Mikhail Solomonov, DMD, Certified Endodontist, Director of the Postgraduate Endodontic Program, Department of Endodontics, Sheba Medical Center, Tel Hashomer, Israel
First Visit
July 2012. A 38-year-old patient with no systemic diseases or allergic reactions presented with complaints of severe pain in the upper left jaw that had persisted for a week. The pain occurred either spontaneously or in response to cold stimuli, lasted several minutes, and radiated to the ear.
Clinical examination revealed the following: tooth 2.7 had a positive response to percussion, negative to palpation, no periodontal pockets greater than 3 mm, and no sinus tract present. The response to cold stimulation lasted over 20 seconds (overshoot). The radiograph (Fig. 1) showed a deep filling and a parapulpal post.
Clinical examination revealed the following: tooth 2.7 had a positive response to percussion, negative to palpation, no periodontal pockets greater than 3 mm, and no sinus tract present. The response to cold stimulation lasted over 20 seconds (overshoot). The radiograph (Fig. 1) showed a deep filling and a parapulpal post.
Beginning of Endodontic Treatment
During the creation of the access cavity, a crack was discovered in the mesial part of the cavity extending in the mesiodistal direction (Fig. 2).
The challenge in treating such cases lies in the fact that the crack may propagate apically and eventually split the tooth. The instrumentation, obturation, and post-endodontic restoration steps must be modified to eliminate wedging forces to prevent crack progression.
The challenge in treating such cases lies in the fact that the crack may propagate apically and eventually split the tooth. The instrumentation, obturation, and post-endodontic restoration steps must be modified to eliminate wedging forces to prevent crack progression.
Instrumentation
Various rotary nickel-titanium instruments can lead to the formation of microcracks due to their shape memory effect, design, and diameter (Shemesh et al., 2009; Kim, 2010). Hand files and the SAF system do not cause microcracks (Yolandas, 2011; Kim, 2013; Shemesh, 2011). The canals were classified by initial diameter (Solomonov, 2011). The MB, MB2, and DB canals were complex.
After using a stainless steel K-File size 10, hand NiTi files from Komet (sizes 15 and 20, titanium nitride-coated) were used. Then, the SAF system was employed. The palatal canal was straightforward (initial diameter: 20K file), and the SAF system was also used.
After using a stainless steel K-File size 10, hand NiTi files from Komet (sizes 15 and 20, titanium nitride-coated) were used. Then, the SAF system was employed. The palatal canal was straightforward (initial diameter: 20K file), and the SAF system was also used.
Obturation
Lateral and vertical compaction techniques using spreaders and pluggers involve wedging forces. Therefore, the Passive Lateral Compaction technique was chosen (Wu, 2005): inserting the master cone first, followed by additional cones without using a spreader.
To solve this clinical challenge, it is crucial to choose the right sealer — in this case, one without any expansion. An epoxy-based sealer, AH Plus, was selected (Fig. 4).
To solve this clinical challenge, it is crucial to choose the right sealer — in this case, one without any expansion. An epoxy-based sealer, AH Plus, was selected (Fig. 4).
Post-Endodontic Restoration
In such cases, the tooth must be crowned as soon as possible to create a "bracing" effect that prevents crack propagation under functional load (Krell et al., 2007). Using a post weakens the tooth and transfers stress to the root (Trope et al., 1985; Albuquerque et al., 2003). For these reasons, Dr. Yoav Grossmann performed the post-endodontic restoration without a post, and the tooth was crowned promptly.
This case demonstrates that endodontic and prosthetic procedures with minimal intracanalar stress can prevent crack progression and preserve the tooth.
This case demonstrates that endodontic and prosthetic procedures with minimal intracanalar stress can prevent crack progression and preserve the tooth.
