Endodoncia guiada estática, una opción para obliteración del canal pulpar: serie de casos / Static guided endodontics, an option for pulpal canal obliteration: a case series

En la práctica endodóntica, la etapa del acceso al canal radicular es fundamental para el éxito de las siguientes etapas del tratamiento. En casos de canales pulpares obliterados o calcificados (PCO), lograr encontrar la entrada a estos es un reto en la endodoncia convencional dado el alto riesgo de sufrir un accidente intraoperatorio. Actualmente, existen los tratamientos de endodoncia guiada o accesos guiados digitalmente, una alternativa innovadora y con múltiples beneficios para el abordaje de este tipo de dientes. El objetivo de este reporte de casos fue describir el protocolo de cuatro casos de accesos guiados estáticos para endodoncia en canales obliterados, indicando las ventajas y consideraciones del tratamiento. Se presenta un reporte de casos de cuatro pacientes atendidos entre julio 2021 y junio 2022, que requerían tratamientos endodónticos en dientes anteriores con canales pulpares obliterados. Para la realización de estos procedimientos se requirió una Tomografía Computarizada de Haz Cónico (CBCT) y el escaneo intraoral de la zona a tratar, para poder a través de la ayuda de un software, planificar virtualmente la dirección y longitud de acceso al conducto radicular. Posteriormente, se realizó la impresión en 3D de la guía estática, la cual dirige la entrada de la fresa que se utiliza para encontrar el acceso al canal radicular. En los cuatro casos clínicos en que se realizó la planificación virtual e impresión de la guía de acceso, fue posible encontrar el canal radicular en una sesión, pudiendo realizar el tratamiento endodóntico de manera exitosa y conservadora. En conclusión, la endodoncia guiada estática permite realizar los tratamientos endodónticos en PCO de manera segura, a pesar de la alta complejidad que presentaban.

SUMMARY: In endodontics, the access to the root canal is essential for the treatment success. Pulp canal obliteration (PCO) is a challenge for conventional endodontic treatments with a high risk of fracture of endodontic instruments.Currently, guided endodontic treatments, or digitally guided accesses, are novel alternatives with multiple benefits for the treatment of PCO. The objective of this case report is to describe the protocol for static guided access in PCO, indicating the advantages and considerations of the treatment. A case report of four patients treated between July 2021 and June 2022 is presented. These patients required endodontic treatments in anterior teeth with PCO. In order to virtually plan the direction and length of the access, using a software, we used a cone Beam Computed Tomography (CBCT) and an intraoral scan. Then, a 3D printing of the static guide was made, which directs the entry of the drill. With this method, it was possible to find the root canal in one session and perform the endodontic treatment successfully and conservatively. In conclusion, although static guided endodontics requires planification, it allows a safe endodontic treatment in patients with PCO.

[Causes, diagnosis and treatment strategies for dental pulp calcification].

Dental pulp calcification can lead to root canal stenosis or obliteration. It is usually difficult to negotiate the root canal if the affected tooth needs to be treated and intraoperative complications are easily brought about during the root canal treatment. The etiologies of dental pulp calcification are complicated and careful considerations should be given to the diagnosis and treatment. Only by weighing the advantages and disadvantages can appropriate treatment plan be chosen. Based on the literature and authors' clinical experiences, the present article summarizes the causes, pathogenesis, diagnosis and treatment strategies of dental pulp calcification, in order to provide some references in diagnosis and treatment for the dental clinicians.

Causes, diagnosis and treatment strategies for dental pulp calcification / 中华口腔医学杂志

Dental pulp calcification can lead to root canal stenosis or obliteration. It is usually difficult to negotiate the root canal if the affected tooth needs to be treated and intraoperative complications are easily brought about during the root canal treatment. The etiologies of dental pulp calcification are complicated and careful considerations should be given to the diagnosis and treatment. Only by weighing the advantages and disadvantages can appropriate treatment plan be chosen. Based on the literature and authors' clinical experiences, the present article summarizes the causes, pathogenesis, diagnosis and treatment strategies of dental pulp calcification, in order to provide some references in diagnosis and treatment for the dental clinicians.

