Endodontic Case Presentation

PRESENTED BY

AHMAD S. ALQAHTANI
[SSC-Dent(Endo)], R3 27 jan 2010

Patient personal data

Chief complaint
I want to complete the

treatment of my tooth and to replace the lost restoration .

Medical History
Past :- NAD Current :- NAD

Extra-Oral Examination NAD

Clinical Evaluation
Tooth No. 13 14 15 Therm al Test +Ve NA +Ve Perc. Test -Ve -Ve -Ve Palp. Test -Ve -Ve -Ve

Toot h No. 14

MB 3

B -

DB 3

DL 3

L -

ML 3

Radiographic findings

.
Diagnosis
Pulpal :- Pulpless tooth Periapical :- Asymptomatic Periradicular Periodontitis Periodontal:- Healthy periodontal attachment

Prognosis
Good

Treatment plan
1-.Non surgical root canal treatment. 2- post and core build up. 3- Full coverage restoration. 4- Follow-up.

Discussion
- Do procedural errors cause endodontic treatment failure?
LOUIS M. LIN et al,2005

- There are three possible outcomes that may be encountered when treating these cases: (I) Retrieval, (ii) Bypass and sealing the fragment within the root canal space, (iii) True blockage. - Success of retrieval depends on the canal anatomy, type of instrument, the location in the canal, the plane in which the canal curves, the length of the separated fragment, and the diameter of the canal itself.
Steven J. Cohen et al,2005

Discussion
- Fors UGH et al, Endodontic treatment of root canals obstructed by foreign objects. Int Endod J 1968, recommended a strategy to be followed:
- in coronal 1/3: attempt retrieval. - in middle 1/3: retrieve or bypass. - in apical third: leave and observe. - Complications Associated with Fractured File Removal Using an Ultrasonic Technique, N. Souter& H. Messer,2005 *Removal of a fractured file fragment from the apical third of canals should not be routinely attempted, and if attempted, the chances of success should be balanced against potential complications. *the root strength decreased by 40% if a fragment located in the apical third is attempted for retrieval.

Studies reporting the effect of a retained fractured instrument on the outcome of endodontic treatment
modified from Spili et al,2005 and Peter Parashos,2006

Study (year)

Observation period (yr)

Control group

Lesion(n)

No lesion(n)

Success %

Stated effect of Fractured instrument on healing No effect

Engstrm et al(1964) Engstrm and Lundberg(1965) Crump and Natkin(1971) Fox et al(1972)

4-5

no

nr

nr

6/9 )67%) 5/5 (100%) 48/53 (91%) 93/100 (93%) 40/46 (87%)

3.5-4

no

5/5

No effect

2 214 (average 23) 0.55 (average 3)

yes

27/29

21/24

No effect

no

nr

nr

Reduced only when lesion present Reduced only when lesion present

Molyvdas et al.(1992)

no

8/11

32/35

Spili et al.(2005)

yes

51/56

62/63

113/119 (92%(

No effect

Discussion
- The overall frequency of fractured endodontic instruments left in the root canal after treatment was found to be 3.3% of treated teeth and comprised 78.1% rotary NiTi files, 15.9% SS hand files, 4.0% paste fillers, and 2.0% lateral spreaders. The frequency of rotary NiTi instrument breakage was comparable to that previously reported for hand files. -endodontic instrument fracture had no adverse influence on the outcome of nonsurgical root canal treatment and retreatment when the instrument remained in the root canal. The presence of a preoperative periapical radiolucency, rather than the fractured instrument per se, was a more clinically significant prognostic indicator.
Spili et al,2005

Discussion
- If a separated instrument can be bypassed and incorporated into the
root canal filling, the prognosis for endodontic therapy is favorable.
Fors et al,1968

- Bypassing and sealing the fragment into place can be very successful, if the canal is thoroughly cleaned around the obstacle, and the apical terminus is sealed.
Steven J. Cohen et al,2005

- effect of a separated instrument on bacterial penetration of obturated root canals.( saunders et al, 2004): The separated instrument itself does not play a large role in the sealing ability of the obturation material, more important is the coronal seal and absence of any residual irritant beyond the level of the separated instrument.

