Endodontics on Don Mills
980 Lawrence Avenue East M3C1R2 Toronto, ON, Canada

Crack diagnosis and beyond Tooth 3.7 Medical history was non-contributory. Patientwas a grinder. CC: spontaneous painand pain upon chewing EO: WNL, IO: crack on the composite, cold test negative, STP, and 7-mm pocket at mesial, Radiograph: crestal bone loss at mesial consistent with clinical deep periodontal pocket at mesial... Question: Should I remove the composite toexplorethe depth of crack? Answer: No. The periodontalpocket talks! The tooth was removed and the socket was grafted. Comments: Be aware of fuzzy appearanceof crestal bone and PDL widening at the cervical third of the root. Either could be a sign of crackAND root fracture ( they are different entities!). #endodontists #dr.danesh #dentist #dentistry #savethetooth #endo #rootcanaltreatment #rootcanal #toothextraction See more

This case was presented a year ago. Re-t was performed and ledges were bypassed. Patient came for follow-up after a year. As you see (in the second photo)The lesions healed and a crownwas installed to protect the tooth. I wish the perio issue at distal was addressed as well. It can definitelyplace the tooth at risk! #endodonticsondonmills #endo #endometriosis #dentist #dentistry #endodontic_treatment #toronto #canda

Tooth 4.6 was referred to Endodontics on Don Mills for 4.6 re-treatment. Clinical exam showed a lump on the buccal attached gingiva. There was a 5 mm-pocket at the buccal furcation. A diagnosis of previous RCT and symptomatic apical periodontitis along with a crack at the pulpal floor was made. Having opened the tooth no crack found. Mesial canals were heavily calcified. Mesial- buccal canal was opened. Mesial lingual canal was still short. CH was placed as an intra- canal me...dication for 2 weeks. When patient came Back, all his symptoms were gone. The attached gingival was normal. No probing was attempted. The canals filled with vertical condensation and Thermaseal. The final x-Ray showed a large accessory canal in MB canal which completely filled, at least on X-ray. This finding along with no crack on the pulpal floor can explain the lump on the attached gingiva. So, whenever there is a swelling on the buccal or lingual attached gingiva a differential diagnosis of a vertical root fracture, crack at the pulpal floor, pulpal floor perforation, strip perforation, or an accessory canal at the pulpal floor or at the cervical third of the roots should be made. ... . . . . . . . . . . . #dentist #dentistry #endodontist #teeth #tooth #teethwhitening #whitening #bleach #dental #dentalcare #smile #endodonticsondonmills #smiles #dentalclinic #dentalcare #endodontics #rootcanals #beautifulsmile #savetooth #hero

This patient was referred to Endodontics on Don Mills for tooth 2.7 re-treatment. The medical history was non-contributory. She had decided for many times to get the treatment done over a couple of years, however, she was never ready! She finally was. There were no symptoms associated with the tooth. She was worried about the fracture of the crown, so she decided to go head. She gave a history of root canal treatment in the past, however, she did not recall why the treatment ...was abandoned. There was no trace of canals on the x-ray rather than a broken lentulo- spiral in the distal-buccal canal (DB). Having said that, I could guess the canals had been filled with calcium hydroxide (CH) and that was why no canal space was visible on the x-ray. That is usually like this! Treatment options, pros and cons, risks and limitations, and the prognosis of the proposed treatment were discussed with her. The coronal filling, which partly was a temporary filling, was removed. There was CH in the canals, which had turned into a hard-setting paste over time. The coronal part of DB canal was adequately opened with number 2 and 3 Gates Glidden drills. A combination of sodium hypochlorite, to remove the debris, and EDTA, to soften the CH, were used. I managed to bypass the broken lentulo-spiral, but it was just the beginning of the challenge! I faced a very hard material at the apical third of all canals. I was short in all canals! Using different stiff files like C and C PLUS files, the mesial buccal and distal buccal canals were opened to their radiographic apices. The presence of an impacted tooth obscured the DB apex and the apex locator device was deemed unreliable in this case for unknown reasons. At the end, the result was good for DB canal! The palatal canal remained blocked! A channel was created alongside the broken instrument by using consecutively large hand files, big enough to accommodate rotary files. Ultrasonic tip was just used to prepare the DB canal, coronal to the broken instrument, to make it more accessible. Very slight direct US energy was applied to the broken instrument, just to dislodge it. It was not supposed to remove the broken instrument by US tip like the previous case. The technique in this case was to make a channel around the instrument and remove it by hand files, rotary files, and irrigation force. However, one may use a very tinny US tip alongside the instrument in the channel in a contra clockwise motion. The broken instrument finally appeared in the pulp camber. The tooth received the standard treatment and referred to her dentist for the restoration. She was booked after a year for follow up.

This patient was referred to Endodontics on Don Mills for tooth 3.6 re-treatment. The medical history was non-contributory. She reported recent flare-up, but once I examined her there were no symptoms. The patient was worried about fracture of the tooth rather than the extension of infection in the future. So, she sought for re-treatment. The available x-ray showed a large filling, previous RCT, broken instrument in one of the mesial canals, apical lesion and apical root reso...rption at the distal apex. The broken file could be in the middle mesial canal, as there was another path filled with the filling material (Picture 1). The diagnosis was previous RCT and asymptomatic apical periodontitis. Options like re-treatment, extraction, or no treatment was discussed with her. Also, pros and cons of each modality along with the risks were explained to her. In addition, she was informed of the risks associated with the broken instrument removal such as perforation, leaving the canal with thin walls, resistant file, etc. She opted for re-treatment, followed by a full coverage by her dentist. The prognosis of treatment was discussed. Having removed the coronal filling material and gutta percha from the canals, it turned out that the file has been broken in mesial-lingual (ML) canal, and the other path was an internal deviation from the original ML canal, most likely created in an attempt to remove the broken file or before the file breakage to find the ML canal. There was no middle mesial canal. Then, the coronal third of the ML canal was enlarged very gently with a thin ultrasonic (US) diamond coated tip. Next, the dentin around the coronal 2-3 mm of the broken file was removed with a very tinny non-diamond US tip (Picture 2). It gave me room to bypass the file and play around it to loosen it up. At the end, the same US tip was used in a contra-clockwise motion to disengage and remove the file. Finally, the canals received standard root canal treatment. The patient was referred to her dentist to restore the tooth and complete the coronal seal. She was booked after a year for follow up.

