prognosis | ENDOMONTREAL

Access Through Both a Crown and a Casted Post to Save a Molar

June 6, 2020 By Dr Pierre Pizem Leave a Comment

Planning access cavity through crown as well as a long casted post

Emergency appointment for a recurrent acute pain on top left side. Root canal casted post and crown have been performed on this second maxillary molar one year ago. Patient is 24 years old, cannot eat on that side and he has been prescribed multiple regimen of antibiotics for this issue. No swelling, no mobility, no deep isolated pocket upon probing. Prognosis is good. Decided not to remove the crown because patient wanted to keep it a few more months. Thus, the post has to be drilled of through the crown.

Emergency appointment access to pulp chamber through casted post

An access has been drilled through the crown , through the casted post up to the pulp chamber level. Due to the non precious alloy it was made of, it took 60 minutes with an electric hand piece and quite a few burs to get through this post.

Palatal root canal entry filled with pus and exudate

Blood exudate and pus drained through the palatal root canal entry and patient has ben rescheduled for root canal revision.

Patient came back, tooth was asymptomatic and access through the casted post had to be enlarged in order to locate MB and DB root canal entries

Confirming absence of MB2 with a small field of view CBCT scan

Interim calcium hydroxyde (Metapaste: premixed paste composed of calcium hydroxide with iodoform)

Patient came back after 10 days and Calcium paste has been removed and per operative X Ray confirm a good cone fit check

Asymptomatic tooth, root canal system sealed with Pulp Canal Sealer from Kerr and cold lateral condensation. Nayyar amalgam core build up.. Crown will be replaced in 6 months.

This challenging root canal procedure has been performed by Dr Pierre Pizem , a general practitioner offering endodontic services for the last 28 years. This procedure took him three appointments totalling 4 hours chair side working time in order to save that natural tooth.

Root canal procedure on a remote maxillary molar in a patient with limited opening of the mouth

April 14, 2017 By Dr Pierre Pizem Leave a Comment

Endodontic procedure instrumentation has been performed with Mani stainless K files and ProTaper Universal (Dentsply). Chelator: RC Prep. PUI Irrigation: NaOCl 5%. Mesio vestibular canal entry located with the help of high magnification and coaxial illumination (Opmi PROergo dental operative microscope from Zeiss) Sealer used: Pulp Canal Sealer. Obturation technique WVC. X Ray Sensors used: CareStream Kodak 6100.

Patient has been advised that the next step would be a crown lengthening and a crown

Saving a Tooth Through an Intricate Root Canal Procedure

August 27, 2015 By Dr Pierre Pizem Leave a Comment

The patient urged my referring dentist to save his own natural tooth even though it was badly decayed and it presented with an uncomplicated crown fracture on its lingual side. Despite its apparent questionable restorability on pre operative Xray, the tooth is very long and its periodontal status is good so we accepted to perform both the root canal procedure and the post and core build up.

RCT procedure on this maxillary molar has been a time consuming one mostly due to its calcified root canal system and its 26mm length. MB2 root canal entry has been located with the help a dental operating microscope high magnification along with a coaxial Xenon illumination.
Armamentarium: Zeiss’s OPMI PROergo Dental Operative Microscope , 556 straight cross cut carbide tungsten bur, Ultrasonic tips (BUC 3), RC Prep, many Mani K files (envelop of motion), ProTaper Universal, 6% NaOCl, PUI, Pulp Canal Sealer + W.V.C.

Tooth has been restored with a FlexiPost (cemented with RelyX luting cement) and an amalgam core build up. (Slight excess of amalgam seen on post operative X ray on palatal aspect of the tooth has been removed prior to sending patient back to his own dentist for crowning)

Opmi Proergo Dental Operative Microscope, a Cutting Edge Technology to Save a Key Tooth. Overcoming an Against All Odds Clinical Pre Operative Condition.

March 13, 2013 By Dr Pierre Pizem 3 Comments

Dental operating microscope assisted root canal procedure on a completely stenosed canal system (calcified canal).

Endodontist. Case Study Number 506712

In order to be preserved and used as an abutment for a fixed bridge replacement, this tooth must have a casted post space preparation in its coronal third. Thus apical endodontic surgery cannot be considered as the best option for the patient.

Pre operative condition:

Canal is not visible on dental X ray film until last few millimeters because the root canal anatomy system does not begin before last few millimeters, this means an extremely narrow canal diameter for the practioner to locate in last apical third of root. Remaining canal diameter can be 3 times smaller than a single strand of human hair diameter. Remaining within tooth long axis when accessing canal entry is of the utmost importance not to create a iatrogenic perforation.
Two previous failed attempts to locate tooth single canal entry, this means complete loss of landmarks when looking through dental operative microscope lens to find it
Number 12 tooth is a 12X21 bridge abutment, this means loss of external landmarks to locate canal entry
Dentine shade composite completely fills up the access cavity, this means even more challenge, when drilling to expose canal entry, not to create additional tooth substance loss (thus increasing tooth weakness.

