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.
