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.
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Patient Centered Endodontics: The Rehabilitation of Compromised Teeth
Resorption Repair
6 year followup on this case. CBCT imaging was used for determination of restorability. This type of resorption is crestal resorption. The resorption was determined to be less than two line angles by way of extent and located on the palatal. The endodontics was performed and a fiber post placed well below the level of the resorption. In this case we performed a burectomy to remove the ginigiva and visualize the cavosurvace once the the resorptive soft and hard tissues were removed A matrix band with a little Dycal was used for isiolation. A bulk fill of glass ionomer was placed and then vaneered with flowable composite. The restorative material approached the bone in the area of resorption, however, on followup there is no recession, and no bleeding on probing. We’re cautiously optimistic about a favorable long term outcome.
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.
IGT of a Lateral
The porcelain crown attempted to correct the spacing caused by a peg lateral and as such the center of the canal was located pretty far distal to the crown. Using the imaging to guide the therapy (Image Guided Therapy or IGT) the access was planned for this particular tooth extending through the incisal edge along the long axis of the tooth. A thin fiber place was placed. The tooth was left in CaOH until there was evidence of radiographic healing.
Bridge Retreatment
The patient presented with pain on the distal abutment of the bridge. Clinical examination revealed caries and that the bridge was loose on the mesial abutment. The patient wasn’t interested in implant therapy due to a prior bad experience and chose to have the bridge remade. The premolar was retreated (Thermafill carrier removed with hedstroms) and the molar treated endodontically. Due to the wide short chamber present on the molar we chose to make a dual access leaving a dentin truss for support. The premolar was restored with a fiber post for rehabilitation purposes. We opted to use custom resin matrices for restorative purposes. The 1 year followup shows a good fitting bridge, and a functional asymptomatic restoration.
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
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