Patient: 82 year-old male with glaucoma

Chief Complaint: slight toothache after recent temporary crown placed

Dental History: The patient presented with history of a pulp exposure on the mandibular right first molar (tooth #30, probably in reality the mandibular 2nd molar (tooth #31) tilted into the first molar position but will be called tooth #30 for simplicity) after a recent crown preparation. He was going to be travelling and was concerned about a slight toothache getting worse. (patient’s case was recently submitted for the tooth #28 recall “Long Term Restorative Failure”, 12/22/2014)

Significant Findings (tooth #30): Percussion of the tooth resulted in a reported “different feeling” than the adjacent teeth. Cold thermal stimulation revealed a “questionable” response. Periodontal probing depths were within normal limits although there was significant gingival recession and a Class 3 furcation defect with a history of bone level stability reported by his periodontist.

Pulp and Periradicular Diagnosis (tooth #30): Questionable pulp status with a history of exposure and a normal periapical periodontium.

Treatment Prognosis (tooth #30): Fair to Good
Treatment Plan: Nonsurgical endodontic treatment (tooth #30)

Special Considerations of Performed Treatment:

This tooth appeared to present with a high risk of treatment failure due to periodontal bone loss involving the furcation but it was regarded as having been periodontally stable over time even though the tooth had been functioning as a long-span distal bridge abutment. Implants had been recently placed so that the tooth could function as an individual crown but the angulation of the implants appeared to be a concern and problem.

If orthodontic treatment had been performed years earlier the sequential complications leading to tooth loss and a need for endodontics might not have occurred. It is a logical presumption that the loss of a first molar and failure to replace it led to the tilting of the mandibular second molar into the first molar position which then led to a complicated bridge design with tilted tooth preparations leading to pulp exposures and over-prepping. Eventually the overloaded mesial bicuspid abutment was lost and hence the current compounded challenges of rehabilitation.

The goal of this submission is to demonstrate the strategically extended endodontic access design required to ideally treat the molar with an existing crown preparation. Direct line access to all canal orifices was achieved without unnecessarily weakening the existing coronal tooth structure. Different mirror angulations to the orifices are shown in the images. The final occlusal outline can be considered conservative in the sense that it was extended to the point necessary to gain a direct line to the first curve in each root preventing unnecessary and dangerous filing on the inside of a curve toward the furcation.

Key Learning Points:

1. Maloccluded teeth prepped for crowns and bridges often lead to a pulp exposure.

2. Direct line access to each canal orifice facilitates better endodontic debridement and safer shaping away from the inside curve minimizing the risk of a strip perforation.

3. Even aggressively prepared teeth can be accessed for endodontic treatment without appreciably weakening the supportive coronal dentin.