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
This case has been posted on a specialized root canal FB forum and earned 596 likes from dentists around the world. See this case at: International Root Canal Procedure Forum
A single canal fast break usually indicate a split in root canal apical third. In this mandibular first molar the canal had split into three branches. Each of it having its own portal of exit. Each branch had to be successively shaped then filled. High magnification with coaxial Xenon illumination allowed to visualize those entries during the procedure. 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.
42 year old patient had pain to both cold and hot and could not eat on this side for the late 7 months. She has been seen by two previous dentists and endured a lot of pain for so long because pre operative X rays showed no signs of visible recurrent tooth decay as well as no obvious signs of periodontal ligament thickening, both X ray signs indicating a potential need for a root canal. Composite filling also showed no clinical signs of leakage. Upon reading the pre operative Xray we could see that the pulp horns were very long and almost touched the filling. I suggested to remove composite filling in order to check underneath. Tooth decay was indeed present and pulp got exposed before the completion of tooth decay removal. Furthermore a vertical crack line was present in distal. Patient also fractured and lost her second mandibular molar due to clenching.
A new Dental Operative Microscope (D.O.M.) assisted root canal treatment in a calcified mandibular molar. Microendodontic. Case Study Number 433336
Broken lingual wall, extended deep restauration, patient has been referred for endodontic therapy with the help of a dental operating microscope because of highly calcified canals.
Radiographic findings: Dystrophic calcifications in the whole canal system are completely obliterating the pulp chamber as well as the mesial root canals entries. It can be expected that the root canal entries are completely embedded in a mass of adherent pulp stones.
Root canal procedure is so difficult because of calcified canals that not so long ago, we would have had to remove this symptomatic tooth and replace it by an implant supported crown. Nowadays, with help of a microscope things have changed a lot.
Microscope can help us to solve Endodontic procedure problem number one: Exposing color map of dentin prior to locating root canal entries without perforating pulpal chamber floor and without destroying to much sound tooth structure in order to keep tooth restorable.
Microscope can help us to solve Endodontic procedure problem number two: Location of root canal entries.
Endodontic procedure problem number three cannot be solved by high tech alone, only experience can help: Cleaning and shaping located root canals without loosing patency, without breaking an endodontic file and without perforating the root.
In order to avoid implant therapy, calcified dentin must be carefully removed with long thin ultrasonic tips under the high magnification of dental operating microscope (OPMI PROergo from Carl Zeiss). No rapid technique exists for dealing with calcified root canal systems. Root canals where shaped and cleaned with Protaper endodontic files and 06, 08,10 K in combination with chelating agent (RC PREP). Canal system has then been filled with Pulp Canal Sealer and Gutta percha laterally and vertically condensed. Provisional filling material: Cavit.
Last X Ray dental film is a post operative control, a crown with a perfect fit is planned by the referring dentist to prevent fracture and leakage.
Root Canal Procedure on Calcified Canals. Case Study Number 513546
First preoperative X ray dental image displays a previously started root canal. This tooth was referred by a clinician who could not locate the four calcified canal entries.
Careful removal of calcification with ultrasonic tips (BUC3) under high magnification, allowed for this root canal treatment to be completed. There is at the present time no other way than the use of a microscope to preserve such a calcified tooth.
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)
MicroEndodontic. Case Study Number 449947
Pulp chamber and root canals are not visible on pre operating X Ray of second mandibular molar. Diffuse calcifications preclude easy canal entries location. Despite its highly calcified canals, this tooth must not be extracted, it can be saved with a dental operating microscope assisted root canal procedure.
This last X ray dental film is a three years post operative control and is showing a complete regeneration of periradicular tissues, teeth are still functional and symptoms free.
Should an implant have been put there in the first place to replace this second mandibular molar simply because this root canal procedure is extremely difficult to perform? Maybe, maybe not!
Both implant therapy and endodontics show excellent prognosis. To let the informed patient decide for himself whether or not he want’s to save his tooth instead of having a dental implant is simply common sense.
Case Study Number 495336
Symptoms: Acute pain to pressure, patient is eating on the opposite side.
Root canal was done three years ago.
A week later, final root canal obturation with gutta percha and pulp canal sealer completed the root canal procedure, an amalgam post and core build up was done during the same appointment to seal coronal part of the tooth.
Six months recall shows a complete healing.
Patient’s dentist can prepare the tooth as an abutment to receive a crown.
Root Canal Procedure with Surgical Operative Microscope.
Case Study Number 156037.
Pre operative film shows a large bony defect reminding us the alleged pathognomonic “J” type lesion. Still, there was no deep and narrow pocket probing. Root canals are not visible neither in mesial or distal root (calcified canals)
First appointment post operative X ray dental film shows shaped and cleaned canal system with inserted intracanal calcium hydroxide.
Post operative control X ray film in December 2011 shows a nice healing of surrounding hard tissues. Endo treatment finished on 2007 with surgical operative microscope Opmi PROergo from Carl Zeiss.This root canal therapy attempt once more enlightens the huge advantages of microendodontics and calcium hydroxide therapy in order to save teeth with an apparent very bad prognosis.
First appointment: Opening through metal bridge abutment, gaining access to pulp chamber, adherent pulpstones and embedded pulpstones removal, root canal entries locations, cleaning and shaping, rinsing, drying, intracanal medication insertion and provisional obturation material.
Second appointment: Intracanal medication removal, rinsing and final obturation with Pulp Canal Sealer from Kerr and gutta percha
Endodontic material and equipment:
- Shaping and debridment instruments: Stainless steel ISO files, Pro taper files (Dentsply)
- Rinsing solution: sodium hypochlorite 6%
- Drying: sterile paper points
- Calcium hydroxide
- Obturation material: gutta percha lateral and vertical condensation, Pulp Canal Sealer
- Dental operative microscope: OPMI PROergo microscope from Carl Zeiss