Endosequence Technique

Endosequence System

I know I sound like a shameless  informercial, but the system I love was created for Brasseler USA by Dr. Dennis Brave and Dr. Ken Koch at Realworldendo.com.  When you order it, be sure to ask for the DVD, where Dr. Brave and Koch describe what I’m telling you with a lot more detail.  I’m posting this, to be a quicker reference for myself and  for anyone who uses this system.  It’s so simple, I love it.

The system comes with everything from access burs to its own post and core system.  At the very least, you should use the rotary files, the gutta percha and the BC Sealer.  The files come in procedure packs, so that you only need to open one pack of files for a case.  Small=sizes 15-30, Medium=sizes 24-40, and Large=sizes 35-50. 

Of course you need a few things before you start a root canal, but the first thing you need is a diagnosis.  Cover yourself, and say something more meaningful than, “patient needs endo.”   If  your radiograph is self-explanatory, then I suppose it serves as the documentation in and of itself.  But if not, then please document symptoms and a diagnosis, or a sound rationale.  Hopefully you are providing endo to help someone out of pain, or for some reason that reflects their best interest (like if ideal positioning of a crown would invade pulp etc.)   Not because you put them under every crown, or “because it’s covered by insurance.”   Sorry, that’s a pet peeve of mine.  Here, the radiograph speaks for itself, and it only takes a second to document, “caries leading to pulp:”

HERE’S WHAT YOU DO: STRAIGHT FROM DRS. BRAVE AND KOCH

1) REDUCE THE OCCLUSION FIRSTIt will affect all of your measurements. If you do it later, you may have to  find working lengths all over again.  Make a conservative access, and establish coronal patency with a hand file.

2) DETERMINE WHICH PACK OF FILES TO USE:   Beginners, if you’re not sure, you can take the expeditor file, which is a .04 taper, size 27 rotary file, to the point of initial engagement.  If it goes 1/2 way or less?/use a small packet, 1/2 way or more?/use a medium packet, if it goes 2/3 or the whole length of the instrument?/use a large packet.  Again, .04 taper is better for multi-rooted and small teeth, while .06 taper is mainly for large canals/max incisors.

3) START WITH TWO ROTARY FILES Begin doing a crown down technique using copious lubrication, with two rotary files.  The technique is smooth and rythmic, like a Waltz. It goes twice like this: “one back, two back, three back,” then you wipe the file.  Be gentle and do not bind the instrument.  If you bind it, the rotary handpiece has auto-reverse, which should tell you you’re using too much force.

4) ESTABLISH WORKING LENGTH:  After you’ve used two rotary files, stop.  Irrigate, and recapitulate with a small hand file.  Establish working length after you’ve used two rotary files, instead of infecting periapical tissues with excessive hand filing.  This approach removes pulp tissue while minimizing post-op sensitivity.  If you’ve picked up the coronal half of the pulp tissue, you’ve removed 80-90% of it (according to Drs. Brave and Koch.)  While you can use a small file or two to  feel for the apex, you are not excessively advancing pulp tissue beyond the apex.  Apex locators are great, but they are no substitute for a radiographic working length.  At this point, you’re also taking time to notice any curvatures or unusual anatomy illustrated by small hand files:

5) WORK TO WORKING LENGTH You’re done with the crown-down technique when you have used the final instrument that has WORKED at your working length.  Of course it assumes copious lubrication, irrigation and hand-file recapitulation between rotary files.  Some people take one file larger to the working length.  Here’s a good quote from Drs. Brave and Koch: “Take from the tooth what it yields easily.  Do not overmanipulate the tooth.”

6) EXTREMELY CURVED ROOTS: HYBRIDIZED TECHNIQUE:  Another good quote: “Don’t take rotary files into harm’s way.”  Once you are where the curve begins, put the rotary files down.  Pick up hand files and prep the apical portion.  Hand files are .02 tapered.  You can then bring a smaller-sized .04 taper rotary instrument to a well hand-filed working length.  If your last hand file to length was a 25, the the next rotary instrument can be a 20, then a 25 to length.  This is not crown-down.  Here, the rotary serves as a finishing file to blend everything together and maintain a constant taper.

7)TRY IN POSTS: Another great quote, “The greatest post drill in the world is actually the last endodontic file used in the canal.”  Posts should not require removal of any more dentin.  Using a corresponding post, try in the post to determine the length it will go, and hence, how much gutta percha you’ll need to burn out.

8)DRY AND OBTURATE THE CANALS: After a final rinse, dry the canals using the corresponding paper points.  (I use regular paper points first to get the bulk, then the nice paper points to finish.)  Take a film with your master cones in place to verify length.  Express the injectable BC sealer PASSIVELY  into the coronal portions of each canal.  Do not press hard or try to get back pressure.  Covering your master cone with sealer is optional, but I like to.  Then slowly advance your master cone to length, and take a film.  Here, the fill is still reversible if you really don’t like it.  Some people cut the gutta percha cone ahead of time, according to the length of the post to come behind it.  I’m not there yet, and I like being able to remove the fill if I still don’t like it.  If the single cone has some room in the coronal and middle 1/3, then you could put some accesory cones here if you wanted, but most of these will not fit that far apically and Drs. Brave and Koch consider this to be hardly necessary at all.  Here, you can see that the single cones went in nicely and expressed a tiny bit of cement into the curving mesial canals:

Here’s another case that I’m pretty proud of.  If the radiograph looks foreshortened, it is.  This patient could barely open his mouth, and getting a film below the apices was a challenge.  The film tended to sit high in the floor of the mouth, so I had to angle the cone to get the root tips in the film.  After thinking I wouldn’t even see one canal, I was pleased to have the case finish the way it did:

3 comments

  1. “Apex locators are great, but they are no substitute for a radiographic working length.”

    Dr. Culpepper,
    With all due respect, you have it backwards. Apex locators, used properly, are far more accurate than a radiograph. Having done a thousand or more canals, I can say that I trust the apex locator for absolute accuracy.
    BTW, after using many rotary systems over the years I am most impressed and continue to use Endosequence.

    1. I agree. I have enjoyed the predictability of apex locators. In some cases when you’re doing endo through a crown, or there is amalgam present, the metal seems to interfere. Lately though, I have tended to replace the old crowns and remove all metal, and that gives me a good reading every time. The patients love emax over metal any day.

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