The opinions within this web page are not ours.Authors have been credited for the individual posts where they are - photographs courtesy: Glenn A van As

From: "Dr. Glenn A. van As"
To: "ROOTS"
Sent: Saturday, November 19, 2005 10:16 AM
Subject: [roots] Replacing the crown

My endo is not up to what many here show but I try. Today I finished a case on a great lady . She was in CaOH for several months because she blew a disc out in her back and is awaiting surgery......

She managed (with alot of narcotics) to lie in the chair so I could finish this tooth.

I wanted to replace the crown on this tooth which is fractured on the DL corner but the mesials were short and there was a lesion. I decided to retreat the tooth myself (maybe not a great decision but a decision all the same).

In the first visit , I found the MB, and ML canals, bypassed a separated file in the MB canal, and found a second distal canal. I didnt get the post out so that is where the fun started today.

I first used a diamond bur to trough around the post which was angled to the lingual, and then used a Carr tip (long thin one) to trough around the tip to gain access to it. I got it a little loose (took 30mins) and then used the Ruddle (I think its the Gonon Post removal system). I tried with a 5 post drill first (too big) then the three .....which was just right. I got the post out with just hand torsion on the post......never be afraid to try this early on (next time I wont try 30 mins of Ultrasonic).

I then noticed something in the MB canal.......darn it all , part of the post got lodged in the MB canal when I took it out....

Utrasonic some more and its in the floor of the tooth, no one breathes and I can just get some very tiny pliers on it too remove it. I couldnt gain patency in the DB, shes getting tired so I packed the case (its healing quite well after the first appointment and is asymptomatic). I wasnt overly pleased with the final result (no puffs) but I did make a big difference in the fills on the Mesial as they are much longer now.

Here are the photos shot with the Xmount, and in addition the Nikon D2X which is on right now because I have my D70 in for repair.....

Its one of the first cases I have done in a while because my associate is doing most of the endo (he just got accepted for next year to Temple Endo program .....I am proud of him but sad he is leaving) and so I put it up for you to criticize.

Again its far from perfect but given the toughness of the case , post removal 2x, then bypassing a file, and working quickly while she tired, I was happy. Next off I will take off the crown and determine if a post is even needed-Glenn

Tough case Glenn................very nice documentation too.

Just a small query.............Do you feel there is a discontinuity in the fill in one of the mesials..............is it because of the bypass?? And is there a file fragment beyond the apex ( looks quite radiopaque and jagged) ? - Sachin

Great question Sachin.......I didnt feel anything or see anything but it does look that way. I may have gotten the tip slightly bent during the fill. The case was extremely difficult for me as mentioned not only technically but because the patient really was uncomfortable with her back. Thanks for the questions - Glenn

Glenn, Very tough case, handled very well, I love the result. I bet the radiolucency will resolve, thanks to the fact that you were able to bypass the sep fragment.

One remark: why didn't you seal the orifices and the pulp floor with an adhesive layer of composite, or even better, close the access opening with composite? - Marga

I am going to see the patient next week to take off the crown and rebuild the tooth. In putting adhesive on the floor I was worried about blocking a pathway for a post or the MB , ML canals for getting better retention. I hate drilling it all out if its so fragile under there that a post is needed (my suspicion is that it is).

Ordinarily I would leave the case with the orifices sealed but in this case without knowing what I need to do to build the tooth up I thought better of it.

I appreciate the kind words Marga, I tell you it was a tough case for me, I am not 100% happy as mentioned to Sachin with the result but thought it was a good one to show Roots for the post removal and for the manner in which I at least got down the mesials better . In addition I think that the healing has already started on the tooth.......

Interesting in that there was no lesion on the distal root even with the extra canal that was missed.

PS the bigger photos are very good........here are two - Glenn

No offense but I believe..Photo 4 demonstrates the tip of a 557 cross cut fissure bur or something of the like......not a piece of parapost......just MHO......Craig

Dear Glenn, How do you manage the pt with broken back, I have a pt who has spinal column denegation, it is had to him to walk and sit on my Dental chair. - Raghu

Patient has a herniated disc........Patient took tons of strong painkillers (not for tooth but for back) including Oxycodone Patient said best position was completely horizontal (not ideal for lower molar with the scope) so I placed her in that position. Our chair for the patient is a Midmark chair (not ideal for scope) but very soft. Hope that helps.....disc herniated was L5......I think. - Glenn

Hi Kendo.....as mentioned to Marga.....no flowable at all in this case as it must be rebuilt and no fun cutting the flowable out (not easy even with the scope) and it doesnt matter if its purple, white, black, or polka dotted if you gotta rebuild the tooth. Given time constraints I was just happy getting it done - Glenn