endomontreal

Case study number: 461716

Patient came to our office with spontaneous intermittent pain on maxillary right side. He can readily identify the tooth, he is showing the first molar. Patient is taking many Aspirin tablets per day and is tired of suffering.

Tooth history: first attempt of root canal treatment which ended up with a broken instrument.The patient was then seen two years ago by another practitioner who succeeded in the broken instrument surgical retrieval. Even thought, at the time, a complete retreatment has been performed, the tooth remained sensitive. Since then, painful episodes became more and more frequent with a growing pain intensity. 

Tooth is sensitive to palpation with a mobility of level 2. A new crown is protecting the cusps and occlusion looks fine. Pre operative Xray shows an apical periodontitis on mesio vestibular root and something that might be a perforation with a bunch of wispy gutta percha points into it. Patient is informed of this concern prior to starting anything. Patient is informed of the high incidence rate of a fourth canal in those first maxillary molars (Studies shows up to a whopping 92% rate). He is also made aware that this fourth canal may have been omitted. After the exam, patient knows that at least two concerns have to be addressed in order to solve his problem. Implant is suggested but patient is reluctant, he is 25 years old and he wants to keep his real tooth. 

The two first X Rays are preoperative

Third X rays show the recovered MB2 with a first instrument (number 08 ISO file) reaching its apex, the fourth X ray film shows the repaired perforation with MTA and intracanal medication (Ca(OH)2 dressing) in MB2. 

Fifth image shows immediate post operative outcome with the Pulp Canal sealer overfill which has no impact on the overall prognosis. An amalgam has been placed as a long term provisional for one year. Symptoms subsided almost immediately after the intra canal dressing. The monitored tooth has been fine all along for one year. The last Xray is a one year post operative control with a brand new crown in place.

Access made through crown makes the treatment much more difficult in that the landmarks that direct the clinician to the pulp chamber are removed. Our microscope integrated video camera recorded a short movie showing treated MB2 and the MTA repair, the position of the repaired perforation site (dark grey shade) in relation to the real position of the MB2, clearly stresses out what can happen while you are looking for the MB2 with external contour of the tooth being altered by a PFM crown. 

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.

Patient has been advised of bad tooth prognosis because of external apical resorptive defect and suspected huge amount of tooth decay in root canal. Nevertheless patient refused implant supported crown on maxillary first premolar. An attempt has been made to save this tooth.

A good diagnosis (you try to probe and there is no probing, you put icy cold water on the tooth and the patient still likes you), a root canal treatment and look at what mother nature can do. This will definitly keep the implant away. Last scan shows a seven years post operative control X ray dental film. The four units fixed bridge has been cemented shortly after complete regeneration of periradicular tissues

A 5 years follow up X ray of lower left molars and second premolar

Two years follow up X ray film (Third to the right) shows nice periradicular tissues healing. A five years control X ray film (Last to the right) shows a perfectly healed PDL and a complete elimination of sealer excess. Sealer excess is not a problem if it is a ZOE based material. Unfortunately, in the name of "good prognosis", retreatment  progressively became an alternative to implant supported crown.

This is a case where, based on the X ray image of a "J" type lesion, and on a deep narrow periodontal probing, one could easily think of a cracked tooth. The microscope showed us otherwise. No crack could be found under microscope observation. As shown on those VRFs, slow but complete periradicular tissues regeneration followed root canal retreatment (which implied a few calcium hydroxyde dressings replacements). This J shaped radiolucency was in fact a narrow desmodontal sinus tract. 

Endodontic retreatment and tooth sectioning procedure performed in 2004. Case study 336

Root canal retreatment in distal root, machined post (Flexipost^TM) cemented with RelyX and an amalgam core build up and tooth sectioning. A complete regeneration of periradicular tissues occured one year later. 

Tooth had a crown in 2008 and is still functional in August 2011

Root canal procedure, case study number 1

First premolar was having an under fill in its distovestibular root canal. Meaning that one small diameter gutta percha point was floating in a canal with a much wider diameter. This available space allowed for a wonderful bacteria colonization which made the patient experiencing an A.A.A. Second premolar was having a root canal filling half way down the canal creating another A.A.A. First molar had a necrotic pulp allowing for another A.A.A. Second molar was having a filled root perforation. This was a rather explosive situation. Fiberglass reinforced composite posts had to be removed in order to allow for endodontic retreatment, calcium hydroxide dressing in root canals helped to stop abundant exudation. An apical ledge was also present in first premolar distovestibular root canal and had to be bypassed. Root canals were filled with condensed gutta percha and Pulp Canal Sealer as a root canal sealer. Casted post were chosen to replace fiberglass reinforced composite posts. 

6 months post operative control X ray film showed good bony repair. Teeth were completely asymptomatic.

Pre operative x ray dental film shows a maxillary upper left canine with no visible root canal. Immediate post operative x ray dental film shows completed case. Canal entry has been localised with a microscope. (magnification 25X) 1 year post operative x ray dental film shows perfect healing of apical bone radiolucency.