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Case with a Metallic buildup and crown- Courtesy ROOTS
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From: Sergiu Nicola
To: ROOTS
Sent: Sunday, April 29, 2007 2:37 PM
Subject: [roots] is this a bad case assesment?

We have here my first case under micro, a # 19, with a metallic buildup and crown.
the patient is the sister of a refferal , and she kindly asked me to try, if anything can be done.
perioprognosis is ok, pockets less than 4 mm,normal mobility,  bitestick -, chunk slightly positive.

I reached patency on all 4 canals, and from the distals a lot of puss came out.
I placed some calcium hydroxide for a couple of weeks.

Now here is the question :
Should I fill the tooth or should I recommend extraction? - Sergiu Nicola

Thanks for posting and doing a very wonderful job disassembling. Although the preop radiographs look odd, and the final transillumination photo looks interesting, this is a very common site for an isthmus of tissue to be (between the MB ML canals). This is your first case with the microscope I believe and often its overwhelming all the visual information that you are provided. What looks like a crack can actually be tissue in between those two roots (its white and looks like a crack). How were the probings on the mesial....this is something on all retreats that I will do to evaluate whether it is worth it or whether there may be a crack. Next off if it is tissue it wont stain too much with methylene blue (www.vista.com) (Vista Blue) and if it is a crack it will. In addition if you leave it with CaOH for a month then if it is a crack there will be no difference and most often still pus in the canals. You mentioned Pus in the distals but nothing in the mesials. Was there blood in there, or pus or anything between the two mesial canals? My feeling is that if you take a thin, pointed ultrasonic and run it between the two canals back and forth slowly working your way down the root while still looking through the scope that your "crack" may disappear. Why? Well if its tissue between the two roots then with bleach , ultrsonics and irrigation it will disappear. I do this alot to rule out Mid Mesial canals so I will always trough out the white lines....more room for the bleach to get in there. If the patients pain does subside (you can change the CaOH every month for 2-3 months) and you start to get bone fill on the radiographs after you remove the tissue then you know that you have a chance. I think that you are too quick here to assume that this white line (old tissue) is indeed a crack.......be patient my friend and let us know. I believe it may be just tissue. Hope that helps and again I am glad you learned your lesson , despite your frustration, always reread the post before you hit send, if its not quite right then hold onto it a day or two before you send and re read it. Once you press the button, its not possible to take it back.......(ask me how I know)....Cheers,- Glenn Thanks a lot Glenn. Indeed, i stood like a fool looking into the canals several times, being so amazed of what a scope can do....... i did used a Carr ultrasonic tip, diamond coated, but the crack was continuing at least 4-5 mm into the mesials, looking from the canal aside the walls...... No pus, no blood or whatsoever on mesials indeed. Thanx a lot for the tip, I will continue to dig deeper with ultrasonic tips , and hopefully, to can say next time that you were right - Sergiu Nicola Dear Doc. Can you post Clark survay or at least PA radiograph with BW radiograph after the instrumentation. - Mohammed I don't use to do xrays after instrumentation..... I don't see the sense(can you tell me why should i do that?). anyway, I will post the xray after 3 weeks.thank you. - Sergiu Nicola Dear Sergiu, I am 100% sure that what you see in there is NO CRACK but only an isthmus between the two mesial canals. With the scope you will see them every day. You can through it and sometimes find the MM canal (don't through too much as you can perf into the furcation) ! Also you will see it disapears after throughing and bleaching as Glenn already said. Don't worry, no need to extract, you will probably save this tooth the way you are working ! Very nice documentation, keep it up - Thomas Thomas...your point about the perforation is something that should not be overlooked ( I did). Sergiu, dont use a Carr tip too far down the root. I assume you are using the Killer tip (round) or the pear one. I would use a pointed tip when you trough this out. That way you stay very conservative and if you do error stay away from the furca working towards the mesial because if the root is fluted you will perf through the side of the mesial root, especially with the wider Carr tip. Thomas as usual made an excellent point, make sure that you trough and leave bleach in there as you are working away. I will be surprised if this is not tissue but a crack. All the best.......and again great point Thomas...thanks - Glenn Agreed. And to go one step further, my standard protocol is to trough the isthmus between mb and ml canals of lower molars on every case. You might be surprised what you occasionally find in there. Excellent points all around here guys, and the topic was endo related. I am euphoric!!!!!! Glenn, when you get a chance, I need an update on what settings for the video camera (hd) you have found useful. - Gary Thanks guys. how I instrumented the isthmus: first I used a miss pear carr tip, then i used some small carr tip, but I didn'nt wanted to insist becouse the "crack" or whatever was continuing apically, too bad that i am not yet used to make better pics. Ahmad and all others who instantly killed my rudeness. When you do a lot of hard, hopeless cases, don't you get nervous??????? - Sergiu Nicola Sergiu, The only "hard hopeless" cases I do are thoroughly discussed beforehand, and require a certain kind of patient, with an understanding and commitment and appreciation for the task at hand. If I am able to achieve these educational goals, then I will be comfortable regardless of the outcome of our heroic adventure. In many ways I enjoy these cases, as long as they are done on my(our) terms as described previously----we go in "with nothing to lose". And yes, sometimes I will only do these for a higher fee, or I may decide to do such a case for any number of reasons, realizing it will simply not be financially profitable. I'm willing to do some cases that are not financially rewarding, as long as there are other rewards in store for the patient and myself. I hope this made some sense, - KendelG Sergiu: I really didn't mean to sound almighty and reverence toward your initial post. but I am glad you hung around and realized when we aren't face to face a lot of things can be misconstrued. I always have some "butterflies" in my stomach when I start treating a case. I don't cruise on auto pilot, No case is routine, until you are done and look at your post operative results....only then it becomes routine. These tough non precious metals are impossible to remove. I have treated several patients from Japan with crowns and posts similar to yours....and they keep referring their friends..))) Start with an iron clad diagnosis........take at least 3 pictures of the PA region and at least one vertical BW. Joey D takes about 10-12 x-rays.....It is always easier to explain the necessity of these x-rays before hand than trying making excuses for a poor result later on. Probe the tooth. Thermal test, Electrical pulp test, percussion and other tests you think are necessary.....Tooth sleuth for example.......... peel the ginigival tissue gently back and look around the tooth for fracture lines under scope..I am sure you did all of this, but we don't know since you didn;t tell us.....For example if the probing depths were normal in mesial and there was no sinus tract, the probablitu of a fracture is remote.....In the tooth you posted that line is probably an isthmus connector ( as Glenn pointed out ) Bleach, ult sonic and deliberate picking in to this area can clear it. It is is bleeding, then it is bad news. Once you are done , then dissambly can be hard or can be easy. If you have ever watched any of Dr. Ruddle's videos, there is a tremendous amount of informnation and pointers you pick up about taking teeth apart. Also, get Glenn's videos and review it to get beter acquainted with the scope. Good luck. ...hope this wasn't condescending...don't want to wake up the dinosaurs. - ahmad