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Advanced Endodontics

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Abstract

Although every effort has been made to ensure that all owners of copyright material have been acknowledged in this publication, we would be glad to acknowledge in subsequent reprints or editions any omissions brought to our attention.

Figures (457)
John S Rhodes qualified from King’s College London in 1990, where he was awarded the Claudius Ash prize in conservation and the Jose Souyave endodontic prize. He continued his postgraduate education at Guy’s Hospital London, where he achieved a distinction in the Endodontic MSc. He is registered on the GDC specialist list in endodontics and now runs a busy endodontic referral practice in Poole, Dorset.
John S Rhodes qualified from King’s College London in 1990, where he was awarded the Claudius Ash prize in conservation and the Jose Souyave endodontic prize. He continued his postgraduate education at Guy’s Hospital London, where he achieved a distinction in the Endodontic MSc. He is registered on the GDC specialist list in endodontics and now runs a busy endodontic referral practice in Poole, Dorset.
Figure 1.1
Figure 1.1
Figure 1.5 The previous case retreated. The distal canal has been renegotiated and instrumented. All the canals have been obturated using gutta percha and sealer.
Figure 1.5 The previous case retreated. The distal canal has been renegotiated and instrumented. All the canals have been obturated using gutta percha and sealer.
Figure 1.4 A Thermafil root filling has been placed in this mandibu- lar second molar. The filling is short in the distal canal, but the mesial canals look reasonably well obturated. A tell-tale sign on the radiograph that this is not the case is ‘bunching’ of gutta percha in the access cavity. The obtu- rating material has been stripped off the carrier as it was inserted. Only the carrier remains in the root canal.
Figure 1.4 A Thermafil root filling has been placed in this mandibu- lar second molar. The filling is short in the distal canal, but the mesial canals look reasonably well obturated. A tell-tale sign on the radiograph that this is not the case is ‘bunching’ of gutta percha in the access cavity. The obtu- rating material has been stripped off the carrier as it was inserted. Only the carrier remains in the root canal.
Figure 1.7
Figure 1.7
Figure 1.6 The root canal of this maxillary left central incisor would appear to have been shaped and disinfected adequately. A lateral canal has subsequently been obturated. The tooth was unfortunately still symptomatic following root canal treatment and there was tenderness over the apex. Root canal retreatment in this instance is going to be complex as the previous attempt is good.
Figure 1.6 The root canal of this maxillary left central incisor would appear to have been shaped and disinfected adequately. A lateral canal has subsequently been obturated. The tooth was unfortunately still symptomatic following root canal treatment and there was tenderness over the apex. Root canal retreatment in this instance is going to be complex as the previous attempt is good.
Figure 1.9
Figure 1.9
Figure 1.8
Figure 1.8
ability to prepare canal systems predictably, while preventing blockage.
ability to prepare canal systems predictably, while preventing blockage.
Figure 1.13
Figure 1.13
Figure 1.12 Figure 1.14
Figure 1.12 Figure 1.14
Figure 1.16
Figure 1.16
Figure 1.17
Figure 1.17
Figure 1.19 Figure 1.18 Root canal retreatment completed. All the separated frag- ments of instrument were successfully removed. The canals were located, renegotiated, shaped, cleaned and obturated with gutta percha and sealer. An adhesive Nayyar core has been constructed in amalgam. The mesiobuccal root has two separate canals that join in the apical third.
Figure 1.19 Figure 1.18 Root canal retreatment completed. All the separated frag- ments of instrument were successfully removed. The canals were located, renegotiated, shaped, cleaned and obturated with gutta percha and sealer. An adhesive Nayyar core has been constructed in amalgam. The mesiobuccal root has two separate canals that join in the apical third.
In this case, the root canals of the maxillary second premolar and first and second molars have been under- prepared and under-filled. In most canals a single cone obturation technique has been utilized. Despite this, it is interesting to note that there is virtually no indication of periapical pathology. Perhaps the root canal treatment was carried out while the teeth were still vital and the root canals were not infected. The restorations on these teeth are destined for replacement and it is therefore necessary to carry out root canal retreatment. In this instance, because of the lack of periapical pathology and obvious technical failings of the previous treatment, a good prog- nosis should be expected. The distobuccal root of the max- illary left first molar has been resected and an amalgam root end filling placed. The root tip is still present and just visible on the radiograph. The root canal will obviously need to be sealed with conventional restorative material to prevent coronal leakage.
In this case, the root canals of the maxillary second premolar and first and second molars have been under- prepared and under-filled. In most canals a single cone obturation technique has been utilized. Despite this, it is interesting to note that there is virtually no indication of periapical pathology. Perhaps the root canal treatment was carried out while the teeth were still vital and the root canals were not infected. The restorations on these teeth are destined for replacement and it is therefore necessary to carry out root canal retreatment. In this instance, because of the lack of periapical pathology and obvious technical failings of the previous treatment, a good prog- nosis should be expected. The distobuccal root of the max- illary left first molar has been resected and an amalgam root end filling placed. The root tip is still present and just visible on the radiograph. The root canal will obviously need to be sealed with conventional restorative material to prevent coronal leakage.
Figure 1.21 The case has been obturated using a vertically compacted gutta percha technique. The finished preparations are ade- quately tapered and the root canal space well sealed with compacted gutta percha and sealer.
Figure 1.21 The case has been obturated using a vertically compacted gutta percha technique. The finished preparations are ade- quately tapered and the root canal space well sealed with compacted gutta percha and sealer.
Figure 1.22 Root canal treatment has been attempted on both abutments of this three-unit bridge. The mesial abutment shows fractured instruments in the coronal part of the root canal, which should be relatively simple to remove during root canal retreatment. The distal abutment shows a grossly over-extended root filling in the palatal root canal with associated periapical radiolucency. The buccal canals are under-prepared and under-filled. It is likely that the palatal root canal was over-prepared and that infected material has been carried through the apex into the periapical tissues. Root canal retreatment should be perfectly feasible but it is sometimes technically chal- lenging to retrieve over-extended filling materials and there is always the possibility of persistent extraradicular bacteria.
Figure 1.22 Root canal treatment has been attempted on both abutments of this three-unit bridge. The mesial abutment shows fractured instruments in the coronal part of the root canal, which should be relatively simple to remove during root canal retreatment. The distal abutment shows a grossly over-extended root filling in the palatal root canal with associated periapical radiolucency. The buccal canals are under-prepared and under-filled. It is likely that the palatal root canal was over-prepared and that infected material has been carried through the apex into the periapical tissues. Root canal retreatment should be perfectly feasible but it is sometimes technically chal- lenging to retrieve over-extended filling materials and there is always the possibility of persistent extraradicular bacteria.
Figure 1.20 Filling material has been removed from the three teeth and a diagnostic working length radiograph shows the canals have been successfully renegotiated. Patency has been achieved in all of them.
Figure 1.20 Filling material has been removed from the three teeth and a diagnostic working length radiograph shows the canals have been successfully renegotiated. Patency has been achieved in all of them.
Figure 1.26 The remaining material was removed with ultrasonics and this revealed carious dentine and a very messy pulp floor. There had been considerable coronal leakage.
Figure 1.26 The remaining material was removed with ultrasonics and this revealed carious dentine and a very messy pulp floor. There had been considerable coronal leakage.
Figure 1.24 Retreatment of the previous case. The fractured instru- ments were simply removed from the mesial abutment under microscopic magnification and the root canals retreated. In the distal abutment the buccal canals have been correctly shaped and now have a tapered form. Over-extended material in the palatal canal has been retrieved and the palatal canal re-prepared and disinfec- ted. All the canals in the distal abutment have been obtu- rated using a vertically compacted gutta percha technique and the case now appears to be adequately sealed. The coronal restoration in this mandibular left first molar is leaking as a result of caries under the distal margin. There is little root filling material in the distal canal and a large periapical area can be seen around it. The mesial canals have been obturated using a silver point technique and there is also a periapical radiolucency present. The coronal restoration is leaking and will need to be removed prior to root canal retreatment.
Figure 1.24 Retreatment of the previous case. The fractured instru- ments were simply removed from the mesial abutment under microscopic magnification and the root canals retreated. In the distal abutment the buccal canals have been correctly shaped and now have a tapered form. Over-extended material in the palatal canal has been retrieved and the palatal canal re-prepared and disinfec- ted. All the canals in the distal abutment have been obtu- rated using a vertically compacted gutta percha technique and the case now appears to be adequately sealed. The coronal restoration in this mandibular left first molar is leaking as a result of caries under the distal margin. There is little root filling material in the distal canal and a large periapical area can be seen around it. The mesial canals have been obturated using a silver point technique and there is also a periapical radiolucency present. The coronal restoration is leaking and will need to be removed prior to root canal retreatment.
Figure 1.23
Figure 1.23
Figure 1.25 The crown was simply elevated using a Couplands chisel and the core material dismantled. The superficial layers were removed using a tungsten carbide bur.
Figure 1.25 The crown was simply elevated using a Couplands chisel and the core material dismantled. The superficial layers were removed using a tungsten carbide bur.
Figure 1.29
Figure 1.29
Figure 1.28 Carious dentine was removed and the root canals reshaped and disinfected.
Figure 1.28 Carious dentine was removed and the root canals reshaped and disinfected.
Figure 1.27
Figure 1.27
Figure 1.31 A radicular cyst was located at the apex of this maxillary central incisor. It may well have been a pocket cyst, as the root tip was located within the tissue lining. Apical pocket cyst.
Figure 1.31 A radicular cyst was located at the apex of this maxillary central incisor. It may well have been a pocket cyst, as the root tip was located within the tissue lining. Apical pocket cyst.
Figure 1.34 This root-filled tooth has unfortunately failed as a result of vertical root fracture. Good illumination and magnification are essential in order to highlight cracks in teeth. This tooth had a micro- crack running down the buccal wall and extending into one of the mesial root canals. Sometimes cracks can be highlighted by staining.
Figure 1.34 This root-filled tooth has unfortunately failed as a result of vertical root fracture. Good illumination and magnification are essential in order to highlight cracks in teeth. This tooth had a micro- crack running down the buccal wall and extending into one of the mesial root canals. Sometimes cracks can be highlighted by staining.
Figure 1.33 Teeth requiring endodontic treatment may benefit from the placement of a band to prevent fracture. Following root canal treatment a full coverage crown or cusp coverage restoration is normally recommended to protect the tooth from subsequent fracture (Figures 1.33-1.44).
Figure 1.33 Teeth requiring endodontic treatment may benefit from the placement of a band to prevent fracture. Following root canal treatment a full coverage crown or cusp coverage restoration is normally recommended to protect the tooth from subsequent fracture (Figures 1.33-1.44).
Figure 1.35 A serious crack running from the mesial to distal of this mandibular molar has unfortunately resulted in vertical root fracture. The tooth will not be saveable.
Figure 1.35 A serious crack running from the mesial to distal of this mandibular molar has unfortunately resulted in vertical root fracture. The tooth will not be saveable.
Figure 1.36
Figure 1.36
Figure 1.38 The superficial core material was removed using a dia- mond bur to reveal the heads of the silver points. The remaining core material was then removed with ultrasonics, which left the silver points intact so they could be grasped with Stieglitz forceps and gently removed.
Figure 1.38 The superficial core material was removed using a dia- mond bur to reveal the heads of the silver points. The remaining core material was then removed with ultrasonics, which left the silver points intact so they could be grasped with Stieglitz forceps and gently removed.
Figure 1.37
Figure 1.37
Figure 1.42
Figure 1.42
Figure 1.41
Figure 1.41
Figure 1.40
Figure 1.40
Figure 1.44
Figure 1.44
Figure 1.45 Figure 1.43
Figure 1.45 Figure 1.43
Figure 1.46
Figure 1.46
Figure 1.47 Following simple root canal treatment the patient is symptom-free. Root canal retreatment of the first molar would have been extremely difficult and would not have resolved the problem.
Figure 1.47 Following simple root canal treatment the patient is symptom-free. Root canal retreatment of the first molar would have been extremely difficult and would not have resolved the problem.
Figure 2.1 The patient may consider success as relief from acute symptoms such as gross swelling.
Figure 2.1 The patient may consider success as relief from acute symptoms such as gross swelling.
Table 2.1 Strindberg criteria for success and failure (Table 2.1). Strindberg considered that the presence of periapical radiolucency after a period of 4 years following root canal treat- ment would indicate signs of biological failure. It is interesting to note however, that complete healing sometimes took up to 10 years.
Table 2.1 Strindberg criteria for success and failure (Table 2.1). Strindberg considered that the presence of periapical radiolucency after a period of 4 years following root canal treat- ment would indicate signs of biological failure. It is interesting to note however, that complete healing sometimes took up to 10 years.
Figure 2.3 The completed root canal retreatment. Sclerosed root canals can normally be located under high magnifica- tion with a microscope and, once located, careful preparation will enable them to be enlarged, irrigated and then sealed.
Figure 2.3 The completed root canal retreatment. Sclerosed root canals can normally be located under high magnifica- tion with a microscope and, once located, careful preparation will enable them to be enlarged, irrigated and then sealed.
Figure 2.2 In this case the maxillary left first premolar has chronic periapical periodontitis associated with it. An attempt at root canal treatment has been made but the root canals are extremely fine and have not been successfully negotiated. It is likely that following access cavity preparation coronal leakage has resulted in complete microbial colonization of the root canal system. The patient is symptom-free. The patient is made aware of the risk of acute exacerbation should the tooth not be treated. The prognosis for a non-surgical approach should be good. Root-end surgery would not be appropriate due to the infected root canals.
