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Endo/Buildup/Crown SystemWARNING: I am not an endodontist. I am just sharing what I do in my office. Never treat a case you dontfeel comfortable with.

But, I would recommend trying to get comfortable more often.

This article is in response to the multiple requests I have gotten lately about how to work in root canalsinto an already full schedule. Years ago I worked with Scott Perkins when he was developing his 15 minuteMolar Root Canal technique. Honestly, I am not that fast. I have gotten to the point, though, where I canvery predictably do a Root Canal, Buildup, and Crown in about 45 minutes.

Scott always knew that his techniques would have to be modified for calcified canals and he and I talked atlength about the need for a Calcified Canal Protocol. As far as I know, he never published one and aboutthat time, I fell in love with a technique I learned at a different seminar. I later meshed what I alreadyknew with the new things I learned and this is what I came up with. It has been more successful in myhands than any other technique I have ever used and has allowed me to really cut down the procedure

time. I have also been able to use this sequence so predictably that I now use it on every root canal, everytime unless there are special circumstances.

Now I am going to share with you my Endo/Buildup/Crown System. Ive only shared this system o ncebefore, so unless you were in the audience in Clarksville, TN, last year you have not likely heard of anythingexactly like this. I am going to cut to the part of the presentation where we have already diagnosed anddone all the office stuff required to give us the green light to go ahead with a needed root canal.

1. Give anesthesia. Then I leave the room to catch up on what s on the Route Board for a couple ofminutes while the anesthesia soaks in.

2. Assistant makes temporary stent. For this we use a plastic triple tray (the cheapest we can get thatworks) because the quality of impression isnt as important for the tem porary as it is for the masterimpression. We also use stiff bite registration material for this temporary impression. We use the fastset for two reasons. First, its fa st. Second, it is what we use for the first stage of our masterimpression and I like to keep different materials to a minimum. It just simplifies things.

3. When I come back in, the first thing I like to do is remove decay. I dont like the idea of pushingdecay into the canal system I just cleaned out, so why not just get it out of the way now. It will alsogive you an idea of any challenges you will run into later when its time to restore the thing.

4. Place Buildup. This is a wonderful time to place the buildup into the huge hole you just made in thetooth when you removed the decay. It is a good time to get a good marginal seal with bonded resin.You can place a tofflemire retainer here and not worry at all about the contact. Just fill it up, cure it,and take off the band.

5. Break the Contacts. This is done here to allow the rubber dam clamp to create a better seal. Tworeasons you might want that are to keep saliva from contaminating the working area and to keep allthe bad tasting st uff out of the patients mouth while you are irrigating and using the Sonic. 6. Placethe Rubber Dam. Make sure that if you are using a mouth prop you do that before placing the dam. Icant tell you how many times I have I have pulled the clamp off the tooth trying to get a bite block inonce I already had the clamped rubber dam in place.

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7. Access. This is a very important part. Obviously you want to get good access without perforating orany other disaster. I always tend to err on the side of having the access too big, rather than too small.Make that thing big enough you can see. With todays bonded core buildups there is no reason for atiny little access. Dont try to show off here.

8. Working length. For this I use the apex locator. I use a Root ZX from J. Morita and I love it, but Iam not recommending it exclusively bec ause I dont have experience with any other. I cant imaginegoing back to the old days of shooting a film with the file in place, even if you do have digital. I get theworking length by working a 0.06 or 0.08 hand file down to the proper working length with the apexlocator clip in place on the shaft of the file. Another note is that with this hand file and every rotary orhand file I use afterwards; I lubricate it with chlorhexidine gel, better known as KY Jelly. No, do notuse the warming kind! Just plain old simple KY Jelly.

9. Unclip the apex locator and leave the hand file in place in the canal. Obviously, you would do thisone canal at a time in a molar or multiple rooted premolar.

