Apical perf healing (by Ilya Mer)

What a pleasure surprise came yesterday to my clinic. Tooth #36 with apical perf healed completely 3 years after treatment. Just GP + AH plus and disinfection definitely.

Red Russian cement molar surgery (by Ilya Mer)

Red Russian cement was very popular in former USSR countries and unfortunately still in use in some cases. The main reason to apply it in the past was canal curvature not possible to pass through. If one been retreated cement is found in coronal and middle third whereas apical third is free of filling and
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12 month CBCT recall after MB root surgery (by Ilya Mer)

Missed anatomy is the most frequent cause of apical development. In first upper molars definitely MB2 is mostly missed canal.  Both approaches surgical and non surgical can be applied to solve this kind of problem. But what to do if the whole MB is missed? Is it mandatory to do surgical treatment instead of non
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When the surgery is the only option (by Ilya Mer)

To tell you the truth my therapeutic nature opposes an idea to do surgery in case of unfounded and untouched root. But in case of crown and two leg cast post surgery is the only option.

Genre busting tooth (by Ilya Mer)

According to the laws of genre this tooth would be extracted  a year before. It’s really looked awful – open margin crown, broken file, ledging, perforation, overfilling, apical periodontitis. I was quite pessimistic while starting that treatment. But this tooth behaved himself as a good one. Broken file was retrieved, canals negotiated and cleaned then
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Second premolar’s apico (by Ilya Mer)

CAP of #35 (13). Cast post and double crown deny coronal access. Surgery is the correct way to try to save the tooth. Retrofilling with MTA I know what some people think – mental nerve, too much risk, open margins, it’s just for a while. Please let me disagree with you. There is no way
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NSRx of AAP (by Ilya Mer)

Prev endo was done aprox 3-4 years before. Obturation looks quite decent but symptoms appears. Percussion and palp both painful.  RD was so kind to remove an old rest and bond a new one.

3+1 (by Ilya Mer)

How many canals in first upper premolar could be? One – sometimes, two – usually, three – rare. Four? Are you serious?

THE case for apico (by Ilya Mer)

Ideal case for apico surgery and not for retreatment. Localized infection (MB root with probably missed anatomy), rest canals are decent obturation. Tooth was retreated aprox 5 years before and MB2 was found. CAP was still there.

Endo surgery saving prosthesis (by Ilya Mer)

Endo surgery can be always considered as an option in case of good prosthesis that patient satisfied with. This is the case is exactly showing that. Cantilever bridge of #21 and pontic of #11 survived for 9 years and I saw no reason why not to continue to do it further. Surgery versus NS ReTx
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Long story with happy end (by Ilya Mer)

The beginning of this story was at April 2013. Patient couldn’t bite on her tooth for a month since  endo was done at another clinic (initial diagnosis pulp necrosis and SAP). Percussion indeed was painful. I adviced her to wait for a few weeks/months hopping that symptoms would release. Actually endo looked not that bad
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Heavy overfill and sinus involvement (by Ilya Mer)

Patient is suffering of sinus tract open and close last year. Tooth had come through two NsReTx resulted with heavy overfilling into sinus.  

Retreatment work (by Ilya Mer)

This tooth is kind of routine work which you’re not always can be satisfied with result. Looks too much for one tooth: lack of hard tissue, distal deep pocket, PARL on all three roots, and Red Russian discoloration that usually promises hard work. Therefore, when you succeed to fix most of these problems it makes
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Technical retreatment (by Ilya Mer)

Some teeth are needed to be retreated in case of new restoration comes. Everything looks inadequate (rest and obturation quality) but result. There are no symptoms and no apical rarefaction. Do we need to retreat in this case? Yes you do! Would I retreat if tooth doesn’t need new rest? Good question. What’s your opinion?

MB2 missed (by Ilya Mer)

Missed MB2 cases are come sort of routine work for endodontist. I am always admire to see upper molars with all shitty filled canals  but PALR usually appears only on MB root    

External apical resorption tooth re-endo (by Ilya Mer)

Русская версия Absolutely asymptomatic tooth and patient. Just wonder how orthodontist could start treatment with such obvious endodontic problem?  

