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ePaper created 2018-05-16, 11:45:19 | version 1.38.0
Fig. 1 Fig. 2 Fig. 3 Fig. 4 Fig. 5 Fig. 6 Fig. 7 Fig. 8 Fig. 9 pulp canal obliteration (extended to the coronal and radicular pulp canal spaces),6 with or without associated periapical pa- thosis. Complete radiographic obliteration of the pulp space does not necessarily mean the absence of the pulp canal space; in the majority of these cases, a pulp space with pulp tissue is present, but the sensi- tivity of conventional radiographs is too low to allow visualization of this.5 Taking into account the degree of diffi- culty of the clinical management of these kinds of cases, the practitioner should be aware of the possible complications that may occur. The complications include root perforation and irretrievable instrument fracture.15 This article presents a case re- port with some valuable tips regarding the clinical approach to such cases. Case report A 47-year-old male patient was referred to our clinic in order to evaluate a symptom- atic tooth (tooth #11). The patient had spon- taneous pain in the right maxilla, in the vestibule of the maxillary right central in- cisor. At the clinical examination, a fistula in the buccal area of the tooth was identi- fied. The tooth was very sensitive to per- cussion and nonresponsive to thermal and electric pulp tests, without mobility, and periodontal probing around it was within physiological limits. The patient gave a history of trauma in childhood. On examination, tooth #11 was found to have a discolored crown (Fig. 1) and undergone a previous root canal ther- apy attempt. Initial radiographs were tak- en (Fig. 2), and these revealed that the canal could not be traced from the coronal and middle thirds. Cone beam computed tomography (CBCT) scans were request- ed for the patient (Figs. 3 & 4). Based on the results of the clinical and radiographic examination, a diagnosis of necrotic pulp with chronic apical abscess was made and root canal therapy recommended. Local anesthesia was performed, and the tooth was isolated with a rubber dam (Fig. 5). The access cavity was prepared, with an incisal orientation (following the long axis of the tooth), under continuous inspection under the operating micro- scope. The action of the long shank bur is only in the darker dentin (tertiary dentin), avoiding removal of the lighter dentin Fig. 1 Initial photograph (tooth #11 was found to have a discolored crown) and the presence of fistula in buccal mucosa). Fig. 2 Initial radiograph. Figs. 3 & 4 CBCT scans (axial and sagittal planes). Fig. 5 Isolated tooth with rubber dam. Fig. 6 Access cavity preparation. Fig. 7 The calcifying process soon becomes circum- ferential, forming a calcified ring around the nerve.18 Fig. 8 Root canal entrance. Fig. 9 Glide path with D Finder files and M4 Safety Handpiece. Article Endodontics issue 2018 — 51