2005 was a huge year for Chicago White Sox – an 11-1 playoff finish, including a World Series sweep of the Astros to give White Sox fans their first world championship in 88 years.
One of these fans was in my chair today… He had this tattoo done after the game.
I just couldn’t resist not to take a photograph.
White Sox – 2005 World Series Champions
White Sox – 2005 World Series Champions
That hurts!!!!
I wanted to post this unedited obturation video just show the obturation process as it happens in my chair.
This was a pulpitis case #19. The root canal system was cleaned and shaped using a hybrid technique with hand files, Protaper and Profile rotary instruments. Obturation is completed using warm vertical condensation (System B and Obtura), .04 tapered gutta percha and Kerr pulp canal sealer.
#19 Pre-op
unedited obturation video
#19 Post-op
Cone beam computed tomography (CBCT) has become a valuable tool in endodontics in the recent years. It allows us to see structures in 3-D and helps us in diagnosis, finding canals, locating and evaluating the extent of resorptions, periapical lesions and so on. The applications of this technology are limitless and it firmly established its place in modern endodontic practice. The following case is an example of diagnosis that could not have been established with out the cone beam.
44 year old healthy woman came in to see me for a consultation. This patient reported occasional discomfort in the area of teeth #9 and 10 for the last two years. It has been getting worse in the recent weeks especially after eating. She broke tooth #9 two years ago and subsequently had an implant placed by a periodontist. Shortly after the implant restoration (which looks great) she developed discomfort in the area and had a root canal done on tooth #10 at the same specialists office by an endodontist. During my examiantion, I saw no swelling, healthy gingiva around both teeth, esthetically her teeth look “perfect”. Tooth #9 (implant) tested normal to palpation, percussion, no mobility and normal perio probings. Tooth #10 was slightly tender to percussion and normal to palpation with normal perio probings aws well. Here is her radiograph:
Tooth #9 and 10
This radiograph looks OK to me: no problem with #10, and the implant looks good as well.
So at this point, besides patient’s symptoms the only significant finding is slight tenderness on percussion on the lateral incisor.
A cone beam image was then taken…
No periapical pathosis over tooth #10
Failing implant #9
Here is a link to a closer look into CBCT technology and more cases: The Endo Blog
I am writing this blog in hopes that all of us will review, discuss and treatment plan various options for the case presented below. There is no hard and fast rule in the literature on how to handle these types of cases. This is a great opportunity for us to brainstorm and treatment plan this patient.
Bisphosphonates are an important class of drugs commonly used to treat bone diseases such as osteoporosis, Paget’s disease and hypercalcemia associated with malignancies such as multiple myeloma and bone metastasis from the breast or prostate. Bisphosphonates inhibit bone resorption by inhibiting osteoclast activity.
Osteonecrosis of the jaws (ONJ) is one of the rare side effects of bisphosphonate treatments and can occur spontaneously or following a surgical procedure such as an extraction, implant placement or a flap surgery.
Treatment of ONJ is difficult and may involve surgical debridment, resection or hyperbaric oxygen.
It is more likely to occur in patients taking bisphosphonates intravenously.
Reviewing patient’s medical history is one of the most important things we can do to prevent potentially disastrous complications.
Elective surgical procedures should be avoided in patients taking long term high doses of these drugs.
It has become a common practice for a treating surgeon to order a CTX test for a patient taking bisphosphonates before dental surgery.
C-terminal telopeptide (CTX) is a marker for bone metabolism. Although this test cannot accurately predict the possibility of ONJ, it can be used as a guideline developed by R. Marx: less than 100 pg/mL = high risk, 100 pg/mL to 150 mg/mL = moderate risk, and greater than 150 pg/mL = minimal risk. Basically, the patient is asked to take a drug holiday until CTX levels are over 150, then surgery is performed.
From the endodontic perspective, we sometimes perform a root canal procedure on a non-restorable tooth to avoid the extraction and hence reducing the risk of ONJ.
Case:
62 y/o AA woman presented with pulsating spontaneous pain on her upper right. She reported having multiple myeloma, history of chemotherapy and receiving monthly Zometa injections for the past two years. My examination revealed a irreversible pulpitis with normal periapical tissues on tooth #4. This tooth also has extensive decay and may not be restorable without additional surgical procedures. In addition, root tips of tooth #3 are tender to palpation and are partially covered by gingiva.
In this case, a root canal on tooth #4 was completed and a “Sequence” ceramic root repair material was placed few millimeters into the canal and into the chamber since this tooth will be “banked” (i.e. non-restorable tooth cut at the gingiva and left alone with out a crown.)
Pre-op
Post-op
Root tips of #3
Tooth #4 was banked at the next visit.
#4 banked
Below are the rest of her x-rays:
#12 previous RCT years ago
#15 previous RCT years ago
Advanced cervical decay #19, 20 and 21
Her anterior teeth have no problems, no decay, molars and premolars are missing on her lower right.
