Saving the lost..... - Courtesy ROOTS

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From: C John Munce
To: ROOTS
Sent: Tuesday, February 22, 2005 1:33 AM
Subject: [roots] Saving the Lost.......

75 year old woman with interesting story.  As a young woman, she was shot in the head by her husband,
depressed after returning from military duty in Guadal Canal.  He then shot himself to death.
She survived.  Son, 5 years old at the time, now says "mother is schizophrenic."  Anyway, she
presented for eval of #30--treat or extract?  #31 will be extracted as there is no opposing
dentition.  #30 probes WNL, though there is ~1+ furcal defect; mobility is 1/2; pain prevents sleep.
Pt wants to keep natural tooth; not open to implant option.  Radiographs are not very encouraging
though...... Interestingly, many times the first impressions of these cases are overly bleak, and on
exploratory access, they begin to look better--more salvageable--than they did on first blush.
Such was the case here.  After caries removal, although the B furca was slightly exposed, turns out
that there was adequate supra-crestal structure for 360 degrees of crown margin. Used non-bonded
composite donut to both isolate and to serve as a "keeper" for my 8A clamp which was quite weakly
retained, but after the donut, wasn't going anywhere.....  Anyway, after spending most of the
morning on her, she called the following day to announce that she had elected to have the tooth
extracted;-(.....  A call to her primary and to her son, and she was back in my chair yesterday for
another sorta lengthy visit.  Hardly opens her mouth.......  Hoping she'll
remain on the lithium until I'm done......;-).

Image 1--Pre-Tx radiograph
Image 2--Weakly-retained 8A clamp
Image 3--Injecting non-bonded composite donut 360 degrees after troughing gingiva with HS tapered
         diamond (Viscostat required....)
Image 4--Donut complete (clamp rock solid; no leakage)
Image 5--Contouring the inside of the donut to serve as matrix barrier for bonded pre-endo build-up
Image 6--Deep exploration into both M & D roots produces 4 canals just shy of mid-root depth
Image 7--MB canal is not negotiable, so will use File Stiffening to drive files to terminus in MB;
         hence the non-shrouded file in the MB
Image 8--Internal matrix barriers to project all canals to occlusal surface of the pre-endo build-up
Image 9--Build-up flattened for endo reference points; internal matrix barriers then removed; RCT to
         proceed at later visit(s)
cjm.



Hey CJM,

Love your work, dude. I guess it better be good if you’re hanging around Pannkuk’s and Buchanan’s
neighborhood. Its always a pleasure seeing your cases. Very nice shapes - especially.

I do have one question about canal projectors and furca accessories.  Most research has shown that
furca accessories are frequently present in molars: Here’s one example:

Incidence of patent furcal accessory canals in permanent molars of a Turkish population.
Int Endod J. 2003 Aug;36(8):515-9
Haznedaroglu F, Ersev H, Odabasi H, Yetkin G, Batur B, Asci S, Issever H.

Department of Endodontics, Faculty of Dentistry, Istanbul University, Istanbul, Turkey.

RESULTS: Patent furcal accessory canals were detected in 24% of maxillary first molars, 16% of
maxillary second molars, 24% of mandibular first molars, and 20% of mandibular second molars.
No statistically significant differences were found between the tooth types. CONCLUSIONS: In a
Turkish population, the incidence of patent furcal accessory canals on the pulp chamber floor
of maxillary and mandibular first and second molars ranged between 16 and 24%.

(I LOVE anatomy studies. At least with those there is NO technique variable to mess up the
research. It’s either there or it isn’t!)

By placing the projectors in early (by that I mean placing the material in the rest of the chamber
before you do your clean and shape of the canals) don’t you eliminate contact time of the
irrigation solution with these critical furcal areas?  I’m not asking just to be a wise guy,
I’d just like to know what you have to say about that problem. - Rob

Rob--The study by Haznedaroglu and colleagues stands at this end of a long line of studies showing
that the system is permeable at all levels (Burch & Hulen, Guttman, Vertucci, Luglie, Hansson....).
Your point about needing to ensure that the tiny exits coming off the floor get adequate irrigation
time is an important one and well-taken.  In a practical sense though, of course we're not using
instruments in these tiny exits--we're just relying on the passive "digestive" effect of the
irrigant(s) to "float" tissue out of these exits.  At least in the canals, we get the action of
files moving in and out of the canals creating some turbulence and "sucking" stuff from the
laterals.  In the end, it's only degrees of "clean" that we get though--even in the canals.  It's
never completely clean.  That said, cleaner is better than not so clean, but at what point is it
clean enough?  With regard to the floor, it presents a particularly complex challenge b/c it can
conduct pathogens directly into the furcation--a far more pesky problem than pathogens at the
primary canal exits.  Not very much time needs to pass with an unsealed floor and a robust
bacterial soup in the chamber, and you've got a blown furcation that may not resolve....  The same
bacteria at the root ends are routinely managed with good endo--it takes much more than that to fix
a blown furca, if it's even fixable....  So, I think some irrigant time on the floor is good--
perhaps even necessary.  But in the end, if we eradicate "some" of the bacteria from the furcal
exits, only to allow them to re-group b/c we've left them a habitat, then what have we achieved?
So when I advocate sealing the floor early, I mean generally sometime prior to the end of definitive
endo therapy.  More specifically, I generally mean by the end of the first treatment visit (if there
will be more than one visit)(You can get in a lot of irrigation time under that protocol....;-).
This robs bacteria of their habitat, and prevents other inflammatory byproducts from passing
into this delicate region....  cjm.

Completed the MB & ML canals on Thurs.  The MB was very calcified.  Used file stiffening to bypass,
but with pt's limited opening, it was tedious, so couldn't get to D canals yet.  When done with Ds,
will bond post through pre-endo build-up. Shaping done by hand with FlexR files and GGs blended with
Hedstroms.  Warm downpack, interfacer-tipped single cone warm backpack, composite bonded directly
over the backpacked GP from ~cervical level to cavo-surface of the projected canals......
(Patient survived--so far.........;-).  Re-attached the original image block along with new
radiographs from Thursday.  cjm.



C John, this is an amzing case
what do you mean by "GGs blended with hedstroms"? Maybe you have already explained this here,
but certainly I can't remember - Marcos Arenal

JL--I use #2-6 GGs--in that order--in the coronal part of the canal, FlexR
files to create apical shape and gage the diameter of the exit, and
hedstroms to blend the FlexR work with the GG work.  Since I use the GGs in
a smaller-to-larger sequence, I go back to the #2 to complete the GG work
b/c that helps to eliminate the dimensional "steps" that otherwise show up
on the walls when you use GGs smaller-to-larger (if you use GGs in a
crown-down manner, you get less of the "step" effect, but I don't prefer
crown-down).  I use the hedstroms to create shape no closer to the canal
exit than 1mm (usually more like 1.5mm), and they blend the apical portion
of the canal prep to the GG portion.  This protocol also eliminates the wine
bottle effect that can occur with GGs.  Some might consider this to be
fossilized endodontics, but it eliminates separated-instrument-anxietitis
and creates great shapes.....  (BTW--Thanks for the compliment :-)).  cjm.