endomontreal

A new Dental Operative Microscope (D.O.M.) assisted root canal treatment in a calcified maxillary incisor. Case study in microendodontics number: 237122

Tooth is asymptomatic patient wants to replace this existing crown for esthetic purposes. Replacing this crown without doing any endo might just be the way. But after prosthesis removal, high magnification under a dental operative microscope abutment shows an horizontal crack close to the margin on its buccal aspect. Hence we do have to find a way to put a casted post in place. Creating a space for the post might create an open gate for bacteria or might disturb the microflora balance within the root canal. So what options do we have here?

Apicoectomy and a post space? Crown to length ratio on this tooth would become a problem if we had to resect last apical 4mm in order to do an apicoectomy and we cannot be certain to have obturated portal of exit with a retro prep and a retrograde filling. Not good enough to my opinion. 

Extraction with an implant surgery? The great classical solution! Why bother? BUT, patient wants to keep her own tooth and cannot invest in an implant surgery. 

Last but not least: The not yet embraced but very effective microendodontic approach. The dental operative microscope OPMI PROergo from Carl Zeiss with its magnified and coaxial Xenon illumination allowed for a great operative field observation and unequaled precise hand micro movements.  As it can be seen in the last postoperative X ray dental film, root canal procedure as been performed with no collateral damage, a casted post is planned with a brand new PFM crown by the referring dentist. 

case: 430646

Resorption associated with chronic apical periodontitis altered the shape and position of the foramen through osteoclastic activity, in the x ray images, 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.

This case is definitly a controversial one, meaning that it is possible for different practitionners to prognosticate endodontic success (very few among practioners) or failure with a great amount of disparity. As stated by John I. Ingles, a senior lecturer in endodontics: "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."

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 a 3 years post operative clinical outcome. Radiographic examination shows a complete regeneration of the periradicular tissues and a resoptive defect healing. 

Should an implant have been put there? maybe, maybe not!

Read more about MTA Precision placement with the microscope (.pdf)

A 3 years post operative Dental Operative Microscope (D.O.M.) assisted root canal treatment follow up on a mandibular molar which presented with  an almost complete destruction of it's periradicular tissues:  Case report in microendodontics number: 460646

A new Dental Operative Microscope (D.O.M.) assisted root canal treatment in a maxillary lateral incisor presenting  an almost complete mineralization of it's root canal system:  Case report in microendodontics number: 73422 

A new Dental Operative Microscope (D.O.M.) assisted root canal treatment in a calcified maxillary incisor. Case study in microendodontics 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. 

Case report in microendodontics number 493847                                  Key words: Root canal anatomy, anatomical variation of teeth, radix entomolaris

The anatomy of the root canal system directly affects the success of the root canal treatment. This post presents a case report of a mandibular second molar with five canals and five different apical foramina. The intraoral clinical examination revealed a tooth affected with deciduous restoration, and a sinus tract. On radiographic examination, the distal root larger than average width did let us suspect the presence of four separate roots. Other radiographic findings: Alveolar bone with circumscribed radiolucent apical lesion. The diagnosis was a pulpal necrosis and a chronic suppurative periradicular periodontitis. Etiology: marginal leakage, caries. 

Endodontic procedure: 

First appointment: gaining coronal-radicular access to the 5 canals, locating entries, shaping and cleaning apical root canal branches inserting intracanal medication for 8 days. Third X ray image shows the fift short canal extending from pulp chamber to the interradicular space.

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, the endodontist microscope insured a better prognosis for this patient because it has been most helpful  when striving to find the root canal split in distal root and because it prevented us from omitting the fifth root canal.

Even when complete root canal treatment has been carried out the patient still has to be periodically evaluated for prognosis.

A new Dental Operative Microscope (D.O.M.) assisted root canal treatment in a Radix Entomolaris presenting  a fift canal (accessory canal) extending from the pulp chamber to the furcation.  Case report in microendodontics number 493847 

A new Dental Operative Microscope (D.O.M.) assisted root canal treatment in a calcified maxillary molar abutment. Case study in microendodontics number: 27526

Acute pain on this maxillary molar is keeping the patient awake all night long. Pain started following a recent filling replacement.  This is an irreversible pulpitis diagnosis, patient has been referred for endodontic therapy with the help of a dental operating microscope. 

Radiographic findings: Dystrophic calcifications in the whole canal system are completely obliterating the pulp chamber as well as the root canals themselves. It can be expected that the root canal entries are completely embedded in a mass of adherent pulp stones. 

Endodontic procedure problem number one to solve: 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.

Endodontic procedure problem number two to solve: Cleaning and shaping located root canals without loosing patency, without breaking an endodontic file and without perforating the root. 

A few years back, when there was no surgical operating microscope in our dental practices and only a handfull of daring (and caring)  pioneers in microendodontics trained by Dr Garry B. Carr (who is an endodontist acknowledged to me as the "father of microendodontics"), removing this symptomatic molar and replacing it  by an implant supported crowns would have been a good option to consider for most of us. 

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. 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 that was done by the referring dentist will warrant a good seal.