Endo treatment - Courtesy ROOTS
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From: Marga Ree
Sent: Monday, December 05, 2005 11:27 PM
Subject: [roots] Three in a row
I completed endodontic treatment on this patient today. He was referred for 15, 14 and 13.
His dentist already told him that the crowns had to be redone, because
he assumed that they could not be removed without permanent damage.
My favourite tool to remove these PFM crowns with a metal occlusal surface is the Metalift.
I was able to remove the crowns without any problems, removed 3 posts, and did the retreatment.
I took care of the lousy isolation, I hate to see blood seeping out of the gingiva. And YES,
I know there is a minimum of tooth structure. However, these crowns have been in place for
many, many years with this amount of tooth structure. The only thing I did is replacement of
the root canal filling and the metal posts, I placed fiber posts, 2 in 14 and 1 in 15.
Then I used the crowns as moulds for the new composite build-ups. The occlusal channel acts
very nicely as a venting hole. After the composite was polymerized, I took off the crowns,
removed the surplus of composite and cemented the crowns again with a definitive cement.
The cuspid was one of the easiest treatments I have done this year - Marga
Don’t you just love that metalift? I bought it when you were here at the ada at cliff
ruddle’s suggestion, hasn’t missed yet, and takes nearly no time at all. I am know removing
a lot more crowns to attack the endo issues than I ever did before. Great unit - Gary
Does the metalift work only on pfm's?
What about replacement of the drills etc? how often do you have to do that? - Girish
All metal or pfm. The key is the metal layer, as you essentially tap that layer and thread
into it. 85% of all crowns in existence fall into those categories. All ceramic crowns,
prayer and a recommendation to the patient BEFORE you start that the crown will need to be
replaced is a much better idea - Gary
Hi Girish, I use the drills several times, till they become dull, it is dependent on the
type of metal - Marga
Nice case Marga! I'd like to look into that Metallift device - who makes it please? - Simon
Marga, your cases are inspirational. I love to see your posts with
attachments in there because on every one i see.......
1. Unprecidented commitment to clinical excellence.
2. Phenomenal tips to see how to improve a techique.
3. Great microscope photography (CLAP CLAP CLAP)
4. A humble attitude of caring and showing others how to do something.
5. One of the best results anywhere.
I mean that Marga, and cant express it more strongly........your cases are fantastic. - Glenn
How come you never help me when the TDO'ers beat me up about placing CRFC's in these cases. :-))
It's PERFECT! I have done this countless times. I tell the patient "It's permanent, but not
perfect." They are happy to have saved the $$ and time, and personally, I think we get a better
result than a new crown in many of these cases because we can finish down in the scope. No?
- John A Khademy
Dear Marga. Fantastic work. nice saving of the crown too. I have a question to ask
you.. Why can't you use the spring loaded crwon remover when you have
metal surfaces in the crwon. It';s better than the metalift and you will
not have a hole puncehd in that too. I use the Anthogyr crwon remover
sometimes and more often the spring loaded one if there is a metallic area
to catch upon.
nice work and nice photogrpahs - vipin
I have what I consider the two best crown removal systems on the planet, the
metalift and the densco pneumatic unit. And I use both. The potential
issue with using the densco or your Anthogyr is damaging the margins, number
one, and number two, since you are interfacing with the periphery of the
crown and not the middle you automatically are providing a torquing force,
and occasionally one can snap off the coronal tooth structure. The metalift
exterts force centrally, and the small hole left is easily repaired. Be
advised that it is not universally applicable either. Use of the metalift
over a very thin wafer of dentin remaining over the pulp can lead to a
perforation into the pulp, thus generating additional endo for your
practice - Gary
The Easy Pneumatic Crown and Bridge Remover by Dentco Research and Development
is designed for the removal of cemented crowns and fixed partial dentures.
It connects directly to any 2/3- or 4-hole handpiece hose. Dental unit
compressed air is used to activate the instrument and deliver a controlled
dislodging force via one of the supplied tips. The instrument is similarly
shaped but slightly larger than a sonic scaler. It comes with three tips; one for
single maxillary crowns, an angled tip for difficult access and mandibular
posterior single crowns, and a bridge removal tip for placement under the
pontic-retainer embrasure. Also included is a flexi-wire kit for special
Gary...I have this crown remover...and have had it for years...like 7-8
You must be very judicious with it's use.....I have fractured teeth with it
trying to be good guy gettting the crown off. Joey D, "I don't use it unless
I have no other choice now....I prefer to cut off the crown"
I have a Dentco crown puller for 6-7yrs and have been pleased with it - Randy Hedrick
Obviously if you are remaking the case, there is no reason to use either of
these. A vertical cut with lateral spreading is by far the safest way available
to remove any man made stuff headed for the trash. And I specifically
listed the possibility of coronal fracture, although the incidence of that
can be reduced by turning down the power. But it is one of the most effective
units available for bridge removal when one abutment has washed out, and for
tapping off single crowns. I actually own two of them. We use them a great
deal in removing superstructures over implant fixtures. It is the only
effective unit I am aware of that has a possibility of leaving the prosthesis
intact. Having said that, the metalift is in most instances a safer unit,
leaves only a small opening which is easily repaired, and is generally my
instrument of choice now for removal of superstructure prior to initiating endo.
