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ePaper created 2017-04-19, 21:15:41 | version 1.38.0
laser_case report Fig. 1: Clinical picture demonstrating aesthetic initial appearance of tooth 11. Fig. 2: Initial radiographic appearance of tooth 11 demonstrating an extensive apical radiolucency and internal root resorption. Fig. 3: Immediate post-operative radiograph of tooth 11. Fig. 1 Fig. 2 Fig. 3 tributory. The patient reported trauma to her upper teeth when she was 20 years old. After performing clinical and radiographic examinations, tooth 11 was diagnosed with pulp necrosis with internal root re- sorption and apical periodontitis. The tooth was slightly tender to percussion, periodontal probing depths were considered normal (< 3 mm), and there was no discoloration (Figs. 1 & 2). Approval for the study protocol (N_682/068) was obtained. Treatment options were discussed and the required consent obtained (Helsinki Declaration, re- vised in Edinburgh 2000). No financial incentive was offered (i.e., patient was responsible for the usual root canal treatment fee). Under local anaesthesia (2 % lidocaine with 1:100,000 epinephrine, Scandonest, Saint Maur des Fossés, France) and rubber-dam isolation (Hy- genic Non-Latex Rubber Dam, Coltène/Whaledent, Germany), an access cavity was prepared with a high-speed carbide bur (SS White, Lakewood, NJ) and Zekrya Endo burs (DENTSPLY Maillefer, Ballai- gues, Switzerland). The working length (WL) was electronically established (Root Zx mini, Morita, USA) as 1 mm short of the biological apex of the root and confirmed by radiography. No bleeding was noted from the root canal. Patency was confirmed with an ISO#20 K-file and root canal preparation was performed with the Protaper system (DENTSPLY Maillefer, Ballaigues Switzerland) up to an F5 (#50.05) 36 1_2017 36 laser instrument. Root canal irrigation was performed between each file with 3 ml of sterile saline solu- tion (Monoject 27G, Kendall-Covidien, USA). No chemical irrigants or inter- appointment dressings were used. For smear layer removal and root canal disinfec- tion, a previously reported laser-assisted protocol was adopted.42, 43 Following root canal preparation, the main canal was filled with distilled water and laser irradiation was performed with the 2,780 nm Er,Cr:YSGG laser (Waterlase MD; Biolase Technol- ogy, San Clement, CA) and radial firing Tip (RFT2 Endolase, Biolase Technology; calibration factor of 0.55) which was 270 µm in diameter, with panel set- tings of 0.75 W, 20 Hz (37,5 mJ), 140 µs pulse, 0 % water and 0 % air. The tip was placed at the working length and irradiation was performed, approxi- mately, at the speed of 2 mm/s until it reached the most coronal part of the canal. The irradiation pro- cedure was repeated four times: 2x with the canal filled with distilled water (for smear layer and gran- ulation/pulp tissue removal) followed by 2x in dry conditions (to achieve deep dentine penetration and disinfection), with approximately 15 seconds between each irradiation. Afterward, a sterile cot- ton pellet was placed in the pulp chamber, and the access cavity was sealed with a reinforced zinc-ox- ide eugenol intermediate restorative material (IRM, DENTSPLY). At the second appointment after seven days, the patient reported pain, tenderness to percussion and swelling upon questioning. Under local anaes- thesia and rubber dam isolation, the canal was re-accessed. The main canal was filled with distilled water and laser irradiation was performed using a 320 µm radial firing tip (RFT3 Endolase, Biolase Technology: calibration factor of 0.85), with panel settings of 1.25 W, 20 Hz (62.5 mJ), 140 µs pulse, 0 % water and 0 % air. The irradiation protocol was identical to the first appointment. After irradiation, a final rinsing of sterile saline solution (3 ml) was performed, and the canal was dried with sterile pa- per points, checking for the absence of any suppu- ration or exudate. Filling was performed with a #50.05 auto-fit gutta-percha cone (DENTSPLY Maillefer, Ballaigues Switzerland) using a down pack-backfill technique (Calamus, DENTSPLY Maillefer) and a resin-based endodontic sealer (Topseal, DENTSPLY Maillefer). Both down pack mo- tion and gutta-percha injection were performed with low pressure and extreme caution due to the root weakness. Radiographic images were taken immediately (Fig. 3) and after one (Fig. 4), two (Fig. 5) and three years (Figs. 6 & 7). Over this follow-up period, the tooth remained completely asymptomatic and periapical healing was noticed.