endomontreal

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

Case study number: 317736 

Patient referred for pre prosthetic endodontic treatment on mandibular first molar. 

Preoperative X ray dental film shows a complete mineralization of both mesial part of pulp chamber and mesial canals as well as a complete stenosis of distal canal(s?)

Dental operative microscope and ultrasonic tips where most helpful in locating both mesial and distal canal entries. First instrument in four canals are K files number 06 (second X ray dental film)

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

Amalgam corono apical core build up (no post) is planned plus a crown.

An intricate root canal procedure, because this pre operative condition involves dealing with complete canal stenosis caused by dystrophic calcifications. Case study: 483136 

Once located, with the help of a dental operative microscope (Opmi Proergo from Carl Zeiss), mesial canals have been shaped and cleaned with the Pro Taper system (Maillefer) and lots of RC PrepTM. Then, they were filled with gutta percha (lateral and vertical condensation) and Pulp Canal Sealer EWT ^TM

Patient is experiencing severe pain on upper left side and is seen on an emergency basis. The first molar is having a necrotic pulp and an acute periapical inflamation. Tooth is having a complete stenosis of canal system. Patient is taking per os bisphosphonate and does not want to remove the tooth, thus extraction with an implant surgery is not an option. All canals were located with the assistance of a dental operative microscope. Canals were shaped, cleaned and filled with Calcium hydroxyde. Symptomes subsided in the following hours. Endodontic treatment has been completed after 8 days. Post and amalgam build up done in our office and patient returned to his dentist for crowning.

Pre operative film shows a large bony defect reminding us the alleged pathognomonic "J" type lesion. Canals are not visible in mesial root. An impressive soft tissues swelling of adjacent vestibular area was also noted. Endo treatment finished on the 16th of march 2009 with surgical operative microscope (three appointments were needed). Post operative control X ray film (16th of october 2009) shows a nice healing of surrounding hard tissues.