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From: Marga Ree
Sent: Monday, March 12, 2007 3:10 PM
Subject: [roots] Dental wreck-1
This 40 year old male came to our practice in July 2005. He had pain all
over his mouth, multiple swellings, bad breath, a lot of decay and lousy
fillings. He wanted his teeth to be nice and healthy.
I started with tooth 46, which caused the patient a lot of pain and
discomfort, you can see a huge swelling and a pocket of + 10 mm.
First session consisted of cleaning, shaping and tons of ultrasonically
delivered irrigation fluids. Then I packed Ca(OH)2 for a month, and
on return, the swelling and pocket had completely disappeared.
As you can see, in the meantime, he went to our oral hygienist, and his
fillings were replaced. There was already a world of difference after
just treating tooth 46 and some professional cleaning by our oral hygienist.
After filling the 4 canals, you can see some puffs in the furcation area,
as well as an anastomosis between the 2 mesials in the apical third on
the angled rads. As usual, I did the BU myself, and placed a fiber post
in one of the distals.
Next tooth was 45. His previous dentist was a thermafil user, and this
was a classic thermafil filling in an underprepared canal. I checked
the probings before treatment, but they were insignificant.........
After having removed the crown and the thermafil filling, I found out
that there was a huge fracture on the distal........., after taking
off the rubber dam, I probed again, and there it was.........+10 mm
Lesson to be learned: never probe without local anesthesia when you
suspect a root fracture...............
Tooth 27 showed a swelling and a sinus tract. I am not proud on this
one, because in the final stage, when I was done with C&S,
I fractured a rotary instrument in the apical third of MB1. Dammit!
What do they say? The enemy of good is better.....
Why didn't I stop one file earlier.....:-))
I didn't even an attempt to remove it, but I could bypass it with
hand files. I informed the patient that surgery may be needed in the
future, but that we would evaluate the result after 1 year and then
take a decision.
The sinus tract was gone after a couple of weeks of Ca(OH)2,
so I decided to fill
Again a Thermafil case, with obviously a missed canal. The removal
of the thermafil carriers I will explain in more detail in the next post.
I wanted to show you how I make a BU when there is not so much tooth
structure left. First of all I try not to remove extra tooth structure
to make room for the post, I try to accomodate the post in the availabe
space. There are a lot of posts out there, and there is always a post
that will fit, because manufacturers provide them nowadays also
in small sizes. This a a very important principle: passive placement
of the post.
Removing dentin to accomodate a post is one of the reasons that posts
have got a bad name in the past. In my opinion, there is no downside
to placing a fiber post, provided you leave the remaining dentine alone.
The posts I frequently use are: Whaledent fiber lux posts and FibreKleer
by Pentron when I deal with parallel post spaces. I use the tapered
FibreKleer or DT light post of RTD when dealing with tapered post
spaces Advantage of these tapered posts is that you can cut them
either at the coronal end or at the apical end to adjust the size.
I use the same composite to cement the post and to make the build-up,
this gives me one material in which the post is embedded.
I prefer a self cure version of BU material, although I frequently
also use dual cure materials. The reason for me to prefer a self-cure,
is because their relatively slow-setting rate are thought to provide
flow to relieve the shrinkage stress developed during setting.
I like to clamp the distal tooth, that gives you more freedom to
manipulate the matrix band. I these cases I like to use a core build-up
of Kuraray, cut the upper part away with a scalpel, and turn it upside
down, insert it in the sulcus, so that the smallest diameter is at the
cervical part of the tooth that has to be restored, and the widest
part is going to be at the occlusal surface. This gives you a kind
of a tooth model. A wedge is usually not necessary, and dont bother
with the weird form after you have removed the form, you can easily
adjust the shape with a diamond and finishing burs. I don't mind
if a don't have a contact point. Usually it is better to have
no contact point at all than a loose contact point, it is only
a temporary restoration.
In this case, I placed 2 tapered posts. The pictures show the try-in
of posts after finishing the canal filling, acid etch, prime and bond,
cementation of posts, application of plastic core form of Kuraray,
build-up of Build-it, adjusting shape of build-up with diamonds
and rubber points - Marga
Tooth no 23, straightforward case, nothing to be mentioned
The last case, tooth 15, thermafil removal:
I used the technique with hedstrom files and a hemostat, nicely
described by Steve Buchanan, you can find this technique on his
website, see: http://www.endobuchanan.com/technques/index.html
Thread a 21 mm #15 Hedstrom file through the softened apical
gutta percha between the carrier and the canal wall until tight.
Clip a curved hemostat to the Hedstrom file shank just below its
handle and rock the hemostat onto the mesial adjacent tooth and
lever the Hedstrom file out as if using a crowbar. The physical
leverage is remarkable and most often the carrier will be
launched out of the canal.
I don't use a # 15, but try to thread a # 25 or 30 between the
carrier and the canal wall. This technique can also be used for
removing silver points.
After removing the carrier, I could not figure out immediately
what the canal configuration was, but after finishing the C&S,
I went back in with a precurved hand file, and found a second POE.
Fiber post and build-up of composite.
Final phase, the 1 year follow-up. I think the pics speak for
themselves. Patient is completely symptomfree. The periodontal
status had improved tremendously, thanks to our oral hygienist
and efforts by the patient. The resorative work was done by my
husband, do you agree he is my best RD?? ........:-))
This is why we love to be dentists, isn't it? - Marga