Dental Tribune United Kingdom Edition

Endo Tribune Endo TribuneEndo TribuneEndo Tribune pages 16-17page 14-15 Dr Sander Loos provides a case report Dr Philippe Sleiman discusses root canals Dr Kenneth Serota James Prichard provides an in-vitro study Treating Patients Flexibility and strength Rubber dam hazards The effect of ultrasonic irrigation pages 18-19 pages 20-22 Endo Tribune G one are the days of the clumsy apicectomy and amalgam retro- grade fillings. Endodontic sur- gery has evolved to become a technically accurate, highly predictable procedure with remarkable success rates. Implant technology has meant many teeth of question- able prognosis are extracted in the name of future predict- ability. While implants have been a wonderful adjunct in the dental armature, our primary role as dentists is to try and conserve the existing dentition that have good long term prognosis. Classically an apicec- tomy was a treatment of last resort, using large bulky in- struments, rough approxima- tions and excess amounts of amalgam. The biological ram- ifications of additional canals, cracks, apical deltas and poor initial root canal treatments may have been overlooked re- sulting in poor success rates. This has understandably resulted in a negative percep- tion of apical surgery amongst the dental profession who erroneously believe success rates to be around 60 per cent when the actual figure for en- dodontic microsurgery is over 91 per cent after five to seven years (1). Modern techniques and equipment have transformed the procedure. Using CBCT scans from the outset we can plan surgery exactly; three dimensional picture of bone loss is clear as is the posi- tion of anatomically sensitive structures; lengths can be ac- curately measured and exist- ing treatment such as posts and MB2s assessed. The following case is an example of the techniques which we now use. The pa- tient presented following multiple episodes of pain and swelling from the UL5. There was an initial root ca- nal treatment and subsequent retreatment provided by a competent GDP using rubber dam and sodium hypochlo- rite irrigation. There was a well-fitting new crown placed and no associated peri- odontal pocketing greater than 3mm. Radiographic examina- tion (Fig 1) revealed a large radiolucency associated with the UL5. There was an over- extended root canal filling. On CBCT (Fig 2) a clearer picture of the size of the api- cal radiolucency emerged and its relationship to adjacent anatomical structures was visualised. There was one ca- nal present with an overfill of gutta percha and sealer. The CBCT scan provided very useful information at this point. Although the treated canal appeared centered in the root there was a question whether there was a second canal present in the tooth. Also there appeared to be an apical bulbosity present which could mean multiple paths of exits present. A provisional diagnosis of acute exacerbation of chronic apical periodontitis was made and treatment options dis- cussed with the patient (who had just paid for and was sat- isfied with a new crown.) 1Root canal retreatment through the crown 2Endodontic microsurgery 3Extraction +/- prosthetic replacement A mucoperiosteal flap was raised with micro-blades that produce neat, precise inci- sions as they cut in multiple directions. Once the flap was raised, the perforation in the buccal plate was identified and root tip located. The gran- ulation tissue was curettaged and haemostasis achieved. Following resection of 3mm of the root tip perpen- dicular to the long axis of the tooth a retropreparation was completed with ultrason- ics, then sealed with MTA. The tissues were compressed and the flap closed with 5/0 monofilament sutures that were removed painlessly after 72 hours as reattachment had taken place. At the four-month review the buccal swelling had com- pletely resolved and radio- graphically there was signifi- cant healing present. The patient was delighted with the outcome of treat- ment. Excellence in endodontics Daniel Flynn discusses endodontic microsurgery page 12DTà Fig 1 Pre-operative periapical radiograph Fig 2 Pre-operative CBCT scan confirming 1 canal present and large periapical radiolucency Fig 3 Pre-operative clinical view ‘Endodontic surgery has evolved to become a technically accurate, highly predictable procedure with remarkable success rates’