Apical split has been cleaned and shaped with precurved stainless steel Mani endodontic K files. Passive ultrasonic irrigation with NaOCl 5%. Filled with gutta and NeoMTA Plus from Avalon Biomed
Endodontic. Case Study Number 505146
A peculiar anatomical variation can be noticed on this mandibular first molar. What appeared to look like hypercementosis on apical aspect of distal root could in fact be a supernumerary root fused to the distal one (Radix Entomolaris). Careful removal of dentine with ultrasonic tips under high magnification of a dental operative microscope helped in locating this extra canal.
Case Study Number 368745
Patient was told seven years ago to remove lower right premolar and replace this tooth by an implant supported crown. Lack of periradicular tissues implied a guided tissue regeneration which, in turn implied a bone curetage close to the mental foramen. Estimated health risk: A possible permanent nerve paresthesia caused by a curetage or by an implant surgery close to the mental foramen on a patient with a narrow crestal mandibular bone. A possible failure of guided tissue regeneration which in turn, would impair implant osseointegration (or simply make the implant surgery impossible). Clinical examination revealed a mobility level of 2 and a sinus tract. Our findings on radiographic appearance: a large but a localized bony defect and a tooth that needed a root canal re-treatment. Our suggestion to the patient: To put aside the implant surgery and to invest in a root canal re-treatment with a few Ca(OH)2 replacements. The patient had to be patient (and faithful) for a few months in order to monitor progressive periradicular tissue healing.
Results: Per and post operative control X ray films show a progressive, then complete healing of periradicular bone tissue. In this case, root canal retreatment proved to be a safe predictable way of saving that tooth at half the cost of an agressive implant surgery.
Now, 7 years later, the tooth has it’s own casted post, a PFM crown and it’s mobility level came back to zero. And above all, patient is now completely safe from any paresthesia risk.
Endodontic Procedure. Case Study Number 449927
To treat such a tooth in endodontics we needed to deal with:
- Difficult access
- Long tooth (24 mm)
- Calcified canals (root canal system with dystrophic calcifications) to locate, shape clean and fill
- Second mesiovestibular (Mb2) to strive for with the help of a dental operative microscope
- Canal curvature with an “S” form (Bayonet shaped root canal)
PRO Taper endodontic files from Dentsply, OPMI PROergo dental operative microscope from Carl Zeiss, Gutta Percha from META, Pulp Canal Sealer from KERR
Root Canal Procedure. Case Study Number 492626
Patient is having an AAA with a necrotic pulp, an extensive deciduous restoration and a huge tooh decay on distal aspect of this first maxillary molar (Some of us might think: “you don’t have to worry it is dead”).
Dystrophic calcifications are obliterating the root canal system and we can expect to strive for a second mesiovestibular too. An extreme curvature is also present in distovestibular root canal.
Prior to the initiation of treatment, an estimate should be made as to the degree of curvature of the canal to be treated. For making this determination merely view the curved canal as having two segments, one extending from the floor of the chamber down the long axis of much of the coronal two thirds of the root and the second from the apex of the root extending back to the occlusal through the apical third of the root. These two lines will intersect and form four angles. The interior angle is the estimate of the degree of the canal curvature. In this specific case, distovestibular root degree of curvature has an estimated 120 degree. Such an estimate is of mesiodistal curvature only and does not take into consideration any buccolingual curvature. The method for making this determination has ben first described by Schneider and then Jungman et al.
This present description of Schneider method is from Franklin S. Weine in his book: “Endodontic therapy” Fourth edition pp 314-315
Carl Zeiss Opmi Proergo dental operative microscope was of a big help in locating both mesiovestibular and distovestibular canals entries, I am using the Pro Taper Endodontic files System from Maillefer for preparation of canals as they are doing very nicely in extremely curved canals. Intracanals treatment procedure is a calcium hydroxide as a medicament (Third x ray from left) since there is a lot of intracanal exudation. Canal filling method: master gutta-percha cone, lateral condensation for the first wave, warm gutta percha for the second wave. Pulp Canal Sealer as the root canal sealer. Amalgam filling has been replaced by a composite filling, because patient wanted to wait a bit for his dental insurance to kick back in. Patients regular dentist will do crowning as soon as possible after that.
