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Endo tips    Better Endo    Endo abstracts    Endo discussions

Apical periodontitis : Restoration in glassionomer : Two molars
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From: RafaŽl Michiels
Sent: Wednesday, March 25, 2009 2:17 AM
Subject: [roots] Today's cases

Case 1:

Diagnosis: 3.6 with apical periodontitis on both roots. Pulp in the 
chamber was removed by the referring dentist. At the lingual side a 
piece of the enamel had broken off. Also alot of chipping
on the other teeth. It is correlated with the tongue piercing she has.

Treatment: RCT, 1 visit. Protapers and Profiles, NaOCl, EDTA, PUI, 
obturation with Gutta condensors. Temp. Restoration in glassionomer

Future: The dentist will restore it with a definitive composite 
resin restoration.

Extra advise to the patient: replace the metal ball of the piercing 
with a plastic one.

Case 2:

Diagnosis: 1.7 was opened by the referring dentist, due to caries 
into the pulp. The temporary restoration he made, was with glass 
ionomer and is well.... not so good, but it doesn't leak.
Tooth is also periodontally compromised, but patient wants to keep 
it at any cost. Treatment: RCT, 1 visit.  Protapers and flexofiles, 
NaOCl, EDTA, PUI, obturation with Gutta condensors. Temp. Restoration
in glassionomer, I did not remove the distal part of the previous 
glass ionomer, since there were no signs of leakage AND, the patient 
has an appointment with his dentist to replace the temporary filling 
with a definitive one, this friday. Future: friday a definitive 
restoration will be placed.

The MB1 and MB2 are very close to each other, which was rather 
difficult to shape - RafaŽl

Rafael.............unless I'm missing something, no Ca(OH)2 was used............ The RCT's are amazing as always, but I do have one question............. even if you're not the person doing the restorative, should we as endudes, NOT BE AT LEAST pre-prepping the tooth - pseudo-transitionalizing it to hasten the timing for restoration, to get the patient committed 110% to proper therapy, to make the restorative lad aware of CLP issues et al.... .... Kendo What can I say? Excellent work!!! Beautiful cases, hat is off, etc.etc. - Jose Rafael, thanks for sharing! No comments... Only questions :-) Could you please tell how do you manage apical part of the canal? Why i ask i that i often have problems with working length control and as a consequence - gross puffs or underfilled areas... so, it's the question for everybody - tell the secrets of apical instrumentation and obturation control :-) I would be more than grateful to get your view on this - Dmitri Dmitri, if you use rotaries, never take them to the full working length, at least 1 mm short of it. Keep in mind that as you are cleaning and shaping the canal, any curvatures in this are going to become straighter therefore your length is now going to be shorter. Always after each rotary instrument check for patency with a 10 file. Finish your apex to 20 or 25 file and then step back 0.5 mm for every higher file. The final instrument will also depend on the original size of the canal as you know, if it is a central on a young pt. your last file to the apex will have to be bigger but the principle is the same. Getting puffs at the end of the canal, not a big thing, do not worry about it. Keep in mind that this is the protocol that I use for my warm vertical condensation tech. Hope it works for you, let me know - Jose Jose, thanks! Now the main question is what should we call a working length? I know.... it's back to basics type of question and look goofy asking this :-)) I take my EAL and substract 1mm from... call it estimated working length. Then after shaping to that est.length approx to 20/.06) i start to explore apical part... if i can i take paper point measurment and substract 0.5mm from red dot (or whatever colour is it). Instrument to the final shape and start irrigation, PUI etc... Now there is the catch - i still sometimes end being short (as viewed on x-ray after obturation) or being too long as seen on conefit x-ray - and then it's a PITA to fit the cone). If not, then i sometimes push through the constriction while doing waves of condensation... Where do i go wrong? - Dmitri Sounds dumb, but no one ever taught me that simple notion of not taking rotaries to full wl. I had to find it out for myself the hard way with some pretty good , what shall we call them, oh yeah, puffs. I canít agree more. I am an apical hand finishing guy also. No way to create a proper capture zone in my estimation otherwise - gary Thanks Jose and Dmitri, As for the apical instrumentation, I mostly do the same which is. Protaper F1 at about 0.5mm of the constriction and I finish with K-flexofiles, handfiles, mostly until a size 30, unless I need more obviously. I almost never (maybe I did it 3 times in 3 years) finish with a size smaller than 30. (This is my protocol, it is not for a warm technique, but for Cold lateral condensation or obturation with the guttacondensors, hence the reason why I have a bigger MAF) Hope it helps, but Jose pretty much said everything - RafaŽl Rafael, thanks! Constriction.. do you mean 0.5 short of EAL measurment? Could you please laborate on what is the benefit of instrumenting to at least #30 for cold lateral condensation? When i did cold lateral i oftentimes left canal instrumented to F1 or F2 depending on the case and went obturation... But if you instrument to #30 with hand files, then what master cone do you use - still ProTaper one or conventional ISO .02 cone? - Dmitri

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