10. Attach a reciprocating slow speed handpiece attachment to the handle of the hand file while it isstill in place inside the canal at working length. This is a little tricky at first and requires some hand

eye coordination, but you will get the hang of it after a while. I use two different models of thereciprocating handpiece. One is called the EndoGripper. I picked it up at one of Kit Weathers RootCamp seminars. The other is made by NSK. They seem to be essentially the same thing.

11. Back the hand file out of the canal to create a glide space for more files. Be careful as you workthe file backwards out of the canal. Sometimes it is hard to back out if the canal is especially calcifiedor curvy. In this rare case you might have to unattach the handpiece head and work it out with yourfingers. After some practice you can usually figure out which ones will need this by the degree ofdifficulty in getting the file to working length at the apex.

12. Now place more hand files in the reciprocating handpiece starting one color above the one you

used for the working length and work in down to the working length. For example, if you used a pinkhand file for the working length, now use a gray file for the next one. If you meet resistance, dropback to the file that did go to working length.

13. Try to get all the hand files down to the working length up to the red size 25 file. This is usuallynot very hard to do. By this time most of the pulpal tissue should be gone from the canal system.

14. Use the Sonic handpiece from Medidenta on each canal. I use a Rispisonic file #15 in the Sonic so Iknow it will more easily go to the working length. Use it for several seconds in each canal withcopious water spray. I figure the more water the better here to flush everything out. I do this forbetween 15 and 30 seconds for each canal. If you have never used the Sonic handpiece, you are in for

a treat.

15. Next, I use the Crown Down technique with Tulsa GT Profile files. I try to get a #35 down to theworking length. Once again lubricating with chlorhexidine gel. I cant always get a file that big toworking length, but I try. At the end of this, the canals are pretty much clean and finished.

16. But wait, theres more. Now, I irrigate the canals with Sodium Hypochlorite. After this, I leave theNaOCl in the canals and turn the water off the Sonic Handpiece with the same #15 Rispisonic file.Now, I run the Sonic in each canal to agitate the NaOCl and aid in the cleaning of the canals. The

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Sodium Hypochlorite will dissolve any leftover tissue tags hanging around in the canal. If it doesntget them all, i t will get more than if you didnt do it.

17. Next, rinse and dry the canals with paper points. Sometimes in the drying process you continue toget a little red tip on the paper point. Not abscess material, mind you, but just a little blood. Maybeyou over instrumented or something. In this case I will dip the tip of the paper point in astringident (Iuse Cuttrol) and place in back in the canal. After just a couple of seconds the bleeding should havestopped. When I do this, I try to use the Sonic again to clean out any Cuttrol, then redry.

18. Once clean and dry I fill the canals with a Master Gutta Percha point that is the same taper as thelast rotary file I got to working length. I make sure I have tugback, then place with AH Plus sealer. Ihave used this technique with AH 26, EZFill, and AH Plus. I have had no remarkable difference inresults with any of the sealers.

19. Now its time for the x -ray. I get up and leave the room to clean off a few priorities from theRoute Board while my assistant takes the check film. I certainly like to have a good fill film with thatrubber dam in place and visible on the x-ray. We use digital SUNI sensors in my office.

20. When I get back to the room, I check the screen to see if it looks good. If it does I use a heatedGlick (old school) to sear off the excess Gutta Percha.

21. Then, I use alcohol on a microbrush to clean any leftover sealer from the floor of the pulpcha mber. I rinse it off and its ready to bond.

22. I use G-Bond and my one-step bonding agent. After the bonding agent is applied, I cure it with my3 second light. Remember, ideally we are only filling the access hole.

23. Now, I use Build-It for my dual cure buildup material. I place that and cure that for 3 seconds.Now, we are ready to prep.

24. Prep the tooth. I have in the past used tooth Carbide burs, super sharp diamonds, very coarsediamonds, or some combination thereof in an electric handpiece or air-driven handpiece. For now, Ihave come to the conclusion that none of these have a serious advantage over the other in a real-lifesetting. Use what makes you feel good here.

