The New Science of Strong Endo

Teeth
Category: Restorative Created: Tuesday, 09 April 2013 13:51 Written by David Clark, DDS; John Khademi, DDS, MS;
and Eric Herbranson, DDS, MS

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INTRODUCTION
Are today’s typical endodontic accesses as outdated as the typical G. V. Black cavity
preparations that remain the current standard? Sadly, yes.
There are several impediments that have stopped progress and left endodontic
access in the dark ages. Whether gouged by general dentists (Figure 1) or “gutted” by
endodontists (Figure 2), the damage is seemingly everywhere and it is irreversible. Similar
to outdated restorative cavity preparations, there are scant resources to devote to the
monumental task of changing the way that we cut teeth. The money is in products. Witness
the incredible advance in implants. When billions are at stake, change happens. In
contrast, dentin and enamel have no advocates, no budget, and no slick advertising
campaigns.
SS White Burs president, Tom Gallup, has made a generous donation to begin a
new textbook, Contemporary Endodontic Access (Figures 3 and 4). This article will contain
excerpts from the upcoming textbook.

Figure 1. Upper and lower Figure 2. Somehow pleasing

incisors badly gouged by
round burs; exacerbated by
cingulum access.
to the eyes of many
endodontists, these pre-op and
post-op radiographs
demonstrate the
“superhighway to the apex”
philosophy. As a restorative
dentist, these hollowed-out
 teeth seen in the radiographs
should elicit an immediate
visceral response; nervous
about any hope for longevity,
and a sick feeling for the tooth
and the patient.

Figures 3 and 4. Covers of Contemporary Cavity

Preparations and Contemporary Endodontic Access
textbooks (soon to be published).
Why Does Endo Access Remain in the Dark Ages?
Endodontics was first recognized as a specialty by the ADA in 1963. From that point on,
endodontists were essentially handed the keys to the kingdom, and were charged with
endodontic shaping design. Interestingly, the cavosurface portion of G. V. Black style
accesses that endodontists inherited remain largely unchanged. Endodontists have instead
been very apex-centric in their focus of endodontic shaping. Most troubling has been the
recent shaping change; grotesque straight-line access, carving a superhighway to the apex.
Sacrificing and obliterating massive amounts of tooth structure is in vogue today. This
machined, man-made shape is referred to as “the look.” This was done without outcome
studies that validated this extravagant expenditure of tooth structure. In a landmark
literature review, apical shaping size and canal taper had no significant relation to better
outcomes.1 To summarize: Big shapes don’t create better outcomes. They do, however,
weaken the tooth badly.
THE NEW LEXICON OF ENDODONTICS
As we seek to redesign endodontic access, it is crucial to create a new lexicon (an
endodontic dictionary of sorts). In this article, we will discuss the new terms: soffit,
pericervical dentin (PCD), orifice enhancement, and dispense with an oft abused term,
endodontic shaping, and replace it with endodontic instrumentation.

The Pulp Chamber Soffit

In architecture, a soffit is described as the underside of a ceiling, at the corner of the ceiling
and wall. The chamber of a young molar tooth is bounded by a roof, 4 walls, and a floor
with small orifices that are arranged along the edges of the floor like pockets along a pool
table. One of the silly rules (taught for decades) is that the entire roof of a chamber needs to
be removed during endodontic access; or, you are a sloppy and lazy dentist. We absolutely
refute that position. Today, when considering endodontic access, a worthwhile goal is to
maintain a small border amount of the chamber roof; near the point where it curves 90° and
becomes the wall. This tiny “lip” or “cornice” could be as small as 0.5 mm, or as large as
3.0 mm in some cases (where extra strength is needed, or when the anatomy allows it).
There are several reasons why an increasing number of clinicians are embracing this
concept (Table).

Figure 5. Dotted line shows

the typical cut made to remove
the entire pulp horn. Area
between the lines should be
maintained and is referred to
as the soffit.

Figures 6 and 7. Stiffness and resisting to bending are basic

engineering principles. The distance from the “centroid” to
the flange areas of both the tooth and the I-beam determine
resistance to bending.
 Figure 8. Endodontists invited
to the SS White Modern
Endodontic Consortium.
Doctor participant names are
listed in reference section.
Their recognition of site-
specific dentin preservation
and commitment to long-term
tooth retention, as evidenced
in Figure 9, a glowing
example of excellence
trumping expedience.

