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Dentin Conservation
Written by David Clark DDS and John Khademi DDS MS
The authors are Dr. David Clark, a general dentist and pioneer in Biomimetic Microendodontics and Minimally Traumatic Restorative Micro-
dentistry; and Dr. John Khademi, an endodontist and pioneer of Restoratively Driven Micro-Endodontics. Together they explore the Endodon-
tic-Endo-Restorative-Prosthodontic (EERP) continuum. This article focuses on the pervasive endodontic problems vexing patients, restorative
dentists and endodontists. The authors provide alternative models and thought processes to treat the tooth in a non-traditional approach -- from
cusp tip to apex. Finally they will propose immediate tools to implement these important changes.
During patient treatment, the clinician needs to con- In both of our practices, our endodontic goals and arma-
sider a multitude of factors that will affect the ultimate mentarium have been in a constant state of flux for nearly
outcome. In simple terms, these factors can be grouped a decade as we have collaborated to bring the EERP con-
into three categories: the operator needs, the restoration tinuum to maturity. The goal? To satisfy the demands
needs, and the tooth needs. The operator needs being of the afore mentioned big 5 forces for change. In so
conditions the clinician needs to treat the tooth. The doing we have come to realize that when cutting end-
restoration needs being the prep dimensions and tooth odontic access our previous needs as dentists were often
conditions for optimal strength and longeity. The tooth in conflict with the needs of the tooth.
needs being the biologic and structural limitations for a
treated tooth to remain predictably functional. In this The Hierarchy of Tooth Needs
article we want to discuss failures of endodontically This table (left) represents
Table 1
treated teeth that occur not because of chronic or acute The Hierarchy of Tooth Needs the hierarchy of needs to
apical lesions but because of structural compromises to for Anterior Teeth maintain optimal strength,
the teeth that ultimately renders the tooth useless. We Extremely High Pericingulum and fracture resistance,
want to shift the coronal focus to the cervical area of the Dentin
along with several other
Pulp in Immature
tooth and create awareness for an endo-restorative inter- Teeth characteristics needed for
face. This article will introduce a set of criteria that will High Cingulum Enamel long-term full function of
guide the clinician in treatment decisions to maintain Axial Wall DEJ
the endodontically treated
Cervical Enamel
optimal functionality of the tooth. tooth. This brief article is
Medium Peri-incisal Enamel
designed to simply intro-
Endodontic accesses are traditionally conservative to Low 2 Dentin
duce the reader to the re-
the occlusal/incisal tooth structure. However with the No Value or 3 Dentin shuffling of the values as-
Liability Inamed Pulp in
changes that occurred in restorative dentistry, this tech- Mature Teeth signed to different tooth
nique is unnecessarily restrictive for the operator and Exposed Dentin in structures and of the nu-
Incisal Area
potentially damaging to the more critical cervical area anced role of the impor-
of the tooth. tance of regional tissues. A full explanation of the new
hierarchy will be presented in future articles.
A New Model For Endodontic Access
As we deconstruct endodontic access, it is crucial to un- The brevity of this article precludes a full definition for
derstand the five catalyst forces that will change the fu- all of the terms of the glossary. However, there are four
ture of endodontic access and coronal shaping. They are: terms that will be explained below. Others will be men-
1. Implant Success Rates (The bar is raised) tioned in the context of the featured case.
2. Operating Microscopes and Micro-Endodontics
The Inverse Funnel and Blind Tunneling are demon-
3. Biomimetic Dentistry
strated by the two endodontic accesses performed on
4. Minimally Invasive Dentistry
my younger brother Tom, who occasionally bumps his
5. Esthetic demands of patients combined with
manufacturers recommendations for axial reduction teeth while on the ski slopes and soccer field (Figure 1).
for porcelain crowns A round bur was used by his general dentist as he la-
bored to discover the canal systems in these calcified in-
Table 2 Glossary of Terms for Modern Endodontic Access
and Acronyms
Note: The red text indicates a nondes irable outcome, or technique.
Glossary of Terms Acronym
The endodontic-endorestorative-prosthodontic continuum EERP
Three-Dimensional ferrule 3-D Ferrule
Peri-Cervical dentin PCD
Peri-Cingulum dentin
The inverse funnel
Blind tunneling
Figure 1
Blind funneling My younger brother Tom received trauma to both upper and lower central inci-
Partial de-roong sors and the teeth subsequently underwent dystrophic calcification. Although the
teeth are still in function, they have been badly weakened. His dentist lacked the
Soft proper tools and followed an access form that is no longer appropriate.
