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Renovo Endodontic Studio
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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 h...alt 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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UNUSUAL PRESENTATION OF A ROOT FRACTURE -
Many dentists are aware of the classic signs of a vertical root fracture such as (1) pain on biting/release (2) a "J-shape" radiolucency, or (3) focal deep periodontal probings. These signs and symptoms typically occur due to a coronal crack that extends apically. This case represents none of the classic hallmarks. Due to the large threaded post and a slight thin defect on the palatal root apex noted on CBCT, there was some suspicion of a possible root fracture, but the suspicion was relatively low given that there was solid crestal bone around the entire coronal 1/2 of the root. Below you will see an unusual circumstance where the root fracture actually started at the apex and was migrating coronally, thereby explaining solid crestal bone without focal periodontal probings or a "J-shape" radiolucency despite a root fracture. Without a high powered microscope, diagnosis would have been impossible as this fracture was on the palatal surface of the palatal root and access for an apicoectomy was done on the buccal. An implant would have been ideal in this situation, but the patient elected to pursue FPD.
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COMBINED NON-SURGICAL AND SURGICAL ENDODONTIC CASES: Is this tooth treatable? Is it saveable? Is it even worth trying? Here we present a case where the tooth was supposedly treated endodontically years ago. We suspect that a pulptomy was done at the time of initial treatment. Pulpotomys are usually reserved for immature teeth to save healthy pulp tissue within the roots to encourage continued root development. Often times the root canal space gets obliterated in the process as a protective mechanism to insulate the pulp from further "trauma". This may become a problem later when the endodontic treatment has to be completed years later, where calcification can block of the canals from being cleansed and shaped to the root terminus. This is the case here, partiularly on the mesial root. Additionally, the lesion associated with the distal root leaves open the possibility of root fracture (none was identified pre-operatively nor intra-operatively). We treated this case both non-surgically with conventional endodontic treatment and surgically. We were unable to negotiate the mesial canals to full length (even though it may appear on several radiographs that this may be possible). Because there is a lesion associated with the mesial root, we know that it will not heal. Should there not be a lesion, we would monitor over time. The decision was made to complete apical surgery of the mesial root. With the combination of non-surgical and surgical endodontic treatment, we are able to provide this patient with a favorable long term prognosis assuming adequate coronal restoration. Happy Monday!
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MINIMALLY INVASIVE ENDODONTICS/RESTORATIVE DENTISTRY? The purpose of this case is to demonstrate "minimally invasive" tooth access as it pertains to endodontics and subsequent restorative dentistry. Although we can't really say that having significant decay on the crown of a tooth would classify as "minmally invasive", there are rarely cases that we come cross that would qualify. In any case, this tooth represents a 5 canaled anatomical presentation. That in itself is pretty ...interesting (although also very common). What we have done here is purposefully left a portion of the pulp chamber unroofed (see red arrow). Access to the mesial canals was already straight and accessible and we did not feel the need to enlarge the access in order to remove the pulp tissue from the mesial pulp horns. In order to save healthy tooth strucutre, we used ultrasonic instrumentation (with curved tips) in order to ensure that the pulp tissue was removed from this space. As evidenced in the clinical photo, we are able to conserve as much healthy tooth structure as possible. This makes the restorative dentists VERY happy!
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Accessory canals causing atypical lesion location: This is a case that was referred to our office for endodontic evaluation and treatment of a buccal sinus tract. The patient reported that he was not in any pain but had a "pimple" in the gums next to the tooth on the lip side. The sinsus tract was traced and was directed to the coronal root lesion on the mesial aspect of the canine tooth (#11). There was no evidence of periapical pathology. After endodontic treatment was rendered, we were able to to demonstrate a sealer trace out of an infected accessory canal and into the lesion (see red arrows). Over time we expect this patient's body to resorb the extruded sealer which is biocompatible and the pimple to resolve with complete bony healing...pretty cool..
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RIDGE AUGMENTATION: This patient was referred to our office for a dental implant in the mandibular edentulous area. Upon initial radiographic survey and clinical exam, it would appear that there would be plenty of bone for the eventual dental implant. However, once the CBCT was taken, one can see that although there is enough vertical height of bone, the width would become an issue as there was significant bone atrophy from years of missing the tooth. In this particular case,... the clincial exam made it appear that ther would be enough width of bone. It turned out that the majority of that ridge thickness was soft tissue rather than hard tissue. The decison was made to perform a selective ridge augmentation procedure to enhance the bone thickness so that a dental implant could be placed. Localized soft tissue flap reflection was done, the cortical plate perforated and particulate cortical bone grafting was placed. The procedure was finished with a resorbable membrane and Vicryl sutures. We anticipate that the added bone thickness will allow us to place a dental implant of acceptable size to ensure a favorable long term prognosis for the patient....stay tuned for documentation of the next steps of the procedure!
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Facebook Participation - We greatly appreciate those who follow our regular updates about our practices and contribute to the discussion regarding unusual cases. Recently, one such follower took participation to a new level! After seeing many of the cases we post to illustrate the oddities and ability of endodontics to save the natural dentition, they wanted to see what all the hype was about at our new practice in Roscoe Village! Low and behold, five canals in this mandibular molar with the distal root demonstrating a 3:1 anatomy (3 orifices and 1 portal of exit).
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UNIQUE ANATOMICAL PRESENTATIONS IN CONSIDERATION OF APICAL SURGERY: We present here an interesting case. This patient initially presented to us with a history of facial trauma requiring root canal therapy on tooth #9 as a teenager. Years later as an adult, he noted a pimple appearing in the gum tissue above the tooth. Our initial evaluation was a previously treated root canal with a chronic abscess. On the 2D image, however, one would not accurately assess the possibiliy of a... non-restorable root fracture; this tooth has a large post and the radiographic lesion seems to start where the large post ends (at least on 2D imaging). When a CBCT was taken, we were able to discover what appeared to be a some sort of defect on the buccal surface of the apical third of the root. It looked too large to be an accessory canal. Additionally, there was no lesion present at the root terminus. Apicoectomy was performed, the defect identifed, and both the defect and retrofill placed. We were able to hide our surgical inicision along the mucogingival line and along the frenum. At the post-surgical follow-up, the area should look like nobody was even there! Great job all the way around and we are very happy with the result of the case!
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"That's Hopeless! - Get an Implant!"
These words are said all too frequently in modern dentistry. Now that we are gathering more data on implants and learning their limitations, potentially saving guarded teeth becomes even more important. Here's an example of a patient who was told by several dentists that there was no choice but to pull tooth #31 which had grade 3 mobility, deep probings, and a lateral root radiolucency.
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FRACTURED TOOTH? OR IS IT?: This case presented to us 6 months ago with concern of a fractured tooth (note the periradicular lesion associated with distal root...the so called J-Shaped lesion). This tooth also exhibited deep periodontal probing. Radiographic survey and clinical exam would be suggestive to a strong possibility of non-restorable fracture. However, we were unable to definitively identify one on CBCT and the patient was highly motivated to try and save the tooth. Low and behold, 6 months later the distal root lesion has completely resolved. We are still keeping an eye on the mesial root as it possesses a smaller lesion, but not completely resolved. Pretty cool....
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