Tooth #12 is already banked (just needs a restoration), tooth #15 asymptomatic and needs a crown.
Tooth #19 is scheduled for RCT and #20 and 21 are likely to have RCTs as well. Note: #20 and 21 test WNL to cold and percussion, #19 lingering response to cold.
Root tips of tooth #3 are partially covered with gingiva and cannot be salvaged. The referring oral surgeon’s treatment plan is NOT to extract any teeth due to a high risk of ONJ. At this time this patient is in a difficult position: on one hand, there is an infection associated with root tips of tooth #3, on the other – the risk for developing osteonecrosis is high.
I would appreciate your input/thoughts related to this case….
You are welcome to leave a comment here, or email us at orlandendo@gmail.com for further discussion.
Additional Sources/Cases
The term “benign fibro-osseous lesion” refers to a group of conditions in which bone is replaced with fibrous connective tissue containing abnormal bone or cementum. One of these conditions occurring in the jaws is osseous dysplasia (OD) or cemento-osseous dysplasia (COD). These are synonymous. The world health organization (WHO) describes 3 clinical presentations of OD/COD:
1. Periapical OD/COD: lesions in the anterior mandible and only a few adjacent teeth
2. Focal OD/COD: similar to periapical OD/COD but limited number of lesions in the posterior mandible (rather than anterior)
3. Florid OD/COD and familiar gigantiform cementoma: more extensive forms, occurring bilaterally in the mandible or all jaw quadrants.
Most of these cases occurr in Asian or African American women in fourth or fifth decade of life and most are asymptomatic.
Since diagnosis of these conditions is based mostly on radiographic and clinical examinations, we must recognize these conditions to avoid misdiagnosis and mismanagement of our patients.
Source: Alsufyani NA et al J Can Dent Assoc 2011;77:b70
The following case is an example of florid osseous dysplasia (cemento-osseous dysplasia).
48 year-old black woman was referred for an evaluation of periapical areas in the mandibular teeth. This lady was asymptomatic. Several root canals were completed by her dentist 4 years ago.
March, 2012
March, 2012
All teeth that did not have root canal treatment responded normally to cold.
The diagnosis was made of florid cemento-osseous dysplasia. No treatment is necessary, just a follow up.
Patient’s general dentist kindly provided available images from 2008:
2008
2008
2008
“A picture is worth a thousand words!”
I just returned from the AAE meeting in Boston and one of the lectures I went to was on oral sedation given by Dr. Michael Silvermann (DOCS Education). I want to share just a couple of things that I thought were relevant to all dentists using nitrous oxide and/or prescribing anxiolytic drugs.
1. Safe Sedate Dental Mask – new single use nasal mask used for nitrous oxide that significantly reduces leakage of nitrous oxide and therefor exposure of dental professionals.
2. When administering nitrous oxide, we all had a patient who doesn’t get the effect for a while saying “crank it up doc”. The reason may be simple: we must not forget to start our patients on 100% oxygen for 3 min to flush out nitrogen out of our patient’s blood stream. (nitrous “bounces” off of nitrogen and cannot have an effect). Then we can start our patients on 25% nitrous and then go up slowly as necessary never exceeding 50%. Oxygen flush should be given at 6 liters/min.
3. Sometimes dentists prescribe Valium for anxious patients. From the medico-legal perspective, if oral valium is prescribed/given the morning of dental visit for sedative purposes, then a clinician should use monitoring protocols for minimal sedation (consider pulse ox and BP readings every 5 min). Also, an informed consent for the procedure should be obtained in advance. For more information on regulations for specific states check out this link: Dental Sedation Regulation for Your State.
For more information on continuing education on sedation dentistry visit DOCS Education website.
This case is worth noting simply because it is rare to have a molar with more than 4 canals, especially mandibular second molar! My initial search of endodontic literature produced many reports of mostly mandibular first molars with five canals, three mesial canals, three distal canals, and one recent report by Ryan JL of a first mandibular molar with six separate canals.
37 year old white female presented to me today with symptoms of pulpitis associated with tooth #31. A referral was made by her general dentist after carious exposure.
In this case, pre-op x-ray did not reveal anything unusual, although an angulated view may have been helpful.
Pre-op
During treatment, I always look for additional canals using the microscope. But often, one can suspect “extra” canals by carefully evaluating the position and relationship of canal orifi to the outer tooth surface at the level of CEJ and to each other. Upon access, I immediately located four canals, but noticed that MB and ML are way apart from each other. Upon trophing between MB and ML canals using ultrasonic and scope, a mid mesial was located. Same was done on the distal.
Six canals
Post-op
Post-op angulated
Case 1.
Apical surgery #14.
Pre-op
Pre-op Angulated
Pre-op Photo
MTA
MB1-MB2 isthmus, DB MTA
Calcium Sulfate Barrier
Five interrupted and one vertical matress sling
Post-op
Case 2.
