WaveOne Gold Shines in Difficult Retreatment Case (Wisdom Tooth)
Name: Dr. Yosef (Yosi) Nahmias
Location: Toronto, Canada
Tooth: #32 US (FDI #48)
Instruments and Products Used: ProGlider, WaveOne Gold Files, ProMark Apex Locator, EndoActivator, Calamus Obturation Device, WaveOne Gold Primary Gutta-Percha Cones
An endodontist retreats a wisdom tooth, but is there a missed distal canal?
The patient was referred to our office for evaluation of a previously treated lower wisdom tooth that was part of a five-unit bridge.
He reported some sensitivity to bite that had been progressing for the last few days. The referring dentist prescribed antibiotics and Ibuprofen to help with the discomfort. The patient mentioned to us that he had had this tooth root canal treated over 20 years ago and that it had been retreated about 15 years later because of an infection.
Clinical examination revealed a five-unit bridge with #32 (FDI #48) as the distal abutment. An amalgam was noted that was used to seal the access opening of the previously done RCT. Periodontal probing around this tooth was within normal limits. The tooth was quite sensitive to percussion, but no swelling or sensitivity to palpation was noted. Lymph nodes were normal. The radiograph sent by the referring doctor (Figure 1) revealed a periapical radiolucency associated with the distal root, and the obturation of all the canals appear to be short. When looking closely at this radiograph, we suspected that a second distal canal may be present. A second radiograph (Figure 2) was taken, but it was not conclusive if there was a second distal canal. The recommendation to have a CT scan was made, however the patient declined for personal reasons.
Our diagnosis for this tooth was periapical periodontitis associated with a previously root canal treated tooth. Options were discussed, and the patient consented to have the tooth retreated at a second appointment.
The patient returned and reported that the tooth was feeling better after taking antibiotics. Local anesthetic was given and a rubber dam was applied. The tooth was re-accessed and cleaned with ultrasonic tips with copious water irrigation. Since a second distal root was suspected, the access was modified to try to identify the presence of this missed root. After careful exploration, a second distolingual orifice was located (Figure 3). This untreated canal was negotiated with #8 SS files and then enlarged very carefully with a ProGlider rotary file. Gutta-percha was removed from the distobuccal, mesiobuccal and mesiolingual canals using a ProTaper D3 retreatment file. With the use of a chemical solvent, the rest of the gutta-percha was removed. All canals were negotiated to their terminus with a #10 SS file, and working lengths were established with the use of the ProMark Apex Locator.
Once a reproducible glide path was established with a #10 SS file in all the canals, a ProGlider file was taken a millimeter past the electronic working length. This file was used as a patency file to prevent any blockage after each instrument instead of a small SS file. The ProGlider files have unsurpassed flexibility and the chances of procedural mistakes, such as apical transportation and/or ledging, are greatly minimized. A WaveOne Gold reciprocating file (Primary) was used several times until the working lengths were reached. Several passes were needed to achieve this step. Copious irrigation and a patency file (ProGlider) were used after each instrument. Disinfection was achieved with the use of 5.25% sodium hypochlorite with alternating rinses with 17% aqueous EDTA.
Final irrigation was done with the use of the EndoActivator for one minute per canal with 5.25% Sodium Hypochlorite. The canals were dried, then obturated with WaveOne Primary GP cones. A single wave technique was used apically, and coronal back fills were done with the Calamus Obturation device. Sealer was used to coat the canals and the master cones.
The access was then sealed with a bonded composite resin. A final radiograph (Figure 4) was taken that demonstrates that the terminus of all the canals was reached and that a second distal canal was present. The patient was contacted the next day, and no major postoperative discomfort was reported.
This case demonstrates that even in cases when the most advanced technology such as the CBCT cannot be used, we have to follow the basic rules of treatment. Difficult, complex cases like this one can be predictably treated with the use of current systems like WaveOne Gold. The safety that this file provides us with cannot be overstated. It is important to add that, in my opinion, the most important step of any endodontic procedure is the creation of a reproducible glide path. This is achieved with careful negotiation of the canals and the use of the ProGlider file as a patency file.
About the Endodontist
Dr. Nahmias was born and raised in Mexico City. After graduating from dental school in 1980, he decided to advance his education and chose to specialize in endodontics. He earned his Master of Science degree in 1983 from Marquette University in Milwaukee, Wisconsin.
Dr. Nahmias has authored and published many articles and continues to lecture in Canada and across the world. The University of Toronto Faculty of Dentistry has involved him in teaching their postgraduate-level students in endodontics. Dr. Nahmias resides in Toronto, Canada, and has maintained a private practice limited to endodontics for over 35 years.
What About You?
What do you think about Dr. Nahmias’ case? Share in the comment section below!
Or maybe you have a tricky, stunning, challenging, or otherwise awe-inspiring case of your own. Why not share it with us? Just submit your case here, and we’ll get the ball rolling.