endomontreal

Case study number 456147

We have been presented with this mandibular second molar that has a periapical lucency which also has a periodontal component. Patient is experiencing pain. This radiographic image also shows a huge radiographic J-shaped lesion that may be indicative of a vertical root fracture in the mesial aspect of the mesial root. 

Are we dealing with a periodontal infection? And, if this is the case, such a periradicular tissues loss would command an extraction of the tooth. 

Are we dealing with a fracture? And, if this is the case, tooth extraction would also be the treatment of choice. 

Are we dealing with an endodontic infection? If this is the case an endodontic revision (endodontic retreatment) would suffice to preserve this tooth. 

The decision of extracting or saving that tooth should be based on a foundation of sound diagnosis.

One of the primary fact that needs to be established in distinguishing endo/perio lesion is the pulp status. Since there is not much pulp left in that case, pulp testing won't help much.

Periodontal probing is the next important measurement in determining if wether this tooth has an endodontic or periodontic infection. Probing shows no wide or narrow pocket on buccal neither on lingual (and on distal) aspects of this tooth, at this stage, periodontal infection might be ruled out.

The remaining question is: "Are we dealing with a fracture or an endodontic infection?" A deep narrow periodontal pocket would indicate a vertical root fracture and the quiz would end right there. The tooth would have to be extracted.The problem is that this defect, if it does exist, might be located just beneath a wide and tight mesial contact point and probing with accuracy this area is not that obvious. Hence the final question cannot be answered without any doubt by probing alone.

One option would be to remove the crown to allow for a direct access to the potential defect. But then, if no deep narrow periodontal pocket exist, the clamp for the rubber dam as well as tooth protection from vertical forces would require a provisional crown to be installed. Even so, probing a deep narrow periodontal pocket is not an absolute waranty that this defect is in deed a crack. It might also be a desmodontal sinus tract. Hence,drilling through the existing crown to access mesials root canals and a direct observation under magnifying lenses of a microscope seemed to be the appropriate way of confirming the presence or absence of a vertical root fracture. 

No crack could be observed from within the mesial root canals, the treatment has been completed in two appointments (third, fourth and fifth images) . Following the first appointment which implied material retrieval, irrigation and calcium hydroxyde insertion (Second X ray image), both pain and swelling disappeared. Following Xray image shows a complete periodontal tissue regeneration after one year. Tooth is asymptomatic.

A new case study has been posted on Friday, April, 1st, 2011 with X ray images: A radiographic j-shape lesion, does the tooth has a vertical root fracture? A periodontal infection? an endodontic infection?

1) A new case study: Carl Zeiss Opmi Pro Ergo microscope vs complete stenosis of an apical root canal split  

2) Stemcells in endodontics an interesting video on YOUTUBE by Dr George Huang, professor at the dental department in Boston University, a SCAP Guru in the US 

Case study number: 487445

Clinical examination: Sinus tract, mobility: 0, deciduous amalgam restoration. 

Radiographic examination: Alveolar bone with circumscribed lucency, apical root canal split, hypertaurodontism (bull's tooth), apical root canal split branches not visible on X ray dental film, hypercementosis 

Diagnosis: pulpal necrosis with chronic periapical infection,

Etiology: marginal leakage, caries

Root canal procedure:

First appointment: gaining access to the split, locating entries, shaping and cleaning apical root canal branches inserting intracanal medication for 8 days.

Second appointment: intracanal medication retrieval, copious CHX 2% irrigation, drying canals and permanent root canal obturation with Pulp Canal Sealer and gutta percha (lateral and vertical condensation).

In that specific case, microscope was most helpful during all the following steps necessary to insure a better prognosis for this patient:

1) Locating and gaining access to buccal and lingual root canal entries (apical split was clearly visible under magnified observation) 

2) Striving to find a third branch in apical split minimizing the chances of omitting an untreated canal 

3) Aiming at the right root canal orifice when:

• Inserting the two first endodontic files to confirm canal lengths 
• inserting a file sequence to shape and clean each canal 
• Positioning irrigating syringe needle tip and calcium hydroxide syringe tip toward the right canal entry 
• Inserting absorbent paper points in both canals when drying canals 
• Inserting master, accessory gutta percha cones and finger plugger when doing final obturation with lateral and vertical condensation  

4) Checking for pulpal tissue remnants prior to final obturation to minimise the chances of pushing them back into the apical area

Case study number: 317736 

Patient referred for pre prosthetic endodontic treatment on mandibular first molar. 