RCT #15
Pre-op
MB1-MB2 obturated
Post-op
Pre-op
Access
Post-op
Pre-op
Post-op
RCT #15
Pre-op
Post-op
Case 6.
Pre-op
Pre-op (buccal IRM)
Post op
One of the challenging tasks in non-surgical retreatment is the removal of cast posts, especially if it’s done through the crown. The challenge is to go through the metal, then cut and isolate the post at the pulpal floor level without damage to the surrounding tissues. The following case is an example of such treatment completed yesterday.
A 29 year old healthy male reported a history of recent pain and swelling associated with tooth #3. He was taking Amoxicillin 500 QID. Previous root canal was done years ago. On examination #3 was tender to percussion and palpation with normal perio probings. Crown is adequate with no opened margins or decay. Patient was scheduled for non-surgical retreatment of tooth #3.
Pre-op #3
Pre-op image clearly shows a large post, very likely a cast post, periapical area on buccal and palatal roots. Oftentimes, case like this (large post) will have a periapical lesion on the buccals (typically due to untreated MB2) and not the palatal, and so I would treat buccal canals only and leave the palatal alone. There was no such luck on this one.
The access cavity was prepared using the following burs and tips: round diamond #4, several H34 (double striped) transmetal burs and an endo access bur #4 (all from Komet USA), then refined with buc-1 ultrasonic tip. Cast post was then cut at the pulp chamber floor and isolated from the core as shown on the image below.
Post isolated
Generally, when I retreat cases involving post removal, after access preparation, I go for the post before removing root fillings to avoid any metal shavings going into other canals. In this case, post was removed using ultrasonic instruments (ET20D and Buc-1 tips), troughing around the post and vibrating it out.
Post is ready to go
7mm post (from the pulpal floor apically)
Once the post was out, canals were cleaned and shaped using a combination of Protaper and hand files, finishing at the following sizes: MB1 and MB2 #55, DB #60 and P #110. All canals were finished by hand, gauged, and .02 tapered gutta percha with pulp canal sealer was used for obturation.
Conservative access opening, 4 canals
Using water bending or prism effect, discussed in one of the previous posts, four canals are shown on the image above.
Post-op
Image above shows retreatment of tooth #3 completed. Periradicular radiolucency on tooth #4 should be treated surgically at a later date.
35 year old healthy woman presented for evaluation and treatment of tooth #19. She reported a swelling and pain on biting. My evaluation confirmed slight swelling and percussion tenderness on tooth #19. No perio probings more than 4mm. Radiographically, periapical radiolucency on the mesial and distal root, and a thin dentin wall mesial to the post were noted. After discussing treatment options, the decision was made to proceed with root end surgery. This patient was then prescribed a coarse of Clindamycin 300mg tabs and Peridex rinse, she was also given an Rx Motrin 800 and Vicoden for post-operative pain to use in a staggerred fashion and was reappointed for surgery.
Pre-op
Pre-op, thin dentin wall mesial to the post
I apologize for dark pre-op and intra-op photographs.
Pre-op photo
MTA root end fillings including isthmus
Bone graft was placed into the surgical crypt prior to closure.
Immediate Post-op
1 year recall
One year recall shows complete periapical healing, tooth #19 is asymptomatic and functional.
1 year recall
The normal anatomy of the mandibular first premolar is well documented in dental literature and text books. However, there are variations in the number of roots, canals and foramenas. A literature review by Cleghorn and Christie in JOE 2007, combining all cited studies with over 6700 teeth revealed the following with regards to the number of canals in the first mandibular premolar:
Single canal – 76% of teeth
Two or more canals – 24% of teeth
Angulated radiographs and their careful interpretation can give us a clue as to the complexity of the root canal space. Specifically, a sudden disappearance of a canal space in the middle third of the root radiographically is a strong sign of multiple canals. In addition, the use of the microscope and symmetry laws are especially helpful when unexpected or unusual anatomy is present. In some cases, a cone beam image may be taken to get a better understanding of a root canal anatomy of a particular tooth.
I saw a 35 year old white male yesterday with irreversible pulpitis on tooth #21. His general dentist referred him for a root canal and noted the unusual anatomy of the pulp space.
Angulated pre-op radiograph reveals presence of more than one canal.
Pre-op tooth #21
Upon endodontic access and microscopic examination, four distinct canals were located and treated. A glass ionomer barrier was placed over the root filling material to augment the seal.
Post-op tooth #21
Any dentist who performs root canal treatment, occasionally has a separated instrument.
The following cases were recently referred for the removal of separated instruments and completion of root canal treatment.
