Root Canal revision procedure on a maxillary molar which implied a plastic carrier removal as well as the by-pass of a fractured instrument previously left in the root.
Patient came in one year ago with large swelling on URQ, gave her AB and told her to let me perform an endodontic revision on 14. She vanished and then came back 6 weeks ago with an even bigger swelling, gave her AB and this time, I did not have to insist too much for her to come back and get the treatment done.
Both 2 Posts and root canal filling removal, cleaned and shaped , sodium hypochlorite irrigation, PUI, Interim Ca(OH)2 , tooth got asymptomatic and then patient came back today for final obturation and amalgam post and core build up. She’ll get the crown later…
Patient experienced recurrent pain episodes and swelling coming from an infected previously treated root canals on tooth 15. Extraction and Implant surgery was the sole option offered to her until she landed in our office to get a second opinion. Upon radiographic examination, noticing the fact that the bone rarefaction was mostly located on the distal aspect of the root, we suspected an infected lateral canal. Treatment plan was a root canal revision procedure, a new core build up and a crown.
Root canal system has once more been completely cleaned, shaped, irrigated with NaOCl and then filled with an interim Ca(OH)2 paste. Patient came back a few weeks later and symptoms had completely subsided. Not all lateral canals will create such an infection issue but this one did. For that specific reason, I felt I had to find a way to fill this oddly located one for a better outcome. Neither cold lateral or WVC did allow for an adequate filling, thus a new technique was needed.
The technique: Both canals were filled in their apical third with NeoMTA root canal sealer and gutta (cold lateral condensation). The remaining coronal part has been loaded with NeoMTA root canal sealer and I have used a sterile strip of Teflon for its thermoplastic properties, condensing it to make the sealer squirt through the lateral canal. The ”Teflon Hydraulic Condensation Pressure Technique”was born. An amalgam post and core build up has then been placed into the coronal part of the root canal.
Tooth is now asymptomatic and functional, a crown will be the next and final step to prevent that tooth from being extracted.
Post removal and endodontic procedure revision on a maxillary first molar presenting with a complete fracture of palatal cusp as well as a previously omitted MB2. Tooth was also tender to percussion, no deep narrow pocket. Amalgam core has been drilled out around the post head. The Flexipost has been removed with an ultrasonic tip and a P5. MB2 has been located with the help of a dental operative microscope (OPMI PROergo from Zeiss). Endodontic revision procedure instrumentation has been performed with Mani stainless K files and ProTaper Universal (Dentsply). Chelator: RC Prep. PUI Irrigation: NaOCl 5%. P5 (Dentsply) Sealer used: Pulp Canal Sealer. Obturation technique WVC. X Ray Sensors used: CareStream Kodak 6100. A replacing casted post has been cemented with RelyX along with a new crown. A 2 years follow up shows both an asymptomatic as well as a fully functional tooth.
First maxillary molars typically have 4 canal entries and four distinct canals. This molar has only two canal entries and a deep split in its vestibular root (A Vertucci type V root canal configuration). Both canal entries were also embedded in a mass of adherent calcifications. Furthermore, to my dismay, palatal canal last apical instrument size was a F5. In a case such as this one a dental operating microscope has been most helpful when attempting to locate root canal entries as well as when time came to visualize the deep apical split.
Endodontic procedure instrumentation has been performed with Mani stainless K files and ProTaper Universal (Dentsply). Chelator: RC Prep. PUI Irrigation: NaOCl 5%. pulp stones removal with Ultrasonic tip: BUC One from Spartan. P5 (Dentsply) Sealer used: Pulp Canal Sealer. Obturation technique WVC. X Ray Sensors used: CareStream Kodak 6100. Opmi Proergo microscope
Due to the presence of rock hard Russian Red filling material in its root canal, the endodontic revision procedure to save her tooth seemed to be too difficult or too risky for the former practitioner to perform, consequently, patient has been offered a surgery to extract this maxillary premolar and to replace it by a dental implant.
Still, patient would rather save her own tooth and asked for a second opinion. Patient has been explained that this tooth periodontal prognosis is excellent, it is restorable and that its endodontic prognosis is solely linked to the difficulty of the case at hand. All it would take to preserve her tooth would be to clean and disinfect contaminated canal area. In order to reach this contaminated area, Russian Red paste had to be retrieved then, the calcified apical third of root canal system had to be cleaned and shaped. Root canal perforation and blockage risks associated with this procedure where also explained. Patient choose to accept those risks.
Russian Red paste has been brushed away with ultrasonic tips from Spartan under high magnification (OPMI PROergo operative microscope from Carl Zeiss) and both calcified canals were shaped and cleaned to length (25 mm long tooth) with C endodontic files, K files, Protaper Universal system and lots of chelating agent (RC Prep). Irrigation PUI with sodium hypochlorite 5%. Interim Calcium hydroxide was left in root canals for 10 days, then these were subsequently filled with both Pulp Canal Sealer and single cone technique.
It is sad to note that this first maxillary premolar narrowly escaped from extraction and dental implant therapy only because patient insisted on asking for a second opinion.
Patient lately experienced several acute apical periodontitis episodes and needed to have this second maxillary premolar treated.
Root canal revision seemed to be a painstaking procedure due to the large casted post cemented within the 2 root canals. Risk of fracturing the tooth while attempting to remove the post is a concern. Still, succeeding in this attempt without fracturing the tooth would allow for an endodontic revision. Using this tooth as an abutment for a 3 unit fixed bridge will spare the patient a 2 implants surgery (witch in turn might as well imply a bone grafting into her sinus). Apical surgery option on this tooth palatal root did not seem to be a good idea either due to the perforation risk of the surrounding sinus membrane. Patient chose to attempt the post removal, and, if tooth would break, he would then opt for the implants.
After crown removal, post has been loosened with a P5 from Dentsply. It took one appointment to successfully remove the post. Half of the Sargenti paste could also be retrieved from the canals during the same setting. In order to remove Sargenti paste, operative field has been enhanced with high magnification and coaxial Xenon lamp illumination.
Patient then came back to finish the root canal cleaning and shaping. Root canal entries were located with a pre curved number 10 stainless steel file. Chelating agent along with numerous stainless K files were needed to progressively regain root canal patency. Instrumentation has been performed with Mani K stainless steel files and ProTaper Universal NiTi file system (Dentsply). Root canal sealer used; Pulp Canal Sealer. Root canal obturation techniqueWVC. X Ray sensor used: CareStream Kodak 6100.
Orthograde Root canal Retreatment ? Apical Surgery with MTA Retrofilling ? or extraction and implant? Which of these options would better serve the patient?
Distal root is short, post is long so this might impair with adequate retrofilling. Adding to this statement the event of a second distal canal and we have a recipe for a potential surgery failure. At best, this second canal might make things even more difficult for the practitioner while performing a surgery.
We also have a symptomatic tooth presenting with an apical radiolucency and a small joint on mesial, thus we can assume some leakage and this would be my second justification for an orthograde revision instead of an apico. Even though apico does give a high success rate, it will not stop coronal leakage as an orthograde approach would. (assuming a good restorative replacement)
I am also quite often engaged with such teeth, and, to my opinion, removing such a post bares less failure risks than an apico in such an area.
For those who feel uncomfortable with big casted post removal or surgery, we all agree that referral is still a better option than a sad straightforward extraction and implant. Up until now this tooth with its redone root canal treatment has been functional for 4 years and is still doing just fine.