endomontreal

Dental operating microscope assisted root canal procedure on a completely stenosed canal system.  endodontist case study number: 506712

Pre operative condition:

1. Canal is not visible on dental X ray film until last few millimeters because the root canal anatomy system does not begin before last few millimeters, this means an extremely narrow canal diameter for the practioner to locate in last apical third of root. Remaining canal diameter can be 3 times smaller than a single strand of human hair diameter. Remaining within  tooth long axis when accessing canal entry is of the utmost importance not to create a iatrogenic perforation.
2. Two previous failed attempts  to locate tooth single canal entry, this means complete loss of landmarks when looking through dental operative microscope lens to find it
3. Number 12 tooth is a 12X21 bridge abutment, this means loss of external landmarks to locate canal entry
4. Dentine shade composite completely fills up the access cavity, this means even more challenge, when drilling to expose canal entry, not to create additional tooth substance loss (thus increasing tooth weakness.

Tooth and prosthesis survival relies solely on endodontic procedure success, if canal cannot be found thus treated, tooth cannot be preserved.  

Nevertheless, a complex root canal retreatment does not have to mean extraction and replacement by a dental implant. 

Surgical operating microscopes have a steep learning curve and require training, as well as patience and practice to master. Still this piece of equipment and the learning effort it implies is well worth it since cases that once seemed impossible can now be treated with a high degree of confidence and clinical success. 

      An endodontist case report. Microendodontics case study number: 505026

Twenty five years old patient presenting with an abscessed maxillary molar. Diagnosis: Persisting disease after root canal treatment. Etiology: untreated second mesio vestibular root canal (MB2).

Two appointments were required to preserve that tooth:

First appointment: Crown and post removals plus root canal filling retrieval, MB2 location and calcium hydroxide insertion as a medicament. 

Second appointment: Calcium hydroxide removal, irrigation, drying, final canal obturation gutta percha and Pulp Canal Sealer. Provisional filling material: Cavit.

Abutment is now symptom free and it is now all set for a casted post and permanent crown replacement.

A 6 months follow up dental Xray film shows an impressive  regeneration of periradicular tissues. Compared to its initial size, apical lesion on mesio vestibular root shrunk up to 80%. Tooth is aymptomatic and functional.

A complex root canal retreatment does not have to mean extraction and replacement by a dental implant. A research study by Farzaneh et al. on treatment outcome in endodontic found an orthograde root canal retreatment success rate of 93% . (Farzaneh M., Abitbol S., Friedman S. Treatment outcome in endodontics: The Toronto Study. Phases I and II: Orthograde retreatment. J Endod 2004; 30(9):627-633)

An endodontist case report. Microendodontics case study number: 511536

Sixty years old patient presenting with an abscessed mandibular molar. Diagnosis: Persisting disease after (25 year old) root canal treatment. A crown and two post removal where necessary in order to gain access to root canal system for retreatment. 

Only two apointments required to save that tooth:

First apointment: Crown and post removals plus root canal filling retrieval and calcium hydroxide insertion as a medicament. 

Second apointment: Calcium hydroxyde removal, irrigation, drying, final canal obturation gutta percha and Pulp Canal Sealer. Provisional filling material: Clip (not radiopaque) from Voco. 

Tooth is now symptom free and it is now ready for a post and a PFM crown.

A complex root canal retreatment does not have to mean extraction and replacement by a dental implant. A research study by Farzaneh et al. on treatment outcome in endodontic found an orthograde root canal retreatment success rate of 93% . (Farzaneh M., Abitbol S., Friedman S. Treatment outcome in endodontics: The Toronto Study. Phases I and II: Orthograde retreatment. J Endod 2004; 30(9):627-633)

Endodontist case study number: 197337

The recent addition of dental operative microscope (DOM) to endodontic therapy can allow better visualization and management of the intricate morphology of the root canal system during endodontic procedures through magnification and greatly improved high intensity lighting. Dental Microscope typically magnifies in the 4X to 25X range. The other commonly used magnification aide, through lens eyeglass mounted surgical telescopes, provides 2.5X to 4.5X magnification. 