Case 1.
pre-op, separated instrument
The pre-op image shows a separated instrument in one of the distal canals in the junction of the coronal and the middle third of the root. Clearly, there is a straight line access to the instrument and its removal is rather predictable.
instrument visualized and being removed using the ultrasonic instruments
instrument was removed and canals obturated
Case 2.
instrument in the MB canal
Most of the separated file is behind the curve making its removal very difficult.
file was removed and canals were retreated
Case 3.
separated file in the apical third
file was removed and canals were obturated
In general:
1. The more coronal the file, the easier is to remove it.
2. Must see it to remove it (straight line access).
3. Must use microscope and ultrasonic instrumentation. Although there are various instrument removal systems and kits out there, in my hands they don’t seem to be helpful.
4. Some luck is always nice!!!!
I often use images taken with the camera attached to the microscope as part of documentation, communication with the referring dentist or patient education.
In this post, lets pay attention to photographs illustrating the use of a concept of liquid surface tension and cappilary adhesion. I call it a “water bending” or a “prism” effect.
Water, or any liquid for that matter exhibits surface tension which is related to the cohesive properties of water (molecules “stick” to each other), and capillary action which in turn is related to adhesive properties of water (molecules “stick” to the surface of an object).
Case 1
Pre op
Access opening
Note, the image above of an access opening: cant see the canals well unless the walls of the prep would be flared quite a bit.
The image below is taken of the same exact access opening but with a little hypochloride liquid in the access. Due to surface tension and capillary adhesion, the liquid bends inside the prep and with proper illumination we can see all four canals nicely.
Same access with liquid in it
Post op
Case 2
Pre op
Due to a “water bending effect” we can clearly see four canals through a very conservative access opening.
Access, "water bending effect"
Post op
The “water bending effect” has limited clinical applications. Occasionally during apical surgery, I use it to view/detect lingual canals and to see where the ultrasonic tip should go with out changing the position/angle of the microcsope.
Case 3
Image below shows an osteotomy for an apical surgery tooth #14.
Note minimally angled resection of the MB root (I try to get as close to 90 degrees resection as possible to minimize the number of exposed dentinal tubules), cant see the canals unless we look at this resection from a slightly different angle.
MB root of #14 resected
Next image was taken from the same angle as the first one but with a little saline in the surgical crypt. Now we can see gutta percha/sealer due to a water bending effect, and the ultrasonic instrumentation can immediately start with out repositioning of the microscope.
Water bending effect
MTA in MB1-MB2 with isthmus and DB
Although its clinical implications are minimal, the “water bending” or a “prism” effect is really cool and can be used in dental photography as an educational tool.
Surgical Endodontics has been my passion for a while now!
In this post I will share several cases and highlight their individual challenges.
Case 1
This women in her early forties had a root canal on tooth #14 over 5 years ago. Clinically, there is a 7mm perio probing with exudate on the buccal. Radiographically, there is a strip perforation on the distal aspect of the MB root.
Options: 1. extraction and tooth replacement 2. MB root amputation.
This patient wanted to retain the tooth if possible.
Since the majority of root amputation failures are due to fractures, case selection is extremely important. DB and P roots on this tooth are not distally inclined and are fairly vertical which minimizes the fulcrum effect during function and a fracture potential is minimal.
Pre-op
Immediate post op, Dynoblast and membrane
A full flap was raised, MB root was resected and removed, a retrograde glass ionomer filling was placed. Dynoblast bone graft was used along with the Biomed membrane.
2 year follow up
2 year follow up shows complete healing. Tooth is functioning normally and tissues look healthy.
2 year follow up
Case 2
This gentlemen is a healthy 60 year old. Teeth #26 and 27 had recent root canals (#27 was retreated by a general dentist, #26 was done by me). He reports discomfort and slight swelling in the area. Perio probings are 4mm or less. Large periapical radiolucency is present radiographically. These teeth are also abutments for an existing lower partial.
pre op
The decision was made to perform apical surgery rather than lose these teeth.
In cases involving lower anteriors, the challenging part is three fold: 1. surgical access in people with prominent chin, 2. labial inclination of the crowns and therefor lingual positioning of root apecies, and 3. Tissue management (thin tissues).
Apical surgery was completed on both #26 and 27. MTA root end fillings were placed and calcium sulfate was placed into the surgical crypt as a barrier to prevent epithelial ingress.
post op, MTA and calcium sulfate
One year follow up shows complete healing.
1 year follow up
Case 3
This women is in her fifties. Presented with discomfort on the buccal of tooth #30. Slight gingival swelling and an 8mm perio pocket on the buccal. Root canal was done years ago. Post perforation with furcal radiolucency is noted radiographically.
My recommendation to her was to remove the tooth and replace it with an implant. She refused to get an implant. We decided to open this up surgically and attempt a repair with guarded prognosis.
pre op
resin cement, post perforation
Photograph below shows several things:
1. Post was reduced back into the root
2. There is adequate root trunk for epithelial attachment
3. A three wall bony defect (conducive to healing if repair is adequate)
post reduced
repair with "Sequence" ceramic material
bone graft
After the repair, Dynoblast bone graft and a Biomed membrane was used.
immediate post op
4 months post op
At four months, perio probings are 3mm, tissues are healthy, tooth is functioning normally and a radiograph shows signs of initial healing.
tissues at 4 months
Patient is scheduled for a 1 year follow up.
