"Midway in the journey of our life

I came to myself in a dark wood,

for the straight way was lost"

My working week has always ended on Saturday, not on Friday. So it is on Saturday that I run in the classic “Friday night’s last case”, which is always tricky, as we all know.

Last Saturday was no exception, and my agenda surprised with a 1.7 tooth retreatment which, starting from the pre-operative radiograph, made my jaw drop.

Can you see that mesio-buccal canal? From experience, I know that (taking for granted that he is not an incompetent doctor who cannot practice cheap football jerseys China endodontics) if the dentist who treated the patient before me manages to get in apex on two canals, but gets lost before the curve of a root, two problems may have occurred:

• He took a wrong path because of a calcified canal, or he made a mistake in locating the access to the pulp chamber
• He fractured an instrument and couldn’t penetrate further.

In this case, the patient informed me that my colleague had told him that she hadn’t managed to get to the end of a root, so at least she knew what she had not been able to do. Based on most of the pathetic treatments that have been carried out in the mouth of the patients who come here for the first time, I believe my forerunners don’t have the faintest idea of how to carry out a correct canal treatment.

So what’s the best strategy to deal with these cases?

First of all, think it over, before you rush and retreat the tooth; explain to Cheap Elite Jerseys – Wholesale NFL Jerseys Free Shipping From China your patient what Cincinnati Bengals jersey youths you’re expecting to find and what difficulties might occur. This way, if you didn’t manage to do much better than your predecessor, you could still manage to turn your failure in a “success” in the eyes of your patient.

Let me rephrase this better.

To this patient here, I said: “Alright, so this tooth might be difficult to treat in one of the roots. If you look at the x-ray, you can see this white material, which should get to the end of the tooth, as in the other two roots (and I point at the monitor). Can you see that it just gets to the half of the root? The problem is that, when a dentist stops before a big curve (and here I point at the mesio-buccal shape of the curve), he might have pierced the root or he might make us pierce it, if we follow his path; or he might Pittsburgh Steelers jerseys have fractured one of those instruments we generally use to go through the nerve canals of the tooth, failing to negotiate the canal. Now let’s see if, using a microscope, we manage to see what’s happened…Maybe we’ll get to the end of the root right away and I am just overthinking it…the problem is that the infection you have under the tooth is due exactly to that root, so if we don’t fix it, we’ll run the risk of having to remove the lesion under the tooth surgically…”

At this point, the patient has understood that the job could be tough, he senses that you know what you are doing and you have covered your ass in case of a possible failure. After all, you’re not the one who’s made a mess in your patient’s mouth and your role is just analyzing it, and possibly fix it. Canal treatments can be difficult in a vergin tooth. When you can’t carry out the treatment at your best the first time around, if you try the second time with gutta-percha or other materials, calcifications that have worsened overtime, possible fractured instruments or false paths, things cannot but get worse, and it is fair for the patient to know that we’re just trying to get right what someone else has previously screwed up, having to solve more problems than our predecessor had to.

Now it’s time to decide if a pre-operative X-ray is enough or we need a Cone Beam.

I myself choose to do a pre-operative CBCT when I suspect the presence of accessory root canals or to retreat external resorptions. In these cases a CBCT helps me to find what I’m looking for right away.

Still, in cases like this a CBCT is useless, because the gutta-percha present in the canals creates obstacles, and in any case seeing that the gutta-percha pushes on the root contour won’t necessarily help you sort out the situation. Besides, we might also unexpectedly find our way effortlessly, in which case we would have just X-rayed our patient for nothing.

So, let’s start the retreatment.

Palatine canal: easy peasy.

Distobuccal canal : easy peasy.

Mesiobuccal canal: there’s a wall.

Then I try to correct the opening axis of the tooth. Nothing happens.

I just check if the one I’ve found may possibly be a fourth canal and the obstruction a 90 degrees confluence with an MV canal that hadn’t been found previously. Always keep your brain active and consider every possible angle, remember. Still, nothing.

I’ll take an endodontic ultrasonic tip like the one below.

I try to enlarge the canal a bit, to understand if there’s a fractured instrument, moving distally, given the curve is in that direction. Sometimes, the canal opening has just not been corrected, forcing the files to take the wrong path. After this maneuver, I go a little deeper, I suddenly feel an empty space and I tell the patient: “ok, let’s see if we’re there yet, or if we’ve ended up deep down, as I feared.” I use the apex locator, and it rings at 12 mm rather than 20.

