Doug Kase
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you have all read in past issues, we are staunch believers in the use of
the apex locator. It is the only way to get an accurate measurement
control to which we can instrument. Accurate apex location results
in fewer post-operative complications, such as pain, because it reduces
over-instrumentation and resulting overfills. The following case
is a perfect example of the importance of using an apex locator when doing
endodontics.
This patient was first referred to our office for
continued discomfort on tooth #12 after the completion of endodontic therapy.
Radiographs showed an acceptable root-canal obturation on #12, but also
a periapical radiolucency on tooth #13 (Figure 1). Symptoms, however,
were specific to #12. I suggested a re-treatment of the endodontics
prior to any surgical intervention. The patient returned two months
after the re-treatment (Figure 2) with continued symptoms, and he also
had developed a small pea-sized swelling over the buccal plate approximating
the apex of #12. He was placed on a regimen of clindamycin and advised
to return for an apicoectomy during which we would also investigate tooth
#13.
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FIGURE 1: Showing an
acceptable root-canal obturation on #12, but also a periapical radiolucency
on tooth #13.
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FIGURE 2: Two months
after the re-treatment.
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The patient returned for the surgery, whereupon, after a local anesthetic
had been given, I created an incision from the mesial of #14 to the mesial
of #11 in attached gingival and also made a vertical release incision on
the mesial of #11. Upon flapping back the tissue, I was able to visualize
the root tip of tooth #12 sticking through the buccal plate with a 3 mm
extension of gutta-percha through the apex. Additionally there was
a bony defect over the apex of tooth #13. I beveled back both the
apex of #13 and buccal apex of #12 and curetted any tissue out of the site.
A check radiograph was taken to help visualize the location of the palatal
root of #12 (Figure 3), and I excavated for that and beveled it back as
well (Figure 4). I made retrograde preparations using ultrasonic
diamond surgical tips, and placed amalgam seals (Figure 5). I sutured the
site, and the patient tolerated the procedure quite well. The patient is
now asymptomatic and doing well.
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FIGURE 3: Check radiograph
taken to help visualize the location of the palatal root of #12.
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FIGURE 4: Palatal root
of #12 beveled back.
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FIGURE 5: After placing
amalgam seals.
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If the original endodontic therapy had included the
use of an apex locator, perhaps this overfill would have not occurred and
thus the surgical intervention on this tooth would have been avoided.
Unfortunately, not all overfills can be avoided. Some may occur due to
open apices combined with an obturation technique that utilizes condensation
or thermoplastics. But it is apparent that overfills are minimized
when accurate electronic apex location is used in conjunction with single-point
obturation in an appropriately tapered canal, as in the EZ-Fill® technique.
The next case is just an example of practical dentistry.
A patient presented to our office with endodontics started on tooth #12
(Figure 6). This tooth was part of a very recent long-span bridge
with tooth #13 as a terminal cantilevered pontic. Teeth #10 and #11
were present as abutments. Because there had been some loss of marginal
seal on the mesial and a distal angulation of the root, I placed an instrument
in the canal to verify and confirm the results from my apex locator (Figure
7). I completed the endodontics using the EZ-Fill technique (Figure
8), and the patient was to return for a post and core.
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FIGURE 6: Showing endodontics
begun on tooth #12.
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FIGURE 7: Instrument
placed in the canal to verify and confirm the results from the apex locator.
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FIGURE 8: Endodontics
completed using the EZ-Fill technique.
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Under normal circumstances, one might ask why we are trying
to restore an abutment for a cantilevered restoration when there is a definite
loss of marginal seal and cantilevers are somewhat unfriendly to the abutments
anterior to them. In this case, restoration was the practical solution
due to the age of the restoration and the patient’s economic wants and
needs. Thus, on the next visit, I prepared the tooth and placed a
#1 Flexi-Post® (Figure 9). I packed an internal amalgam core
into the marginal opening and sealed the access (Figure 10). The
patient is happy, and the referrer is happy as well.
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FIGURE 9: Showing a
#1 Flexi-Post® in place.
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FIGURE 10: With an internal
amalgam core packed into the marginal opening and the access sealed.
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Spring 2004
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