Root Canals and Retreats of Root Canals #18

Hello, welcome back to my YouTube channel. Thanks for checking in again. So this morning's video, I wanted to talk a little bit about retreatments and some endo general discussion. I know in my most recent video last week, I talked a little bit about, you know, dealing with, excuse me, dealing with challenges that come, come your way and being willing to correct them sometimes either at a significant discount or even free of charge, depending on the situation. And I wanted to follow up a little bit with one of my own particular cases. So this case, this is of course a root canal and a crown. This is my work and, you know, looking at the x-ray, I'm not really happy with the way it looks on the x-ray. And of course, the patient presented with this big fractured portion of her tooth right here. But this is about, you know, nine months old. She wasn't having any symptoms aside from the tooth being fractured. You know, preoperatively, there's no lesion here. The reason we did the endo is because of excessive decay into the canal structure. So the reason for the root canal, like I said, was decay, not intense pain or anything like that. So she presented, we took an x-ray to see what the tooth looked like. And I decided I wanted to go ahead and redo the root canal and the crown for her. Of course, the crown was a no brainer, but the root canal was. Because look at that distal canal structure here. It looks like we've missed something and it looks a little bit anemic in there. Anyway, so here is the scan. You know, I didn't want to just remill the crown. I went ahead and cut it off. I re-scanned it. This is her buccal scan. Of course, you can see the upper and the lower jaw here. Here's the prep. There's a couple of little sharp edges. I ended up smoothing that just a little bit with a burr before we bonded it in place. Here is the design. And you can see there are no thin spots, no warnings there. Nice and rounded. I always try to keep my contact pressure on the ceric less than the adjacent teeth, just to accommodate any inflammation and make sure the bite works well for the patient. So, you know, all these red marks here, no red, just a little bit of green there. That worked really, really well. We actually didn't have any postoperative adjusting to do. And checking in with her later in the evening, she was just a little sore and that was it. So here's the design. And I know there's been a lot of discussion about, you know, putting a core inside of a tooth. My personal thoughts, and this is just me based on my experience, is if it's done well and managed appropriately, I don't think there are any issues long term doing this. But I always trim these little sharp areas off with a burr before it goes in. I don't want to put any pressure on that pulpal floor. I want to make sure that it's, you know, there's only cement touching the pulpal floor. There's no ceramic actually touching that pulpal floor. Okay, so I'll show you the ending of this case in just a minute. But let's talk about a few endos that I've done. You know, personally, I like to do root canals. It's something that I enjoy. And I feel pretty good about doing it. You know, I've done thousands of them. I even tried to do one on myself. Here's one with five canals and a lower first molar. Interestingly enough, this patient also had five canals on our other lower first molar, number 30, which we also did. And I have pictures of those somewhere. But this is, excuse me, wave one. This is a primary size wave one. I did not use gutter core, though. I use the master cones, the wave one gutter perch and master cones with sealer. And that, for me, tends to work really well. And this is the same technique, wave one master cone with sealer. So the way that this worked is I had instrumented, I had shaped and measured four canals, you know, I thought it was just four canals. And then when we got to the, you know, the drying part with the paper points, blood was coming out from somewhere. And I thought, well, maybe it's bleeding a little bit. So I let it sit for a minute, went back in there. And sure enough, the blood was still coming out. And it was right along, you know, between the mesial buccal and the mesial lingual. And there was a little fin along the floor of that pulpal floor. And I opened it up with a 330 burr. And sure enough, there was a full size canal in there. So we went ahead and shaped that one to the same size and disinfected it filled. Here's the post seat crown here looks really good. This is cemented with Fuji. Looks like we may have a little bit of sealer gutter perch in there. But this is cemented with Fuji, which tends to disappear on an x ray. So I really like this outcome here turned out really, really good. Okay, moving on. Here is a five canal upper molar. And this is actually the same patient, this is the left side, this is the right side. And these are two images of the same right side tooth, tooth number three, and this is number 14. This is, you know, this was taken early on in my practice, this is probably about 10 years ago. You know, looking back, I would have liked to shape those a little bit larger, you know, potentially, this palatal canal may have connected in here, if I would have shaped a little more, you know, vigorously, not necessarily aggressively, but vigorously. But yeah, this one turned out well, we got a little spurts of sealer here and a little bit there, two mesial mesial buckle canals, you know, a distal and then two palatals here. Now on the other side, we have two distal canals, one palatal and two mesials. So lots of canals there, you know, and talking about root canals, generally, my thought is if we're going to do a molar personally with appropriate magnification, depending on the needs, some people don't necessarily need that much. A molar with four or five canals like you see here is no different than doing five anteriors. Now let me let me clarify that. We certainly don't want to bite off more than we can chew. And I wouldn't encourage you to do anything you're not prepared for and trained for. But that being said, if you manage each canal individually, as long as you can identify them, find them and measure them appropriately, if you manage them individually, you can treat it just like it's a single canal and do four canals in one tooth, one after the other, back to back to back. Just be cautious with your instruments, you know, as you use an instrument more and more, it increases the risk of potential fracture. So let's talk about some curvatures. These are some interesting curvatures. This is, these are two different upper left first molars, and you can see they will each only have three canals. You know, statistically, I don't remember the exact statistic, but it's like three out of four upper first molars have four or more canals. So you should always assume there are four canals in an upper first molar, unless you just are proven wrong. But I would assume there are four or five canals in an upper first molar. Anyway, so in these two, you can see the curvature here, and this is filed to wave one large. So I think this is a 40 tip here. Same thing on both of these. But I almost always when I'm doing a canal like canal structure like this, I'll measure with a purple hand file. And then I will shape with a measure