Estética y color en dientes calcificados: Informe de tres casos clínicos con blanqueamiento / Esthetics and shade in calcified teeth. Report of three clinical cases with whitening

Objetivo: El objetivo de este informe es presentar tres casos clínicos de piezas dentarias anterosuperiores calcificadas y con decoloración, resueltos según tres protocolos clínicos de blanqueamiento diferentes, con un mismo fin: devolver la estética al sector anterior. Casos clínicos: Cada una de las tres situaciones clínicas de decoloración dentaria se trató siguiendo un protocolo diferente. A partir del análisis clínico y radiográfico, se estableció un diagnóstico y un plan de tratamiento acorde. Todos los casos evolucionaron de manera favorable y siguen siendo controlados periódicamente. Conclusiones: En casos clínicos como los que se muestran en este trabajo, en los que el conducto y la cámara pulpar están calcificados u obliterados totalmente, sería posible realizar blanqueamiento interno y externo para recuperar la armonía óptica de forma conservadora. Este tipo de tratamientos permitiría responder a la alta prevalencia de demanda estética debido a traumatismos y cambios de coloración (AU)

Aim: To present three clinical cases of discoloration in calcified upper anterior teeth, that were resolved following different clinical protocols for teeth whitening to return the aesthetics of the anterior teeth. Clinical cases: Each clinical case of discoloration was treated following a different treatment protocol based on a correct clinical and radiographic diagnosis. All cases had a favourable outcome and have no regular review. Conclusion: In clinical cases as those presented in this article where the canal and pulp chamber are totally calcified or obliterated, it was possible to perform internal and or external whitening to restore optical harmony in a conservative way. This type of treatment would allow responding to the high prevalence of aesthetic demand due to trauma and colour changes (AU)

Clinical aspects of pulp stones: A case report series.

Pulp stones (PSs) are calcified masses that can be found in the pulp cavity of any deciduous or permanent tooth. They can be observed in healthy, diseased, and even unerupted or impacted teeth. Calcifications within the pulp may lead to a poorer outcome of a root canal procedure, as they can block access to the root canals, and hinder their subsequent cleaning and shaping. The paper describes 4 clinical cases of denticles located in the coronal and radicular pulp. Therapeutic methods of PS removal with different techniques and instruments are discussed. Specialist root canal treatment (RCT) was performed in aseptic conditions with the use of long-shank rose-head burs and an endodontic ultrasonic device under the magnification of a dental operative microscope (OM). During endodontic treatment, all PSs were totally removed, which allowed the further preparation, and finally obturation of the canal system. The use of modern diagnostic and therapeutic methods - three-dimensional (3D) diagnostic radiology, endodontic techniques, such as ultrasounds used during the removal of PSs and the irrigation of the canals, and the thermoplastic methods of canal obturation - can provide good results of treatment of this pathology. The removal of PSs from the pulp cavity is a complex and difficult procedure, requiring skill, dexterity, and appropriate equipment and facilities. The clinical approach introduced in this paper allows endodontists to avoid potential complications like perforation, the unnecessary removal of hard tissues or the weakening of the tooth structure.

Microguided Endodontics: a method to achieve minimally invasive access cavity preparation and root canal location in mandibular incisors using a novel computer-guided technique.

