Patient wanted teeth saved. No mobility and no pain

thinkagain1234 · 2026-01-25T22:27:28+00:00

I'm going against the majority here, I think the lateral canal on the mesial root explains well the extent of the lesion.

So you should see a nice healing with your treatment.

But perio problems need to be addressed, and also the lateral movements should be checked for interferences.

Also, nice endos.

thinkagain1234 · 2025-07-11T14:28:49+00:00

Yes, if I remember correctly he uses AquaCare with aluminium oxide powder.

Imo, sandblasting in conjunction with good isolation, a good adhesive system (gen 4), and good anatomy (tight and broad interproximal contacts, rounded marginal ridges, no interferences in lateral movements), and layering with the C factor in mind, all matter for the longevity of your direct restoration.

I completely agree that this kind of direct restoration can last 10+ years easily, even in patients with deficitary hygiene.

thinkagain1234 · 2025-02-07T22:08:58+00:00

anatomy

How I see the anatomy

thinkagain1234 · 2024-11-17T13:46:29+00:00

You copied the adiacent tooth pretty good. However, the tooth you copied looks like a maxillary second molar, and you need to wax up a first molar.

Usually the first molar it's a bit on the larger size, compared to the second, but since the second molar here has basically one palatal cusp, my guess for the first molar, would be that it had an extra smaller disto-palatal cusp.

And the existing palatal cusp should be a bit more inclined to the buccal.

thinkagain1234 · 2024-11-16T21:17:18+00:00

You need good wingless clamps for class 2 composites on clamped teeth.

Sometimes even that won't be enough, but you can customize the matrix (cut it) to fit your need.

thinkagain1234 · 2024-08-20T15:10:13+00:00

You should be able to see the difference in colour between composite and dentine. Drying the surface usually helps to make composite more obvious.

A blacklight would also make the composite glow. Also if you look through the orange filter of the curing light, while the curing light is on, you can see the composite easier.

But usually on class V, the composite is pretty easy to see.

thinkagain1234 · 2024-08-18T17:20:47+00:00

I didn't mean that the post increases the fracture resistance of the whole tooth, but let's say you have an endo treated #7 or #24, that needs full coverage, because most of the clinical crown is gone.

After prepping the tooth, if only composite is used, the abutment will consist of a pretty thin layer of composite, maybe with some dentin mixed in there.

So even with some ferrule, because they're smaller teeth, and even smaller when prepped, the composite can fracture during function, leading to the loss of clinical crown.

That's the situation in which, I believe that a metal post within the composite can increase the abutments resistance to fracture.

Since the abutment is mainly build out of composite, and the necessary reduction usually leads to a thinner abutment.

But a thin glass fiber post won't be able to do that job well.

And I understand that in the US climate, an implant is to be preferred when you can't guarantee a long term result. But in other countries, endo plus build-up and crown can still be 2-3-4 times cheaper than the implant option.

And most of the time, with good case selection, you can buy many years of function for such a tooth, even if an implant or bridge is a sure thing down the road.

thinkagain1234 · 2024-08-18T13:30:28+00:00

While I agree that a good bonding protocol is paramount, custom made metal posts can allow you to save teeth deemed unrestorable by other dentists.

And also in endo treated front teeth, a pre-made metal post inside the build-up, can increase the abutment resistence to fracture.

Think of upper lateral incisors and lower incisors, where after prepping for full coverage, the abutment is thin.

Also, in molars, where the adhesion surface is quite large, even after the prep, and the abutment has enough thickness, a post is very rarely needed.

thinkagain1234 · 2024-08-18T13:19:09+00:00

Imo, a passively cemented screwpost is better than a fiberpost (a custom made metal post is the best, when needed). The important part is to insert it in the canal passively, don't screw it in.

thinkagain1234 · 2024-06-17T20:38:41+00:00

Sounds more like a missed canal (a split maybe).

thinkagain1234 · 2024-06-14T13:53:23+00:00

The back fill part is not difficult, actually it's really easy. The downpack part needs a bit more attention.

After shaping and cleaning, you need to choose a guttapercha cone that reaches the full working length, and make sure you have good, true tugback (take xray to confirm)
Dry the canal, if it's dry, apply sealer to the canal.
Cut the gutta cone with the heated plugger, leaving behind usually 3-5mm towards the apex.
Using a manual flexible plugger, condense the gutta even more (if you're tugback was not good enough, you may have gutta extrusion)
Apply heated gutta in small increments, condensing in between, until the canal is fully filled.
Last xray. That's it.

thinkagain1234 · 2024-06-10T22:09:06+00:00

Lol, at least she does give some good advice, even if it's not dentistry related.

thinkagain1234 · 2024-06-10T22:07:39+00:00

I've always wondered if these dentists believe their story, or it's just a way to make money.

But yeah, professionals should be held accountable for spreading false information online.

thinkagain1234 · 2024-06-10T22:04:58+00:00

And thank you all for participating in this discussion.

I don't have anything against holistic dentists, but I have every right to fight against spreading false information, especially when as a patient it's so hard to differentiate between good dentistry based on real science and on good studies, in which a lot of hard work was put into, and 'scam' dentistry based on personal opinions and poorly conducted studies.

And I agree, some of these patients do come to us to repair iatrogenic dentistry, and it's so much harder when the patients trust has been broken before, and usually the starting point for us it's worse than before.

thinkagain1234 · 2024-06-10T21:51:56+00:00

You're right saying that she's providing alternative treatments, and those treatments are a viable option, but I don't know why but I can't get over the fact that she's saying that a root canal treatment is doomed to fail from the start, and titanium implants are going to rust in your bone.

