O meu caso clínico é sobre um retratamento de um incisivo lateral superior escolhido de uma série de retratamentos que fiz a um paciente referido por um colega que se dedica à reabilitação oral.
Não se deve dizer, olhando para uma radiografia que um retratamento é fácil, os retratamentos, até prova em contrário, devem ser sempre encarados como tratamentos de elevado grau de complexidade.
Aqui neste caso existem complexidades e obstáculos à entrada do sistema de canais radiculares:
a) coroa fixa;
b) espigão metálico pré-fabricado;
c) cimento usado para o espigão;
d) guta-percha e cimento usado na obturação:
e) perda da noção da anatomia inicial;
f) degrau em consequência da preparação do canal para espigão;
g) suspeita de encontrar um calibre apical elevado.
O diálogo entre quem faz o tratamento endodôntico e o referidor é muito importante para obter o melhor planeamento do tratamento. Neste caso, havia necessidade de colocar coroas provisórias, o paciente após a consulta de avaliação endodôntica regressou ao colega prostodontista para remoção de coroas fixas existentes e preparação dos dentes para colocação de coroas provisórias, o que me poupou imenso trabalho, ou seja, o dente já voltou para mim sem a coroa fixa, menos um “problema”…
A primeira fase do tratamento é remover o espigão e passa por eliminar qualquer tipo de material que se situe à volta do espigão, para termos espaço (algum!) entre o espigão e as paredes do dente/canal para partir o cimento que possa existir.
Sem coroa let’s start the show
As suspeitas iniciais sobre a eventualidade de encontrar um calibre apical alto confirmaram-se após a preparação químico-mecânica e calibragem do ápice. A abordagem mais correcta, segundo os conceitos actuais, em casos como este é fazer um selamento apical com MTA. O controlo visual é de extrema importância, por isso o microscópio assume um papel fundamental na colocação de uma barreira apical com MTA.
A barreira apical de MTA deve ter entre 3 a 5mm para proporcionar um selamento eficaz.
O MTA precisa de algumas horas para ganhar presa o que torna a conclusão do tratamento numa sessão pouca prática, obrigando quase sempre a uma nova sessão para finalizar a obturação do sistema de canais radiculares.
A fase seguinte do caso que apresento entra numa zona de fronteira entre a Endodontia e a Dentisteria Restauradora e/ou Prostodontia e que é motivo de alguma controvérsia, quem coloca o espigão num canal radicular? Será o endodontista capaz de fazer a melhor escolha ao eleger o canal radicular para receber o espigão? A quem cabe zelar pela inviolabilidade do sistema de canais radiculares? Quem terá maior sensibilidade para escolher o tipo e tamanho dos espigões? Quem tem maior conhecimento da anatomia radicular? Muitas mais perguntas se podem fazer, mas ninguém duvida que este é o elo mais fraco da relação endodontia-prostodontia e havendo um bom entendimento entre o prostodontista e o endodontista, este último já que está com a mão na massa pode ser uma mais-valia nesta fase do tratamento porque:
a) conhece melhor a anatomia radicular;
b) tem maior sensibilidade para preservar a estrutura radicular;
c) pode dispensar a utilização de espigões temporários.
Por estas e por mais razões pode colocar os espigões e contribuir para a redução do risco de infiltração coronária.
E termino com uma frase:
“O tratamento endodôntico só acaba quando devolvemos a integridade ao dente”
José Manuel Sacramento
Parabéns pelo brilhante caso! Uma pergunta apenas. Pelo que percebi nao foi feito numa sessão por causa do tempo de presa do MTA… Sendo assim como adaptaste a provisória? Esclarece os amigos leitores e atentos seguidores deste blog.:)
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what the…. , after reading some forums and saw that allot of people reported better backs after doing either deadlifts and/or RDL’s, I purchased about 2 books and 3 dvd’s on olimpic lifts ( of course I know very well who are capable ).So after reading the dvd’s and the books, I started with the deadlifts. Low weight at the beginning ( 84 lbs at first ) and good form. I noticed that my hamstring flexibility was poor so I also started to do flexibility work ( also after reading some books ) and got my flexibility just right.At the beginning, when I was deadlifting, through the motion, the back felt good and low back pumped, but as soon as I finished deadlifting, I had a little discomfort. ( I forgot to notice that every night when I went to bed, in the first 1-2 minutes my lower back hurt a little even before starting doing deadlifts ).So basically I trained through pain and now fast-forward 4 months ahead, I deadlift 340 lbs ( 3 reps with good form ) and atm still going up in reps and lbs. My lower back is like a brick, my legs are monsters ( and the bed pain is gone, now I don’t fear that when I go to bed, I will have some pain ).I don’t really know what kind of problem I had but now it’s fixed ( I guess I’m a little lucky ).So I think it depends, if you don’t afford / have time to go to a chiropractor or someone who can check you, you can start training with low weights and if the pain when you train is greater than it is when you are “idle” then stop and go to a medic.I was lucky to be able to deadlift with my bad back because when I did that motion, my back didin’t hurt so I was able to train it and get it stronger.Like you, I agree that it depends and your body is the best instrument to tell you if you can train or not.Have a nice day
Damn, I wish I could think of something smart like that!
