Treatment Planning in Endodontics
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Patient Centered Endodontics: The Rehabilitation of Compromised Teeth
Deep Negotiation on a Retreatment
This was a retreatment case where we had to negotiate towards the apical 1/3 before finding the canal. 3D imaging shows resolution of the distal apical finding. In deciding whether to retreat the tooth we followed the retreatment algorithm. The tooth was symptomatic, and while there was some significant tooth removal during the prior treatment and crown, the tooth still has enough tooth structure to meet the patients expectation.
Dycal Help with Matrix
The distal invagination of maxillary molars can create a bit of a challenge when adapting a matrix band. There are lots of matrix options, but if your normal armamentariam is a toffle-meyer and band, then an application of a little Dycal can help out. Just a dab applied with a perio probe to fill the space. Then smooth carbide to clean up the flash. This can be removed an interproximal carver at the time of amalgam carving or later with a scaler. Having this tip in the bag helps one practice Restoratively Driven Endodontics.
Margin Salvation
We got a two year followup on this patient when looking at the premolar. There were three mesio-buccals on this case. The patient requested we keep the crown so we salvaged the mesial margin with amalgam.
Palatal Split
The chamber had a narrow tall platform which lends itself to a small yield access. At 1 year there is healing evident in 2D.
Parfocus in Endodontics
Simply put, parfocus in endodontics is where the object of interest is in focus for the endodontist, the scopeside assistant, and the camera. The lack of parfocus can lead to team incohesiveness, lack of efficiency, headaches, and poor documentation. I’ve seen a number of methods for parfocaling. This is mine; it’s worked for me when many other methods haven’t. There are two distinct parts of parfocaling the scope: parfocaling the rig and parfocaling the case.
Parfocaling the Rig
Step 1. Make sure all the components of the microscope are tight . With a fully loaded rig, there are many parts including spacers, beamsplitters, dual iris, and binoculars. You want to make sure each of these are completely aligned, seated, and tight. You may need an allen wrench or screwdriver depending on your setup.
Step 2. Using either your dental chair, desk, or sliding backwall worksurface create a horizontal worksurface and place some fine print on it. Bring the scope around so that you can comfortably look into the scope and view the fine print under the microscope. Adjust the binocular inclination and interpupillary distance so that your comfortable and you see one circular image surrounded by a singular clear black ring. Set both of the oculars to zero (+/-). Bring the image into decent focus at first second to highest mag, then highest mag. It does not need to be in perfect focus at this point. Now, lock down all 6 knobs on the rig such that it can’t move at all in any plane.
Step 3. If you have a dual iris, open it all the way. If your camera adaptor has an iris, make sure it’s open all the way. Take a picture of a single letter of the fine print. Pull the captured image up to full size on your best monitor in the operatory. Then adjust the fine focus. And take another picture. It will be either better or worse just like at the optometrist. If it’s better, keep going in that direction. Worse, reverse it. Keep playing better or worse using the images on the monitor until you get perfect images. The body of the microscope and your camera are now parfocaled. Trouble at this stage means there is likely something not set up correctly in the microscope setup downstream of the beamsplitter.
Step 4. You have a decision to make here. Glasses or no glasses. I wear flat faced glasses for eye protection. But to each their own. If you typically wear glasses, put em on. Using just the right eye adjust the ocular as you look into the scope. Slowly adjust in the plus direction. Like before, if + is better keep going. If not reverse it. Keep going until things start to get worse. If After you finished dialing in the right eye, repeat with the left. Now go to the lowest setting and double check each on their own. If an adjustment needs to be made use the ocular adjustments at the lowest setting. Make note of your new ocular settings. Do it either mentally, or with a wax pencil. You don’t want anything permanent, because as we age things will change.
Step 5. With the rig still locked down, have your scopeside assistant adjust his/her ocular in the same way you just did. Your rig should now be parfocaled.
Parfocaling the Case
After adjusting the scope for comfort for both the endodontist and scopeside assistant, using the patient chair bring the cavosurface of the tooth into focus at first low, then medium, and finally high magnification. With the iris wide open, take a picture. The picture should be clear and in focus albeit over exposed. The case is now parfocaled. Depending on the depth of the chamber, the focus may need to be adjusted, but most of the case should be in focus throughout the rest of the procedure. Before taking pictures, bump the mag to high and fine-focus using your legs underneath the chair.
C Shaped Lone Molar
A little over a year shows radiographic healing. We found 4 portals of negotiation.
Root Tip Endo
Consider these observations:
These are but a few of the many documented cases of root tip endos that I’ve seen over the years in practice. The patients are all asymptomatic, albeit clearly not functional. We can see food, plaque, and caries sitting on the root filling. These roots have been infected for years. If we were to say that there was some sort of threshhold of bacteria that need to be removed to have a favorable endodontic outcome; these teeth would represent the maximum, most bacteria filled, most infected roots possible. And as such these teeth should have both clinical symptoms of pain and swelling as well as radiographic signs of endodontic pathosis. However, all of these patients are asymptomatic. And radiographic interpretation suggests they are typically free of apical findings. How could it be that the most infected roots have no radiographic findings? It must be something more than just the presence of bacteria or some degree of bacteria in the root of the tooth that defines endodontic pathosis.
Perhaps the lack of occlusion on these roots has something to do with it. If this is true, as the available evidence suggests, then occlusal function plays a role in “endodontic pathosis”. Such a supposition isn’t terribly surprising in that occlusal parafunction can lead to endodontic necrosis in the absence of caries. Furthermore, many of the signs and symptoms traditionally associated with infection related endodontic pathosis can be associated with occlusal parafunction even in the absence of infected roots or proximal caries. Thus, the myriad of endodontic conditions that present in clinical practice are not well explained by the apical periodontitis disease model and the relationship between radiographic findings and endodontic pathosis is not a direct one.
Post or No Post?
A pretty common question that comes up when I’ve lectured on restoring endodontically treated teeth is “Do molars need a post?”. I would say, on most initial treatments, the answer is no. Reason being, with a conservative access, the internal access shape is convergent leading to a frustum shaped access which lends considerable retention. In some cases, what your dealt, has already compromised this retentive form. In this root tip endo case, the root filling had been exposed for a long time, and with regard to remaining tooth structure- it already had 3 strikes. The patient knew that this tooth didn’t have a favorable long-term prognosis but wanted to buy some time. So, we pitched a tent with 3 stainless steel posts and placed a bonded amalgam. A little heroic? More or less heroic than Nacho Libre?
C- Shaped Canal System
This patient was in for another tooth so we go this followup image. We had waited for a couple months after starting the case before obturating. Looks like complete healing at a year.
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