Transcription
So welcome to uh this week's uh Friday clinical case. And this is another unusual uh case I've got to show you today. You know, I like to um throughout the week I'm doing lots of root canals. I'm looking for the most unusual and uh and difficult cases. And this is a very easy case actually but um quite a unusual case with regard to treatment planning. And this is essentially a a root canal uh tooth which has had a previous apasectomy which I think needs a uh root canal. And before we get into that sort of case what I want to say is that over 50% of the people who watch these videos are nonsubscribers. So, if I could ask you to do one really easy and free thing, takes two seconds, just to hit that subscribe button. If you hit the subscribe button, I promise each week, each case will be better and better and better. And if you want to bring your support for the channel even further, we've got a membership program. The membership program has early access to content. So, we usually work about three to four weeks ahead with these videos. And it also has exclusive content. We've got a endodontic access video on there. It's about an hour long. It's fantastic. And we're about to upload a new uh newly qualified dentist exclusive content video as well. So, we'll get on with the case.
So, this is um a lady who has three uh uh teeth which are not in the best of shape. And the uh tooth that we are concentrating on today is the upper right one. And you might ask yourself, well, why does this um root canal need to be treated? Because yes, the uh the the remaining opturation in this tooth is less than ideal. Um but so there's no apical lesion. The patient's not having any um any symptoms. However, if I show you a picture of the tooth intraorally, we can see that the gut perk here is exposed to the the elements. So this patient um is thinking longterm. So say we um we we this tooth is going to have a crown on it eventually. So say we crown this tooth as is and then the patient gets symptoms. Well, there's no kind of back stop in this situation. um you know to to to do an apectomy on this tooth again with a less than ideal obturation is is is is is not going to be great and she'll probably lose the tooth. So we're giving the patient options in the future. Now I know that this tooth is quite badly broken down. I know the bone levels around this tooth is pretty poor. So an apectomy uh might not be the best option but I just want to give the patient options. And essentially the inside of the tooth was full of bacteria, all nastiness and gunk. And um you know she wanted a crown on this tooth. She wanted to take the risk. We could just take the tooth out but she's got not many teeth remaining and this was her choice. So you know I was happy to uh re retreat this uh tooth. Um the only issue of course with doing a root canal like this is that what happens to the piece of amalgam? I'm assuming it's amalgam at the end of the tooth when we do this root canal because there's a real strong risk of us dislodging this amalgam when we are shaping and cleaning this tooth. And of course if we dislodge the amalgam there's a possibility then that then the tooth um continues to be inflamed um or the tooth start to become inflamed around this piece of amalgam. So the tooth will need some sort of apectctomy or or apical surgery to remove that that piece. But overall, I think the patient um she wants a crown. The uh the GP is exposed to the oral cavity, meaning that the GP is uh is full of nastiness. And we're just going to just sort the foundations to these teeth before we put any sort of crown on top. So, the patient was happy uh to go ahead with this treatment. So, we're going to we'll move over to the video here. You can see that the intraoral uh aspect of this tooth the the you know this the tooth's got decay. The GP can be shown. Um overall this tooth is in quite quite a sorry state and um essentially what we've got to do first is we got to just check if the tooth is restoable or not. So, at this point, I'm not actually going to pop rubber dam on. I um I what I'm going to do is I'm just going to remove all of the Kay and all of the filling just to see what we've got left and to see really if the tooth is genuinely uh restorable. And the uh the sort of composite filling in the meal aspect is so bad that can just be flicked away. And I'm looking at this tooth now and I'm thinking, you know, I I I think this tooth is restorable. It's not entirely in the best of shape, but I think once we've removed the vast majority of the decay, it is restorable. And I'm thinking also this GP is going to be nice easily removed because it's so uh sort of loose within the the canal space. So, I'm going to pop the the rubber dam on and then I am just going to have a little assessment to see what we've got. And um I'm going to get my slow hand piece here and I'm just going to remove um all sort of infected dentin. And I'm going to make sure that this uh this this this dentin is all nice and clean. And of course, this just leaves a small piece of enamel left. I'm not too fussed about that, mainly because the tooth's going to be crowned eventually. And now all the