Dentaltown August 2017 - 50

Case 2

B

y the time I completed this case in 2015,
I was taking preoperative CBCTs on
many cases. Tooth #18 presented with
a necrotic pulp and chronic apical abscess.
Periodontal probing depths in the furcation
were 15 millimeters. Root canal therapy was
indicated to remove the infection and save
the tooth, but the CBCT revealed that the
root was only 0.3mm wide on the furcation
side of the mesial root-a very dangerous
danger zone. This means that there is
almost no room for shaping without strip
perforation and potential immediate loss of
the tooth. But without adequate shaping,
would it be possible to adequately clean and
pack? Other than extraction, I didn't have
a choice but to try.
I shaped the mesiobuccal and mesiolingual canals to a #20 K-file with a balanced
force technique. No attempt was made to
create apical taper or push-pull file. A Tulsa
ProGlider was used to shape the coronal third
of the canal for a little bit of convenience
form. EDTA and NaOCL were actively
irrigated with an EndoActivator with a
small (15/02) tip for 15 minutes, refreshing
the NaOCL between canals. Ultradent
Ultracal calcium hydroxide was placed with
a NaviTip and brought to length with the
EndoActivator. To prevent coronal leakage
between visits, a double-layer temporary,
consisting of Temp-it and bonded composite,
was used to seal the access.
The patient was seen again in two months
to repeat the irrigation steps and to place
calcium hydroxide for another two months.
The case was obturated at the third visit,
after confirming healing of the periodontal
defect with a 2mm probing measurement
and bone regeneration radiographically. The
periapical radiograph and CBCT showed
excellent healing at the one-year recall.

50

AUGUST 2017 // dentaltown.com

Before this case, I'd seen cases even
more conservative than this work in the
hands of clinicians more skilled than I.
The cognitive dissonance from all I knew
about endodontics made it hard to believe
that such conservative shapes could work
on completely infected cases. This case
didn't prove to me that this technique was
the best way to treat a root canal system-it
certainly wasn't the most convenient-but
it did prove that successful endodontics is
possible with minimal instrumentation.
I'm not here to say we've been doing it
all wrong. Millions of root canal-treated
teeth last a lifetime. The unfortunate
reality is that millions also do not. In
my practice it's rare that a tooth can't be
saved just because of infection, no matter
how severe. Conversely, it's very rare that
I can actually save a tooth with a fractured
root. It's the teeth with broken roots that
patients end up losing.
It already is possible to complete successful endodontics with less impact on tooth
structure; new systems and techniques can
help us to better preserve tooth structure
and disinfect teeth simultaneously. Two
endodontic rotary file systems that I like
to use are S.S. White V-Taper files and
Dentsply Sirona TruShape files. Both
systems will conservatively shape a canal
and have an available maximum wire
diameter of 0.8mm (compared with the
common 1.2mm of many other systems).
Both will create deep apical shapes while
conservatively preserving dentin in the
remainder of the root.
When using such conservative shapes,
thorough active irrigation becomes critical.
I use a combination of negative pressure
irrigation with EndoVac and sonic irrigation
with EndoActivator.


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Table of Contents for the Digital Edition of Dentaltown August 2017

Dentaltown August 2017 - Intro
Dentaltown August 2017 - Cover1
Dentaltown August 2017 - Cover2
Dentaltown August 2017 - 1
Dentaltown August 2017 - 2
Dentaltown August 2017 - 3
Dentaltown August 2017 - 4
Dentaltown August 2017 - 5
Dentaltown August 2017 - 6
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