Restoration of a Grossly Carious tooth using Canal Projection: A Comparative Analysis of different materials for use as Canal Projectors

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1 Restoration of a Grossly Carious tooth using Canal Projection: A Comparative Analysis of different materials for use as Canal Projectors Saurabh Ahuja 1, RPS Bedi 2, Ankur Garg 3, Himantika Singh 4, Nidhi walia 5 1-Dental Officer, Army Dental Corps. 2-Classified Specialist (Orthodontics), Army Dental Corps. 3-Department of Oral and Maxillofacial Surgery, ITS Dental college Greater Noida. 4- Department of Endodontics and Conservative Dentistry, ITS Dental College Greater Noida. 5-Department of prosthodontics, ITS Dental College Greater Noida. Correspondence to: Dr. Saurabh Ahuja, Dental Officer, Army Dental Corps. Contact Us: ABSTRACT Grossly carious teeth or teeth with fractures of the coronal portion or a perforation frequently cause various problems during endodontic management like coronal /radicular fractures, in-growth of soft tissue, difficulty in placement of rubber dam clamps and coronal leakage, leading to treatment failure. Thus pre-endodontic restoration of the tooth is advocated during management of such teeth to aid in maintenance of proper aseptic conditions for the canals, structural integrity of the tooth and also in placement of rubber dam clamps. Maintaining the structural integrity and canal patency is a big challenge during such restorations for the clinician, this can be effectively achieved by canal projectors as suggested by Gerald N Glickmann and Roberta Pilleggi in which tapered plastic sleeves are used to maintain canal patency. [Projector Endodontic Instrument Guidance System (CFN engineering, Santa Barbara CA) ], due to limited availability of the original canal projection system in the government institutions various alternatives have been used successfully. This paper describes a much simpler, easily available, economic yet an effective alternative to the conventional projection system for pre-endodontic management of the grossly carious tooth without causing canal blockage and maintaining individual canal access and shape for use in service hospitals. KEYWORDS: Grossly carious teeth, canal projection technique, hypodermic needles, gutta percha cones, coronal fractures AASSSAAsasasss INTRODUCTION Grossly carious teeth with open pulp chambers and missing one or more coronal walls often cause problem during their endodontic management, hence a preendodontic restoration is often advocated to help in maintenance of aseptic conditions during the procedures as well as to maintain the structural integrity of the tooth long enough for proper prosthodontic rehabilitation of the affected tooth. Maintaining the canal patency and individual access during such procedures pose the greatest challenge for the operator. This can be achieved by canal projection technique as suggested by Gerald N Glickmann and Robert Pilleggi wherein a tapered plastic sleeve was used to maintain the canal patency. 1 In this article, we have described the management of two cases of grossly carious teeth with broken/ lost two or more coronal walls, both of which have been restored using canal projection technique prior to endodontic treatment. We have used Hypodermic needle and gutta percha cones as sleeves instead of the above mentioned plastic sleeves as they are not readily available in field/ peripheral areas while supply of hypodermic needles/ gutta percha cones are adequate. Therefore, we have used hypodermic needles/ gutta percha cones as the sleeves instead of the tapered plastic sleeves as advocated in the texts, A case has also been presented in which the tapered plastic sleeves were used as a control, and comparative analysis was done between the 2 techniques on basis of difficulty of usage, and outcomes of the procedure in which the short term and long term follow up revealed minimal to no difference in the healing of the tissue postop but the difficulty of use of needles and gutta percha instead of pre tapered plastic sleeves was higher with greater incidence of fracture of the restoration and chances of root fracture due to undue stress from use of non uniformly tapered metallic needles and the force required to insert them into the canals. 2-5 Case 1: A 17 year old daughter of a serving soldier reported to dental section with the complaint of pain in the lower left posterior tooth region since 10 days. Clinical examination revealed a grossly carious left mandibular first molar with pulpal exposure. Radiograph revealed caries approaching pulp with excessive loss of tooth structure, complete loss of buccal wall and partial involvement of the distal wall. Vitality tests conducted on the tooth gave a lingering pain response. A diagnosis of irreversible pulpitis was established and endodontic How to cite this article: Ahuja S, Bedi RPS, Garg A, Singh H, Walia N. Restoration of a Grossly Carious tooth using Canal Projection: A Comparative Analysis of different materials for use as Canal Projectors. Int J Oral Health Med Res 2017;4(3): International Journal of Oral Health and Medical Research ISSN SEPTEMBER-OCTOBER 2017 VOL 4 ISSUE 3 70

15, 20 no. K files, orifices were enlarged using Sx file (hand protaper). A hypodermic needle with an outer diameter of 1mm and inner diameter of 0.

