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  Could have been a nice case : Irreversible pulpitis : gingivectomy

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From: Marga Ree To: ROOTS Sent: Saturday, August 19, 2006 7:59 PM Subject: [roots] Could have been a nice case.....:-( Irreversible pulpitis in tooth 28, due to caries profunda. New 3 unit bridge was indicated, so I cut through the bridge distal of tooth 26, removed the dummy and the crown on 28, did a gingivectomy, removed caries, and started the endo. All 3 canals were extremely curved, so I was cautious, and did a lot of hand filing before introducing taper 02 rotaries, which I like to use for these type of very curved canals, and usually are very safe, because of their flexibility. I thought it was doable with rotaries, but it wasn't......:-( , at least not in my hands....:-( Useless to say that I didn't do an attempt to remove this one...:-)) Since it was a vital case, so it will highly likely not compromise the outcome. - Marga

Dear Marga, Thank you for posting yet another excellent case. In my opinion, the severe abrupt curvature (almost recurvature) of the DB canal in this tooth would probably defy most rotary file designs! Therefore, (rotary) file fracture is always a (high) possibility in such situations. I agree with all your statements here. - Marga You are correct to state that prognosis will most likely not be affected in this case...especially because it occurred under very controlled conditions, in your very skilled hands, and of course, in a vital tooth. I have enjoyed reading your paper on instrument fracture and outcome of treatment, I agree with Ben, a very nice study. It must have been a lot of work, to collect all those data!!- Marga Incidentally, up to what hand file size did you prepare a glide path in the DB canal before introducing the rotary files? # 20 - Marga Did you use a 15/02 rotary before the 20/02? Yes - Marga I too would spend quite some time with small hand files, from size 6 to hopefully size 15 (if possible) in such cases. I would get each of these files as 'loose' as I can before introducing rotaries. So, assuming rotaries could negotiate such an abrupt apical curvature, then my rotary sequence after hand filing would be ProTaper S1, S2, then ProFile 25/02 (but perhaps ProFile 20/02 first, if the 25/02 did not want to get to length easily), and...yes, I would also try and get a ProFile 30/02, or even a ProFile 25/04, or larger .04 taper file if the canal allowed this (probably wishful thinking though...:-)). As you can see, I feel that .02 taper ProFile files seem to negotiate such curvatures well in my hands. I have not had any experience with K3 .02 rotaries. I have the sizes #15-40 in K3 taper 02 in my set-up. My file sequence in these kind of cases: Gates #(4), 3, 2 till resistance, K3 shaper 12, 10 and 8 to resistance, sometimes I repeat this sequence in a later stage of the instrumentation, dependent on the canal shape. Establish a glide path with handfile # 15 or #20 K3 #15/02T K3 #20/02T K3 #25/02T K3 #30/02T (K3#35/02T) not always, dependent on the canal shape K3 #15/04T K3 #20/04T K3 #25/04T (K3 #30/04T) If I have problems to get an 25/04 or 30/04 taper to length, or I notice that there is significant resistance to cutting, then I throw in more 02 tapers. Usually I introduce a taper 04 in the taper 02 sequence, with a tip diameter that is 2 sizes smaller that the last used 02, e.g, when I have gotten a 25/02 to length, my next file is a 15/04, etc. I have learned this sequence from Bill Watson, and it is (usually...:-)) a very safe way of instrumentation. In this case, I finished with 30/04 files in the MB and PAL canal - Marga By the way, If I could not get any rotaries around the curvature, then I would instrument the canal with rotaries TO the most apical level that they would freely go, and then finish beyond this level with 'appropriately' sized hand files. Yes - Marga Finally, one further question: could you attribute the fracture of your K3 file to anything in particular, e.g., torsional failure, flexural fatigue, file used more than once before this case, difficult/restricted access during instrumentation, etc?- Peter I think overconfidence of the operator....:-) Yes - Marga Hi Marga, Thanks for your prompt response to my message. In particular, I appreciate your describing your complete instrumentation technique for such cases. I will certainly give the 'Bill Watson sequence' a go as soon as I encounter another similar case. By the way, have you ever attempted coronal preenlargement (or initial crown-down) with only the ProTaper shaper files? I find this approach is very efficient and quick. In my hands, the problem I sometimes experience with a #20 hand file (usually a Hedstrom file) is that it can be a bit too stiff, with a high risk of ledging or transportation for such severe abrupt curvatures. This might create a problem for the ensuing rotary files (i.e., it might create a non-smooth glide path). Usually, if I can get a #15 hand file to length, the ProTapers and subsequent rotary files (previously described) will get to length when used correctly. Of course, all my rotaries are single-use in such cases. Incidentally, your comment: I think overconfidence of the operator....:-) is definitely not the reason for file separation. I feel the reason was simply bad luck in this case. And, as I mentioned in the previous post, this case will still be a resounding success! (Thanks for your kind acknowledgment of my paper:-)). Marga, you are far too great an operator who has every right to be confident (or overconfident) in your brilliant work. I, like many others, absolutely adore your fantastic posts on this forum. Overconfidence should not be the cause instrument fracture in the hands of truly adept clinicians such as yourself ...however, it might be yet another possible reason for failure in the hands of incompetent or disinterested clinicians who are not willing to take the time to learn novel (or alternative) instrumentation sequences for complex cases;-)) - Peter Ravinder Sharma 10:01pm Aug 10, 2013 in Dental surgeons of India, Facebook grouo No dear it can be done with copper amalgam OK just try it will give u best results Dr.ravi Kumar 11:39pm Aug 10, 2013 in Dental surgeons of India, Facebook grouo Nice case

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