Table. The Pulp chamber Soffit

Superstition-based beliefs Fact-based understandings
1. Complete roof removal is required 1. Orifices are arranged along the
to visualize the orifices of the canals. periphery of the floor at the floor-
floor interface, not hiding along the
roof-wall interface.

2. Complete removal of the roof 2. Complete roof removal invariably

allows complete pulp removal, leads to gouging of the chamber
especially of pulp horn tissue. walls, in fact requires removal of wall
dentin.
3. Complete roof removal is required 3. Straight-line access is itself being
for safe straight-line access. redefined as we form this new model
of access, but even in its old
fashioned sense has no need for
complete roof removal per se.

4. Just put a crown on the tooth after 4. The roof wall interface likely
endo to make the tooth strong. Most provides natural strength and stiffness
of the dentin is expendable. to the tooth. Future studies and finite
analysis are indicated.
Soffit (as used here within the context of describing dental access procedures) is a
term that Dr. Khademi coined, and is an excellent descriptor (Figure 5). The preservation of
the soffit and its comparison to the second moment of area is shown in Figures 6 and 7.
The Science of Bending
The second moment of area (also referred to as second moment of inertia or mass moment
of inertia) is a mathematical representation of an I-beam’s resistance to bending. The value
relies on the cross-sectional area and the location of the centroid. The design of an I-beam
resists bending, even though it has huge hollow areas. When the flange of the I-beam is a
good distance from the centroid, the second moment of area is great and the I-beam resists
bending. Roughly speaking, the further away the tip of the flange from the center, the
stronger the I-beam.
We do not want our teeth to bend and flex at the cervical area, which for
demonstration purposes is identified as the centroid of the tooth. It (the cervical) is the most
common area of occurrence for fracture failures in endodontically treated teeth (endo
teeth). When brittle items such as teeth start to bend, they easily break. The myth of
endodontic teeth being brittle may finally be explained in over-torqued dentin that slowly
degrades until it finally fractures years (or decades) later. The endo tooth doesn’t dry out,
but a hollowed out endo tooth is constantly bending. When robust coronal dentin is
maintained good distances away from the tooth’s centroid, the tooth is stiffened, resists
bending, and should resist fracturing. An additional component of the soffit, aside from a
second moment of area, is the strength that is inherent in a continuous ring of dentin that
can act like a metal barrel ring around an oak barrel.

Figure 9. This mural features post-op radiographs, demonstrating the preservation of

the roof-wall interface (or soffit). These cases are a small sample of the exquisite
work done by the endodontists in Figure 4.Notice the small shapes, and preservation
of key dentin.

Figure 10. If the pulp chamber

is indeed sufficiently large
enough, then a round bur can
truly “drop in” to the pulp
chamber; as shown here with a
No. 6 round bur superimposed
on the lower molar of this 11-
year-old child. How often does
that happen?

Figure 11. SS White High- Figure 12. Especially safe and

Speed Tapering Diamond
Burs; some in surgical length,
designed for endodontic
access. These replace round
burs.
useful for general dentists is
the slow-speed surgical length
latch grip diamond bur which
is compared to old fashioned
No. 4 round bur. (left) It is a
perfect replacement for
iatrogenic latch grip surgical
length round burs. (The kit is
shown in Figure 13.)

Figure 13. Clark Khademi Figure 14. Pericervical dentin

Endo Bur Kit (SS White) with is the most common area for
burs from Figures 12 and 13. catastrophic root fractures and
 catastrophic restorative
failures. It is also an area that
is gouged, abused, and often
mutilated by clinicians who
use the wrong burs (round burs
and square-ended 557 carbide
burs) and overuse of outdated
burs (Gates Glidden burs).