decay is removed. I'm going to concentrate on removing some of the gutter perka. And I'm just having to feel around here with my DG16 endodontic probe. And sometimes when I flick around with these probes, uh the the GP just falls out. And you know, if that happens, then you know you're on to a winner. But um in that case it doesn't work. So I'm just going to use the twist and pull technique with my headstrum files. And essentially these headroom files you just screw the headstrum files in. You pull them out and sometimes the GP goes with it. I think the 25 is probably a bit too uh bit too narrow to grab onto the GP. Uh so I'm going to move up to a size uh 35. Giving it a little bit of a clean, a little bit of an activation. Have a little feel around with the BG16 andic probe. And then you'll notice here that I like to activate um uh the irrigance when the GP is in there. And what it does is it gives you just a little bit more clarity, a little bit more vision to see what you're working with. Um and then I'm just going to use my GP, my Yoshi GP remover here. This is like a DGendodontic probe with a tiny hook on the end. And I'm just having a feel around here just to try and push this out. I'm trying to think why, you know, I'm not really too sure why this GP isn't isn't being removed. Maybe there's a bit of an overhang within the chronal third of this tooth, but I'm having a little fiddle around, little bit of a push, little bit of a twist with my size 35. And then what we see here is I screw this size 35 in. It removes the last little bit of cheap. We can see here now that the canal space is uh nice and clear. And then straight away, I just see there's a little bit of decay that we can see within the chronal third of this tooth. So I'm just going to use my fast hand piece and a slow hand piece here just to clean everything out. When we have a little look, we can see that the inside of the tooth is now uh nice and clean. And um so I'm just going to give the the the canal space a little bit of a clean out, a little bit of an irrigant. And in fact, when we look right down the canal space here, we can see that very very large sort of glint of amalgam here. And this is essentially a great sign because we know we're at the end of the the the tooth. What we got to do now is we've got to be just be very very careful we don't dislodge this uh this this piece of amalgam. And then just as if just to prove my point, I'm going to hook up my size 35 headron file. And as you see here with the apex locator, as I touch the hedgeron file onto the amalgam, we can see that um we're right at the end because this is showing that we're out the end. So this is shortcircuiting on the amalgam. So we know we're absolutely at the end. I do want to just check them at the end, however, um uh with a GP cone. And when we sort of place my size 40 high flex GP cone to length, we take an X-ray, we can see that this GP cone is um at the correct length to the to the to the piece of amalgam. And you might think this, well, well, if you can see the amalgam, what's the point? I always think it's great to have a process and make sure that each stage is um got kind of like a bit of a back stop. We know we're at the right stage. So, I'm now ready for my uh final irrigation and opturation. I'm going to pull out my GP cone and put it in my disinfectctor. These like kind of little wells. I'm going to fill this well up with some sodium uh hypocchlorite. And then I'm going to just kind of start my irrigation uh protocol. And essentially what I do is like sodium hypocchlorite. I activate it. EDTA activate. And uh sodium hypocchlorite is a final wash. However, I still notice a little bit of decay and it is quite far down the coronal aspect of this tooth. So, what I'm going to use, I'm going to use these long necked uh gooseeneck burrs here. And this is just basically a rose head bird with a very, very long neck. And I don't often use these, but I do want to remove all the decay within this tooth. I'm very, very acutely aware of though that if I remove too much of the coronal tooth tissue, it's going to cause this tooth to become quite weak. But now the tooth is free from decay and it's all nice and clean. I'm ready to again just finish my final irrigation protocol. Don't be scared to go back a step. If you feel like that um you know uh if if you're moving on with the root canal and you feel like the previous step, the previous previous step hasn't worked, you go back to it. You make sure you do a good job. So once we have irrigated and cleaned um the the tooth up, I am ready to dry uh the canal space. I'm going to use these kind of paper points. And at this point, I'm thinking to myself, do I need uh the the the GP cone? I'm not entirely sure because I know that um I'm probably not going to uh uh uh go say say I'm going to this tooth needs to be retreated. I'm probably not going to retreat this tooth um orthograde. I'm probably going to do it retrograde. And what I mean by that is I'm not going to go through the uh the p uh the singulum of the of the of the of the of the of the crown. I am almost certainly if I'm going to retreat this tooth go the other way. And I suppose