Virtually all dentists are intrigued when endodontic posttreatment radiographs exhibit filled accessory canals. Filling root canal systems represents the culmination and successful fulfillment of a series of procedural steps that comprise start-to-finish endodontics...
3D Obturation & Technique Tips Warm Vertical Condensation Technique & Some Helpful Pointers
This episode opens with a brief discussion of the future of dentistry. Ruddle then goes on to describe how to obturate a canal using Schilder’s warm vertical condensation technique. In the next segment, Ruddle gives some technique tips related to occlusal adjustment, rubber dams and clamps, and how to achieve isolation. Finally, what makes Cliff, Cliff? To wrap up Season 2, we will bring you some exclusive, insider footage of what it is like to be Cliff Ruddle in a segment we fondly call, Being Cliff.
Downloadable PDFs & Related Materials
Allow me to describe a clinical dilemma that frequently happens when performing endodontic treatment. Let’s say you have experience, are well trained, and have just finished cutting a fabulous endodontic access cavity preparation...
Ruddle on Shape•Clean•Pack
Ruddle on Retreatment
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: The Future of Dentistry
Welcome to The Ruddle Show. I'm Lisette and this is my dad, Cliff Ruddle. So how are you today? Have you had a good week?
I have had great week. In fact I had a power long weekend – Friday, Saturday, Sunday just recently – and I spent it in my histo lab and I think I'm creating the future of endodontics.
Well that's great; because this being our last show of the second season, we got to thinking about the future a little bit. And regarding our show, we are pleased to announce that there is going to be a third season so stay tuned for that. But what about the future of dentistry? A while ago you made a video of the future as you see it, and we want to share that with you now.
[Showing video – no audio]
Well that was a neat video. Can you tell us a little bit more about the future that we saw in the video and how it relates to what's on the horizon?
Sure. I guess first I should acknowledge my multi-media team, Glen Derbyshire and Mitch Goodgin and Eric the animator. They captured some of my ideas, but I see actually several futures, but that was one future.
Yeah, I think how I see the future – there are several futures that any of us can see – but I think one of the futures that we just saw is the ability to be better diagnosticians and use laser Doppler flowmetry to look at blood flow; that's the first thing to degenerate inside a root canal space. So if we can pick up early vascular disease, we're going to be better diagnosticians and we'll treat the client better for no surprises. Access cavities.
Incidentally, everything you're looking at is being done. This isn't like something that's totally made up, because in the first one that I just talked about, there's people doing that. I have a friend in northern Europe and he has used algorithms through using CBCT and oral scanners, and you can look right down through your microscope in an isolated tooth and you can see through a metal crown, through an amalgam, through a composite, through miles of dentin; you can see the pulpable roof, so you know exactly how to plan your entry into the pulp chamber. We can use demass modes and get rid of all the soft tissue and we can do reconnaissance on the canals and we can map them out and understand what it is we're going to do just ahead. So that's pretty cool to map anatomy. We'll use the endurance limit concept. We'll probably not go to Niti anymore; there will probably be a day that our shapes will be very, very small because we'll be able to look at bacterial loads that are remaining, and not only will we watch our files move on screens just like medicine looks at stents being place up through the angular artery into the heart we're going to watch our files work. We're going to be able to have scanners chairside; in less than 30 seconds – I know a kid in grad school, his name is anonymous – but he is already working on a device; he's using it chairside and in less than 30 seconds, it'll tell you if his bacterial load is zero or if he should reappoint or continue disinfecting. So that's right around the corner.
Finally, we'll have chairside way to say you're clean. I've wanted that my whole life. And then finally the last thing you saw was some kind of an obturation device and it's going to be regenerating materials with a stiff enough biological core-type material that our sealer will be impregnated inside the outer skin, and it'll be a one-piece unitary device and it'll fill root canal systems in less than 5 seconds.
So that's the future I see. But what I see really a little bit beyond that is we're going to be moving away from more mechanical solutions to biological disease and we're going to move more to a biomedical solution to treat biological disease. So we're going to move more away from the mechanics of endodontics.
So I think that artificial intelligence will also be playing a role in the future of dentistry as we saw recently when we talked about Dr. Cherilyn Sheets' periometer. But also we will be doing a segment on AI in the future, right?
