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Root Canal

Portfolio Case 1

Patient:
Age 52, female, no medical issues declared

Background Info
My principal referred with a request to complete endodontic treatment of the upper right 3. An attempt had been made to gain access to the canal system but no canals had been found. My principal then stopped and referred to me, as she did not want to perforate and knew the risks of locating a canal when under a bridge. There was a cavit temporary placed in the access preparation. The tooth had been giving bouts of intermittent dull pain over the past few weeks. The tooth was part of a bridge that was from 5-3 with 5 being an ossiointegrated implant. The radiograph was noted as grade 2.

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Visit 1 (90 mins)

The initial consultation was completed, dental exam and specific exam including radiograph to show angulation of root under the bridge and to show any pathology. Nothing significant was noted except that is not common practice to have a root / implant retained bridge. The 13 was slightly TTP and reacted possitvely to endofrost . After discussing options a working diagnosis of chronic irreversible pulpitis was made. A success estimate was given of 80% chance of 10 year survival assuming that no fractures were found and that the patient went on to have a full coronal restoration placed with associated post and core. It was explained that we would section the bridge and let the 15 14 act as a cantilever bridge while fully restoring the 3 with a post and core…depending what we found on removal of the crown.

Full verbal and written consent was gained and local anaesthesia was achieved and rubber dam placed. 2.5 x loupes were used after initial dam placement.

Access was obtained removing the dressing and using the diagnostic radiograph the nerve canal was found. The internals of the access chamber were checked for caries, perforations and fractures. Caries could be seen and the patient was advised. This was subsequently removed with a small high speed round head burr.

Working length was found with a size 15 K-file, post slight coronal flaring and irrigation, as the apex locator was not functioning due to the bridgework and contents of the abutment. It was decided that a radiograph would be used for working length. This was calculated to be 19mm as the reading on the file from the radiograph was 19.5mm

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The canal was prepped using the “simply Endo” protocol using Protaper Gold to carry out coronal flaring, prior to finding working length, with the SX file then using S2 F1 and finally F2 to give a 8% taper and an apical working size of just under .25mm. During this time copious amounts of irrigation was carried out with Sodium hypochlorite 3% and water. This was completed until the canal preparation was complete and the irrigant was seen to be clear and without debris.
The canal was then treated with 17% EDTA and then washed with Sodium hypochlorite 3% and dried with paper points.

An S2 was tried to working length and tug back was established as a good obturation length from using the diagnostic radiograph. No cone fit radiograph was taken.

AH+ was used as a sealer and the canal obturated with a single S2 cone. The patient was then asked to wait in the surgery for 15 minutes while the AH Plus set so a post could be prepared and fitted. This was subsequently done and an appointment was made to review the endodontics and to section the bridge and make a new stand-alone crown on the 3.

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Visit 2 (90 mins)

The bridge was sectioned without local anesthesia; the abutment on the 3 removed and a new full coverage ceramic Empress cerec crown was placed to maintain the good aesthetics after minimal preparation.

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Learning outcomes

Ideally a cone fit radiograph is normally taken. This is to show an exact fit.

I was fortunate that the diagnostic radiograph had the size 15 k- file at the apex. This made the calculation of working length a little easier.

Implant / root retained bridges are not normally seen but on this occasion it was seen best to separate the bridge to reduce stresses on the root retained part. The separate crown would have much less stress placed on it and the implant retained bridge would still be well supported.

The patient was referred to a Perio specialist for maintenance of the implant and associated pathology.

Hours claimed

Consultation 30 mins
Preparation 60 mins
Obtruation 30 mins
Restoration 30 mins
Presentation 90 mins

Total 4Hr


Portfolio Case 2

Patient:
Age 48, Male, no medical issues declared

Background Info

The patient attended with his son who was having orthodontic treatment. I agreed to take a look at a tooth he was complaining about. After form filling and examination, it was seen that the 25 was very sensitive cervically. The patient stated that he had his regular dentist and he had applied a coat to try to reduce the sensitivity a few weeks after a composite (DO) filling was placed. . This had not worked. The tooth was not ttp but was sensitive to cold. The options of review or possible rct were given to the patient. The patient chose to be review. Topical fluoride was applied and an appointment was made to review.

A peri-apical radiograph was taken was taken and was deemed to be grade 1. From the radiograph it was advised that the previous dentist may have destroyed some of the pulpal anatomy or there maybe some kind of internal resorption. The patient still choose to be reviewed so he could decide what to do. A future appointment was made. The severity of the situation was stressed to the patient.

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The patient attended , the next day, with severe pain in the offending area and now was complaining of a severe throbbing pain from the 25. The tooth was very TTP and very sensitive even to air. The patient gave full verbal and written consent to RCT. A diagnosis of acute pulpitis with peri-apical periodontitis was made.

Visit 1 (90 mins)

Full verbal and written consent was gained and local anaesthesia was achieved after some difficulty but firstly using lignospan and then articaine to achieve profound anaesthesia and rubber dam placed. 2.5 x loupes were used after initial dam placement.

Click on image to enlarge

Access was obtained removing the center of the composite filling and using the diagnostic radiograph the nerve canal was found. The internals of the access chamber were checked for resorption but no vascular or granulation like tissue could be found. Just a void filled with a resin like material. This was advised to the patient and noted.

Working length was found with a size 15 K-file and an electronic apex locator, post slight coronal flaring and irrigation. This was calculated to be 21mm as the reading on the file from the apex locator was 21.5mm on the two canals found.

Click on image to enlarge

The canals were prepped using the “simply Endo” protocol using Protaper Gold to carry out coronal flaring, prior to finding working length, with the SX file then using S2 F1 and finally F2 to give a 8% taper and an apical working size of just under .25mm. During this time copious amounts of irrigation was carried out with Sodium hypochlorite 3%.

At this time, after a short discussion with the patient, it was decided to complete the RCT in a single visit. The initial plan was to complete in 2 visits but as good progress was made and there was no clinical evidence to suggest otherwise, it was felt that the outcome would have the same prognosis.

Irrigation was then was completed until the canal preparation was complete and the irrigant was seen to be clear and without debris.
The canal was then treated with 17% EDTA and then washed with Sodium hypochlorite 3% and dried with paper points.

2 x S2 were tried to working length and tug back was established as a good obturation length from using the diagnostic radiograph. A cone fit radiograph was taken. This was graded at grade 1

Click on image to enlarge

AH+ was used as a sealer and the canals obturated with single F2 cones in each if the bucal and palatal canals.

The GP was “heat trimmed” and then a temporary composite restoration was placed, to be replaced at a later date with a full cuspal coverage restoration in the form of a full or ¾ full ceramic crown. The occlusion was checked and final radiograph taken, post dam removal. This was recorded as Grade 1. Another peri-apical was taken at a different angle but showed no difference in final image.

Click on image to enlarge

Learning outcomes

“fixing” other dentists mishaps is all part of the Job and it is very important not to judge. The patient was very understanding and decided not to return to his dentist , but more importantly, not to take the matter further with him or her. We must be so careful when we first look at other dentists work and not be too quick to criticize or “rubbish” his or her efforts. “There but for the grace” should be remembered and time should be taken to explain to patients that, even with our best endeavours, we may not be able to achieve.

Hours claimed

Consultation 30 mins
Preparation 60 mins
Obtruation 30 mins
Restoration 15 mins
Presentation 90 mins

Total 3.75 Hr

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