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17Endo TribuneApril 1-7, 2013United Kingdom Edition Best ever value cone beam CT Veraviewepocs 3D R100 & F40 Up to three times the image detail of other 3D X-ray systems Revolutionary R100 Reuleaux triangle full arch field of view Compact, versatile and affordable Extra clarity for implantology, endodontics and oral surgery Focus on the anatomy you need to see Up to six fields of view from 40mm to R100 Reuleaux arch Confidence of high definition, distortion-free radiographs High speed, high quality, low dose image Easy and accurate automatic scout positioning Multi-layer panoramic images Up to three times the image The Dental Imaging Experts G Comprehensive service and support plans G Independent specialists in digital X-ray systems Telephone: 0845 602 4944 Email: FREE demonstration call 0845 388 3380 or email See what you’re missing NEW updated Conebeam A4 advert 9280.indd 1 17/10/2012 10:46 approaches. When I had just graduated as an endodontist, a 36-year-old male patient was referred be- cause he was experiencing some mild pain in his left mandibular second molar. I was acting as a third-line practitioner in this case. Another endodontist did not wish to begin treatment and finally re- ferred the patient to me. The tooth was diagnosed as having symptomatic apical periodontitis and was previously treated inadequately, including a separated instrument in one of the mesial canals (Fig. 1). In the first visit, I removed the gutta percha from the me- siolingual canal, and cleaned and shaped it completely. The sepa- rated instrument was located in the mesiobuccal canal, but I could not remove it completely. I left the distal canal untouched. Calcium hydroxide was used as an inter- appointment dressing, and the tooth was restored with a cotton pellet and glass ionomer cement. An initial error was made by not removing the old restoration and caries completely. One month later the patient returned in agony. When I re- opened the tooth, a great deal of pus and blood came out of the tooth. I then tried to bypass the remainder of the fragment in the mesiobuccal canal, but perforat- ed the root with a 15.04 ProFile (DENTSPLY Maillefer; Fig. 2). I also retreated the distal canal in this session and fractured a small piece of a 25.06 ProFile in the apical part, but could bypass it. I then filled the canals again with calcium hydroxide and sealed the tooth with a glass ionomer filling. One month later, I saw the patient again for the comple- tion of the treatment. He no longer had any symptoms. I re- stored the perforation with grey MTAAngelus (Fig. 3). I obturated the canals with gutta percha and Topseal (DENTSPLY Maillefer) using warm vertical condensa- tion. I sealed the cavity with Fuji IX A1 (GC) immediately on top of the gutta percha (Fig. 4). I then referred the patient back to the dentist for a permanent restora- tion, with the explicit advice to have the distal restoration re- placed too. Nine months later the patient returned to my office for another tooth. I decided to take a follow-up radiograph of the left mandibular second molar to see if healing was favourable. The patient had not experienced any complaints since I completed the treatment and the radiograph showed a favourable apical outcome. However, the permanent restoration was less than ideal (Fig. 5). I had to refer the patient back to the dentist for a new restoration. Conclusion Looking back upon this case, I can conclude that I should have re- moved the old restoration and the caries at the start of the treatment. Positively, it was good that the glass ionomer filling was placed immediately above the canal ori- fices, preventing contamination via a leaky restoration. Ideally, I should have finished the restora- tion myself. It required a change in my behaviour and some persever- ance to begin to perform cases in accordance with the afore- mentioned approaches, as can be seen in Figures 6, 7 and 8. DT About the author Dr Rafaël Michiels graduated from the Department of Dentistry at Ghent University, Belgium, in 2006. In 2009, he completed the three-year post- graduate programme in endodontic- sat Ghent University. He works in two private practices specialised in endo- dontics in Belgium. He can be con- tacted at rafael.michiels@ontzenu- and via his website www. Fig. 8_Post-op radiograph, with temporary glass ionomer restoration.