NSRCT OR EXTRACTION?

Fig. 1

The patient,48y/male,was referred for an evaluation and treatment of tooth 3.6.
Patient reported a dull pain when biting. The symptoms had started about 3 months previously but symptoms were never severe enough to seek immediate dental care.

      Extraoral examination:Examination revealed no swealing,extra-oral fistula or limphadenopathy of the submandibular and neck areas.

      Intraoral examination:Soft tissue appeared healthy with no sings of intraoral swelling, fluctuance or sinus tract. Patient had minor gingivitis.

      Diagnostic test:  - Percussion+

                                   - Palpation-

                                   - Mobility-WNL

      Periodantal pocket depth:  - Buccal side-less 4 mm

                                                     - Lingual side-less 4 mm

                                                     - Mesial proximal side-less 4 mm

                                                     - Distal   proximal side-less 4 mm

      Bleeding on probing: +

Fig. 2

Radiographic interpretation:Tooth 3.6 had root canal treatment.There was a full crown with pinlay restoration at the molar area. A threated post in the distal root shoowed a 3-4 mm gap apically to the broken file.
Besides apical transportation was identified in apical third of distal root. In the mesial root, 2 separated files were found. Crestal bone loss was noticed at the interproximal bone between teeth 3.6 and 3.7. The furcation was intact.

CBCT:A definite radiolucency of middle part mesial root was noticed.The coronal portion of the post and root canal filling in the distal root were located slightly off-center towards the buccal aspect.

Diagnosis:Previously treated 3.6, Symptomatic Apical Periodontitis 3.6

Treatment plan:

                           Recommended-NSRCT 3.6

                           Alternative-Extraction and replacement with implant fixed partial denture or no treatment

                           Restorative-Post,core and crown

Fig. 3

Pre-operative view

Fig. 4

Anesthesia was performed with Wand STA(Milestone Scientific) used Ubistesin 4%-1/200000.Isolation split-dam for dismantling coronal build-up was used. Crown removed with Safe Relax.

Fig. 5

Pinlay was fragmented with bur H34L.314.012 by Komet until it reached a furcation zone under control of operating microscope.Then,two parts of post were extracted with using US tip G26(NSK)&unit Varios 970(NSK)

Fig. 6

Build-up phases:

-Sandblasting was performed with RondoFlex(KaVo),abrasive powder-Allustral 50 micron

-Etching-Ultra-Etch(Ultradent)

-Opti Bond FL(Kerr/Sybron Endo)

-Core composite - Luxa Core Z(DMG)

Fig. 7

Treatment started from the distal root, the distal-lingual r/c was filled with glass ionomer cement. US tip E7(NSK) was used to remove the material and retrieve two broken files.

Extracted fragments were removed E11(NSK)+U-File#25(Mani).

Each step was executed with copious irrigation of hypochlorite 

Fig. 8

View after removing both broken files.

In addition, the distal-buccal r/c  had not been touched by the previous operator, and still some pulp was present.
The shaping evidenced the merging of disto buccal and disto lingual in the middle third of the root.

Fig. 9

Mesio-lingual r/c  was passed without any problems, finishing of preparation - Vortex Blue(Perfect)45.04.

In the mesio-buccal root, the fractured instrument was retrieved by US with the same approach used in the distal root.
It was also possible to determine the location of the perforation.

Fig. 10

After dressing of calcium hydroxide, the perforation was cleaned-up by US tip & heated Sodium Hypochlorite, after that carefully dried with paper points. Surgispone-hemostatic sponge was used like matrix for protect from protrusion of material into the periodontal tissues.

Fig. 11

Post-op

Fig. 12

Reinforcement was performed by  Prosthetic Over Post size #1&#2 (Over Fibers) and fixed by Luxa Core Z(DMG).PMMA’s crown was fixed by Ketac Cem Plus(Solventum)

Fig. 13

E.Max Press was fixed by VarioLink LC warm

Fig. 14

Chronology of cement residues removal

Fig. 15

Two years follow-up.

Fig. 16

About the author:

Dr. Anton Pundyk

I was born in 1984 in Tumen,Russia.I studied National Pirogov Memorial Medical University,Vinnitsa and graduated in 2008.I am an author articles regarding endodontics on Ukrainian dental magazine "DentArt" and using of the operating micropscope in everyday practice.Since 2017 I am working in private clinic in Vinnitsa,Ukraine.The main specialization is an endodontics,cad/cam and aesthetic dentistry.

In private life,I am enjoying my life with my family and my hobby is my work!