Peter Parashos et al,2006

Discussion
(Lee et al. 2006), found that the

root canal curvature is greatest in the apical third compared with the other thirds of the root.
The fact that roots are curved was

initially appreciated by simply stating the angle of the curve and then categorizing roots as straight (5 and less), moderately (10 to 20) or severely (>20) curved.
Schneider SW,1971

Discussion

- the radius of the curve has to be viewed together with its angle because two canals measured at the same angle in degrees by the Schneider method could have very different radii or abruptness of curvatures, thus having a very different impact on the difficulty of canal instrumentation. Pruett JP et al,1997

Discussion

Schfer et al. (2002), found by taking radiographs in both clinical

and proximal view, that 84% of all root canals in all teeth in the jaw (third molars excluded) showed a curvature of at least 10 degrees and 17.5% of all root canals also showed a secondary curvature, so called Sshaped root canals.

Endodontic Tx

Measurements

Canal

MAF

WLs

Filling Material

MB

30

21.5mm

G.P+AH26
G.P+AH26

DB

30

22mm G.P+AH26

30

23.5mm

Patient personal data

Chief complaint
my dentist told me that I need a root canal treatment of

my tooth prior to restore it permanently

Hx of C.C.

-initial Tx of the tooth in question was done 6 weeks ago. - the tooth is asymptomatic since that time except for mild discomfort due to partial loss of filling and subsequent food impaction since last week prior to this visit. - no hx of swelling, severe or spontaneous pain.

Medical History
Past :- NAD Current :- NAD

Extra-Oral Examination NAD

Clinical and radiographic Evaluation

Tooth No. 11 12 13 Tooth No. 12

Therm al Test +Ve NA NA MB B -

Perc. Test -Ve -Ve -Ve DB 3 DL 3

Palp. Test -Ve -Ve -Ve L ML -

.
Diagnosis
Pulpal :- pulpless. Periapical :- asymptomatic Periradicular Periodontitis Periodontal:- Healthy periodontal attachment

Prognosis
Good

Treatment plan
1- Non surgical root canal treatment. 2- cast post and core. 3- full coverage restoration.

Root Number of Maxillary First Premolars with 3 roots in Various Studies

Author
Hess

year 1925

No. of Teeth

model In vitro

3 canals % 1.2

260

Barrett
Mueller Pineda & Kuttler Green Carns & Skidmore Vertucci& Gegauff Bellizzi

1925
1933 1972

32
130 259

In vitro
In vitro In vitro

3.1
0 0.5

1973
1973 1979 1985

50
100 400 514

In vitro
In vitro In vitro In vivo

0
6 5 3.3

Root Number of Maxillary First Premolars with 3 roots in Various Studies cont

Author
Vertucci

year 1984

No. of Teeth

model In vitro

3 canals % 4

400

Walker
Pecora Caliskan Kartal Loh Chaparro Awawdeh Al ateiah

1987
1991 1995 1997 1998 1999

100
240 100 300 957 150

In vitro
In vitro In vitro In vitro In vitro In vitro

0
2.5 0 1.66 0 3.3

2008
2008

600
246

In vitro
In vitro

0.8
1.2

Cont
- Evaluating the maxillary premolar with three canals for

endodontic therapy Ralph B e l l i z z i ,1981

* categories of three-rooted maxillary premolars:

Category 1:fusion of all three roots or only the two buccal ones, and a semifused or free palatal root. Category 2: normal separation of the buccal roots at the midroot or apical-third level, with either a semifused or free palatal root. Category 3: normal separation of the buccal roots up to the cervical level, with a free palatal root and the classic tripod appearance.

Endodontic Tx

The three-canalled maxillary premolar requires an access cavity modification into a "T shape, mesial-distally extending the buccal aspect of the usual outline form. This modification allows good access to each of the two buccal canals.
Sieraski,1989

Measurement Tooth No.12

Canal MAF Length Canal Initia WLs Last Filling l file file

B MB L

20 mm 30 18 mm 30

10

35

Materi al

21mm G.P+AH 10 30 26 20mm G.P+AH 26

DB

35

23.5mm G.P+AH 26

Endodontic Tx