- Mass of embedded pulp stones is still present in pulp chamber and it must be removed to increase both retention and strength of planned core
- Big chunk of metal must be removed from mesio vestibular root canal
- Patency must be recovered in all 3 blocked canals in order to shape, clean and fill those to the apex
Because of the huge post cemented within 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 infected and painful mandibular premolar and to replace it by a dental implant.
But patient would rather save her own tooth and asked for a second opinion. Patient has been explained that all it would take to preserve that tooth is to clean and disinfect contaminated canal area. In order to reach this contaminated area, a huge casted post must be removed from root canal, Sargenti paste must also be retrieved and a ledge has to be bypassed. Risks associated with this procedure where also explained. Patient choose to accept those risks.
It took twenty minutes in order to retrieve the casted post. Sargenti paste has been brushed away with ultrasonic tips from Spartan under high magnification (OPMI PROergo microscope from Carl Zeiss) and ledge was bypassed within 10 minutes working time. A number 10 file displays full canal patency on this X Ray dental film.
Calcium Hydroxide has ben used as an intra canal medicament and left in for 8 days
Tooth became asymptomatic on following appointment.
Final obturation (Pulp Canal Sealer + Gutta Percha).
Provisional obturation material: Clip from Voco.
Tooth has been saved no implant needed.
Endodontic procedure case study number 49747
A large post removal and root canal retreatment procedure on a calcified tooth, followed by a casted post and crown performed in our clinic back in 1993.
20 years later, tooth still can withstand occlusal forces despite a huge post replacement in distal root, it is still asymptomatic and functionnal.
Long term prognosis can be excellent with endodontic revision.
Endodontic. Case Study Number 502636
Patient has been referred to our dental clinic for a root canal retreatment evaluation on this very sensitive mandibular first molar. On radiographic examination, distal root canal has a blunderbuss apical opening caused by transportation along with some filling material overextension. Mesial root canals obturations fall short from the apical constriction probably due to apical ledges. There is also evidence of apical radiolucency.
Referring dentist question was: “Endodontic retreatment or extraction with an implant supported crown?” In order to answer that question we must ask ourselves the following questions: Is the tooth restorable? Yes. Can severe inflammation be eliminated by endo retreatment? Yes. Is this a straightforward endo retreatment case? No. Is this a good enough reason to pull this tooth? no.
Root canal filling material is removed, an untreated fourth canal is found in distal root.
All three previously treated canals have been shaped and cleaned all over again and fourth canal has also been treated.
This third X ray dental film displays root canal system filled with calcium hydroxide.
Symptoms subsided in the following hours and, 8 days later, tooth root canal system could be permanently filled.
Immediate post operative vu (and angled one). Is there some excess material past the blunderbuss apical opening? Yes. Is this an issue? No, but removing that tooth and replacing it by an implant supported crown would definitely have been one. in a 6 months post op control check up, this tooth was still symptom free.
Microendodontic. Case Study Number 511536
Sixty years old patient presenting with an abscessed mandibular molar. Diagnosis: Persisting disease after (25 year old) root canal treatment. A crown and two post removal where necessary in order to gain access to root canal system for retreatment.
Only two apointments required to save that tooth:
First apointment: Crown and post removals plus root canal filling retrieval and calcium hydroxide insertion as a medicament.
Second apointment: Calcium hydroxyde removal, irrigation, drying, final canal obturation gutta percha and Pulp Canal Sealer. Provisional filling material: Clip (not radiopaque) from Voco.
Tooth is now symptom free and it is now ready for a post and a PFM crown.
A complex root canal retreatment does not have to mean extraction and replacement by a dental implant. A research study by Farzaneh et al. on treatment outcome in endodontic found an orthograde root canal retreatment success rate of 93% .
(Farzaneh M., Abitbol S., Friedman S. Treatment outcome in endodontics: The Toronto Study. Phases I and II: Orthograde retreatment. J Endod 2004; 30(9):627-633)
This is a case where, based on the X ray image of a “J” type lesion in combination with a deep narrow periodontal probing, one could easily think of a cracked tooth. However, when observing under high magnification, no crack could be seen from within the root canal mesial wall. This J shaped radiolucency was in fact a narrow desmodontal sinus tract originating from an endodontic infection. Saving that tooth implied a retreatment, a ledge bypass and a few calcium hydroxide dressings replacements. As shown on those control post operative X ray images, a slow but complete periradicular tissues regeneration occured. In this case study, even a CBCT 3D imaging would have shown a deep narrow bony defect that could have misled the practionner to conclude the presence of a cracked tooth. Direct observation under a dental operative microscope showed us otherwise, proving once more how micro dentistry is elevating endodontic care to a higher level.
Case Study Number 34571514
Pre-operative X ray film shows symptomatic maxillary right premolars. Four years after retreatment, recall radiographic follow-up (above) shows complete healing. Teeth are still asymptomatic and functional in 2010.
Silver points have been present in root canals for 25 years, sealer in apical region is long gone due to coronal “macroleakeage”, this allowed for silver points to come into contact with tissue fluids and a huge amount of corrosion occurred.
“Corrosion products such as silver sulfide, chloride, sulfate and carbonate not only occurs on the point itself but also in dentine and within the adjacent periapical adjacent soft tissues”
Pocket atlas of endodontics by Rudolf Beer,Michael A. Baumann,Andrej M. Kielbassa
This spreading of silver points corrosion products and the important deterioration of root canals walls in the apical region by tooth decay explains why root canals had to be enlarged to a number 80 endodontic file.