AIM: To present a novel miniaturized and minimally invasive treatment approach for root canal localization in mandibular incisors with pulp canal calcification and apical periodontitis. SUMMARY: A 51-year-old male patient presented with pain from his mandibular incisors. The patient had a history of severe dental trauma over 30 years ago. Both mandibular central incisors (teeth 31, 41) were tender to percussion and had a yellowish discoloration. They did not respond to thermal and electrical sensitivity tests. Two periapical radiographs from different projections revealed severe pulp canal calcifications and signs of periapical periodontitis. To facilitate the 'Microguided Endodontics' technique, a CBCT and an intra-oral surface scan were aligned using special software. This allowed the virtual planning of optimal access cavities up to the apical third of the root. In this technique, a 3D-printed template guides a customized drill to the orifice of the root canal. After negotiation of the root canals, conventional root canal treatment was performed. This case report demonstrates that minimally invasive and apically extended access cavities are feasible in mandibular incisors with this technique. KEY LEARNING POINTS: The 'Microguided Endodontics' technique is a safe and minimally invasive method for root canal location and prevention of technical failures in anterior teeth with pulp canal calcification.

CBCT-Aided Microscopic and Ultrasonic Treatment for Upper or Middle Thirds Calcified Root Canals.

Root canal calcification is considered a great challenge during root canal treatment. Although the application of ultrasonic instruments and dental operating microscope (DOM) has advantages, dealing with calcified root canals still suffers a great risk of failure because of limited information about the location, length, and direction of obliteration on periapical radiographs. In this work, a cone-beam computed tomography- (CBCT-) aided method aimed at solving complicated calcified root canals in which conventional approaches could not work was proposed. Thirteen teeth with sixteen calcified canals (12 calcified in the upper third, 4 calcified in the middle third), which cannot be negotiated with conventional methods, were treated with the aid of CBCT. The location of calcification and depth of instrumentation and operating direction were calculated and assessed in three dimensions with ultrasonic instruments under DOM. In all thirteen teeth, canals with upper and middle thirds calcification were treated successfully. Finally, a guideline was proposed to help achieve consistent apical patency in calcified canals.

Alternativa terapéutica en la discromía de un diente con distrofia pulpar por fuerzas ortodóncicas: presentación de caso / Therapeutic alternative for the decoloration of a tooth with pulp dystrophy caused by orthodontic forces: a case report

FUNDAMENTO: las fuerzas ortodóncicas excesivas pueden producir distrofias pulpares al modificar el sistema neuro-vascular de la pulpa. La necrosis de este tejido es la causa más conocida de alteración de color de los dientes. El tratamiento endodóntico y el blanqueamiento convencionales en estos casos se ven comprometidos cuando se desarrolla, además, una degeneración cálcica pulpar. OBJETIVO: mostrar una alternativa terapéutica a la discromía por necrosis pulpar de un diente con calcificación total de la pulpa. Caso clinico: se presenta una paciente de 18 años de edad con calcificación total de la pulpa posterior a un tratamiento ortodóncico y discromía en tercio cervical de corona del incisivo central superior derecho. CONCLUSIONS: se realizó tratamiento restaurador con carilla vestibular de composite fotocurable, logrando resultados estéticos satisfactorios.

BACKGROUND: excessive orthodontic forces may cause pulp dystrophies since they modify the pulp neuro vascular system. Necrosis of this pulp tissue is the most known cause of teeth color changes. Conventional endodontic treatment and bleaching are compromised in these cases whenever pulp calcification is developed. OBJECTIVE: to show an alternative therapy for dental discoloration due to pulpal necrosis in a tooth with pulp calcification. CLINICAL CASE: a eighteen year-old female is reported with pulp calcification following an orthodontic treatment and tooth discoloration in cervical third of a maxillary central right incisor. CONCLUSIONS: a restorative treatment with visible light cure composite veneer was performed, achieving satisfactory aesthetic results.

Apical plug technique in a calcified immature tooth: a case report.

Traumatic injury to an immature tooth may result in pulpal necrosis secondary to pulp canal obliteration, which makes the management of the tooth a clinical challenge for dentists. The present case report describes an innovative apical plug technique with mineral trioxide aggregate in a calcified immature tooth using an ultrasonic tip and long, thin, tapered fissure burs. The technique was proven to be successful clinically and radiographically at 2 years postobturation.

