5.25 % heated NaOCl was performed and a glide path was established with 2 % taper K files , 10-20 with patency being confirmed by recapitulating with a size 10 stainless steel K file . The files were then used with a watchwinding action and finished with a push-pull motion until a smooth glide path was created .
Canals were dried and a temporary dressing of calcium hydroxide paste placed in each canal with 1mm of the working length . A foam pellet was placed in the pulp chamber and a temporary restoration placed in the access cavity .
Two weeks later at the second appointment , the patient reported LL4 to be completely symptom-free . Upon clinical examination , no submandibular , buccal or lingual swelling was noted , the tooth was not tender to percussion and the temporary dressing was in situ .
Fig 7
After topical anaesthetic was applied and local anaesthetic administered , a rubber dam was placed as before and the temporary dressing removed . The canals were irrigated and prepared with reciprocating rotary files using an endodontic motor and both canals were prepared to length with a pecking motion as per the manufacturers guidelines . A master apical cone radiograph was also taken to verify GP lengths after gauging each canal to an apical width size 25 ( MAF ). ( Fig . 7 )
A final rinse was performed with 5.25 % heated sodium hypochlorite ( NaOCl ) with sonic agitation for 30 seconds in each canal . Each canal was again irrigated with NaOCl and then irrigated with 17 % ethylenediaminetetraacetic acid for a further 30 seconds with a final flush with NaOCl . The canals were then dried with paper points until the tips of the points were withdrawn from the canals dry .
Obturation was performed with guttapercha cones , which used sealer via continuous wave and heated backfill . The heated gutta-percha was condensed with a size 2 plugger and Gooseneck burs were then used to level and smooth it to the canal orifice level .
The chamber was cleansed with isopropyl alcohol and sealed with light-cured flowable composite after applying 37 % hydrophosphoric acid for 20 seconds , washing with water for 20 seconds , drying with air and applying a dentine bonding agent . The remainder of the access cavity was restored with composite resin and light cured for 20 seconds . The rubber dam was then removed , the occlusion checked in intercuspation position and lateral excursions and the surface polished with rubber cups and diamond polishing paste . A final radiograph was taken showing a wellcondensed obturation with good coronal , mid and apical seal . Some sealer extrusion was noted .
REVIEW At a one-year review appointment the patient reported no symptoms and he was delighted at how quickly the tooth had settled posttreatment . Clinical examination reported no significant findings and the radiograph taken showed signs of radiographic healing . The definitive restoration was also functioning well . ( Fig . 8 )
The Carl Zeiss OPMI pico dental microscope
Fig 8
DISCUSSION / REFLECTIONS Root canal treatment can be a very challenging dental discipline due to the complexity of the root canal system . Root canal re-treatment adds another dimension because the clinician has to dismantle another clinician ’ s work and orientate himself according to the radiographic evidence available . Fortunately , in this case , the radiographic view available was sufficient to obtain the necessary canal anatomy . Upon reflection , another 5 ° angled view periapical radiograph may have given a better image of the additional root . The decision was made , however , according to ionising radiation medical exposure regulations ( IRMER 2000 and IRR99 ), not to expose the patient to further radiation , as the available radiograph was sufficient for diagnostic purposes .
This case also demonstrates the importance of using scanning optical microscopy ( SOM ). The lingual canal could be seen with the SOM but was not visible with x2 magnification surgical loupes . The SOM certainly enhanced the operative procedure and enabled me to treat this case more effectively and with greater precision .
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Dental Practice Magazine
19