UNIVERSITY OF OSLO FACULTY OF DENTISTRY Department of Endodontics Postgraduate Program in Endodontics Case Book Trude Handal Autumn Semester 2014 1 Table of contents Endodontic treatment guidelines ............................................................................................... 1 Non-surgical cases Case 1 ............................................................................................................................................................... 6 Endodontic treatment of the mandibular right second molar with irreversible pulpitis and cracked tooth syndrome Case 2 ............................................................................................................................................................ 12 Endodontic treatment of the mandibular right second molar with irreversible pulpitits and iatrogenic furcal perforation Case 3 ............................................................................................................................................................ 17 Endodontic treatment of a mandibular right first incisor in a patient with DiGeorge Syndrome (velo-cardio-facial-syndrome) Case 4 ............................................................................................................................................................ 22 Endodontic retreatment of the maxillary right second molar Case 5 ............................................................................................................................................................ 28 Endodontic treatment of the maxillary left first molar Case 6 ........................................................................................................ 3Error! Bookmark not defined. Endodontic retreatment of the maxillary right first incisor Case 7 ........................................................................................................ Error! Bookmark not defined.8 Endodontic retreatment of the maxillary left first molar Case 8 ............................................................................................................................................................ 42 Endodontic retreatment of the mandibular left first molar Case 9 ............................................................................................................................................................ 47 Endodontic retreatment of the maxuíllary left first incisor Case 10 ......................................................................................................................................................... 52 Endodontic treatment of a maxillary anterior tooth Case 11 ......................................................................................................................................................... 56 Patient with persistent pain maxilla left side Surgical cases Case 12 ......................................................................................................................................................... 62 Endodontic retreatment and apical surgery of the maxillary right canine Case 13 ......................................................................................................................................................... 69 Endodontic retreatment in conjunction with apical surgery of the mandibular right first molar with a separated instrument Case 14 ......................................................................................................................................................... 76 Explorative surgery of the maxillary left second incisor with sinus tract Case 15 ......................................................................................................................................................... 82 Endodontic retreatment of the maxillary left first molar and surgical retreatment of the maxillary left first and second premolar Case 16 ......................................................................................................................................................... 88 Endodontic treatment and apical surgery of the mandibular left first molar Case 17 ......................................................................................................................................................... 94 Surgical retreatment of the maxillary right first incisor Case 18 ......................................................................................................................................................... 99 Evaluation of a root-filled mandibular right first molar and surgical retreatment of the maxillary left first molar with a sinus tract Case 19 .......................................................................................................................................................106 Endodontic retreatment of the maxillary right first molar with a sinus tract Case 20 .......................................................................................................................................................112 Treatment of multiple idiopathic cervical root resorption Endodontic Treatment Guidelines Treatment of Tooth with Apical Periodontitis Pre-operative radiograph. Anaesthesia. Removal of plaque, caries and leaking fillings. Pre-endodontic tooth build-up if required for isolation. Access cavity preparation. Localization of canal orifices. Application of rubber dam. Disinfection of the working field with 0.5% chlorhexidine in 70% ethanol. Measurement of working length, using apex locator and working length radiograph. Instrumentation to desired apical length and size: . Goal: 0.5-1mm short of the anatomic apex Frequent irrigation with: . 0.5% sodium hypochlorite (NaOCl) . Alternative: 0.5 % chlorhexidine (from 2013) . Final irrigation with 17% ethylenediamine tetraacetic acid (EDTA) Drying of the canals with paper points. Mastercone radiograph. Root filling: Obturation techniques: . Lateral compaction, warm vertical compaction, apical plug with MTA Sealers: . AH Plus Seal Core materials: . Gutta-percha Temporary IRM top filling with a 2 mm IRM plug in the canal orifice . Alternatively a final composite restoration Removal of rubber dam. Post-operative radiograph. 1 Treatment of Tooth with Apical Periodontitis The same treatment as for teeth without apical periodontitis, but two-appointment treatment is the standard procedure: 2-3 weeks between 1st and 2nd appointment is the standard, mainly due to practical reasons: . Intra-canal dressing with Ca(OH)2 . Two-layered temporary top filling: Cavit G and IRM In retreatment cases: Final irrigation with 17% EDTA and 2% chlorhexidine-di- gluconate. The periapical index (PAI) (Ørstavik et al. 1986) is used for radiographic evaluation. Emergency treatment Acute irreversible pulpitis: . Pulpotomy . Eugenol pellet in pulp chamber . IRM top filling . NSAIDs when severe pain Acute apical periodontitis: . Incision and drainage of abscess/pus if applicable . Preparation of canals and intracanal dressing (Ca(OH)2) as the optimal treatment . NSAIDs when indicated . Systemic antibiotics if systemic complaints and disseminating infection 2 Endodontic files for instrumentation of canals Hand files: . K-files . Stainless steel files (SS) . Hedstrøm files . Nickel-titanium files (NiTi files) NiTi rotary files: . Biorace . Reciproc Endodontic surgery All relevant radiographs mounted on viewer or screen. Anaesthesia. 1 minute mouth rinse with Corsodyl®(Chlorhexidine 2mg/ml). Incision: . A horizontal incision extending one to several teeth mesial and distal of the involved tooth and one vertical-releasing incision, usually placed at the mesial end of the prospective flap. Retraction: . To hold the flap away from the surgical site, providing maximum access and visibility, without causing harm to the flap or the surrounding tissues. Osteotomy: . Involves removal of cortical and cancellous bone to gain direct access to the apical portion. This is achieved routinely by using burs/rotary instruments. Surgical curettage: . To remove all pathologic tissue, foreign bodies, and root and bone particles from the periradicular area. Biopsy: . Any soft tissue lesion removed during the surgical procedure should be submitted for biopsy. Microbiological sample: . With paper point directly in the periapical sample, placed in pre-reduced anaerobic transport medium, or periapical tissue placed in 4% formalin for scanning electron microscopy. 3 Root end resection: . By sectioning the apical segment of the root and/or bevelling it to the line of sight/3 mm. Ultrasonic root end preparation: . To provide a clean, well-shaped class I cavity. Haemorrhage control: . Local anaesthetic solutions possessing vasoconstrictor properties; Stryphnon gauze (Adrenalonchlorid 0,33 mg/cm2); Ferric sulphate (Fe2[SO4]3 with 15.5% astringent and 21% stasis). Root-end filling: . Using either IRM or MTA. Use of the MAP system (Micro-Apical Placement) or the MTA pellet-forming block will ease the application of MTA. Cleaning of surgical site: . Saline solution to remove debris, and tissue edges are re-approximated in their correct position to promote healing by primary intention. Compression of the repositioned tissue with a saline-moistened piece of gauze will reduce the coagulum to a thin fibrin layer between the repositioned tissue and cortical bone. Tissue margins should rest passively in the desired place before suturing. Wound closure: . Using nonabsorbable suture material in sizes 4-0 and 6-0.