again with a path file, which is a, you know, a non engaging instrument to get to working length again. And then I'll size from a small to a primary and depending on the engagement with the primary, I may go to a large wave one. So we're using multiple files. And my thoughts there, I would not encourage you, I'd recommend that you do not reuse any rotary files that enter a canal, the risk of a fracture is just too high if you sterilize them. And the manufacturer recommends single use anyway. Okay, so here's another one with some curvature. You know, this is an interesting little S curve here. And then two mesial buccal canals going all the way to the apex. I think this is actually the same tooth, just different angle of x-rays. Yeah, that's the same tooth. So look at this, this x-ray and then get a little different view from that x-ray. What I like to do is I instruct my assistants to take one x-ray, leave the sensor in place, move the cone just a little bit and take another one. So this is, it should be back to back x-rays of the same tooth immediate post-op. Okay, so here's a lower first molar. You know, you can see you've got two mesial buccal canals here and then two distal buccal that have a separate exit. Oftentimes those distals come together, but they run roughly parallel and then they have a separate exit. And this is the same technique. You know, this is wave one guttapercha master cone with sealer. So now let me talk to you about, talk to you about one of my largest failures in root canals. So early on before I really had, before I was really prepared for it, I jumped in a little bit too much, I guess I could say. I tried to do a little more than I should have. And I did, you know, botched up a few cases, which all of us do. But here is one of my great failures. So this is tooth number three. This was me using a system that I really wasn't trained to use. It was the Elements obturation system with an obtura attached to it, system B and obtura, which was a great system, but I didn't use it appropriately. So this system, the system B Elements obturation unit, you know, the protocol is do all your shaping, you put an apricot plug in there with a master cone, you sear it out and then you backfill. Well, I think what happened when I seared out the back portion of the master cone is it pulled it out of there. And so what happened was when I put in the gun, which that particular unit had a button in, you push it and it would just pump the guttapercha out the end. It had little cartridges. It's pretty cool. Normally you get back pressure and it slowly pushes you back out of the canal. Well, I didn't get any of that and I just waited. And I waited too long, obviously, because it pumped all this guttapercha out of the root tips. So what ended up happening, of course, is we ended up sending this patient. I ended up not charging her for anything after looking at this x-ray and sent her over to my root canal specialist buddy and he ended up having to do an apicoectomy on this tooth. Now, we didn't have to do a retreat because this is fresh guttapercha. He just did an apico with a plug in there and it ended up being a good long-term outcome for her, but it was a debacle and it was something that I should have done better. I jumped the gun a little bit on this one, but she ended up being okay. Okay, speaking of more curvature, see the S-curves in these. Now, these are real high risk to break instruments in these S-curves. So if you get into a situation where you're having to actually put pressure on either the handpiece or the hand file, you probably have a significant S-curve, which you may or may not be able to see on a radiograph. So the more pressure you put in there, the slower I would go, whether it's with a hand file or a machine instrument. And then take, rather than going straight to a primary, if you're using wave one, start with a small, put in a master cone, get an x-ray before you seal it and fill it. But yeah, these are a lot of fun, but they can be a challenge with these S-curves, really a big challenge. Here's another upper first molar there, some significant high cervical breakup in here, which again, high risk for fracturing a big portion of the instrument. So be real cautious when you're doing these. So let's go back to the case that I started with. So here's her preoperative situation. And this is master cone with sealer in there. Obviously, I don't like that distal. I think probably what happened to us was the day was a busy day. The assistant took a post-op x-ray on the endo and I didn't look at it. And then we put the crown in, we got maybe a bite wing across the top and I didn't see the endo. So totally my bad. Looking at this, there's obviously something wrong with that distal canal. That's not a outcome for the patient. So I felt obligated and she never asked me. She was actually willing to pay for a retreatment, but I didn't feel right about that. So I went ahead and I told her, you know, it looks like we can do a better job on this, the back half of this tooth, the root canal filler. And I want to replace that crown for you because it broke so recently, which, you know, like I said, it was about eight or nine months. And so we numbed her up and I spent a couple hours and I retreated that tooth. So here's the pre-op and here's a little bit of an angled post-op. You can see how much wider the canals are and how clearly we filled those. This is the large wave one versus the primary here. And then here is the final delivery x-ray. So in the end, I think we did her a great service. Things turned out real well. Again, she was just sore post-operatively. I want to monitor this and make sure this recovers. I think the reason she developed some of this, you know, widening of the PDL space was because we left some space in there. And so bacteria working its way down through here after the tooth cracked could lead to that reinfection. Anyway, good case. You know, it just goes to show that personally my feelings are something like this. It goes a long way for making a patient for life. You know, even though for me, technically I lost, you know, the production that I could have technically, officially charged out for a retreatment and maybe a new crown, you know, but I didn't feel good about either of those since it was less than a year. And honestly, I could have done a better job on that root canal from the first place. So a couple of thoughts there just in wrapping and closing. Make sure you take a clear view, look at your x-ray before the patient walks out the door. If there's any issue, you know, it would have been really easy to sterilize a file, stick it down there, pull all that gutter perch out and redo that again before she left and before we put the crown in and had to drill the whole thing off. And number two, when you come up with issues that, you know, whether the patient's aware of them or willing to pay for them or not, do what's right, do what's ethical, not necessarily focusing on the patient's wallet, but focus on the patient's welfare. In the end, that's how we build patients for life. So I've got another video that I'll be putting out here in a little bit about retreatment that ended up being a non-savable tooth. We'll talk about that here. So thank you again for spending a few minutes watching this video. We'll talk to you later.