These three very different cases illustrate the importance of case selection! All of the above teeth could have easily been extracted and replaced with implants! Instead, they live to bite another day!
In this post, I would like to share an effective technique that I use to remove plastic thermafil carriers.
This patient was referred for a re-treatment of tooth #19.
Previous root canal was done 4 years ago and periapical areas have increased in size since then.
Clinical crown has good marginal integrity and no recurrent decay. Perio probings are 4mm or less. Tooth #19 is asymptomatic.
Pre-op #19
Diagnosis: #19 previous RCT with chronic periradicular periodontitis.
Treatment plan: Non-surgical re-treatment.
Technique:
1. Upon access opening, plastic thermafil carriers are visualized.
Carriers visualized
2. Temperature on System B is set to 350 degrees F and a fine or fine-medium tip is placed into a canal while activated to resistance. So, basically, a plastic carrier is melted down about 5mm into canal.
Carrier burn-down
3. Immediately following the “burn down”, a headstrom file (typically #30, #25 on smaller canals and #40 or 45 on larger canals) is inserted into canal clockwise until it engages the carrier. I typically feel the resistance when a file engages and the carrier cools off and sets again. It is imparative to place the file into canal while the carrier is still warm.
If the file doesn’t engage, I would repeat step 2 and 3. The reasons may be that the carrier cooled off and set before the file placement or the file is too large in diameter to engage enough length of the carrier.
Carrier removal
4. Hemostats are then used with the fulcrum on an opposite end of cotton pliers rested on the tooth itself (that is my preference, but it could be a mirror handle etc.) to remove the headstrom file along with the carrier.
Carrier removed
Removed carriers
Access cavity after cleaning and shaping
Immediate post-op #19
This technique is my favorite, it is very effective and doesn’t take a long time to perform. The clear advantage is that the carrier is removed completely and in one peice, and the rest of the re-treatment becomes much easier.
Following trauma, discoloration of teeth is common. Staining comes from the hemolyses of red blood cells and formation of ferric sulfide (iron coming from the hemoglobin) penetrating dentinal tubules and trapped in the pulp horns. During the access preparation, it is imparative to remove staining especially concentrating on pulp horns that extend coronaly. At the same time, care must be taken to preserve facial dentin as much as possible.
Often, endodontic treatment alone would result in restoration of natural color of the tooth. If tooth is still discolored, a “Walking Bleach” technique can be used.
Bleaching has been used by dentists for half a century!
Historically, Spasser in 1961 proposed mixing sodium perborate and water for simple bleaching. Since then, dentists have used Superoxol (30%H2O2), Superoxol with heat, H2O2 with sodium perborate and so on… Eventually, none of those techniques were better than simply sodium perborate mixed with water.
Pre-op #9
This 26 y/o woman said: “My tooth is grey and it hurts”. She also reported history of trauma associated with tooth #9.
This tooth was tender to percussion and no response to cold.
Root canal treatment was completed and a flowable composite resin barrier of 1-2 mm was placed, anticipating a bleaching procedure in the future.
Pre-op
RCT and barrier
One week following root canal treatment, there was no significant improvement in color.
Sodium perborate was then mixed with sterile water and placed into the access opening followed by a temporary restoration.
1 week after RCT, still grey
Walking bleach - two weeks
Traditional treatment of an immature, necrotic tooth has normally been accomplished in one of two ways; (1) Ca(OH)2 calcification or (2) MTA apexification. Both methods have been proven to provide clinically acceptable results. However, there are downsides to each method. Ca(OH)2 calcification is a time consuming procedure, and relies as much on the compliance of the patient as the skill of the practitioner. MTA apexification is extremely efficient and allows for immediate obturation of the tooth, but both methods result in a tooth with thin and short dentinal walls predisposing the tooth to fracture.
A recent “hot topic” in the field of endodontics involves methods to regenerate or revascularize the root canal system. Regenerative endodontics utilizes the concepts of tissue engeneering to treat the pulp/dentin complex. The advantages of this method include the possibility of further root development and reinforcement of the dentinal walls with hard tissues thus strengthening the tooth against a potential fracture. This phenomena was previously thought only to be possible following re-implantation of an avulsed, uninfected immature tooth. However recent research has shown otherwise. Although regenerative endodontics is still in its infancy, there have been case reports that show the ability of a necrotic, immature tooth, to “regenerate” pulp-like tissues that allow for continued root development.
Regeneration/Revascularization procedures are based upon the theory that the nercotic, infected tooth can also be successfully revascularized if the envirorment was made similar to that of the avulsed, uninfected immature tooth. There is no current procedure method endorsed by the AAE for this treatment. Practitioners have been seeing positive results based on a variety of adapted methods.
