endomontreal

Case number: 482036

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)." 

Root canal procedure case study number: 29537

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 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.

Root canal procedure case study number: 492626 

Patient is having an AAA with a necrotic pulp, an extensive deciduous restoration and a huge tooh decay on distal aspect of this first maxillary molar (Some of us might think: "you don't have to worry it is dead").

Dystrophic calcifications are obliterating the root canal system and we can expect to strive for a second mesiovestibular too. An extreme curvature is also present in distovestibular root canal. 

Prior to the initiation of treatment, an estimate should be made as to the degree of curvature of the canal to be treated. For making this determination merely view the curved canal as having two segments, one extending from the floor of the chamber down the long axis of much of the coronal two thirds of the root and the second from the apex of the root extending back to the occlusal through the apical third of the root. These two lines will intersect and form four angles. The interior angle is the estimate of the degree of the canal curvature. In this specific case, distovestibular root degree of curvature has an estimated 120 degree. Such an estimate is of mesiodistal curvature only and does not take into consideration any buccolingual curvature. The method for making this determination has ben first described by Schneider and then Jungman et al. This present description of Schneider method is from Franklin S. Weine in his book: "Endodontic therapy" Fourth edition pp 314-315

Carl Zeiss Opmi Proergo dental operative microscope was of a big help in locating both mesiovestibular  and distovestibular canals entries, I am using the Pro Taper Endodontic files System from Maillefer for preparation of canals as they are doing very nicely in extremely curved canals. Intracanals treatment procedure is a calcium hydroxide as a medicament (Third x ray from left) since there is a lot of intracanal exudation. Canal filling method: master gutta-percha cone, lateral condensation for the first wave, warm gutta percha for the second wave. Pulp Canal Sealer as the root canal sealer. Amalgam filling has been replaced by a composite filling, because patient wanted to wait a bit for his dental insurance to kick back in. Patients regular dentist will do crowning as soon as possible after that.

Case number: 186336

A few days ago we were confronted to this three rooted mandibular first molar (Radix Molar or Radix Entomolaris), a very rare anatomic variation where a a third supernumerary root is located distolingually in mandibular molars. Tremendous amount of calcifications and a limited opening of the patients mouth made this endodontic procedure an extremely complex one. Dental Operative Microscope was most helpful in locating all canal entries.

To lurn more about Radix Entomolaris, please go to: R. Bansal & P. Ajwani: Prevalence and Morphological study Of Three Rooted Mandibular First Molar (Radix Molar) in Indian population. The Internet Journal of Human Anatomy. Volume 1 Number 1