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Renovo Endodontic Studio
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ENDODONTICS, ORTHODONTICS, AND ORAL SURGERY...

This 13 yo healing male was referred to our office for management of an anticipated carious pulp exposure on tooth #31. The boy's chief complaint included pain on chewing due to food entrapment within the carious defect and sensitivity to temperature (cold/hot) and sweets. Additionally, this tooth was mesially inclined significantly and was treatment planned for molar uprighting by an orthodontist. The upper left represents the pre-operative radiograph (we apologize for the blurriness as this boy had a slight issue with his gag reflex on this particular day). The upper right depicts the post-operative radiograph where we performed apexogenesis using Brasseler Root Repair Material and glass ionomer as a permanent restoration. The lower left depicts the 1 year recall where the patient remained asymptomatic and we have evidence of continued root development. At this time, the patient had already initiated orthodontic treatment. The final radiograph on the lower right represents 1 year, 6 month recall. We can see that the root has completely developed at this time with significant calcification of the canal system. This may be impactful in the future should the tooth become infected as it would make endodontic treatment very difficult. Additionally, the tooth has been significantly uprighted. The tooth is now primed for full coronal restoration. We have included Oral Surgery in the discussion due to the partial soft tissue impacted 3rd molar (#32) which is slightly visible in all radiographs. We have recommended that an evaluation be made pre-prosthetically to have the 3rd molars removed to aid in restoration of #31. Additionally, the roots have not fully developed yet so extractions would be made easier at this time (panoramic radiograph not included above)
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CBCT and RESORPTION:
This case illustrates the use of CBCT to determine if root resorption that was present on tooth #3 was internal or external. This is particularly useful as internal resorption tends to carry a much more favorable prognosis for the patient.
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The Easy Ones:
Many practitioners assume that molars are the most complex teeth with regards to their internal anatomy. However, the most variable of all teeth in the oral cavity are mandibular first premolars. This case demonstrates a seemingly quality RCT (arguably an unnecessary post) in terms of fill and length. This patient presented with severe facial swelling, grade 3 mobility, and incredibly pain following recent RCT #28 completed by an emergency dentist (not their usual dentist). After removal of the post, several additional canals were located in an apical split. Due to the severity of the infection and grade 3 mobilitiy, a surgical flap was elevated for debridement, the teeth were splinted, and calcium hydroxide was placed to disinfect this unusual anatomy for several weeks. This patient returned asymptomatic and the splint was removed to demonstrate physiologic mobility only. Obturation material was placed and the patient returned to their dentist for final restorative treatment. An interesting reminder that the seemingly easy mandibular premolar can bifurcate >15% of the time (granted, this trifurcated tooth is quite rare!).
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MANAGING LARGE LESIONS: Here we present a 23 YO healthy Asian female with a necrotic #10 secondary to a shovel shaped coronal anatomy. We chose to to treat this tooth non-surgically in 2 stages. After 8 months not only did the lesion not heal, but she failed to have the permanent restoration of the endodontic access completed. We had then chosen to manage this case surgically via apicoectomy and also hooked her up with a local restorative dentist who could restore the access for her. 4.5 years later, this patient remains asymptomatic and we see evidence of complete bony healing of what started as an very large bony defect in the maxilla. SUCCESS!!
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THERMAFIL - Every retreatment case is not the same. As endodontists, we remove posts, separated files, gutta percha, and in this case: plastic carriers. Careful technique allows complete retrieval of the plastic carriers which can poorly obturate the apical 1/3rd due to their design. This case also demonstrates a missed DL canal which was contributing to the persistent apical pathosis.
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MASSIVE TOOTH RESORPTION: We have been waiting to post this case until after the restorative procedure has been done by the restorative dentist, but we couldn't resist posting this case which we feel is quite interesting. This patient came to us as a 4th opinion (2 endodontists, 2 oral surgeons). Every time this tooth has been written off as non-saveable due to the extensive amount of tooth resorption. After very careful discussion with the patient, the decision was made to attempt saving it. The limiting factor to a favorable prognosis here is not the endodontics, but rather the restorative treatment to follow. We were able to remove all the resorptive tissue, complete the root canal, and cemented a fiber reinforced D.T. LightPost in the canal with proper mesial contour of the restoration. The clinical pictures represent pre and post-op from the same day. The post-op radiograph is actually a 3 month recall. As one can see, there has been a slight mesial bony defect and a minor black triangle in the papilla (sorry no pic available at this time). This patient is considering pre-prosthetic forced orthodontic extrusion per our recommendation to allow for an adequate margin for the prosthesis as well as to pull the periodontium coronally to aid in the esthetic outcome. Not an ideal case to start, but I think we managed pretty well and was able to help this patient save her tooth which she so desperately wanted to do!