I'm really excited about it. You know AI – I've been looking at this for quite some time and sometimes there's a little branch between some futuristic technology and then maybe AI. But AI has already invaded our lives very insidiously. We've all heard of Alexa and Siri, right? They are digital executive assistants and they can do a lot for us because there was enormous machine learning so that they could field all those questions and have pretty much appropriate responses. As we move forward, IBM's Watson you know; it can read 500,000 peer reviewed papers in 15 seconds.
So not only can it read 500,000 papers, it can tell you what the results were, the conclusions, and help you chair time plan in real time. And of course CBCT, we'll analyze it. There's already databases; if they go to dentistry – I think it's dentistry.ai website – you'll already see that we're using the CBCT in x-rays. Did you know that AI can read films probably better than Cliff Ruddle? They did blind tests and they found out that AI was more accurate than a panel of dentists looking at films. So all those troublesome CBCTs and you've got too big of a point of field and you don't want to see maybe a tumor or cancer; they'll tell you what's there and give you a digital printout and you can put it right in your chart. So I'm pretty excited about AI.
Yeah, it sounds exciting and I’m definitely feeling your excitement talking about the future. So we'll get on with our show today. We have a really busy show today filled with obturation. Get it? Filled with obturation.
Oh that's good! That's really good. I bet they missed it.
And some technique tips too, so let's get started.
SEGMENT 1: ENDO 101 - Obturation with Warm Vertical Condensation
One of the most intriguing things that fascinates international dentists is filling root canal systems. So today we're going to talk about how to mold thermal softened gutta percha into the intaglio of the root canal space. And certainly when you look at this pre-operative film, you can see a single cone is going to be woefully deficient. So we need to have an idea so we can mold this rubber, thermal soften it and compress it, and really get a dense fill. Of course in a vertical condensation technique, we fit a master cone. And then we're going to get on this cone with heat and pressure and carry a wave of warm rubber right up into the intaglio. And you can all see that big resorptive defect, right? So that's what we're going to try to mold rubber into.
When you have a lot of lateral space – just as an aside – before you commence with your plugger and you start pushing vertically, remember you can throw another cone in around your master cone; or if you have some kind of an injectable gun-type method you can squirt lateral to your master cone.; that squirted 60° roughly gutta percha will start to thermal soften your cone and it'll help you get a more dense pack.
So that's what we did. And you can see – this is kind of exciting to get wall-to-wall GP. Our sealer is on a thin microfilm order of 7, 8, 9 microns and we have an achievable result. Notice the incredible control, even when we have massive, massive diameters; massive diameters. Thermal softened gutta percha only has to be elevated 3° above body temperature to be sufficiently moldable to fill root canal systems.
Okay. Well what has been the problem over time is this word called "system based", and on a previous show I already showed you about some new cones, so we won't beat this to death. But traditional cones were 2% tapered and they only theoretically agreed with the last file that was carried to length. So they were basically like a 25 cone, a 30, a 35, iso 2% tapered. So they might have had some agreement in our terminal diameter, but they were woefully too skinny up in the body of the canal so that led to what? That led to non-standardized gutta percha master cones. And those cones were 6% tapered so they more properly filled the shapes we were compacting across these decades of time, but oftentimes the taper of the cone was too rapid. So our tug back was sometimes up in the body of the canal, but we had space terminally.
So you can see in another view; this might look like it's at length radiographically. When you go to remove it, it might exhibit tug back. But oftentimes if your tug back is where it needs to be apically, then we call it short, crisp tug back. In other words you lift that cone up even half a millimeter and it's loose. Long tug back when you pull the cone out you can look at the cone and oftentimes you'll see skid marks, indentations, scratches over a longer range and that's artificial tug back. Your tug back is not at length, it's up in the body of the canal; and that's dangerous. Because if we're using warm gutta percha and you remove all this material up here, this is free to go. It can sail and it can sail long. So cones have not always been very good.
So we use the word “system based endodontics” – let's acknowledge John Engel. Back in the '50s he was the first guy on planet Earth to start working with the manufacturers to insist that they have some kind of parameters where the master cone was related to the paper point, and the paper point was related to the last file that was length. So we called all that “system based endodontics”. It was a great concept by John Engel but unfortunately it was not working very well with such wide parameters of tolerances between and among various companies' master cones.
