endomontreal

Dental operating microscope assisted root canal procedure on a completely stenosed canal system.  endodontist case study number: 506712

Pre operative condition:

1. Canal is not visible on dental X ray film until last few millimeters because the root canal anatomy system does not begin before last few millimeters, this means an extremely narrow canal diameter for the practioner to locate in last apical third of root. Remaining canal diameter can be 3 times smaller than a single strand of human hair diameter. Remaining within  tooth long axis when accessing canal entry is of the utmost importance not to create a iatrogenic perforation.
2. Two previous failed attempts  to locate tooth single canal entry, this means complete loss of landmarks when looking through dental operative microscope lens to find it
3. Number 12 tooth is a 12X21 bridge abutment, this means loss of external landmarks to locate canal entry
4. Dentine shade composite completely fills up the access cavity, this means even more challenge, when drilling to expose canal entry, not to create additional tooth substance loss (thus increasing tooth weakness.

Tooth and prosthesis survival relies solely on endodontic procedure success, if canal cannot be found thus treated, tooth cannot be preserved.  

Nevertheless, a complex root canal retreatment does not have to mean extraction and replacement by a dental implant. 

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. 

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)." 

Microendodontics case study number: 508126

Root canal procedure case study number: 29537

        509217

Source: 

Case study in microendodontics number: 506846

Patient referred for endodontic treatment on this mandibular first molar. Coronal-radicular access was already done but canal entries are embedded in a mass of calcified dentine and could not be found.

Preoperative X ray dental film shows a complete mineralization of both mesial and distal canals coronal third. This is an intricate root canal procedure, because this pre operative condition involves dealing with complete canal stenosis caused by dystrophic calcifications. 

Dental operative microscope (Opmi Proergo from Carl Zeiss) and ultrasonic tips where most helpful in locating both mesial and distal canal entries.

Once located, our first instrument in four canals were K files number 06 (second X ray dental film). Then, mesial and distal canals have been shaped and cleaned with the Pro Taper system (Maillefer) and lots of RC PrepTM. They were subsequently filled with gutta percha (lateral and vertical condensation) and Pulp Canal Sealer EWT ^TM

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

Amalgam corono apical core build up is shown in last post operative X ray dental film. A crown is planned by patient regular dentist.

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