Treatment plan dilemma (by Ilya Mer)

Русская версия One more puzzle case which treatment plan better in this case. Surgical or non surgical? Well, MB root looks hopeless, ledge in mid third in most cases means you can’t negotiate this canal till apex. In cases like that surgical approach can be considered as a first choice. But how about MB2? Can
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Minimal invasive concept (by Ilya Mer)

There is a very popular concept of minimal invasive dentistry, means trying to save what can be saved.  My question is why we need to reatreat canals with no lesion and good done endo treatment? In this case I decided not to enter to Palatal root at all and go for both mesials  

1 year follow up after apical surgery of central incisor (by Ilya Mer)

Patient appeared with pain and swelling in area of #41 (25). Prosthesis was done a couple of years before. Deep probing on MB aspect of #41 (25). Percussion and palpation was painful as well.

Just wait a little bit (by Ilya Mer)

Do we expect large cyst-like lesion after non surgical RCT? Yes, sure! Caliscan showed that almost 74% of these sort of lesions could disappeared if follow up was longer than usual.    

Sealer extrusion (by Ilya Mer)

There is a strong correlation btw success rate of endodontic treatment and obturation level. Longer – worst! This is true if we know that GP cone is extruded out of root. How about sealer extrusion? It’s difficult to say in  retrospective study – this is guttapercha or for sure it’s sealer. Good example is a
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Missed canal as a second opinion (by Ilya Mer)

Русская версия  Patient came to get a second opinion  about treatment plan of first mandibular molar. He had consulted with 2 dental surgeons (!)  and was suggested apicoectomy or GUESS?  Right – extraction and implant!

3 month healing after lower molar apico (by Ilya Mer)

This tooth was treated in 2005 with diagnosis SAP  but 9 years later the PAL om mesial root is still there. Surgical decision was suggested and applied        

Bleaching related external root resorption (by Ilya Mer)

First endo 11 years ago due to caries. 4 years before patient complained of discoloration then bleaching with H2O2 was done. Actually the bleaching technique is not exactly known, it was walking method for sure        

Continue non surgical? (by Ilya Mer)

Русская версия Again surgical non surgical dilemma Two previous apicos were done 20 and 8 years ago. Sinus tract appeared 4 months before. Referred dentist has decided to go for non surgical retreatment but  4 visits later sinus tract was still there. On my first visit osteoplastic material granules were seen going out of sinus
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Just routine retreatment work (by Ilya Mer)

Just everyday routine work, not to say “easy work” but that what we deal with              

Treatment failure

You can be a very experienced clinician you read tons of literature and use relevant protocols but never have 100% success treating apical periodontitis. This case was  NSRTx retreatment of first upper molar after Resorcinol Formaldehyde technique with CAP on buccal roots.          

5 years story of 4.6

It started at Nov 2009 with irreversible pulpitis, one visit endo. Two distals and three mesials and I was very proud by final X-ray picture    

Failure treatment (by Ilya Mer)

History of pain for more than 6 months. Tooth #2.4 with CAP was treated by dentist who found only on canal. During 2 months retreatment was attempted, last time with microscope, additional merged canal was found. Patient still had pain in touching her tooth and also had a painful point  to push near her nose.
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Retreatment due to PARL (by Ilya Mer)

Endodontic treatment was looking good but PARL showed that something wrong was in root canal IMO options of surgical and nonsurgical retreatment were available.  Patient was confident with non surgical way.      

Surgical retreatment of MM failure (by Ilya Mer)

                         

Surgical or non surgical? (by Ilya Mer)

History of pain in Jan 2013 second molar was extracted and pain was released No complaints since there. Accidental finding on X-ray Two options were possible – surgical and non surgical – we discussed both with patient and decided to go surgically.                

What file would you choose for apical preparation? (by Ilya Mer)

That periapical lesion was an accidental finding Patient came after  consultation of implatologist with conclusion there was no possible to put an implant. Means full of motivation to save the tooth.        