So Nathan Li – Dr. Nathan Li – doctor, doctor, doctor – he's a dentist in southern California; he's an entrepreneur, he has a gutta percha business, he's been making the best gutta percha in the world for the last 15 years. But it's been a secret. So what he did is put gutta percha balls in acid baths; he used machines to stretch these long-chain hydrocarbons; he could add nanoparticles – first guy in the world – and that could lower the working temperature, that's desirable. We could extend the heat wave from about 4-6mm – that's 50%; that's a 50% longer heat wave – and then finally, the cones are incredibly accurate. You see, most iso-cones had to have tolerances of +/- 05. So when you grab, as an example, a 25 master cone, it could be as big as a 30 or it could be a small as a 20. No wonder we were so frustrated chair side going through box after box of master cones hoping one would come out and be perfect!
Well dream on; that never happened. So what he was able to do is use a concept called “electro discharge machining”. He could send a spark, 0.0025mm across an acid bath and remove out of the mold small, small, infinitesimal amounts of metal so when he does his injection molding process, his tolerances were now +/- 0.02. So now we have tolerances consistent with machining and that is related to the files. So the files cut the shapes; now our cones have tolerances within the same tolerances as the manufactured files.
So this is all very, very good news for colleagues. So you've got master cones that actually are specific at Dentsply Sirona to match various commercially sold files. Like ProTaper Gold has conformed fit; conformed fit. WaveOne Gold: conformed fit. These are cones made specifically for those systems.
Okay. Well, I'm often asked around the world, when am I ready to pack? My answer has always been: when you can fit the cone. Your job shaping is to remove everything that isn't a system based cone. So you're ready to pack when you can fit the cone. When you can fit the cone; when you've got the shape. Oh, we're in a circle. How do you know if you've got the shape? When the apical 3, 4 or 5mm of your file is loaded with dentin mud upon removal and you visually inspect it, you know that file just cut its shape in the apical 1/3, you're through shaping. Now we can move on to disinfection, active irrigation and then filling root canal systems. So that's when you're ready to pack is when you can fit the cone.
Well we fit the cone in a wet bath. Typically we would like to use sodium hypochlorite. You want to use sodium hypochlorite so you can have a wet cone in a wet canal to more carefully simulate the sealer that will be used and give us less friction just ahead. So fit the cone in sodium hypochlorite; that'll sterilize your cone. Nothing lives in sodium hypochlorite, no viruses, no spores, no microorganisms after 10 seconds of contact. So you've also sterilized your cone. I fit the cone right to the radiographic terminus, recognizing if we extract the tooth, you might see a little bit of pink through the terminus.
So what do we do? We dry the canal. Decades ago I think I was the first in the world to teach paper point drying. So we talk about the radiographic terminus – that's where we mechanically instrument to – but we would like to fit our cone to the physiologic terminus. That part of the paper point that is consistently clean, white and dry, is that part of the paper point that's inside the canal. The part of the paper point that spots red or it might be clear, and when you push that against your glove nail it accordions, that's beyond. So we can trim our cone accordingly to paper point drying.
You know, I need to go to artificial intelligence and have a special digital assistant that can erase for me.
All right. Now we've got this cone fit, we've trimmed it back, and now we're ready to clean out the irrigant, the sodium hypochlorite. There it is out, and we can begin to think about dividing our roots into thirds; coronal 1/3, 3, 4, 5; middle 1/3, 3, 4, 5mm; and our apical 1/3 about 3, 4, or 5. So roots are about 9-15mm from the orifice down.
Well, the reason these thirds are important is it helps us judge where to place our armamentarium. So we need some pluggers, because pluggers are going to push on thermal softened gutta percha, and that's what's going to mold and adapt and compact that gutta percha so we can fill a root canal space and a system. We have pluggers. I think you can maybe read their numbers, but if you can't they're 0.5 at their working tip; we have a 0.7, we have a 0.9 and 1.1mm. So we choose a plugger that's effective and efficient – it's the bigger one – and it would probably fit in this range. We would fit a progressively smaller plugger that would fit over a few millimeters. The idea would be to get within 5 millimeters of the terminus. So if we can fit our plugger within 5 millimeters of the terminus, we're going to get a heat wave through our cone and we'll be able to move that warm gutta percha laterally and in depth, and cork the foramen. Okay, so that's the pluggers. Two pluggers; longer roots maybe you use a third plugger.