“Ok, as I was fearing, we are likely to have ended up off the right path, let’s just have an X-ray taken to understand where we are…”

And here’s the X-ray.

At this point, the patient isn’t worriex because what is happening is exactly what you had predicted, so he understands that the situation is difficult, but you know what you are doing.

Knowing that I proceeded mesially, I forget about that path, and through the ultrasound I create a small room in a distal direction. I try a couple of times with ultrasounds and then files, but still nothing. Ok, so this is the moment when we want to understand a bit more, because we can’t risk on turning the root into Swiss cheese.

Now I am going to perform a 3D scan of your tooth because we need to understand where we’ve ended up, whether  there is a canal or not, how the root curves and if the lesion is due to that root, because if we discovered that the canal didn’t exist at all because it’s completely calcified, and that under the root there were no infection, then closing the false path and stopping wouldn’t be a problem.”

We are providing logical explanations, and the patient understands that we have a precise strategy. Moreover, he has never seen a doctor who works with a microscope and has all these means at his disposal. He probably remembers a dentist who didn’t even have magnifying lenses and who surrendered after 10 minutes in a sweat.

Now we’ve green bay jersey cheap got the CT scan results and we can discuss them together.

Once I start working again, using the same endodonic tip that I had used previously, I make my way from where I had created the explorative room in disto-palatine direction. Ideally, I should find a pretty accessible canal without having to advance too much. 15 seconds, with an endodontic tip. I find a file…I feel it crack…Pounding heart…I use the locator…12 mm, 14 mm, 16 mm…19 mm! Ring ring ring! Awesome! Now I’m sure this is the right canal, given it is as long as the disto-buccal one, and I manage to figure out the disto-palatine curvature that I had been expecting.

Both we and the patient are greatly relieved. After this last attempt, we would have been envisaging an apicectomy, that he wanted to avoid and I would have had a hard time performing because of its unfavorable position.

I don’t even carry out the double-check X-ray to make sure that I am in the root. The patient has has been X-rayed long enough today.

I assume that the false path is so small that it can be considered just like a perfectly disenfected lateral canal, so I can rely on gutta-percha for closing it.

Instrument, irrigation and filling using Thermafil.

Voilà.

To enjoy my well-deserved satisfaction, I wait with my patient for my assistant Anna to develop the final X-ray, to have a look at it together.

The result is self-explanatory, and the patient can see for himself that he is in good hands. He’s found a professional he can rely on and he regards his expense as worth the therapy,considering the two hours spent on it, the instruments used, the skills and the competence showed.

Let’s draw our conclusions from this story.

Before rushing on a re treatment, always analyze that your predecessor did wrong and anticipate the difficulties you might have to face. Talk about it with your patient. Find a strategy and stick to it.

Then, a little tip. You might want to treat a case like this with goggles and coaxial light, but, trust me, it’s hard even if you have some chances to succeed. It could be done by an expert who’s been used to operating with a microscope for years. Not by an inexperienced professional who’s just started to use the goggles and doesn’t do much endodontics.

Advanced endodontics must be carried out through a microscope and a CBCT. If you don’t have this technology, but you’re interested in endodontics, make sure you buy it.

If you can’t afford it, or you don’t want to go mad working on these cases, do your patient a favor: send him to an endodontist when you start treating your first false path. Don’t try to be a hero at you patient’s expense or, even worse, scratch the tooth and place an implant tricking the patient into thinking that his tooth couldn’t be recovered due to the first (bad) treatment.

If you know what you need to look for and you see it tank to a CBCT first, and then a microscope, these are complex cases, but not impossibile ones. And, more importantly, they can be solved without resorting to an extraction.

L'articolo HOW TO FIND THE STRAIGHT WAY YOU LOST: CAN YOU CORRECT A FALSE PATH? sembra essere il primo su Mastering Dentistry.

In this post I want to show you a couple of tricks to remove a fiber post, since at the beginning of my career they were my bogeyman, as well as retreating Thermafil.