Figure 2.2 In this case the maxillary left first premolar has chronic periapical periodontitis associated with it. An attempt at root canal treatment has been made but the root canals are extremely fine and have not been successfully negotiated. It is likely that following access cavity preparation coronal leakage has resulted in complete microbial colonization of the root canal system. The patient is symptom-free. The patient is made aware of the risk of acute exacerbation should the tooth not be treated. The prognosis for a non-surgical approach should be good. Root-end surgery would not be appropriate due to the infected root canals.
Table 2.2 Diagnosis of success and failure
Table 2.2 Diagnosis of success and failure
Figure 2.5
Figure 2.5
Figure 2.6
Figure 2.6
Figure 2.8 The lateral incisor teeth have been root filled and in the maxillary right lateral incisor an amalgam root end filling has been placed. Post crown restorations would have a guarded prognosis as the root length is short, and the patient is completely edentulous in the posterior segments. It would be appropriate in this case to consider alternative treatment options such as an overdenture or perhaps an implant-supported prosthesis.
Figure 2.8 The lateral incisor teeth have been root filled and in the maxillary right lateral incisor an amalgam root end filling has been placed. Post crown restorations would have a guarded prognosis as the root length is short, and the patient is completely edentulous in the posterior segments. It would be appropriate in this case to consider alternative treatment options such as an overdenture or perhaps an implant-supported prosthesis.
Figure 2.9 Root canal retreatment of these maxillary central incisors in a young adult should be relatively simple as the single cone root filings can be easily removed. It is important to try and retain such teeth if an alternative such as an implant solution is to be considered in the long term.
Figure 2.9 Root canal retreatment of these maxillary central incisors in a young adult should be relatively simple as the single cone root filings can be easily removed. It is important to try and retain such teeth if an alternative such as an implant solution is to be considered in the long term.
Figure 2.7
Figure 2.7
In some situations root end surgery may be considered in combination with root canal retreatment. In this case a large radicular cyst was present above the maxillary left central and lateral incisors. Root canal retreatment was completed prior to surgery. The radicular cyst was removed surgically.
In some situations root end surgery may be considered in combination with root canal retreatment. In this case a large radicular cyst was present above the maxillary left central and lateral incisors. Root canal retreatment was completed prior to surgery. The radicular cyst was removed surgically.
Figure 2.12 If a tooth is unrestorable or the prognosis for root canal retreatment is poor, extraction is the only option. As the prognosis for modern root canal retreatment has become clearer, fewer teeth have been placed in this category (Figure 2.12).
Figure 2.12 If a tooth is unrestorable or the prognosis for root canal retreatment is poor, extraction is the only option. As the prognosis for modern root canal retreatment has become clearer, fewer teeth have been placed in this category (Figure 2.12).
Figure 2.10
Figure 2.10
Figure 2.13 Figure 2.15 Root canal retreatment of the maxillary left second pre- molar was completed by an endodontist. The tooth was subsequently restored using a post core and crown. There is a small periapical area present and the tooth is occa- sionally symptomatic. The root filling and restoration are excellent and therefore a surgical approach was consid- ered more appropriate in this case.
Figure 2.13 Figure 2.15 Root canal retreatment of the maxillary left second pre- molar was completed by an endodontist. The tooth was subsequently restored using a post core and crown. There is a small periapical area present and the tooth is occa- sionally symptomatic. The root filling and restoration are excellent and therefore a surgical approach was consid- ered more appropriate in this case.
Figure 2.14 A view of the resected root end during surgery showing the well-condensed gutta percha root filling, and a small piece of separated instrument not visible on the radiograph.
Figure 2.14 A view of the resected root end during surgery showing the well-condensed gutta percha root filling, and a small piece of separated instrument not visible on the radiograph.
The completed root end surgery. The patient is now symptom-free.
The completed root end surgery. The patient is now symptom-free.
Figure 2.18
Figure 2.18
Figure 2.17
Figure 2.17
Figure 2.16
Figure 2.16
Figure 2.20
Figure 2.20
Figure 2.19
Figure 2.19
Figure 2.21
Figure 2.21
Table 2.3 Treatment success following endodontic retreatment in teeth with and without apical periodontitis to be achieved when treating teeth with apical periodontitis. root canal retreatment was shown to be 62%. In another study the presence of preoperative periapical radiolucency was shown to have a significant negative effect on the outcome of root canal retreatment, although overall success rates were high (91%).”
Table 2.3 Treatment success following endodontic retreatment in teeth with and without apical periodontitis to be achieved when treating teeth with apical periodontitis. root canal retreatment was shown to be 62%. In another study the presence of preoperative periapical radiolucency was shown to have a significant negative effect on the outcome of root canal retreatment, although overall success rates were high (91%).”
Periapical index (PAI). Adapted with permission from @rstavik et al.1”
Periapical index (PAI). Adapted with permission from @rstavik et al.1”
Figure 2.23 Figure 2.25 In this case the maxillary right premolar teeth have been root filled. The root-filling material is short of the root apex in both teeth. There is a periapical radiolucency asso- ciated with the maxillary first premolar. However, there is little evidence of periapical pathology associated with the maxillary second premolar.
Figure 2.23 Figure 2.25 In this case the maxillary right premolar teeth have been root filled. The root-filling material is short of the root apex in both teeth. There is a periapical radiolucency asso- ciated with the maxillary first premolar. However, there is little evidence of periapical pathology associated with the maxillary second premolar.
Figure 2.24 During root canal retreatment it was possible to regain patency in the root canals of the first premolar. This is important as the root canals are undoubtedly infected and should be disinfected to their full extent if possible. The second premolar was blocked apically and it was not pos- sible to gain patency. This should not be of serious con- cern, as the tooth is not associated with periapical pathology and optimistically there will be little chance otf residual bacteria in the apical portion.
Figure 2.24 During root canal retreatment it was possible to regain patency in the root canals of the first premolar. This is important as the root canals are undoubtedly infected and should be disinfected to their full extent if possible. The second premolar was blocked apically and it was not pos- sible to gain patency. This should not be of serious con- cern, as the tooth is not associated with periapical pathology and optimistically there will be little chance otf residual bacteria in the apical portion.
The completed case shows the canals obturated with gutta percha. As expected, root-filling material is short in the second premolar but the canals in the first premolar have been obturated to their full extent.
The completed case shows the canals obturated with gutta percha. As expected, root-filling material is short in the second premolar but the canals in the first premolar have been obturated to their full extent.
Figure 2.27
Figure 2.27
Figure 2.28 A missed second mesiobuccal canal was located during root canal retreatment. All the other canals were success- fully renegotiated, shaped, cleaned and obturated. The patient is now symptom-free.
Figure 2.28 A missed second mesiobuccal canal was located during root canal retreatment. All the other canals were success- fully renegotiated, shaped, cleaned and obturated. The patient is now symptom-free.
Figure 2.26 Instruments that have fractured coronally are easier to remove than those positioned more apically. If the instrument is visible with good
Figure 2.26 Instruments that have fractured coronally are easier to remove than those positioned more apically. If the instrument is visible with good
Figure 2.32
Figure 2.32
Figure 2.30
Figure 2.30
Figure 2.29
Figure 2.29
Figure 2.31
Figure 2.31
Figure 2.33 This mandibular molar presented with a buccal sinus tract and significant gingival recession exposing the furcation. An access cavity has been cut in the occlusal surface; how- ever, the root canals had not been located.
Figure 2.33 This mandibular molar presented with a buccal sinus tract and significant gingival recession exposing the furcation. An access cavity has been cut in the occlusal surface; how- ever, the root canals had not been located.
Figure 2.34 Under microscopic magnification, the temporary filling material in the access cavity was removed.
Figure 2.34 Under microscopic magnification, the temporary filling material in the access cavity was removed.
Figure 2.35 Using a bur, the superficial filling material was removed and the remainder carefully retrieved using ultrasonic tips.
Figure 2.35 Using a bur, the superficial filling material was removed and the remainder carefully retrieved using ultrasonic tips.
Figure 2.36
Figure 2.36
Root canal retreatment decision-making tree.
Root canal retreatment decision-making tree.
Figure 3.1 From a technical viewpoint, it can sometimes be difficult to achieve good positioning of the rubber dam clamp when a crown has been removed. In this case it may be recemented as
Figure 3.1 From a technical viewpoint, it can sometimes be difficult to achieve good positioning of the rubber dam clamp when a crown has been removed. In this case it may be recemented as
Figure 3.3 A Coupland’s chisel should be held firmly in the hand with a forefinger placed near the blade. This will help prevent injury to the patient should the instrument slip.
Figure 3.3 A Coupland’s chisel should be held firmly in the hand with a forefinger placed near the blade. This will help prevent injury to the patient should the instrument slip.
Figure 3.7 Specialist crown pliers can be used to remove restorations. The rubber beaks of the pliers are coated in carborundum powder to improve the grip.
Figure 3.7 Specialist crown pliers can be used to remove restorations. The rubber beaks of the pliers are coated in carborundum powder to improve the grip.
Figure 3.4 Figure 3.6 The tip of the Coupland’s chisel has been modified for use in removing cast restorations.
Figure 3.4 Figure 3.6 The tip of the Coupland’s chisel has been modified for use in removing cast restorations.
Figure 3.5 When removing anterior crowns, it is sometimes possible to cut a groove in the palatal aspect of the crown (as shown by the black lines) into which a flat plastic or Coupland’s chisel can be inserted. Flexing the crown allows removal so that the restoration may be recemented as a temporary.
Figure 3.5 When removing anterior crowns, it is sometimes possible to cut a groove in the palatal aspect of the crown (as shown by the black lines) into which a flat plastic or Coupland’s chisel can be inserted. Flexing the crown allows removal so that the restoration may be recemented as a temporary.
Figure 3.8 A straight chisel and mallet can be used to tap off the crown. However, there are obvious A CT4 tip can be used to remove cement from around the margins of a cast restoration.
Figure 3.8 A straight chisel and mallet can be used to tap off the crown. However, there are obvious A CT4 tip can be used to remove cement from around the margins of a cast restoration.
Figure 3.9 The WamKey (Dentsply, Weybridge, Surrey, UK) looks rather like a small key and can be A crown tapper can be used to remove cast restorations. The beak of the instrument is placed underneath the crown margin and the weights used to produce a sudden force in the long access of the tooth.
Figure 3.9 The WamKey (Dentsply, Weybridge, Surrey, UK) looks rather like a small key and can be A crown tapper can be used to remove cast restorations. The beak of the instrument is placed underneath the crown margin and the weights used to produce a sudden force in the long access of the tooth.
Figure 3.13 The pneumatic handpiece is used to deliver a sudden force into the hoop of the forceps. A wire loop is inserted under the pontic of a bridge for removal with this device.
Figure 3.13 The pneumatic handpiece is used to deliver a sudden force into the hoop of the forceps. A wire loop is inserted under the pontic of a bridge for removal with this device.
Figure 3.10 The KaVo CORONAflex pneumatic crown and bridg remover.
Figure 3.10 The KaVo CORONAflex pneumatic crown and bridg remover.
Figure 3.11 The KaVo CORONAflex forceps are placed at the margins of the restoration.
Figure 3.11 The KaVo CORONAflex forceps are placed at the margins of the restoration.
Figure 3.12
Figure 3.12
Figure 3.17 A small access has been cut in the buccal surface of this full-coverage gold crown. The WamKey has been inserted into it and, when rotated, directs force between the under- side of the crown and the core material.
Figure 3.17 A small access has been cut in the buccal surface of this full-coverage gold crown. The WamKey has been inserted into it and, when rotated, directs force between the under- side of the crown and the core material.
Figure 3.15 The heads of the WamKeys.
Figure 3.15 The heads of the WamKeys.
Figure 3.16
Figure 3.16
Figure 3.21
Figure 3.21
Figure 3.18
Figure 3.18
Figure 3.19
Figure 3.19
Figure 3.20
Figure 3.20
Figure 3.23 Figure 3.25 The CPR range of ultrasonic tips. The CPR 1 is for post removal. Tips 2 to 5 are all diamond coated and can be used at varying depths within the root canal. Dentatus screw-posts come with two wrenches: a cross- head, which can be used to slot into the head of the Dentatus screw; and a box wrench, which can be fitted over the head. A Pro-Ultra Tip 2.
Figure 3.23 Figure 3.25 The CPR range of ultrasonic tips. The CPR 1 is for post removal. Tips 2 to 5 are all diamond coated and can be used at varying depths within the root canal. Dentatus screw-posts come with two wrenches: a cross- head, which can be used to slot into the head of the Dentatus screw; and a box wrench, which can be fitted over the head. A Pro-Ultra Tip 2.
The BUC tips.
The BUC tips.
Figure 3.22
Figure 3.22
Figure 3.29
Figure 3.29
Figure 3.28 Figure 3.26
Figure 3.28 Figure 3.26
Figure 3.27
Figure 3.27
Figure 3.32
Figure 3.32
There are three phases to the removal of a cast post (Figures 3.31-3.42): The Radix Anker showing the groove along its shank. If this is filled with resin-based cement, removal can be more difficult.
There are three phases to the removal of a cast post (Figures 3.31-3.42): The Radix Anker showing the groove along its shank. If this is filled with resin-based cement, removal can be more difficult.
