C Shape Retreatment
We ended up retreating both of these molars. Unfortunately there was a lot of tooth spent on the initial treatment the probably affects the long term prognosis. Intermediate term outcome, almost.
Author: Fix It Crew
3 Rooted Premolar
We recently finished up this 3 rooted premolar. I considered using amalgam on this one due to the caries rate. Also considered deeper Markley wires. However, since the furcal floor was 3-4 mm below the bone level, I opted for a larger fiber post.
Management of Pulp Horns
Pulp horns recede with age and from pulpal insults resulting from caries, restorations, and trauma. Because of the patient population we care for, many of the teeth we treat as endodontists, don’t have prominent pulp horns. Thus, for the vast majority of our patients, a simple incisal based approach is appropriate for canal management, conservation of tooth structure, and post reinforcement. However, one subset of our population is trauma. More often, trauma affects younger patients. As a result endodontic management of teeth with pulp horns may be necessary. In this case, the patient was injured playing soccer. The tooth began discoloring and lost sensibility to cold. If the pulp horns aren’t managed, and a conservative approach is used, it’s possible to leave debris and or voids in this area. It’s possible that such a process centered outcome may predispose the tooth to an aesthetic failure if the tooth discolors over time. This is particularly true during apexification procedures if MTA is used and MTA (regardless of whether grey or white is used) ends up in this void. Access along the long axis of the tooth leaves a sharp angle of dentin adjacent to the pulp horn. This transition leads to void formation during the restorative procedure. Adjusting the dentin here with an internal axial groove allows air to vent and restorative materials to proceed without jumping over the sharp transition leaving a void. In order to prepare such a vent, adjusting the enamel in the apical aspect of the access can facilitate the use of small burs and/or ultrasonics. In the more rare situation that a shovel shaped incisor presents with the need to manage pulp horns, the risks and benefits must be carefully weighed if contemplating a buccal approach as a larger more demanding composite restoration may be necessary if the pulp horns are to be managed.
Long Max Molar
Some daily work. An example of image guided access and root-form appropriate instrumentation.
We opaqued the silver to achieve an esthetic access closure.
Typical Instrumention
One year followup. Pretty typical instrumentation for a maxillary molar.
-Trudeau
Large Canals
Kind of rare to see these wide open canals on a 60 year old. The patient initially presented with buccal probings to the apex on this second molar. I used some pre-bent 10 and 15 files on the distal, mesial lingual, and mesiobuccal canals. I used a 7.04 rotary file on the mid-mesial canal. Instrumenting large canals takes a little more time. Continuous taper shaping of these canals would have likely perforated it coronally. So for these large canals, this is root-form appropriate instrumentation of the internal aspect of the root. Looks like there were 3 POE’s on the MB root. The lateral canal evident on the postop may have contributed to the furcal blowout.
-Trudeau
Lots of Healing
Measurements had it it over 12mm preoperatively.
-Trudeau
Restoratively Driven Endodontics
It isn’t a new term. Restoratively Driven Endodontics that is. It’s not new. I came up with it in 2007/ 2008 during my endodontic residency at Albert Einstein making the term about 10 years old now. I came up with the term to help myself with a congnitive dissonance. That’s the term for that pesky feeling when you hold two ideas at the same time that go counter-current to each other. The dissonance that I was experiencing was that endodontic therapy was a type of disease control that was distinct from the restorative process. Let me explain. See during the formation of our endodontic specialty, the founding fathers of endodontics thought it necessary (and maybe it was), to distinguish the practice of endodontics from restorative dentistry. In fact they went to great lengths to do so in order to create the specialty. However, some of these processes that would come to be common practice, often ran counter-current to restorative processes as I began to think about them 10 years ago. So, there I was looking at problem, and I needed some language to help myself out of it.
My program director, Fred Barnett is one of the finest educators I’ve ever known, and I have spent more than a ridiculous amount of getting educated. Due to his vision and progressiveness I was lucky enough to have implant courses which I readily soaked up. Additionally, I had a great lecture from my now buddy John Khademi, that centered mainly on “looking at things through the restorative lense.” Which as a restorative dentist practicing before my endo program, came naturally and made decision making easier. Many of the problems associated with implants at the time were associated with misplacement, issues with abutments, and occlusal spacee etc. So, the fix for their problem was that the model of implants needed to be restoratively driven. So, I made the leap, namely that those processes that were necessary and sufficient to rehabilitate compromised teeth with endodontics needing to be seen and guided through the restorative lens. And thus, Restoratively Driven Endodontics was born in my mind.
Here’s the definition as it sits today:
“Restoratively Driven Endodontics is the overarching philosophy that guides clinical decision making and strategic management to maximize the potential for favorable patient centered outcomes in the rehabilitation of compromised teeth. “
I gave the first iteration of Restoratively Driven Endodontics at Albert Einstein in 20011, and then the more updated version in 2012 in Carroll County. It continues to evolve as new evidence presents itself.
What’s interesting is what’s developed over the last decade. Certainly a great deal.
If Restorativley Driven Endodontics is the overarching philosophy there are some main ideas that act as pillars that support it. Those pillars of Restoratively Driven Endodontics include Conservation of Tooth Structure, Exacting Restorative Methodology, Dental Conditions Management, Hostility Management, and Restorative Treatment Planning. We will tackle these in time, and touch on them with cases as we go along.
As we tackle Restoratively Driven Endodontics the landscape of what we know and how we do it will undoubtedly change. The armamentarium of models guiding our thinking and the technology that guides our processes will hopefully drive better outcomes for our patients. With that in mind it is important that we realize that many concepts are linked. Such that it is hard to understand one area, without having knowledge of another.
To that end, the efforts of this blog will be to illuminate and elucidate the network of these mutually supporting ideas, concepts, practices, and philosophies in a coherent way.
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