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Treatment of a cervical resorption by internal approach.
Note the point of entrance was found and sealed with BC sealer and BC putty under microscope!
Follow up would be after 3 months in this case.
This patient was referred for tooth # 3.6 Re-t. Diagnosis was previous RCT and symptomatic apical periodontitis. Treatment options were offered and risks discussed.
She also was informed about the severe ledges in mesial canals and necessity of perio treatment before installing a crown.
She elected Retreatment. The ledges were negotiated to the apical foramen. The canals were filled with gutta percha and BC sealer. You may note osseous dysplasia at the periapical area! The follow up would be 1 year.
This patient was referred to Endodontics on Don Mills for tooth 3.6 re-treatment. The medical history was non-contributory. She reported recent flare-up, but once I examined her there were no symptoms. The patient was worried about fracture of the tooth rather than the extension of infection in the future. So, she sought for re-treatment. The available x-ray showed a large filling, previous RCT, broken instrument in one of the mesial canals, apical lesion and apical root resorption at the distal apex. The broken file could be in the middle mesial canal, as there was another path filled with the filling material (Picture 1). The diagnosis was previous RCT and asymptomatic apical periodontitis. Options like re-treatment, extraction, or no treatment was discussed with her. Also, pros and cons of each modality along with the risks were explained to her. In addition, she was informed of the risks associated with the broken instrument removal such as perforation, leaving the canal with thin walls, resistant file, etc. She opted for re-treatment, followed by a full coverage by her dentist. The prognosis of treatment was discussed.
Having removed the coronal filling material and gutta percha from the canals, it turned out that the file has been broken in mesial-lingual (ML) canal, and the other path was an internal deviation from the original ML canal, most likely created in an attempt to remove the broken file or before the file breakage to find the ML canal. There was no middle mesial canal. Then, the coronal third of the ML canal was enlarged very gently with a thin ultrasonic (US) diamond coated tip. Next, the dentin around the coronal 2-3 mm of the broken file was removed with a very tinny non-diamond US tip (Picture 2). It gave me room to bypass the file and play around it to loosen it up. At the end, the same US tip was used in a contra-clockwise motion to disengage and remove the file. Finally, the canals received standard root canal treatment. The patient was referred to her dentist to restore the tooth and complete the coronal seal. She was booked after a year for follow up.
This patient was referred to Endodontics on Don Mills for tooth 2.7 re-treatment. The medical history was non-contributory. She had decided for many times to get the treatment done over a couple of years, however, she was never ready! She finally was. There were no symptoms associated with the tooth. She was worried about the fracture of the crown, so she decided to go head. She gave a history of root canal treatment in the past, however, she did not recall why the treatment was abandoned. There was no trace of canals on the x-ray rather than a broken lentulo- spiral in the distal-buccal canal (DB). Having said that, I could guess the canals had been filled with calcium hydroxide (CH) and that was why no canal space was visible on the x-ray. That is usually like this! Treatment options, pros and cons, risks and limitations, and the prognosis of the proposed treatment were discussed with her.
The coronal filling, which partly was a temporary filling, was removed. There was CH in the canals, which had turned into a hard-setting paste over time. The coronal part of DB canal was adequately opened with number 2 and 3 Gates Glidden drills. A combination of sodium hypochlorite, to remove the debris, and EDTA, to soften the CH, were used. I managed to bypass the broken lentulo-spiral, but it was just the beginning of the challenge! I faced a very hard material at the apical third of all canals. I was short in all canals! Using different stiff files like C and C PLUS files, the mesial buccal and distal buccal canals were opened to their radiographic apices. The presence of an impacted tooth obscured the DB apex and the apex locator device was deemed unreliable in this case for unknown reasons. At the end, the result was good for DB canal! The palatal canal remained blocked!
A channel was created alongside the broken instrument by using consecutively large hand files, big enough to accommodate rotary files. Ultrasonic tip was just used to prepare the DB canal, coronal to the broken instrument, to make it more accessible. Very slight direct US energy was applied to the broken instrument, just to dislodge it. It was not supposed to remove the broken instrument by US tip like the previous case. The technique in this case was to make a channel around the instrument and remove it by hand files, rotary files, and irrigation force. However, one may use a very tinny US tip alongside the instrument in the channel in a contra clockwise motion.
The broken instrument finally appeared in the pulp camber. The tooth received the standard treatment and referred to her dentist for the restoration. She was booked after a year for follow up.