The bondable surfaces were etched for 30 seconds and rinsed.

compromising the structural integrity of the tooth (Figure 2-6).

etched surface and light cured for 20 seconds.

The final restoration was done up to the occlusal level with an opening through which the canals were patent up to the apex.

2 therapy was initiated (Figure 1). Figure 4: Files with sleeves in the canal Figure 1: grossly carious tooth Access opening was done under local anesthetic cover, pulp extirpated and glide path created using 15, 20 no. K files, orifices were enlarged using Sx file (hand protaper). A hypodermic needle with an outer diameter of 1mm and inner diameter of 0.75mm cut off at the hub and bevel was placed into the canal as sleeve for canal projection. Three such sleeves were used each with a 15/ 20 no. K and H file inside them. The bondable surfaces were etched for 30 seconds and rinsed. The sleeves were coated with a separating media and then the sleeves with their respective files were placed into the canals and pushed apically as far as possible without compromising the structural integrity of the tooth (Figure 2-6). Figure 5: Hypodermic needles as sleeves Figure:2 Caries removal done and Access achieved Figure 3: Sleeves with files placed in canals Bonding agent was applied to the etched surface and light cured for 20 seconds. A thin layer of flowable composite Figure 6: Sleeves removed canals seen followed by packable composite was condensed and incrementally cured for 40 seconds. The final restoration was done up to the occlusal level with an opening through which the canals were patent up to the apex. The projectors /sleeves were removed by engaging with 25 no. H files/ curved hemostat forceps. After removal of the sleeves, the orifices were rewidened. The access refined and the working length was determined using INGLE S technique. 1 The canals were cleaned and shaped using crown down technique using hand protaper files (6% taper),mesiobuccal and mesiolingual were prepared till F1 and distal till F3.The canals were obturated using cold lateral condensation of gutta-percha with resin-based root canal sealer. The canals were sealed off at the orifices and the remaining projected space was filled with flowable composite (Figure 7-10). International Journal of Oral Health and Medical Research ISSN SEPTEMBER-OCTOBER 2017 VOL 4 ISSUE 3 71

$On examination a grossly carious second molar with a faulty restoration was observed, the tooth were tender on percussion in both apical and lateral directions, Radiograph revealed a fractured$ restoration with gross coronal radiolucency below the restoration and exposure of mesial pulp horn with loss of mesial coronal wall, Vitality tests conducted gave a lingering pain response, a

restoration with gross coronal radiolucency below the restoration and exposure of mesial pulp horn with loss of mesial coronal wall, Vitality tests conducted gave a lingering pain response, a

Access opening was done under local anesthetic cover and four canals were located. Pulp was extirpated and glide path was created using 10, 15, 20 no. K files.

) was placed into the canal as sleeve for canal projection. Four such sleeves were used for the molar after application of separating medium (petroleum jelly) on them.

The sleeves coated with separating media were placed into the canal and pushed apically as far as possible without compromising the structural integrity of the tooth.

3 Figure 7: gutta percha cones for obturation Figure 8: Master cone IOPA Figure 9: Post op projector space filled temperatures and during mastication. On examination a grossly carious second molar with a faulty restoration was observed, the tooth were tender on percussion in both apical and lateral directions, Radiograph revealed a fractured restoration with gross coronal radiolucency below the restoration and exposure of mesial pulp horn with loss of mesial coronal wall, Vitality tests conducted gave a lingering pain response, a diagnosis of irreversible pulpitis with periapical abscess was established and endodontic therapy was initiated for the tooth. Access opening was done under local anesthetic cover and four canals were located. Pulp was extirpated and glide path was created using 10, 15, 20 no. K files. The orifices were enlarged using Sx file (hand protaper) and working length was established using INGLE S technique. 1 A 6% tapered gutta percha point (30 no.) was placed into the canal as sleeve for canal projection. Four such sleeves were used for the molar after application of separating medium (petroleum jelly) on them. The bondable surfaces were etched for 30 seconds and rinsed. The sleeves coated with separating media were placed into the canal and pushed apically as far as possible without compromising the structural integrity of the tooth. Bonding agent was applied to the etched surface and light cured for 20 seconds. A thin layer of flowable composite followed by packable composite was condensed and incrementally cured for 40 seconds. The final restoration was done up to the occlusal level with an opening through which thecanals were patent up to the apex. The projectors /sleeve was removed by engaging with 25 no. H files/ curved hemostat forceps. After removal of the sleeve, the orifice was rewidened using Gates Glidden drill. The access was refined and the working length reconfirmed using INGLE S technique. 1 The canals were cleaned and shaped using crown down technique utilizing hand protaper files (6% taper), the canals were prepared till F2 for Mesio-Buccal and Mesio-Lingual and F3 for the Disto-Buccal and Disto-Lingual canals, following which the canals were obturated using cold lateral condensation of gutta-percha with resin-based root canal sealer. The canals were sealed off at the orifices and the remaining projected space was filled with glass ionomer cement. Figure 10: Post op IOPA Case 2: A 32 year old serving soldier reported to the dental section with the complaint of dull continous pain in the lower right posterior tooth region since last 20 days. Pain was aggravated on exposure to extreme Fig: 1 Grossly Carious Tooth International Journal of Oral Health and Medical Research ISSN SEPTEMBER-OCTOBER 2017 VOL 4 ISSUE 3 72