Now we have the Calamus Dual; you can use the touch and heat. There's a lot of things; I used to use a Bunsen burner in the '70s. It was really fun to fire up that Bunsen burner on a cold Boston day and it was warming the patient; we could take off the blankets and the double coats and the goggles and we could start doing dentistry. So this modernized everything, and you have two sides. On this side of the panel, this panel controls your electric heat plugger. And on this side of the panel you can control up and down temperature, because this is what squirts thermal softened gutta percha. So you have two panels to control.
Now there are electric heat pluggers and there is a 40/03, there is a 50/05 and there is a 60/06. I am permanently using that one; that's all I ever use. It gets me down into the apical 1/3; I use it in the big canals, the small canals, the medium size canals; it permanently works. These were only made if you wanted to use this instrument in a method different than I'm teaching; that would be called continuous wave. I am not teaching continuous wave; I am teaching classic Schilder with modern technology.
Okay. So you see 350, you know continuous wave is supposed to be about 200, but we're not doing that technique, so we're using a classic a little higher temperature, and the temperature transfer from inside the canal if you put thermal couples along the roots – it's less than 2° Centigrade. So we don't have to worry with an interrupted down packing method; whereas continuous wave is permanently on.
Okay, you got the cone, system based, you got it fit and now you're thinking about sealer. We'll talk about this a lot more because I want to talk about – you know there's resin cements, there's MPA based, there are bio-ceramics, there are glass ionomers, there are a multitude of different sealers and it's funny how everybody right now really is migrating towards your bio-ceramic sealers. It's kind of the blind leading the blind. Great repair material; I'm not thinking today it's a sealer, but it's being used as a sealer.
So here's the one that I use. This was invented by Dr. Herb Schilder with the Kerr Company back in the '50s for warm gutta percha. He didn't want to ruin the physical characteristics of a material upon heating. That's an important concept that hasn't been worked out properly with the bio-ceramics or BC sealers.
Excellent flow; I did my Master's thesis on it; you can get it into the order of 7, 8, or 9 microns. It has small particle sizes, flows beautifully. You can change the viscosity; manufacturer says in this eugenol powder zinc oxide based sealer a shovel of powder to one drop of liquid. So that would be an example of one to one. I'm oftentimes mixing it two shovels of powder to one. How do I know? In longer, narrower and more curved or re-curved canals, I’m mixing it more towards one to one. However if it's shorter, wider, straighter – two shovels of powder to one. Okay, so we can bury it.
Now everything that goes out of the foramina, wherever they are, the communication is between the root canal space and the attachment apparatus, there are going to be puffs of cement associated with those portals of exit. So everything initially beyond the root will be inflammatory; it's a foreign body. So we want something that sets very, very fast. This is the fastest setting sealer in the business. It's less than 2 hours on the bench; in a body 37° temperature and humidity it's going to set even quicker. So we want something that sets by the time the patient's leaving your office. It's already healing because what? It's dimensionally stable, biologically inert because it's set; healing can commence. You'll see this material on 30 and 40-year recalls because I have them. I don't like materials that get carried away and are resorbable. I want to see them there because that's what maintains the seal. If it's starting – if you get a puff and now it's getting carried away, well then you're wondering well what's happening to all the other portals of exit? Are you getting the ingress – okay, the ingress of irritants which can precipitate longitudinal failure?
Leakage, okay. So it's basically – we did block sections on prisoners before it was illegal back in the early '70s – that's what Harvard did – and we saw osteoid – that's a precursor for bone scaffolding growing right through curved pulp canal sealer and butting right up on the lateral side of the roots. So we know pretty much how this works. Again, Schilder had in mind a warm gutta percha technique so unlike the other zinc oxide and eugenol sealers they tend to degrade; degrade in terms of their biomechanical and physical properties upon heat, so this is the only sealer that's really made to heat up and get warm.