Case Study Number 397137
Tooth history: First attempt of RCT on this mandibular second molar in 2005 did not eliminate symptoms, a second attempt in 2006 did not turned out to be any better, tooth was still having episodes of severe pain (preoperative X ray dental film taken in January 2007). Patient was told by the second practitioner to remove that tooth but she would rather try to save it for the third time.
Patient was already aware of the tooth poor prognosis and that implant therapy would be the safest way to eliminate symptoms. Still she agreed to retreat the tooth endodontically.
During the procedure, a zip with perforation and apex blunderbuss could be noted on mesial root canals as well as in distal root canal. An apical split (with no existing apical constrictions) was also noted by probing in the distal canal. Serous exsudate was coming out of those root canals in such an amount that it could not be dried even with lots of paper points. Calcium hydroxide was inserted into the canals and patient came back 8 days later. By then symptoms had subsided. After removal of calcium hydroxide into the canals, serous exsudate was still present but in lesser amount. Another attempt with calcium hydroxide replacement was made. Patient came back, symptoms free, 2 weeks later. At this point, almost no exsudate was remaining. All canals, including apical split in distal root, were “plugged” with MTA (Mineral trioxide aggregate) under high magnification. Coronal part of the tooth was sealed with a posterior composite and no promises where made to the patient who decided not to invest in a crown considering the prognosis. This procedure has been achieved in August 2007, the X ray dental film on the right shows a 4 years post operative outcome. Even though circumscribe apical radiolucency is still present the tooth remained symptom free and functional.
In this specific case, MTA used as a root-end filling material proved so far to be effective in promoting regeneration of the original tissues when it is placed in contact with the periradicular tissues. High magnification with excellent coaxial illumination insured a better placement of this material.
To read more about MTA applications please go to:
Calcified Canals. Case Study Number 487445
Clinical examination: Sinus tract, mobility: 0, deciduous amalgam restoration.
Radiographic examination: Alveolar bone with circumscribed lucency, apical root canal split, hypertaurodontism (bull’s tooth), apical root canal split branches not visible on X ray dental film, hypercementosis
Diagnosis: pulpal necrosis with chronic periapical infection,
Etiology: marginal leakage, caries
Root canal procedure:
First appointment: gaining access to the split, locating entries, shaping and cleaning apical root canal branches inserting intracanal medication for 8 days.
Second appointment: intracanal medication retrieval, copious CHX 2% irrigation, drying canals and permanent root canal obturation with Pulp Canal Sealer and gutta percha (lateral and vertical condensation).
In that specific case, microscope was most helpful during all the following steps necessary to insure a better prognosis for this patient:
1) Locating and gaining access to buccal and lingual root canal entries (apical split was clearly visible under magnified observation)
2) Striving to find a third branch in apical split minimizing the chances of omitting an untreated canal
3) Aiming at the right root canal orifice when:
- Inserting the two first endodontic files to confirm canal lengths
- inserting a file sequence to shape and clean each canal
- Positioning irrigating syringe needle tip and calcium hydroxide syringe tip toward the right canal entry
- Inserting absorbent paper points in both canals when drying canals
- Inserting master, accessory gutta percha cones and finger plugger when doing final obturation with lateral and vertical condensation
4) Checking for pulpal tissue remnants prior to final obturation to minimise the chances of pushing them back into the apical area
Case study number 485946
Symptomatic mandibular molar, patient can’t chew on that side. Referred to us for endodontic revision.
First appointment intervention steps:
Coronal-radicular access (access through PFM crown, access through coronal build up) taking great care not to perforate the previously weakened pulpal floor, gutta percha removal, locating DB, regaining patency in calcified distal canals to the apex without perforation or deviation, correcting step in apical third of mesiolingual canal, negotiation of mesial canals, CHX 2% irrigation, CHX 2% left in canal system for one minute, drying canals, insertion of calcium hydroxide dressing, provisional obturation (Cavit)
Second appointment intervention steps:
Removal of Ca(OH)2, CHX 2% for one minute, dry canals, cone fit checking and final obturation with Pulp Canal Sealer and Gutta Percha.
Small sealer overflow is a good warrant of apical seal.
Referring dentist is planning a fixed bridge 37, 36, 35 X. (Patient did not want an implant to replace missing #34)