It’s posts like this that make surfing so much pleasure
I was seriously at DefCon 5 until I saw this post.
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Tip top stuff. I’ll expect more now.
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Tip top stuff. I’ll expect more now.
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Olá Professor Rui Costa!
Felicito-o pelo Blog e pelo exelente trabalho aqui apresentado! No entanto surgiu-me uma dúvida:
Sei que o utra-som se apresenta como a hipótese mais conservadora de remover um Espigão Intra-radicular. No entanto, 40 minutos a remover o espigão ainda é um tempo considerável. Sugestão: Com uma broca fina faça um sulco entre o canal e o espigão. Coloque uma lima nesse espaço e o ultra-som em contacto com a mesma de modo a tranferir a energia ultra-sónica mais apicalmente. É um modo que parece acelerar o processo. Se demorar mais do que 15 minutos com o ultra-som, porque não utilizar um aparelho de remoção de espigões através de tracção com força oponente na região cervical do dente? Sei que esses dispositivos apresentam limitações em diâmetros mesio-distais baixos, no entanto, parece-me possível num 1.2.
Olá Miguel penso que queiras dirigir a tua sugestão ao autor do caso, por isso vou responder nessa qualidade. Não conheço a técnica descrita e tenho algumas reservas em relação à sua eficácia. A criação de um sulco entre o dente e o espigão só vai destruir mais estrutura dentária tornando as paredes do canal mais frágeis… Quando seleccionamos a(s) técnica(s) a usar temos que fazer um balanço entre os benefícios e os riscos. Há um artigo sobre retratamento não cirúrgico do Dr. Clifford Ruddle (JOE Dezembro 2004), que talvez não fosse mal dar uma vista de olhos. Em relação ao tempo, em Endodontia estamos habituados a ser pacientes e 40min não é assim tanto tempo para remover um espigão, numa sessão que durou cerca de duas horas.
There are so may trainers who doesnb4t see their lack of kwgdlenoe and having huge ego trying to fix something that they donb4t know how and just continuing with the fatloss or performance training before they are ready. As naparapath and trainer I often get new client. which has been training with personal trainer before and have got broken down and got more pain. If you have the kwgdlenoe and skills to help the client, YES continue the work. If not refer them to someone who do know.Thanks for bringing these thoughts out. Good one Mike!
We took our gondola ride at night under a full moon…nothing more maagicl! What a way to get the feeling of Venice, the quiet of out of the way canals, evening life going on behind the shuttered windows, music faint in the background, the lapping of the quiet water…amazing really!
Obrigado por me teres felicitado Filipe, e aproveito para dizer que gostei muito do caso apresentado por ti aqui no nosso blog. Quanto ao esclarecimento sobre a adaptação da restauração provisória, este paciente antes de eu ter iniciado o tratamento da parte endodôntica foram confeccionadas e colocadas pelo prostodontista coroas provisórias todas unidas. À entrada do canal radicular foi colocada uma bolinha de algodão e o canal selado com Cavit®, as coroas provisórias foram cimentadas com Temp-BondNE®. O espigão de fibra foi colocado em menos de uma semana.
Por isso, e volto a referir, é de extrema importância a comunicação com o referidor de forma a que os tratamentos possam decorrer com o máximo de previsibilidade possível.
what the . , after reading some frumos and saw that allot of people reported better backs after doing either deadlifts and/or RDL’s, I purchased about 2 books and 3 dvd’s on olimpic lifts ( of course I know very well who are capable ).So after reading the dvd’s and the books, I started with the deadlifts. Low weight at the beginning ( 84 lbs at first ) and good form. I noticed that my hamstring flexibility was poor so I also started to do flexibility work ( also after reading some books ) and got my flexibility just right.At the beginning, when I was deadlifting, through the motion, the back felt good and low back pumped, but as soon as I finished deadlifting, I had a little discomfort. ( I forgot to notice that every night when I went to bed, in the first 1-2 minutes my lower back hurt a little even before starting doing deadlifts ).So basically I trained through pain and now fast-forward 4 months ahead, I deadlift 340 lbs ( 3 reps with good form ) and atm still going up in reps and lbs. My lower back is like a brick, my legs are monsters ( and the bed pain is gone, now I don’t fear that when I go to bed, I will have some pain ).I don’t really know what kind of problem I had but now it’s fixed ( I guess I’m a little lucky ).So I think it depends, if you don’t afford / have time to go to a chiropractor or someone who can check you, you can start training with low weights and if the pain when you train is greater than it is when you are idle then stop and go to a medic.I was lucky to be able to deadlift with my bad back because when I did that motion, my back didin’t hurt so I was able to train it and get it stronger.Like you, I agree that it depends and your body is the best instrument to tell you if you can train or not.Have a nice day
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Concordo contigo, Sacramento, embora 40 minutos seja de facto muito tempo. No entanto, o método por ti usado seria exactamente o mesmo que eu usaria, apesar de que sei que à medida que fosse perdendo a paciência iria tentando movimentos anti-rotacionais com um mosquito curvo ao mesmo tempo que aplicava ultrassons. De resto, se fossem necessários apenas 40 minutos para remover bem qualquer espigão eu ficaria sempre muito satisfeito:)
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