Figure 3.30
Figure 3.30
The distal portion was removed using ultrasonics. When removing a complex posterior cast core, material is normally sectioned into pieces before removal. In this case the mandibular molar has been restored with a cast core. The core has been sectioned into two halves using a tungsten carbide fissure bur.
The distal portion was removed using ultrasonics. When removing a complex posterior cast core, material is normally sectioned into pieces before removal. In this case the mandibular molar has been restored with a cast core. The core has been sectioned into two halves using a tungsten carbide fissure bur.
Figure 3.36 The mesial portion was then retrieved and debris and caries removed from the coronal tooth substance prior to root canal retreatment.
Figure 3.36 The mesial portion was then retrieved and debris and caries removed from the coronal tooth substance prior to root canal retreatment.
Figure 3.35 Figure 3.33
Figure 3.35 Figure 3.33
Figure 3.40
Figure 3.40
Figure 3.38
Figure 3.38
Figure 3.39
Figure 3.39
Figure 3.37
Figure 3.37
Figure 3.44
Figure 3.44
Figure 3.41
Figure 3.41
Figure 3.42 Following removal, the pulp floor was cleaned. There were two canals in the mesiobuccal root. There is some gutta percha retained in a fin adjacent to the main mesiobuccal canal. The second mesiobuccal canal had not been prepared during primary treatment. This highlights the importance of using a solvent when removing condensed gutta percha from root-treated teeth.
Figure 3.42 Following removal, the pulp floor was cleaned. There were two canals in the mesiobuccal root. There is some gutta percha retained in a fin adjacent to the main mesiobuccal canal. The second mesiobuccal canal had not been prepared during primary treatment. This highlights the importance of using a solvent when removing condensed gutta percha from root-treated teeth.
Figure 3.43
Figure 3.43
Figure 3.48 The removal assembly consisting of self-tapping remover, rubber bung and pliers. Using a tungsten carbide non-end cutting bur, core material was reduced so that a trephine from the Ruddle post removal kit could be fitted over it. The trephine machines the core material into a cylinder onto which a self-tapping remover can be fitted.
Figure 3.48 The removal assembly consisting of self-tapping remover, rubber bung and pliers. Using a tungsten carbide non-end cutting bur, core material was reduced so that a trephine from the Ruddle post removal kit could be fitted over it. The trephine machines the core material into a cylinder onto which a self-tapping remover can be fitted.
Figure 3.47
Figure 3.47
Figure 3.46 The Masserann Kit
Figure 3.46 The Masserann Kit
Figure 3.53
Figure 3.53
Figure 3.51
Figure 3.51
Figure 3.50
Figure 3.50
Figure 3.52 Figure 3.49
Figure 3.52 Figure 3.49
Figure 3.57
Figure 3.57
Figure 3.55
Figure 3.55
Figure 3.56
Figure 3.56
Figure 3.60 Figure 3.59 This radiograph shows a maxillary incisor in which a post has fractured. The tooth is restorable as there is sufficient tooth substance remaining to provide a ferrule. During removal, as much of the coronal tooth substance should be preserved as possible. A fractured post viewed through an operating microscope.
Figure 3.60 Figure 3.59 This radiograph shows a maxillary incisor in which a post has fractured. The tooth is restorable as there is sufficient tooth substance remaining to provide a ferrule. During removal, as much of the coronal tooth substance should be preserved as possible. A fractured post viewed through an operating microscope.
Removal of fractured post.
Removal of fractured post.
Figure 3.63
Figure 3.63
Figure 3.62
Figure 3.62
Figure 3.64 The post is then retrieved using a smaller Masserran trephine.
Figure 3.64 The post is then retrieved using a smaller Masserran trephine.
Figure 3.61
Figure 3.61
Figure 3.67 An LN bur, Gates—Glidden bur, Peeso drill and fibre post drill. The pilot channel in the centre of the post.
Figure 3.67 An LN bur, Gates—Glidden bur, Peeso drill and fibre post drill. The pilot channel in the centre of the post.
Figure 3.65 Composite is removed using a diamond bur to uncover the fibre post. The LN bur is used to make a pilot hole along the centre of the post.
Figure 3.65 Composite is removed using a diamond bur to uncover the fibre post. The LN bur is used to make a pilot hole along the centre of the post.
Figure 3.68 The remainder of the post was removed using a post drill.
Figure 3.68 The remainder of the post was removed using a post drill.
Figure 3.74 Following removal of the core, root canal retreatment could be completed. The amalgam was removed conservatively from them using the same ultrasonic tip.
Figure 3.74 Following removal of the core, root canal retreatment could be completed. The amalgam was removed conservatively from them using the same ultrasonic tip.
Figure 3.73
Figure 3.73
Figure 3.72 Eventually, the canal orifices, which were packed with amalgam, were located.
Figure 3.72 Eventually, the canal orifices, which were packed with amalgam, were located.
Figure 3.70 An amalgam Nayyar core has been constructed on this maxillary right first molar tooth. There is little evidence of root-filling material in the root canals and the palatal root has periapical pathology associated with it. Core material was carefully removed from the coronal part of the tooth using a tungsten carbide fissure bur. The lateral boundaries of the previous access cavity were located.
Figure 3.70 An amalgam Nayyar core has been constructed on this maxillary right first molar tooth. There is little evidence of root-filling material in the root canals and the palatal root has periapical pathology associated with it. Core material was carefully removed from the coronal part of the tooth using a tungsten carbide fissure bur. The lateral boundaries of the previous access cavity were located.
Figure 3.71 When the pulp floor was reached, a diamond-coated ultrasonic tip was used to break up material lying across the floor and retained on the walls.
Figure 3.71 When the pulp floor was reached, a diamond-coated ultrasonic tip was used to break up material lying across the floor and retained on the walls.
Figure 3.69
Figure 3.69
Figure 3.78 Six months following root canal retreatment, there appeared to be complete healing radiographically and the tooth will be restored with a cast restoration.
Figure 3.78 Six months following root canal retreatment, there appeared to be complete healing radiographically and the tooth will be restored with a cast restoration.
Figure 3.75 Figure 3.77
Figure 3.75 Figure 3.77
Table 4.1 Pastes
Table 4.1 Pastes
Figure 4.1 An endosonic tip can be used to remove paste root fillings. The energized file will help loosen the material and irrigant will wash it away.
Figure 4.1 An endosonic tip can be used to remove paste root fillings. The energized file will help loosen the material and irrigant will wash it away.
Figure 4.2
Figure 4.2
Figure 4.4 In this case, a maxillary right first premolar has been obtu- rated using Endomethasone. A small amount of material has been extruded from the apex and careful examination of the radiograph shows that only one canal has been instrumented. The case was obturated using a vertically compacted gutta percha technique and the access cavity sealed with resin-modified glass ionomer. In this radiograph, that was taken 6 months following obturation, there has been good evidence of bony healing. A small amount of extruded sealer should not affect the prognosis of treatment.
Figure 4.4 In this case, a maxillary right first premolar has been obtu- rated using Endomethasone. A small amount of material has been extruded from the apex and careful examination of the radiograph shows that only one canal has been instrumented. The case was obturated using a vertically compacted gutta percha technique and the access cavity sealed with resin-modified glass ionomer. In this radiograph, that was taken 6 months following obturation, there has been good evidence of bony healing. A small amount of extruded sealer should not affect the prognosis of treatment.
Figure 4.6 A view into the access chamber shows Endomethasone paste across the pulp floor. This material was removed using an ultrasonic tip and the pulp space irrigated with 3% sodium hypochlorite. There is a small amount of retained Endomethasone under the remnants of the roof of the pulp chamber. This was removed very carefully using endosonics and traced across to the unprepared root canal.
Figure 4.6 A view into the access chamber shows Endomethasone paste across the pulp floor. This material was removed using an ultrasonic tip and the pulp space irrigated with 3% sodium hypochlorite. There is a small amount of retained Endomethasone under the remnants of the roof of the pulp chamber. This was removed very carefully using endosonics and traced across to the unprepared root canal.
Figure 4.5
Figure 4.5
Figure 4.3
Figure 4.3
Figure 4.10
Figure 4.10
Figure 4.8 A diagnostic working length radiograph clearly showing two root canals. Both have been instrumented to their full extent.
Figure 4.8 A diagnostic working length radiograph clearly showing two root canals. Both have been instrumented to their full extent.
Figure 4.9 Chloroform is probably the most effective solvent for gutta percha.
Figure 4.9 Chloroform is probably the most effective solvent for gutta percha.
Figure 4.7
Figure 4.7
Figure 4.11 Endosolve E is useful for the removal of zinc oxide eugenol-based materials.
Figure 4.11 Endosolve E is useful for the removal of zinc oxide eugenol-based materials.
Table 4.2 Removal of pastes This mandibular molar has been root treated. However, the root canals are under-prepared and poorly tapered. The root filling material is short of the root canal terminus and poorly condensed. The distal canal contains a post and there is a large periapical radiolucency around the distal root. Such radiolucency can sometimes indicate the presence of a root fracture. While operating in this area, careful examination will be made under high magnifica- tion to check that there is not a vertical root fracture. The gutta percha can be easily removed using Gates—Glidden burs and nickel-titanium instruments.
Table 4.2 Removal of pastes This mandibular molar has been root treated. However, the root canals are under-prepared and poorly tapered. The root filling material is short of the root canal terminus and poorly condensed. The distal canal contains a post and there is a large periapical radiolucency around the distal root. Such radiolucency can sometimes indicate the presence of a root fracture. While operating in this area, careful examination will be made under high magnifica- tion to check that there is not a vertical root fracture. The gutta percha can be easily removed using Gates—Glidden burs and nickel-titanium instruments.
Figure 4.14 The case has been thoroughly cleaned and shaped and is now medicated with a calcium hydroxide/iodoform material. The material is radio-opaque and it can be quite useful to take a radiograph to check that the medicament is dispersed effectively throughout the root canal system.
Figure 4.14 The case has been thoroughly cleaned and shaped and is now medicated with a calcium hydroxide/iodoform material. The material is radio-opaque and it can be quite useful to take a radiograph to check that the medicament is dispersed effectively throughout the root canal system.
Figure 4.15
Figure 4.15
Figure 4.13
Figure 4.13
Figure 4.17 When engaged, the Hedstroem file will retrieve the gutta percha cone. In this case, the cone is still stuck to the Hedstroem instrument.
Figure 4.17 When engaged, the Hedstroem file will retrieve the gutta percha cone. In this case, the cone is still stuck to the Hedstroem instrument.
Figure 4.16 A single cone root filling in a mandibular molar. Following the preparation of an adequate access cavity, space can be seen alongside the cones of gutta percha. A Hedstroem file can be easily inserted alongside the cone and, when removed, will retrieve the gutta percha. Alternatively, the case could be prepared in the normal manner with nickel-titanium rotary instruments and during coronal flaring the majority of this material will be removed.
Figure 4.16 A single cone root filling in a mandibular molar. Following the preparation of an adequate access cavity, space can be seen alongside the cones of gutta percha. A Hedstroem file can be easily inserted alongside the cone and, when removed, will retrieve the gutta percha. Alternatively, the case could be prepared in the normal manner with nickel-titanium rotary instruments and during coronal flaring the majority of this material will be removed.
Figure 4.20 Following this, the root canal system was obturated with a vertically compacted gutta percha technique and the access cavity filled with a resin-modified glass ionomer.
Figure 4.20 Following this, the root canal system was obturated with a vertically compacted gutta percha technique and the access cavity filled with a resin-modified glass ionomer.
Figure 4.21 Six months following obturation, there was good evidence of bony healing.
Figure 4.21 Six months following obturation, there was good evidence of bony healing.
Figure 4.19 A diagnostic working length estimation radiograph clearly shows that the canals are patent to their full extent. The case was disinfected using sodium hypochlorite, EDTA and iodine in potassium iodide. Calcium hydroxide was used as a medicament for 1 week. A single cone root filling in a mandibular canine. The tooth has been under-prepared and poorly root filled. Space can be seen alongside the two cones that have been inserted in the root canals. The coronal restoration was leaking and as a result of persistent infection there is a large periapical radi- olucency associated with the tooth. The tooth is restorable, has no periodontal disease associated with it and root canal retreatment should offer a good prognosis. The single cones were easily removed by engaging with a Hedstroem file. The buccal and lingual canals were prepared separately.
Figure 4.19 A diagnostic working length estimation radiograph clearly shows that the canals are patent to their full extent. The case was disinfected using sodium hypochlorite, EDTA and iodine in potassium iodide. Calcium hydroxide was used as a medicament for 1 week. A single cone root filling in a mandibular canine. The tooth has been under-prepared and poorly root filled. Space can be seen alongside the two cones that have been inserted in the root canals. The coronal restoration was leaking and as a result of persistent infection there is a large periapical radi- olucency associated with the tooth. The tooth is restorable, has no periodontal disease associated with it and root canal retreatment should offer a good prognosis. The single cones were easily removed by engaging with a Hedstroem file. The buccal and lingual canals were prepared separately.
Figure 4.18
Figure 4.18
Figure 4.25
Figure 4.25
Figure 4.23 The single cone root fillings in these immature maxillary central incisors are not sealing the root canals adequately. There is a large area of periapical radio-lucency around both root apices. Because the roots are immature, disinfection should be carried out with the intention of preserving as much root dentine as possible.
Figure 4.23 The single cone root fillings in these immature maxillary central incisors are not sealing the root canals adequately. There is a large area of periapical radio-lucency around both root apices. Because the roots are immature, disinfection should be carried out with the intention of preserving as much root dentine as possible.
