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.
On July the 29th 2009, we have been presented with this mandibular second molar. Patient was experiencing pain. This radiographic image showed a huge radiographic J-shaped lesion in the mesial aspect of the mesial root. Back then, according to some experts, this type of lesion along with a deep narrow probing was considered as a pathognomonic sign of a vertical root fracture. Since vertical root fracture has a hopeless prognosis, standards of care would have commanded its extraction. In the presence of such a periradicular tissues loss, extraction would have also been indicated in the event we were dealing with a periodontal infection.
Still, what if we were dealing we an endodontic infection? If this was the case, an endodontic revision (endodontic retreatment) would suffice to preserve this tooth. The decision of extracting or saving that tooth has been based on a foundation of sound diagnosis, as we opened the existing PFM crown to confirm the presence of a crack which we could not find.
An endodontic revision which implied an interim calcium hydroxide has proven to be the correct approach, no dental implant needed here.
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.
Dental operative microscope root canal procedure (Microendodontics). Case Study Number 392346.
Referred patient has had two root canal procedure previously done on this very same tooth and pain was still present for weeks. Extraction and an implant supported crown has been suggested but patient still preferred to once more try to save his own tooth. The dental operative microscope allowed the uncovering of an extra canal ramification during the endodontic procedure. Pain subsided immediately after treating that previously under seen part of the root canal system.
This a class 3 level of difficulty root canal procedure which means that a root canal treatment such as this one is difficult and time consuming to perform. Nevertheless, treating that extra canal was all that was needed to save that tooth. No need for a dental implant here.
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.