in previous shows. It’s the Schilder technique. It’s the technique that fills root canal systems.
I often am amazed, and I keep saying this, I’m just amazed you would spend $70,000 to clean out lateral canals, when you can do it in a lot less time with a lot less simplicity, and for about $2. We’re going to talk about that later. I just got a packet of stuff, I’m digressing, about this thick, and it was a cost analysis between GentleWave and just doing regular endodontics a more traditional way. It’s hundreds of thousands of dollars a year. So, think about it. You can get all the lateral canals and seal all four portals of exit, with a simple idea. Then we’ll backpack.
That’s my post-op, the day of the treatment, and if we go out 10 years, if we go out 10 years, you can still see some of that midline fissure right in here, but you can see how tight the bone’s gotten around the apical part, around the lateral part of the root, and another, no post, but another crown, another crown, and I repaired the access cavity. A lot of these teeth don’t need posts. You could have put a post in there. I might have after hearing Marco’s lecture, but I’m not the general dentist. And the general dentist elected not to. Marco would have put a post in there, because he would have said it will strengthen the root and it will behave much like surrounding dentin with the Brinell hardness number.
All right, that’s how I get out fiber posts, and we just need a simple set of drills. I like UniCore, and I’ve taken a lot of posts out with the UniCore drills. So, we need to have ideas in our bag of tricks, so when we see a post, if it’s all-metal we have some ideas. We haven’t talked yet about the post removal system for metallic posts, okay, active posts, passive posts, and we’re going to still talk about those. So, I hope you learned something today, and that is the show for today, and I’ll see you next week.
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.
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Moving with the Cheese & Delving Deeper
A Better Understanding of Change & File Brushing
The Dark Side & Post Removal
Industry Payments to Academics & Removing a Screw Post
Special Guest Presentation by Dr. Don Tyndall
Controversies & Iatrogenic Events
Sharing Knowledge Pros/Cons & Type II Transportations
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