Well, let me say this…In dentistry there’s a lot of clichés…Thermafil, for example: at University they used to tell me that retreating them was a pain in the ass. But when you happen to retreat teeth with Thermafil, you immediately realize it’s something that just a person who’s never retreated any could fear. Or rather, after treating many of them, you’ll notice that you may have a hard time with a carrier in tight and curved root canals. But learning methodologies to facilitate the removal doesn’t take long.

The same goes for silver cones…When I came across one for the first time, I scheduled the procedure for one hour in my calendar and I remember removing it in 5 seconds using tweezers… ?

Ditto for fiber posts.

If you want to remove a fiber post quickly, you can try and bet on dentists’ little ability to get high adhesion values in post space. Therefore, you can remove the composite around the post until the bottom of the root canals, take universal plier, pull and…voilà! A huge number of posts come off in 5 seconds, along with the composite cement.

In case the post unravels or rips with this method, though, you’ll have to use the second method for fiber post removal, in which you wear them away with thin burs or with an ultrasonic tip, according to how deeply they are placed.

This is also the method I’ve used the most, since I have my microscope.

If you see that the post is in the coronal third of the root in the preliminary X-ray, you can wear it away with a very thin diamond bur with a head of 0.8-1 mm diameter, like this one from Komet

If the post goes deeper, then you’ll have to resort to ultrasound, using a Start X 3 kind of tip, making a perforation, like this one.

You’ve got to use this tip shifting between dry sessions and “wet” sessions in which you clean the field with water, because a fiber post (be it in quartz, glass or carbon) releases a black dust that darkens all the tooth inside, when heated. So, it is essential to wash the field with sodium hypoclorite or EDTA, and sometimes use the ultrasonic tip with water, in order to get to see what you are doing.

When you use the ultrasonic tip dry, you mustn’t use it as if you were making a metal post vibrate, but you’ve got to push hard at the center and perform circular moves, as if you were putting an umbrella in the sand on the beach, to be clear ⛱

You should feel the tip sink slowly…every so often, make sure to clean the post surface gently, letting the tip swing. Then wash everything as I told you, target the center of the post and repeat the “umbrella in the sand” movement dry.

When you think you got to the bottom of the post, you may try and “break down” the last millimeter using an endodontic retreatment tip. I use this one, with Mtwo system.

But if you can’t feel it cave in immediately, don’t push too hard or you’ll risk on damaging everything.

As I told you, since I have a microscope, I have almost never resorted to the removal method with pliers, because it almost takes me longer than wearing away the post with ultrasound. But without a specific enlargement and coaxial light, you might, at some point, find yourself not understanding where the post is, and you might risk on damaging the root or wrecking the tooth too much. Carbon fiber posts are difficult to distinguish in the middle third of the root of very dyschromic teeth, or if you try to remove them by drilling metal ceramic crowns, which darken the the field of view. Glass posts, instead, can become difficult to distinguish in non-dyschromic teeth rehabilitated with composite material. In this case too, the challenge is to figure out where the heck the post is, after 2 or 3 mm depth in the root canal.

To figure out if you are touching the post or the dentin, you can use two little tricks. The first one is to use ultrasound without water and push quite hard towards the area where you expect the post to be. Ultrasounds in this case will sink deep, produce smoke but no noise, while if they touch the dentin, they will emit the typical “creek creek” sound that you hear in a scaling session. The second trick is to dig a little, using an endodontic probe, like a DG16 …the fiber posts generally get “defibered” in this way.

Here’s an illustrative video in which I remove a carbon fiber post.

In the endodontics course which we are going to post soon on www.masteringdentistry.dental we’ll deal with the removal of fiber posts more thoroughly, and we’ll also deal with the removal of other kinds of posts, revealing all the tricks that just experience and the use of a microscope can give you!

Stay tuned!

Stefano

L'articolo HOW TO REMOVE A FIBER POST?…DON’T MISS THIS POST! sembra essere il primo su Mastering Dentistry.

Let alone capable of treating it properly.

Hoping you are one of the colleagues who knows what I am talking about, let me briefly introduce the topic to everybody else.

Although the reason why this happens is still unknown, sometimes teeth develop an inflammatory reaction for which, starting from the cervical margin of the tooth, a granulation tissue substitutes dental hard tissue by osteoclasts.

It looks like all this happens because of a damage occourred at the amelocemental junction, and this happens concurrently with:

• traumas
• endodontic bleaching
• orthodontics
• surgical periodontal therapies

Although some etiologic hypotheses exist, the ones above are the main correlations found in external resorption patients’ medical history.