The protocol for the following case report is as follows:
Appointment (1): Standard access, irrigation with copious NaOCl and peridex. Delivery of triple antibiotic paste (ciprofloxacin, minocycline and metronidazole) into canal with a lentulo spiral to length. This is made with equal parts of each antibiotic, crushed and mixed with sterile saline, or compounded by a local pharmacist. The mixture should be a consistency that you find easiest to work with. Be careful to keep the paste contained within the canal. If the paste touches the chamber walls, it can turn the enamel blue. Forewarn patients of this possibility. Cotton and temporary restorative material of choice.
***I waited 4 weeks in between appointments. Literature has supported anywhere from 2 weeks to 8 weeks for this interval.
Appointment (2): Re-access and irrigate with NaOCl. Dry canal and re-establish length. Introduce bleeding into the canal by overinstrumenting #20 K-file past the apex. Allow bleeding to clot as high as possible towards the cervical 1/3. This process may take some time, as much as 20 minutes. Pack an MTA plug against the blood clot. Deliver MTA with the instrument of your choice. In this instance, it was delivered with an amalgam carrier and packed with an amalgam condenser. Approximately 5mm of MTA is required in order to maintain a good coronal seal. Any root structure apical to the MTA plug has the opportunity to regenerate. Therefore, keep the plug minimal. Either place a wet cotton pellet and a temporary material, or directly place a permanent restoration in the access. The MTA will still set if a final restoration immediately placed from the moisture of the blood. Follow up within 2-4 months to determine if the lesion has resolved, then periodically to monitor progress of root formation.
So, why do root canal files break?
1. Operator errors
- pushing rotary files, no glyde path, instrumenting dry, overusing files
2. File defect
- It is extremely unlikely that a file has a manufacturing defect, however it can have defects and/or fatigue from multiple use.
3. Root canal anatomy
- Canals are generally not round. They can be bunch of different shapes: tear drop, figure eight, oval… There are also fins and isthmuses where a file may get caught and inevidably break.
The important thing is if a procedural error happens, and most of these occur during intra-operative stage as we saw from the last post, a prudent clinician should evaluate why the error occured to minimize such things in the future.
Had a very humbling experience yesterday…
I broke a file in a seemingly straight-forward case!
Had a patient that came in for a root canal #30. This tooth is asymptomatic, perio probings are 5mm or less, no response to cold, WNL to percussion and palpation, periradicular area radiographically. Tooth #31 is planned to be extracted due to extensive endo-perio involvement and loss of furcal bone due to a fracture.
pre-op #30
I believe that my yellow protaper got caught in a fin, but this doesn’t make me feel any better. The reason I think it was a fin is because during instrumentation, my instrument was “grabbed” as it was rotating (so it started screwing into the canal actively) and it snapped in the ML canal before my foot was off the pedal. Now, this canal had a glyde path, patency, instrument had a lubricant on it, and a previous instrument in a Protaper series (white protaper) was to the apex with out problems.
mid-op #30, broken file ML canal
Once the file broke, I continued with instrumentation of three other canals and an x-ray was taken with master cones. This film shows that the ML canal is fairly straight, root walls are rather thick and the access to the instrument in the apical 1/3 is possible. The file was then removed using the microscope and ultrasonic instruments in the following order: buc1, cpr#4, cpr#5 and finally cpr#6.
Instrumentation was then completed and canals were obturated using Resilon obturation material in a warm vertical fashion and a thin layer of glass ionomer resin was placed over each orifis as a barrier. This patient was then scheduled for a routine 6 months follow-up.
post-op1 #30, instrument removed
post-op#2, instrument removed
These types of cases remind us that the root canal system is a network of very complex and delicate structures and we must treat it with the utmost care and respect!
In this post I really wanted to simply go through some of the concepts involved in apical surgery and to share my thought process when considering such procedures.
So, why do some root canals fail?
1. Intra-radicular infection.
2. Extra-radicular infection.
3. True periapical cyst.
Root canal failure in most cases can be attributed to at least one of three reasons listed above. When I get a patient with failing root canal, I prefer a non-surgical re-treatment when possible to save the natural tooth. Sometimes however, this option is not possible or practical. In this case, a decision must be made whether or not endodontic surgery is a viable option.
Indications for apical surgery:
1. Conventional re-treatment is not possible or practical.
2. Re-treatment has already been done.
3. Biopsy is necessary.
So, at this point in a treatment planning algorithm, a clinician must evaluate the tooth in question and together with the patient choose the course of treatment.
Is it just better to extract the tooth and place an implant? In many cases it is.
Case selection and surgical skills!!!!! These two are paramount when considering apical surgery!
Case selection, in my mind, simply involves patient factors (medical history etc.) and “tooth” factors. I will concentrate on “tooth” factors.
