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)

Case study in endodontics number: 498946

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 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

Case number: 6937

Case study number: 63727

This is a symptomatic mandibular first premolar (bridge abutment) with a "C" shape root canal system. Most C-shaped canals occurs in mandibular second molars but they have been also reported in the mandibular first molar, the maxillary  first and second molars and the mandibular first premolar. This "C" shape first mandibular premolar root canal system is extremely rare. The only orthograde way to endodontically treat this anomalous root is to bring our first K file #06 to the apical third by bypassing what looks like a "mega concretion". Use of the dental operative microscope, sonic and ultrasonic instrumentation is mandatory. Being familiar with access cavity preparation for "C" shape RC through prosthetics, being familiar with cleaning, shaping and an obturation of a mineralized "S" shape root canal is also important. A cone beam tomography would have been most helpful in determining which root canal configuration we were dealing with prior to initiating this RCT and this very same tomo would have helped us in orienting our search for the pathway to the apex, but patient was reluctant to this innovative technology and decided to go for it only if symptoms persisted. Only one single pathway to the apex was found, tooth is now completely asymptomatic. Since we could not confirm this with a tomo, lets hope we were dealing with only one apex. (a type III Vertucci root canal configuration). A close follow up is planed.  

Esforzandose para hallar los caminos hacia el apice contorneando un "mega pulpolito" en  un sistema de canales radiculares anormales.

Este es un primer molar mandibular sintomatico (diente pilar) con un sistema radicular (nervio)  en forma de "C". Muchos canales radiculares en forma de "C" ocurren en los segundos molares pero ellos han sido reportados en el primer molar mandibular(inferior), el primer y segundo molar maxilar(superior), y el primer premolar mandibular(inferior). Esta forma de "C" en el canal radicular del primer premolar mandibular(inferior) es extremadamente raro. La unica forma(orthograde) para tratar endodonticamente de esta anomalia radicular es trayendo nuestro K file #06 hacia el tercio apical contorneando lo que parece un mega pulpolito (piedra). El uso del microscopio dental, instrumentacion sonica y ultrasonica es obligatoria. Estar familiarizado con el acceso a la preparacion cavitaria en forma de "C" a traves una corona, estar familiarizado con la limpieza, dar una forma al canal y hacer la obturacion de un canal radicular mineralizado en forma de "S" es tambien importante. Una tomografia (CBCT) podria haber sido de mucha ayuda determinando cual canal radicular nosotros debemos tratar antes de comenzar, y esta misma tomografia podria habernos ayudado en la orientacion de nuestra busqueda de los caminos hacia el apice, pero el paciente rehusa esta tecnologia innovadora y decide ir solo si los sintomas persisten despues del tratamiento. Solo fue hayado un camino simple hacia el apice, el diente es ahora completamente asintomatico. Desde que nosotros no podamos confirmar esto con una tomo, esperando que nosotros tratamos solo un apice. (un canal radicular de tipo III de Vertucci), un seguimiento cercano del caso es planeado.

Radiografia preoperatoria de un segundo molar inferior(mandibular), caso un poco complejo debido a la morfologia radicular propia de este caso en el podemos observar un canal radicular en "S", pero despues de haber realizado la instrumentacion nos damos cuenta que la raiz mesial presenta dos conductos que se intercomunican entre si, despegandose al final del primer tercio radicular y volviendose a unir al conducto principal a nivel del tercio apical. 

Case study number: 331737

Heated gutta percha was most useful to obtain that so sought after 3D obturation in this mandibular second molar.

En esta radiografia podemos observar la dificultad para tener un acceso adecuado al canal radicular en su tercio distal en forma ¨S¨ ; La gutapercha caliente fue mas util para obtener el resultado que se deseaba, los canales radiculares han sidos sellados tanto hacia apical como hacia sus extensiones laterales, como una obturacion 3D.