Be sure to check out our newest article in the OD journal, as it can help you clinically in differential diagnosis!

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Sometimes Endodontists get crazy! This patient was referred to our office for endodontic evaluation and treatment of tooth 2.1. The medical history was non-contributory. His chief complaint was pain in 2.1 area. E/O exam was normal. I/O exam showed both 1.1 and 2.1 had cavity/ or abrasion/ erosion at the cervical third of crown. Palatal surfaces of the teeth were intact. Tooth 2.1 was sensitive to percussion and palpation. Cold test was negative on 2.1. A diagnosis of pulpal ...necrosis and symptomatic apical periodontitis were made. The aim of an access cavity preparation is to prepare a cavity on the designated areas of the teeth to give an unimpeded access to canal orifices, first curve of the canals, or apical third of the canals; all are different concepts. In back teeth, occlusal surface is the best and in front teeth access cavities are prepared on palatal/lingual surface. However, in some situations, we can prepare access cavity on buccal surface of upper or lower front teeth. When there is decay on buccal surface, or the crowding is such that the palatal/lingual surface is not accessible, or imagine a lower front tooth has abnormal inclination to lingual, then buccal access cavity is permitted. With the invention of Guided Endodontic Access for Calcified canals access cavity from any point of the crown is feasible. This case was presented with buccal cavity/abrasion. He was informed of buccal access cavity. Root canal treatment was completed through buccal access cavity. Single cone and BC sealer. Limitations of this technique include aesthetic issues, file breakage due to excess strain on the file, inaccurate length determination as the file deflects from incisal edge, and small access cavity due to limitation on tooth structure removal.

We had an unexpected guest today at the office! Our patient today showed up with his dog! And we did not have any other choice! A bit distracting, as he was moving around, but every thing went well!

Is a broken file in the canal a disaster? The answer is yes and no! In general, in cases with a broken instrument, the likelihood of having problem and recurring infection in the future depends on the previous status of the pulp and periapical tissue( inflamed vital pulp VS necrotic pulp, normal periapex VS apical lesion), and the time at which the file breaks. The principle remains the same: to bypass or remove the broken file and disinfect and seal the root canal system. ... This patient was referred to Endodontics on Don Mills for tooth 4.6 Re-t. There was no major symptoms associated with the tooth other than a sinus tract at the attached gingival and mucosal junction. The diagnosis was previous RCT + broken file in mesial canal+ chronic apical abscess. Patient was warned of possible vertical root fracture, due to the location of sinus tract. She was serious in saving the tooth and knew that the tooth can just be filled like as is, otherwise crown lengthening surgery would be needed. The file was bypassed in mesial canal, the ledge was bypassed in distal canal, and the canals were thoroughly disinfected and filled. Having bypassed the broken file and solving all the problems in this case, still the prognosis of this case is moderate to good, like when there is no broken file in the canal. If the file could not be bypassed, the prognosis would have been poor, as infection was left behind!

See how x-ray fools us! Tooth 14 CC: Pain upon touch and chewing, started few days ago, no initiating factor Soft tissue normal, STP, mobility normal, Perio B 333 P 335 X-ray: crown, inadequate RCT, fiber post in buccal canal... Diagnosis: 14 previous RCT, symptomatic apical periodontitis She would like to save the tooth. Treatment plan: 14 Re-t through crown Treatment rendered: access through crown, no chipping , fiber post in buccal root was removed by ultrasonics, gutta percha removed from palatal canal, bleeding started, it turned out that there was a pulpal floor perforation and gutta percha has been placed into perforation. She was informed of the guarded prognosis. Then, the palatal canal was found. Next, the canals were cleaned and sealed with gutta percha and Thermaseal. The perforation was rinsed thoroughly and gently with hypochlorite, the edges of perforation refreshed by ultrasonics, and finally sealed with MTA. Based on the case, the perforation is sealed first, followed by fillings of canals or vice versa. If we look at the preop x-ray more meticulously, the gutta percha to the right which I thought would be palatal canal, was a bit off center and finally turned out to be a perforation. This is the limitation of 2-dimensional x-ray. X-rays from different angulation, and in this case, perhaps straight -on x-ray, could have been useful. The prognosis of a perforation depends on several factors, like, the age of perforation, location, material used, etc. With the invention of MTA, the prognosis of perforation now is considered good ( when we speak to patient, better to talk about worse case scenario. I told her guarded). First follow up would be 3-6 months. Dr. Farzad Danesh DDS, FRCD(C), Certified Endodontist See more

This patient was referred for tooth # 3.6 Re-t. Diagnosis was previous RCT and symptomatic apical periodontitis. Treatment options were offered and risks discussed. She also was informed about the severe ledges in mesial canals and necessity of perio treatment before installing a crown. She elected Re-t. The ledges were negotiated to the apical foramen. The canals were filled with gutta percha and BC sealer. You may note osseous dysplasia at the periapical area! The follow up would be 1 year.

Treatment of a cervical resorption by internal approach. Note the point of entrance was found and sealed with BC sealer and BC putty under microscope! Follow up would be after 3 months in this case.