No glide path canal preparation (by Ilya Mer)

Using any NiTi rotary systems  with one length  philosophy you have to create glide path up to #20 before rotary. It decrease breakage of files. Sounds logically.  But in practice this stage can take you 15-20 minutes for molar and also increase chance to make an apical ledge which will be difficult to bypass. Why crown down approach is
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External resorption (by Ilya Mer)

This patient had no any complains but aesthetics. Restoration was replaced 3 times during 5 years. A year before  dentist  noticed a pink spot on palatal side. X-ray and CBCT  confirmed diagnosis of external resorption    

Lower incisor with CAP 18 years after trauma (by Ilya Mer)

This patient was sent to my clinic because his dentist has noticed a sinus tract against a lower incisor. Patient himself never felt any discomfort in that area. Clinically teeth looked with no signs of damage. PA film showed huge periradicular lesion around of tooth #4.2 and a small  periapical rarefaction on #41’s  apex. Both
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Second DB canal of first upper molar (by Ilya Mer)

See no worth for non surgical treatment in cases like that. Endo was done twice. The first time 3 canals were founв and obturated. The second time endo specialist tried to fix the problem. Four canals were instrumented and obturated. 4 years later symptoms appeared.      

С-shaped second lower molar (by Ilya Mer)

Sometimes during a routine work you suddenly face a challenging  anatomy like this tooth C-shaped second mandibular molar with irreversible pulpitis          

16 month recall of apicoectomy (by Ilya Mer)

Symptomatic lesion of central mandibular incisor The patient desired to save her crowns.

Couldn’t be done by conventional endo (by Ilya Mer)

This patient had no complaints but needed new crown and prosthetic dentist asked me to evaluate an endodontic status Tooth was treated endodontically at least twice. The first attempt was done more than 20 years before, tooth underwent treatment with “Red Russian Paste” which caused obliteration  in root canals.  The started to hurt 12 years
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Internal resorption of lower incisor (by Ilya Mer)

Referred case with internal resorption of central lower incisor. The tooth was not vital and sinus tract appeared. The treatment was already started by referred dentist to relieve suffering of patient. Complete instrumentation of apical portion was done with SAF and apex was enlarged up to #50 with Nitiflex #50. After the calcium hydroxide dressing
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Should we retreat all canals? (by Ilya Mer)

The patient was absolutely asymptomatic, PARL on MB root of #1.6 has pointed to missed anatomy and poor disinfection protocol Should we retreat all canals in this case or only MB root?          

Restoration determines endo (by Ilya Mer)

Poor integrity of distal margin of PFM put in doubt that tooth could restored one more. Diagnostic removal of all old restorations in this case should be done before decision of endo retreatment            

Apical periodontitis two years after crowning (by Ilya Mer)

#47 (31) developed apical periodontitis with sinus truct 2 years after the crowning.      

NSRCTx of #46 (#30) (by Ilya Mer)

Nothing special, just routine re-endo before crowning. In orthograde beam preop looks decent but eccentric (off-centered) view shows non obturated space of MB canal.            

6 month recall of CAP RTx (by Ilya Mer)

  Русская версия   No symptoms before the treatment and no symptoms after 6 months.

Red Russian NSRTx case (By Ilya Mer)

  Русская версия   Here is a typical case of Red Russian cement retreatment. The first endotreatment was done more than 5 years before. Patient said he had some pain in region. Actually symptoms could come from second molar with deep mesial decay, which was referred to RD to treat.          
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SAF instrumentation (by Ilya Mer)

Русская версия A relatively new philosophy of root canal cleaning and shaping called Self Adjusting File (SAF) shows great ability to clean long oval canals. The problem still remains in apical third when SAF has a limitation to clean properly. In my view the simple and probably effective way is to complete the apical shape
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12 month follow up after maxillary premolars NSRCTx (by Ilya Mer)

What is the periapical lesion size depended on? Probably it has a correlation with number of intracanal microorganism’s taxons and number of microbiota itself. Does the periapical lesion size has an influence on a decision making process?  Most of my referring dentists  DO believe so. That’s why I got this patient for the consult firstly.
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Surgical retreatment of lateral incisor (by Ilya Mer)

Lateral incisor underwent endodontic treatment more than 5 years before. The only complains was a weak pain when a patient pressed under her nose. She was sent to evaluate surgical or non surgical RCT of  lateral incisor. Patient was waiting for implants exposure and healing abutments.                

