endomontreal

Case study number: 171516

Nature of pain: Severe pain to cold heat and spontaneous pain

Clinical examination: deciduous amalgam restorations, leakage, thickened PDL

Radiographic finding: long tooth presenting with severe curvature on buccal root canals

Diagnosis: irreversible pulpitis

No MB2 could be found under high magnification of dental operative microscope. Shaping and cleaning performed using ProTaper system (Dentsply), Gutta percha lateral and vertical packing, root canal sealer: Pulp Canal Sealer EWT (Kerr)

Case number 474446

Deep deciduous restorations have been replaced 4 days ago. Patient has been experiencing severe spontaneous throbbing pain for the last two days. Tooth is presenting an irreversible pulpitis following a restoration replacement. 

Radiographic examination shows calcifications in apical third of all root canals, a thickened PDL in furcation and a very long tooth with a severe curvature in mesial root. The two mesial canals are merging in apical third and their length is 27mm.

Calcifications have been removed from pulp chamber with ultrasonic diamond coated tips from Spartan^TM, Endodontic treatment done in one appointment with lots of RC Prep^TM for chelating agent, Pro Taper^TM NITI files, gutta percha and Pulp Canal Sealer^TM . 

Case study number: 486726

Patient was referred to us with a partial pulpectomy in 3 out of four canals. The case came with a note from referring dentist that MB1 was blocked with a calcification. Patient was in pain and was taking an opioïd analgesic prn (Oxycodone) and prn was high. First appointment we needed to take care of the pain issue by completely removing pulp tissue remnants from palatal and distovestibular root canals. Roots are very long and lots of denticles had to be removed from the canal system. Intervention has been done under observation with a dental operative microscope. A mixture of calcium hydroxide and Iodine was then inserted into those canals. This was the only thing that could be done on an emergency basis. Patient had to come back to address the blockage concern in mesio vestibular root canal.

Patient came back 8 days later, symptoms had completely subsided in a mater off hours post op and patient was able to sleep. On second appointment we have been striving to regain patency in MB1 but failed. Then, since a lot of MB1 and MB2 are merging at the apex, we strived to find MB2 canal entry and we did find it. We were hoping to be able to bypass MB1 blockage and seal both canals at once. But blockage was there too, exactly at the same level as in MB1. Root canals have been sealed with Pulp Canal Sealer EWT. Patient has been advised that the mesiovestibular root canals could not be shaped and cleaned to the apex and that for each missed millimeter from the apex a 14% increase in treatment failure might be expected. Both uncleaned canals parts represented a total length of 20 mm. 

This patient is working (as a explosive expert) in a Nickel mine in a very remote area of Northern Canada. Closest dentist is 1000 miles from the exploiting site. He did not want to experiment another blow up of this kind up there, so he decided to come back for a corono apical amalgam, an apicoectomy and a MTA retrofilling on MB1 and 2 before going back to work. Crowning was done by his own dentist. (The very same dentist asked me to do the core build up in amalgam)

Case study: 431446

Question one: Casted post or amalgam post and core?

Endodontic post does not increased the strenght of the remaining tooth substance, on the contrary it weakens it as a result of the additional tooth substance loss due to the post hole drilling.

"On posterior teeth with enough pulp chamber depth to obviate the need for a post (2 to 4 mm), amalgam is the material of choice. Where a post is required to retain the build-up, amalgam is cheaper and faster than a cast gold core and often less destructive of tooth structure."  Alex McClean, DMD, B.Sc. (Eng.) "Predictably restoring endodontically treated teeth" Web Reference: http://www.cda-adc.ca/jcda/vol-64/issue-11/782.html

Question two: To bond or not to bond amalgam? "As apparently the bond of amalgam to dentin will ultimately degrade, there is concern about increased leakage after bond failure. The bonded surface of the amalgam may be more corrosion resistant than an unbonded amalgam, leading to the risk of increased leakage on a long-term basis.⁹ (9. Meiers JC, Turner EW. Microleakage of dentin/amalgam alloy bonding agents: Results after 1 year. Oper Dent 1998; 23:30-3.)" Alex McClean, DMD, B.Sc. (Eng.) "Predictably restoring endodontically treated teeth" Web Reference: http://www.cda-adc.ca/jcda/vol-64/issue-11/782.html Nevertheless, amalgam cores should be covered with a crown as soon as possible to prevent corono apical leakage. 

Note: Most of the retention needed is located within the pulp chamber.This corono apical amalgam extend too far in the distal root canal, it does not need to be that long. 1 mm lengh would have been enough.

Pre op. clinical situation:

1  Long roots, root canals calcified in apical thirds on mandibular molar

2  Post to remove and endo to retreat on mandibular premolar

Lower left first molar

Multiple portals of exit in distal root and severe curves in mesial root in a mandibular second molar. Refering dentist asked us to restore the tooth. Casted gold post and a gold crown with a long bevelled edge margin. Crown and casted post by Dental Ceramic Studio in Westmount.

Multiples puertas(sitios ) de salida en la raiz distal y muchas curvas en la raiz mesial en el segundo molar mandibular(inferior); lo que hace del tratamiento ser mas complicadol. referido al odontologo para la restauracion del diente. Poste moldeado en oro y una corona en oro con un largo biselado marginal. Corona y poste hechos por Dental Ceramic Studio en Westmount (Montreal)