Tales from the Chamber
The Dark Challenge

Doug Kase
 
 

IRST, a hearty “welcome back” to all my loyal readers. I certainly hope that your summer was as enjoyable as it was hot and humid! Every once in a while, a case comes along that throws down the gauntlet to challenge the best of us as practitioners and bring out the superhero in us. Whether we succumb to the needs of the case or the wants of the patient or even to both of those, I am quite sure that we have all been presented with unique situations that require us to retire to our back offices, put on our thinking caps, and spend hours looking at our diagnostic data in order to come up with that unique solution. And of course that solution must fit the clinical, cosmetic, functional, and economic requirements of the patient while absolutely remaining dental-medically proper.
    In olden days—you know, before 1990—when implants were not as commonplace, routine, and predictable as they are today, we would go to all lengths to save a tooth, particularly a terminal abutment. Trying root canal therapy, hemisection, root amputation, crown lengthening, post and core, and finally a crown or bridge was routine in the effort to avoid a removable partial denture. Now, of course, if it were not for the stigma of extraction and oral surgery to place an implant, these heroic procedures would be rare indeed. We have to face the fact that some patients still would rather keep their own teeth, even when they know the risks and poor long-term prognosis. Thus being a dental superhero still may have its place.
    As resources, the surgical microscope, ultrasonic file tips, and MTA are as valuable to an endodontist who faces a heroic super-dental procedure as the Batmobile is to Batman. Without the microscope, fixing what you can’t see becomes very difficult. Without fine ultrasonic tips in combination with the scope, uncovering where the problem lies is difficult if not impossible. And last but not least, without a material such as MTA, fixing the problem and allowing the body to heal becomes impossible. Thus my readers, with that being said, coincidently I have just the case to present!
    A patient presented to my office with an asymptomatic radiographic lesion associated with the distal root and furcation of tooth number 19 that had been discovered by his dentist during a routine checkup (Figure 1). “Take that out and do a predictable implant,” I immediately thought, but after discussing the patient’s expectations, wants, and needs, it was time to put on my Superendo costume and come up with an alternative plan. Since the lesion was associated with the distal root only, I decided to try to remove the existing material—which looked on x-ray to be either a carbon fiber post or just composite over the distal gutta percha and probably filling a strip perforation as well. Obviously, and most importantly, I obtained an informed consent and thoroughly discussed risks and prognosis.
    Working under the microscope, I carefully removed the material in the distal canal to the top of the gutta percha. I used an explorer as a radiographic guide to make sure that I was mesially distally centered and following the root axis (Figure 2), leaving the mesial material along the perforation.

Figure 1	Figure 2

    Once the gutta-percha fill was exposed, I worked an instrument down the canal to obtain a measurement control with the apex locator and confirmed it by radiograph (Figure 3). I re-instrumented the canal to clean filings and finally disinfected it with chlorhexidine and ultrasonic activation. Then I fitted a master cone to the apex (Figure 4) and filled the canal using EZ-Fill® sealer. I placed the patient on antibiotics and also prescribed appropriate pain killers just in case.

Figure 3	Figure 4

    Due to the large apical opening and the fear of driving filling material out of the apex, I brought the patient back for a second visit once the sealer had set to remove the coronal gutta-percha to a level below the perforation (Figure 5), using a number 4 Peeso reamer. Then, working carefully under the microscope with a CPR5 ultrasonic file, I was able to flick out the remaining composite material on the mesial wall, exposing the clear perforation into the furcation. I re-cleaned this area and disinfected it with chlorhexidine for two minutes, dried the area, and then pushed a small plug of collicote through the perforation to act as a matrix to pack MTA against (Figure 6).

Figure 5	Figure 6

    I placed a wet cotton pellet over the MTA to facilitate the set, and the patient subsequently returned to have the access closed permanently. The patient was asymptomatic throughout the procedures and took only the antibiotics. Happy ending? It’s hard to say; only time, lack of symptoms, and a recall x-ray will tell!
    We’ll roll the credits, and I am sure you can’t wait for the sequel!