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Dental Tribune Middle East & Africa Edition | 3/2016 endo tribune2 Getting to the 00.00 point ByProf.PhilippeSleiman,Lebanon Anatomy and nature still teach us on a daily basis. Root canal treat- ment, while it is becoming a routine procedure, surprises and sometimes bad cases still occur. In this article, I willpresenttwounusualcasereports frommyownpractice. Case1 The first is a clinical case that in my experience posed rather a challenge. Thepatientwasreferredtomyoffice suffering from paraesthesia of his lower lip on the one side after a root canaltreatmenthadbeenperformed onhismandibularsecondmolar. The preoperative radiograph (Fig. 1), which was sent by his dentist, showed a well-performed root canal treatment that did not explain the clinical manifestations, but looking closely at the apical part one could observe that the obturation mate- rial lay in proximity to the apex of the mandibular canal. Immediate retreatment was required. Unfortu- nately, the material that had been used was the plastic carrier Therma- fil (DENTSPLY), and it was extend- ing into the nerve, causing the in- flammation, and the inflammation was causing pressure on the nerve. The Thermafil was removed from the canals—never an easy thing to do—using K3XF files (Sybron -Endo; Fig. 2) and without any solvent in order to avoid any more damage to the nerve in case of leakage. I set the Elements Adaptive Motor (Kerr En- dodontics; Fig. 3) to K3XF mode, first usinga25.06fileinthesoftenedpart of the gutta-percha with the System B plugger. I was very careful not to push the carrier further inside the nerve and not to damage the plastic carrier and lose the grip. The second file used was the 25.04 K3XF to re- move more gutta-percha and to lib- eratethecarrier. Theinstrumentwasusedtoholdthe carrier and to remove it from the ca- nal (Fig. 4). Once the Thermafil had been removed and the exact work- ing length had been determined us- ing the Apex ID apex locator (Axis, SybronEndo, Fig. 5), the canals were shaped following the SM sequence in TF Adaptive mode to the working length,andIusedtheEndoVacirriga- tionsystem(SybronEndo,Fig.6)with cold physiological saline in order to reduce the inflammation by cooling downtheroots.Allofthecanalswere irrigated with the cold saline for at least 20 minutes. The reason I used this technique was to immediately lower the in flammation inside the mandibular canal, which is not well innervated. Reducing the inflamma- tioninsideandaroundthenervecan take a while and I needed to lower it as soon as possible. The canals were kept empty with a cotton pellet in- side the access cavity and a hermetic seal on top. I asked immediately for a CT scan (i-CAT, Imaging Sciences International) to be taken in order to study the case. To my surprise, I found that the position of the man- dibular canal was different from the contralateral one and that it was in contact with the apex of the second molar where the root canal treat- mentwasperformed(Fig.7). The patient was prescribed anti- inflammatories and kept under ob- servation. Several days later, his lip was normal in function, but there was still some of loss of sensibility. Thirty days postoperatively, another CT scan was taken (Fig. 8) in order to check the inflammation inside the nerve itself, but during this time we continued to irrigate the canals with cold physiological saline at intervals ofthreedays. Until the patient reported the slow return of sensitivity, I decided to seal the canals, and it was for me the moment of truth, since I knew thatIneededtosealthecanalstothe 00.00pointandplaceasmallpuffof sealerattheendtoo.Carefullyad- justed master cones were placed insidethecanalswithaverytight tug back. The correct amount of sealer was applied in order to avoid any excess and gentle warm obturation was performed with the Elements Obturation Unit (SybronEndo). The integrity of the obturation was checked withaCBCTscan(Figs.9&10). Six months later, a conventional radiograph was performed (Fig. 11) in order to follow up on the case; the patient was doing very well with a completely functional and sensi- tive lip. The final radiograph showed asealedrootcanalspaceandnoneof the sealer inside the mandibular ca- nal remained. The conclusion of this case is that we will never know the reason for such a difference in the position of the mandibular canal be- tween the right and left of the man- dible, and that we need to respect the 00.00 point of the length of the roots—nothing more and nothing less.Andthemostimportantconclu- sion is that nature and the human body have a truly amazing healing power once the cause of inflamma- tionhasbeeneliminated. Case2 In the second clinical case, the pa- tient presented at the office with problems biting on his molar, with a fistula on the buccal side of his man- dibular first molar. The preoperative radiograph showed an acceptable root canal treatment performed in accordance with recommendations (Fig.12). Studying the radiographs in detail, we could obviously see that some- thing was not right in the apical area of the mesial canals. A closer look indicated some kind of pathology in the coronal part of the distal canal and possibly a cervical resorption or aninternalresorptionthatmightex- plainthefistulainthisarea. Again K3XF files were used to retreat the case, with the proper irrigation technique using the Endo Vac. A 50.04 file or the ML3 file in TF Adap- tive mode was used to shape the last 3 mm of the canals. Adequate mas- ter cones were prepared with a very strong tug back placed 0.5 mm short oftheworkinglength. My choice was the Elements Obtu- ration Unit in order to perform the sealing of the root canal system. The choice of the plugger was made, se- lecting the largest plugger to reach 5 mm from working length in each canal, in order to generate hydraulic pressureandtosealin3-Dduringthe down-pack or the first wave of obtu- ration. Manual pluggers were also adjusted to reach 5 mm and 10 mm from the working length. Medium viscosity was chosen for the car- tridge with a large opening and the extruderwassettotwoarrowsorfast injection. The sealer was placed on the cones and inserted into all four Fig1 Fig3 Fig5 Fig4 Fig6 Fig2 Fig7 Fig9 Fig8 Fig10 ÿPage3