A New Dental Operative Microscope (D.O.M.) Assisted Root Canal Treatment on Maxillary Incisor with a Calcified Canal.
MicroEndodontic. Case Study Number 73422
Patient has been referred for dental operating microscope assisted root canal. Acute pain on this heavily restored lateral incisor kept the patient awake all night long. Pulpal necrosis and acute apical periodontitis is the diagnosis.
Radiographic findings: Pulp chamber is not visible and root canal is barely visible in its last apical third on preoperative X Ray of this maxillary lateral incisor. This is because dystrophic calcifications in the whole canal system are completely obliterating the pulp chamber as well as two thirds of the root canal itself. It can be expected that the root canal entry is completely embedded in a mass of adherent pulp stones. Diffuse calcifications preclude easy canal entry location.
Problem number one to solve: Creating a pathway to the remaining portion of root canal with patency without perforating the root laterally and without destroying to much sound tooth structure in order to keep tooth restorable.
Problem number two to solve: Locating root canal entrie (which is located very apically in the root canal system) without perforating the root and without destroying to much sound tooth structure in order to keep tooth restorable.
Taking into consideration the fact that root canal system is not visible on pre operative Xray dental film, and being aware of the technical problems that might be expected during the endodontic procedure, an antibiotic therapy (which is going to leave the patient in pain for another two or three days) followed by an apicoectomy with a retrograde MTA filling might have been considered as an option. But, then again for how long? Tooth crown is heavily restored and when the time comes for a PFM, a space for a post is going to be needed anyway. By locating and treating this root canal STAT with calcium hydroxide, pain will subside almost on the spot and canal prep for a post will be obtained by the same token.
Patient is given full knowledge of the possible risks and benefits of such a complex procedure. Patient just wants the pain to stop, he also wants to keep his own tooth. An informed consent is given.
Treatment protocol:
In order to save that tooth, 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. Progressive abrasion of dense calcifications both in pulp chamber and root canal led to the canal entry in the last apical third of root canal.
24 mm long root canal has been easily 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 calcium hydroxide for 8 to ten days. It has then been filled with Pulp Canal Sealer and vertically condensed Gutta percha. Provisional filling material: Clip from Voco.
Last X Ray dental film is a post operative control. Casted post and crown are planned for this tooth.
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