C-shape second molar retreatment (by Ilya Mer)

I have no idea why this tooth was endodontically treated, patient didn’t  remember why when and where it was done. Patient had no complains but fracture of composite restoration. RD has planned to get a new restoration for this tooth and sent patient for my evaluation whether endo should be redone      

NSRTx of first upper molar (by Ilya Mer)

This patient was sent for retreatment due to symptoms of chronic abscess and sinus tract. Guttapercha tracing film showed that incomplete RCT in first upper molar caused the inflammation.      

First upper premolar apico (by Ilya Mer)

Русская версия The endo of premolar and cast post were done about a year before. Provisional crowns joined two premolars and an implant. Patient complained of intermittent  pain in region.        

Irreversible pulpitis (by Ilya Mer)

Just a regular case of irregular pulpitis of #17 (2). Interesting anatomy – very long buccal roots (23mm) and relatively short palatal one (17mm)        

Broken H-file removal (by Ilya Mer)

I was asked to make an attempt of non surgical re-Tx of lateral man incisor Two broken fragments are seen in the apical third, root canal is over-enlarged probabaly because of previous attempts to remove the fragments.        

Perio determines endo (by Ilya Mer)

Patient was sent to retreatment of second molar as a possible cause of odontogenic sinusitis            

Confusing MB2 (by Ilya Mer)

RCT of the only premolar  was done because of pulp necrosis approximately 7 months before but still had tenderness to percussion and patient couldn’t bite on it sometimes.            

Continuous wave versus injection – video (by Ilya Mer)

Routine retreatment of first mandibular molar, previous endo done more than 5 years before, PARL on mesial root, normal peridontal probing.      

Surgical Re-endo (by Ilya Mer)

The initial endo treatment of the central incisor was done more 20 years before and cystectomy two years later. Patient felt discomfort in the area and sinus tract appeared from time to time. She has been suggested to change crown restorations and sent to my office for evaluation of re-endo treatment.        
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Second premolar retreatment (by Ilya Mer)

The tooth had no symptoms for long 8 years under the bridge but started to bother a month before the appointment. The bridge was removed шт one piece. Non surgical retreatment procedure was done in two visits.        

Lateral lesion (by Ilya Mer)

Sinus tract  appeared two years after the crown placement. Tracing with GP cone leaded to middle third area, that could get a clue of big lateral canal. It was found and cleaned with ultrasonic agitation of NaOCl. After initial shaping and Ca(OH)2 placement the sinus tract healed.      

Short? Not sure! (by Ilya Mer)

Referrative patient was sent for RCT of second right molar. During  caries and old restoration removing  pulp was exposed      

Middle third ledge and interesting apical anatomy (by Ilya Mer)

Patient referred for RCT of second upper right premolar with ledge in middle third and piece of file.        

Two visit endo (by Ilya Mer)

Nothing special, just a routine work. Non-symptomatic second lower molar was sent to retreatment I enjoy the shaping, don’t you?        

Central-lateral dilemma solved by endodontic approach (by Ilya Mer)

The term “central-lateral dilemma” was borrowed from the lecture of one of the most  brilliant speakers  in a field of Periodontics Dr Maurice Salama. Missing of  two incisors – central and lateral creates huge difficulty for both perio and prosthodontist to make good aesthetic restoration. Just wanted to show my way to solve this dilemma.    