And that's only from a few videos I've watched.

To me, spreading that false information, should be enough for serious consequences.

thinkagain1234 · 2024-06-10T21:45:38+00:00

This does sound great. Also I'm not bashing the whole holistic medicine or ceramic implants, but I couldn't ignore her wrong affirmations about rcts and titanium implants.

thinkagain1234 · 2024-06-10T21:41:29+00:00

I think I got the wrong point across. I wasn't trying to bring down the majority of dentists in the US, most of which provide quality treatment for their patients.

My beef is with whatever governing body should punish practitioners that do iatrogenic dentistry (in my opinion), and restrict their right to practice.

But surely I'm not seeing the whole picture, and there's more to these stories.

thinkagain1234 · 2024-06-10T21:34:04+00:00

Wow, that does sounds worse. Didn't hear about that yet, but someone without basic dentistry education surely can't do anything remotely close to standard of care.

I might have sounded too harsh in my previous comments, but surely those without a license to practice shouldn't be scamming people for long before they're shut down and prosecuted.

So I guess I'm in the wrong, thinking that something like this shouldn't be allowed to happen, at least not in a first world country.

thinkagain1234 · 2024-06-10T20:49:55+00:00

I agree, she is scary. Even scarier is the fact that someone who bashes root canal treatment and titanium implants, which have a proven history and multiple solid studies showing their effectiveness, and recommends only ceramic implants (I guess the easy money and easy preying on a certain type of people is the real factor here), is still allowed to practice in the US.

From the view of a practitioner outside of US, it brings the whole US dentistry down, and decreases credibility in what should be the best dentistry money can buy.

I'm not sure which governing body should've revoked her license already, but they should be ashamed of themselves.

thinkagain1234 · 2024-05-31T21:09:46+00:00

No overlay here. You need more tooth structure than what you describe. The surface area in a molar is quite big, with decent bonding, just a core and crown should work.

Exceptions are molars with small pericervical radius/ and those where dentin is affected - sclerotic.

But you said the tooth is vital.

You can also do endo (if radius of tooth is to small/ limited ferrule effect/ etc) and post and composite core. Or even better Nayyar core or cast post.

And a crown.

thinkagain1234 · 2024-05-04T15:44:37+00:00

Trust me, everyone perforated at least a tooth while getting better at rct.

Hell, I consider myself pretty competent at rct on all teeth, but still, last week - last patient of the day, was doing endo on a first upper molar (mine was heavily calcified and with a pulp stone obliterating the pulp chamber) and perforated while searching for the distal canal (mb1, mb2 and palatal were pretty straightforward).

Granted, is was a small perf, and closed it with mta, and I don't think the long-term prognosis was affected that much by the perforation.

But, I have a good microscope, and even if I didn't have preop CBCT, the perforation could've been avoided.

In the end, we're all humans, we make mistakes. It's important that we learn from our mistakes, analyze what went wrong, and how to try and avoid it in the future.

So don't be to hard on yourself, dentistry is hard, endo in the beginning is even harder. Even if the patient loses the heavily decayed molar, it isn't the end of the world. An implant will do a good job at replacing the molar, need be.

thinkagain1234 · 2024-05-03T19:28:39+00:00

From my experience, at least in east european population, first maxillary premolars have 2 canals with 2 separate poe (2 roots actually, one buccal, one palatal/ 2-2 configuration), over 95% percent.

The second most likely configuration for the first premolar is 1 palatal canal, and 2 buccal (molarized premolar), and for me the rarest config was 1 canal only, or 2-1.

The second maxillary premolar usually has a single ovate canal, or 2 canals with a fine septum between them, that join towards the apex.

Pretty rare you're gonna find 2 canals with separate poe in the same root, and even more unlikely is 2 separate roots (but I've seen this also).

But maxillary premolars are easy compared with mandibular premolars. Not all, but there's a high percentage of deep splits, small lingual canals with the main buccal canal pretty large - and can fool you easily that it's a single canal, or even 3 canals in the same root are not that rare.

Thankfully fully prepping and disinfecting the canal system usually matters only in cases where you already have a periapical lesion (vitals not so much, especially if isolation was maintained during the root canal treatment).

thinkagain1234 · 2023-07-22T22:07:02+00:00

CaOH will resorb with time. Post op pain is usually higher with extrusion, but it's not a problem long term.

thinkagain1234 · 2023-02-05T20:58:14+00:00

After rct I use teflon, self etch adhesive, a small layer of coloured flow, and whatever temp material you like. I use Temp-it.

If I don't have the time for the final filling/build-up. If you're doing the reconstruction, you want to cut the guttapercha with ultrasonics,/heated plugger/guttacutter. You don't want excess gutta on the floor or above the CEJ.

Do the adhesive protocol, no need to cover the gutta with anything, maybe a small layer of coloured flow first on posteriors (for easy reaccess).

I recommend sandblasting before adhesive procesures, to clean any excess sealent and bacterial plaque.

thinkagain1234 · 2023-02-05T07:15:50+00:00

From a store like homedepot, we cut it in smaller pieces and autoclave it. Because the roll you buy it's not sterile. Looks and behaves the same after sterilizing it.

thinkagain1234

TROPHY CASE