endomontreal

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. 

A new Dental Operative Microscope (D.O.M.) assisted root canal treatment in a calcified maxillary molar abutment. Case study in microendodontics number: 27526

Acute pain on this maxillary molar is keeping the patient awake all night long. Pain started following a recent filling replacement.  This is an irreversible pulpitis diagnosis, patient has been referred for endodontic therapy with the help of a dental operating microscope. 

Radiographic findings: Dystrophic calcifications in the whole canal system are completely obliterating the pulp chamber as well as the root canals themselves. 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: Exposing color map of dentin prior to locating root canal entries without perforating pulpal chamber floor 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. 

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 symptomatic molar and replacing it  by an implant supported crowns would have been a good option to consider for most of us. 

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. Root canals where 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.

Last X Ray dental film is a post operative control, a crown with a perfect fit that was done by the referring dentist will warrant a good seal. 

Study case number: 482026

Because of an extreme canal stenosis by calcification and because of its obliterated pulp chamber by adherent pulpstones, this first maxillary molar root canal system is not visible on preoperative X ray dental film.

Patient is given full knowledge of the possible risks and benefits of such a complex procedure.  This tooth vestibular cusps are broken, the patient is in pain. She definitly wants to keep her own tooth and give an informed consent. 

Operative field observation is enhanced with high magnification and coaxial xenon lamp illumination (Carl Zeiss OPMI PROergo dental operative microscope). Dystrophic calcifications have been removed from pulp chamber with ultrasonic diamond coated tips. We have been striving to locate all four canal entries (we have been striving a lot more to find MB2 canal entry) and we also had been striving to progressively regain patency by widening each root canal. Lots of chelating agent was needed.  

Our first instruments in the root canals were ISO K Files 06. Canals have then been shaped to K file size 15 and calcium hydroxide inserted. Following appointment allowed us to finish shaping, cleaning and obturation of the root canal system. Root canals have been sealed with Pulp Canal Sealer EWT. 

MB1 and MB2 were not merging at the apex, but both exits were closely juxtaposed. For that reason only a single mesiovestibular root canal shows on post operative X ray dental film. It also appear to be overenlarged but this is not the case.

Knowing that for each uninstrumented millimeter from the apex, a 14% increase in treatment failure might be expected, help of a dental operative microscope in such a case is a no brainer to us. 

Case number: 403616

Case study number: 465016

Patient has been referred to to us in order to complete a previously started root canal treatment on completely calcified root canal system. Pulp chamber is obliterated with embedded pulpstones, root canals are not visible on preoperative X ray dental film.

Patient is given full knowledge of the possible risks and benefits of such a complex procedure.  Patient is in pain and she wants to keep her own tooth and give an informed consent. 

Dystrophic calcifications have been removed from pulp chamber with ultrasonic diamond coated tips. Operative field observation is enhanced with high magnification and coaxial xenon lamp illumination. Once located root canal entries had to be widened in order to progressively regain patency in each root canal. Second X ray shows our first instruments in the root canals, these are K Files 06. Canals have then been shaped to K file size 15 and calcium hydroxide inserted. Following appointment allowed us to finish shaping, cleaning and obturation of the root canal system. Final outcome can be seen on fourth X ray dental film. 

Case study number: 487445

Clinical examination: Sinus tract, mobility: 0, deciduous amalgam restoration. 

Radiographic examination: Alveolar bone with circumscribed lucency, apical root canal split, hypertaurodontism (bull's tooth), apical root canal split branches not visible on X ray dental film, hypercementosis 

Diagnosis: pulpal necrosis with chronic periapical infection,

Etiology: marginal leakage, caries

Root canal procedure:

First appointment: gaining access to the split, locating entries, shaping and cleaning apical root canal branches inserting intracanal medication for 8 days.

Second appointment: intracanal medication retrieval, copious CHX 2% irrigation, drying canals and permanent root canal obturation with Pulp Canal Sealer and gutta percha (lateral and vertical condensation).

In that specific case, microscope was most helpful during all the following steps necessary to insure a better prognosis for this patient:

1) Locating and gaining access to buccal and lingual root canal entries (apical split was clearly visible under magnified observation) 

2) Striving to find a third branch in apical split minimizing the chances of omitting an untreated canal 

3) Aiming at the right root canal orifice when:

• Inserting the two first endodontic files to confirm canal lengths 
• inserting a file sequence to shape and clean each canal 
• Positioning irrigating syringe needle tip and calcium hydroxide syringe tip toward the right canal entry 
• Inserting absorbent paper points in both canals when drying canals 
• Inserting master, accessory gutta percha cones and finger plugger when doing final obturation with lateral and vertical condensation  

4) Checking for pulpal tissue remnants prior to final obturation to minimise the chances of pushing them back into the apical area