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VERTICAL ROOT FRACTURE: This case was referred to us because a j-shaped periapical lesion was noted on routine radiographic assessment of tooth #18 by the patient’s general dentist. The patient denied history of pain or swelling. Tooth #18 is an abutment of a three unit FPD with intact margins, was sensitive to percussion, and tested within normal limits to palpation and periodontal probing. In absence of direct visualization of a crack or fracture, there was no definitive evidence of vertical root fracture. However, the possibility of vertical root fracture could not be ruled out as a possible etiology.
As the patient was motivated to save the tooth at all costs, selective retreatment of the distal root with long-term (8 week) calcium hydroxide application was recommended. If upon re-evaluation at the 8 weeks, sensitivity to percussion and size of the periapical lesion improved, vertical root fracture could be more confidently ruled out, and endodontic retreatment could be completed.
At the 8 week evaluation appointment, three imporatant findings were noted:
1. Temporary restoration was intact
2. Periapical lesion persisted
3. Calcium hydroxide was completely washed out of the canal
These three factors demonstrate that there must be a communication or fracture within the root canal system. Consequently the patient was advised that the tooth is non-restorable and recommended for extraction.
TAKE HOME MESSAGE: The presence of a j-shape lesion was likely consistent with vertical root fracture. However, this is NOT ALWAYS the case. If a patient is motivated to save the tooth, the tooth can be deconstructed and medicated for further evaluation. The key to diagnosis in this case was comparing quality pre-op, immediately after calcium hydroxide application, and 8 month post calcium hydroxide application radiographs.
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THE DENTAL EMERGENCY: This case was referred to us because of extreme pain associated with tooth #30. The root canal had been performed by the restorative dentist who had done seemingly well done endodontic treatment and coronal restoration. As evidenced in the CBCT, we were able to identify the source of failure to be an untreated DB canal. Upon access and canal location, we acheived immediate drainage for quite some time. To considerations for this case:
1] The treatment was completed in one visit because we were able to acheive a completely dry canal system after disinfection.
2] We decided with the restorative dentist to selectively treat the distal canal only for the reasons that there was only evidence of periapical pathology associated with the distal root, the pre-existing endodontic treatment appeared adequate, the crown was recently done. Whenever we choose to pursue selective root retreatment, our patients can be confident knowing that we will rectify any pathology associated with the root(s) not initially addressed should it arise. This was no different here. In this way, we were able to keep the endodontic access smaller despite having to also remove a fiber reinfoced post.
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COMPLEX RESORPTION PATTERNS
This case presents a unique challenge with extensive internal resorption that has perforated the lingual surface in the apical 1/3rd. This tooth has a guarded/fair prognosis due to the severity of resorption, but due to the extent of bone loss and high smile line, both a dental implant and an FPD would result in a poor esthetic outcome for this patient. How do we treat this tooth then? Calcium hydroxide therapy for several weeks is recommended to halt resorptive processes by killing clastic cells. In order to get a very dense temporary 'fill' in the resorption with calcium hydroxide, the apical 2 mm was obturated with gutta percha. The mid-root was filled with calcium hydroxide using a fair amount of pressure (which would cause massive extrusion if an apical gutta percha stop were not there). Note how this allowed the calcium hydroxide to completely fill the defect so we could feel confident that all residual clastic cells and tissue were being destroyed. After one month, the calcium hydroxide was removed, and BC Root Repair Material (Brasseler's version of white MTA in a putty form) completely obturated the defect. Thinking outside of the box allowed for a unique approach and great outcome for this patient.
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ENDODONTICS AND IMPLANT DENTISTRY: Here is an interesting case of endodontics and implant dentistry working hand in hand (the sequence of treatment timeline is from left to right). This patient was diangosed with a symptomatic pulpitis #2 and non-restorable #3 simultaneously. This patient was informed pre-extraction of #3 that a conventional sinus augmentation could be necessary to allow for adequate bone volume for a dental implant. This patient was unwilling to pursue this procedure. After conventional endodontic therapy on #2 and extraction/site preservation of site #3 was done. A CBCT was taken to deterimine that we were able to use a standard sized implant angled in such a manner to follow the palatal root socket of site #3. In this way, the patient was able to get her dental implant without sinus augmentation. This case could not be possible without the aid of the CBCT!
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