From: Rafaël Michiels
To: ROOTS
Sent: Thursday, September 10, 2009 3:08 AM
Subject: [roots] This case made me sleep badly.

This was yesterday's last patiënt.
A 2 visit treatment of a 4.6.
4 canals.
Lots of NaOCl
EDTA final rinse
PUI
Cone pumping
Shaping with hybrid technique Protaper-Profile.
Obturation: warm vertical compaction. I had excellent tug back, everything fitted perfect.
Patient was asymptomatic between the two visits.
When I was finished, I was hoping to see a nice RCT. But what I saw was an incredible overextension of sealer,
straigth to the lower alveolar nerve.
The patient did not feel anything when I obturated.
Today I called him: no paralysis, no pain, nothing. I'm relieved for now. I'll follow him up in one year - Rafaël




That is a nice case.  You worry too much.  Thin long streams of sealer like that probably represent flow of least
resistance into a nutrient canal and are innocuous.  We all get those.  Mandibular nerve problems occur when you
aggressively blow out an apex, iatrogenically create a ripped path to the mandibular canal, then push gross amount
of material into the pre-ripped path.

Your case looks much to "artfully" handled and meticulous to have warranted any concern even after seeing the sealer
stream.   No need for sleep disturbance.   Beautiful result! - Terry

Terry put it nicely...  (with this writing skill, Terry, you ought to right books :-)), always a pleasure to read...
well, i guess if get Rob's rants and John Khademi's irony back here on list it would just heaven on earth :-)))   )
-  Dmitri

Terry, I respectfully disagree because, if I understand your remarks correctly, you imply that a path must be
iatrogenically created in order for damage to occur to the bundle from diffusion of sealer such as this.

Fact is that the IAN is covered by a cribiform plate of cancellous bone which can allow passage of materials
through it to the neurovascular bundle. It is not an impenetrable continuous tube of cortical bone that must
be perforated before damage can occur. I cannot understand how one can look at a radiographic image and correctly
deduce from the sealer stream seen whether or not it represents something potentially negative.

The attached photo comes from the Tilotta-Yasukawa et al article. It is a longitudinal section through the
mandible over the bone covering the IAN - Craig



Craig, You are certainly allowed to disagree, but I'm primarily considering clinically realistic risks when prudent
care is delivered.  The liklihood that someone is going to damage a nerve with a meticulously controlled technique
that has not been compromised by iatrogenic heavy-handedness is virtually zero and for clincal purposes of
practicality should be considered zero.

It just doesn't happen and most clinicians who are properly trained to treat cases with patency and obturate
completely are well aware of that.

There seems to be an assoication with butchered apices, butchered nerves, gross overfills, and paresthesia.

Although it's harder to observe and associate, I theoretically believe that those clinicians who inject manibular
and lingual nerves like they are harpooning Moby Dick probably have more paresthesia incidents as well.

Association is not causation, but consider the following:

1. Permanent paresthesias are very rare.
2. Reported case histories almost universally show gross overfills and apical mismanagement.
3. Do you really think you can hydraulically push enough material through a naturally occuring nutrient canal
   into the a large mandibular nerve to cause damage unless you are squirting or using a System A technique? :):):)

-  Terry

Hi Raf, Nice shot! By the way isn't there a cortical bone around the V3? If so I guess that as long as we don't
perforate it with files we shouldn't worry too much...do u agree? - Amir

Rafael, you call THIS incredible overextension??? C'mon... :-)))  Sure you have seen pics of what Sargenti people
do with their paste and lentulos - now THAT is scary... :-(

rafel if it bothers u so much just get denta scan done, what was the sealer? and imho its not in  the canal but
its n the  bony trabacula  because the y that is  forming is an indiacatot that  the angle of branching is very
acute and if it was a canal it wold have given a tube  like  appearance and the  branching would had  been if
there within the canal space that is why it would have been rounded and since patient is symptom less why bother ,
still for ur self and if patient is alarmed get a c t scan done - gurpreet

No need to lose your sleep over it... The only thing i would do differently in this case (if i had done this) -
get some cold beer in the evening :-) - Dmitri

Hi, I wouldn't lose any sleep over it neither. As already stated, the sealer probably follows the trabeculae or
feeding vessel. The nerve is still quite isolated from all our nasty endo-products. :)  I added a radiograph of mine
that shows a similar pattern... Patient had no complaints after treatment too - Nikolaas Dewilde



Dear Raf, This is not at all a problem (also had a case like this). This is probably plastination of the feeding
blood vessel. It's like the guy from the Körperwelte-exhibition is doing. Although he uses cadavres ;-) - Bart

Still Watson would say Poor apical control.  And he’d be right but this happens to anyone doing endodontics.
I’ve still got the record that has been posted.  He’s doing fine.  Was at a course being given by Dan Fischer
and he showed that slide of me blowing out about have a tube of EndoRez into the IAN canal and bone.
The problem was he gave credit to two dental students.  I demanded that credit be given where credit is due so
in the future, Dan will give a 65 yo dentist with 44 years of dental experience the credit for that screw up.
Your case will be fine - Guy