Figure 4.24
Figure 4.24
Figure 4.22
Figure 4.22
Figure 4.28 In this case, a tooth has been root filled using a gutta per- cha technique. However, on preparing an access cavity it was apparent that the roof of the pulp chamber had not been removed. Root canal treatment had been carried out through the pulp horns.
Figure 4.28 In this case, a tooth has been root filled using a gutta per- cha technique. However, on preparing an access cavity it was apparent that the roof of the pulp chamber had not been removed. Root canal treatment had been carried out through the pulp horns.
Figure 4.27 In this maxillary molar there has been gross over-extension of gutta percha in the palatal canal. There is also a large periapical radiolucency associated with this root. It is likely that the canals were over-instrumented, and infected material was pushed through the apex. In this particular case, the tooth had been left open for some time and was probably highly infected. Retrieval of over- extended gutta percha is dependent on whether the cone has become trapped at the apex. A fine Hedstroem file can sometimes be used to engage the cone and retrieve it. The gutta percha cone was retrieved and the root canals shaped and disinfected. They were obturated using a vertically compacted gutta percha technique.
Figure 4.27 In this maxillary molar there has been gross over-extension of gutta percha in the palatal canal. There is also a large periapical radiolucency associated with this root. It is likely that the canals were over-instrumented, and infected material was pushed through the apex. In this particular case, the tooth had been left open for some time and was probably highly infected. Retrieval of over- extended gutta percha is dependent on whether the cone has become trapped at the apex. A fine Hedstroem file can sometimes be used to engage the cone and retrieve it. The gutta percha cone was retrieved and the root canals shaped and disinfected. They were obturated using a vertically compacted gutta percha technique.
Figure 4.26 Heat
Figure 4.26 Heat
Figure 4.30 The access was refined using a non-end-cutting tungsten carbide bur. The coronal aspect of the root canals was prepared with nickel-titanium rotary instruments. A trough was created from the mesiobuccal canal in the direction of the palatal canal to ascertain whether there was a second mesiobuccal canal.
Figure 4.30 The access was refined using a non-end-cutting tungsten carbide bur. The coronal aspect of the root canals was prepared with nickel-titanium rotary instruments. A trough was created from the mesiobuccal canal in the direction of the palatal canal to ascertain whether there was a second mesiobuccal canal.
Figure 4.31 Cleaning the access with sodium hypochlorite revealed the roof of the pulp chamber. The access cavity had to be refined to provide straight-line access to the orifices of the root canals.
Figure 4.31 Cleaning the access with sodium hypochlorite revealed the roof of the pulp chamber. The access cavity had to be refined to provide straight-line access to the orifices of the root canals.
A Gates—Glidden bur is a very efficient means of removing gutta percha from the coronal aspect of the root canals.
A Gates—Glidden bur is a very efficient means of removing gutta percha from the coronal aspect of the root canals.
Figure 4.34
Figure 4.34
Figure 4.35
Figure 4.35
Figure 4.33
Figure 4.33
Figure 4.32
Figure 4.32
Figure 4.37
Figure 4.37
Figure 4.36
Figure 4.36
Figure 4.40 After a third application of chloroform, there was little gutta percha being retrieved on the Hedstroem file and wicking was started with paper points.
Figure 4.40 After a third application of chloroform, there was little gutta percha being retrieved on the Hedstroem file and wicking was started with paper points.
Figure 4.41 Wicking is carried out until the paper points are not discoloured when retrieved from the root canals. On the right-hand side, the cone is stained slightly pink from dissolved gutta percha, whereas on the left, the cone is virtually unchanged. In this case the root canal system should be devoid of gutta percha.
Figure 4.41 Wicking is carried out until the paper points are not discoloured when retrieved from the root canals. On the right-hand side, the cone is stained slightly pink from dissolved gutta percha, whereas on the left, the cone is virtually unchanged. In this case the root canal system should be devoid of gutta percha.
Figure 4.39 After a while, the amount of gutta percha coating the Hedstroem file will be reduced. Additional increments of chloroform will be required to dissolve the remaining gutta percha as it evaporates.
Figure 4.39 After a while, the amount of gutta percha coating the Hedstroem file will be reduced. Additional increments of chloroform will be required to dissolve the remaining gutta percha as it evaporates.
Figure 4.38 Following retrieval of the majority of gutta percha from the root canals, a solvent is used to dissolve the remaining material. In this case, chloroform has been introduced to the root canals and a Hedstroem file used to retrieve the mass of dissolved gutta percha. To start with, a large amount of gutta percha can be seen coating the Hedstroem file. This is cleaned on a gauze before reinsertion.
Figure 4.38 Following retrieval of the majority of gutta percha from the root canals, a solvent is used to dissolve the remaining material. In this case, chloroform has been introduced to the root canals and a Hedstroem file used to retrieve the mass of dissolved gutta percha. To start with, a large amount of gutta percha can be seen coating the Hedstroem file. This is cleaned on a gauze before reinsertion.
Figure 4.44 In this case a maxillary central incisor has been restored with a post core and crown. It has already been root filled and apisected using an amalgam retrograde technique. There is a periapical radiolucency associated with the tooth. In this instance root canal retreatment should be carried out first. The gutta percha can easily be removed with Gates—Glidden burs and the amalgam root end fill- ing visualized with the operating microscope. The root canal space is then cleaned with sodium hypochlorite and endosonics. Six months following obturation, there were good signs of early bony healing.
Figure 4.44 In this case a maxillary central incisor has been restored with a post core and crown. It has already been root filled and apisected using an amalgam retrograde technique. There is a periapical radiolucency associated with the tooth. In this instance root canal retreatment should be carried out first. The gutta percha can easily be removed with Gates—Glidden burs and the amalgam root end fill- ing visualized with the operating microscope. The root canal space is then cleaned with sodium hypochlorite and endosonics. Six months following obturation, there were good signs of early bony healing.
Figure 4.43 Due to the shortened root length and requirement for a post, it could be difficult to achieve sufficient length of gutta percha to produce an adequate seal (minimum 4 mm). Therefore, in this case, the root canal was obturated with mineral trioxide aggregate (MTA).
Figure 4.43 Due to the shortened root length and requirement for a post, it could be difficult to achieve sufficient length of gutta percha to produce an adequate seal (minimum 4 mm). Therefore, in this case, the root canal was obturated with mineral trioxide aggregate (MTA).
Figure 4.47 Asmall amount of gutta percha has been removed from a Thermafil obturator to reveal the V-shaped groove. It is into this groove that the Hedstroem file can be inserted to remove the Thermafil carrier from the root canals.
Figure 4.47 Asmall amount of gutta percha has been removed from a Thermafil obturator to reveal the V-shaped groove. It is into this groove that the Hedstroem file can be inserted to remove the Thermafil carrier from the root canals.
Figure 4.46 In this mandibular molar, the root canals were under- prepared and the root filling was inadequate. In the distal canal there may have been some resorption, leading to over-extension of gutta percha or perhaps the gutta percha was over-extended during obturation. There is a minor periodontal defect on the mesial aspect of the tooth, but it is restorable. Root canal retreatment should offer a good prognosis. The existing root filling was removed using a combination of Gates-Glidden burs and nickel-titanium rotary instruments. It was then disinfected with 4% sodium hypochlorite and EDTA. Calcium hydroxide was used as a medicament between appointments.
Figure 4.46 In this mandibular molar, the root canals were under- prepared and the root filling was inadequate. In the distal canal there may have been some resorption, leading to over-extension of gutta percha or perhaps the gutta percha was over-extended during obturation. There is a minor periodontal defect on the mesial aspect of the tooth, but it is restorable. Root canal retreatment should offer a good prognosis. The existing root filling was removed using a combination of Gates-Glidden burs and nickel-titanium rotary instruments. It was then disinfected with 4% sodium hypochlorite and EDTA. Calcium hydroxide was used as a medicament between appointments.
Figure 4.48 In this mandibular molar, the root canals have been obturated using Thermafil. An access cavity has been prepared and the black carriers can be easily distinguished from the gutta percha. Space is made alongside them to aid retrieval.
Figure 4.48 In this mandibular molar, the root canals have been obturated using Thermafil. An access cavity has been prepared and the black carriers can be easily distinguished from the gutta percha. Space is made alongside them to aid retrieval.
Figure 4.45
Figure 4.45
Figure 4.49 Figure 4.50 In this case, the cones in the mesial canals were retrieved using the Hedstroem files. The area where the Hedstroem file engaged the cone can be seen.
Figure 4.49 Figure 4.50 In this case, the cones in the mesial canals were retrieved using the Hedstroem files. The area where the Hedstroem file engaged the cone can be seen.
Figure 4.51 The Quickfill carriers were all retrieved using endosonics, Hedstroem files and Stieglitz forceps.
Figure 4.51 The Quickfill carriers were all retrieved using endosonics, Hedstroem files and Stieglitz forceps.
This molar has been obturated using Quickfill. The carrier in this case is made of nickel-titanium and can be removed in a similar way to separated instruments. The carrier is coated in gutta percha and normally it is easier to remove some of the material first before attempting retrieval of the carrier.
This molar has been obturated using Quickfill. The carrier in this case is made of nickel-titanium and can be removed in a similar way to separated instruments. The carrier is coated in gutta percha and normally it is easier to remove some of the material first before attempting retrieval of the carrier.
Table 4.3 Cements
Table 4.3 Cements
Figure 4.52 Epiphany is a bondable root filling material and can be removed in a similar manner to conventional gutta percha. dissolved with solvents such as chloroform. Epiphany (Pentron Clinical Technologies, LLC, Wallingford, CT, USA) is a dual curable dental resin composite sealer that is used with Resilon. It is claimed that the resin can impregnate dentinal tubules,” providing a bond between the mass of obturating material and the wall of the root canal. In a retreatment situation, this hybrid layer may need to be removed mechanically by enlarging the canal (Figure 4.52).
Figure 4.52 Epiphany is a bondable root filling material and can be removed in a similar manner to conventional gutta percha. dissolved with solvents such as chloroform. Epiphany (Pentron Clinical Technologies, LLC, Wallingford, CT, USA) is a dual curable dental resin composite sealer that is used with Resilon. It is claimed that the resin can impregnate dentinal tubules,” providing a bond between the mass of obturating material and the wall of the root canal. In a retreatment situation, this hybrid layer may need to be removed mechanically by enlarging the canal (Figure 4.52).
Table 4.4 Removal of cements working with a microscope and allows easy drying of the operating field when working at higher magnifications (Figure 4.55).
Table 4.4 Removal of cements working with a microscope and allows easy drying of the operating field when working at higher magnifications (Figure 4.55).
The Pro-Ultra endosonic tips. These tips are all diamond coated and can be used to retrieve cements from the coronal to mid-third of the root canal. Swan-necked tungsten carbide LN burs are an invaluable tool for removing cements from the root canal. They should always be used with direct vision, preferably with an operating microscope to prevent the risk of perforation.
The Pro-Ultra endosonic tips. These tips are all diamond coated and can be used to retrieve cements from the coronal to mid-third of the root canal. Swan-necked tungsten carbide LN burs are an invaluable tool for removing cements from the root canal. They should always be used with direct vision, preferably with an operating microscope to prevent the risk of perforation.
Figure 4.53 Figure 4.55
Figure 4.53 Figure 4.55
A disposable Stropko-style irrigator with an Endo-Eze tip fitted. The assistant can puff air across the operating site to disperse dentine chips as they are created by the ultrasonic tip.
A disposable Stropko-style irrigator with an Endo-Eze tip fitted. The assistant can puff air across the operating site to disperse dentine chips as they are created by the ultrasonic tip.
Figure 5.1 The operating microscope is invaluable in endodontics for treatment, retreatment and surgical procedures. This global microscope has three steps of magnification. It has a beam splitter, which allows the mounting of a digital camera. The camera can be used to take still photos or to provide a con- tinuous video stream for viewing on a computer screen. Cross-infection barriers are placed on the handles and over the main lens; they are changed between patients. Microscopes can provide magnifications in the range X3 to X30. Low magnifications are excellent for general work and have a wider field of view and good depth of focus. Higher magnifications are used for specific tasks such as hunting for missed canals and retrieving sep- arated instruments. The field of view and depth
Figure 5.1 The operating microscope is invaluable in endodontics for treatment, retreatment and surgical procedures. This global microscope has three steps of magnification. It has a beam splitter, which allows the mounting of a digital camera. The camera can be used to take still photos or to provide a con- tinuous video stream for viewing on a computer screen. Cross-infection barriers are placed on the handles and over the main lens; they are changed between patients. Microscopes can provide magnifications in the range X3 to X30. Low magnifications are excellent for general work and have a wider field of view and good depth of focus. Higher magnifications are used for specific tasks such as hunting for missed canals and retrieving sep- arated instruments. The field of view and depth
Figure 5.2 The beam splitter divides the light (red arrows) from the objective and diverts it into the eyepieces and other accessory devices: these include additional assistant viewing binoculars, a mini camera or digital camera.
Figure 5.2 The beam splitter divides the light (red arrows) from the objective and diverts it into the eyepieces and other accessory devices: these include additional assistant viewing binoculars, a mini camera or digital camera.
