Expertise | ENDOMONTREAL

Completely calcified tooth does not necessarily condemn it to extraction

November 4, 2015 By Dr Pierre Pizem 6 Comments

One must not decide a tooth extraction on the sole basis of an x-ray observation. In cases of complete calcification of root canal systems, the prognosis of teeth that require an endodontic procedure will not become evident until the practitioner has initiated an endodontic treatment to determine whether the canal can be completely negotiated and then adequately disinfected and filled. Thus root canal procedure should always be attempted even if teeth are presenting with narrow or non-existent root canal.

In this specific case, the endodontist operative microscope from Zeiss was most helpful when striving to find the three narrow canal entries hidden under a layer of Russian red. This microendodontic case study also enlightens how dental operative microscope may assist the practicing dentist into a more secure root canal procedure for his patient.

Root canal shaping was completed with stainless steel K endodontic files in conjunction with the Pro Taper system from Dentsply. Chelating agent: RC Prep. Root canal obturation was completed with gutta percha and Pulp canal Sealer from Kerr using the warm vertical condensation technique.

Going the extra mile to secure root canal treatment success

October 15, 2015 By Dr Pierre Pizem 2 Comments

Patient has been referred for root canal treatment on both first and second maxillary molars. Tooth number 16 had necrotic pulp and tooth 17 presented with irreversible pulpitis. Patient was taking both antibiotics and analgesics.

To alleviate patient’s pain, both teeth had to be simultaneously cleaned and shaped during the first setting. A pulpectomy on 17 and a cleaning and shaping of 3 canals of tooth 16 have been performed. An interim calcium hydroxide dressing has been inserted and patient had to come back in order to locate clean and shape the second mesio vestibular. During the second appointment the dental operative microscope allowed us to uncover and treat both an apical split in tooth number 17 and a fourth canal in tooth 16.

Despite the fact that on the pre operative X Ray image tooth number 17 seemed to have a single large canal, it ended up being a Vertucci type 5 root canal configuration (a single canal splitting in two branches short of the apex). As for tooth 16 a second mesio vestibular was expected to be present in its mesio vestibular root, still, dental operative microscope has there too been very useful when trying to locate it.

Access opening has been performed with a combination of a 556 cross cut and a round tungsten carbide bur (Friction Grip). Operative field observation has been enhanced with high magnification and coaxial xenon lamp illumination (Carl Zeiss OPMI PROergo dental operative microscope). Dystrophic calcifications have been removed from pulp chamber with ultrasonic diamond coated tips in order to expose the second mesiovestibular root canal entry location.

Instrumentation has been performed with Mani stainless K files and ProTaper Universal (Dentsply). Chelator: RC Prep. PUI Irrigation: NaOCl 5%. Ultrasonic tip: BUC One from Spartan. P5 (Dentsply) Sealer used: Pulp Canal Sealer. Obturation technique WVC. X Ray Sensors used: CareStream Kodak 6100.

Too much calcification for a root canal treatment?

October 2, 2015 By Dr Pierre Pizem Leave a Comment

This tooth is a 23XX26 leaking fixed bridge abutment. Prior to bridge replacement it needs a root canal procedure.

Performing a root canal procedure on an abutment showing narrow canals and a complete obliteration of the pulp chamber by a large amount of calcification represents a challenge for any dentist or endodontist. Close observation of the pulpal floor map under a dental operative microscope helps in locating root canal entries. Still, this floor needs to be exposed first to be able to read the map.

Access opening was performed with a combination of a 556 cross cut and a round tungsten carbide bur (Friction Grip).
Operative field observation was enhanced with high magnification and coaxial xenon lamp illumination (Carl Zeiss OPMI PROergo dental operative microscope). Dystrophic calcifications have been removed from pulp chamber with ultrasonic diamond coated tips in order to expose the pulpal floor allowing for all canal entries location. Then, lots of chelating agent as well as many stainless steel files were needed to progressively regain patency in the narrow canals.
Instrumentation has been performed with Mani stainless K files and ProTaper Universal (Dentsply). Chelator: RC Prep. PUI Irrigation: NaOCl 5%. Ultrasonic tip: BUC One from Spartan. P5 (Dentsply) Sealer used: Pulp Canal Sealer. Obturation technique WVC. X Ray Sensors used: CareStream Kodak 6100.

Relieving Pain With An Intricate Root Canal Treatment on a C Shape Root Canal

November 1, 2013 By Dr Pierre Pizem Leave a Comment

An intricate endodontic therapy to perform in order to preserve a very painful tooth, patient was taking 3 X 200mg Ibuprofen Pills every 3 hours in order to get through the preceding night. Serous exudate accumulation resulted in mucosa swelling

This type of root canal treatment has a high level of difficulty because debridement of those ribbonlike C shape root canals is extremely painstaking to perform.

These pictures of a “C” shaped second mandibular molar from the rootcanalanatomyprojectblogspot.com have been taken by Dr Marco Versiani. They display the complex anatomy of such a root canal system. Those pictures give a better understanding on how difficult the cleaning and filling tasks of a “C” shape root canal may be.

Calcified root canals entries where located with the help of a Carl Zeiss Microscope. These where embedded in a mass of pulpstones and calcifications which had to be removed with an ultrasonic tip. Calcium Hydroxide Antibacterial gel insertion was mandatory to control infection within the root canal system. This gel has been removed in a subsequent appointment and replaced by a permanent root canal filling. Tooth corono apical build up is an amalgam Nayyar core. A permanent crown is planned.

Root Canal Procedure on Calcified Wisdom Tooth Presenting With a Severe Root Canal Curvature

October 25, 2013 By Dr Pierre Pizem Leave a Comment

Advanced Root Canal Procedure on a Tooth Presenting with a severe Root Canal Curvature

: Root canal procedure on Calcified and Curved Root Canal

What’s new on this blog on Friday,11th, 2011

February 13, 2011 By Dr Pierre Pizem 2 Comments

A new case study number: 411716: "The dental operative microscope and the MTA tooth perforation repair. The impossible made possible". This new post in NEW CASES is also featuring a video sequence showing what can be seen through my Zeiss OPMI PRO ergo dental operative microscope. This video is a provisional one, the real McCoy will replace this one soon enough. (I still have to master I Movie and Youtube processes, hopfully it should not be too long, I have got some support from my 13 years old daughter).
A nice comment left on post number: 297716 from Dr Juan C Mesia, a GP in Florida who also wanted to know what kind of files I was using and the sequence I used for curved canals. I gave an answer and I also added my four rules of thumb in shaping and cleaning ANY root canal systems. The answers are right there! However, there should be a fift rule: Always adapt your ISO K files shape to the suspected canal curvature in order to reach the apex.
A nice comment left on post number: 483136 from Dr Nguyen at hotmail.com who also had a concern about sealer overfill showing on my postoperative X Ray film. I readily refered him to an interesting article written by Stephen L. Buchanan who (among other things) addressed this topic in the 2010 January issue of Dentistry Today: Tapered Shaping can make your life easier!
The thought of the day: "There ain't any answer. There ain't going to be any answer. There never has been an answer. That's the answer." Gertrude Stein (Boy, do I like this one!)

May you enjoy your visit

Pierre Pizem

The Dental Operative Microscope and a MTA Tooth Perforation Repair. The Impossible Made Possible.

February 11, 2011 By Dr Pierre Pizem Leave a Comment

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.