Here are some of the things I look at during evaluation for possible apical surgery:
1. Proximity of the apical lesion to vital anatomical structures. For example, if the apex of tooth #29 is “sitting” on a mental foramen, apical surgery is contraindicated and an implant, bridge or intentional replantation (to be discussed in future posts) should be considered.
2. If there are deep pockets or fractures – implant! I need crestal bone around the tooth to give me better prognosis.
3. How deep is the vestibule? Lets say on a lower molar, typically lower second molars, if there is a thick buccal plate and a shallow vestibule, I will typically recommend an extraction and an implant because the apical surgery will destroy lots of good bone and in a case like this, an implant will be less traumatic. Conversely, if the vestibule is deep, the surgical access is easier and I am more likely to choose apical surgery option.
4. Size of the lesion – the larger, the worse! There is no “cut and dry” rule here. We do know however that apical surgery performed on a lesion more than 5mm in diameter tend to have a lower chance for healing.
5. Existing restoration is to be considered and also intangibles.
Surgical skills:
Besides all the obvious, like basic principles of flap design and tissue handling, the following should be done during apical surgery:
1. Periapical granuloma/cyst should be removed.
2. Must resect the root(s), best completed at a 3mm level from the apex.
3. Must place root-end filling(s) and according to research best material for that appears to be MTA. It is desirable to make the root-end preparation and therefor a root-end filling as long as possible to prevent apical leakage.
4. If the root-end filling is not placed, failure will follow!
5. During the root-end preparation – isthmus (if present) between canals MUST be incorporated into the preparation and sealed. Often isthmus is present on MB root of an upper molar (between MB1 and MB2), lower anteriors, upper premolars and lower molars (between buccal and lingual canals)
6. In order to achieve best possible outcomes, surgical operating microscope and ultrasonic instrumentation should be used.
CASE 1
30 year old healthy male presented with the swelling around #13. Periapical area is present on the radiograph. Diagnosis #13 failing root canal with acute periapical abscess.
Options: re-treatment with the post removal and a new crown, implant supported crown or apical surgery.
In this case, my patient opted for apical surgery.
Pre-op #13
Full periosteal flap was raised and the periapical lesion was curretted out. Roots were then resected. In this case, untreated palatal root was discovered.
Root end preparation using ultrasonic instruments
MTA root-end fillings in buccal and palatal roots (no isthmus here, roots are separate here)
Immediate post-op #13
Follow-up 2 years
Follow-up 2 years
Both 2 year follow-up radiographs show complete periapical healing, tooth is asymptomatic and functional.
CASE 2
50 year old woman with controlled hypertension, reported persistent discomfort in the periapical area associated with tooth #7, previous root canal was done by an endodontist. Diagnosis #7 Previously treated root canal with chronic periapical periodontitis.
Pre-op #7, large periapical area
Flap raised, lesion was curretted out
MTA root-end filling
Immediate post-op, calcium sulfate barrier was placed into the surgical crypt.
Follow-up 3 years
At the 3 year follow up, tooth is asymptomatic and functional, radiograph shows a complete healing with the classic “star burst” appearance of a periapical scar.
CASE 3
34 year old healthy male reported a “bubble” on his gum.
Diagnosis: #30 previously treated root canal with chronic periapical abscess.
Pre-op #30, sinus track traced
Separated instrument is “peeking” out of the mesial root. Large periapical lesion.
No perio probings above 3mm, new crown placed 3 weeks ago.
Immediate post-op #30
Mesial and distal roots were resected and MTA root-end fillings were placed. Isthmus was also prepared and sealed between MB and ML canals.
Follow-up 1 year
At one year, tooth #30 is asymptomatic and functional. Radiograph shows complete periapical healing.
Maxillary molar with four distinct roots is a rarity!
The overall incidence of four-rooted maxillary molars has been reported to be less than 0.4%. Nevertheless, dentists should be aware of such variation.
When examining the pre-operative periapical radiographs of maxillary molars, if the outlines of the roots are unclear, the root canals show sharp density changes, or the apices cannot be well defined, then extra roots can be suspected! Horizontally angulated radiographs can also be helpful to distinguish the multiple root morphology of maxillary molars. Most definitive means however is visualizing the “road map” on the pulp chamber floor.
The following two cases had pulp chambers shaped like a quadrangle with one orifice in each corner.
Case 1: Tooth #14 (palatal roots length: 23mm on both)
Pre-op
Post-op
Case 2: Tooth #15 (palatal roots length: 25mm MP and 24mm DP )
Pre-op
Post-op
In both cases canals were instrumented with a combination of hand files and Protaper rotary instruments and sealed with Resilon cones and sealer using warm vertical condensation.
It is often challenging to clean and shape curved canals. Most, if not all dentists who perform root canal treatment are familiar with this ugly feeling of breaking an instrument in the canal. I get a jolt down my spine and “butterflies” in my stomach when it happens.
