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The opinions within this web page are not ours. Authors have been credited
for the individual posts and photographs where they are. -

From: Marga Ree 
Sent: Monday, March 12, 2007 3:10 PM
Subject: [roots] Dental wreck-1

This 40 year old male came to our practice in July 2005. He had pain all 
over his mouth, multiple swellings, bad breath, a lot of decay and lousy 
fillings. He wanted his teeth to be nice and healthy. 

I started with tooth 46, which caused the patient a lot of pain and 
discomfort, you can see a huge swelling and a pocket of + 10 mm. 
First session consisted of cleaning, shaping and tons of ultrasonically 
delivered irrigation fluids. Then I packed Ca(OH)2 for a month, and 
on return, the swelling and pocket had completely disappeared. 
As you can see, in the meantime, he went to our oral hygienist, and his 
fillings were replaced. There was already a world of difference after 
just treating tooth 46 and some professional cleaning by our oral hygienist.

After filling the 4 canals, you can see some puffs in the furcation area, 
as well as an anastomosis between the 2 mesials in the apical third on 
the angled rads. As usual, I did the BU myself, and placed a fiber post 
in one of the distals. 

tooth 46

tooth 46 Next tooth was 45. His previous dentist was a thermafil user, and this was a classic thermafil filling in an underprepared canal. I checked the probings before treatment, but they were insignificant......... .........I thought............:-( After having removed the crown and the thermafil filling, I found out that there was a huge fracture on the distal........., after taking off the rubber dam, I probed again, and there it was.........+10 mm Lesson to be learned: never probe without local anesthesia when you suspect a root fracture............... tooth 45 Tooth 27 showed a swelling and a sinus tract. I am not proud on this one, because in the final stage, when I was done with C&S, I fractured a rotary instrument in the apical third of MB1. Dammit! What do they say? The enemy of good is better..... Why didn't I stop one file earlier.....:-)) I didn't even an attempt to remove it, but I could bypass it with hand files. I informed the patient that surgery may be needed in the future, but that we would evaluate the result after 1 year and then take a decision. The sinus tract was gone after a couple of weeks of Ca(OH)2, so I decided to fill

tooth 27

tooth 27

tooth 27 Again a Thermafil case, with obviously a missed canal. The removal of the thermafil carriers I will explain in more detail in the next post. I wanted to show you how I make a BU when there is not so much tooth structure left. First of all I try not to remove extra tooth structure to make room for the post, I try to accomodate the post in the availabe space. There are a lot of posts out there, and there is always a post that will fit, because manufacturers provide them nowadays also in small sizes. This a a very important principle: passive placement of the post. Removing dentin to accomodate a post is one of the reasons that posts have got a bad name in the past. In my opinion, there is no downside to placing a fiber post, provided you leave the remaining dentine alone. The posts I frequently use are: Whaledent fiber lux posts and FibreKleer by Pentron when I deal with parallel post spaces. I use the tapered FibreKleer or DT light post of RTD when dealing with tapered post spaces Advantage of these tapered posts is that you can cut them either at the coronal end or at the apical end to adjust the size. I use the same composite to cement the post and to make the build-up, this gives me one material in which the post is embedded. I prefer a self cure version of BU material, although I frequently also use dual cure materials. The reason for me to prefer a self-cure, is because their relatively slow-setting rate are thought to provide flow to relieve the shrinkage stress developed during setting. I like to clamp the distal tooth, that gives you more freedom to manipulate the matrix band. I these cases I like to use a core build-up of Kuraray, cut the upper part away with a scalpel, and turn it upside down, insert it in the sulcus, so that the smallest diameter is at the cervical part of the tooth that has to be restored, and the widest part is going to be at the occlusal surface. This gives you a kind of a tooth model. A wedge is usually not necessary, and dont bother with the weird form after you have removed the form, you can easily adjust the shape with a diamond and finishing burs. I don't mind if a don't have a contact point. Usually it is better to have no contact point at all than a loose contact point, it is only a temporary restoration. In this case, I placed 2 tapered posts. The pictures show the try-in of posts after finishing the canal filling, acid etch, prime and bond, cementation of posts, application of plastic core form of Kuraray, build-up of Build-it, adjusting shape of build-up with diamonds and rubber points - Marga tooth No 25

tooth No 25

tooth No 25

tooth No 25 Tooth no 23, straightforward case, nothing to be mentioned in particular tooth 23 The last case, tooth 15, thermafil removal: I used the technique with hedstrom files and a hemostat, nicely described by Steve Buchanan, you can find this technique on his website, see: Steve's recommendations: Thread a 21 mm #15 Hedstrom file through the softened apical gutta percha between the carrier and the canal wall until tight. Clip a curved hemostat to the Hedstrom file shank just below its handle and rock the hemostat onto the mesial adjacent tooth and lever the Hedstrom file out as if using a crowbar. The physical leverage is remarkable and most often the carrier will be launched out of the canal. I don't use a # 15, but try to thread a # 25 or 30 between the carrier and the canal wall. This technique can also be used for removing silver points. After removing the carrier, I could not figure out immediately what the canal configuration was, but after finishing the C&S, I went back in with a precurved hand file, and found a second POE. Fiber post and build-up of composite. tooth No 15

tooth No 15

tooth No 15 Final phase, the 1 year follow-up. I think the pics speak for themselves. Patient is completely symptomfree. The periodontal status had improved tremendously, thanks to our oral hygienist and efforts by the patient. The resorative work was done by my husband, do you agree he is my best RD?? ........:-)) final phase

final phase

final phase This is why we love to be dentists, isn't it? - Marga

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