Fig:2 Caries removal done and Access achieved Fig: 6 Post Obturation IOPA Fig:

as Canal projectors Fig: 5 Sleeves Removed Canals Seen Fig: 8 POST-OP CASE 3

the complaint of pain in the upper right posterior tooth region since last 5

mastication and consumption of hot liquids.

structure, complete loss of distal wall and partial involvement of lingual wall.

A diagnosis of irreversible pulpitis was established and endodontic therapy was

4 Fig:2 Caries removal done and Access achieved Fig: 6 Post Obturation IOPA Fig: 3 Working Length IOPA Fig: 7 Final Coronal Build-up Fig: 4 Gutta Percha Cones as Canal projectors Fig: 5 Sleeves Removed Canals Seen Fig: 8 POST-OP CASE 3 (Control): A 25 year old serving soldier reported to the dental section with the complaint of pain in the upper right posterior tooth region since last 5 days. Pain was of dull and continuous in nature which increased during mastication and consumption of hot liquids. On examination a grossly carious maxillary right first molar with pulpal exposure was observed. Radiograph revealed caries approaching pulp with excessive loss of tooth structure, complete loss of distal wall and partial involvement of lingual wall. Vitality tests conducted gave a lingering pain response. A diagnosis of irreversible pulpitis was established and endodontic therapy was initiated. Access opening was done under local anesthetic cover and four canals were located. Pulp was extirpated and International Journal of Oral Health and Medical Research ISSN SEPTEMBER-OCTOBER 2017 VOL 4 ISSUE 3 73

glide path was created using 15, 20 no. K files.

K and H file inside them. The bondable surfaces were etched for 30 seconds and rinsed.

rewidened, and working length was reconfirmed.

gutta percha cones with cold lateral compaction technique with resin-based root canal sealer.

5 glide path was created using 15, 20 no. K files. The orifices were enlarged using Sx file (hand protaper) and working length was established using INGLE S technique. 1 Four pre-tapered plastic sleeves (canal projector system) 1, were used each with a10,15,20 no. K and H file inside them. The bondable surfaces were etched for 30 seconds and rinsed. The sleeves were coated with a separating media and were placed into the canals with their respective files. They were then pushed apically as far as possible without compromising the structural integrity of the tooth. The coronal build-up was done as described earlier using flowable composite, orifices were rewidened, and working length was reconfirmed. Canal preparation was completed (6% hand protaper files) and obturation was done using 6% taper gutta percha cones with cold lateral compaction technique with resin-based root canal sealer. The canals were sealed at the orifices and the projector space was filled with composite (Figure 1-8). Fig: 4 Files With Plastic Sleeves Fig: 5 Files Removed Sleeves Visible Figure 1: Pre-Op Tooth Fig: 6 Core Build Up Done Figure 2: Pre-Op Close Up View Fig: 3 Access Opening With Working Length Fig: 7 Sleeves Removed Canal Access Seen International Journal of Oral Health and Medical Research ISSN SEPTEMBER-OCTOBER 2017 VOL 4 ISSUE 3 74

Preservation of grossly destructed tooth by endodontic treatment is a universally preferred mode of treatment to tooth extraction and replacement with prosthesis.