Figure 5.6 When there has been significant microleakage, the silver points are generally much easier to remove. In this case, removal of the temporary restoration from the existing access cavity revealed that the pulp roof had not been ade- quately removed. The small hole that had been created was filled with Endomethasone paste and the heads of the silver points were visible within this. The Endomethasone was removed using endosonic tips and CPR 5, following which the silver points could be removed very simply using Hedstroem files and Stieglitz forceps. The roof of the pulp chamber was then removed with a non-end-cutting tung- sten carbide bur to provide visualization of the pulp floor. The mesial canals following coronal flaring and refine- ment of the access chamber. The pulp floor was stained pink by the Endomethasone paste that had previously been used as a root filling material.
Figure 5.6 When there has been significant microleakage, the silver points are generally much easier to remove. In this case, removal of the temporary restoration from the existing access cavity revealed that the pulp roof had not been ade- quately removed. The small hole that had been created was filled with Endomethasone paste and the heads of the silver points were visible within this. The Endomethasone was removed using endosonic tips and CPR 5, following which the silver points could be removed very simply using Hedstroem files and Stieglitz forceps. The roof of the pulp chamber was then removed with a non-end-cutting tung- sten carbide bur to provide visualization of the pulp floor. The mesial canals following coronal flaring and refine- ment of the access chamber. The pulp floor was stained pink by the Endomethasone paste that had previously been used as a root filling material.
Figure 5.3 Figure 5.5 This mandibular first molar has been root filled using a silver point root filling technique. The root canals have been inadequately prepared and there has been significant microleakage. Paste can be seen both in the coronal aspect of the distal root canal and in the apical third of the mesial canals. There is a large periapical area that extends around both root tips and an area of internal resorption in the dis- tal root. The tooth is restorable and there are no significant periodontal problems surrounding it. Root canal retreatment is therefore justified and should have good prognosis.
Figure 5.3 Figure 5.5 This mandibular first molar has been root filled using a silver point root filling technique. The root canals have been inadequately prepared and there has been significant microleakage. Paste can be seen both in the coronal aspect of the distal root canal and in the apical third of the mesial canals. There is a large periapical area that extends around both root tips and an area of internal resorption in the dis- tal root. The tooth is restorable and there are no significant periodontal problems surrounding it. Root canal retreatment is therefore justified and should have good prognosis.
Figure 5.4 Following refinement of the access cavity, the root canals were thoroughly irrigated using sodium hypochlorite. A diagnostic working length estimation radiograph revealed that the canals in this tooth were completely patent. Some refinement in the preparation was required using tapered nickel-titanium rotary instruments. The root canal space was then disinfected with 3% sodium hypochlorite and EDTA.
Figure 5.4 Following refinement of the access cavity, the root canals were thoroughly irrigated using sodium hypochlorite. A diagnostic working length estimation radiograph revealed that the canals in this tooth were completely patent. Some refinement in the preparation was required using tapered nickel-titanium rotary instruments. The root canal space was then disinfected with 3% sodium hypochlorite and EDTA.
Figure 5.9 A biopsy of the sinus tract was taken and a histopathology report requested. Under low magnification, silver parti- cles can clearly be seen dispersed through the epithelium.
Figure 5.9 A biopsy of the sinus tract was taken and a histopathology report requested. Under low magnification, silver parti- cles can clearly be seen dispersed through the epithelium.
Figure 5.10 Retrieval of objects from the access chamber can be achieved using forceps. The Stieglitz forceps are modified to make the beaks slimmer. Micro artery forceps can also be useful.
Figure 5.10 Retrieval of objects from the access chamber can be achieved using forceps. The Stieglitz forceps are modified to make the beaks slimmer. Micro artery forceps can also be useful.
Figure 5.8 Obturation completed using a vertically compacted gutta technique and Obtura thermoplasticized gutta percha. A foam sponge has been placed in the pulp chamber and the access sealed with intermediate restorative material (IRM). This tooth was due to be restored within 2 weeks of completion of the root canal treatment. The clinical view of the mandibular molar showing a sinus tract on the buccal mucosa. This healed following initial cleaning, shaping and medication with calcium hydroxide. The area was stained black. This was a result of corrosion of the silver points in the root canal.
Figure 5.8 Obturation completed using a vertically compacted gutta technique and Obtura thermoplasticized gutta percha. A foam sponge has been placed in the pulp chamber and the access sealed with intermediate restorative material (IRM). This tooth was due to be restored within 2 weeks of completion of the root canal treatment. The clinical view of the mandibular molar showing a sinus tract on the buccal mucosa. This healed following initial cleaning, shaping and medication with calcium hydroxide. The area was stained black. This was a result of corrosion of the silver points in the root canal.
Figure 5.7 Once the core material has been removed, the access cavity is thoroughly irrigated with sodium hypochlorite or iodine solution.
Figure 5.7 Once the core material has been removed, the access cavity is thoroughly irrigated with sodium hypochlorite or iodine solution.
Figure 5.13
Figure 5.13
Figure 5.12
Figure 5.12
Figure 5.14
Figure 5.14
Figure 5.11
Figure 5.11
The Meitrac II system for removal of small objects.
The Meitrac II system for removal of small objects.
Figure 5.16 The silver point shows corrosion products on its tip. The coronal end is intact and clearly shows where it was severed during an apical silver point technique.
Figure 5.16 The silver point shows corrosion products on its tip. The coronal end is intact and clearly shows where it was severed during an apical silver point technique.
Figure 5.15
Figure 5.15
Figure 5.19
Figure 5.19
Figure 5.21
Figure 5.21
Figure 5.20 Figure 5.18
Figure 5.20 Figure 5.18
Figure 5.23 When placing a post in the root canal, a sec- tional silver cone technique was often used. The cone was usually severed 4 or 5 mm from its tip and, after insertion, the apical fragment separated by rotating the coronal portion. In order to remove the apical portion of a sectional silver cone, adequate access and coronal flaring must first be carried out. An The cone was retrieved and root canal retreatment carried out in a conventional manner. The root canals were sealed using a vertically compacted gutta percha technique.
Figure 5.23 When placing a post in the root canal, a sec- tional silver cone technique was often used. The cone was usually severed 4 or 5 mm from its tip and, after insertion, the apical fragment separated by rotating the coronal portion. In order to remove the apical portion of a sectional silver cone, adequate access and coronal flaring must first be carried out. An The cone was retrieved and root canal retreatment carried out in a conventional manner. The root canals were sealed using a vertically compacted gutta percha technique.
Figure 5.22 In this maxillary molar, there was a silver point in the mesial buccal canal. The point had sheared off at orifice level and the root canal was moderately curved. The point was also well cemented. Retrieval in this situation is com- plex. Space will need to be made alongside the cone so that it can be retrieved. It is useful in the mesiobuccal root of maxillary molars to assess whether there is a second root canal. Sometimes preparing the second mesiobuccal canal will allow the introduction of irrigant to the level of the primary mesiobuccal canal. These canals are often joined by an isthmus. The isthmus will occasionally pro- vide a channel along which small files can be introduced to bypass the cone.
Figure 5.22 In this maxillary molar, there was a silver point in the mesial buccal canal. The point had sheared off at orifice level and the root canal was moderately curved. The point was also well cemented. Retrieval in this situation is com- plex. Space will need to be made alongside the cone so that it can be retrieved. It is useful in the mesiobuccal root of maxillary molars to assess whether there is a second root canal. Sometimes preparing the second mesiobuccal canal will allow the introduction of irrigant to the level of the primary mesiobuccal canal. These canals are often joined by an isthmus. The isthmus will occasionally pro- vide a channel along which small files can be introduced to bypass the cone.
Figure 5.28 The access cavities have been modified and now extend from the cingulum to the incisal edge (indicated by red arrows). Good straight-line access to both buccal and lin- gual canals can now be achieved. The coronal part of the silver point root filling is clearly visible. There is space alongside the cone. The root canal was irrigated with 3% sodium hypochlorite and endosonics inserted alongside the coronal part of the silver point to loosen it.
Figure 5.28 The access cavities have been modified and now extend from the cingulum to the incisal edge (indicated by red arrows). Good straight-line access to both buccal and lin- gual canals can now be achieved. The coronal part of the silver point root filling is clearly visible. There is space alongside the cone. The root canal was irrigated with 3% sodium hypochlorite and endosonics inserted alongside the coronal part of the silver point to loosen it.
Figure 5.26
Figure 5.26
Figure 5.27
Figure 5.27
Figure 5.25
Figure 5.25
Figure 5.32
Figure 5.32
Figure 5.30
Figure 5.30
Figure 5.31
Figure 5.31
Figure 5.29
Figure 5.29
Figure 5.34 Six months following root canal retreatment, there was good evidence of bony healing. The tooth was not symp- tomatic, and therefore the likelihood of surgery being required is extremely slim.
Figure 5.34 Six months following root canal retreatment, there was good evidence of bony healing. The tooth was not symp- tomatic, and therefore the likelihood of surgery being required is extremely slim.
Figure 5.33 Due to the angulation and curvature of the mesiobuccal root, a modified access was created and a staging platform created over the coronal aspect of the silver cone. The silver cone was then retrieved using endosonics. Next, the canal was renegotiated, shaped, cleaned and obturated using a vertically compacted gutta technique.
Figure 5.33 Due to the angulation and curvature of the mesiobuccal root, a modified access was created and a staging platform created over the coronal aspect of the silver cone. The silver cone was then retrieved using endosonics. Next, the canal was renegotiated, shaped, cleaned and obturated using a vertically compacted gutta technique.
Figure 5.35 There was a spiral filler in the distal root of this mandibular molar. The access can be modified using a non- end-cutting tungsten carbide bur such as the Endo-Z (Maillefer, Ballaigues, Switzerland) or
Figure 5.35 There was a spiral filler in the distal root of this mandibular molar. The access can be modified using a non- end-cutting tungsten carbide bur such as the Endo-Z (Maillefer, Ballaigues, Switzerland) or
Figure 5.36 Access was created using tungsten carbide burs and the spiral filler loosened with an endosonic tip (CPR 5).
Figure 5.36 Access was created using tungsten carbide burs and the spiral filler loosened with an endosonic tip (CPR 5).
Figure 5.38
Figure 5.38
Figure 5.37
Figure 5.37
Figure 5.39
Figure 5.39
Figure 5.42 Following medication for 1 week, the tooth was symptom- free and the buccal sinus tract had healed. The root canals were subsequently obturated with a vertically compacted gutta percha technique and the access sealed with inter- mediate restorative material (IRM).
Figure 5.42 Following medication for 1 week, the tooth was symptom- free and the buccal sinus tract had healed. The root canals were subsequently obturated with a vertically compacted gutta percha technique and the access sealed with inter- mediate restorative material (IRM).
Figure 5.43 The instrument removal system (IRS). This consists of a tube with a small window at the tip through which a rod is inserted. The tube is placed over the separated object and, when the rod is inserted and screwed down, it becomes trapped in the window.
Figure 5.43 The instrument removal system (IRS). This consists of a tube with a small window at the tip through which a rod is inserted. The tube is placed over the separated object and, when the rod is inserted and screwed down, it becomes trapped in the window.
Figure 5.41 In this maxillary molar, there was a fractured stainless steel instrument in the mesiobuccal canal. The tooth had periapical radiolucency associated with it and the root canals were undoubtedly infected. The instrument had fractured at the point of curvature of the mesiobuccal canal. Retrieval would be complicated and at best it may only be possible to bypass the instrument, clean the root canal and incorporate it in the root canal filling material. Access was prepared and the root canals flared in the nor- mal manner. The object was retrieved using endosonics. The root canal system could then be cleaned, shaped and disinfected in the normal manner. A second mesiobuccal canal was located and instrumented. In this case, a calcium hydroxide /iodoform-based medica- ment was used to attempt further disinfection of the root canals between visits. A radiograph of the material shows it has been well dispersed in the root canal system.
Figure 5.41 In this maxillary molar, there was a fractured stainless steel instrument in the mesiobuccal canal. The tooth had periapical radiolucency associated with it and the root canals were undoubtedly infected. The instrument had fractured at the point of curvature of the mesiobuccal canal. Retrieval would be complicated and at best it may only be possible to bypass the instrument, clean the root canal and incorporate it in the root canal filling material. Access was prepared and the root canals flared in the nor- mal manner. The object was retrieved using endosonics. The root canal system could then be cleaned, shaped and disinfected in the normal manner. A second mesiobuccal canal was located and instrumented. In this case, a calcium hydroxide /iodoform-based medica- ment was used to attempt further disinfection of the root canals between visits. A radiograph of the material shows it has been well dispersed in the root canal system.
Figure 5.40
Figure 5.40
Figure 5.44 The instrument removal system (IRS) being used to retrieve a stainless steel instrument from the distobuccal canal of the maxillary molar.
Figure 5.44 The instrument removal system (IRS) being used to retrieve a stainless steel instrument from the distobuccal canal of the maxillary molar.
Figure 5.45 The fractured instrument has been trapped in the tube. Once engaged, a gentle watch-winding action will often release the object and allow it to be retrieved.
Figure 5.45 The fractured instrument has been trapped in the tube. Once engaged, a gentle watch-winding action will often release the object and allow it to be retrieved.
Figure 5.47
Figure 5.47
Figure 5.48
Figure 5.48
Figure 5.51 A modified endosonic tip can be a useful tool for the removal of small objects. CPR 6, 7 and 8. These tips are extremely fine and can be used deep into the root canal system with little risk of damage to the root canal. They are a means of applying ultrasonic force to the lateral aspect of an object that may be wedged in the root canal.
