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Clinical Master Magazine

62 — issue 1/2015 Endodontics Article 2. In posterior teeth, premolars and molars, it is important to remember that their occlusal surfaces are not centeredovertherootstructure,but are skewed towards the idling cusp side of the root structure. As pulp chambers are centered in the root structure,notcenteredundertheoc- clusal surface, access in posterior teethisbestaccomplishedbycutting near working cusps, while staying 1- 2mm awayfrom idling cusps (Fig. 2). 3. In molars, conservation form is held by avoiding the distal half of the oc- clusal plane, as ideal file paths from the distal canals of upper and lower molars are canted severely to the mesial, so much so that distal canals of lower molars are best referenced toMBorMLcusptips,anddisto-buc- cal canals of upper molars are best referenced to palatal cusp tips. Con- venience form is achieved bycutting the mesial wall of molar access cavi- ties, parallel to the mesial surface of the tooth (Fig. 3). Back from the abyss I wastaught Schildertechnique at Univer- sityofthe Pacific byDr. Michael Scianam- bloandaftergradschool,byDr.CliffRud- dle. I understood the clinical imperative Dr. Schilder had placed on cutting an ac- cess cavity adequate to treat the entire rootcanalsysteminapredictablemanner, and I enjoyed working through the large access cavities and the generous coronal canal shapes he recommended, until I was broughtupshortbyDr.CarlReider,awell- known prosthodontic lecturer from SouthernCalifornia.WhenIaskedwhathe mostwantedfromtheendodontistshere- ferredhispatientsto,hesaidhewishedwe could "just suck the pulp out, without cut- ting any tooth structure." As we talked, I came to better understand the structural imperative of saving teeth in the long term, setting me on a quest for tools and methods that would allow us to achieve the same consistently ideal endodontic outcomes through smaller access open- ings and coronal canal shapes. Ultimately, it was the inspiration for my invention of the Maximum Flute Diameter (MFD) lim- itations on GT and GTX rotary files (DENTSPLY/TulsaDentalSpecialties),the LAX (line angle extension) Guided Access Diamond Burs by SybronEndo, as well as obturation methods using flexible con- densationdevices,suchasSystem-BCon- tinuous Wave electric heat pluggers (SybronEndo) and GT/GTX Obturators (DENTSPLY/Tulsa Dental Specialties). The Itty Bitty Access Committee Since that initial awakening in the 80's, it felt like being a lone voice in the wilder- ness until the last ten years, until a new generation of dentists and endodontists, steeped in the new reality of implant den- tistry as an alternative to RCT, and have takenupthecryforlongertermoutcomes through improved post-treatment struc- turalpreservation,becomingagroupIcall TheIttyBittyAccessCommittee.Assoof- ten happens, somebody outside of our specialty, a general dentist named Dr. David Clark, started lecturing on the ac- cess elephant in the endodontic living room. He got mybuddyDr.John Khademi turned on by the possibilities that more conservative access cavities could offer the specialty,4 and one-by-one a group of young endodontists joined the game of who can do a perfect RCT through the smallest access cavity? and became the IBAC club. The cases shown in Figures 4 through 10–mostly done by IBAC members–make meveryhappyandafraidatthesametime. What the heck are they doing? Little, tiny entries,leavingpulpchamberroofsintact, lateral pulp horns unroofed as well, or just total RCT through previously cut restora- tive cavities! After getting over my initial shock at what they were accomplishing, I came to understand that the future of endo is very good in these extremely tal- ented hands, and I saw that the procedure I was developing for endodontic surgery– CT-Guided Endodontic Surgery (CT- GES)–could be applied to conventional treatment as well (Figs. 11 and 12). And morning breaks over the field of Endodontics. Editorial note: A complete list of references is available from the publisher. Fig. 4 Mandibular molar with nearly total calcification of the pulp chamber prior to RCT, accomplished through two perfectly dead-on ac- cess entry ports, leaving a .75mm high pulp chamber isthmus between. Note the definitive treatment results in the apical thirds of each canal (courtesy Dr. N. Pushpak). Fig. 5 Postoperative radiograph of a mandibular molar treated through the mesial carious defect and a second small entry cut through the cen- tral fossa. Preserving dentin between entry points is re- ferred to as a "truss" access configuration (courtesy Dr. John Khademi). Fig. 6 This postoperative radi- ograph shows a very diminutive access cavity opening with both mesial and distal lateral pulp horns unroofed during the RCT procedure, and filled during the postendodontic restorative effort. This ap- pearance is a matter of pride among those in the "IBAC" club (courtesy Dr. Jeff Pafford). Fig. 7 Access cavities cut in a mandibular molar requiring RCT (left). Postoperative radiograph (right) showing beautiful management of root canal shaping, clean- ing, and filling--despite the minimal size of entry. Note the largely remaining pulp chamber roof (courtesy Dr. Steve Baerg). Fig. 8 This restored access cavity design was opportunistic in the best sense of the word. This patient's endodontic disease state was resolved with almost no tooth struc- ture being cut and the post- operative structural in- tegrity of a tooth with only a mesial operative restora- tion. No need for a full-cov- erage crown (courtesy Dr. Michael Trudeau).

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