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Clinical FAQ

Clinical FAQ

Q: The Vortex Blue File 15/.06 is the first file. Wouldn’t I use a #8 or 10 to get a length with apex locator first?

A: You can use the Vortex Blue File15-.06 many ways. You can use it as an orifice widener only until you negotiate to length with an .08 and .10 K-File. You can use it to the apical third, negotiate by hand, and then bring the Vortex Blue File back and cut it to length. Or, like I do, you can let it cut where it will-most often to length-and bring in hand files for negotiation when it won’t because of tight curved canals or impediments.

Q: The finishing file is 30/.06 for most molars.  Do you ever use .04 tapers?

A: 20-.06 is the size I finish 1/3rd of my small molar canals to, 30-.06 is the size I finish small molar canals 2/3rds of the time (40-.06 in one out of 20 small molar canals). When the terminus is tiny, holding to a 30-.06 shaping objective will increase your chances of breaking a file or transporting the canal terminus. Large molar canals-Palatal in upper molars and distal in lowers-are finished in my hands w a 30-.08 or 40-.08.

I only use .04 tapers when I am having trouble getting an .06 taper to length, never for final shape. Finishing with this small taper requires cutting the end to larger diameters to adequately clean canals-a move that significantly increases chances of apical transportation. The only well thought out rationale for finishing with an .04 taper is to limit coronal enlargement-with conventional files having 16mm of flute length-when the root is long and the terminal diameter is large. If you use finishing files with Maximum Flute Diameter limitations-like GT and GTX Files-you can cut any size taper you want without fear of needlessly weakening coronal root structure.

Q: If you were setting up to provide endodontic therapies, what size rotary files would you purchase?

A: For finishing files, all the GTX sizes, but in different proportions. Lots of 20-.06, 30-.06, 30-.08, 40-.08 and just a few of the other sizes. For initial negotiation/initial shape a lot of Vortex Blue File 15-.06’s as they do most of the work cutting dentin.

Q: What are your techniques with Gow Gates injections, especially landmarks for initiation of the injection? 

A: Simply place a long 27 gage needle in the groove of the distal marginal ridge of the upper second molar, head straight back, and you are perfectly positioned for entry. Penetrate the soft tissue 1/8-1/4″ straight in, depositing solution as you go, then move the syringe cross arch and drop it to the mandibular occlusal extent, and slowly move the needle tip toward the medial surface of the ramus (slowly injecting as you go) with the intention of touching it carefully midway between its mesial and distal extents (example: this is easily determined by placing the left side your thumb on the mesial of the ramus intra-orally and your index finger on the distal extent extra-orally). Be sure to aspirate for blood, as this injection technique places the needle near vascular structures-which is good because nerves travel with vessels. This mandibular block method works 95% of the time as opposed to the conventional block technique which works 70%-80% of the time.

Q: I am looking to get more conservative and move away from Protaper. I noticed that with GTX rotary they were slower to cut. Do you have some tip cards on what steps you use and when you would use the hybrid tech with vortex that you have written about?

A: You are correct that GTX Files cut slower than ProTaper and most other non-landed files. That is why I am using GTX after I cut an initial shape with a Vortex Blue 15-.06, then after gauging the use of landed-flute GTX Files is quick, easy, and always true to the original canal path near the foramen. That’s what’s missing from the ProTaper- a way to finish the shape without ripping the curved canal terminii as the F2, F3, etc. do

Q: You told us about using CBCT as an endo diagnostic tool. Which company and what type do you prefer?

A: By far the best CT machine for endo is J.Morita’s R100

Q: I started an RCT on a patient and I was able to traverse past an apical impediment curve with a #10 file and to the length by curving the file tip, and I made sure I map the curve with the mark on my stopper reference and to the curve on the file. No other file bigger than 10 would go in that curve. I have no clue why, I tried widening coronal to the curve, still no luck. What would you recommend should be the line of action from here?