Figure 5.51 A modified endosonic tip can be a useful tool for the removal of small objects. CPR 6, 7 and 8. These tips are extremely fine and can be used deep into the root canal system with little risk of damage to the root canal. They are a means of applying ultrasonic force to the lateral aspect of an object that may be wedged in the root canal.
Figure 5.50
Figure 5.50
Figure 5.54 Following irrigation and ultrasonic vibration, the Profile is unscrewed from the root canal. It is now situated in the access cavity and can be easily retrieved with a pair of Stieglitz forceps.
Figure 5.54 Following irrigation and ultrasonic vibration, the Profile is unscrewed from the root canal. It is now situated in the access cavity and can be easily retrieved with a pair of Stieglitz forceps.
Figure 5.55 The Profile instrument removed intact.
Figure 5.55 The Profile instrument removed intact.
Figure 5.53 The access cavity is first modified so that straight-line access to the head of the instrument can be achieved and the instrument has a clear exit pathway for retrieval. A red arrow indicates extension of the access cavity onto the incisal edge. A fine ultrasonic tip, such as the CPR 2, 3 or CT4, is used to apply ultrasonic force to the lateral aspect of the Profile. In this maxillary lateral incisor, a nickel-titanium Profile instrument has separated. The entire working length is present in the root canal system. Retrieval of an instrument fragment such as this should be relatively simple, as it is most likely to be binding coronally.
Figure 5.53 The access cavity is first modified so that straight-line access to the head of the instrument can be achieved and the instrument has a clear exit pathway for retrieval. A red arrow indicates extension of the access cavity onto the incisal edge. A fine ultrasonic tip, such as the CPR 2, 3 or CT4, is used to apply ultrasonic force to the lateral aspect of the Profile. In this maxillary lateral incisor, a nickel-titanium Profile instrument has separated. The entire working length is present in the root canal system. Retrieval of an instrument fragment such as this should be relatively simple, as it is most likely to be binding coronally.
Figure 5.52
Figure 5.52
Figure 5.57
Figure 5.57
Figure 5.58
Figure 5.58
Figure 5.63
Figure 5.63
Figure 5.62
Figure 5.62
Figure 5.61
Figure 5.61
Figure 5.60
Figure 5.60
Figure 5.65
Figure 5.65
Figure 5.64
Figure 5.64
Figure 5.67
Figure 5.67
Figure 5.66
Figure 5.66
Removal of nickel-titanium instrument.
Removal of nickel-titanium instrument.
Figure 6.1 (A) A maxillary molar that requires root canal treatment. There has been significant irritation dentine formed in response to bacterial leakage around extensive restora- tions. The pulp chamber roof and floor are in very close proximity. It would be easy to accidentally perforate the furcation during access cavity preparation. Careful meas- urement from the preoperative radiograph, magnification and illumination all allow the operator to prepare an access confidently without risk. (B) The completed case. CONTENTS e Introduction e Preventing Perforation « Important Factors in Dealing with Perforations e Furcation Perforation e Materials e Perforation Repair Technique e Strip Perforation Repair e Post Space Perforation Repair e Perforation Repair in the Apical Region e Renegotiating the Root Canal Following Dismantling e References
Figure 6.1 (A) A maxillary molar that requires root canal treatment. There has been significant irritation dentine formed in response to bacterial leakage around extensive restora- tions. The pulp chamber roof and floor are in very close proximity. It would be easy to accidentally perforate the furcation during access cavity preparation. Careful meas- urement from the preoperative radiograph, magnification and illumination all allow the operator to prepare an access confidently without risk. (B) The completed case. CONTENTS e Introduction e Preventing Perforation « Important Factors in Dealing with Perforations e Furcation Perforation e Materials e Perforation Repair Technique e Strip Perforation Repair e Post Space Perforation Repair e Perforation Repair in the Apical Region e Renegotiating the Root Canal Following Dismantling e References
Figure 6.2 In this mandibular molar, a micro-perforation has been made in the wall of the access cavity indicated by a blue arrow. In this situation, the perforation can be cleaned with sodium hypochlorite and sealed very effectively with a glass ionomer or light-cured composite. - The pulp floor is disinfected using sodium hypochlorite and EDTA. The area over the perforation is either acid-etched with phos- phoric acid and then restored with conven- tional flowable composite or conditioned and restored with a resin-modified glass ionomer (Figures 6.2, 6.3).
Figure 6.2 In this mandibular molar, a micro-perforation has been made in the wall of the access cavity indicated by a blue arrow. In this situation, the perforation can be cleaned with sodium hypochlorite and sealed very effectively with a glass ionomer or light-cured composite. - The pulp floor is disinfected using sodium hypochlorite and EDTA. The area over the perforation is either acid-etched with phos- phoric acid and then restored with conven- tional flowable composite or conditioned and restored with a resin-modified glass ionomer (Figures 6.2, 6.3).
Figure 6.4
Figure 6.4
Figure 6.3
Figure 6.3
Figure 6.6 Intermediate restorative material (IRM) is a reinforced zinc oxide-eugenol material that can be used for perfora- tion repair.
Figure 6.6 Intermediate restorative material (IRM) is a reinforced zinc oxide-eugenol material that can be used for perfora- tion repair.
Figure 6.5 Super EBA (ethoxybenzoic acid) has been used for root- end surgery for many years and can be used to repair perforations. It will work well in smaller cavities.
Figure 6.5 Super EBA (ethoxybenzoic acid) has been used for root- end surgery for many years and can be used to repair perforations. It will work well in smaller cavities.
Figure 6.7 Figure 6.9
Figure 6.7 Figure 6.9
Figure 6.10 The defect has been filled with a resin-modified glass ionomer.
Figure 6.10 The defect has been filled with a resin-modified glass ionomer.
Figure 6.8 In this mandibular molar, a large perforation has been cre- ated in the wall of the access chamber. This is supracrestal but at the level of the gingival tissues. (The red arrow indi- cates perforation, the blue arrow the position of the canal orifice.)
Figure 6.8 In this mandibular molar, a large perforation has been cre- ated in the wall of the access chamber. This is supracrestal but at the level of the gingival tissues. (The red arrow indi- cates perforation, the blue arrow the position of the canal orifice.)
The root canal orifice has been identified and the access cavity modified so that it can be repaired. The defect has been cleaned with 4% sodium hypochlorite and EDTA.
The root canal orifice has been identified and the access cavity modified so that it can be repaired. The defect has been cleaned with 4% sodium hypochlorite and EDTA.
Figure 6.14 The Super EBA material has been covered with a coating of resin-modified glass ionomer.
Figure 6.14 The Super EBA material has been covered with a coating of resin-modified glass ionomer.
Figure 6.13 In this maxillary premolar, a furcal perforation has been created during post preparation. This has subsequently been sealed with Super EBA.
Figure 6.13 In this maxillary premolar, a furcal perforation has been created during post preparation. This has subsequently been sealed with Super EBA.
Figure 6.12 The defect in this case was repaired with IRM. Material has been plugged into the perforation site and burnished.
Figure 6.12 The defect in this case was repaired with IRM. Material has been plugged into the perforation site and burnished.
Figure 6.11 In this maxillary molar, there is a perforation adjacent to the distobuccal canal (red arrow). The root canals have been cleaned, shaped and medicament placed for 1 week. Following further irrigation, the perforation can be repaired.
Figure 6.11 In this maxillary molar, there is a perforation adjacent to the distobuccal canal (red arrow). The root canals have been cleaned, shaped and medicament placed for 1 week. Following further irrigation, the perforation can be repaired.
Figure 6.16
Figure 6.16
Figure 6.17 Figure 6.15
Figure 6.17 Figure 6.15
Figure 6.20 In this case, a strip perforation had been created in the mesial canals during over-use of nickel-titanium rotary instruments (arrow). The apical portion of the root canal was obturated with gutta percha and the coronal part sealed with MTA. This will also seal the strip perfora- tion defect.
Figure 6.20 In this case, a strip perforation had been created in the mesial canals during over-use of nickel-titanium rotary instruments (arrow). The apical portion of the root canal was obturated with gutta percha and the coronal part sealed with MTA. This will also seal the strip perfora- tion defect.
Figure 6.19 The root canal has been obturated using the vertically compacted gutta percha technique and thermoplasti- cized Obtura gutta percha. The perforation has been repaired with MTA. (Radiograph courtesy of James Aquilina.)
Figure 6.19 The root canal has been obturated using the vertically compacted gutta percha technique and thermoplasti- cized Obtura gutta percha. The perforation has been repaired with MTA. (Radiograph courtesy of James Aquilina.)
Figure 6.18 In this maxillary lateral incisor, there is a perforation below crestal bone level. The tooth has also suffered from internal resorption.
Figure 6.18 In this maxillary lateral incisor, there is a perforation below crestal bone level. The tooth has also suffered from internal resorption.
Figure 6.21 Figure 6.23 The root canal of this tooth has been perforated. (Red arrow indicates the position of the perforation, the blue arrow shows the root canal.)
Figure 6.21 Figure 6.23 The root canal of this tooth has been perforated. (Red arrow indicates the position of the perforation, the blue arrow shows the root canal.)
Figure 6.22 Matrix material has been plugged through the perforation into the bony defect. The root canal has been sealed with gutta percha.
Figure 6.22 Matrix material has been plugged through the perforation into the bony defect. The root canal has been sealed with gutta percha.
MTA has been used to seal the perforation site and the coronal aspect of the root canal.
MTA has been used to seal the perforation site and the coronal aspect of the root canal.
Internal matrix perforation repair.
Internal matrix perforation repair.
Figure 6.28 An indicator dye such as Canal Blue (Dentsply Weybridge, Surrey, UK) has been used to identify orifices of any remaining root canals in this maxillary molar.
Figure 6.28 An indicator dye such as Canal Blue (Dentsply Weybridge, Surrey, UK) has been used to identify orifices of any remaining root canals in this maxillary molar.
Figure 6.26 In this maxillary central incisor, there was a possibility that the root canal had been perforated by previous post space preparation. Because the root canal was very large, it was decided to obturate the apical region with MTA, which will seal any potential perforation (arrow). The pulp floor map has not been used in a previous attempt to find the root canals (blue arrows indicate canal orifices). The bur holes made in attempt to locate the ori- fices are off-centre (red arrows). Direct vision with the operating microscope makes the mistake look obvious and reinforces the benefit of magnification and illumina- tion for better visualization.
Figure 6.26 In this maxillary central incisor, there was a possibility that the root canal had been perforated by previous post space preparation. Because the root canal was very large, it was decided to obturate the apical region with MTA, which will seal any potential perforation (arrow). The pulp floor map has not been used in a previous attempt to find the root canals (blue arrows indicate canal orifices). The bur holes made in attempt to locate the ori- fices are off-centre (red arrows). Direct vision with the operating microscope makes the mistake look obvious and reinforces the benefit of magnification and illumina- tion for better visualization.
Figure 6.27 The correct orifices have now been accessed and flared.
Figure 6.27 The correct orifices have now been accessed and flared.
Figure 6.25
Figure 6.25
Figure 6.30
Figure 6.30
Figure 6.29
Figure 6.29
Negotiating the lingual canal in a mandibular premolar.
Negotiating the lingual canal in a mandibular premolar.
Figure 6.33 Negotiating a ledge. Figure 6.34 Once a ledge has been negotiated, a precurved nickel- titanium hand instrument can be used to flare the root canal beyond the ledge, thus reducing the step.
Figure 6.33 Negotiating a ledge. Figure 6.34 Once a ledge has been negotiated, a precurved nickel- titanium hand instrument can be used to flare the root canal beyond the ledge, thus reducing the step.
In this mandibular molar, ledges have been created in the mesial root canals. The root canals are under- prepared and the root filling material is short in both mesial and distal roots. The gutta percha root filling was easily removed with Gates—Glidden burs followed by solvent. A fine precurved hand instrument was then inserted and directed towards the midline area. The mesial canals were renegotiated and could be refined with nickel-titanium instruments. In the distal canal, a previous attempt had ledged midway down the root. Having removed material from the coronal aspect, the root canal orifice could be visualized under the operating microscope and was then prepared in the normal manner.
In this mandibular molar, ledges have been created in the mesial root canals. The root canals are under- prepared and the root filling material is short in both mesial and distal roots. The gutta percha root filling was easily removed with Gates—Glidden burs followed by solvent. A fine precurved hand instrument was then inserted and directed towards the midline area. The mesial canals were renegotiated and could be refined with nickel-titanium instruments. In the distal canal, a previous attempt had ledged midway down the root. Having removed material from the coronal aspect, the root canal orifice could be visualized under the operating microscope and was then prepared in the normal manner.
Figure 6.38 Six months following obturation, there was good evidence of bony healing. The case was irrigated with 4% sodium hypochlorite and EDTA and medicated with calcium hydroxide for 1 week prior to obturation with a vertically compacted gutta percha technique. The access cavity, which was made through an existing restoration, was sealed with IRM.
Figure 6.38 Six months following obturation, there was good evidence of bony healing. The case was irrigated with 4% sodium hypochlorite and EDTA and medicated with calcium hydroxide for 1 week prior to obturation with a vertically compacted gutta percha technique. The access cavity, which was made through an existing restoration, was sealed with IRM.
Figure 6.36 The case has been obturated with a vertically compacted gutta percha technique and the access cavity sealed ready for restoration with a Nayyar core. This mandibular molar has been poorly root filled. The canals are under-prepared, under-filled and the root fill- ing material is short in both mesial and distal roots. There was a buccal sinus tract which could be delineated with a gutta percha cone. This traced to the distal root canal around which there was a large periapical radiolucency. The mesial canals were both ledged and required renego- tiation. The gutta percha was removed using Gates—Glidden burs, Hedstroem files and chloroform. The root canals were then renegotiated, prepared and shaped using nickel-titanium rotary instruments.
