endomontreal

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

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

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.

Case study number: 497935

Patient has already been treated on an emergency basis for an acute apical periodontitis with an irreversible pulpitis on second mandibular premolar. Access opening through bridge abutment  allowed for pulpectomy and calcium hydroxide insertion at a specialist office. A provisional filling sealed the opening on occlusal. Still, as it happens often, huge leakage occurred from second bicuspid abutment margin although molar abutment was still rock hard cemented.

On pre operative Xray dental film, molar abutment shows a canal system filled with calcification and a PDL widening on its mesial root, this tooth is asymptomatic. Patient wanted to save her bridge, she understood that in order to do so, her bridge had to be removed with minimum damage in order to cement it back. By the same token, molar endodontic condition could be assessed prior to the final bridge re-cementation. 

Bicuspid bridge abutment cement has been washed out for a long time now. Existing bridge has been safely removed with minimum damage in a matter of minutes using Metalift crown and bridge removal system^TM on molar. An endodontic procedure has been performed on the bicuspid. After removal of deciduous occlusal glass ionomer filling on molar abutment, a recurrent tooth decay reaching the pulp justified a second endodontic procedure. Opmi PROergo dental operative microscope has been usefull in denticles safe  removal. Endodontic procedures have been performed using the ProTaper system endodontic files from Maillefer, root canal systems have been filled with Pulp Canal Sealer (Kerr) and gutta percha.

X ray dental film on the right shows a post endodontic outcome with existing bridge back in its original position (not cemented), that fixed prosthesis has been autoclaved and had its inner part sandblasted. Referring dentist will cement it back on abutments once he will be done with posts and cores build up of his choice. Not having to bore a large hole in the bridge abutments will definitly contribute a lot in rescuing it.

To look at a video on Metalift removing a PFM restoration please go to: http://www.metalift.com/video_downloads.html

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

Case number: 63724 

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 number: 6937