But what happens exactly to teeth affected by this phenomenon?

Basically, some bleeding tissue is created, clinically similar to a bone in a long-standing process, or to a nervous tissue in “younger” teeth, taking over the dentin.

I want to tell you how I discovered what an external root resorption was, clinically.

Yeah, because now I’m acting all cool, but back in 2011, a patient having this tooth shows up.

This was my reaction.

What the heck had happened to that tooth!?! Pretty alarmed, I showed the X-ray to Federico, my business associate, and he also thought it was something really bad. Who knows, like one of those absurd tumors we had only studied in radiology books, that had weaseled its way in this 4.6 tooth! What did I come up with, then? An explorative cavity and a biopsy of that tissue!

When I opened the cavity as if to perform a filling, to my great surprise, the tooth has bleeding where there was supposed to be dentin…! and it wouldn’t stop…???

With a spoon, I took a sample of that misterious tissue, that I thought had probably been implanted there by some aliens during the poor patient’s sleep; after doing this very gently, I kept digging until I could, looking for some healthy tissue, but I had a hard time understanding if I was touching the nerve or that bleeding kept coming from the tooth.

I didn’t want to resort to a devitalization, because I wouldn’t have known how to carry it out successfully, without a distal root; so I placed a composite filing.

After a week, the patient was asymptomatic and the test results were ready.

I thought the diagnosis could be something like a tooth carcinoma or a tissue of unknown origins, probably alien.

Instead the verdict was:

“fragments of sclerocalcific tissue”

I think the histologist hadn’t understood much more than I had.

After 5 years, the girl still has an asyntomatic tooth and the X-ray shows that the process stopped.

This happened because, unknowingly, I carried out a correct therapy for a problem I didn’t even know. I removed the granulation tissue as best as I could, stopping or slowing down the process of destruction of the tooth.

When this case was submitted to my attention, in 2013:

I recognized the same phenomenon I had observed in the abovementioned girl infested with the alien tissue, and I suddenly remembered that cheap nfl jerseys at Uni we had learned about external root resorptions.

So I studied the phenomenon and I was able to make a diagnosis.

That was an external resorption of class IV.

In 1999, in fact, Heithersay classified external root resorptions in four classes (Heythersay, 1999):

• class 1 presents with a little resorption in the cervical area, with a superficial dentin penetration;
• class 2 presents with a well-defined resorption, which penetrated near the pulp chamber with little or no extention to the root dentin;
• class 3 presents a resorption extended in the coronal third of the root;
• class 4 identifies invasive and extended root resorptions, which go beyond the coronal third of the root.

Perfect.

The treatment included removing the granulation tissue surgically or with an orthograde approach and filling the tooth with composite material, as if it were a cavity filling, in class 1 and 2 cases (it is often necessary to combine this procedure with a root canal treatment and a clinical crown lengthening. In class 3 or 4 external resorption the lesion is often filled with MTA, given it often communicate with the periodontium (so far I’ve used Biodentine, but we’ll discuss this in a further post).

Ooooook. Just when I was ready to start, this time well-aware of what cheap jerseys nfl I was about to do, I read that Heithersay recommended not to treat class 4 external root resorptions, because the success rate was 12,5%!!!! (Heithersay, 1999)

But could I possibly think of extracting a seemingly healthy tooth, that had a purely aesthetic function for my patient (who was, in the meantime, wearing an invisible brace)?

Of course not.

So, to get a deeper understanding of all the situation, I performed a  CBCT.

At this point, I wondered:

“Do I really have to surrender to a defect which is perfectly treatable, and also clearly visible, thanks to magnifying goggles or a microscope?”

After all, Heithersay worked before 1999, when enlargements and microscopes weren’t that common, as well as 3D teeth scans. And if you read the paper where he describes the technique he used, you’ll shudder. With such an antediluvian technique, I’m surprised he’s had such a high success rate!

As you’ll be able to see in this video, my idea totally made sense. With a microscope and a CBCT, treating such cases surgically is absolutely feasible and, let me tell you, not even that difficult.

You see?

Do you think this tooth will last less than 3 years? I can tell you “no” already, since this treatment turned 3 years old in September 2016 and the tooth is still perfectly healthy, both clinically and from the X-rays.

