Tuesday, September 27, 2011

Endo Re-treatment of Sybron Endo's Real Seal 1


Endo retx1.jpgEndo Retx2.jpg
Endo Retx 3.jpg
I absolutely love endodontics!!! For the non-dentists reading this, that is "dental speak" for root canals.
One of the great things about my  speaking and consulting career, is that it gives me opportunities to get to know some really great people in my beloved profession.  Because of that I've gotten a chance to know some amazingly talented endodontists and to pick their brains about the best way to do things.   Due to this, I've found that i have a great love of the field of endodontics and absolutely fell in love with providing the best endodontic services that I could. This means that I don't refer out very frequently... I think it has been once in the last 5 years.  I also do a fair number of retreat services in my practice.
Also, because I love doing root canals and I also love helping companies develop new products and new techniques, I had a great opportunity about 5-6 years ago to be involved with the development of a unique obturation system.
At the time I got involved with the project, Pentron Clinical Technologies had brought an endodontic product called "Epiphany" to market.  Epiphany is a synthetic material that mimics gutta percha which had long been the gold standard of endodontic filling materials.  The material's generic name is Resilon and It was starting to make some serious in-roads into the profession.  It is a material that looks and handles very much like gutta percha, however it bonds to the tooth structure of the root like a composite (white) filling. This means that there is considerably much less bacterial leakage and the odds of a successful procedure go up because of that.
However, there is a certain percentage of the dental profession that prefers to use obturators to fill root canals and Pentron was working to enter that portion of the endodontic market as well.  The idea of "root canal filling material on a stick" had been a popular one for several years.  Tulsa Dental had provided a filling system for literally millions of endodontically treated teeth by developing Thermafill in the late 1980's.  It effectively changed the way endodontics was filled and brought the idea of general dentists doing root canals into mainstream dental thinking.
For years one of the biggest drawbacks to carrier based obturation was the carriers themselves.  The leader in carrier based obturators, Tulsa Dental Specialties, had originally used metal carriers and then moved over to plastic.  These rigid carriers were coated with gutta percha.  The carriers were placed in a warming oven which softened the gutta percha.  After placing the sealer, the carrier was placed into the canal and used to drive the softened gutta percha into the canal in a 3D filling.
The problem with these carriers was on the rare occasion that a re-tereat procedure was necessary.  At that point in time, it was necessary to removed the carrier which could be difficult & frequently impossible.  To put it bluntly, it was very easy to get carriers into teeth, but usually it was extremely difficult to get them back out of the teeth.
Pentron approached this problem in a different manner.  When dealing with a non-carrier based re-treat a solvent of some type was used to soften the gutta percha which made it much easier to remove.  When Pentron developed Resilon, they had made a conscious effort to make it as much like gutta percha as possible... only better.  One of the ways they had worked to help make it acceptable to the profession is that the same solvents that worked with gutta percha also worked with Resilon/Epiphany.  This made re-treatments very straightforward and helped the profession accept Resilon as a viable alternative to gutta percha.
So... when the idea of a carrier based Resilon obturator was being discussed, it was decided that it needed to be easy to re-treat as well.  To accomplish this, Pentron used a plastic obturator that was soluble in the same solvents that would be used in a normal re-treatment scenario.  The idea was beautiful in its simplicity: make the carrier soften in the same way, using the same solvent, that worked on non-carrier based re-treatments.  When Pentron sent me one of the early prototypes just so I could get an idea of what it would look like, I excitedly placed it in a coffee cup with a small amount of solvent.  I returned to my desk a few minutes later to find the obturator as a gooey blob in the bottom of the cup.
So where is this story leading?  Well today, I had to do a re-treatment on a Real Seal 1 case.  The first radiograph shows the obturator in place and a periapical lesion present.  The third radiograph shows the tooth after the obturator has been removed and patency obtained.  While I usually do most of my endodontic cases in one visit if possible, I chose to do this one in 2 appointments since it is a re-treatment and I want to make sure that all is well before filling.  This radiograph shows calcium hydroxide in place (Ultradent's  Ultra Cal) with a nice puff of the CaOH in the radiolucency.  I'm confident this one will heal nicely, especially since the CaOH shows that patency was achieved.
However, what I think is the coolest part of this whole case is the second radiograph.  In this view you can clearly see that all of the Real Seal 1 has been removed as well as the sealer.  This was accomplished using Eucalyptus oil as the solvent.
In order to remove the obturator, we achieved access and placed Eucalyptus oil in the chamber.  This sat for about 5 minutes and then a Gates Glidden #2 was used to removed some of the filling material.  After the GG, I used hand files in the Sybron Endo M-4 Safety Handpiece to help removed more filling.  We copiously irrigated with Eucalyptus and carefully worked hand files down to the apex.  We frequently checked our length with the Sybron Elements Apex Locator and when we were within 2 mm of the apex we began very careful hand instrumentation to remove the final 2 mm and to gain patency.
Once patency was achieved, a Sybron Twisted File .08 taper was used with more Eucalyptus for  final removal of the obturating material.
For anyone who has ever had to retreat a carrier based canal system, you know how difficult it can be.  This case will hopefully be a reassurance that Real Seal 1 cases can be less stressful.
Also a "hats off" to Tulsa Dental for their new GuttaCore product.  This new carrier uses 2 types of gutta percha, one as the carrier and one that softens and is used to obturate.  Removing these should be as easy as removing gutta percha alone.
Questions or comments?  I'd love to hear them.


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