بسم الله الرحمن الرحيم

1. بسم الله الرحمن الرحيم Endodontic case presentation Presented by Dr.MohammadAl-Ahmari [SSC-Dent(Endo)], R3 Mohammad Al-Ahmari [SSC-Dent(Endo)],R3

2. First case Mohammad Al-Ahmari [SSC-Dent(Endo)], R2

3. Patient Personal Data Age: 83 years old Sex: Female Nationality: Saudi • Chief complaint: • Referred from GP to removal broken instrument. Mohammad Al-Ahmari [SSC-Dent(Endo)], R2

4. Medical history : • Significant medical history: Hypertensive, Diabetic. • History of allergic reactions: None • Dental history : • Multiple fillings & missing teeth. Mohammad Al-Ahmari [SSC-Dent(Endo)], R2

5. (Subjective) examination: Mohammad Al-Ahmari [SSC-Dent(Endo)], R2

6. (Objective) examination: Mohammad Al-Ahmari [SSC-Dent(Endo)], R2

7. Per-operative picture # 13 Mohammad Al-Ahmari [SSC-Dent(Endo)], R2

8. Pre - operative radiograph Mohammad Al-Ahmari [SSC-Dent(Endo)], R2

9. Radiographic Findings : Mohammad Al-Ahmari [SSC-Dent(Endo)], R2

10. Causes of instrument separation: • improper use. • Limitation in physical properties. • Inadequete access. • Root canal anatomy. • Possibly manufacturing defect. Pathways of the pulp, Ninth editin,2006 Mohammad Al-Ahmari [SSC-Dent(Endo)], R2

11. The location of separated instrument is critical importance. The location of the separated instrument extended into stright coronal portion of the canal, retrieval is likely. However, the instrument has separated deep in the canal and the entire broken segment is apical to the canal curvature , then orthograde removal will not be possible. Pathways of the pulp, Ninth editin,2006 Mohammad Al-Ahmari [SSC-Dent(Endo)], R2

12. (Treatment Plan) Mohammad Al-Ahmari [SSC-Dent(Endo)], R2

13. The out come is better if the canal was instrumented in the later stages of preparation when the separation occur. • Principles and practice of endodontics, 3ed,2002 • If the preoperative pulp was vital and noninfected( e.g, irreversible pulpitis) and there was no apical periodontitis, the presence of the separated instrument should not affect the prognosis. • Crump MC, Relationship of broken root canal instrument to endodontic case prognosis,1970,J Am Dent Assoc Mohammad Al-Ahmari [SSC-Dent(Endo)],R3

14. If the instrument can not be removed or bypassed in the tooth with a necrotic, infected pulp and apical periodontitis, the prognosis will be uncertain. These cases should be observed closely, and if symptoms persist, apical surgery or extraction should be consider. • Yeo JF, retrograde removal of fractured endodontic instruments,1989 Mohammad Al-Ahmari [SSC-Dent(Endo)],R3

15. Mohammad Al-Ahmari [SSC-Dent(Endo)],R3

16. Guideline for when to discardand replace instrument: • Shiny areas detected on the flutes. • Excessive use ( constant monitoring of usage is mandatory) • Corrosion is noted. • Excessive bending or precurving. • Compacting instrument have defective tips or have been excessively heated. Problem solving in Endodontic, 3 ed, 1997 Mohammad Al-Ahmari [SSC-Dent(Endo)],R3

17. MASTER APICAL CONE Mohammad Al-Ahmari [SSC-Dent(Endo)],R3

18. Recall Radiograph After two months Mohammad Al-Ahmari [SSC-Dent(Endo)],R3

19. Second case Mohammad Al-Ahmari [SSC-Dent(Endo)],R3

20. Patient Personal Data Age: 20 years old Sex: male Nationality: Saudi • Chief complaint: • Referred from GP to do RCT. Mohammad Al-Ahmari [SSC-Dent(Endo)],R3

21. Medical history : • Significant medical history: N.A.D • History of allergic reactions: None • Dental history : • Multiple fillings & extractions. Mohammad Al-Ahmari [SSC-Dent(Endo)],R3

22. (Subjective) examination: Mohammad Al-Ahmari [SSC-Dent(Endo)],R3

23. (Objective) examination: Mohammad Al-Ahmari [SSC-Dent(Endo)],R3

24. suspected tooth : (Normal: WNL, No Response:- , Mild:+ , Severe: +++ , Lingered: L , Delayed: D ) Mobility: I , II & III Furcation: I , II & III Mohammad Al-Ahmari [SSC-Dent(Endo)],R3

25. Per-operative picture # 45 Mohammad Al-Ahmari [SSC-Dent(Endo)],R3

26. Pre - operative radiograph Mohammad Al-Ahmari [SSC-Dent(Endo)],R3

27. Radiographic Findings : Mohammad Al-Ahmari [SSC-Dent(Endo)],R3

28. (Assessment): Mohammad Al-Ahmari [SSC-Dent(Endo)],R3

29. (Treatment Plan) Mohammad Al-Ahmari [SSC-Dent(Endo)],R3

30. Nonsurgical Endodontic Re-treatment outcome in Teeth with PeriapicalPeriodontitis. • Friedman S, Treatment outcome and prognosis of endodontic therapy, Essential endodontology,1998. Mohammad Al-Ahmari [SSC-Dent(Endo)],R3

