In this case, the doctor referring the patient asked me if I could retrieve the broken file.
File retrieval is always changeling for me because usually requires a lot of time and the collaboration of the patient trying not to move due to the high magnified field of view where I work on and a lot of patience as well; the use of the proper equipment plays a very important role.
This case has been done with ProUltra ultrasonic tips (Dentsply) under the LabomedMagnasurgical microscope view.
These tips are made of titanium and can be pre-curved allowing to work in the direction you want. The bad side of these instruments is that they tend to get blunt and break very easily.
The use of the macriscope is a must, you need to see where are you activating the ultrasonic tip to preserve as much dentin as possible and to avoid perforations.
The broken file it behaves as a rigid body due its short length although the alloy what is made of should let it behave as a flexible metal. As I told before, be patient and remove dentin little by little to create more space is the only way to get the file out of the canal.
My advice for this kind of situations is try to bypass the broken file first, and if you can’t, try to retrieve it. Bypassing instruments is something that I’m not able to do 90% of the time.
As you can see on the video, please watch it on 720p50 HD, the case I want to show today is a re-treatment of a lower left six first molar #36. The tooth presented a ledge and missed canal on the mesial root and another ledge and a broken instrument on the distal.
Although ledges sometimes can look easy to bypass, is not always possible to do mainly because of the location of the ledge and the patient’s opening mouth range.
Our instruments are flexible but tend to work in a straight line because their memory effect. To bypass and fix this kind of problems, we need to approach the canal in the proper angulation and as I said, sometimes is really tricky because of the limited opening range of the patient. We need to pre-bend our instrument with the proper angulation and remove dentin, as less as possible, from inside of the canal with small ultrasonic tips in order to straighten the access. A CBCT will allows us to visualize the anatomy of the root and identify the real angulation of the canal which is something we have to keep in mind when we try to bypass the ledge.
Patient, knowledge of the anatomy and the use of high magnification as the surgical microscope are the keys to success in this kind of treatments.
“Remove know from knowledge and you are standing on the ledge”.
In this case, I found a pulp stone inside of a mandibular second molar. Dental pulp tissue can form dentin or osteodentin in the reaction to the homeostasis induced either by surgical or chemical stimulation, and the activity of pulp cells regulates the calcification of pulp tissue.
Pulp stones are calcified bodies in the dental pulps of the teeth, which can be seen in the pulps of healthy, diseased, and even un-erupted teeth in the primary and permanent dentition. Dental pulp stones may be free, attached, or embedded in the coronal or radicular pulp. They are considerably more common in the pulp chamber than in the root canal and may occur in a single tooth or several teeth.
Although pulp stones have no clinical significance, they lead to complications when endodontic therapy is needed.
As you can see in the video, their large size in pulp chamber may block access to canal orifices and alter the internal anatomy, and attached stones may deflect or engage the tip of exploring instruments, preventing their easy passage down the canal. In this kind of situation the use of the surgicalmicroscope is mandatory.
One of the most important things in Endodontics is planification, for that, we need to have an excellent knowledge of the pulp chamber anatomy as well as the different variants in configurations of the root canal system anatomy. Nowadays, and according to the American Association of Endodontists, the use of the CBCT is a standard in our field. This tool, allow us to see the tooth in a 3D model, and check the anatomy from every angle.
On the next case, I completed a root canal treatment in a second maxillary molar, almost the last tooth! the complexity of the case was the minimal mouth aperture of the patient and the tricky root canal anatomy with this 4 canals. Planning the cases before, allow me to do the treatments in a shorter and safer way.
Today’s case is a 11 year old patient with a big caries on the second maxillary molar referred to me to save the tooth. My duty as endodontist is not only providing root canal treatments but also preserving teeth from them too.
In this particularly case I performed a pulp horn amputation.
These are the steps taken:
– Rubber dam isolation.
– Microscope magnification.
– Manual removal of the soft dentin with excavator.
– Pulp horn amputation.
– Disinfected and rinsed with NaOCl from “outside” to achieve haemostasis.
– Dried with sterile cotton pellets.
– Bioceramic capping.
– Direct glass ionomer as temporally filling on top.
Last month I gave a lecture at The 9th Palestinian International Dental Conference. I have to start this post thanking particularly to the BAIRD Academy and the Palestine Dentistry Society for inviting me to the congress and make me feel like I was at home. I want to thank especially Dr. Hassan Maghaireh, Dr. Raed Junaidy, Dr. Anan Amro, and Dr. Ahmad Abd El-Ghani for all their help and for showing me the most beautiful areas of Jordan, Palestine and Jerusalem.
The topic I covered was about Magnification, Cumulative Trauma Disorders (CTDs), Ergonomics and 4 Handed Workflow. For me, all those 4 concepts, are intimately related.
Our manual capacity is limited by our own eyes. It’s because of that why we can not be more precise, simple as that. To be able to see fine details, we have to bring the object closer to the eye. This is why dentists have to bend down over the patient’s mouth, and this is why dentist have back problems.
The use of magnification is the way to overcome our eye’s limitations. This will also make us work in a neutral and healthy position resulting in long lasting professional career.
4 handed work flow is the master piece which completes the ergonomic puzzle. Here you have a couple of videos where I show basic movements which you can start using till you develope your own technique. The first video has been recorded in 30 minutes with an assistant with no previous experience at all; and the second one with a new assistant after one month training. Watch in HD.
“Make it a point to do something every day that you don’t want to do. This is the golden rule for acquiring the habit of doing your duty without pain.” Mark Twain.