Figure 15. An uncalcified

tooth such as this has a natural
“funnel” and often needs no
orifice enhancement. A
calcified tooth, on the other
hand, will benefit from the
creation of a small polished
cone shape, which is
best created with a conical
carbide such as the Endoguide
bur (SS White).
 Figures 16 and 17. Figure 16 shows the sequence of tapering diamonds and then the
EndoGuide Bur (SS White). Figure 17 demonstrates just touching the canal orifice to
flare it slightly; then the transition into the access prep is made smooth by wiping the
bur up with lateral pressure, away from the furcation. This enhancement will make
the rest of the procedure easier and worth the time that it takes to create.
A talented group of endodontists, assembled at the behest of the 3 authors of this
article, recently met at the first SS White modern Endodontic Consortium2 (Figure 8).
There was an overwhelming consensus on the issue of preservation of the soffit. A mural of
their cases is presented in Figure 9.
Multiple studies have shown that removal of dentin weakens both the root and the
crown, leading to lower load failures. Further studies examining site-specific dentin
conservation are warranted. However, until that time, we must use common sense and
accepted engineering principles when deciding which dentin to sacrifice, and which dentin
to conserve.
Dr. Khademi: Why Round Burs are so Dangerous
The traditional way of performing endodontic access is predicated on mental models
derived from chalkboard constructs that no longer represent the day-to-day clinical realities
presenting to the clinician, if they ever represented those realities. Yet text after text
continues to show the same chalkboard constructs in the form of drawings of round bur
access technique relying on tactile feedback as the round bur “drops in” to the chamber.
I was always baffled by these kinds of drawings because they didn’t seem at all like
the cases I was seeing. Clearly, from a strict geometric argument standpoint, for the bur to
truly “drop in” to the chamber, the chamber height needs to be larger than the height of the
bud of the bur, just as they have been drawn (ie, made-up) here. While that happens
routinely when drawing these things on a chalkboard or PowerPoint presentation, it hardly
seems to happen on real patients.
It wasn’t until I lectured with Dr. Clark and the 2007 New Jersey Association of
Endodontists Meeting when I saw this case of his (Figure 10) that I realized from where
these bankrupt mental models might have come. Images like these, so frequently shown in
dental schools, textbooks, and lectures are predicated on mental models based on occlusal
decay in children.
Presuming one could drop into the pulp chamber in the way drawn and described in
Figure 10, the chamber roof is now to be removed by scooping it up and away with the
backside of the round carbide. A 2-dimensional (2-D) drawing with the relatively small size
of the bur and chamber roof overhanging a large pulp chamber makes this seem like a
reasonable proposition. The chamber walls are always drawn flat even though they are
point-cut by a round bur.
In reality, it is truly impossible to cut flat walls in 3 dimensions with a round
instrument. The difficulty is demonstrated by attempting a simpler 2-D version of flattening
the occlusal surface of a tooth in-hand with a round bur, then examining it under
magnification. If we wanted to flatten the occlusal surface, it would make much more sense
to use an instrument that already has a flat shape, like a wheel diamond.
What happens clinically is that the chamber is not unroofed in some areas, leaving
pulpal and necrotic debris (which is not such a big deal), but that was the purpose of the
procedure; and the walls are overextended and gouged in other areas. Further, the internal
radius of curvature at many of the pulpal line angles is simply too small for all but the
smallest of round burs. As an endodontist seeing cases for retreatment, a feature of the
previous access attempts with these instruments and mental models was the consistent
gouge-up of the chamber walls and floors, and chambers full of debris. So the technique
didn’t work anyway.
In the final analysis, round burs point cut in an endodontic access application, when instead
what is needed is planing.
What is needed is a new set of mental models based on vision, and a new set of
instruments reflective of the task at hand and the desired shaping outcomes. The new
vision-based mental model is look, groom, and follow. The new instruments are all round-
ended tapers (Figures 11 to 13).
The rounded ends are to increase the radii of the gouges and nicks that can act as
stress concentration points. The flat sides help create smoother, flatter walls and minimize
the gouges and dings that inevitably occur even with the most careful technique.
Pericervical Dentin
Pericervical dentin is a term that we first described in 2008. Pericervical dentin is an area
roughly 4 mm coronal to crestal bone and 6 mm apical to crestal bone (Figure 14). It acts as
the “neck” of the tooth and is key because it transfers occlusal forces to the root. In the end,
strong, unmarred PCD trumps just about everything else in long-term retention of the tooth.
Endodontic Instrumentation Versus Endodontic Shaping
The problem, according to one of the endodontists in the MEC group (Dr. Steve Baerg of
Tacoma, Wash), is that the term endodontic shaping is a poor choice of words and should
be replaced with the term endodontic instrumentation. Ideally, we would prefer to just suck
out the pulp, irrigate, and then obturate. An unenlightened work ethic demands that we
need to grind and reshape the tooth. Simply massaging a small hand file in a young patient
with a naturally ideal canal space, say a maxillary central incisor, then irrigating and
obturating may feel like cheating.
Dr. Herbranson: Orifice Enhancement
We prefer the term orifice enhancement to orifice enlargement. The transition between the
pulp space and the canal system in a young uncalcified tooth forms a natural “funnel” into
the canal system (Figure 15). This makes finding the canal fairly easy and allows
endodontic files to easily slide into the canal. It is one of the main reasons endodontic
procedures are easier on young people. However if the canal space is calcified, which is too
often the reality, this does not exist. In that case, it is prudent to recreate the funnel
mechanically. It will make your life easier for the rest of the procedure. This is a delicate
operation and must be done with the understanding that any dentin removal should be
minimal and away from the furcation. The dentine is thin toward the furca and robust
toward the external surface in this area. Traditionally, this has been done with Gates
Glidden burs, but it is easy to overdo it with that system, and we see lots of examples where
their use was too aggressive. Today, a better solution is found in using a small, cone-
shaped, low-speed bur (such as the EG2 [SS White]) (Figures 16 and 17).
IN SUMMARY
Clinical Recommendations Two questions invariably come up:
How do you get the pulp out of the soffit/pulp horn? The answer is a back action explorer,
with a little patience. Worst case, we have disassembled dozens of teeth where scraps of
pulp were inadvertently left in chambers and it has not seemed to affect the tooth adversely,
even after decades.
How much is too much soffit? In our hands-on courses, we have seen a tendency to
leave excess soffit in one area, and gouging in another. It is better to leave a tiny 360° soffit
and make a safe environment for a GP, than to be a “hero” and overdo it, compromising
with gouging elsewhere and creating impossibly difficult working conditions within the
tooth.
When it comes to endodontic access and directed dentin conservation, each case
must be titrated. Opportunistic access, creativity, and a long view of the structural integrity
of the dentin must be foremost in our minds. The time has come to integrate modern
engineering to help design a strong endo tooth that will withstand the forces of occlusion
and the detrimental effects of disease.