31. Mohammad Al-Ahmari [SSC-Dent(Endo)],R3

32. Mohammad Al-Ahmari [SSC-Dent(Endo)],R3

33. Delivery system for root canal filling materials: • Rigid system: thermafil Plus….simplifill….Fiberfil. • Injection techniques : e.g. Obtura … • Rotary techniques: McSpadden compactor instrument…Quickfil.. Mohammad Al-Ahmari [SSC-Dent(Endo)],R3

34. Mohammad Al-Ahmari [SSC-Dent(Endo)],R3

35. Thermafil metallic group took significantly more time to be retreated than the other two groups at 99% Confidence. • In our study in which post space prepared teeth were used, the removal of the apical stainless steel carrier segment was very difficult and could be compared with the retrieval of a broken file from the canal. Six of 15 devices used in the Thermafil metallic group could not be removed (Fig. 2) despite the extended period of time used during the retreatment routine, vigorous instrumentation with frustrating attempts to engage the carrier with files, and the copious irrigation delivered by ultrasound level. • Endodontic Retreatment of Thermafil or Lateral Condensation Obturations in Post Space Prepared Teeth, Mario Luis Zuolo, CD, Noboru Imura, CD, and Maria Olivia Fernandes Ferreira, CD,JOE.1994 Mohammad Al-Ahmari [SSC-Dent(Endo)],R3

36. The results showed that in the coronal one-third of the canal, use of the Thermafil device resulted in significantly more remaining gutta-percha than use of laterally condensed gutta-percha. However, in the apical and middle one-third of the canal the difference in remaining gutta-percha between Thermafil and laterally condensed gutta-percha was not significant. The metal carrier was easily removed and the mean time for retreatment was 6.3 min for Thermafil compared with 5.7 min in the lateral condensation group. • Endodontic Retreatment of Thermafil Versus Laterally Condensed Gutta-percha, Lisa R. Wilcox, DDS, MS, and Jon J. Juhlin, DDS, MS, MARCH 1994,JOE Mohammad Al-Ahmari [SSC-Dent(Endo)],R3

37. Mohammad Al-Ahmari [SSC-Dent(Endo)],R3

38. In recent years, the Thermafil technique has become popular in Poland. As with any obturating system, failures do occur with this technique. When they do occur, there are three remedies according to Lovdahl (3): nonsurgical retreatment, endodontic surgery, or extraction. Although organic solvents (chloroform, xylene, eucalyptol, and halothane) have been proposed for softening the guttapercha during retreatment (4- 8), heat remains an appealing option • Clinically, it has been observed that retreatment of Thermafil with the System B is accompanied by pain and the sensation of burning. Therefore, it was decided to measure in vitro the temperature rise on the outer root surface during retreatment of Thermafil with the System B technique. • In Vitro Infrared Thermographic Assessment of Root Surface Temperature Rises During Thermafil Retreatment Using System B, MariuszLipski, Dr n. med., and Krzysztof Woiniak, Dr n. med. JUNE20 03,JOE Mohammad Al-Ahmari [SSC-Dent(Endo)],R3

39. Our findings indicated that the plastic carriers were easily removed during post space preparation and reinstrumentation, and therefore should be selected if Thermafil is elected as obturation technique when post space is required. • It is generally accepted that a 10°C elevation in temperature on the root surface, to approximately 47°C is potentially damaging to the cementum, periodontal ligament, and alveolar bone. • In Vitro Infrared Thermographic Assessment of Root Surface Temperature Rises During Thermafil Retreatment Using System B, MariuszLipski, Dr n. med., and Krzysztof Woiniak, Dr n. med, J UNE20 03,JOE Mohammad Al-Ahmari [SSC-Dent(Endo)],R3

40. Mohammad Al-Ahmari [SSC-Dent(Endo)],R3

41. The mean time for retrieval of the plastic carrier was significantly less for the System B technique (1.8 min) than for the solvent technique (3.6 min) (p < 0.001). The difference between the two groups in the amount of filling material (carrier, gutta-percha, and sealer) removed was not significant (p > 0.05). • During a pilot study in which the System B temperature was set as high as 300°C, the carrier melted through leaving a 5 mm fragment in the apical portion of the canal. Hence, the clinician should be aware of the melting point of the plastic to avoid overheating the carrier and causing separation of the apical portion of the carrier. • The present study used #30 obturators. This is significant because #45 and larger carriers are made with a plastic that is soluble in chloroform, whereas the sizes smaller than #45 are not soluble in the solvent. However, carriers that are #40 or smaller seem to represent a large majority of the difficult retrieval situations experienced by endodontic practitioners. • Thermafil Retreatment Using a New "System B“ Technique or a Solvent, James F. Wolcott, DDS, Van T. Himel, DDS, and M. Lamar Hicks, DDS, MS, NOVEMBER 1999,JOE Mohammad Al-Ahmari [SSC-Dent(Endo)],R3

42. MASTER APICAL CONE : Mohammad Al-Ahmari [SSC-Dent(Endo)],R3

43. FINAL OBTURATION Mohammad Al-Ahmari [SSC-Dent(Endo)],R3

44. Recall Radiograph Recall after four months Mohammad Al-Ahmari [SSC-Dent(Endo)],R3

45. THANK YOU Mohammad Al-Ahmari [SSC-Dent(Endo)],R3