To avoid these types of errors, I come up with a “game plan” and think through every case from the beginning to the end before I actually do it . It takes only a minute….
When I get a curved case, these are some of the things that go through my mind:
1. Slow down!!!!!!!!!!
2. Straight line access to make those curves gentler.
3. Lots of lubricant (RC Prep, Glyde, etc.) and irrigation (NaOCl, EDTA)
4. Use hand instruments more. (I may finish the apical third by hand, pre-curving stainless steel files or using Ni-Ti hand files)
5. Check patency more often with #6, 8 or 10.
6. Instrument in a “crown down” fashion.
7. I typically use Protaper files for rotary instrumentation, but in curved cases I will use those for coronal shaping and may choose Profile instruments (since they are landed and tend to stay centered in the canal and zip less) to finish the apical third.
8. Choose rotary files with the lesser taper as well, like .02 rather than .04 or .06.
9. Do not “push” rotary files, they will break!
10. Be more conservative with apical enlargement.
Case 1: Tooth #32
Pre-op
Post-op
Case 2: Tooth #4
Pre-op
Post-op
This is an example of palatal root surgery.
Tooth #14 was retreated 1 month prior to this film. Regretfully, I lost apical control of my obturation on the palatal root and this tooth was symptomatic (biting tenderness).
Pre-op
MTA in MB1, MB2, isthmus, and DB
MTA in the palatal root
Post-op
5 days post-op at suture removal
18 months follow-op
Trigeminal neuralgia (TN), also called tic douloureux, is a chronic pain condition that affects the trigeminal nerve. The disorder causes extreme, sporadic, sudden burning or shock-like face pain that lasts anywhere from a few seconds to as long as 2 minutes per episode. These attacks can occur in quick succession. The intensity of pain can be physically and mentally incapacitating.
The presumed cause of TN is a blood vessel pressing on the trigeminal nerve as it exits the brainstem. This compression causes the wearing away of the myelin sheath. TN may be part of the normal aging process or can also occur in people with multiple sclerosis, or may be caused by damage to the myelin sheath by compression from a tumor.
TN is characterized by a sudden, severe, electric shock-like, stabbing pain that is typically felt on one side of the jaw or cheek. The attacks of pain, which generally last several seconds, come and go throughout the day. These episodes can last for days, weeks, or months at a time and then disappear for months or years.
The intense flashes of pain can be triggered by vibration or contact with the cheek (such as when shaving, washing the face, or applying makeup), brushing teeth, eating, drinking, talking, or being exposed to the wind. The pain may affect a small area of the face or may spread. The bouts of pain rarely occur at night, when the patient is sleeping.
The attacks often worsen over time, with fewer and shorter pain-free periods before they recur.
TN occurs most often in people over age 50, but it can occur at any age. The disorder is more common in women than in men.
There is no single test to diagnose TN. Diagnosis is generally based on the patient’s medical history and description of symptoms, a physical exam, and a thorough neurological examination by a physician.
(Source: www.nih.gov)
For a dentist, it is imperative to recognize symptoms and make an appropriate referral to a neurologist.
CASE
58 year old healthy white female was referred for an evaluation of pain in the maxillary right area. She reported spontaneous pulsating, stabbing like pain lasting for seconds to minutes in the area of tooth #3 occurring several times a day. This pain was also brought on by brushing her teeth around tooth #3, during eating and occasionally when washing her face.
Pre-op
Previous root canal on tooth #3 was done years ago. Clinically, tooth #3 tested WNL to percussion and palpation, and no response to cold. Perio probings no more than 4mm. Radiographically, normal periapical areas, untreated DB and possibly MB2 canals.
Post-op
Endodontic retreatment was completed, DB and MB2 were located and treated as well.
This lady was happy for exactly one week (no pain at all).
She came back two weeks later reporting “electric shock” like sensations, and feeling worse: pain was more severe and more often. A neuralgia was then suspected.
This patient was diagnosed with Trigeminal Neuralgia and placed on Trileptal (form of Tegretol) 300 mg BID by her neurologist after which her symptoms went away.
79 years old petite indian woman was referred for an evaluation of tooth #19. Her medical history included a hypertension and type II diabetes controlled by medications. She reported no pain, occasional bad taste and discomfort when eating. Clinical examination revealed periodontal probings right to the apex of a distal root of #19, and 4mm or less around the mesial root.
Pre-op
Treatment options:
1. Extraction and tooth replacement
2. Root canal treatment and distal root amputation.
Post-op
After root canal treatment was completed on the mesial root, dual cure core resin was placed into the distal root and a root amputation was completed.
When considering a root amputation, one must evaluate the face type, the musculature (how strong are the masseters, angle of the jaw, etc.), occlusion. This procedure may not work for a 30 y/o with bradycephalic face, however in older individual with weaker muscles of mastication, it can last a lifetime.