We have been presented with this second mandibular molar that has only two canal entries on pulpal chamber floor. At first sight one could have easily concluded the presence of only two canals. In fact, the mesial root has a Vertucci's type 5 canal configuration. A Vertucci type V pulp space configuration can be described as follow: One canal leaves the pulp chamber and divides short of the apex into two separate distinct canals with two distinct foramina (1-2). Without magnification the root canal apical "split" could have been under seen, treating one branch out of two and leaving  pulp tissue inside the other branch. 

Surgical operating microscopes have a steep learning curve and require training, as well as patience and practice to master. Still this piece of equipment and the learning effort it implies is well worth it since cases that once seemed impossible can now be treated with a high degree of confidence and clinical success. 

"As the saying goes:"A picture is worth a thousand words", Click here to have a look at what can be seen at an operative field under magnified observation (10X to 25X range)." 

Microendodontics case study number: 508126

Root canal procedure case study number: 29537

        509217

Source: 

  A new Dental Operative Microscope (D.O.M.) assisted root canal treatment in a calcified maxillary second molar. Case study in microendodontics number: 506317

Radiographic findings: Dystrophic calcifications in the whole canal system are completely obliterating the pulp chamber. It can be expected that the root canal entries are completely embedded in a mass of adherent pulp stones. 

Endodontic procedure problem number one to solve: Locating all four root canal entries without lateraly perforating the root and without destroying to much sound tooth structure in order to keep tooth restorable.

Endodontic procedure problem number two to solve: Cleaning and shaping located root canals without loosing patency, without breaking an endodontic file and without perforating the root. 

Thus, the difficulty level of this endodontic procedure can be considered as very high. A few years back, when there was no surgical operating microscope in our dental practices and only a handfull of daring pioneers in microendodontics, removing this tooth and replacing it  by an implant supported crown would have been a good option to consider in most instances. 

Times have changed. In order to save that tooth, calcified dentin must be carefully removed with long thin ultrasonic tips under the high magnification of dental operating microscope (OPMI PROergo from Carl Zeiss). No rapid technique exists for dealing with calcified root canal system. Root canals has been shaped and  cleaned with Protaper endodontic files and 06, 08,10  K in combination with chelating agent (RC PREP). Canal system has then been filled with Pulp Canal Sealer and Gutta percha laterally and vertically condensed. Provisional filling material: Cavit ^TM.

 Case study number: 495336

Symptoms: Acute pain to pressure, patient is eating on the opposite side. Root canal was done three years ago. (X ray image number one)

Tooth root canal system has been retreated ( reshaping and cleaning) and calcium hydroxide paste inserted as an intracanal medication (x ray image number two), symptoms subsided.

A week later, final root canal obturation with gutta percha and pulp canal sealer completed the root canal procedure, an amalgam post and core build up was done during the same appointment to seal coronal part of the tooth. (X ray image number three)

Six months recall shows a complete healing (X ray image number four). Patient's dentist can prepare the tooth as an abutment to receive a crown.

Endodontic procedure case study number: 378415

A Vertucci type VI pulp space configuration can be described as follow: Two canals leaves the pulp chamber, intersect in the body of the root and redivide short of the apex into two separate canals with two distinct foramina (2-1-2).

In this per operative X ray dental film, crossed canals are highlighted with endodontic ISO files within the root canal system. During shaping procedure, only one file at once could pass through the root canal intersection in the body of the root, each root canal branch has been shaped cleaned and filled individually with lateral and vertical condensation. 

Preoperative radiological findings that might help us in suspecting such a pulp space configuration: root canal abruptly becomes invisible short of the apex. 

Armamentarium: OPMI PROergo dental operative microscope from Carl Zeiss, Rubber dam and rubber dam clamp and frame, Stainless steel K endodontic files, gutta percha and Pulp Canal Sealer, finger plugger.