Figure 6.36 The case has been obturated with a vertically compacted gutta percha technique and the access cavity sealed ready for restoration with a Nayyar core. This mandibular molar has been poorly root filled. The canals are under-prepared, under-filled and the root fill- ing material is short in both mesial and distal roots. There was a buccal sinus tract which could be delineated with a gutta percha cone. This traced to the distal root canal around which there was a large periapical radiolucency. The mesial canals were both ledged and required renego- tiation. The gutta percha was removed using Gates—Glidden burs, Hedstroem files and chloroform. The root canals were then renegotiated, prepared and shaped using nickel-titanium rotary instruments.
Figure 6.35
Figure 6.35
Figure 6.37
Figure 6.37
Figure 7.3
Figure 7.3
Figure 7.2 Figure 7.1
Figure 7.2 Figure 7.1
Parcan is a 3% stabilized solution of sodium hypochlorite.
Parcan is a 3% stabilized solution of sodium hypochlorite.
Figure 7.4
Figure 7.4
Figure 7.7 A 17% EDTA solution is normally used in endodontics. It is used to remove smear layer and can therefore be used in conjunction with other biologically active irrigants.
Figure 7.7 A 17% EDTA solution is normally used in endodontics. It is used to remove smear layer and can therefore be used in conjunction with other biologically active irrigants.
Figure 7.6 Corsodyl is a 0.2% chlorhexidine gluconate solution.
Figure 7.6 Corsodyl is a 0.2% chlorhexidine gluconate solution.
Figure 7.8
Figure 7.8
The Sterilox unit. Preprepared electrolyte is poured into the unit and the two solutions are then derived (Optident, Yorkshire, UK). The Sterilox system utilizes a catalyst tube to produce two solutions from a quality-controlled prepackaged solution: Sterilox solution (anolyte) and sodium hydroxide (catholyte).
The Sterilox unit. Preprepared electrolyte is poured into the unit and the two solutions are then derived (Optident, Yorkshire, UK). The Sterilox system utilizes a catalyst tube to produce two solutions from a quality-controlled prepackaged solution: Sterilox solution (anolyte) and sodium hydroxide (catholyte).
Figure 7.13 The PAD system being used to disinfect a disto-occlusal cavity in a premolar. The red laser light is visible, shining through the buccal aspect (Denfotex, Scotland, UK).
Figure 7.13 The PAD system being used to disinfect a disto-occlusal cavity in a premolar. The red laser light is visible, shining through the buccal aspect (Denfotex, Scotland, UK).
Photoactivated disinfection (PAD). The PAD system has an endodontic insert (on the right-hand side). This allows direction of red laser light into the root canal system (Denfotex, Scotland, UK). The PAD endotip (Denfotex, Scotland, UK).
Photoactivated disinfection (PAD). The PAD system has an endodontic insert (on the right-hand side). This allows direction of red laser light into the root canal system (Denfotex, Scotland, UK). The PAD endotip (Denfotex, Scotland, UK).
Figure 7.11
Figure 7.11
Figure 7.14 Calcium Hydroxide Endosonics being used to irrigate the root canal system of a maxillary molar.
Figure 7.14 Calcium Hydroxide Endosonics being used to irrigate the root canal system of a maxillary molar.
Figure 7.18 The mesiolingual root canal in this mandibular first molar has been fully prepared, irrigated and dried ready for the placement of calcium hydroxide medicament. A lentulo spiral filler can be introduced into the sachet and will pick up calcium hydroxide. This can then be placed into the root canal.
Figure 7.18 The mesiolingual root canal in this mandibular first molar has been fully prepared, irrigated and dried ready for the placement of calcium hydroxide medicament. A lentulo spiral filler can be introduced into the sachet and will pick up calcium hydroxide. This can then be placed into the root canal.
Figure 7.17 Figure 7.15 Sachets of 100% calcium hydroxide. The slurry can provide a pH of 12.6. This is sufficiently alkaline to kill most bacteria found in the root canal system but needs to be in contact with bacteria to be most effective.
Figure 7.17 Figure 7.15 Sachets of 100% calcium hydroxide. The slurry can provide a pH of 12.6. This is sufficiently alkaline to kill most bacteria found in the root canal system but needs to be in contact with bacteria to be most effective.
Figure 7.16 The calcium hydroxide sachet should be kneaded before use to thoroughly mix the contents.
Figure 7.16 The calcium hydroxide sachet should be kneaded before use to thoroughly mix the contents.
Figure 7.22
Figure 7.22
Figure 7.21
Figure 7.21
Figure 7.20
Figure 7.20
Figure 7.23
Figure 7.23
There is the risk that without bacterial culturing or analysis, the injudicious use of antibiotics may result in bacterial resistance. An infected root canal contains a complex mixed flora and it is, therefore, inappropriate to rely on them to eliminate all of the bacteria.” Topical application of antibiotic may also increase the risk of a patient becoming sensitized to it (Figure 7.23). Clindamycin placed in teeth with necrotic pulps undergoing root canal treatment offered no advantage over conventional root canal dressings such as calcium hydroxide for elimination of bacteria. Its clinical use was not recommended.”
There is the risk that without bacterial culturing or analysis, the injudicious use of antibiotics may result in bacterial resistance. An infected root canal contains a complex mixed flora and it is, therefore, inappropriate to rely on them to eliminate all of the bacteria.” Topical application of antibiotic may also increase the risk of a patient becoming sensitized to it (Figure 7.23). Clindamycin placed in teeth with necrotic pulps undergoing root canal treatment offered no advantage over conventional root canal dressings such as calcium hydroxide for elimination of bacteria. Its clinical use was not recommended.”
Figure 8.2
Figure 8.2
Figure 8.1
Figure 8.1
Figure 8.3
Figure 8.3
Figure 8.7 Inspection of the MTA root end filling prior to flap closure. A biopsy can be required when a suspicious lesion is present at the periapex. An indication of size should be recorded and the sample sent in formal saline to a histopathology laboratory for assessment. In this case a lesion has been curetted in toto.
Figure 8.7 Inspection of the MTA root end filling prior to flap closure. A biopsy can be required when a suspicious lesion is present at the periapex. An indication of size should be recorded and the sample sent in formal saline to a histopathology laboratory for assessment. In this case a lesion has been curetted in toto.
Figure 8.6
Figure 8.6
Figure 8.4 Root canal retreatment has been completed and as a result of further irrigation an apical delta has been revealed following obturation. It was not possible to remove the extruded gutta percha from a lateral canal in the mid-third. Unfortunately, despite a thorough approach to root canal retreatment, the tooth was still symptomatic. Root end surgery was therefore indicated.
Figure 8.4 Root canal retreatment has been completed and as a result of further irrigation an apical delta has been revealed following obturation. It was not possible to remove the extruded gutta percha from a lateral canal in the mid-third. Unfortunately, despite a thorough approach to root canal retreatment, the tooth was still symptomatic. Root end surgery was therefore indicated.
Figure 8.5 The maxillary incisor following root resection, prepara- tion and placement of an MTA root end filling. Extruded gutta percha has been removed from the lateral canal and the gutta percha burnished. The tooth was symptom-free following surgery.
Figure 8.5 The maxillary incisor following root resection, prepara- tion and placement of an MTA root end filling. Extruded gutta percha has been removed from the lateral canal and the gutta percha burnished. The tooth was symptom-free following surgery.
Figure 8.9 Root end surgery has been completed on the maxillary premolars. The first premolar was retreated using a non- surgical approach. During surgery, extruded material was removed from the bone surrounding the root apices and the root ends resected. It was felt that root end filling was not necessary in this case as root canal retreatment had only recently been completed. The gutta percha was therefore burnished. In the second premolar, the root end was resected and a separated instrument retrieved from the root canal. This was then prepared using ultrasonic tips and sealed with MTA.
Figure 8.9 Root end surgery has been completed on the maxillary premolars. The first premolar was retreated using a non- surgical approach. During surgery, extruded material was removed from the bone surrounding the root apices and the root ends resected. It was felt that root end filling was not necessary in this case as root canal retreatment had only recently been completed. The gutta percha was therefore burnished. In the second premolar, the root end was resected and a separated instrument retrieved from the root canal. This was then prepared using ultrasonic tips and sealed with MTA.
Figure 8.8
Figure 8.8
Figure 8.10
Figure 8.10
Figure 8.11 The maxillary second premolar was associated with chronic periapical periodontitis and a well-established sinus tract was present. On reflection of the flap, the tract can be seen firmly attached to the underside of the mucosa. It is important not to tear the friable mucosa, and sometimes the tissue will need to be separated from it using a pair of dissecting scissors or a scalpel blade.
Figure 8.11 The maxillary second premolar was associated with chronic periapical periodontitis and a well-established sinus tract was present. On reflection of the flap, the tract can be seen firmly attached to the underside of the mucosa. It is important not to tear the friable mucosa, and sometimes the tissue will need to be separated from it using a pair of dissecting scissors or a scalpel blade.
Figure 8.13 Root end surgery was considered in the posterior maxilla of this patient. Access is excellent, as the oral cavity is large and the sulcus deep. Good access will be provided to the roots of the maxillary premolars. In this patient, there was a thick band of attached gingiva, which may lend itself to the use of a submarginal flap.
Figure 8.13 Root end surgery was considered in the posterior maxilla of this patient. Access is excellent, as the oral cavity is large and the sulcus deep. Good access will be provided to the roots of the maxillary premolars. In this patient, there was a thick band of attached gingiva, which may lend itself to the use of a submarginal flap.
Figure 8.12
Figure 8.12
Figure 8.14
Figure 8.14
Figure 8.16
Figure 8.16
Figure 8.15
Figure 8.15
Figure 8.17 Figure 8.18 Due to the close proximity of the maxillary premolar root apices to the antrum, perforation will occasionally occur. In this case the maxillary antrum can be seen at the back of the osseous crypt (blue arrow). The defect will be closed when the flap is replaced and it is not normally necessary to prescribe an antral regimen.
Figure 8.17 Figure 8.18 Due to the close proximity of the maxillary premolar root apices to the antrum, perforation will occasionally occur. In this case the maxillary antrum can be seen at the back of the osseous crypt (blue arrow). The defect will be closed when the flap is replaced and it is not normally necessary to prescribe an antral regimen.
Access to the palatal root of maxillary premolars can be achieved from a buccal approach. However, when the roots are divergent the palatal root canal may be positioned a long way from the cortical plate. There is also an increased risk of perforating the antrum.
Access to the palatal root of maxillary premolars can be achieved from a buccal approach. However, when the roots are divergent the palatal root canal may be positioned a long way from the cortical plate. There is also an increased risk of perforating the antrum.
Figure 8.20 During root end surgery in the mandibular premolar region the mental nerve should be _ identified. Occasionally, the root end will need to be resected rather more aggressively to prevent damage to the nerve tissue.
Figure 8.20 During root end surgery in the mandibular premolar region the mental nerve should be _ identified. Occasionally, the root end will need to be resected rather more aggressively to prevent damage to the nerve tissue.
Figure 8.19 The resected root end of a mandibular incisor showing an isthmus. Due to the angulation of the mandibular incisors, it is not uncommon to have to bevel the root end slightly. This elongates the length of the isthmus that has to be prepared.
Figure 8.19 The resected root end of a mandibular incisor showing an isthmus. Due to the angulation of the mandibular incisors, it is not uncommon to have to bevel the root end slightly. This elongates the length of the isthmus that has to be prepared.
Figure 8.21
Figure 8.21
Figure 9.1 After approximately 15 minutes following infiltration of local anaesthetic, blanching of the tissues should be seen (blue arrow). Local anaesthetic in volumes of 0.5 ml is normally deposited into numerous infiltration sites around the tooth that is to be treated. This ensures good anaesthesia and haemo- stasis. Injection should be carried out slowly at a rate of 1 or 2 ml/min.’ Rapid injection produces pooling of anaesthetic in the tissues,
Figure 9.1 After approximately 15 minutes following infiltration of local anaesthetic, blanching of the tissues should be seen (blue arrow). Local anaesthetic in volumes of 0.5 ml is normally deposited into numerous infiltration sites around the tooth that is to be treated. This ensures good anaesthesia and haemo- stasis. Injection should be carried out slowly at a rate of 1 or 2 ml/min.’ Rapid injection produces pooling of anaesthetic in the tissues,
Mandibular Surgery
Mandibular Surgery
Figure 9.6
Figure 9.6
Figure 9.5
Figure 9.5
Figure 9.4
Figure 9.4
Figure 9.10
Figure 9.10
Figure 9.8
Figure 9.8
Figure 9.7
Figure 9.7
Figure 9.9
Figure 9.9
Good visibility and access has been achieved for the root end of the mandibular first premolar. The borders of the flap will be on sound bone when replaced. Root end surgery was required on this mandibular first premolar. A full-thickness triangular flap will be used with a relieving incision mesial to the mandibular canine.
Good visibility and access has been achieved for the root end of the mandibular first premolar. The borders of the flap will be on sound bone when replaced. Root end surgery was required on this mandibular first premolar. A full-thickness triangular flap will be used with a relieving incision mesial to the mandibular canine.