6 Preservation of grossly destructed tooth by endodontic treatment is a universally preferred mode of treatment to tooth extraction and replacement with prosthesis. 6 This is done under rubber dam isolation since it reduces aerosol contamination and cross infection by up to 98.5%. 7 Teeth with sub-gingival caries, open pulp chambers and little cervical tooth structures are a challenge for the clinician due to difficult isolation, in-growth of soft tissue, increased chances of coronal fractures. Grossly mutilated teeth with sub-gingival caries, deep carious lesions, and open pulp chamber are often a challenge for a successful endodontic management and getting a favorable outcome, due to difficulty in rubber dam placement (isolation) maintenance of canal patency, ingrowth of tissue and salivary leakage prevention in between appointments. Techniques such as split dam technique using a clamp with prangs inclined gingivally, use of serrated clamps and clamp stabilization( by placing them on attached gingival), surgical exposure of sub gingival tooth structure with gingivectomy/ gingivoplasty are helpful in isolation of a severely destructed tooth use of orthodontic bands bands pins retained amalgam and adhesive restoration are also advocated however they are not as effective in providing moisture control, safety and comfort to the patient. Pre-Endo buildup of lost coronal structure following caries removal provides a strong core, good coronal seal, and reserves for irrigating solutions during instrumentation, Pre-Endo buildup can be done using Amalgam, composite, GIC assisted by copper bands, orthodontic bands crown pre-forms. 2 If leakage occurs it can be managed by temporary restoration, Oro-Seal or Liquid Dam, pre-endo buildup may result in blockage of root canal orifices compromising thorough cleaning and shaping of the canals resulting in suboptimal outcome. Canal projectors reduces this to a greater extent by closing the orifices thus preventing ingress of restoration material into the canals during pre Endo buildup plus it has added advantages like: DISCUSSION Fig: 8 Post-Op Iopa Better sealing of chamber floor. Orientation and easy insertion of rotary instruments into the canals especially in closely located orifices and loss of dentinal mapping. Aids in sealing of furcal perforations and maintenance till next appointments. Recontouring the chamber floor and walls Lengthening of the root canal This can be effectively achieved by canal projectors as suggested by Gerald N Glickmann and Roberta Pilleggi in which tapered plastic sleeves is used to maintain canal patency. 1 Due to limited availability of the original canal projection system in the service hospital alternatives have been used successfully. This paper describes a much simpler, easily available, economically viable yet an effective alternative to the conventional projection system during pre-endodontic management of the grossly carious tooth without causing canal blockage. Similar modification has been successfully attempted in civil clinical setups using gutta percha cones as an alternative to the pre tapered plastic sleeves with equally successful results. 8 The technique of using stainless steel needles or gutta percha cones offers all the benefits of conventional (PEIGS) pre-tapered plastic sleeves as advocated in the text with added benefit of being easily available economical and yet being equally effective alternative for the original canal projector system. With limited access to recent modifications in the field or restorative dentistry in remote locations and difficulty in follow up of patients due to operational commitments many teeth are lost to extraction, use of the pre Endo buildup would aid in ease of treatment as well as long term survivability of the tooth. CONCLUSION A comparative case analysis was done using the Projector Endodontic Instrument Guidance System (CFN engineering, Santa Barbara CA) which provides a technique for pre-endodontic reconstruction of debilitated coronal and radicular tooth structures while preserving individual access to the canals. 1 This technique suggests the use of tapered plastic sleeves that mimics the canal shape. 2 The analysis was done between alternatives for the progressively tapered plastic sleeves as suggested in the text as such sleeves are not readily available or accessible in service hospitals and remote locations where most of our men are deployed, the alternatives used were stainless steel hypodermic needles and gutta percha cones while the pre tapered plastic sleeves were used as control in one of the cases and the long term outcomes compared; at immediate post-op no difference in outcomes was evident except for difficulty in removal of the hypodermic needles and gutta percha cones after core buildup. At 3 month follow up no difference was evident in healing of the tissue and survivability of the tooth. REFERENCES 1. Cohen S and Barns. Pathways of pulp. 8 th Ed, St Louis, MO, USA Mosby p Lazarus Jp. Provisionally restoring a necrotic tooth while maintaining root canal access. J Am Dent Assoc 2004; International Journal of Oral Health and Medical Research ISSN SEPTEMBER-OCTOBER 2017 VOL 4 ISSUE 3 75

7 135: Reid and Callis. Rubber dam in clinical practice. Quintessence publication: Chong BS. Coronal leakage and treatment failure. J Endod 1995:21: Bhargavi N, Lakshmi Neelima, Velmurugan N, Kandaswamy D. Restoration of a vertical tooth fracture using canal projection. Indian J Dent Res 2007; 18: Roda Rs, Gelleman BH non surgical restoration. Cohen S, Haegreaves K, Pathways of pulp. 9 th Ed, St Louis, MO, USA Mosby 2006 p Marshall K. Dental workspace contamination role of rubber dam CPD Delster 2001; 2 p Tanikonda R. Canal projection using gutta percha points: a novel technique for pre-endodontic buildup of grossly destructed tooth. J Conserv Dent 2016;19:194-7 Source of Support: Nil Conflict of Interest: Nil International Journal of Oral Health and Medical Research ISSN SEPTEMBER-OCTOBER 2017 VOL 4 ISSUE 3 76

WaveOne Gold reciprocating instruments: clinical application in the private practice: Part 2

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