A: Make sure you maintain patency with a #08 and #10 Files. Use the 15-.06 Vortex Blue lightly in the canal, then prebend a 15-.04 Vortex Blue and see if you can thread it to length by hand. Once it is at length click the hand piece head onto it and cut it 1-2 mm long. If the 15-.06 still balks, cut a 30-.08 GTX file short of the curve and fill with an obturator.

Q: Do you prefer GuttaCore of GT Obturators?

A: I now use GuttaCore carriers.

Q: What is your protocol when a case cannot be completed in one day?

A: I use Ultadent’s CaOH to temporarily fill the canals- I like its tiny needle. When the patient returns, I irrigate it out with 17% EDTA.

Q: When I attended your “Art of Endodontic” Two- Day Hands-On course, we went right to a 15.06 Vortex before we put any other files in the tooth, or at least that’s what I did. My question is when working on a live body do we get patent first with .08 to a 10, get working length, then go to 15.06 Vortex to length then go to a 30 .06?

A: I enter each canal with a 15-.06 Vortex Blue File and let it tell me how far it wants to reasonably cut without any resistance. Many times, after cleaning cut debris out of the flute space several times, it cuts to length and I get a righteous apex locator read of length, then after gauging I am just a single GTX File from finished shape.

Conversely, any time the 15-.06 Vortex Blue File balks, I drop the hand piece, pull out an #08 or #10 K-File (this is done with lube filling the access cavity) and confirm that I have a clear path to and through the terminus. After a #15 K-File is worked to length, usually a 15-.06 Vortex Blue File will follow to length as well.

Q: Do you always try to go to a 30 .06 from a Vortex 15 .06 or do you go 15 .06 Vortex, 20 .06, 30.06?

A: I use a 15- .06 Vortex Blue File to length (when possible), capture a length, gauge to determine the terminal canal diameter, and choose the appropriate GTX File to finish shape. Done.

For example, if a #20 NiTi K- File binds at length during gauging  in a small root canal after initial shape has been cut, I use a 20- .06 GTX File and gauge again. Obviously, if a #20 K-File slips through the terminus and a #30 binds short of length, I cut a GTX 30-.06 to length, and gauge again.

Q: Is there a time when you use a 15.04 Vortex or is that too risky?

A: The 15-.04 Vortex Blue Files are very fragile. I use them at 300 RPM with a hand piece set at only 100 Ncm torque limit. If I am using one to cut shape around an impediment, I prebend its tip and use it by hand to finesse it past the impediment. My next move is to click my endo hand piece onto its latch-grip handle and if I successfully get it to length then effortlessly cut it to length.

Q: Working length: when going to the rotaries, do you use the working length that the Morita apex locator finds? I think it is the .5mm mark or do you back off 1mm that mark to use when starting to shape the canals?

A: I measure canal length to the Morita RootZX display “half mm mark” although that descriptor is bogus. At the “.5” mark the file is at the root canal terminus, regardless of Morita’s DFU (directions for use), where they explain that apex locators find the “apical constricture”- they don’t. What electronic apex locators find is where inside of the canal changes to outside the canal, as that is where the conductive threshold changes from little current to significant current as measured by what in essence, is the most expensive meter on earth.

Q: I had a patient come in and the mesial canals were only about 1 mm or less apart at the most and were in the same canal opening. I had a hard time getting files separately in them. How do you shape these canals much less fill them when they are that close together.

A: A #15 hedstrom file, bent and directed into each canal will quickly rip the dentin and open up two separate paths. Canals that have a common orifice usually curve towards each other as they reach the pulp chamber, so a couple of cutting strokes and the orifice will be opened to a buccal and lingual path.

Q: If you get the 10 to length do you go to 15.06 Vortex Blue File? Can you elaborate on this sequencing?

A: In small canals I use the 15-.06 Vortex Blue file until I feel light resistance with a clean file. Then (all this with lubricant in the pulp chamber) work a #08 and #10 K-File to length with an apex locator. Then I see if the #15 K-File will negotiate to length and use the 15-.06 Vortex Blue file again-Nearly always it will.