endomontreal

Endodontic procedure case study number: 378415

A Vertucci type VI pulp space configuration can be described as follow: Two canals leaves the pulp chamber, intersect in the body of the root and redivide short of the apex into two separate canals with two distinct foramina (2-1-2).

In this per operative X ray dental film, crossed canals are highlighted with endodontic ISO files within the root canal system. During shaping procedure, only one file at once could pass through the root canal intersection in the body of the root, each root canal branch has been shaped cleaned and filled individually with lateral and vertical condensation. 

Preoperative radiological findings that might help us in suspecting such a pulp space configuration: root canal abruptly becomes invisible short of the apex. 

Armamentarium: OPMI PROergo dental operative microscope from Carl Zeiss, Rubber dam and rubber dam clamp and frame, Stainless steel K endodontic files, gutta percha and Pulp Canal Sealer, finger plugger.

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.

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. 

Root canal procedure case study number: 49821617

Note on the post operative Xray dental film, the dilacerated apical curves in both vestibular roots on second maxillary molar and disto vestibular root of first maxillary molar. The values of those root canal curvature radius based on three mathematical points are all below 4 mm, these are very small radius. Thus, those cuvatures can be defined as severe. For the endodontist, choosing the right endodontic file is of the utmost importance in order to avoid damaging consequences such as: apical transportations, loss of working length, zip and perforations and fracture of instruments.

An interesting point has been raised by Drs Pruett, Clement and Carnes affiliated with the Department of Endodontics/Dental School of University of Texas Health Science Center at San Antonio:" These results indicate that, for nickel-titanium, engine-driven rotary instruments, the radius of curvature, angle of curvature, and instrument size are more important than operating speed for predicting separation".  

Much more can be learned on small curvature radius by reading the following article:  Method for determination of root curvature radius using cone beam computed tomography images                  Carlos Estrela, Mike Reis Bueno, Manoel Damiao Sousa Neto, Jesus Djalma Pécora Braz Dent J (2008) 19(2): 114-118 ISSN 0103-6440

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 report in microendodontics number: 500047

Canal curvatures are a challenge to preparation and can be the origin of many technical complications leading to failure of treatment. Canals that curve in the mesio-distal direction are usually readily detected in radiographic dental films. However, as it is the case here, many canals curve also in the bucco lingual direction.  The bucco lingual aspect of this sharp curvature has been displayed using a mesio distal angulation of our X ray cone beam.

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. 

case: 430646

Resorption associated with chronic apical periodontitis altered the shape and position of the foramen through osteoclastic activity, in the x ray images, the modified foramen in distal root is positioned farther from the radiographic apex and gutta percha appears in overextension. A large and circumbscribed radiolucency involves both roots as well as the furcation. This indicates an important periradicular tissues destruction. Tooth mobility level 2 goes along with this tissue loss.

This case is definitly a controversial one, meaning that it is possible for different practitionners to prognosticate endodontic success (very few among practioners) or failure with a great amount of disparity. As stated by John I. Ingles, a senior lecturer in endodontics: "The practicing dentist should not be cited for faulty judgment when even the so-called experts tends to disagree on prognosis… All in all, one must ultimately develop confidence in one's own abilities. Being able to practice using a great variety of techniques and not being "married" to a single approach in every case will greatly enhance one's capabilities. And on this is based good prognosis, the result of skill, knowledge, and self confidence."

Endododontic retreatment and MTA root-end fillings have been performed with a Zeiss Pro Ergo Microscope in september 2008. Last displayed X ray film on this post shows a 3 years post operative clinical outcome. Radiographic examination shows a complete regeneration of the periradicular tissues and a resoptive defect healing. 

Should an implant have been put there? maybe, maybe not!

Read more about MTA Precision placement with the microscope (.pdf)

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.