References

1. Ng YL, Mann V, Rahbaran S, et al. Outcome of primary root canal treatment:

systematic review of the literature—Part 2. Influence of clinical factors. Int Endod J.
2008;41:6-31.
2. Honored KOL Endodontists at the SS White Modern Endodontic Consortium: Drs.
Steven Baerg, Marc Balson, David Clark (GP), Robert Corr, Mitchell Davich, Glen
Doyon, Eric Herbransen, John Khademi, Jihyon Kim (GP), Charles Maupin, Pushpak
Narayana, Jeffrey Pafford, Michael Trudeau, Scot Weed, Rahim Karmali. November 30
to December 1, 2012. Half Moon Bay, Calif.

Dr. Clark founded the Academy of Microscope Enhanced Dentistry, which is an

international academy formed in 2002 to advance the art and science of microdentistry,
microendodontics, microperiodontics, and dental microsurgery. He has also developed the
Bioclear Matrix System, a comprehensive, tooth specific, clear anatomic matrix and
interproximal restorative system. He can be reached at drclark@microscopedentistry.com.
Disclosure: Dr. Clark is the owner of Bioclear Matrix Systems and is a consultant to SS
White Burs.
Dr. Khademi is an endodontist and pioneer of restoratively driven micro-endodontics. He
can be reached at jkhademi@mydurango.net.
Disclosure: Dr. Khademi is a consultant for SS White Burs and Caresteam Dental.

Dr. Herbranson earned a BS from La Sierra College, a DDS from Loma Linda University,
and an MS in endodontics from Loma Linda University. Dr. Herbranson is a cofounder
and, until recently, was the executive director of Brown & Herbranson Imaging, a company
that develops dental and human anatomy education software under the eHuman moniker.
He is also the developer of the Xmount series of microscope camera mounts. With more
than 30 years in practice, Dr. Herbranson is a dedicated clinical endodontist. He has made a
significant contribution during the last 20 years as clinical assistant professor at the
University of the Pacific School of Dentistry, where he lectures to students and special
interest groups on endodontics, technology in dentistry, and microscope photography. His
study of physics and 40 years of experience in film and digital imaging provide him with an
educated understanding of macro- and microphotography, and afford him a unique vision
of endodontic education and image production. With his innovative approach and advanced
imaging skills, Dr. Herbranson developed the unique processes and methodology for
capturing images of human and dental anatomy now used as the basis for Brown &
Herbranson Imaging’s educational technology. Dr. Herbranson is the coauthor of the
chapter on tooth anatomy in Pathways of the Pulp, and is a frequent speaker and educator at
universities and conferences on the subjects of integration of new technology into dentistry,
the use of software and computers in presentations, and surgical operation microscope
photography. He can be reached at eherbran@hotmail.com.
Disclosure: Dr. Herbranson is a consultant for eHuman and SS White Burs.