Successful removal of a 16 mm long pulp stone using ultrasonic tips from maxillary left first molar and its endodontic management
A 40-year-old female reported to the department of conservative dentistry, with a chief complaint of food impaction and pain in the left upper molar region. The pain started a month ago and was dull, gnawing in nature with moderate intensity. She reported to the clinic only when the pain became severe. On clinical examination, it was observed that the maxillary left first molar had a deep occlusal caries with an exposed pulp. The tooth was severely tender on percussion and had moderate pain on palpation. Pulp testing with electric pulp tester (Parkell Inc. Edgewood, NY, USA) and thermal test using hot gutta percha elicited non-responsiveness from the suspect tooth, intraoral periapical (IOPA) radiograph revealed diffused radio-opacities throughout the pulp chamber and in the palatal root canal. The canal outlines for the mesiobuccal and distobuccal roots were quite clear and traceable till the apex [].\nBy evaluating the tooth clinically and radiographically, a diagnosis of pulpal necrosis with acute apical periodontitis was made and an endodontic approach was planned for this tooth.\nAccess was gained to the pulp chamber after administration of local anesthesia (2% lignocaine with 1:100,000 epinephrine) under rubber dam isolation. No drop was felt in the pulp chamber since it was completely obliterated. The calcified mass was clinically visible as an irregular translucent mass attached to the walls and the floor of the pulp chamber. After careful extensions of the access cavity, an ultrasonic nonactive tip with active lateral part Start-X™ #1 (Dentsply Maillefer) was introduced with a Piezo ultrasonic generator (EMS MINIPIEZON) for further refinement of access cavity walls and displacement of the calcified mass. An ultrasonic tapered and active tip Start-X™ #3 (Dentsply Maillefer) [] was introduced to remove the calcific obstruction. The entire mass could be dislodged from the walls of the pulp chamber and its underlying attachment. The calcified mass thus removed, had its extension into the palatal root canal that traversed along its entire length []. The length of calcified tissue was measured to be 16 mm long []. The shape of the calcified mass confirmed to the shape of pulp chamber and palatal root canal.\nAfter locating the root canal orifices, the patency of all the three root canals was checked with #10 K file (Kerr USA). The working length was determined by Root ZX II (J. Morita, Kyoto, Japan) apex locator for all the three root canals and confirmed by a radiograph []. The root canals were cleaned and shaped by rotary nickel-titanium ProTaper instruments (Dentsply Maillefer) using Glyde (Dentsply Maillefer) as a lubricant. The canals were sequentially irrigated using 5.2% sodium hypochlorite and 17% ethylenediaminetetraacetic acid (EDTA) during the cleaning and shaping procedure. The canals were thoroughly dried and all the root canals were coated with AH-plus resin based sealer (Dentsply Maillefer). Obturation was carried out using the ProTaper gutta percha point. The access cavity was restored with posterior composite resin (ClearfilmajestyTposterior, Kuraray America, Inc. NY, USA). Post-obturation radiograph was taken which showed well-obturated root canals []. The patient was asymptomatic during follow-up after 6 months [] and was advised to get this tooth crowned.\nThe calcified mass thus removed was preserved in 10% neutral buffered formalin and was embedded in paraffin wax for the histopathological evaluation []. The histopathological result revealed multiple calcified masses lying free within the pulp tissue. These calcified masses varied in their size and were scattered throughout the substance of pulp, they resembled dystrophic calcification [].