Stepped access
Figure 2
Secondary dentin 2 Dentin A new model for lower incisor
access is depicted, along with
Tertiary dentin 3 Dentin the new EndoGuide Bur 1A
which was used to create ideal
Biomimetic endodontic shaping BES access. Note that the access
has been moved away from the
Arbitrary round shaping ARS cingulum and towards the inci-
The dentinal map sal edge. The diminutive size
of the tip, along with the conical
The Dentino-enamel junction DEJ shape of the cutting surface are
helpful to both visual (dentists
The junction of primary and secondary dentin DJ using microscopes) and tactile
(little or no magnification) end-
The junction of primary and tertiary dentin DJ odontics.
Pulp tissue remnant PTR
Points of negotiation PON
cisors. Note that as the access goes deeper into the tooth,
it becomes wider internally, hence the term inverse fun-
nel. In the new approach advocated by Clark/Khademi,
the access and EndoGuideTM Bur (SS White Burs, Inc.
Lakewood, NJ) selection should allow the formation of
a true funnel; wherein the narrow portion of the funnel
is in the pericervical dentin zone, and the cavosurface
Figure 3a, b, c, d, e
has a 45 angle with an infinity edge margin which be- Blind Tunneling: Gouging that is common with round burs and cingulum access.
comes a generous mouth or top of the funnel. Mod- BuccalLingual gouging which is not easily seen in x-rays, occurs in nearly every
traditionally accessed case. Fig 3b, 3c, 3d, 3e; The Inverse Funnel. As the size
els contrasting the C/K funnel created with EndoGuide of the access cavitation is enlarged internally, an inverse funnel results. Vital
peri-cervical dentin is removed each time the bur enters the tooth.
Burs, the inverse funnel and the blind tunnel are shown
in Figures 2 and 3. The stark difference between the tip
size of the patented EndoGuide Bur designed for use long term retention of the tooth and resistance to frac-
for endodontic access & exploration and a comparable turing are directly relational to the amount of residual
round bur is shown in Figure 4. tooth structure.1, 2 The more dentin we keep, the longer
we keep the tooth.
Peri-Cervical Dentin or PCD is the dentin near the al-
veolar crest. While the apex of the root can be amputat- Peri-Cingulum Dentin: In the instance of incisor ac-
ed, and the coronal third of the clinical crown removed cess, the research done by Pascal Magne 3 and others in
and replaced prosthetically, the dentin near the alveolar regards to the importance of the cingulum directly con-
crest is irreplaceable. This critical zone, roughly 4 mil- flicts with traditional cingulum positioned endodontic
limeters above the crestal bone and extending 4 milli- access that is currently taught. There are severe tensile
meters apical to crestal bone, is sacred for 3 reasons: 1) forces that are concentrated at the cingulum when the
ferrule, 2)fracturing, and 3)dentin tubule orifice prox- maxillary anterior teeth are functionally loaded. These
imity from inside to out. The research is unequivocal; forces can lead to structural breakdown when the peri-
Figure 4
This illustration compares the En-
doGuide Bur to a corresponding
round bur. The tip size of the En-
doGuide Bur is less than half the
width as the corresponding round
bur. The EndoGuide Bur (right)
is shown in contrast to the cor-
responding surgical length round
bur (left). The EndoGuide Bur,
designed by Dr. Clark and Dr. Kha-
demi, were introduced in February
2011.
Figure 5
Lingual view of the C/K model of lower anterior ac-
cess. This extremely calcific tooth shows the ideal
cavity outline to satisfy operator, restorative, and
tooth needs. Collage of Gouged Access
(Mural is described in the text) Note: Blue arrows indicate gouges. Red arrows
indicate perforations. JK indicates that case was done by Dr. John Khademi
with adherence to the modem model of directed dentin conservation.
FEATURED CASE
The Calcified Incisor (Clark)
The maxillary left central incisor (#9) in a 21 year old Figure 12
EndoGuide Bur 1A is shown.
female was undergoing dystrophic calcification (Figures This bur is appropriate for
larger incisors. The diminu-
8-9). For such teeth, a cingulum positioned round or fis- tive size of the tip is actually
sure bur driven access runs a high risk of gouging. When more delicate than a #2 round
bur and creates the ideal cone
the access is moved toward the incisal edge utilizing En- shaped access.
cavosurface design. Create a beveled margin as region of the tooth will resist future staining and wear.
you begin the access, instead of later in the process. You Thus you bless the tooth as you create endodontic ac-
will get better lighting to enhance vision and the cess, as opposed to cursing the tooth with traditional
smaller internal shape will be compensated by a burs and techniques. In vital (non-lesion) cases you can
better funnel shape externally as we insert instru- confidently make very small endodontic shapes, more
ments and gutta percha into the tooth. In the words consistent with lateral condensation techniques. These
of the great John Stropko, Dont fight the case. techniques are best accomplished with the use of a mi-
croscope and proper instrument selection.
2. In a calcific canal case, switch to the EndoGuide Bur 1
or EndoGuide Bur 6, as you move deeper into the
tooth. Constant visualization of the DJ offers guid-
ance for the orientation of the bur, which allows you to
stay centered in the bullseye of the dentinal map.