Alternativa terapéutica en la discromía de un diente con distrofia pulpar por fuerzas ortodóncicas: presentación de caso / Therapeutic alternative for the decoloration of a tooth with pulp dystrophy caused by orthodontic forces: a case report

Fundamento: las fuerzas ortodóncicas excesivas pueden producir distrofias pulpares al modificar el sistema neuro-vascular de la pulpa. La necrosis de este tejido es la causa más conocida de alteración de color de los dientes. El tratamiento endodóntico y el blanqueamiento convencionales en estos casos se ven comprometidos cuando se desarrolla, además, una degeneración cálcica pulpar.Objetivo: mostrar una alternativa terapéutica a la discromía por necrosis pulpar de un diente con calcificación total de la pulpa.Caso clínico: se presenta una paciente de 18 años de edad con calcificación total de la pulpa posterior a un tratamiento ortodóncico y discromía en tercio cervical de corona del incisivo central superior derecho.Conclusiones: se realizó tratamiento restaurador con carilla vestibular de composite fotocurable, logrando resultados estéticos satisfactorios(AU)

Background: excessive orthodontic forces may cause pulp dystrophies since they modify the pulp neuro vascular system. Necrosis of this pulp tissue is the most known cause of teeth color changes. Conventional endodontic treatment and bleaching are compromised in these cases whenever pulp calcification is developed.Objective: to show an alternative therapy for dental discoloration due to pulpal necrosis in a tooth with pulp calcification.Clinical Case: a eighteen year-old female is reported with pulp calcification following an orthodontic treatment and tooth discoloration in cervical third of a maxillary central right incisor.Conclusions: a restorative treatment with visible light cure composite veneer was performed, achieving satisfactory aesthetic results(AU)

[A case of isolated pulmonary valve infective endocarditis in a 78-year-old woman].

A 78-year-old woman was admitted to our hospital with lumbago. Her activities of daily living had previously been completely independent. However, she developed temporary chills in January 2009, that improved without treatment, but recurred on February 7, 2009 in association with left lumbago and loss of appetite. She was then referred to our hospital with a disturbance of consciousness and high fever on February 14. A blood test performed on admission revealed an elevated inflammatory response, coagulation disorder and low platelet count, and abdominal computed tomography demonstrated findings suggestive of pyogenic spondylitis. The patient was therefore admitted and treated with antibiotic therapy; however, she died on day 8 due to complications of disseminated intravascular coagulation. An autopsy showed isolated pulmonary valve endocarditis. The patient's history was later found to include regular dental treatment, and the same Streptococcus group G was detected in cultures of the sputum, blood and vegetation. It is important to interview patients regarding their history of dental treatment, particularly elderly individuals with fever of unknown origin.

A technique to salvage endodontically compromised maxillary anterior tooth.

A complication of endodontic treatment is over-preparation of the tooth structure in an attempt to access calcified pulp chambers and root canals. This could result in thin root walls that might compromise the long-term prognosis of the tooth. There are various treatment options when such a complication occurs, among them, extraction of the compromised tooth and its replacement with a dental implant. This clinical report describes a nonsurgical, multidisciplinary treatment alternative where a maxillary anterior tooth with a thinned root wall was successfully saved by repairing the damaged root to its original thickness using a composite resin material and subsequently restoring with a cast post and core and a crown.

Calcific metamorphosis. Literature review and clinical strategies.

UNLABELLED: Calcific metamorphosis (CM) is a commonly observed phenomenon following traumatic injuries like concussion, subluxation and luxation. Depending on the severity of the injury and the developmental stage of the tooth, there can be either complete or partial obliteration of root canals. However, histologically, there is always persistence of fine residual filaments of pulp tissue or tracts of organic material without the presence of any inflammatory component. A periodic clinical and radiographic follow-up examination is preferred and usually, for cosmetic reasons, only a conservative aesthetic treatment is required. Endodontic treatment is only advocated if there is development of apical periodontitis and, if executed properly, can be highly successful. CLINICAL RELEVANCE: Appropriate management of calcific metamorphosis can present a clinical dilemma to the clinician. Thus a judicious and prudent decision should be made between endodontic intervention for the involved tooth and other available restorative (and/or aesthetic) treatment options.