Missed MB2 (by Ilya Mer)

Tooth #26 (14) – accidental finding on X-ray. The patient’s cheaf complaint was bleeding while flossing between first and second molar. The crown was done 2 years before. According to what patient was talking the RCT was done more than 5 years before and a new bulid up with FP was done before  a new crown placement but
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Hard paste and via false (by Ilya Mer)

This patient was referred to our practice deu to impossibility to get patency in all canals Tooth was previously treated and partially filled with hard whitish paste. There were no radiographic signs or symptoms that patient pointed at, but RD has decided to perform RCT properly        

Irreversible pulpitis #36 (19) (by Ilya Mer)

There is a typical clinical situation: bad spontaneous pain, pain provoked by cold agent, deep distal caries    

Broken file into maxillary sinus (by Ilya Mer)

This patient was referred to my office due to lingering pain in first upper molar and not succeeded treatment attempt          

Just retreatment du jour (by Ilya Mer)

No symptoms, incidental finding on X-ray before orthodontic treatment      

6 month recall after internal resorption surgery (by Ilya Mer)

The beginning of the case is here      

Resistant pain after NSRCT (by Ilya Mer)

  Русская версия The initial situation was that: RD has started non surgical re-endo of 36 which had been treated by resorcinol formaldehyde technique in the past. The dentist could negotiate all the canals but not the MB one because of the ledge in the middle third. He has obturated all available space and prepared the tooth
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Furcation LEO and 12 month follow up (by Ilya Mer)

Русская версия The patient came with acute toothache and periapical  abcess caused by #46. The percussion was very painful and tooth had a high mobility

Three canal upper premolar (by Ilya Mer)

Русская версия Patient came to our clinic about 18 months before with complains on cold sensitive on his right left jaw.      

12 month recall after NSRCT with maxillary sinus involvement (by Ilya Mer)

Русская версия Incidental finding on CBCT   #26 has been treated a year before and in spite of were no symptoms  LEO on every root and the bigest one in the palatal root        

24 month follow up after cyst like lesion (Ilya Mer)

Check the whole case here   Check the whole case here  

Bypass and fragments embedding (by Ilya Mer)

Русская версия In most cases but not always separated instrument is possible to be retrieved.   In case like this retrieving could bring about terrible hard tissue lost and jeopardize the outcome. IMHO the best management strategy is bypassing and embedding fragments into RC filling.    

12 month follow up after LEO included 2 roots of adjacent teeth (by Ilya Mer)

Русская версия It was incidental finding on CBCT made before implant placement instead of missed 45. #46 and 47 underwent endodontic treatment several years ago, LEO on every root and huge LEO inclided distal root of #46 and mesial root of 47   PostOp 47    

Pulp necrosis (by Ilya Mer)

Русская версия Here is a very typical necrotic case. The patient suffers from spontaneous pain, pain caused by hot drinks, pain during mastication No response for cold test, very sensitive to percussion.    

Fragment retrieval and 8 month follow up (by Ilya Mer)

Русская версия The patient was sent to re-endo of several teeth before a new prosthetic reconstruction  

Lateral lesion (by Ilya Mer)

Русская версия This patient was referred to our clinic for evaluation of RCT #37 (18) The initial therapy was carried out 5 years before that moment.  A year before symptoms appeared: swelling, pain, sinus tract. The NSTCT was attempted (patient said that  several dressing were changed during number of weeks) Symptoms gone but came ot
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Lateral canal and apical hook (by Ilya Mer)

Русская версия Patient was referred for apical surgery of #12 due to acute apical periodontitis and sinus tract. Elective endo treatment was done 3 years before just before PFM placement. After consult we made a decision of orthograde revision first then surgery if need. I had no illusions I could negotiate the apical curve but
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Referred from dental surgeon (by Ilya Mer)

Русская версия This patient was referred from dental surgeon that refused to carry out apicoectomy and advised patient to try NSRCT first.    

