endomontreal

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.

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.

 

A tricky post removal and a previously omitted disto-lingual canal entry localised and treated with the help of a microscope (20X magnification). Ca(OH)2 was left in 4 canals for 10 days prior to final obturation. (Pulp Canal Sealer and lateral and vertical Gutta Percha condensation). Previous Zip in mesio-vestibular canal could not be bypassed despite extensive labor work. This distal canal falls into Vertucci’s type V canal configuration most probably due to its coronal preparation for a post.

Symptomatic apical lesion on mesio vestibular root of first upper left molar. Pre operative X ray film shows a tough post to remove and a pre-existing root canal treatment performed 20 years ago. First appointment: Crown and casted post removal: MB1,P, DB retreatment and MB2 locating cleaning and shaping. Complete canal system is then filled with Ca(OH)2 and a provisionnal post and crown cemented with Temp Bond insure a good seal for the next ten days.  Second appointment : Final obturation with Pulp Canal sealer lateral and vertical packing of gutta percha One year post-op X Ray shows nice bone healing It's worth it to note that in this case, MB and MB2 apex anastomosis did not prevent this patient from getting an AAA. In first upper molars, an MB2 is present in 93% of the cases. Thus, to always strive to find, clean and shape MB2 should be the standard of care.