25. Finish the margin. I now only do two margins on the facial of any prep. Mostly, I do a featheredge and place it subgingival. I have not found it to cause any of the gingival problems you readabout. If I am concerned with aesthetics, I do a porcelain shoulder margin. If I do the all porcelainmargin on the facial of a PFM, I make sure to wrap it to the mesial and distal to make sure you dontget that ugly dark line where the PFM meets the tooth root. For the All porcelain margin, I use a GW2toothed Carbide bur to refine the flat gingival portion of the shoulder margin. For some reason I like itbetter than any round ended diamond or even the barrel shaped diamonds that are flat on the end.

26. Check the clearance of the bite visually. There are any number of ways to make sure you haveprepped enough, but after thousands of crowns, I think looking is good enough.

27. Reach for the GunRack of impression material on your template. Remove the Gun with the Biteregistration material and take the FIRST IMPRESSION. This is done with the 30 second fast set BlueVelvet bite impression material that you used back in step 2 for the temporary stent. You fill a triple

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tray on both sides with the bite material (I prefer the metal ones from Clinicians Choice, but I have noreal empirical evidence that they are better).

28. Have the patient bite down all the way into this triple tray impression. You can check the bite tomake sure the occlusion is correct by pulling back the cheek to see if the occlusion is correct on theopposite side, or if anterior, make sure that the posteriors on both sides are in maximumintercuspation. Sometimes a little trick I use if you have a patient with third molars getting in the wayis to place the triple tray into the patients mouth and have them only close h alf way down. Thenreposition the triple tray until the back metal loop goes distal to the last tooth in the arch. Then havethem close all the way down.

29. Remove the triple tray with the blue bite material after 30 seconds. This will almost certainlyhave blood and saliva all over it. What I like to do here is to quickly rinse and dry the first impressionin a little pede stal sink that I have installed on the doctors side in all my doctors operatories. I dothis quickly. Some people teaching this technique have you either leaving the opposing arch in themouth and applying the wash directly onto the tooth, or adding the wash and reinserting it withoutcleaning it first. I found that my way decreases the YUCK factor. Maybe that leads to a couple ofextra referrals a month.

30. Then I use an interproximal carver (amalgam instrument) to cut away all the undercuts andinterproximal impression isthmuses from the blue impression on both the prep and opposing side.Then I cut pressure channels into the impression in the prep area at the mesial and distal walls of theprep. Once you have done this, you will have 2 Vs on the mesial and distal of the prep in theimpression.

31. Fill the prep side of the triple tray impression with your wash material for your SECONDIMPRESSION. I use SnoWhite that I purchase from KISCO for that. It sets in 30 seconds. I have usedlots and lots of different washes in the past. After much experimentation I found the 30 second to beas accurate as any of the rest of the stuff. There are 2 different 30 second washes from KISCO. Youcan use the yellow, but I have found it too viscous to get an accurate bite registration. The SnoWhiteseems to flow better in my hands.

32. Place the impression back into the patients mouth and have them bite back down.

33. Check the occlusion by pulling back the cheeks the same as in step 28. If it looks good you aredone. If you see some space where it shouldnt be, tell the assistant to take a bite registration oncethe impression sets up and they remove it.

34. You are now out of there. Get up, give any last minute instructions, exchange pleasantries withthe patient and get.

35. Go to the Route Board and Focus on the next patient to treat. The assistant will remove the tripletray and then make a temporary using a Bisacryl material (any of them will do) and cement the temp.For cement we use Sensitemp from Sultan. It wont come off unless there are dire circumstances.

There you have it. My own double naught spy secret endo-buildup-crown technique that I use every singleday. Like I said last week, this is a great service to offer a patient in pain. This, along with the ability tooffer extractions, give you a great one-two punch to offer the patient in pain.

Go ahead and give my technique a try, then let me know how it worked out.