Preoperative X ray dental film shows a complete mineralization of both mesial part of pulp chamber and mesial canals as well as a complete stenosis of distal canal(s?)

Dental operative microscope and ultrasonic tips where most helpful in locating both mesial and distal canal entries. First instrument in four canals are K files number 06 (second X ray dental film)

Third X ray dental film (Clark's rule) shows all four treated canals. 

Amalgam corono apical core build up (no post) is planned plus a crown.

A new case study: Zeiss Opmi Pro Ergo dental operative microscope VS almost complete stenosis of root canal system  

Case study number 485946

Symptomatic mandibular molar, patient can't chew on that side. Referred to us for endodontic revision.

First appointment intervention steps:

Coronal-radicular access (access through PFM crown, access through coronal build up) taking great care not to perforate the previously weakened pulpal floor, gutta percha removal, locating DB, regaining patency in calcified distal canals to the apex without perforation or deviation, correcting step in apical third of mesiolingual canal, negotiation of mesial canals, CHX 2% irrigation, CHX 2% left in canal system for one minute, drying canals, insertion of calcium hydroxide dressing, provisional obturation (Cavit)

Second appointment intervention steps:

Removal of Ca(OH)2, CHX 2% for one minute, dry canals, cone fit checking and final obturation with Pulp Canal Sealer and Gutta Percha.

Small sealer overflow is a good warrant of apical seal.

Referring dentist is planning a fixed bridge 37, 36, 35 X. (Patient did not want an implant to replace missing #34)

A new case study: Steps of intervention in an endodontic revision on a first crowned mandibular molar 

Conceived and maintained free of charge by a dentist, for dentists, both the experienced professional and the beginner – endomontreal.com is dedicated to the exchange of substantive technical content, covering the full range of information requirements. Inviting members from all over the world, speaking from a wide range of technical experiences, this forum addresses questions about root canal aspect of dentistry today.

Vast majority of endodontic treatments performed on teeth presenting wide canals with apical constrictions and readily accessible canals entries do not require particular skills, a dental operative microscope or even a specialist diploma. They are of routine complexity. On many occasion though, some clinical cases require, as stated by John I. Ingle: "to greatly enhance one's capability by being able to practice using a vast variety of techniques and not being "married" to a single approach in every case". These are the clinical cases that are presented in this blog.

New posts with special cases in endodontics are being added to our blog on a weekly basis (Up until now, 171 clinical cases have been added to this blog).These cases were referred to us and where all done in our office using up to date technics and advanced technology. Those clinical cases, despite their extremely high level of risk and difficulty are showing a nice predictable outcome on post operative X ray films.

This blog is  stressing out the utmost importance of the role played by the dental operative microscope in endodontics and the 20 years of experience in root canal therapy that led me to its mandatory use in my everyday practice. As the saying goes: "The truth is in the pudding"

All in all, above technical experience, above advanced technology and even above an expert diploma, those cases require passion and determination.    

An online patient referral form is now on display in the referring doctors section. 

A patient information center display two fact sheets: "Tooth saving tips from the AAE" and "A microscope for dentists? What for?"

An important new feature: A translating plugin powered by GOOGLE TRANSLATE located in the right column of this page will maybe enable more dentists on the Web to "guess" in 48 languages what endodontics and more specifically what microendodontics can do for their patients.

A new case study, orthograde plus retrograde endodontics:

Dealing with dystrophic calcification in mesiovestibular root canals   Case: 486726

Conceived and maintained free of charge by a dentist, for dentists, both the experienced professional and the beginner – endomontreal.com is dedicated to the exchange of substantive technical content, covering the full range of information requirements. Inviting members from all over the world, speaking from a wide range of technical experiences, this forum addresses questions about root canal aspect of dentistry today.  

An online patient referral form is now on display in the referring doctors section. 

A patient information center display two fact sheets: "Tooth saving tips from the AAE" and "A microscope for dentists? What for?"