What about this one; nobody even talks about that. When you mix zinc oxide with eugenol it forms zinc eugenolate. Zinc eugenolates block plastic prostaglandins. Prostaglandins are well known to cause mast cells to lice releasing histamine. Histamine is a precursor for pain; it's a pain mediator. So if you can stop that pathway, patients are peaceful.
Oh yes, peaceful. People are happy; they can sleep very well. Geez, I didn't know I didn't hit the right button. Boy that waste basket's getting pretty small.
One last comment. Paul Eleazer, University of Bellingham or Birmingham in Alabama; he showed in this article in 2008 that there is a significant volumetric expansion of gutta percha when combined with eugenol. And he studied it out to at least four and a half years, and he found the gutta percha still expanding at four and a half years. Tell me one material on the market that does that? But nobody is quoting this paper; probably most people didn't even read the paper. But we'll have another show notes.
So now we've got the sealer. So what do we do? You butter the cone. And when you butter the cone, a lot of your cement is going to vent this way. So when you slide the cone in, the cone's going apical, the sealer is venting coronally. In a single cone, most of your sealer is ending up the pulp chamber. In bio-ceramic single cone technique, they love to say hydraulics, hydraulics, hydraulics. Do NOT – I repeat do NOT confuse hydraulics of a material that needs water and moisture to set up and be confused and think that means compression; the piston effect; waves of condensation and 2000 pounds per square inch. That's vertical condensation; that's hydraulics.
Okay so we'll come off of the hole; we'll take a hot instrument or electric heat plugger and we'll slice that off. You'll get a heat wave about 5mm down the cone and that thermal softened gutta percha can be compacted. So we'll go on pause.
I want to come back to this one more time. Sear it off; appreciate you'll get a 5mm heat wave. Thermal softened gutta percha has compaction potential. Take your prefit plugger, step it methodically, circumferentially around the orifice level, fold all the gutta percha off the walls, level it out, make a platform and press. And when you press, you seal the canal only in its coronal part. The sealer cannot vent; it cannot vent. It is driven laterally and apically. That's where you get the hydraulics. So we would call that a wave of condensation and here we come; hot instrument; activate the cuff; plunge, plunge in 3-4mm, deactivate for a brief second – go 1001, that's a second, go 1000, boom; deactivate and take out a bite of gutta percha. Another 5mm heat wave; thermal softened gutta percha has compaction potential. And when you get all that gutta percha flattened out, press; 1001, 1002, 3, 4. You'll feel it digitally beginning to get hard; you can’t move hardened gutta percha. It's already cooled down so you would have missed your cycle. But remember, during that 5 second press, that's what's entrapping the sealer and again giving you a second opportunity to fill in to lateral anatomy. Pretty fun!
And we can take one more. So you come in with your electric heat plugger, you're moving progressively deeper. This is the 40/03; it will easily go down in here. Activate, gets hot, plunge. Notice the 4-6mm heat wave right to the terminus of the cone; take out the bite of gutta percha. By removing the gutta percha, a smaller pre-fit plugger fits progressively deeper and now you can cork the apex. Step, step, step; make the platform and press, 2, 3, 4, 5; and fill into root canal systems. Oh my goodness!
And what's in the lateral canals? Well the bigger ones, it's certainly all gutta percha. We know this histologically. In the really micro fine ones, it's certainly all sealer. That's why we don't want resorbable sealers. What is it usually? Usually it's a mixture, and you'll have a piston of gutta percha moving laterally and then as it gets further away from the force of condensation and the heat wave, it'll die out and it'll be driving sealer all the way out to the cable surface and that's when you get you get your puck. It's kind of fun to know how this behaves because it'll give you a little more security when you try it.
This is a technique that fills root canal systems. I started lecturing in the '70s. People loved the lectures; they didn't care about shaping the access cavity; they didn't care about irrigation. They wanted to know how to fill root canal systems. Well, once you down pack you have an ideal post space, so if restorative dentistry dictates you can already place a post. If you don't want to place a post – and we're replacing a lot less posts because dentists are waking up that posts don't strengthen teeth – what we can do is fire up this panel, okay? We're going to fire up the squirter – we call it affectionately the gun. The gun is going to deliver gutta percha. So there's a motor, the motor pushes a ram, there's a heat chamber, there's gutta percha in here, you're going to use a 23 gauge needle and you're going to be able to have that ram squirt gutta percha from the thermal softened chamber, through the cannula into the canal.