I have used the Metalift in the past with pretty good success. I have also used
the Richwill sticky things, Koronaflex, and a tapered screw (I think it is called
Atwood). A few points to be aware of using the Metalift:
1. The drills and tap and die will wear out and have to be replaced after a
limited number of cases.
2. Sometimes the tap and die threads will engage both the crown and the underlying
dentin which results in no traction to the crown.
3. If removing a crown with something soft under it such as old cavit, cotton or
a pulp chamber, stuff cotton until a firm mattress of cotton is created to offer
resistance to the tap and die.
4. If the metal under porcelain is thin the tap and die may flex the metal and pop
all the porcelain off of the crown.
5. Using oil to lubricate will help it work better and extend the life of the instruments.
6. Referring dentists will be amazed at how small and access opening you made to
treat the tooth. Tell them that the microscope deserves the credit.
Good luck - Larry
As to point two, metalift now has an undercutting bur to provide some space to prevent
engaging the dentin.I haven’t had any issue when that bur has been used - Gary
Larry!!!!! Excellent advice below!!!....i learned something……..
Which do you like better….the Atwood or the Metalift?.........arent they about the same?
The Atwood is just a tapered blue screw probably made of aluminum. You made a hole
thru the metal with a bur of your choice and then screwed in the remover with your
fingers and then a little open box wrench that was part of the kit.
I used to use it about 10 years ago so what I can tell you is from memory.
I would not use it on any crowns other than those of full metal ie. not porcelain
on metal crowns as it would pop the porcelain. It is less expensive and
did not wear out very fast.
The Metalift uses a parallel sided die which necessitates the entry hole be machined
precisely by the supplied kit drills. Being papallel sided you can fill the hole in
after treatment with an internal hex nut which all but disappears into the crown.
I used the hex nut just a few times so I don't know how well they would hold up.
Once sealed with the hex nut, the crown can be removed without further drilling in
the future by backing out the hex nut and then using the same die again on the
protected threads. Both the drills and die could only be used a limited
number of times.
As to your question about are they about the same: both involve removing the
crown with a screw, but differ in that the Metalift uses a papallel sided die which
creates a potentially reusable threading in the crown. If you need to
screw deeper into the crown to get the needed force to remove the crown,
the Atwood screw will deform a larger and larger hole on the crown as it screws
deeper. The Metalift does not have this issue. Also the Metalift usually has a
booth at the AAE with the dentist who designed the system to explain its use.
I think he is from Miss. and he is most helpful.
Overall I prefer the Metalift as it was more controlled in my hands, was more
amenable to repeated crown removal and gave a smaller hole in the restoration.
Regretably I no longer remove crowns as much as I once did because of
referring dentist preference and because bonded cements have unfortunately
become standard practice.
I also us the Koranaflex for bridge removal. It is very quick, has no recurring
costs (as long as the staff don't throw away the parts after it is used), and
works about 80% of the time.
The mallet and old cement spatula (with a sharpened tip) placed at the MB
crown margin (or on buccal margin if possible) is the technique I use most often.
It is quick and has removed many crowns that had a poor cement seal or
worse hiding under the crown. This does chincker the crown margin sometimes
and may break a chunck of porcelain off so use with caution on crowns where
this would be a big problem.
I hope this was of some help - Larry
If you want a cheap Atwood copy, get a small metal screw, blunt the tip,
drill the hole to grab the screw and tighten. It works also. Tom Peak,
an endodontist now teaching at Iowa had a picture of one still in the bridge I
removed for him over 25 years ago. Tom is a 76 U of Ia grad and a 78 endo
MS grad - Alan Cady
The Metalift has parallel sided threads like a machine screw rather than
a wood screw. Because of this the threads, once cut, will stay the same
allowing repeated use of the same threads. Atwood type removers cut a
changing thread pattern like a wood screw so repeated use of the same hole
forces you to make larger and larger holes to grab new solid metal to engage.
I hope I explained this ok. It is not as complicated as my language used here.
Properly bonded crowns should have a bond strength that may well exceed the
inherent strength of the tooth stump or the strength of the bond between the
porcelain and the base metal. These devices can generate enough traction to pop
the porcelain off of a crown and not break the cement bond. This can happen
even with small amounts of force if the base metal is thin or if the porcelain
had stress fired into it when originally made. Many bonded crowns can be
removed because they were never proberly "bonded".
For crowns placed with ionomer, the cement strength and bond strength will
also be very high and presents some of these same issues. I think the fujii
is this type of chemistry.
Removing any crowns or bridges is always a bit of a crap shoot. Those bonded
present more risk of not getting the crown off, or worse, giving damage
to the crown, or worse yet, damage to the underlying tooth.
The Koronaflex cost me $1,600-2,000 about 10 years ago.
I don't remember the excact cost - Larry