Figure 9.11
Figure 9.11
Figure 9.14
Figure 9.14
Figure 9.13
Figure 9.13
The relieving incision meets the gingival crevice at 90 degrees and runs vertically upwards
The relieving incision meets the gingival crevice at 90 degrees and runs vertically upwards
Figure 9.17 The rectangular flap has been designed so that good visibility can be achieved. The lesion associated with these teeth is large and extends superiorly to the floor of the nose. The boundaries of the flap will lie on sound bone when it is replaced.
Figure 9.17 The rectangular flap has been designed so that good visibility can be achieved. The lesion associated with these teeth is large and extends superiorly to the floor of the nose. The boundaries of the flap will lie on sound bone when it is replaced.
Figure 9.16 There is a large periapical lesion around the apices of the upper left central and lateral incisor. A rectangular flap will be required to gain surgical access.
Figure 9.16 There is a large periapical lesion around the apices of the upper left central and lateral incisor. A rectangular flap will be required to gain surgical access.
Figure 9.15
Figure 9.15
Triangular flap. Triangular flap.
Triangular flap. Triangular flap.
Relieving incision “a” papilla intact Relieving incision “b” papilla retracte:
Relieving incision “a” papilla intact Relieving incision “b” papilla retracte:
Scalloped incision follows gingival contour Three days later, there is good evidence of healing by primary intention. Figure 9.23
Scalloped incision follows gingival contour Three days later, there is good evidence of healing by primary intention. Figure 9.23
Rectangular flap. In this case a Luebke-Ochsenbein flap was raised. The flap has been sutured using silk sutures.
Rectangular flap. In this case a Luebke-Ochsenbein flap was raised. The flap has been sutured using silk sutures.
Figure 9.25
Figure 9.25
Figure 9.27
Figure 9.27
Figure 9.24
Figure 9.24
Pressure is applied to the flap following replacement to initiate good adaptation and help reduce haemorrhage.
Pressure is applied to the flap following replacement to initiate good adaptation and help reduce haemorrhage.
Figure 9.30
Figure 9.30
Reflection of the flap starts at the relieving incision and proceeds in the order:
Reflection of the flap starts at the relieving incision and proceeds in the order:
Figure 9.29 A gauge 5/0 silk suture. Tissue tags (blue arrows) are present on the cortical bone surface. They will help reattachment of the flap and also healing following surgery.
Figure 9.29 A gauge 5/0 silk suture. Tissue tags (blue arrows) are present on the cortical bone surface. They will help reattachment of the flap and also healing following surgery.
Figure 9.33 A Prolene (polypropylene) monofilament suture has been used to retain a Luebke—Ochsenbein flap with interrupted sutures. The sutures will be removed in 3 days. A minor frenectomy has also been carried out in this case.
Figure 9.33 A Prolene (polypropylene) monofilament suture has been used to retain a Luebke—Ochsenbein flap with interrupted sutures. The sutures will be removed in 3 days. A minor frenectomy has also been carried out in this case.
Figure 9.32 Monofilament sutures such as polypropylene can be very useful in endodontic surgery. There is no risk of bacterial wicking and the suture is relatively easy to use. The cut ends can be prickly on the buccal mucosa.
Figure 9.32 Monofilament sutures such as polypropylene can be very useful in endodontic surgery. There is no risk of bacterial wicking and the suture is relatively easy to use. The cut ends can be prickly on the buccal mucosa.
A variety of sutures sizes 4/0 to 6/0, with various curvatures and radii of needle are used, depending on the anatomical situation. The minimum number of sutures that are required to retain the flap should be used. Interrupted sutures are frequently used to retain a full-thickness flap. They can be modi- fied to provide a sling, thereby avoiding hav- ing to place the suture material through the papilla (Figure 9.34).
A variety of sutures sizes 4/0 to 6/0, with various curvatures and radii of needle are used, depending on the anatomical situation. The minimum number of sutures that are required to retain the flap should be used. Interrupted sutures are frequently used to retain a full-thickness flap. They can be modi- fied to provide a sling, thereby avoiding hav- ing to place the suture material through the papilla (Figure 9.34).
Figure 10.1 The cortical plate has been perforated by expansion of this radicular cyst.
Figure 10.1 The cortical plate has been perforated by expansion of this radicular cyst.
Figure 10.3 The radicular cyst has been curetted in one piece and the bony cavity remains.
Figure 10.3 The radicular cyst has been curetted in one piece and the bony cavity remains.
Figure 10.2 There is a very large radiolucency associated with the maxillary second molar. Non-surgical retreatment would be carried out first, as it is quite likely that the root canals are infected. The lesion undoubtedly perforates the max- illary sinus and is very large. Surgery in this instance may be better carried out under general anaesthetic in a hospital environment.
Figure 10.2 There is a very large radiolucency associated with the maxillary second molar. Non-surgical retreatment would be carried out first, as it is quite likely that the root canals are infected. The lesion undoubtedly perforates the max- illary sinus and is very large. Surgery in this instance may be better carried out under general anaesthetic in a hospital environment.
Figure 10.4
Figure 10.4
Figure 10.6 The resected root end has a rough appearance when a diamond bur is used. Root end resection.
Figure 10.6 The resected root end has a rough appearance when a diamond bur is used. Root end resection.
Figure 10.8
Figure 10.8
Figure 10.9 Root end preparation.
Figure 10.9 Root end preparation.
Figure 10.11 Preparation of a root end cavity in a maxillary premolar using a tip ultrasonic KiS.
Figure 10.11 Preparation of a root end cavity in a maxillary premolar using a tip ultrasonic KiS.
Figure 10.12 A high-magnification view of the ultrasonic tip being used to prepare the mesiobuccal root of a maxillary molar.
Figure 10.12 A high-magnification view of the ultrasonic tip being used to prepare the mesiobuccal root of a maxillary molar.
Figure 10.10 A KiS ultrasonic tip for root end cavity preparation. The tip has a diamond-coated end and an irrigant channel.
Figure 10.10 A KiS ultrasonic tip for root end cavity preparation. The tip has a diamond-coated end and an irrigant channel.
Figure 10.13 Figure 10.15
Figure 10.13 Figure 10.15
Figure 10.14
Figure 10.14
Figure 10.17
Figure 10.17
Modified MTA, with a faster setting time, may prove easier to manage. Mineral trioxide aggregate (MTA) is dispensed as a pow- der and water. When the two are mixed, the material takes on the consistency of wet sand.
Modified MTA, with a faster setting time, may prove easier to manage. Mineral trioxide aggregate (MTA) is dispensed as a pow- der and water. When the two are mixed, the material takes on the consistency of wet sand.
Figure 10.18
Figure 10.18
Figure 10.23 A previous attempt at root end surgery using amalgam as a root end filling can be seen in this maxillary central incisor (blue arrow). The case was retreated non- surgically to ensure that the root canal was adequately disinfected and the gutta percha root filling can be seen at the canal orifice (red arrow). The amalgam retrograde filling had been placed incorrectly and the root canal had not been prepared during surgery. It is perhaps not surprising that the previous attempt at endodontic sur- gery failed. The value of using an operating microscope is clearly highlighted.
Figure 10.23 A previous attempt at root end surgery using amalgam as a root end filling can be seen in this maxillary central incisor (blue arrow). The case was retreated non- surgically to ensure that the root canal was adequately disinfected and the gutta percha root filling can be seen at the canal orifice (red arrow). The amalgam retrograde filling had been placed incorrectly and the root canal had not been prepared during surgery. It is perhaps not surprising that the previous attempt at endodontic sur- gery failed. The value of using an operating microscope is clearly highlighted.
Figure 10.20 The Lee block is a device for creating small cubes of MTA that can be loaded onto a plugger or flat plastic.
Figure 10.20 The Lee block is a device for creating small cubes of MTA that can be loaded onto a plugger or flat plastic.
A view at high power showing the compacted gutta percha following root end cavity preparation.
A view at high power showing the compacted gutta percha following root end cavity preparation.
Figure 10.22 The cavity has been filled with ProRoot MTA and the surface wiped free of excess material with a damp sponge.
Figure 10.22 The cavity has been filled with ProRoot MTA and the surface wiped free of excess material with a damp sponge.
Figure 10.25
Figure 10.25
Figure 10.27
Figure 10.27
Figure 10.24
Figure 10.24
Figure 10.26
Figure 10.26
Figure 10.30 The case filled with IRM and the root surface polished.
Figure 10.30 The case filled with IRM and the root surface polished.
Figure 10.29 When the IRM has set, the resected root and filling material can be polished with an ultrafine diamond or tungsten carbide bur. The completed root end preparation in a maxillary premolar.
Figure 10.29 When the IRM has set, the resected root and filling material can be polished with an ultrafine diamond or tungsten carbide bur. The completed root end preparation in a maxillary premolar.
Figure 10.31
Figure 10.31
Figure 10.28
Figure 10.28
Figure 10.35 A view of the distal canal, showing the completed root end filling.
Figure 10.35 A view of the distal canal, showing the completed root end filling.
Figure 10.32 A triangular flap was raised to provide good surgical access.
Figure 10.32 A triangular flap was raised to provide good surgical access.
Figure 10.33 The lesion was curetted and the bony crypt enlarged to allow root resection and root end preparation of both roots.
Figure 10.33 The lesion was curetted and the bony crypt enlarged to allow root resection and root end preparation of both roots.
Figure 10.34 The completed root end filling in the mesial root, showing an isthmus connecting the two canals. This would not have been visible without an operating microscope.
Figure 10.34 The completed root end filling in the mesial root, showing an isthmus connecting the two canals. This would not have been visible without an operating microscope.
Figure 10.39
Figure 10.39
Figure 10.38
Figure 10.38
Figure 10.37
Figure 10.37
Figure 10.36
Figure 10.36
Figure 10.43
Figure 10.43
Figure 10.40 Figure 10.42
Figure 10.40 Figure 10.42
The case filled with Super EBA.
The case filled with Super EBA.
Figure 10.47 With the introduction of operating micro- scopes into endodontics, the methods available for repair of perforations using a non-surgical approach have increased enormously. However, there are occasions when a surgical approach may be required. Planning is very important, as access can be extremely difficult, especially if the root perforation is on the lingual surface. The mesiobuccal root of this maxillary molar has been resected. The patient has been instructed on oral hygiene measures to keep the area plaque-free.
Figure 10.47 With the introduction of operating micro- scopes into endodontics, the methods available for repair of perforations using a non-surgical approach have increased enormously. However, there are occasions when a surgical approach may be required. Planning is very important, as access can be extremely difficult, especially if the root perforation is on the lingual surface. The mesiobuccal root of this maxillary molar has been resected. The patient has been instructed on oral hygiene measures to keep the area plaque-free.
Figure 10.46 A failing root-filled tooth. There was evidence of marginal periodontitis, which required treatment. The distal root was fractured and unsaveable. The patient did not want a denture in the lower arch and was not a suitable candidate for implants. Hemisection of the molar was a possibility. The mesial roots were retreated and the molar hemi- sected. A metal composite bridge has been constructed as a temporary measure. There appears to be good bony healing, and the teeth are not mobile. The patient is aware of the importance of good plaque removal around the bridge abutments.
Figure 10.46 A failing root-filled tooth. There was evidence of marginal periodontitis, which required treatment. The distal root was fractured and unsaveable. The patient did not want a denture in the lower arch and was not a suitable candidate for implants. Hemisection of the molar was a possibility. The mesial roots were retreated and the molar hemi- sected. A metal composite bridge has been constructed as a temporary measure. There appears to be good bony healing, and the teeth are not mobile. The patient is aware of the importance of good plaque removal around the bridge abutments.
Figure 10.45 as a guide for cutting. Traditionally, a silver cone was placed through the furcation to act as a guide. The occlusal surface is first reduced by 2-3 mm and then a high-speed bur with coolant water spray used to section the tooth. If one of the roots is to be removed, it can be elevated using luxators. Occasionally, the individual
Figure 10.45 as a guide for cutting. Traditionally, a silver cone was placed through the furcation to act as a guide. The occlusal surface is first reduced by 2-3 mm and then a high-speed bur with coolant water spray used to section the tooth. If one of the roots is to be removed, it can be elevated using luxators. Occasionally, the individual
Figure 10.48 An attempt at surgical perforation repair has resulted in the demise of this tooth. The amalgam filling in the lateral aspect of the root does not seal effectively. When surgery has been completed efficiently without unnecessary trauma to the surgical site, postoperative healing is usually unevent- ful. Patients should be provided with postop- erative instructions both verbally and in writing. These will ensure good home care
Figure 10.48 An attempt at surgical perforation repair has resulted in the demise of this tooth. The amalgam filling in the lateral aspect of the root does not seal effectively. When surgery has been completed efficiently without unnecessary trauma to the surgical site, postoperative healing is usually unevent- ful. Patients should be provided with postop- erative instructions both verbally and in writing. These will ensure good home care
Table 10.1 Analgesic efficacy’
Table 10.1 Analgesic efficacy’
Bruising is possible following endodontic surgery.
Bruising is possible following endodontic surgery.
Figure 10.50
Figure 10.50
Figure 10.51
Figure 10.51

Key takeaways

  • There is little root filling material present and the root canal would undoubtedly be infected.
  • Perhaps the root canal treatment was carried out while the teeth were still vital and the root canals were not infected.
  • An attempt at root canal treatment has been made but the root canals are extremely fine and have not been successfully negotiated.
  • This can then be placed into the root canal.
  • In the majority of cases, root end surgery would not be carried out unless the root canal had been thoroughly cleaned prior to treatment.

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