Now some people use this as a solo obturation technique; they just squirt. They just squirt in with no cone fit. Well I think you know that that can be a little fraught with problems. We're looking for predictable results, not anecdotal sometimes events. So fitting the cone gives us a lot of confidence. We can already imagine the pack on the post-op film. I'm working at 180°. If you hit this blue activating cuff you'll be able to immediately start that ram moving to squirt gutta percha. And here's the cuff that would activate your electric heat plugger.
So we can squirt. Take the 23 gauge needle, place it right on top because it is itself hot; it will re-thermal soften the top part of your previously established core, and squirt off about 3-4mm, and really be disciplined to step that plugger around the circumference of the canal so you can marry your squirted aliquot to the existing gutta percha that you down packed. Squirt a little bit more. Do not squirt in one continuous sweep out of the canal; you can only move gutta percha 5mm max. So if you want to move your gutta percha and mold it laterally and vertically over 5mm, you do an incremental back pack, not a continuous total complete backfill.
Take solvents like Xylol and clear out your chamber with a cotton pellet; chase that with isopropyl 70% alcohol. Now this removes all the residues of eugenol and allows you to bond. You can get tags, resin tags and dentinal tubules. Out of UCLA many years ago, the materials science guy, the department chairman, was Angelo Caputo. And Angelo wrote a book with John Stanley from Santa Barbara, a restorative dentist, and that book was Restoration of the Endodontically Treated Tooth. And they routinely showed resin tags and dentinal tubules; if they used the solvent Xylol and chased that with 70% isopropyl you can bond. Adhesion dentistry works, and it works quite well.
So you've got your back pack. Yes, a lot has been written about this over the years, but I think this one slide is kind of fun. We've back packed and finished the work. We've back packed and finished the work but before I back packed this canal, it was empty up in here and I can look right up here with my microscope and I could see right in the lateral wall, right in the lateral wall of the buckled canal, I could see pink. I could see pink and that pink is a rope of gutta percha. I don't know if this is all gutta percha, if the last part is sealer; I'm not worrying about it because I'm using dimensionally stable, non-resorbable materials. Very important.
So it's kind of fun to be able to fill root canal systems. It's going to be an abutment under a long splint and in the most funereal sense. That abutment needs to work. It needs to endodontically work for the life of the patient. So let's not worry about anything other than how many POEs, how many portals of exit can we seal today? The thrill of the fill.
So in summary, you're opening up teeth that need endodontics. The access is going to be critical, the first step. You're going to negotiate the most difficult thing and secure canals so they can be prepared. You'll prepare the canals so they can be flooded with a reagent and 3-dimentionally cleaned. Let's really start emphasizing 3-dimentional cleaning, because then filling the root canal system is self-evident. You see it routinely on post-op films. For decades, I was able to count about 2.8 filled portals of exit per every one shaped canal. So, you should be able to start seeing anatomy if you're cleaning well, shaping well and filling.
Okay, so now one last case. Let's see how this really works. So you're negotiating the canals; you're getting them secured so you can get your rotary mechanical files in there and you can produce the shape you desire. Cones fit really easy, system based cones fit predictably successfully in the system they're used for; the last file, the cone. And there's the cone. Notice the lesion; notice the lesion is asymmetrical. The lesions form adjacent to the portals of exit. There is the down pack and you're already seeing it looks like it might be kind of exciting down there. And if we go to the post-op, you can see the 7 or 8 portals of exit in the apical few millimeters of that second bicuspid. And not so bad; we have 3 portals of exit and a little bifidity in even the first bicuspid.
All right. So we've talked about filling root canal systems. This is the most predictably success technique that has ever been invented. It really takes about 10 minutes a molar. When you get used to it and you get the armamentaria going and you have your assistant trained up, you too can fill root canal systems.
