Endo/Buildup/Crown System

WARNING: I am not an endodontist. I am just sharing what I do in my office. Never treat a case you dont
feel 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 canals
into an already full schedule. Years ago I worked with Scott Perkins when he was developing his 15 minute
Molar Root Canal technique. Honestly, I am not that fast. I have gotten to the point, though, where I can
very 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 at
length about the need for a Calcified Canal Protocol. As far as I know, he never published one and about
that time, I fell in love with a technique I learned at a different seminar. I later meshed what I already
knew with the new things I learned and this is what I came up with. It has been more successful in my
hands 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, every
time unless there are special circumstances.
Now I am going to share with you my Endo/Buildup/Crown System. Ive only shared this system once
before, so unless you were in the audience in Clarksville, TN, last year you have not likely heard of anything
exactly like this. I am going to cut to the part of the presentation where we have already diagnosed and
done 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 whats on the Route Board for a couple of
minutes while the anesthesia soaks in.
2. Assistant makes temporary stent. For this we use a plastic triple tray (the cheapest we can get that
works) because the quality of impression isnt as important for the temporary as it is for the master
impression. We also use stiff bite registration material for this temporary impression. We use the fast
set for two reasons. First, its fast. Second, it is what we use for the first stage of our master
impression 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 pushing
decay into the canal system I just cleaned out, so why not just get it out of the way now. It will also
give 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 the
tooth 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. Two
reasons you might want that are to keep saliva from contaminating the working area and to keep all
the bad tasting stuff out of the patients mouth while you are irrigating and using the Sonic. 6. Place
the Rubber Dam. Make sure that if you are using a mouth prop you do that before placing the dam. I
cant tell you how many times I have I have pulled the clamp off the tooth trying to get a bite block in
once I already had the clamped rubber dam in place.

7. Access. This is a very important part. Obviously you want to get good access without perforating or
any 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 a
tiny 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 I
am not recommending it exclusively because I dont have experience with any other. I cant imagine
going back to the old days of shooting a film with the file in place, even if you do have digital. I get the
working length by working a 0.06 or 0.08 hand file down to the proper working length with the apex
locator clip in place on the shaft of the file. Another note is that with this hand file and every rotary or
hand file I use afterwards; I lubricate it with chlorhexidine gel, better known as KY Jelly. No, do not
use 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 this
one 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 is
still 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 the
reciprocating handpiece. One is called the EndoGripper. I picked it up at one of Kit Weathers Root
Camp 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 work
the file backwards out of the canal. Sometimes it is hard to back out if the canal is especially calcified
or curvy. In this rare case you might have to unattach the handpiece head and work it out with your
fingers. After some practice you can usually figure out which ones will need this by the degree of
difficulty 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 pink
hand file for the working length, now use a gray file for the next one. If you meet resistance, drop
back 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 usually
not 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 I
know it will more easily go to the working length. Use it for several seconds in each canal with
copious water spray. I figure the more water the better here to flush everything out. I do this for
between 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 the
working length. Once again lubricating with chlorhexidine gel. I cant always get a file that big to
working 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 the
NaOCl 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

Sodium Hypochlorite will dissolve any leftover tissue tags hanging around in the canal. If it doesnt
get them all, it 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 to
get a little red tip on the paper point. Not abscess material, mind you, but just a little blood. Maybe
you over instrumented or something. In this case I will dip the tip of the paper point in astringident (I
use Cuttrol) and place in back in the canal. After just a couple of seconds the bleeding should have
stopped. 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 the
last rotary file I got to working length. I make sure I have tugback, then place with AH Plus sealer. I
have used this technique with AH 26, EZFill, and AH Plus. I have had no remarkable difference in
results 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 the
Route Board while my assistant takes the check film. I certainly like to have a good fill film with that
rubber 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 heated
Glick (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 pulp
chamber. 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 my
3 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 coarse
diamonds, or some combination thereof in an electric handpiece or air-driven handpiece. For now, I
have come to the conclusion that none of these have a serious advantage over the other in a real-life
setting. 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 feather
edge and place it subgingival. I have not found it to cause any of the gingival problems you read
about. If I am concerned with aesthetics, I do a porcelain shoulder margin. If I do the all porcelain
margin on the facial of a PFM, I make sure to wrap it to the mesial and distal to make sure you dont
get that ugly dark line where the PFM meets the tooth root. For the All porcelain margin, I use a GW2
toothed Carbide bur to refine the flat gingival portion of the shoulder margin. For some reason I like it
better 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 have
prepped 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 Bite
registration material and take the FIRST IMPRESSION. This is done with the 30 second fast set Blue
Velvet bite impression material that you used back in step 2 for the temporary stent. You fill a triple

tray on both sides with the bite material (I prefer the metal ones from Clinicians Choice, but I have no
real 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 to
make sure the occlusion is correct by pulling back the cheek to see if the occlusion is correct on the
opposite side, or if anterior, make sure that the posteriors on both sides are in maximum
intercuspation. Sometimes a little trick I use if you have a patient with third molars getting in the way
is to place the triple tray into the patients mouth and have them only close half way down. Then
reposition the triple tray until the back metal loop goes distal to the last tooth in the arch. Then have
them close all the way down.
29. Remove the triple tray with the blue bite material after 30 seconds. This will almost certainly
have blood and saliva all over it. What I like to do here is to quickly rinse and dry the first impression
in a little pedestal sink that I have installed on the doctors side in all my doctors operatories. I do
this quickly. Some people teaching this technique have you either leaving the opposing arch in the
mouth and applying the wash directly onto the tooth, or adding the wash and reinserting it without
cleaning it first. I found that my way decreases the YUCK factor. Maybe that leads to a couple of
extra referrals a month.
30. Then I use an interproximal carver (amalgam instrument) to cut away all the undercuts and
interproximal 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 the
prep. Once you have done this, you will have 2 Vs on the mesial and distal of the prep in the
impression.
31. Fill the prep side of the triple tray impression with your wash material for your SECOND
IMPRESSION. I use SnoWhite that I purchase from KISCO for that. It sets in 30 seconds. I have used
lots and lots of different washes in the past. After much experimentation I found the 30 second to be
as accurate as any of the rest of the stuff. There are 2 different 30 second washes from KISCO. You
can use the yellow, but I have found it too viscous to get an accurate bite registration. The SnoWhite
seems 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 are
done. If you see some space where it shouldnt be, tell the assistant to take a bite registration once
the impression sets up and they remove it.
34. You are now out of there. Get up, give any last minute instructions, exchange pleasantries with
the patient and get.
35. Go to the Route Board and Focus on the next patient to treat. The assistant will remove the triple
tray 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 single
day. Like I said last week, this is a great service to offer a patient in pain. This, along with the ability to
offer 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.