endomontreal

Study case number: 491047

We have been presented with this previously treated tooth. The canal system has been filled with Sargenti's paste and a separated past filler still remains in mesial canal. Second image displays a mesial root close up with the broken paste filler reaching it's apical third. 

Patient is informed about these facts and is made aware of the tooth poor prognosis if separated instrument cannot be removed and if Sargenti's paste cannot be completely removed from canal system. Extraction and implant therapy is considered but patient wants to keep her own tooth. Informed consent is given by the patient.

Pulp chamber is accessed trough amalgam obturation, filling material is then removed with ultrasonic tips and two canal entries (out of three) are localised. Sargenti's paste is broken into smaller pieces until a softer aspect of the material is found, coronal part of paste filler is exposed and the separated instrument is retrieved and an Xray dental film is taken (Third image). First instrument, a number 06 ISO K file is reaching the apex in fourth X ray image. Fift image is a" calcium hydroxide paste insertion" post operative X ray dental film. Last image (bottom to the right) is a final obturation with Pulp Canal Sealer and gutta percha (lateral and vertical condensation).

Tooth presenting an "against all odds" clinical situation , many would think: "you don't have to worry it is dead!". Dental operative microscope allows the practitioner to  let it be something he tried his damnedest on. 

Crown and post removal on second mandibular premolar,  broken instrument in middle third root canal removed under the high magnification of dental operating microscope(DOM), an acute apical abscess to manage made this tooth rescue a very challenging one.

Teeth 12, 13 and 17 are existing 17XXX13,12 bridge abutments. Previous bridge done by a prosthodontist lasted 12 years. Lack of bone structure precluded implants surgery in number 16,15 and 14 and patient did not want any sinus lift surgery.  Tooth number 12 became a key abutment to save without shortening its root lenght. Root canal performed 12 years ago on tooth number 12, a casted post has to be removed, broken Hedstrom file number 45 ISO also has to be removed in apical third of root canal. Tooth decay surrounded the file fragment and apical root canal size diameter had to be enlarged to 80 ISO diameter file. After re-endo, casted posts on teeth number 12,13 and a new 17XXX13,12 bridge are planned. Last Xray is a post operative X ray with cemented post and abutment 12 of 17XXX13,12 bridge.

Lower symptomatic first molar with broken instrument in mesial root. When broken instrument cannot be removed, tooth sectioning with mesial root removal can be an option. Another alternative to implant supported crown.

Endodontic retreatment on lower right first premolar (Vertucci's Type V canal configuration) Pre operative X ray film shows: 1- First separated instrument in lingual canal 2-Second separated instrument in vestibular canal Second X ray film (post operative from first session) shows the other fragment yet to be removed with the help of a surgical operative microscope. Provisional material obturation left in canal is called Clip from Voco. Not very radio opaque but still is an excellent provisional material easy to insert and remove. Second appointment post operative showing second fragment removal and Ca (OH)2 with barium sulfate dressing in canals. Acrylic crown with radicular retention has been cemented with Temp Bond. Fourth X ray shows final root canal filling with casted post for try in at third appointment. Last X Ray shows a 7 years post operative outcome. Sealer extrusion into the periapex vanished, tooth is asymptomatic and has been a partial denture keytooth since then.

1 Broken instrument in palatal root canal

2 Calcified root canal

3 Broken instrument removed under the high magnification of dental operating microscope(DOM). A No 8 ISO file reaches the apex.

4 Completed root canal.

Case study number 042210

This case shows more than one factor listed in the HIGH DIFFICULTY category: non-negotiated canal, ledge and separated instrument in the apical third of a very sharply curved mesiovestibular root canal, a very long casted post in palatal root canal to remove involving a risk of tooth fracture. Step 1 Crown and post removal Step 2 Separated instrument removal and ledge bypass in MB root canal Step 3 Cleaning and shaping all canals plus Ca(OH)2 insertion for 8 days Step 4 Obturation of the cleaned and shaped root canal system Last X ray: One year post operative with new post and crown. Link to the Endodontic Case Difficulty Assessment Form : http://endomontreal.com/wp-content/uploads/2008/09/case-difficulty-assessment-form.pdf

Légend:

1 Separated file

2 Machined post

3 Previously underseen fourth canal apex

Endo retreatment steps:

A) Opening through PFM 17 16 15 X 13 bridge abutment, mesio buccal (MB) and mesio buccal 2 (MB2) canals location.

B) MB root canal retreatment implying separated instrument retrieval.

C) MB2 canal entry location with 30 X magnification and canal instrumentation.

D) Cemented post removal in palatal root of # 16 and retreatment.

E) DB root canal retreatment implying separated instrument retrieval .

A mixture of Barium sulfate Calcium Hydroxide dressing was left for a minimum of 8 days in different canals until allowed final canals obturation.