SEGMENT 2: Technique Tips
So now my dad is going to give you a few technique tips related to occlusal adjustment, rubber dams and clamps, and how to achieve and maintain isolation. Sometimes small technique tips can yield big results, so hopefully these are helpful. And the reason we chose these three topics is because we get a lot of email questions regarding them. Probably you learned all this stuff in dental school but sometimes a little reminder can help a lot.
So first why don't you tell us about occlusal adjustment? What do you use and why?
Okay. If you're planning ahead to the restorative effort that would follow the endodontic procedure, then if you're going to put a casting on the tooth, then you have permission to knock the tooth down. Get it out of occlusion; take it down probably 2mm. Obviously we don't normally adjust the occlusion – maybe just a smidge – if there's an exquisitely placed restoration, a bridge abutment, something like that, then we don't really have permission to knock it down. So let's get started.
Well the first thing I'd like to say is you get a lot of patients that get referred in to you if you're an endodontist, and general dentists also have patients that move in from other locales where somebody has already started the treatment, and this patient came in and they cannot even touch the tooth it's so sore. And they like to say when they bring their teeth together it's the first tooth to hit. So what you can do immediately to be a hero is use my favorite burrs; use a big, tapered football, large or small based on the occlusal table, what's appropriate. But you can reduce the occlusion, bevel the sharp edges off, and now you have a nice place for your reference points and you'll be able to do more predictable treatment that lies just ahead. And when you knock that tooth down, of course, it really helps them a lot and it paves the way to do successful treatment where you can do complete endodontics. So that's a little bit about occlusal adjustment; just do it when you can.
What about rubber dams and clamps? What do you most frequently use and do you have any technique suggestions?
Well I do. I've used a lot of different kinds of rubber dams over the years and I kind of settled about 15 years ago on the HandiDam by Aseptico. It has a built in plastic frame, so when it's on the tooth and it's isolated, it's wrapped around the face, if the assistant's taking radiographs we don't have to worry about a metal frame being superimposed over something strategic that we're trying to see. So the HandiDam will do almost all teeth at all times. Maybe if you're back on a second molar and it's way back, you might need a 6x6, because they come square; they come like the HandiDam kind of ovoid; there's round ones. There's 6x6, there's 5x5, so we have different sizes. Sometimes those 6x6 – heavy vs. lightweight, medium heavy – they can withstand the pull longer and give you a little bit more durability. Because in endodontics, we do longer procedures than like a 15-minute crown prep or something.
So in any event, there's the tooth, isolated, the dam's over it. One step isolation – I guess we could talk about that at another time – how to punch it, how to pick it up in one step isolation. But essentially, I like the Ivory 9 for all anterior teeth, and here we are doing a re-treatment so the crown has been removed by the general dentist; it's now provisionalized so Ruddle can come in here very easily and I can gently rock that forced and fused to metal provisionalized crown off the tooth. And when I do that, you can see the clamp in the Ivory 9 is just about a millimeter below the margin. And what that means is that clamp gives you a bulldog grip; and also that clamp then the wings are out of the way. They're left and right of where you're working so your hand piece can come in, your armamentaria can come in, your fingers can come in and you have total control.
So the Ivory 9 – one last thing – get them matt finished. In the old days we sandblasted because they never had clamps that came matt finished, or anodized, which means they're very shiny; they're bright. So microscope lights, tramolucination devices, overhead lights can reflect off that shiny metal and it can be quite annoying to the operator or the dental assistant. So this is a great anodized clamp that's great for all maxillary and all mandibular anterior teeth.
What do I use for bicuspids? For all mandibular bicuspids, maxillary or mandibular, I use the Ivory 9 again; because the wings are out of the way, it has a bulldog grip. Those bicuspid teeth, those cervical areas are thin. So clamps a lot of times will rock and the bowl will awkwardly come back up over the distal marginal ridge of the tooth you're working on, and now you have things in your way. So use the Ivory 9; just take it back. Just take it back, okay?
And when take the bridge off, you can see that this one is anodized only in a small zone from about the ®, the Registered mark down to here; that is so you don't get the nuisance reflection to the operator on the facial side. So that's something to think about there. And of course when you get the bridge off you can see how this clamp grabs just below the preparation margin and those bows are out of the way and I have unbelievable room to come in to the DB – look that I'm coming from the anterior – and I can come from the posterior to get an .08 thread into the MB and I'm doing the buccal systems on this 3-rooted tooth.
