endomontreal

case: 430646

Resorption associated with chronic apical periodontitis altered the shape and position of the foramen through osteoclastic activity, in the x ray images, the modified foramen in distal root is positioned farther from the radiographic apex and gutta percha appears in overextension. A large and circumbscribed radiolucency involves both roots as well as the furcation. This indicates an important periradicular tissues destruction. Tooth mobility level 2 goes along with this tissue loss.

This case is definitly a controversial one, meaning that it is possible for different practitionners to prognosticate endodontic success (very few among practioners) or failure with a great amount of disparity. As stated by John I. Ingles, a senior lecturer in endodontics: "The practicing dentist should not be cited for faulty judgment when even the so-called experts tends to disagree on prognosis… All in all, one must ultimately develop confidence in one's own abilities. Being able to practice using a great variety of techniques and not being "married" to a single approach in every case will greatly enhance one's capabilities. And on this is based good prognosis, the result of skill, knowledge, and self confidence."

Endododontic retreatment and MTA root-end fillings have been performed with a Zeiss Pro Ergo Microscope in september 2008. Last displayed X ray film on this post shows a 3 years post operative clinical outcome. Radiographic examination shows a complete regeneration of the periradicular tissues and a resoptive defect healing. 

Should an implant have been put there? maybe, maybe not!

Read more about MTA Precision placement with the microscope (.pdf)

Persistent disease on second mandibular premolar. Tooth decay on abutment. Risks of post removal include: fracture of the tooth, leaving the tooth non restorable, root perforation, post breakage, and inability to remove the post. An additional concern is ultrasonically generated heat damage to the periodontium. Therefore, an apicoectomy and retrofilling or an extraction and replacement with an implant or a fixed prosthesis is a treatment option before initiating the retreatment. Post has been removed in 20 minutes.The use of ultrasonic energy for short periods and water cooling to prevent excessive amount of heat generation proved to be most efficient in this case. A casted post and a new crown are planned.

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.

Pre op. clinical situation:

1  Long roots, root canals calcified in apical thirds on mandibular molar

2  Post to remove and endo to retreat on mandibular premolar

Denticles and an MB2 canal entry to find in this maxillary first molar makes preoperative condition complicated. Post removal, tooth positon in the arch, ledges to bypass and the fact that this is a retreatment case, makes preoperative condition complicated in this maxillary second molar.

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.

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.