Recently there has been a push towards patient-centred outcomes in dentistry. This means we should treat towards outcomes that are important to the patient. Most patients want teeth that are aesthetic and free of disease and pain, and they want the teeth to be there forever.
In recent years, there has also been a push towards conservation of dentine during endodontic procedures in order to maintain as much strength in the tooth as possible. A recent study by Krishan et al showed that the concept of “straight line access” may lead to significant decreases in fracture resistance in premolar and molar teeth. Although this is a bench-top study, and a long way from a definitive link to outcome, to me it makes sense that if we are going to give the patient the longest lasting solution, then giving them the strongest tooth possible should be one of our primary goals.
In this case, a 22 year old patient was referred for endodontic treatment of the lower left second molar as an odontogenic cyst was to be removed and this would have resulted in loss of vitality of the tooth. There had also been some resorption of the mesial roots. Careful planning of the access allowed all canals to be treated without unnecessary removal of of “pericervical” dentine, the tooth structure that Clark and Khademi feel is the most important to be conserved. The pulp chamber was filled with amalgam and the access closed with composite resin.
I would warn that this approach is more clinically challenging to do well, and that when attempting to be conservative, that the procedure should be titrated. That is, if you need to prepare a canal, and your access isn’t allowing you to do this, then obviously, you need to remove further tooth structure in order to complete the endodontics.
Endodontic access allows good vision and file access whilst conserving tooth structure.
Pulp chamber filled with amalgam and the access closed with composite resin.
References:
Krishan R, Paque F, Ossareh A, Kishen A, Dao T, Friedman S. Impacts of Conservative Endodontic Cavity on Root Canal Instrumentation Efficacy and Resistance to Fracture Assessed in Incisors, Premolars, and Molars. JOE In Press.
Clark D, Khademi J. Modern molar endodontic access and directed dentin conservation. Dent Clin North Am 2010;54:249–73.
Why use amalgam for first stage closure?
It’s isolated from the mouth so expansion shouldn’t be a problem but there could be ‘shine through’ and if you’re relying on composite to isolate it from the mouth then why not a RMGI?
This is a form of endodontic utopia. My opinion is that this is nothing but a case to show at courses and congresses.
Few of us have microscopes, even fewer of us have the time to sit and try to mimic the above concept (both financial and patient schedule pressure). In fact, I believe that this concept will cause more harm then good in respect to the amount of file-fracture cases in everyday endo.
Maybe its thought by endodontist to GP so they can have more filefracture cases? 🙂
/GA
Excellent work Pat. Big Thumbs up!
HI Liz,
To be honest, amalgam is used because it is easier to pack unto the pulp chamber. I use an ultrasonic instrument to help get it into the pulp horn spaces. It also seals well over a very long period. I’m not sure what alternative material could do the job as well. There is no shine through as a layer of opaque flowable is used over the amalgam and before the resin. There should be good bond of the resin to enamel.
Pat
Hi George,
It’s good to show what we can aim for sometimes. I’m not sure if you read the last paragraph of the post? Here it is again for you:
“I would warn that this approach is more clinically challenging to do well, and that when attempting to be conservative, that the procedure should be titrated. That is, if you need to prepare a canal, and your access isn’t allowing you to do this, then obviously, you need to remove further tooth structure in order to complete the endodontics.”
I can guarantee you that the last thing endodontists want is more fractured files.
Pat
May I know histopathological diagnosis of this cyst although this is referral case? Thanks
It was an orthokeratinized odontogenic keratocyst.
i am not agree with this approach, writing “if you need to prepare a canal, and your access isn’t allowing you to do this, then obviously, you need to remove further tooth structure in order to complete the endodontics.” IT is not enough . . .
There is no evidence in this misleading approach, of course if you leave more structure the tooth is more resistent…but there is nothing that on the other hand tell you if you will break a ni ti instrument overloading its flexure resistence.
Doing all of this for what? ( Khademi docet) . . to sell ( i am not reffering to you) those special burs with which you would be able to save tooth structure?
I would like to see all instruments broken (that obviosly nobody shows) in attempting such openinngs . . .