Pulp stone--an endodontic challenge: successful retrieval of exceptionally long pulp stones measuring 14 and 9.5 mm from the palatal roots of maxillary molars.

Pulp stones are nodular, calcified masses commonly appearing in the coronal pulp and occasionally extending in radicular pulp. Retrieval of pulp stones remains a challenge for the endodontist as complete cleaning and shaping of root canal system is the bases for successful endodontic therapy. The aim of this case report is to show the retrieval of long pulp stones measuring 14 and 9.5 mm by utilizing synergistic effect of ultrasonics and sodium hypochlorite from the palatal roots of maxillary molars. Such case has not been reported in the literature so far.

Pulp canal obliteration: an endodontic diagnosis and treatment challenge.

AIM: To review the literature on pulp chamber and root canal obliteration in anterior teeth and to establish a clear protocol for managing teeth with fine, tortuous canal systems. SUMMARY: Pulp canal obliteration (PCO) occurs commonly following traumatic injuries to teeth. Approximately 4-24% of traumatized teeth develop varying degrees of pulpal obliteration that is characterized by the apparent loss of the pulp space radiographically and a yellow discoloration of the clinical crown. These teeth provide an endodontic treatment challenge; the critical management decision being whether to treat these teeth endodontically immediately upon detection of the pulpal obliteration or to wait until symptoms or signs of pulp and or periapical disease occur. The inevitable lack of responses to normal sensibility tests and the crown discoloration add uncertainty to the management; however, only approximately 7-27% of teeth with PCO will develop pulp necrosis with radiographic signs of periapical disease. Root canal treatment of teeth with pulpal obliteration is often challenging. This article discusses the various management approaches and highlights treatment strategies for overcoming potential complications. KEY LEARNING POINTS: Up to 25% of traumatized anterior teeth can develop pulp canal obliteration; Discolouration is a common clinical finding in teeth with pulp canal obliteration; Up to 75% of teeth with pulp canal obliterations are symptom-free and require no treatment other than radiographic monitoring; Routine pulp sensibility tests are unreliable in the presence of pulp canal obliteration; Teeth with pulp canal obliteration in need of root canal treatment pose particular diagnostic and treatment challenges.

The clinical treatment of complicated root canal therapy with the aid of a dental operating microscope.

OBJECTIVES: To evaluate the clinical application of the dental operating microscope (DOM) in the management of complicated root canal therapy. METHODS: 345 teeth with 546 root canals which could not be successfully managed by conventional methods received therapy under the DOM with ultrasonic instruments by the same endodontists. The aetiology of the canals included calcification, broken instrument, missed canal and canal perforation. The teeth and canals successfully managed were then calculated. RESULTS: 406 canals were successfully managed with a rate of 74.4%; 246 teeth were successfully managed with a rate of 71.3%. The rates in each category of the complicated root canals were: 74.0% for calcified canals, 72.3% for canals blocked by broken instruments, 82.5% for missed canals and 72.7% for canal perforations. CONCLUSIONS: The clinical application of the DOM is an effective way of managing complicated root canal therapy.

Not to be forgotten: denticles. Case reports and review of the literature.

Denticles are foci of calcification in the dental pulp located mostly in pulp chambers. Their etiology is not fully understood. They occur mostly in molars and lower incisors. Denticles vary in size, ranging from microscopic particles to larger masses that almost obliterate the pulp chamber and are visible on radiographs. In the absence of pain, observation is recommended. The aim of this study was to present a case of a denticle in tooth 21 which possibly lead to pulp necrosis and two cases when denticles were detected accidentally during management of dental caries. Denticles are usually found on plain radiographs taken for other reasons.