um what I'm thinking this is my rationale here is that I want to fill uh the the canal space completely with the bioeramic the bryeramic then we'll create this kind of perfect monolocked opturation of the tooth. Don't forget as well our biceramic uh uh expands on setting. So, it's going to um push into all the little nooks and crannies of the tooth and really give it a good seal. And that's essentially what we want. We want to seal the tooth off from the rest of the mouth and make sure it doesn't get reinfected with bacteria or to intune the bacteria remaining in the tooth. So, I'm going to use one fill here. This is a bioceramic uh uh uh sealer. And I'm just gonna completely back fill the whole tooth with this biceramic seal. I'm using these uh visca tips here. But what I'm slightly concerned about is like there's maybe like a bit of a bubble. So I'm going to use my DG16otic probe just to make sure that the opturation material, the sealer is all squirted into all the nooks and crannies. Once I've done that, I'm going to fill it up a tiny little bit more with our uh biceramic. But it's at this point I'm thinking to myself, well, how am I going to uh uh close this tooth up because obviously this is a liquid. So, what I'm going to use, I'm going to use a uh bioamic putty. And this is wellroot comes in like a little compule capsule. I'm going to put a little bit on the back of my hand. I am then going to roll this uh bioceramic putty into a very very small uh sausage and I'm going to pick it up with my uh Mac 2 plugger. And then what this does is it creates this kind of seal at the top of the tooth which is not a liquid. So I can place my final restoration on top. And I'm just going to very very gently place this biceramic putty into place. I'm going to dampen it down a little bit. We got to be careful with this biceramic putty of course is that it can sometimes get stuck to your instruments and they can be pulled away quite easily. So I'm just going to have a very very quick dampen down. Once you've dampened down this bismic though, it's it's it's not easily sort of dislodged. And when I assess this tooth, I'm thinking to myself, how am I going to remove this excess? Because I could use uh an ultrasonic. I could use my um my my MC 2 plugers just to move uh things out the way. Got to be dead careful I don't dislodge this because I don't want to wash out all the sealer. I think in this case what I'm going to use is a ultrasonic uh tip, but I'm not going to use it directly on uh the the putty uh because I just really want that kind of washing effect. And we can see here now that it's all been washed away the excess and it looks pretty good. So I'm going to use a Lycure GIC to place over the top of this. This is vitra bond. And then to place this vitra bond I am going to use an acidos tip. So this is kind a self-loading uh tip which uh goes into your compule gun. So you can see here that I'm just going to place this uh GI into the tip and then we get a very very small rubber bung which acts as the plunger for you to dispense this uh GIC to a place where you want it to go. So just going to make a small bend in the end of this tip and I'm going to just pop the tiniest tiniest little bit of GI. I don't want to fill this up because what you'll notice is this GI shrinks on setting. So if you if you filled this up completely um sometimes what happens is it sort of peels away from the walls. And we can see now that the tooth uh the the root canal is complete. But I'm not too sure about the uh the the rest of the tooth tissue in this case. So I'm just going to get my uh slow hand piece and have a little feel around uh the the the remaining tooth tissue just to see if we removed all the decay. I feel like we have. And then we're ready to do our uh our final etch um and bond protocol. And we can see here now I've etched the tooth completely and it's ready to uh receive the bond. In this case, I'm using eyebond. Usually I like to use scotch bond, but the scotch bond is self-etching. So if you use an etch with a scotch bond, it doesn't work as well. So in this case, I'm using ibond. We'll get it all nice and clean. And then in this case I am going to fill the access cavity with SDR. This is smart dentin replacement. And then I am going to fill the rest of the tooth with just a normal uh composite compule. And we can see our post-up radioraph here looks looks fantastic. We've got a nice solid monoblock uh fill in the canal space. the coronal aspect of the tooth. Of course, the crown looks awful, but um that is due to have a crown placed on top um at a later date. So, I'm not too concerned about that. I feel like the uh the the core filling in this tooth is all uh all nice and overall again nice results. Bit of unusual one. Listen, if you feel like you would have done something differently, if you feel like um my decision- making in this case was was was not correct, please put in the comments section below. This channel is about learning. And I love to hear all of your comments if you think something's done wrong, if you're happy with this result. Again, show your support. And overall, I'll see you in the next video next week. Thank you.