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complex anatomy and severe pulp calcification - Courtesy ROOTS

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From: Terry Pannkuk
Sent: Thursday, September 10, 2009 2:54 AM
Subject: [roots] 6 canal Molar

This case was time consuming and a challenge.  The patient has a 
Class 2 jaw relationship, narrow arch, limited jaw openning, TMD, 
and a tooth with very complex anatomy and severe pulp calcification.

The during the first visit I found 5 canals (2 MB's, 2 DB's and a P), 
but today as I flared the MB1 I found a third MB which was the MB2.  
There were separate DB roots and the MB1-MB2 were confluent
with the MB3 having a separate system and separate POE - Terry

Hi Terry! Great to "see" you again. Nice job on this one! - Becci Prescott Dear Terry, This case is astonishing -- accomplishing what you did despite so many different challenges. Do you happen to have any photos of the access before you opened up the canals making them obvious? I wonder what it looked like before you opened them. But to think you did all of that and spent the time taking these great photos as well ... A pedestrian question ... What bur do you or anyone use to flare the access of a crown? I use a diamond to cut through porcelain and a carbide to cut through metal ... but I've never been thrilled with anything for flaring the access and making sure it is large enough. Some metal seems harder to extend than other metals. Finally, I know you're not a big fan of ultrasonics. Did you use any here, or was all canal exploration done with burs? Your fan, - Patrick Wahl No ultrasonics for troughing or extension. I hate them. :) Great White bur for initial penetration (metal occlusal surface)---> Football diamond to bowl out the corners and "SEE" access direct lines---> Egg shape composite finishing bur to refine/smooth bowl lips--->Cone shape composite finishing bur to "dot" the orifices----->narrow flame tip composite finishing bur to connect the "dots"/trough grooves. I also flood the pulp chamber with EDTA during the discovery process. Furcation side dentin is always preserved for safety. Some of the cases I see troughed with ultrasonics always look like near strip perfs to me, especially the poorly extended ones. I didn't take any initial access pics; wish I did. I spent a lot of time drilling out irritational dentin the first visit. Both visits were very long. Ideally, I would have like to have extended and found the MB2 (sixth canal) the first visit because I placed CH and like to have all systems cleaned and shaped to near completion figuring if I don't, I'm not really getting the benefit of the CH. If the MB2 had not been a simple confluent track to the MB1 I probably would have placed CH for another 2 weeks and closed even if there wasn't drainage; one month more if there was. Luckily it blotted nicely with the paper points and I was good to go today. This tooth would have been very interesting to scan with a CBCT. The second DB root was a very odd presentation. Maybe at some point in the future she'll need a CBCT and I'll be able to check it out (hopefully not because of this tooth!). - Terry Terry, Exemplary endo! However, IMO, due to this pts occlusal scheme and the fact that she has already lost the second molar and this is now the distal abutment in that quad it predisposes it to an early demise. What was the dx and how old was the crown? Any decay under the crown? Could have been occlusal trauma, especially given the occlusal environment - Arturo Good points. I didn't detect any recurrent caries; simply a previous pulp cap in my opinion, but I imagine occlusal trauma could have been contributory. Many patients can live with first molar occlusion, not necessarily needing a second molar. I'm not sure an early demise in in the card for her. I routinely schedule long term recalls so remind me of this case in 10 years. :):):) - Terry If I'm not too busy looking for a fresh diaper I will :-) Question: will the referring doc do a new restoration or seal the access with amalgam? How do you feel about sealed accesses through full coverage restorations on pre and molars? - Arturo In a perfect world (which I constantly try to bully people into but rarely succeed), I would rip the crown off before doing the endo and convince all patients that they should automatically invest in a new restoraton/build-up after endo. In the real world that forces me to make uncomfortable compromises, I succumb to patients economic limitations, indoctrinated mythologies, and referring dentist's pragmatic concerns playing reasonable odds that working through crowns like this and not taking them apart will in all probability work out fine; which it usually (but not always) does. I placed a bonded composite core. Clearfil bond, Luxacore, sandblasted the prep, porcelain etch, silanated, Filtek surface. Hopefully this will be a definitive result. We'll see. - Terry Terry, i wonder what would this case be in your "hair"-classification? :-))) Thanks for posting this... that's da bomb of a case!!! - Dmitri Not sure about the cosmotology on that one. :)- Terry

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