A successful endodontic treatment outcome thanks to an accurate diagnosis and the use of high-quality materials
Featured Products Promotional FeaturesPosted by: Dental Design 10th April 2023
Dr Sagi Shavit graduated from dental school in 2009 in Bucharest, and developed a special interest in endodontics shortly after. He then undertook a number of endodontic training courses, including microsurgical endodontics in London. In 2015, Dr Shavit gained an MSc in Endodontics from the University of Chester. Now he exclusively treats endodontic patients at Cleveland Terrace Dental Practice, Darlington.
Here, he presents a case which discusses the importance of making an accurate diagnosis for a high-quality treatment and a successful outcome.
Initial presentation and examination
A male patient in his early 30s was referred to our clinic in Darlington, regarding his lower molar. He complained of painful episodes and pain upon mastication.
Clinical examination revealed that the LR6, restored with composite filling, was grade 1 mobile and tender upon light percussion. It was non responsive to cold testing, and periodontal probing around the tooth showed deep localised distal periodontal pocketing. No other periodontal pocketing was noted.
Radiographic examination (see figure 1) shows deep restoration on the LR6, with a ‘J’- shaped lesion associated with the distal root. This, alongside the localised periodontal pocketing and the increased mobility of the tooth, is an indication of two possible diagnoses with two completely different prognoses.
Figure 1. Preoperative radiograph
The first is vertical fracture of the distal root, which requires extraction of the tooth due to the poor long-term prognosis. The second possible diagnosis is endo-perio lesion, which responds well to non-surgical root canal treatment (RCT).
As the intraoral examination revealed no obvious crack lines on the tooth, it was less likely that a vertical fracture has occurred, although it could not be excluded.
Diagnosis
A diagnosis of chronic apical periodontitis following pulp necrosis, was made. The treatment options of endodontic treatment, extraction of the tooth, or do nothing were discussed, as well as the possibility of vertical fracture. The patient elected to have endodontic treatment, if possible.
Treatment
To begin treatment, the tooth was accessed under rubber dam and the canals were located with the aid of the dental operating microscope. The use of higher magnification and superior illumination from the dental microscope allows easier identification of canal orifices and crack lines. A vertical fracture line could be clearly seen in a different tooth, with the aid of the dental operating microscope (see figure 2). In this case, 4 canals were identified and no obvious cracks were present.
Figure 2. Vertical fracture line involving the distal root
The access to all 4 canals was refined using the COLTENE HyFlex™ Orifice Opener 25/.12 in order to allow better entry into each canal. The working length was then determined using the CanalPro™ Apex Locator, also from COLTENE, and verified with a radiograph.
A smooth glide path was achieved using manual 8 and 10 K-Reamer files, and the 10/.05 GlidePath™ file from the COLTENE HyFlex™ EDM system. Mechanical instrumentation continued using the 20/.04 and HyFlex™ EDM OneFile in all canals.
This was performed under copious irrigation of 5.25% sodium hypochlorite (NaOCl), and a final rinse with 17% EDTA. Both irrigation solutions were activated ultrasonically using the cordless endodontic activator CanalPro™ EndoUltra from COLTENE.
HyFlex™ Guttapercha points were fitted inside the wet canals to verify ‘tug-back’ and another radiograph was acquired to confirm fit. The canals were then dried using matching HyFLex™ EDM Paper Points, and obturated using warm vertical compaction.
The access cavity was sealed with resin composite and the patient was advised to return in 3 months-time for assessment of the treatment outcome. The post-operative radiograph (see figure 3) shows adequate 3-dimensional obturation of the endodontic space.
Figure 3. Postoperative radiograph
Patient returns for review
The patient returned for his review 6 months post-operatively. The tooth has been symptom free, and upon examination there was no tenderness to percussion, no mobility and no periodontal probing associated with the tooth.
The 6 months post-operative radiograph (see figure 4) shows complete healing of the lesions associated with both roots. The patient was discharged back to their referring dentist for full cusp coverage of the tooth.
Figure 4. 6 months postoperative radiograph
Conclusions
The management of vertical fracture lines is complex, and making the correct diagnosis is essential for a successful outcome.
The use of a dental operating microscope alongside the HyFlex™ EDM file system from COLTENE allows quick and safe instrumentation of the root canal system, and more time for copious irrigation, the most important part of the endodontic treatment. Ultrasonic activation of the irrigation solutions with the CanalPro™ EndoUltra, provides much more efficient debridement.
HyFlex™ EDM files are super elastic, efficient and safe, for excellent performance across all canal types. CanalPro™ Apex Locator provides crisp and accurate readings of the working length and is an indispensable tool during endodontic treatment.
The matching HyFlex™ EDM Paper Points and Guttapercha points allow safe and accurate obturation of the endodontic space, and a predictable, successful outcome.
For more on COLTENE, visit www.coltene.com,
email info.uk@coltene.com or call 0800 254 5115.
