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. 

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. 

Microendodontics case study number: 508126

        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.

Root canal procedure with surgical operative microscope, microendodontics case number: 156037. Pre operative film shows a large bony defect reminding us the alleged pathognomonic "J" type lesion. Still, there was no deep and narrow pocket probing. Root canals are not visible neither  in mesial or distal root.

First appointment post operative X ray dental film shows shaped and cleaned canal system with inserted intracanal calcium hydroxide. 

Post operative control X ray film in December 2011 shows a nice healing of surrounding hard tissues. Endo treatment finished on 2007 with surgical operative microscope Opmi PROergo from Carl Zeiss.This root canal therapy attempt once more enlightens the huge advantages of microendodontics and calcium hydroxide therapy in order to save teeth with an apparent very bad prognosis.

Treatment protocol:

First appointment: Opening through metal bridge abutment, gaining access to pulp chamber, adherent pulpstones and embedded pulpstones removal, root canal entries locations, cleaning and shaping, rinsing, drying, intracanal medication insertion and provisional obturation material.

Second appointment: Intracanal medication removal, rinsing and final obturation with Pulp Canal Sealer from Kerr and gutta percha

Endodontic material and equipment:

Shaping and debridment instruments: Stainless steel ISO files, Pro taper files (Dentsply) 

Rinsing solution: sodium hypochlorite 6%

Drying: sterile paper points

Calcium hydroxide 

Obturation material: gutta percha lateral and vertical condensation

Dental operative microscope: OPMI PROergo microscope from Carl Zeiss

A new Dental Operative Microscope (D.O.M.) assisted root canal treatment in a calcified maxillary lateral incisor. Case study in microendodontics number: 501812

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

Endodontic procedure problem number one to solve: Locating root canal entry 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 canal without loosing patency, without breaking an endodontic file and without perforating the root. 

This is an extreme endodontic procedure. 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 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. In this specific case ultrasonic tip went off centered creating a groove in canal toward distal, X ray dental film taken during the root canal procedure alowed us to notice this and alowed us to correct the tip orientation before making a perforation. This groove has been filled within the canal itself with Geristore from DenMat. 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: ProTemp (A provisional crown with anchorage).

Last X Ray dental film is a post operative control, the referring dentist asked us to make and cement a casted post in order for him to cement a planned fixed crown. 

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. 

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.