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. 

Case study number: 434426

Patient was refered to us to locate MB2 and DB canal entries with the help of a dental operative microscope. Calcifications had to be removed with ultrasonic diamond coated tips from the pulpal chamber floor in order to expose those canal entries. 

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. 

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.

Persistent apical periodontitis. Patient unable to chew on this tooth. Endo retreatment (Ca(OH)2 for ten days). Symptoms subsided after 8 days. Mesiovestibular root canal has a curvature into an "S" form.

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.

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.

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.

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.