Case Study Number 461716
Patient came to our office with spontaneous intermittent pain on maxillary right side. He can readily identify the tooth, he is showing the first molar. Patient is taking many Aspirin tablets per day and is tired of suffering.
Tooth history: first attempt of root canal treatment which ended up with a broken instrument.The patient was then seen two years ago by another practitioner who succeeded in the broken instrument surgical retrieval. Even thought, at the time, a complete retreatment has been performed, the tooth remained sensitive. Since then, painful episodes became more and more frequent with a growing pain intensity.
Tooth is sensitive to palpation with a mobility of level 2. A new crown is protecting the cusps and occlusion looks fine. Pre operative Xray shows an apical periodontitis on mesio vestibular root and something that might be a perforation with a bunch of wispy gutta percha points into it. Patient is informed of this concern prior to starting anything. Patient is informed of the high incidence rate of a fourth canal in those first maxillary molars (Studies shows up to a whopping 92% rate). He is also made aware that this fourth canal may have been omitted. After the exam, patient knows that at least two concerns have to be addressed in order to solve his problem. Implant is suggested but patient is reluctant, he is 25 years old and he wants to keep his real tooth.
The two first X Rays are Pre Operative.
Third X rays show the recovered MB2 with a first instrument (number 08 ISO file) reaching its apex, the fourth X ray film shows the repaired perforation with MTA and intracanal medication (Ca(OH)2 dressing) in MB2.
Fifth image shows immediate post operative outcome with the Pulp Canal sealer overfill which has no impact on the overall prognosis. An amalgam has been placed as a long term provisional for one year. Symptoms subsided almost immediately after the intra canal dressing. The monitored tooth has been fine all along for one year. The last Xray is a one year post operative control with a brand new crown in place.
Access made through crown makes the treatment much more difficult in that the landmarks that direct the clinician to the pulp chamber are removed. Our microscope integrated video camera recorded a short movie showing treated MB2 and the MTA repair, the position of the repaired perforation site (dark grey shade) in relation to the real position of the MB2, clearly stresses out what can happen while you are looking for the MB2 with external contour of the tooth being altered by a PFM crown.