Tooth survival relies solely on endodontic procedure success, if canal cannot be found thus treated, tooth cannot be preserved.

While being a less straightforward approach than implant therapy, this successful endodontic procedure outcome strongly suggests that, nowadays, a complex root canal retreatment does not necessarily have to mean extraction and replacement by a dental implant.

Surgical operating microscopes have a steep learning curve and require training, as well as patience and practice to master. Still this piece of equipment and the learning effort it implies is well worth it since cases that once seemed impossible can now be treated with a high degree of confidence and clinical success.

An Intricate Root Canal Retreatment Procedure on a Calcified Second Mandibular Molar Allowed for this Tooth to Be Preserved for the Last 20 years

January 4, 2013 By Dr Pierre Pizem Leave a Comment

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.

Was that First Maxillary Molar Restorable? A 7 years Post Operative Outcome

May 31, 2012 By Dr Pierre Pizem 1 Comment

Case Study Number 357016 Implant versus natural tooth

Both implants and root canals have similar success rates (above 90%) so the remaining concerns are periodontal status and tooth restorability. If it not restorable, or if bone loss is to important, then prognosis is bad and tooth should be extracted. In that case implant would be the righteous option for a fixed prosthesis.

Periodontal apparatus is fine but a huge part of the existing amalgam and tooth on this maxillary molar just broke. Patient is in pain because of pulpal severe inflammation. Patient has a private insurance coverage which does not include implant surgery. Saving her own tooth will spare her this big expenditure. After thoughtful reflection and discussion with his patient, referring dentist decided to incorporate this tooth as a 16, 15 X 13 bridge abutment.

Patient is in good health, radiographic examination shows some partly calcified canals, the mandatory rubber dam is not difficult to install, root canal procedure is achieved with no complications and patient went back to see her own dentist who placed a long casted post in palatal canal.

This last X ray dental film is a seven years post operative control proving that his severely worn tooth could be used as a very effective abutment. Patient avoided implant therapy and above all preserved her own tooth.

A Root Canal Retreatment Involving a Crown and Two Posts Removal allowed for this Painful Tooth to Be Preserved

April 13, 2012 By Dr Pierre Pizem Leave a Comment

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)

Sven-Erick Hamp Class III Furcation Defect? Parodontal Prognosis? A Seven years Follow Up

December 10, 2011 By Dr Pierre Pizem Leave a Comment

Preoperative X ray dental film shows a “furcation defect” encompassing the entire width of the tooth (no probing). A root canal treatment implying a few Calcium Hydroxyde dressings (and being patient) helped this patient in saving what appeared to be a hopeless tooth.

Last scan shows a seven years post operative control X ray dental film. The four units fixed bridge has been cemented shortly after complete regeneration of periradicular tissues.

Good Prognosis is in the eye of the beholder

September 23, 2011 By Dr Pierre Pizem 2 Comments

Case Study Number 430646

External root resorption associated with chronic apical periodontitis altered the shape and position of the foramen through osteoclastic activity, in the x ray images (2008), the modified foramen in distal root is positioned farther from the radiographic apex and gutta percha appears in overextension. A large and circumbscribed radiolucency involves both roots as well as the furcation. This indicates an important periradicular tissues destruction. Tooth mobility level 2 goes along with this tissue loss.

Based both on this 2008 pre operative X ray dental image and clinical findings, should an extraction plus an implant have been an appropriate decision? most certainly not in my book, time has proven otherwise. Still, up until nowadays, this case is definitely a controversial one, meaning that it is possible for different practitioners to prognosticate endodontic success (very few among practioners) or failure with a great amount of disparity.

Endododontic retreatment and MTA root-end fillings have been performed with a Zeiss Pro Ergo Microscope in september 2008. Last displayed X ray film on this post shows an 8 years post operative clinical outcome. Radiographic examination shows a complete regeneration of periradicular tissues and a resorptive defect healing. An implant would not have been indicated in this case.

As stated by John I. Ingles: “The practicing dentist should not be cited for faulty judgment when even the so-called experts tends to disagree on prognosis… All in all, one must ultimately develop confidence in one’s own abilities. Being able to practice using a great variety of techniques and not being “married” to a single approach in every case will greatly enhance one’s capabilities. And on this is based good prognosis, the result of skill, knowledge, and self confidence.”