Perforating internal resorption 2.0 (by Ilya Mer)

Русская версия I’d like to share with you the second case of perforating internal resorption This patient came to our practice with no referring, just found our homepage on the Internet and came to consult Tooth #12 (#7) was opened for endodontics 2 weeks before because of acute pain and swelling in some place but
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Necrotic one step (by Ilya Mer)

Русская версия Had to stop my day off and open the office for the patient with emergency The patient just returned from the vacation and had to leave next day on business The pain has began couple of months before for cold water, then for hot tea, last week hurt spontaneously Because of the patient schedule had to finish
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Extra-radicular infection ? (by Ilya Mer)

Patient suffered from swelling and vestibular sinus tract, buccal-lingual mobility. Probable trauma in childhood and/or internal inflammatory resorption. Previous endo was done 3 years ago. After the first visit everything was going right: tooth became asyptomatic, sinus tract tended to heal. I have tried to seal the apex with MTA but it didn’t set twice.
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Missed anatomy via falsa and apical perforation (by Ilya Mer)

Русская версия Patient have had a toothache and after he was examinated by his dentist got recommendation to make RCT of tooth #36. By some reason he had held the decision making over until the severe pain come and that time extirpation has been made by another dentist. Nonetheless the treatment the patient was still
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18 months follow up (by Ilya Mer)

Русская версия Two molars retreatment. The patient came from referral with two ruined molars, pain and swelling in region #36-37 (19-18). It looked like # 36 had caused the problems, but 37’s percussion was much more painful. So the #18 was re-treated first. #36 has had separated fragment that sat exactly in the apex but
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Buried into the deep (by Ilya Mer)

Russian version This patient has been referred to complete NSRreT, RD has tried but couldn’t negotiate one of the mesial canal due to “hard cement” in the apical third.    

Radix entomolaris (by Ilya Mer)

Русская версия An additional root in lower molar, so called “radix entomolaris”. There were two point made the treatment more difficult – distal access and 25mm of the working length.

Unexpected result (by Ilya Mer)

Русская версия The patient suffered from chronical pain in area of the first lower premolar. Endodontic treatment was done aprox   13 years ago (elective treatment before bridge placement).  Patient decided to change the bridge and Re-Endo procedure was done by RD. Patient has suffered for several weeks after the treatment  by finally the tooth calmed
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Open apex and MTA apical plug (by Ilya Mer)

Русская версия Patient referred to endo retreatment of central incisor. RD has started the procedure but faced to hard cement in the middle third which couldn’t be taken out without direct vision. This problem was solved easily with microscope and ultrasonic.  Wide open apex probably caused by external resorption was closed with MTA plug.

С-shape anatomy (by Ilya Mer)

Русская версия This patient has been referred after RD opened “hot” tooth and was confused by its anatomy. I was told the only distal canal has been identified but pulp chamber all the time filled out by blood come from hidden orifices. Dentist put some iofodorm contenting paste in the pulp chamber and sent the
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Let’s glue. Video remake (by Maxim Belograd)

  Russian version Here is a remaked video of  broken file removal using glue. Have fun

Wisdom tooth pulpitis (by Ilya Mer)

Русская версия Acute pulp inflammation of #38 (17), disto-lingual wall fracture, old fillings, secondary decay – no chance for conservative treatment even there was no communication with pulp chamber #10 K-file  no apical patency PreRace 35.08 Profile 25.06 #10 K-file WL EAL Pathfile #13  to WL Pathfile #19 to WL X-ray verification of WL Profile
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Squirt per se (by Ilya Mer)

Русская версия Patient with pain and swelling in area of #47 (31) sent to retreatment.

By small pieces. (by Maxim Belograd)

Crufty lentuloes very often surprise during removal procedures. This case is not an exclusion. It took me two appointments to complete the task. During the first one I was truing to “lift up” broken instrument using ultrasonic but failed due to lentulo’s separation. Had to dress Ca(OH)2 and go to time out.   Second visit
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Reversible pulpitis and pulpotomy with MTA (by Ilya Mer)

Русская версия Primary caries of #27 (15), chief complaint was sensitivity for sweet. After referral dentist has performed vitality test with Endofrost patient felt continuous pain for several seconds (I was told about 10 sec). So patient was referred to my office with irreversible pulpitis After my examination was clear that spontaneous pain never occurred,
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Internal perforated resorption (by Ilya Mer)

Patient suffered from swelling and sinus tract in area of frontal anterior teeth.  It was about trauma of #11 (8) that happened approximately 8-9 months before the visit. Percussion and palpation was painful. X-ray showed internal resorption with perforation of the wall. I spent 3 visits to remove all soft tissue from insight the tooth
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