endomontreal

Dental operating microscope assisted root canal procedure on a completely stenosed canal system.  endodontist case study number: 506712

Pre operative condition:

1. Canal is not visible on dental X ray film until last few millimeters because the root canal anatomy system does not begin before last few millimeters, this means an extremely narrow canal diameter for the practioner to locate in last apical third of root. Remaining canal diameter can be 3 times smaller than a single strand of human hair diameter. Remaining within  tooth long axis when accessing canal entry is of the utmost importance not to create a iatrogenic perforation.
2. Two previous failed attempts  to locate tooth single canal entry, this means complete loss of landmarks when looking through dental operative microscope lens to find it
3. Number 12 tooth is a 12X21 bridge abutment, this means loss of external landmarks to locate canal entry
4. Dentine shade composite completely fills up the access cavity, this means even more challenge, when drilling to expose canal entry, not to create additional tooth substance loss (thus increasing tooth weakness.

Tooth and prosthesis survival relies solely on endodontic procedure success, if canal cannot be found thus treated, tooth cannot be preserved.  

Nevertheless, a complex root canal retreatment does not have to mean extraction and replacement by a dental implant. 

Surgical operating microscopes have a steep learning curve and require training, as well as patience and practice to master. Still this piece of equipment and the learning effort it implies is well worth it since cases that once seemed impossible can now be treated with a high degree of confidence and clinical success. 

Case number: 482036

      An endodontist case report. Microendodontics case study number: 505026

Twenty five years old patient presenting with an abscessed maxillary molar. Diagnosis: Persisting disease after root canal treatment. Etiology: untreated second mesio vestibular root canal (MB2).

Two appointments were required to preserve that tooth:

First appointment: Crown and post removals plus root canal filling retrieval, MB2 location and calcium hydroxide insertion as a medicament. 

Second appointment: Calcium hydroxide removal, irrigation, drying, final canal obturation gutta percha and Pulp Canal Sealer. Provisional filling material: Cavit.

Abutment is now symptom free and it is now all set for a casted post and permanent crown replacement.

A 6 months follow up dental Xray film shows an impressive  regeneration of periradicular tissues. Compared to its initial size, apical lesion on mesio vestibular root shrunk up to 80%. Tooth is aymptomatic and functional.

A complex root canal retreatment does not have to mean extraction and replacement by a dental implant. A research study by Farzaneh et al. on treatment outcome in endodontic found an orthograde root canal retreatment success rate of 93% . (Farzaneh M., Abitbol S., Friedman S. Treatment outcome in endodontics: The Toronto Study. Phases I and II: Orthograde retreatment. J Endod 2004; 30(9):627-633)

Endodontist (microendodontics) case study number: 449947 Pulp chamber and root canals are not visible on pre operating X Ray of second mandibular molar. Diffuse calcifications preclude easy canal entries location. This tooth needs a dental operating microscope assisted root canal procedure. 

 Progressive abrasion of attached pulp chamber calcifications with ultrasonic tips led to the canal entries. Required state of mind: No pushing but resolution. 

  First mandibular molar has an apical external root resorption in distal root making it difficult to obturate because of the absence of apical constrictions

   Post operative X ray dental film displaying final root canal obturation with gutta percha and Pulp Canal Sealer

 Amalgam post and core build up.

This last X ray dental film is a three years post operative control and is showing a complete regeneration of periradicular tissues, teeth are still functional and symptoms free. 

Should an implant have been put there in the first place to replace this second mandibular molar simply because this root canal procedure is extremely difficult to perform? Maybe, maybe not!

Both implant therapy and endodontics show excellent prognosis. To let the informed patient decide for himself  whether or not he want's to save his tooth instead of having a dental implant is simply common sense. 

Endodontist case study number: 197337

The recent addition of dental operative microscope (DOM) to endodontic therapy can allow better visualization and management of the intricate morphology of the root canal system during endodontic procedures through magnification and greatly improved high intensity lighting. Dental Microscope typically magnifies in the 4X to 25X range. The other commonly used magnification aide, through lens eyeglass mounted surgical telescopes, provides 2.5X to 4.5X magnification. 

We have been presented with this second mandibular molar that has only two canal entries on pulpal chamber floor. At first sight one could have easily concluded the presence of only two canals. In fact, the mesial root has a Vertucci's type 5 canal configuration. A Vertucci type V pulp space configuration can be described as follow: One canal leaves the pulp chamber and divides short of the apex into two separate distinct canals with two distinct foramina (1-2). Without magnification the root canal apical "split" could have been under seen, treating one branch out of two and leaving  pulp tissue inside the other branch. 

Surgical operating microscopes have a steep learning curve and require training, as well as patience and practice to master. Still this piece of equipment and the learning effort it implies is well worth it since cases that once seemed impossible can now be treated with a high degree of confidence and clinical success. 

"As the saying goes:"A picture is worth a thousand words", Click here to have a look at what can be seen at an operative field under magnified observation (10X to 25X range)." 

Microendodontics case study number: 508126

Root canal procedure case study number: 29537

        509217

Source: 

Case study in microendodontics number: 506846

Patient referred for endodontic treatment on this mandibular first molar. Coronal-radicular access was already done but canal entries are embedded in a mass of calcified dentine and could not be found.

Preoperative X ray dental film shows a complete mineralization of both mesial and distal canals coronal third. This is an intricate root canal procedure, because this pre operative condition involves dealing with complete canal stenosis caused by dystrophic calcifications. 

Dental operative microscope (Opmi Proergo from Carl Zeiss) and ultrasonic tips where most helpful in locating both mesial and distal canal entries.

Once located, our first instrument in four canals were K files number 06 (second X ray dental film). Then, mesial and distal canals have been shaped and cleaned with the Pro Taper system (Maillefer) and lots of RC PrepTM. They were subsequently filled with gutta percha (lateral and vertical condensation) and Pulp Canal Sealer EWT ^TM

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

Amalgam corono apical core build up is shown in last post operative X ray dental film. A crown is planned by patient regular dentist.

  A new Dental Operative Microscope (D.O.M.) assisted root canal treatment in a calcified maxillary second molar. Case study in microendodontics number: 506317

Radiographic findings: Dystrophic calcifications in the whole canal system are completely obliterating the pulp chamber. 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: Locating all four root canal entries without lateraly perforating the root 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. 

Thus, the difficulty level of this endodontic procedure can be considered as very high. A few years back, when there was no surgical operating microscope in our dental practices and only a handfull of daring pioneers in microendodontics, removing this tooth and replacing it  by an implant supported crown would have been a good option to consider in most instances. 

Times have changed. 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 system. Root canals has been 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 ^TM.