You don’t need to practice this technique 1000 times to be successful, and this is confirmed by the fact that this tooth was the first one for me.

Since then, I carried out four more class IV resorptions, publishing the clinical records first on the Journal of Endodontics and then on the Italian “Giornale Italiano di Endodonzia”, and I had previously won the Lavagnoli Award at the Italian Society of Endodontics, presenting these 4 cases.

In the meantime, I used the same technique in at least 5-6- class III or II cases, while I restored surgically other 3 or 4 cases (I don’t remember how many, right now).

This teaches us two lessons:

Firs: external root resorptions are not rare, but rather difficult to diagnose in their early stages, because they look like cavities.

Second: if you know what you’re doing and you use your brain, you don’t need to go through extraordinary experiences or attend dozens of courses for years, before actually practicing some new techniques.

I went from total idiot in 2011 to great expert, in just two years and after two cases!

There are still many aspects to consider about external root resorptions. I’d like to talk you you about how I’m thinking about proposing a new classification of the problem, based on therapy options, and I’d like to show you more videos about it.

But since this is not a course on this topic, but just a hint I wanted to give you, I hope you were intrigued, and I suggest that you keep following us, since you’ll see pretty exciting stuff!

Stefano

L'articolo EXTERNAL ROOT RESORPTION: THE GREAT UNKNOWN sembra essere il primo su Mastering Dentistry.

As many of you, for me mandibular first molars had 3 or 4 root canals, two mesial and one or two distal ones, while mandibular second molars typically had 3, at times just 2, and I would pay close attention to the possible presence of C-shaped canal.

Despite knowing that molars with 5 root canals exsisted, I contented myself just finding the traditional root canals.

I knew about the existence of a middle-mesial canal, but eventually I never managed to see it, not even with a microscope, maybe because for years I have been working on teeth that had to be retreated, so I wasn’t helped by possible bleedings after the instrumentation of “conventional” root canals.

Middle-mesial canal prevalence varies from 1 to 25%, I would read everywhere.

Then I ran into this paper:

Azim AA ET AL. – J Endod. 2015 Feb

Azim & Co. had found the middle mesial canal in 42 cases out of 91 molars! Moreover, 21 of those were second molars!

????????

How could they do that? They dug 2 mm deep into the isthmus between the mesio vestibular and the mesio lingual canal with a little diamond bur 1 mm wide on the head. In doing so, they managed to expand their total retrievals from 6 cases (all of them first molars) to 42 cases, 21 of which were second molars!

Incredible!

The day after, as soon as I stumbled upon a mandibular sixth, I immediately tried and insert a Mtwo in the isthmus between the two MV and ML canals and….BANG! The instrument engaged immediately!!!!

????????

Since then, on 48 first molars I’ve found the middle mesial root canal 24 times in 17 months! A 50% success percentage!!!

And I am considering here just first molars, while I manage to find the middle-medial canal even in mandibular second molars, as you can see below.

Usually, since purple Mtwo is a phenomenal instrument to retrieve and probe tight or calcified root canals all at once, I try to insert this instrument in the isthmus between the MV and ML canals several times, after shaping them. If I don’t feel any engagement, I go 2 mm deeper between MV and ML root canals with a Start-X 3 or, more often, with a small diamond bur 0,8 mm wide on the head and that’s it.

If I can’t find anything, after these two maneuvers, I just give up.

Realizing that the middle-mesial canal must be searched and it is often right there helps me solve this kind of cases, which I observe fairly frequently. Mesial canals of mandibular first molar apparently well obturated but having a lesion. My associate, who mostly deals with surgery, kept telling me that it might have been a cleansing issue, but I have never believed this. If a canal looks well filled from the X-rays but presents a lesion, it’s either vertically fractured or lacks a root canal.

In these events, I immediately inform the patient, and as soon as I have cleaned the chamber I immediately start looking for the missing root canal right away. It’s almost always there.

Below, I’ll show you how to find the middle-mesial canal.

I hope that starting tomorrow you’ll change the way you consider mandibular molars too.

In other future posts, I’ll tell you how I have dramatically increased the number of root canals found also in other teeth, in endodontics. Keep following us!

Stefano

L'articolo IN SEARCH OF THE LOST CANAL! THE MIDDLE-MESIAL CANAL sembra essere il primo su Mastering Dentistry.