Could have been a nice case : Irreversible pulpitis : gingivectomy
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From: Marga Ree
Sent: Saturday, August 19, 2006 7:59 PM
Subject: [roots] Could have been a nice case.....:-(
Irreversible pulpitis in tooth 28, due to caries profunda.
New 3 unit bridge was indicated, so I cut through the
bridge distal of tooth 26, removed the dummy and the crown
on 28, did a gingivectomy, removed caries, and started
the endo. All 3 canals were extremely curved, so I was
cautious, and did a lot of hand filing before introducing
taper 02 rotaries, which I like to use for these type of
very curved canals, and usually are very safe, because of
their flexibility. I thought it was doable with rotaries,
but it wasn't......:-( , at least not in my hands....:-(
Useless to say that I didn't do an attempt to remove this
one...:-)) Since it was a vital case, so it will highly
likely not compromise the outcome. - Marga
Thank you for posting yet another excellent case. In my
opinion, the severe abrupt curvature (almost recurvature)
of the DB canal in this tooth would probably defy most
rotary file designs! Therefore, (rotary) file fracture is
always a (high) possibility in such situations.
I agree with all your statements here. - Marga
You are correct to state that prognosis will most likely
not be affected in this case...especially because it
occurred under very controlled conditions, in your very
skilled hands, and of course, in a vital tooth.
I have enjoyed reading your paper on instrument fracture
and outcome of treatment, I agree with Ben, a very nice
study. It must have been a lot of work, to collect all
those data!!- Marga
Incidentally, up to what hand file size did you prepare a
glide path in the DB canal before introducing the
# 20 - Marga
Did you use a 15/02 rotary before the 20/02?
Yes - Marga
I too would spend quite some time with small hand files,
from size 6 to hopefully size 15 (if possible) in such
cases. I would get each of these files as 'loose' as I
can before introducing rotaries. So, assuming rotaries could
negotiate such an abrupt apical curvature, then my rotary
sequence after hand filing would be ProTaper S1, S2, then
ProFile 25/02 (but perhaps ProFile 20/02 first, if the 25/02
did not want to get to length easily), and...yes, I
would also try and get a ProFile 30/02, or even a ProFile
25/04, or larger .04 taper file if the canal allowed this
(probably wishful thinking though...:-)). As you can see,
I feel that .02 taper ProFile files seem to negotiate such
curvatures well in my hands. I have not had any experience
with K3 .02 rotaries.
I have the sizes #15-40 in K3 taper 02 in my set-up. My file
sequence in these kind of cases: Gates #(4), 3, 2 till
resistance, K3 shaper 12, 10 and 8 to resistance, sometimes
I repeat this sequence in a later stage of the instrumentation,
dependent on the canal shape.
Establish a glide path with handfile # 15 or #20
(K3#35/02T) not always, dependent on the canal shape
If I have problems to get an 25/04 or 30/04 taper to length,
or I notice that there is significant resistance to cutting,
then I throw in more 02 tapers. Usually I introduce a taper
04 in the taper 02 sequence, with a tip diameter that is 2
sizes smaller that the last used 02, e.g, when I have gotten
a 25/02 to length, my next file is a 15/04, etc.
I have learned this sequence from Bill Watson, and it is
(usually...:-)) a very safe way of instrumentation. In this
case, I finished with 30/04 files in the MB and PAL canal
By the way, If I could not get any rotaries around the
curvature, then I would instrument the canal with rotaries TO
the most apical level that they would freely go, and then
finish beyond this level with 'appropriately' sized
Yes - Marga
Finally, one further question: could you attribute the
fracture of your K3 file to anything in particular, e.g.,
torsional failure, flexural fatigue, file used more than
once before this case, difficult/restricted access during
instrumentation, etc?- Peter
I think overconfidence of the operator....:-) Yes - Marga
Hi Marga, Thanks for your prompt response to my message.
In particular, I appreciate your describing your complete
instrumentation technique for such cases. I will certainly
give the 'Bill Watson sequence' a go as soon as I encounter
another similar case. By the way, have you ever attempted
coronal preenlargement (or initial crown-down) with only the
ProTaper shaper files? I find this approach is very efficient
and quick. In my hands, the problem I sometimes experience
with a #20 hand file (usually a Hedstrom file) is that it
can be a bit too stiff, with a high risk of ledging or
transportation for such severe abrupt curvatures. This might
create a problem for the ensuing rotary files (i.e., it might
create a non-smooth glide path). Usually, if I can get a #15
hand file to length, the ProTapers and subsequent rotary files
(previously described) will get to length when used correctly.
Of course, all my rotaries are single-use in such cases.
Incidentally, your comment: I think overconfidence of the operator....:-)
is definitely not the reason for file separation. I feel the
reason was simply bad luck in this case. And, as I mentioned
in the previous post, this case will still be a resounding
success! (Thanks for your kind acknowledgment of my paper:-)).
Marga, you are far too great an operator who has every right
to be confident (or overconfident) in your brilliant work.
I, like many others, absolutely adore your fantastic posts on
this forum. Overconfidence should not be the cause instrument
fracture in the hands of truly adept clinicians such as yourself
...however, it might be yet another possible reason for failure
in the hands of incompetent or disinterested clinicians who
are not willing to take the time to learn novel (or alternative)
instrumentation sequences for complex cases;-)) - Peter
Ravinder Sharma 10:01pm Aug 10, 2013 in Dental surgeons of
India, Facebook grouo No dear it can be done with copper amalgam
OK just try it will give u best results
Dr.ravi Kumar 11:39pm Aug 10, 2013 in Dental surgeons of India,
Facebook grouo Nice case