Well for lower molars, upper molars, this is the second clamp I use. So I've identified the Ivory 9 and now I'm identifying the Ivory 26. Now incidentally, Hu-Friedy makes a 26, they make a 9. So I'm not so concerned where you get the clamp; it's more the shape of the clamp, the style of the clamp, and if it's matt finished. The 26 has these little tines that curve up, but it really can grab like a half a millimeter below the margin of the preparation; so you can get a bulldog grip and it'll keep the tooth isolated very nicely. So that's pretty much the rubber dam I use and that's the two clamps.
Okay. I think you had one more tip for us regarding how to maintain and/or achieve isolation if there's some leakage.
Oh, did you hear how she worded that?
No, it was perfect.
Like how to maintain a good seal I meant to say.
But she said to maintain a seal; because a lot of times when we first start our treatment we have a good seal, right? Everything's fine. It's when you get about an hour in and all of a sudden if the dam is getting full quite a bit because of the stretch you'll start to see micro tears, micro pores. So I like that when she said either achieve the seal – because when you first put it on it might not be sealed; or it might be sealed when you first put it on but you now need to maintain it. That's very clever. That means you know what you're doing.
So in this case, the bridge is referred in to me about a month after it was accessed on an emergency basis. So when you look at this tooth, you can see that it's been opened; you can see the perforation in the fercal floor; it's got periapical extension; it was an abscessed tooth, so the patient did get comfortable because the colleague did get it open. But regrettably, there was a perforation.
So when I isolated the tooth, that's how it looked. So I'm using my Ivory 26 with the matte finish, but the pull of the dam is straight down from the height of contour on the MD to the DB, and right down that line you'll see the dam is pulling straight. So you might take some OraSeal – some OraSeal caulk – that's an Ultradent product – and squirt that in there. Take a cotton pill if it's moist and just tamp that putty into place to stop the nuisance bleeder or oozer – it's a 2-way street – and to keep your reagents inside the tooth.
But as you work along and you're spending some time addressing the fercal floor perf and you haven't really started your endodontics – remember it had been opened up previously. So what we can do is we talked about the OraSeal, but if you really have a more nuisance problem, you can use a methyl methacrylate light-cured material. And what that material can be done, you can use Opal Dam. Opal Dam can be syringed around the tooth wherever there's a 2-way street. And then you can take your light – Dentsply Sirona makes the smart light – and you can light cure that. They call it a soft bomb because it'll stick to the tooth, it'll stick to the clamp, it'll stick to tissue; but it isn't tenacious, so when you're done you can flick it off really easily and continue with your work.
So those are the tricks, and then of course we can get the perf repaired. You can see the light works and we can get the perf repaired with the composite. That's another lecture at another time, but we'll talk about barriers and how to do perfs; that's coming in the third season. And of course then we're back to we hope the tips helped.
Well great; thank you for those useful tips.
Yeah, keep your questions coming and we'll work your questions into our technique tips.
CLOSE: Being Cliff
Maybe some of you have wondered sometimes what makes Cliff Cliff. So in this last segment of our second season, we're going to bring you some exclusive insider footage of what it's like to be Cliff Ruddle. We call this segment "Being Cliff".
I'm not so sure I'm going to like this segment. I haven't even seen it; I don't even know what's coming. But just like IBM has Watson, endo has Edward. So I have a look-alike and it's Endo Edward.
Okay. So enjoy the segment and we look forward to seeing you late September or early October to start our third season.
See you then.
[Showing Video clips of Cliff Ruddle everyday activities]
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The content presented in this show is made available in an effort to share opinions and information. Note the opinions expressed by Dr. Cliff Ruddle are his opinions only and are based on over 40 years of endodontic practice and product development, direct personal observation, fellow colleague reports, and/or information gathered from online sources. Any opinions expressed by the hosts and/or guests reflect their opinions and are not necessarily the views of The Ruddle Show. While we have taken every precaution to ensure that the content of this material is both current and accurate, errors can occur. The Ruddle Show, Advanced Endodontics, and its hosts/guests assume no responsibility or liability for any errors or omissions. Any reproduction of show content is strictly forbidden.