endomontreal

Microendodontics case study number: 500446

A few days ago we were confronted to this three rooted mandibular first molar (Radix Molar or Radix Entomolaris), a rare anatomical variation of teeth, where a third supernumerary root is located distolingually in mandibular molars. Root canal system calcifications and a canal curvature with an "S" form made this endodontic procedure an extremely complex one.

In that specific case, endodontist  operative microscope was most helpful when striving to find the fourth canal entry in distal root, allowing for us not to omit the fourth deeply embedded root canal. This microendodontic case study enlightens how dental operative microscope may assist the practicing dentist into a more secure root canal procedure for his patient.

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)

Clinical endodontic case study number: 505146 

A peculiar anatomical variation can be noticed on this mandibular first molar. What appeared to look like hypercementosis on apical aspect of distal root could in fact be a supernumerary root fused to the distal one (Radix Entomolaris). Careful removal of dentine with ultrasonic tips under high magnification of a dental operative microscope helped in locating this extra canal.  

Case study in endodontics number: 498946

Root canal procedure case study number: 49821617

Note on the post operative Xray dental film, the dilacerated apical curves in both vestibular roots on second maxillary molar and disto vestibular root of first maxillary molar. The values of those root canal curvature radius based on three mathematical points are all below 4 mm, these are very small radius. Thus, those cuvatures can be defined as severe. For the endodontist, choosing the right endodontic file is of the utmost importance in order to avoid damaging consequences such as: apical transportations, loss of working length, zip and perforations and fracture of instruments.

An interesting point has been raised by Drs Pruett, Clement and Carnes affiliated with the Department of Endodontics/Dental School of University of Texas Health Science Center at San Antonio:" These results indicate that, for nickel-titanium, engine-driven rotary instruments, the radius of curvature, angle of curvature, and instrument size are more important than operating speed for predicting separation".  

Much more can be learned on small curvature radius by reading the following article:  Method for determination of root curvature radius using cone beam computed tomography images                  Carlos Estrela, Mike Reis Bueno, Manoel Damiao Sousa Neto, Jesus Djalma Pécora Braz Dent J (2008) 19(2): 114-118 ISSN 0103-6440

Endodontic procedure case study number: 449927

To treat such a tooth in endodontics we needed to deal with:

• Difficult access
• Long tooth (24 mm)
• Calcified canals (root canal system with dystrophic calcifications) to locate, shape clean and fill 
• Second mesiovestibular (Mb2) to strive for with the help of a dental operative microscope
• Canal curvature with an "S" form (Bayonet shaped root canal) 

Armamentarium:

PRO Taper endodontic files from Dentsply, OPMI PROergo dental operative microscope from Carl Zeiss, Gutta Percha from META, Pulp Canal Sealer from KERR 

Case report in microendodontics number: 500047

Canal curvatures are a challenge to preparation and can be the origin of many technical complications leading to failure of treatment. Canals that curve in the mesio-distal direction are usually readily detected in radiographic dental films. However, as it is the case here, many canals curve also in the bucco lingual direction.  The bucco lingual aspect of this sharp curvature has been displayed using a mesio distal angulation of our X ray cone beam.

Case study number: 497935

Patient has already been treated on an emergency basis for an acute apical periodontitis with an irreversible pulpitis on second mandibular premolar. Access opening through bridge abutment  allowed for pulpectomy and calcium hydroxide insertion at a specialist office. A provisional filling sealed the opening on occlusal. Still, as it happens often, huge leakage occurred from second bicuspid abutment margin although molar abutment was still rock hard cemented.

On pre operative Xray dental film, molar abutment shows a canal system filled with calcification and a PDL widening on its mesial root, this tooth is asymptomatic. Patient wanted to save her bridge, she understood that in order to do so, her bridge had to be removed with minimum damage in order to cement it back. By the same token, molar endodontic condition could be assessed prior to the final bridge re-cementation. 

Bicuspid bridge abutment cement has been washed out for a long time now. Existing bridge has been safely removed with minimum damage in a matter of minutes using Metalift crown and bridge removal system^TM on molar. An endodontic procedure has been performed on the bicuspid. After removal of deciduous occlusal glass ionomer filling on molar abutment, a recurrent tooth decay reaching the pulp justified a second endodontic procedure. Opmi PROergo dental operative microscope has been usefull in denticles safe  removal. Endodontic procedures have been performed using the ProTaper system endodontic files from Maillefer, root canal systems have been filled with Pulp Canal Sealer (Kerr) and gutta percha.

X ray dental film on the right shows a post endodontic outcome with existing bridge back in its original position (not cemented), that fixed prosthesis has been autoclaved and had its inner part sandblasted. Referring dentist will cement it back on abutments once he will be done with posts and cores build up of his choice. Not having to bore a large hole in the bridge abutments will definitly contribute a lot in rescuing it.

To look at a video on Metalift removing a PFM restoration please go to: http://www.metalift.com/video_downloads.html

Root canal procedure case study number: 492626 

Patient is having an AAA with a necrotic pulp, an extensive deciduous restoration and a huge tooh decay on distal aspect of this first maxillary molar (Some of us might think: "you don't have to worry it is dead").

Dystrophic calcifications are obliterating the root canal system and we can expect to strive for a second mesiovestibular too. An extreme curvature is also present in distovestibular root canal. 

Prior to the initiation of treatment, an estimate should be made as to the degree of curvature of the canal to be treated. For making this determination merely view the curved canal as having two segments, one extending from the floor of the chamber down the long axis of much of the coronal two thirds of the root and the second from the apex of the root extending back to the occlusal through the apical third of the root. These two lines will intersect and form four angles. The interior angle is the estimate of the degree of the canal curvature. In this specific case, distovestibular root degree of curvature has an estimated 120 degree. Such an estimate is of mesiodistal curvature only and does not take into consideration any buccolingual curvature. The method for making this determination has ben first described by Schneider and then Jungman et al. This present description of Schneider method is from Franklin S. Weine in his book: "Endodontic therapy" Fourth edition pp 314-315

Carl Zeiss Opmi Proergo dental operative microscope was of a big help in locating both mesiovestibular  and distovestibular canals entries, I am using the Pro Taper Endodontic files System from Maillefer for preparation of canals as they are doing very nicely in extremely curved canals. Intracanals treatment procedure is a calcium hydroxide as a medicament (Third x ray from left) since there is a lot of intracanal exudation. Canal filling method: master gutta-percha cone, lateral condensation for the first wave, warm gutta percha for the second wave. Pulp Canal Sealer as the root canal sealer. Amalgam filling has been replaced by a composite filling, because patient wanted to wait a bit for his dental insurance to kick back in. Patients regular dentist will do crowning as soon as possible after that.

Case number: 186336

A few days ago we were confronted to this three rooted mandibular first molar (Radix Molar or Radix Entomolaris), a very rare anatomic variation where a a third supernumerary root is located distolingually in mandibular molars. Tremendous amount of calcifications and a limited opening of the patients mouth made this endodontic procedure an extremely complex one. Dental Operative Microscope was most helpful in locating all canal entries.

To lurn more about Radix Entomolaris, please go to: R. Bansal & P. Ajwani: Prevalence and Morphological study Of Three Rooted Mandibular First Molar (Radix Molar) in Indian population. The Internet Journal of Human Anatomy. Volume 1 Number 1