Endodontic Retreatment or Implant?

This patient is wondering if she would be better off having tooth #10 extracted and an implant placed.

This is her situation. She had this silver point root canal done back in the 70's. A new crown was placed about a month ago and then the crown broke off. She came to my office for an evaluation. I recommended that we retreat the root canal, and place a new post for retention of the build-up/crown.

Since the crown broke off the remaining tooth structure supporting it, the ideal situation would be to make a new crown and improve the ferrrule effect.

I explained to her that as long as the tooth is not fractured, the retention of the natural tooth will actually help maintain the bone in the esthetic zone and give her the most natural appearance.

The silver point root canal is almost 40 years old. There is no sign of failure of the endodontics. This is actually a restorative failure. Any disturbance of the silver point can jeopardize it's seal. In retrospect, it would have been best to have retreated the RCT and placed a new post and core prior to the new crown.

Research Update: Use of Articaine for Buccal Infiltration of Mandibular Molars

The inferior alveolar nerve block (IANB) is the most commonly used technique for pulpal anesthesia in the mandible, especially the mandibular molars. Due to the dense cortical bone of the mandible, buccal infiltration techniques have been known to be less successful.

However, the IANB has challenges of its own. Passing through layers of soft tissue and muscle and depositing the anesthetic in adjacent to the mandibular foramen can be very difficult. Anatomical variation among patients, including the course of the nerve, location of the mandibular foramen, accessory nerves also innervating the area can all make consistancy with this technique challenging.

If the block is unsuccessful, then the practitioner has typically repeats the block or trys another technique. The most common alternative techniques are: closed mouth block (Vazirani/Akinosi), Gow-Gates Block, intraligamentary injection, intrapulpal injection, or intraosseous injection.

Manibular buccal infiltration has traditionally not been considered as an option due to the inability for the anesthetic to diffuse through the thick cortical plate. Kanaa et al. reported that a mandibular buccal infiltration is more effective with 4% articaine with 1:100,000 epinephrine than with the traditional 2% lidocaine.

A recent study by Il-Young Jung et. al. compared the efficacy of IANB with that of buccal infiltrations in mandibular first molars.

Using 4% articaine subjects were given IANB and BI on separate appointments. Pulpal anesthesia was determined using an electric pulp tester. 54% of BI were successful and 43% of IANB were successful. (the difference was not significant p=0.34) The onset of pulpal anesthesia was significantly faster with BI (p=0.03). This study concluded that BI with 4% articaine for mandibular first molars can be a useful alternative to IANB due to it's faster onset and similar success rate.

Having difficulty with anesthetizing mandibular molars? Try using some 4% articaine in a buccal infiltration.

Sources:

Kanaa MD, Whitworth, JM, Corbett, IP, Meechan JG. Articaine and lidocaine mandibular buccal infiltration anesthesia: a prospective randomized double blind cross-over study. JOE 2006:32:919-23.

Jung, Il-Young, Kim, Jun-Hyung, Kim, Eui-Seong, Lee, Han-Young, Lee, Seung Jong. An evaluation of buccal infiltrations and inferior alveolar nerve blocks in pulpal anesthesia for mandibular first molars. JOE 2008:34:11-13.

Rotary & Warm Vertical Obturation

This video clip shows my non-surgical RCT technique on an extracted bicuspid.

Specific instruments I like to use:
1. Endo Z bur (long shank, non-end cutting bur to create direct line access)
2. Hand files #10 & #15 to open canals and create a path
3. Gates Glidden drills #2, #3, #4 to open the coronal third of the canal system (inexpensive, easy to remove if separation occurs)
4. #15 hand file for length determination (using Root ZX or radiographs)
5. .06 tapered, ISO sized NiTi Rotary files
6. .06 tapered gutta percha, gauged to ISO size at tip using a gutta gauge
7. System B heat carrier
8. Obtura for gutta percha backfill